HIV/AIDS in Zimbabwe Lisa Garbus, MPP Gertrude Khumalo-Sakutukwa, MSc, MSW AIDS Policy Research Center, University of California San Francisco Published November 2002 Last Updated October 2003 (c) 2003 Regents of the University of California All Rights Reserved. Table of Contents PREFACE 3 EXECUTIVE SUMMARY 5 EPIDEMIOLOGY 15 POLITICAL ECONOMY AND SOCIOBEHAVIORAL CONTEXT 22 IMPACT 59 RESPONSE 72 LINKS 96 REFERENCES 97 Preface The Country AIDS Policy Analysis Project is managed by the AIDS Policy Research Center at the University of California San Francisco. The project is funded by the U.S. Agency for International Development, Cooperative Agreement PHN-A-00-01-00001-00. Stephen F. Morin, PhD, is the project's principal investigator. The project receives additional support from the International Training and Education Center on HIV (I-TECH), a collaboration of the University of Washington and UCSF funded through a cooperative agreement with the HIV/AIDS Bureau of the U.S. Health Resources and Services Administration. The views expressed in the outputs of the Country AIDS Policy Analysis Project do not necessarily reflect those of USAID or I-TECH. The Country AIDS Policy Analysis Project is designed to inform planning and prioritizing of effective and equitable HIV/AIDS prevention and treatment interventions through multidisciplinary research on HIV/AIDS. The project evolved from the acute need for analysis of the epidemiology of HIV/AIDS in tandem with analysis of countries' political economy and sociobehavioral context¾at household, sectoral, and macro levels. This multidisciplinary analysis aims to: * help inform national HIV/AIDS policies * strengthen ability to plan, prioritize, and implement effective interventions * highlight the range of sectoral interventions that may affect or be affected by HIV/AIDS * facilitate multisectoral/interministerial coordination * facilitate intercountry information sharing * increase national and subregional capacity for effective partnerships The project develops and disseminates online, fast-download, continually updated analyses of HIV/AIDS in 12 USAID priority countries: Ethiopia, Kenya, Malawi, Senegal, South Africa, Uganda, Tanzania, Zambia, Zimbabwe, Brazil, Cambodia, and India Each analysis is linked with national strategic plans for HIV/AIDS prevention, care, and support. Analyses also include a comparative table of 70 key HIV/AIDS and socioeconomic. The primary audience for the country analyses is in-country HIV/AIDS planners, including those from government ministries and agencies, multi- and bilateral donors, international and local NGOs, health care institutions, prevention programs, academia, affected communities, and the private sector. International investigators and policymakers also report using the analyses in their work. All country analyses undergo peer review at the AIDS Research Institute of the University of California San Francisco. In addition, two in-country experts from each profiled country serve as peer reviewers. A scientific advisory board also reviews all analyses. Acknowledgments The following individuals served as peer reviewers and provided valuable inputs to this paper: Dr. Thomas J. Coates, Dr. William McFarland, and Dr. Nancy Padian, all of the University of California San Francisco; and Dr. Tsungai Chipato and Dr. Godfrey Woelk, both of the University of Zimbabwe. They are not responsible for any errors of fact or judgment. Note on Terminology All racial categorizations and nomenclature used in the data sources cited throughout this profile have been maintained; they do not constitute an endorsement of any particular terminology. Users please note that this version contains two bibliographies; we will post a corrected version shortly. Contact Information Because this analysis is continually updated, comments and suggested sources of new data are welcome and may be sent to the coinvestigator/project director at UCSF's AIDS Policy Research Center: Lgarbus@psg.ucsf.edu Executive Summary Epidemiology The first AIDS case in Zimbabwe was identified in 1985. HIV sentinel surveillance was initiated in 1991. In 2000, Zimbabwe undertook the first fully implemented ANC survey since 1997. It found that 35 percent of women attending ANCs were infected with HIV. The 2001 ANC findings appeared to indicate that ANC prevalence had fallen to 29.5 percent. In August 2003, Zimbabwe released a report presenting new national HIV/AIDS prevalence data, indicating that HIV prevalence in ANC surveys peaked in 2000 at 34 percent, fell in 2001 to 30 percent, and decreased further in 2002 to 25.7 percent. Using these figures, 24.9 percent of Zimbabwean adults are HIV-positive. Several Zimbabwean HIV/AIDS experts stated that the new figures did not represent a real decline in HIV prevalence, but rather a correction of flawed data from previous surveys. At the end of 2001, UNAIDS estimated that 2.3 million Zimbabweans were living with HIV/AIDS (range: 1.8 to 2.7 million) Of them, 2 million were adults (ages 15 to 49), with the adult prevalence at 33.7 percent. UNAIDS estimates that of adults infected with HIV at the end of 2001, 1.2 million (60 percent) were women. At the end of 2001, there were 240,000 Zimbabwean children (ages 0 to 14) living with HIV/AIDS. The epidemic is driven largely by heterosexual transmission, which accounts for 92 percent of infections. Mother-to-child transmission is also an important factor, accounting for 7 percent of infections. Transmission via blood transfusion is rare: Zimbabwe was one of the first countries in the world to implement universal screening of blood and the selection of all voluntary, low-risk donors. Transmission via men who have sex with men is probably underestimated, given the government's fervent antihomosexual stance. In 2001, UNAIDS estimated that there were 200,000 adult and child AIDS deaths. Among adult Zimbabwean women, CDC has found that mortality peaks at 5.7 percent for the 30-34 age group, with 5.5 percent dying because of AIDS. Among men, mortality peaks at 5.2 percent for the 40-44 age group, with 4.8 percent dying because of AIDS. ANC data currently serve as Zimbabwe's primary sentinel surveillance of HIV/AIDS. Though ANCs prevalence is widely used, they are imperfect. For example, antenatal data may underestimate HIV prevalence in women of reproductive age, as recent studies indicate that fertility among HIV-positive women is substantially lower than among uninfected women. That ANC surveys have not been conducted on an annual basis in Zimbabwe does constrains analysis. Another issue is the disparity in the number of antenatal clinics participating each year. This scenario may be related to reduced budgetary allocations for ANC surveys; famine and the political and economic crises may also be limiting the ability of researchers to conduct such surveys. In addition, they may be limiting the number of women who are able to attend ANCs, thus affecting samples. The August 2003 report appeared to confirm that laboratory errors regarding the Chiredzi and Musume data were made in the 2000 ANC survey, leading to overestimates of HIV prevalence and thus the very large prevalence declines observed in 2001. It appears that there may be a decline in HIV prevalence among women attending ANCs, particularly those in the youngest age cohorts. To what this decline can be attributed, however, remains unclear. Political Economy and Sociobehavioral Context The relationship between HIV prevalence and socioeconomic indicators is highly complex. Increasingly, risk of HIV infection is recognized as related to individual as well as community variables. Additionally, since 1999 the political and economic situation in Zimbabwe has dramatically deteriorated, and the country is currently undergoing a massive food shortage¾all these affect and are affected by HIV/AIDS. Recent laws passed in Zimbabwe put tight restrictions on access to information. Although the 2002 Zimbabwean presidential elections were widely viewed as unfair, SADC governments declared the outcome "legitimate." Paralleling a dramatic decline in overall living standards and an uncertain political situation, serious crime levels in Zimbabwe appear to be rising. Corruption is pervasive in the country. European colonizers displaced the majority of indigenous farming population onto unproductive lands called communal areas. Historically, Zimbabwe's white minority owned most of the country's productive land through large-scale commercial farms, whereas the majority of the population lived on less-fertile land. The need for land reform in Zimbabwe is widely acknowledged, even by representatives of the commercial farming sector. In 2000, the government began a fast-track land redistribution program, which is being carried out very rapidly, bypassing legal procedures. The allocation of plots has frequently discriminated against those believed to support opposition parties. There have been numerous reports of land going to President Mugabe's relatives and supporters. Under the fast-track land reform, forced expulsion of white farmers and violence against both farmers and farm employees are occurring. The disruptions to commercial agriculture¾combined with severe drought¾have disrupted a significant portion of the commercial farm economy. Uncertainty surrounding the farming sector has jeopardized the country's exports. Fast-track land reform has been accompanied by large movements of people, regroupings of family units, and exposure to new sexual networks. Reports from aid agencies that have conducted missions in Zimbabwe concur that one of the key underlying factors contributing to the food crisis is HIV/AIDS, as well as inappropriate macroeconomic policy, fast-track land resettlement program, and natural phenomena, e.g., drought. A UN mission to Zimbabwe in January 2003 found that although food shortages were easing in other parts of southern Africa, the number of Zimbabweans at risk of starvation was rising. It reported that the political situation has severely hampered the high-potential agricultural areas from operating at maximum capacity during the current growing season, leading to a significant food deficit for the 2003-04 marketing season. Drought is a normal part of the cycle in Zimbabwean agriculture and that poverty is the norm for the majority of Zimbabweans. Subsequently, households have an array of coping mechanisms. However, in 2002-03, because of HIV/AIDS, drought, fast-track land reform, and the deteriorating economic situation, most of these coping strategies are irrelevant, and the extended family safety net and local support networks are increasingly under pressure. Households already affected by HIV/AIDS, those that are poor, and/or those headed by women, children, or the elderly may have difficulty accessing food aid because of impaired mobility, ostracism, or stigma. Vulnerable populations are adopting an array of survival strategies, including generating additional sources of food or income, migrating, dropping out of school, engaging in hazardous work, or exchanging sex for food or cash. For some young women, sex work provides the only way to support themselves and their families. Another factor involves the response to the food crisis, i.e., aid workers and truck drivers delivering food aid. Some women and girls may offer sex to workers involved in transporting and distributing food aid to try and obtain preferential treatment in the distribution of supplies and services; women and children may be particularly vulnerable to sexual exploitation during humanitarian crises. Several aid agencies report that state-sponsored militias are controlling the distribution of food supplies in rural areas and using food as a tool of repression against opposition MDC supporters. Fast-track land reform has led to serious human rights violations, including serious acts of violence against farm owners and farm workers, and, using occupied farms as bases for attacks, against residents of surrounding areas. The police have done little to halt such violence, and in some cases are directly implicated in the abuses. There has also been an increase in rape of young girls living on farms that have been invaded following fast-track land reform. Part of Zimbabwe's colonial legacy involves gender-segregated, inter- and intracountry labor migration. Moreover, excombatants who fought to attain independence returned to Zimbabwe during the 1980s; this movement may have facilitated HIV transmission. There is high mobility among urban, rural, mining, and port areas, within Zimbabwe as well as within the southern Africa subregion. Much of this movement is dominated by men. Migrant labor separates men from their families, places them in close proximity to "high-risk" sexual networks, and may result in their having an increased number of sexual contacts. Concurrently, it may also lead to women's reliance on sex to supplement their incomes while their male partners are away for long periods. Food shortages, fast-track land reform, and the political and economic situation are also spurring population dislocation. Intercountry mobility is also high, as many Zimbabweans are emigrating. Zimbabwe's 2000 ANC survey found that HIV prevalence was highest in commercial farming and mining areas, followed by border posts, growth points, other urban areas, and other rural areas. At independence, the Zimbabwean economy was more industrialized than most in Africa, with a diversified productive base, well-developed infrastructure, and a relatively sophisticated financial sector. In 1991, Zimbabwe undertook a structural adjustment program. During the 1990s, poverty in Zimbabwe increased significantly. In the mid-1990s over 60 percent of Zimbabwean households fell below the national poverty line. The World Bank attributes this increase in poverty to the poor performance of the economy and to flaws in the structural adjustment program. Since 1999, the country has been experiencing a socioeconomic crisis, resulting from poor economic policies, falling prices for key exports, a decrease in farm outputs following farm invasions and expulsion of white farmers and farm workers, increased deficit, drought, and loss of investor confidence due to uncertainty about domestic policies. Economic deterioration was also exacerbated by military involvement in the Democratic Republic of Congo from 1999 to 2002. Given the current political and economic situation, some donors have suspended funding, citing violence and abrogation of the rule of law. Others have reduced their operations to activities in social sectors (including HIV/AIDS), social protection, and human rights/governance programs. Increased donor support is contingent upon progress in orderly land reform and macroeconomic stabilization. In 2000, public expenditures on health represented 3.1 percent of GDP, whereas private health expenditures represented 3.6 percent of GDP. After independence, the government made great strides in improving access to social services. By the end of the 1980s, the country was one of Africa's leaders in terms of overall access to health and education. However, the health care system is now deteriorating, exacerbated by the current crises. The public health sector has been severely affected by an array of problems, including drug shortages and the exodus of skilled medical personnel. WHO ranks Zimbabwe a "high TB burden" country. In 2001, it had the world's 17th highest burden of TB in terms of new cases. An estimated 67 percent of adult (ages 15-49) TB cases are HIV-positive. Zimbabwe's past achievements in sexual & reproductive health have eroded and the reproductive health status of Zimbabweans has deteriorated. The country's contraceptive prevalence rates¾though much higher than the regional averages¾have stagnated. The maternal mortality ratio has been increasing. It is unclear whether the reported number of STIs is decreasing. It appears that viral, rather than bacterial, STIs, are driving the epidemic. Knowledge of HIV/AIDS is high in Zimbabwe. However, there are profound gender differences in the way in which personal HIV risk is construed, which may affect policy and program interventions. And despite high levels of awareness of HIV/AIDS, it remains highly stigmatized. Sexual behaviors driving the HIV/AIDS epidemic in Zimbabwe are influenced by a complex interplay of social, economic, and cultural factors. For women, casual sex before marriage is not socially sanctioned. It is, however, expected that men will have had several sexual partners before marriage. Among women who had sex in the past year, 4.3 percent used a condom during last sexual intercourse with a spouse or cohabiting partner; 42 percent used a condom during last sex with a noncohabiting partner. Among men, these figures were 6.5 and 70.2 percent, respectively. A significant decline in condom use within marriage occurred during the latter half of the 1990s Twenty-eight percent of women and 16.7 of men cannot not cite a source for obtaining a male condom. Zimbabwe has a very young population; 40 percent of Zimbabweans are under age 15. In 2000, the median age in the country was 17.5. The Zimbabwean government has failed to adopt laws and policies that ensure young people the right to access the information and methods to protect themselves from unwanted pregnancy and HIV/STIs. The Zimbabwean government has made parents the gatekeepers for their children's access to reproductive health services, and as a result, health workers have tended to turn away adolescents seeking dual protection information and services. In addition, young people tend to lack confidence that health workers will keep their requests confidential. Consumption of and demand for harmful substances still center on alcohol and cannabis. There are reports that certain inhalants and over-the-counter stimulants are being abused. Anecdotal reports indicate an increase in the abuse of cannabis, cocaine, and ecstasy. In rural areas, alcohol consumption plays an important part in community life as it is associated with ceremonies and rituals. It is also seen as an essential recreational activity, especially for some men. A variety of alcoholic beverages are consumed, but beer is the most frequent. Far more men than women drink alcohol, particularly in drinking establishments. For many, the purpose of drinking is to get drunk, and there is a high frequency of drunkenness among those who indicate they drink. Drinking is associated with casual and transactional sex. Shona and Ndebele societies are patriarchal and patrilineal. They impose strict controls on female sexual behavior, whereas the attitude toward male sexual behavior is more lenient. Before independence, women were socially and legally minors, and their rights were subordinate to men. Their active participation in the country's liberation struggle for independence demonstrated their capacity to fight against oppression. After Zimbabwe's independence in 1980, women struggled to liberate themselves socially, politically, and economically by lobbying the government through various women's organizations. Their major triumph was the passing of the Legal Age of Majority Act (1982), which made 18 the age of majority for both women and men. However, Zimbabwe's constitution permits discrimination against women on the basis of customary law, under which women are designated minors. Zimbabwean women become infected with HIV at younger ages than men for both biological and behavioral reasons (though the lifetime risk of acquiring HIV is about equal for both sexes). Women's subordinate socioeconomic status affects their vulnerability to acquiring HIV and, once infected, accessing care and support services. Fourteen percent of married Zimbabwean women report being in a polygynous union. Studies on age mixing have found that older age of sexual partner was associated with increased risk of HIV infection in men and women. Zimbabwean women are vulnerable to domestic abuse because of their low status and lack of power in the family, and because violence within marriage is widely tolerated. Zimbabwean women lack substantial legal recourse if they experience abuse. Over half of Zimbabwean women believe that wife beating is justified in at least one of five situations. Abuse of girls (sexual and nonsexual) in schools is widespread. Reported violence against Zimbabwean women has been rising dramatically. Since 2000, human rights groups have documented systematic rape and sexual torture of women in the context of the country's political violence. A 1994-95 study found that 86 percent of sex workers tested in Harare were HIV-positive. The deteriorating economic situation is rendering sex in exchange for money or material good more common. There is very limited male circumcision in Zimbabwe. Male circumcision is practiced by a Xhosa ethnic group known as amaFengu in Zimbabwe. The amaFengu are originally from South Africa and live in some areas of Matabeleland. Impact During 2000-2005, Zimbabwe will have the world's second-lowest life expectancy at birth (33.1). During 2000-05, life expectancy would have been 67.6 without AIDS. For 2010-15 and 2045-50, life expectancy would have been 70.5 and 76.2, respectively, without AIDS. These figures represent a 40 to 55 percent reduction during 2000-50. Zimbabwe's population will be 61 percent smaller in 2050 than it would have been in a "no-AIDS" scenario. General mortality figures have been radically eroding in Zimbabwe. There were approximately 1.1 million cumulative AIDS deaths in Zimbabwe through 2000, with AIDS increasing mortality by 67 percent. Between 2000 and 2015, there will be 4.2 million AIDS deaths, representing a 311 percent increase in mortality in Zimbabwe. The number of AIDS deaths is projected to rise to 6.0 million during 2015-50, a 119 increase in mortality during this period. HIV/AIDS has further strained coping mechanisms through its enormous and complex impact on households. Women are traditional caregivers and thus take on additional responsibilities when family members become ill. When an adult Zimbabwean woman dies, her children are likely to be fostered by an elderly woman, who faces numerous material and psychosocial constraints in caring for HIV-infected children and/or orphans. At the end of 2001, UNAIDS estimated that 780,000 AIDS orphans (ages 0 to 14) were living in Zimbabwe. The percent of Zimbabwe's orphans due to AIDS rose from 16.0 percent in 1990 to 76.8 percent in 2001; it projected that this percentage would rise to 85.7 percent in 2005 and 88.8 percent in 2010. Fewer than 4,000 of Zimbabwe's orphans are living in the country's 45 registered orphanages. Maintaining a child in one of these orphanages is far costlier than other forms of care. Some researchers have posited that increased resources for AIDS orphans would be optimally targeted to strengthen existing community groups at the local level. According to FAO, between 1985 and 2020, Zimbabwe will have lost 23 percent of its agricultural labor force because of AIDS. Seventy percent of hospital admissions are HIV-related. Demand for the time and services of trained health care providers is increasing; concurrently, those working in the health sector are also affected by HIV/AIDS. Between 2000 and 2010, 2.1 percent of Zimbabwe's teachers will die annually because of AIDS. On the demand side, there will a 0.25 percent reduction in Zimbabwe's school-age population (ages 5-14). Of new teachers who needed to be trained in Zimbabwe in 2000, 54.3 percent replaced teachers lost to AIDS; for 2010, a projected 82.6 percent of newly trained teachers will replace teachers who have died because of AIDS. Response After the first AIDS case in Zimbabwe was identified in 1985, the government's initial response involved the introduction of universal screening of blood and blood products for HIV. This initiative has been a great success, as HIV transmission via blood transfusion is rare. In 1987, the Ministry of Health and Child Welfare established the National AIDS Coordination Program (NACP). In 1991, the government implemented a program of HIV sentinel surveillance. Between 1988 and 1998, the government created several short- and medium-term plans to address HIV/AIDS, the implementation of which was the responsibility of NACP. Increasing levels of HIV infection, especially among youth, coupled with the many impacts of epidemic, forced the Zimbabwean government to acknowledge that its actions against HIV/AIDS had been inadequate and limited in scope and effectiveness. Among other things, the government had no HIV/AIDS policy until 1999. In addition, the government had faced criticism that although the enormity of the HIV/AIDS epidemic in Zimbabwe has been recognized for some time, the government was slow to acknowledge the scale of the problem and take appropriate action. Prior to 2000, for example, President Mugabe rarely mentioned HIV/AIDS publicly; when he did so, it was deemed newsworthy. The government introduced the National Policy on HIV/AIDS in December 1999. The National AIDS Council was created in May 2000 to implement the policy. The government has been criticized for insufficient consultation with all stakeholders, especially PWLHA. In June 2002, the government enacted a declaration of a six-month period of emergency (HIV/AIDS) to increase availability of and access to generic AIDS drugs. To what degree the national HIV/AIDS policy is being implemented is unclear. NAC, for example, is constrained by inadequate capacity (human and financial resources), overwhelming and competing demands for its services, internal struggles for visibility and power, denial and stigma around HIV/AIDS, and difficulty in bringing different stakeholders together. Zimbabwe's HIV/AIDS policy is also unclear regarding how a multisectoral response will be implemented. More generally, given the country's myriad and interrelated crises, the government's motivation and/or ability to focus on and support HIV/AIDS policy implementation is impeded. In March 2003, the UN Relief and Recovery Unit reported that "a vigorous response" to HIV/AIDS within the context of the current humanitarian crisis in Zimbabwe was lacking, citing, inter alia, limited coverage and quality of interventions, as well as weak coordination at all levels. An AIDS levy was introduced in 1999 to supplement the MOHCW's HIV/AIDS budget. The government has taken steps to make the disbursement of funds from the AIDS levy more transparent. However, donors and local AIDS committees continue to raise concerns that disbursements are not reaching local committees and have been politicized (i.e., are being disbursed through ZANU-PF-affiliated channels). Zimbabwe's Labor Relations Regulations on HIV/AIDS bar employers from requiring HIV testing as a precondition to employment, termination, or benefit eligibility. However, to what degree preemployment HIV testing and HIV/AIDS-related workplace discrimination are occurring is unknown. In accordance with international guidelines, Zimbabwe's policy places no restriction on travel of HIV-positive persons. Many other laws and policies are not sufficiently up-to-date or comprehensive to address the myriad impacts of HIV/AIDS. Zimbabwe relies heavily on funding from international donors for its HIV/AIDS programs. Because of the political situation¾and because Zimbabwe is not servicing its debt¾most multi- and bilateral donor resources are being withdrawn or reduced. Many donors, however, are continuing to fund HIV/AIDS programs, often through NGOs. The Global Fund to Fight AIDS, Tuberculosis & Malaria awarded Zimbabwe two grants in April 2002; HIV/AIDS funds, however, have not yet been disbursed. Zimbabwean civil society, including NGOs, CBOs, religious and academic organizations, and private industry, provide a significant amount of HIV/AIDS prevention, care, and support. Zimbabwe's national HIV/AIDS policy considers counseling to be a vital component of HIV/AIDS prevention and care and addresses VCT in depth. The Zimbabwe AIDS Prevention and Support Organization (ZAPSO) opened the first VCT center in Zimbabwe in 1998. Almost 12 percent of Zimbabwean women report having been tested for HIV; among those not tested, 59.1 percent would like to be tested. Among men, 9.2 percent report having been tested for HIV; of those not tested, 56.8 percent would like to be tested. Among women who have not been tested for HIV, 63.4 percent do not know a source for HIV testing. Among men, the comparable figure is 66.5 percent. USAID, in collaboration with Population Services International (PSI) and the Government of Zimbabwe, launched 10 New Start VCT centers at strategic locations throughout the country. In 2001, these 10 sites counseled and tested over 50,000 clients. The female condom was launched in Zimbabwe in 1997. It was initially sold through selected pharmacies and clinics at a heavily subsidized retail price of US$0.24 for a box of two; distribution has since expanded to other urban outlets, including large supermarkets and convenience stores. The high cost of the female condom (vis-à-vis the male condom) is leading many Zimbabwean women, particularly sex workers, to reuse it to save money. Although users of the female condom perceive it to be effective and reliable both as an STI/HIV and pregnancy prevention method, 30 percent of men and 57 percent of women reported some difficulty with use, such as problems with insertion, discomfort during sex, noise or squeakiness during use, and excess lubrication. A study of married Zimbabwean women found that offering them multiple prevention options increased the reported percentage of sex acts protected by any method. Most women preferred the male condom and least liked the female condom. Based on a phase I clinical trial of Buffergel that found that it appeared to be safe and well tolerated, a phase 2/2B study of the safety and effectiveness of BufferGel and PRO 2000/5 Gel (P) is currently taking place in Zimbabwe. Preliminary findings indicate that both Zimbabwean men and women generally accept the diaphragm. Although the majority preferred male condoms because of their known efficacy against HIV, most women felt protected and empowered through use of the diaphragm. In August 2002, the Gates Foundation awarded US$28 million to the University of California San Francisco to continue testing the diaphragm as a potential prevention method for HIV/other STIs. There are numerous HIV prevention interventions under way that have an economic/livelihoods focus. WHO estimated that as of the end of 2001, only 4 percent of Zimbabweans in need of PMTCT services was receiving them. With GFATM financing, the government's target for 2002 was to have 30,000 pregnant women counseled and tested for HIV; by 2004, this figure would rise to 70,000. The GFATM grant would also fund expansion of ART for PMTCT. In January 2002, the government launched the PMTCT Program, through the MOHCW and NAC (using funds from the AIDS levy). MOHCW funds 60 to 70 percent of PMTCT activities and coordinates all PMTCT programs. Donors either support individual sites or provide resources to the national office to enhance capacity to implement and coordinate activities. The program offers free VCT to pregnant mothers and free nevirapine at the time of labor in a single dose. Because of personnel and training constraints, the program is not yet available in all maternity units. Currently, between 200 and 2,000 Zimbabweans are receiving some form of ART (of highly variable quality and with highly variable levels of adherence) through the private sector and clinical trials. Zimbabwe's Antiretroviral Therapy Subcommittee has produced draft ART guidelines. The government's (draft) Plan for the Nationwide Provision of ART calls for detailed implementation strategy to be developed for all aspects of ART. In its 2002 GFATM proposal, the government requested US$2.2 million for antiretroviral drugs and US$1.5 million for logistics and training support for 2002-04. In September 2002, Zimbabwe's Antiretroviral Therapy Subcommittee estimated that the cost of ART ranged from US$25 to US$50 per person per month. As of late 2002, three major local companies-Datlabs, CAPS, and Varichem-were negotiating with foreign companies to manufacture generic ARVs under license. Pfizer has donated Diflucan to government for free provision to patients. A 2000 study from Zimbabwe described ART prescribing practices as "therapeutic anarchy"; lack of treatment guidelines, links between private practitioners and specialists, and access to research evidence were all factors contributing to this scenario. Epidemiology At a Glance HIV Sentinel Surveillance * HIV sentinel surveillance was initiated in 1991. In 2000, Zimbabwe undertook the first fully implemented ANC survey since 1997. It found that 35 percent of women attending ANCs were infected with HIV. The 2001 ANC findings appeared to indicate that ANC prevalence had fallen to 29.5 percent. * The Zimbabwean MOHCW and CDC concluded that there seemed to be a decline in HIV among women attending ANCs between 2000 and 2001. They viewed the greater decline in prevalence among younger women and lower decline in older women as suggesting a declining incidence of HIV infection. As for the size of the decline, they believed that it was unclear whether the findings from 2000 were too high, or whether the 2001 findings reflected a true decline. * In August 2003, Zimbabwe released a report presenting new national HIV/AIDS prevalence data, indicating that HIV prevalence in ANC surveys peaked in 2000 at 34 percent, fell in 2001 to 30 percent, and decreased further in 2002 to 25.7 percent. Using these figures, 24.9 percent of Zimbabwean adults are HIV-positive. Several Zimbabwean HIV/AIDS experts stated that the new figures did not represent a real decline in HIV prevalence, but rather a correction of flawed data from previous surveys. UN Estimates * At the end of 2001, UNAIDS estimated that 2.3 million Zimbabweans were living with HIV/AIDS (range: 1.8 to 2.7 million) Of them, 2 million were adults (ages 15 to 49), with the adult prevalence at 33.7 percent. * UNAIDS estimates that of adults infected with HIV at the end of 2001, 1.2 million (60 percent) were women. HIV prevalence among women ages 15 to 24 ranged from 26.4 to 39.61 percent; the comparable range for men in the same age group was 9.9 to 14.85 percent.) * At the end of 2001, there were 240,000 Zimbabwean children (ages 0 to 14) living with HIV/AIDS. Transmission Patterns * The epidemic is driven largely by heterosexual transmission, which accounts for 92 percent of infections. Mother-to-child transmission is also an important factor, accounting for 7 percent of infections. Transmission via blood transfusion is rare: Zimbabwe was one of the first countries in the world to implement universal screening of blood and the selection of all voluntary, low-risk donors. Transmission via men who have sex with men is probably underestimated, given the government's fervent antihomosexual stance. AIDS Mortality * In 2001, UNAIDS estimated that there were 200,000 adult and child AIDS deaths. * Among adult Zimbabwean women, CDC has found that mortality peaks at 5.7 percent for the 30-34 age group, with 5.5 percent dying because of AIDS. Among men, mortality peaks at 5.2 percent for the 40-44 age group, with 4.8 percent dying because of AIDS. Data Quality Issues * ANC data currently serve as Zimbabwe's primary sentinel surveillance of HIV/AIDS. Though ANCs prevalence is widely used, they are imperfect. For example, antenatal data may underestimate HIV prevalence in women of reproductive age, as recent studies indicate that fertility among HIV-positive women is substantially lower than among uninfected women. * That ANC surveys have not been conducted on an annual basis in Zimbabwe does constrains analysis. Another issue is the disparity in the number of antenatal clinics participating each year. This scenario may be related to reduced budgetary allocations for ANC surveys; famine and the political and economic crises may also be limiting the ability of researchers to conduct such surveys. In addition, they may be limiting the number of women who are able to attend ANCs, thus affecting samples. * The August 2003 report appeared to confirm that laboratory errors regarding the Chiredzi and Musume data were made in the 2000 ANC survey, leading to overestimates of HIV prevalence and thus the very large prevalence declines observed in 2001. * It appears that there may be a decline in HIV prevalence among women attending ANCs, particularly those in the youngest age groups. To what this decline can be attributed, however, remains unclear. HIV Sentinel Surveillance The first AIDS case in Zimbabwe was identified in 1985. HIV sentinel surveillance was initiated in 1991, with subsequent HSS conducted in 1993, 1994, 1995, 1997, 2000, and 2001.[1] 2000 Findings In 2000, Zimbabwe undertook the first fully implemented antenatal clinic (ANC) survey since 1997 (with support from the U.S. Centers for Disease Control and Prevention).[1] For the 2000 ANC survey, anonymous, unlinked blood samples were collected over a three-month period from 6,121 women ages 15 to 44 at their first appointment at ANCs across 19 sentinel sites spanning all provinces (including urban center, municipalities, rural areas, commercial areas, farming areas, mining areas, growth points, and border posts). Of the 6,121 women studied, 22.6 percent were ages 15-19, 35.9 percent ages 20-24, 23.4 percent ages 25-29, and 11.4 percent ages 30-34 yrs, and 6.7 percent were over age 35. Fifty-five percent were from rural areas, 93 percent were married, and 66 percent had a secondary education.[2] The 2000 ANC survey found that 35 percent of women attending ANCs were infected with HIV.[2] Prevalences at the 19 sentinel sites ranged from 13.0 percent (Binga Kariyangwe) to 70.7 percent (Chiredzi). Prevalence was highest among women ages 30 to 34 (43.5 percent).[1] The 2000 ANC survey found that prevalence among married women was 34.5 percent. Provincial prevalences in 2000 ranged from 25.6 percent (Mashonaland Central) to 49.4 percent (Masvingo). Prevalences in Harare and Bulawayo were 30.0 and 31.1 percent, respectively. HIV prevalence was highest in clinics located in commercial farming and mining areas (53.9 percent), followed by border posts (48.7 percent), growth points (business centers servicing a collection of villages, including grocery shops, petrol station, bottle shop, nightclub, and sometimes a small hotel) (41.5 percent), urban areas (31.6 percent), and other rural areas (26.8 percent).[1] 2001 Findings At the XIV International AIDS Conference in Barcelona in July 2002, officials from Zimbabwe's Ministry of Health and Child Welfare (MOHCW) and the CDC presented preliminary findings. The 2001 ANC survey appears to have been carried out in the same 19 sites as in the 2000 ANC survey except that Banket was included and Hwange St. Patrick's was excluded in 2001. In 2001, data for 880 women attending ANCs were collected through anonymous, unlinked blood samples. The Genlavia MIXT HIV Assay was used to test specimens; EpiInfo 2000 and SAS were used to analyze the data.[3] The findings presented in Barcelona indicated that national HIV prevalence among ANCs had fallen to 29.5 percent (from 35 percent in 2000). HIV prevalence among the sentinel sites ranged from 19.2 percent (Binga and Karanda) to 41.9 percent (Gwanda). Thirteen sites registered decreases in HIV prevalence compared to 2000. In Chiredzi and Musume, absolute prevalence declines were greater than 25 percent; these two sites accounted for almost half of the total change in prevalence over 2000-2001. Excluding Chiredzi and Musume from the 2000 and 2001 data indicates that national ANC prevalence declined from 32 to 29.5 percent. Prevalence declines were observed in all age groups except those ages 40 to 44. Prevalence remained highest among those ages 30 to 34.[3] Based on these findings, the Zimbabwean MOHCW and CDC concluded that there seemed to be a decline in HIV among women attending ANCs in Zimbabwe between 2000 and 2001. They viewed the greater decline in prevalence among younger women and lower decline in older women as suggesting a declining incidence of HIV infection. As for the size of the decline, they believed that it was unclear whether the findings from 2000 were too high, or whether the 2001 findings reflect a true decline. They noted that an absolute difference in HIV prevalence greater than 5 percent in just one year appears to be too large to be a true epidemiologic change. They encouraged immediate validation and calibration of the 2001 ANC data using other population-based probability sampling, such as the young adult survey conducted in 2001 (the findings of which have not yet been released).[3] HSS Findings 1991 - 2001 Ten of the 19 sentinel clinics included in the 2000 survey were also part of the 1997 ANC survey. Comparing results from these 10 clinics only finds that HIV prevalence rose from 27.0 percent in 1997 to 35.0 percent in 2000. A comparison involving all participating clinics in 1997 (total 28) with the 19 that participated in 2000 finds that HIV prevalence rose from 29.0 percent in 1997 to 35 percent in 2000.[1] As mentioned, the 2001 ANC survey was carried out in the same 19 sites as in 2000 save for two sites. The preliminary findings from the 2001 ANC indicate that HIV prevalence fell from 35.0 percent in 2000 to 29.5 percent in 2001. [3] August 2003 Release of Revised HIV Figures On August 21, 2003, Zimbabwe officials released a report presenting new national HIV/AIDS prevalence data indicating a possible decline in the number of HIV-positive Zimbabweans. According to the report, 1.82 million are living with HIV/AIDS. The figures, compiled using surveys conducted by local experts with technical assistance from the CDC, WHO, UNAIDS, and the Imperial College of London, reported that 24.9 percent of Zimbabwean adults are HIV-positive, down from 33.7 percent in 2001, as reported by UNAIDS. Zimbabwe Health Minister David Parirenyatwa stated that the new data suggest that HIV prevalence in ANC surveys peaked in 2000 at 34 percent, fell in 2001 to 30 percent, and decreased further in 2002 to 25.7 percent. However, Parirenyatwa cautioned that "more work was needed" to determine whether the recent prevalence estimates marked a true decline. [1] Several Zimbabwean HIV/AIDS experts stated that the new figures did not represent a real decline in HIV prevalence, but rather a correction of flawed data from previous surveys.[2] For example, Dr. Godfrey Woelk of the University of Zimbabwe noted: "There were also some mistakes made in the testing in earlier surveys, which overestimated the prevalence....It is not a decline, simply a more accurate estimation. In one of the previous ANC sentinel surveillance surveys, there was probably a mistake in the lab testing (where Chiredzi and another area had rates of 70% HIV prevalence)."[3] Dr. Katherine Fritz of the UZ-UCSF Collaborative Research Program commented: "It could be that the epidemic peaked around 2000. I think it's also very possible that previous surveillance was flawed. The thing that worries me about the future is that with all the land redistribution over the past 18 months, people are on the move more than ever and husbands and wives spend more time apart. For example, men from Harare who have acquired land often send their wives to live on the land and tend it while men stay in the city."[4] HIV Incidence Reductions in HIV-1 prevalence, especially those in young adults, may indicate concomitant declines in HIV-1 incidence. However, other factors, such as mortality rates, migration, and survey coverage, also contribute to prevalence trends. Thus, incidence trends cannot be estimated directly from prevalence trends. Reductions in HIV-1 incidence trends would provide the most convincing evidence of a decrease in epidemic size, but large, long-term, longitudinal studies (cohort studies, which indicate both incidence as well as prevalence) are needed to obtain such evidence. [5] Since November 1999, women ages 18 to 35 years from family planning and STI clinics and community settings in Zimbabwe (as well as Thailand and Uganda) have been screened for and enrolled in a study of hormonal contraception and risk of HIV acquisition. Analysis of data from Zimbabwe through mid-August 2001 (n=1,600) found that HIV incidence was about 3.5 percent in Harare and Chitungwiza.[4] U.N. Estimates At the end of 2001, UNAIDS estimated that 2.3 million Zimbabweans were living with HIV/AIDS (range: 1.8 to 2.7 million) Of them, 2 million were adults (ages 15 to 49), with the adult prevalence at 33.7 percent.[5] (At the end of 1999, UNAIDS estimated adult prevalence at 25.06 percent.[6]).[5] The U.N. Population Division estimates that Zimbabwe's adult HIV prevalence peaked at 34.0 percent in 2000. By 2050, the division estimates that adult prevalence will have fallen to 18.3 percent. (This projection assumes that HIV/AIDS dynamics remain unchanged until 2010. Thereafter, prevalence levels are assumed to decline. By 2050, prevalence levels are lower but still substantial in the most highly affected countries.)[6] Gender and Age UNAIDS estimates that of adults infected with HIV at the end of 2001, 1.2 million (60 percent) were women. HIV prevalence among women ages 15 to 24 ranged from 26.4 to 39.61 percent; the comparable range for men in the same age group was 9.9 to 14.85 percent.) At the end of 2001, there were 240,000 Zimbabwean children (ages 0 to 14) living with HIV/AIDS.[5] Transmission Patterns The epidemic is driven largely by heterosexual transmission, which accounts for 92 percent of infections. Mother-to-child transmission is also an important factor, accounting for 7 percent of infections.[7] Transmission via blood transfusion is rare: Zimbabwe was one of the first countries in the world to implement universal screening of blood and the selection of all voluntary, low-risk donors (see Response section for more detail on the National Blood Transfusion Service). Transmission via men who have sex with men is probably underestimated, given the government's fervent antihomosexual stance. AIDS Mortality See also the Impact section below. In 2001, UNAIDS estimated that there were 200,000 adult and child AIDS deaths.[5] (The comparable figure for 1999 was 160,000.[6]) Zimbabwean health officials estimate that there are 2,500 HIV/AIDS-related deaths in the country each week.[1, 7] Among adult Zimbabwean women, CDC has found that mortality peaks at 5.7 percent for the 30-34 age group, with 5.5 percent dying because of AIDS. Among men, mortality peaks at 5.2 percent for the 40-44 age group, with 4.8 percent dying because of AIDS.[10] Data Quality Issues ANC data currently serve as Zimbabwe's primary sentinel surveillance of HIV/AIDS. Though ANCs prevalence is widely used, they are imperfect (see box 1). For example, antenatal data may underestimate HIV prevalence in women of reproductive age, as recent studies indicate that fertility among HIV-positive women is substantially lower than among uninfected women. Gregson et al. have found 25 to 40 percent lower fertility in women with HIV in high-prevalence African countries; they attribute about half of this "subfertility" directly to HIV infection.[11] There is also the possibility that women attending ANCs are significantly older or younger than women in the general population; however, when Zimbabwe's 2000 ANC data were adjusted to account for the age distribution among women in the general population, minimal differences in HIV prevalence were found.[12] That ANC surveys have not been conducted on an annual basis in Zimbabwe does constrains analysis. Another issue is the disparity in the number of antenatal clinics participating each year. For example, 28 clinics participated in the 1997 survey, but only 19 in 2000 and in 2001. The number of women surveyed has also decreased, from 6,121 in 2000 to 880 in 2001. This scenario may be related to reduced budgetary allocations for ANC surveys; famine and the political and economic crises may also be limiting the ability of researchers to conduct such surveys. In addition, they may be limiting the number of women who are able to attend ANCs, thus affecting samples. Finally, in 2001, women aged less than 15 and between 44 and 49 were included, whereas this does not appear to have been the case in 2000. The August 2003 report appeared to confirm that laboratory errors regarding the Chiredzi and Musume data were made in the 2000 ANC survey, leading to overestimates of HIV prevalence and thus the very large prevalence declines observed in 2001.[12] It appears that there may be a decline in HIV prevalence among women attending ANCs, particularly those in the youngest age groups. To what this decline can be attributed, however, remains unclear.[12, 13] Political Economy and Sociobehavioral Context At a Glance * The relationship between HIV prevalence and socioeconomic indicators is highly complex. Increasingly, risk of HIV infection is recognized as related to individual as well as community variables. Additionally, since 1999 the political and economic situation in Zimbabwe has dramatically deteriorated, and the country is currently undergoing a massive food shortage¾all these affect and are affected by HIV/AIDS. Governance * Recent laws passed in Zimbabwe put tight restrictions on access to information. * Although the 2002 Zimbabwean presidential elections were widely viewed as unfair, SADC governments declared the outcome "legitimate." * Paralleling a dramatic decline in overall living standards and an uncertain political situation, serious crime levels in Zimbabwe appear to be rising. * Corruption is pervasive in the country. Fast-Track Land Reform * European colonizers displaced the majority of indigenous farming population onto unproductive lands called communal areas. Historically, Zimbabwe's white minority owned most of the country's productive land through large-scale commercial farms, whereas the majority of the population lived on less-fertile land. * The need for land reform in Zimbabwe is widely acknowledged, even by representatives of the commercial farming sector. In 2000, the government began a fast-track land redistribution program, which is being carried out very rapidly, bypassing legal procedures. * The allocation of plots has frequently discriminated against those believed to support opposition parties. There have been numerous reports of land going to President Mugabe's relatives and supporters. * Under the fast-track land reform, forced expulsion of white farmers and violence against both farmers and farm employees are occurring. The disruptions to commercial agriculture¾combined with severe drought¾have disrupted a significant portion of the commercial farm economy. * Fast-track land reform has been accompanied by large movements of people, regroupings of family units, and exposure to new sexual networks. * Uncertainty surrounding the farming sector has jeopardized the country's exports. Food Crisis * Reports from aid agencies that have conducted missions in Zimbabwe concur that one of the key underlying factors contributing to the food crisis is HIV/AIDS, as well as inappropriate macroeconomic policy, fast-track land resettlement program, and natural phenomena, e.g., drought. * A UN mission to Zimbabwe in January 2003 found that although food shortages were easing in other parts of southern Africa, the number of Zimbabweans at risk of starvation was rising. It reported that the political situation has severely hampered the high-potential agricultural areas from operating at maximum capacity during the current growing season, leading to a significant food deficit for the 2003/2004 marketing season. * Drought is a normal part of the cycle in Zimbabwean agriculture and that poverty is the norm for the majority of Zimbabweans. Subsequently, households have an array of coping mechanisms. However, in 2002-03, because of HIV/AIDS, drought, fast-track land reform, and the deteriorating economic situation, most of these coping strategies are irrelevant, and the extended family safety net and local support networks are increasingly under pressure. * Households already affected by HIV/AIDS, those that are poor, and/or those headed by women, children, or the elderly may have difficulty accessing food aid because of impaired mobility, ostracism, or stigma. * Vulnerable populations are adopting an array of survival strategies, including generating additional sources of food or income, migrating, dropping out of school, engaging in hazardous work, or exchanging sex for food or cash. For some young women, sex work provides the only way to support themselves and their families. * Another factor involves the response to the food crisis, i.e., aid workers and truck drivers delivering food aid. Some women and girls may offer sex to workers involved in transporting and distributing food aid to try and obtain preferential treatment in the distribution of supplies and services; women and children may be particularly vulnerable to sexual exploitation during humanitarian crises. Human Rights * Several aid agencies report that state-sponsored militias are controlling the distribution of food supplies in rural areas and using food as a tool of repression against opposition Movement for Democratic Change supporters. * Fast-track land reform has led to serious human rights violations, including serious acts of violence against farm owners and farm workers, and, using occupied farms as bases for attacks, against residents of surrounding areas. The police have done little to halt such violence, and in some cases are directly implicated in the abuses. * There has also been an increase in rape of young girls living on farms that have been invaded following fast-track land reform. Population Mobility * Part of Zimbabwe's colonial legacy involves gender-segregated, inter- and intracountry labor migration. Moreover, excombatants who fought to attain independence returned to Zimbabwe during the 1980s; this movement may have facilitated HIV transmission. * There is high mobility among urban, rural, mining, and port areas, within Zimbabwe as well as within the southern Africa subregion. Much of this movement is dominated by men. Migrant labor separates men from their families, places them in close proximity to "high-risk" sexual networks, and may result in their having an increased number of sexual contacts. Concurrently, it may also lead to women's reliance on sex to supplement their incomes while their male partners are away for long periods. * Food shortages, fast-track land reform, and the political and economic situation are also spurring population dislocation. Intercountry mobility is also high, as many Zimbabweans are emigrating. * Zimbabwe's 2000 ANC survey found that HIV prevalence was highest in commercial farming and mining areas, followed by border posts, growth points, other urban areas, and other rural areas. Economy * At independence, the Zimbabwean economy was more industrialized than most in Africa, with a diversified productive base, well-developed infrastructure, and a relatively sophisticated financial sector. * In 1991, Zimbabwe undertook a structural adjustment program. During the 1990s, poverty in Zimbabwe increased significantly. In the mid-1990s over 60 percent of Zimbabwean households fell below the national poverty line. The World Bank attributes this increase in poverty to the poor performance of the economy and to flaws in the structural adjustment program. * Since 1999, the country has been experiencing a socioeconomic crisis, resulting from poor economic policies, falling prices for key exports, a decrease in farm outputs following farm invasions and expulsion of white farmers and farm workers, increased deficit, drought, and loss of investor confidence due to uncertainty about domestic policies. Economic deterioration was also exacerbated by military involvement in the Democratic Republic of Congo from 1999 to 2002. * Given the current political and economic situation, some donors have suspended funding, citing violence and abrogation of the rule of law. Others have reduced their operations to activities in social sectors (including HIV/AIDS), social protection, and human rights/governance programs. Increased donor support is contingent upon progress in orderly land reform and macroeconomic stabilization. Health System * In 2000, public expenditures on health represented 3.1 percent of GDP, whereas private health expenditures represented 3.6 percent of GDP. * After independence, the Government of Zimbabwe made great strides in improving access to social services. By the end of the 1980s, the country was one of Africa's leaders in terms of overall access to health and education. * However, the health care system is deteriorating, exacerbated by the current crises. The public health sector has been severely affected by an array of problems, including drug shortages and the exodus of skilled medical personnel. Tuberculosis * WHO ranks Zimbabwe a "high TB burden" country. In 2001, it had the world's 17th highest burden of TB in terms of new cases. An estimated 67 percent of adult (ages 15-49) TB cases are HIV-positive. * Major constraints to achieving TB targets include ? weak political commitment to TB control ? lack of TB manager and other staff ? funding gaps ? low access to treatment because of poor infrastructure in new settlements ? limited community involvement in TB control Sexual and Reproductive Health * Zimbabwe's past achievements in sexual & reproductive health have eroded and the reproductive health status of Zimbabweans has deteriorated. The country's contraceptive prevalence rates¾though much higher than the regional averages¾have stagnated. The maternal mortality ratio has been increasing. Sexually Transmitted Infections * It is unclear whether the reported number of STIs is decreasing. It appears that viral, rather than bacterial, STIs, are driving the epidemic. Awareness and Knowledge of HIV/AIDS * Knowledge of HIV/AIDS is high in Zimbabwe. However, there are profound gender differences in the way in which personal HIV risk is construed, which may affect policy and program interventions. Stigma and Discrimination * Despite high levels of awareness of HIV/AIDS, it remains highly stigmatized. Sexual Behavior * Sexual behaviors driving the HIV/AIDS epidemic in Zimbabwe are influenced by a complex interplay of social, economic, and cultural factors. For women, casual sex before marriage is not socially sanctioned. It is, however, expected that men will have had several sexual partners before marriage. * Among women who had sex in the past year, 4.3 percent used a condom during last sexual intercourse with a spouse or cohabiting partner; 42 percent used a condom during last sex with a noncohabiting partner. Among men, these figures were 6.5 and 70.2 percent, respectively. * A significant decline in condom use within marriage occurred during the latter half of the 1990s * Twenty-eight percent of women and 16.7 of men cannot not cite a source for obtaining a male condom. Youth * Zimbabwe has a very young population; 40 percent of Zimbabweans are under age 15. In 2000, the median age in the country was 17.5. * The Zimbabwean government has failed to adopt laws and policies that ensure young people the right to access the information and methods to protect themselves from unwanted pregnancy and HIV/STIs. The Zimbabwean government has made parents the gatekeepers for their children's access to reproductive health services, and as a result, health workers have tended to turn away adolescents seeking dual protection information and services. In addition, young people tend to lack confidence that health workers will keep their requests confidential. Alcohol and Drug Use * Consumption of and demand for harmful substances still center on alcohol and cannabis. There are reports that certain inhalants and over-the-counter stimulants are being abused. Anecdotal reports indicate an increase in the abuse of cannabis, cocaine, and ecstasy. * In rural areas, alcohol consumption plays an important part in community life as it is associated with ceremonies and rituals. It is also seen as an essential recreational activity, especially for some men. A variety of alcoholic beverages are consumed, but beer is the most frequent. Far more men than women drink alcohol, particularly in drinking establishments. For many, the purpose of drinking is to get drunk, and there is a high frequency of drunkenness among those who indicate they drink. Drinking is associated with casual and transactional sex. Gender * Shona and Ndebele societies are patriarchal and patrilineal. They impose strict controls on female sexual behavior, whereas the attitude toward male sexual behavior is more lenient. * Before independence, women were socially and legally minors, and their rights were subordinate to men. Their active participation in the country's liberation struggle for independence demonstrated their capacity to fight against oppression. After Zimbabwe's independence in 1980, women struggled to liberate themselves socially, politically, and economically by lobbying the government through various women's organizations. * Their major triumph was the passing of the Legal Age of Majority Act (1982), which made 18 the age of majority for both women and men. However, Zimbabwe's constitution permits discrimination against women on the basis of customary law, under which women are designated minors. * Zimbabwean women become infected with HIV at younger ages than men for both biological and behavioral reasons (though the lifetime risk of acquiring HIV is about equal for both sexes). * Women's subordinate socioeconomic status affects their vulnerability to acquiring HIV and, once infected, accessing care and support services. * Fourteen percent of married Zimbabwean women report being in a polygynous union. * Studies on age mixing have found that among seronegative women, having a male partner 10 or more years older increased the risk of never having used a male condom. Older age of sexual partner was associated with increased risk of HIV-1 infection in men and women. Sexual Violence * Zimbabwean women are vulnerable to domestic abuse because of their low status and lack of power in the family, and because violence within marriage is widely tolerated. Zimbabwean women lack substantial legal recourse if they experience abuse. * Over half of Zimbabwean women believe that wife beating is justified in at least one of five situations. * Reported violence against Zimbabwean women has been rising dramatically. Since 2000, human rights groups have documented systematic rape and sexual torture of women in the context of the country's political violence. * Abuse of girls (sexual and nonsexual) in schools is widespread, including aggressive sexual behavior, intimidation and physical assault by older boys; sexual advances by male teachers; and corporal punishment and verbal abuse by both female and male teachers (this last directed at boys as well as girls). Sex Work * A 1994-95 study found that 86 percent of sex workers tested in Harare were HIV-positive. * The deteriorating economic situation is rendering sex in exchange for money or material good more common. Male Circumcision * There is very limited male circumcision in Zimbabwe. Male circumcision is practiced by a Xhosa ethnic group known as amaFengu in Zimbabwe. The amaFengu are originally from South Africa and live in some areas of Matabeleland. In a paper prepared for the WHO Commission on Macroeconomics and Health, David Bloom of Harvard and his colleagues note that: Existing data provide some indication that the relationship between poverty and HIV is growing stronger over time, both between and within continents. But it is not possible to infer causality from these data. That is, it is difficult to tell whether poverty causes AIDS or vice versa¾or whether another variable, such as war, inadequate health, or poor education, explains the relationship....In sum, the link between economic status and AIDS is complex.[8] Håkan Björkman, senior adviser on HIV/AIDS to UNDP's Bureau for Development Policy, states that: HIV/AIDS is not strictly speaking a "disease of poverty" as it affects people at all income levels. But evidence from some countries at advanced states of the epidemic shows that new HIV infections disproportionately affect poor people, unskilled workers, and those lacking literacy skills¾especially young women in each of these categories. The relationship among poverty, gender, and HIV vulnerability has important policy implications.[9] Many of the factors discussed in this section exist in countries that, unlike Zimbabwe, have low HIV prevalence; these include poverty, gender inequality, and history of colonialism and political and economic disenfranchisement. The relationship between HIV prevalence and socioeconomic indicators is highly complex. Increasingly, risk of HIV infection is recognized as related to individual as well as community variables.[14, 15] Additionally, since 1999 the political and economic situation in Zimbabwe has dramatically deteriorated, and the country is currently undergoing a massive food shortage¾all these affect and are affected by HIV/AIDS. This section does not seek to demonstrate causality; rather, it aims to analyze key political economy and sociobehavioral contextual elements to highlight the range of sectoral policies and interventions that may affect or be affected by HIV/AIDS. In addition to the table of key HIV/AIDS and socioeconomic indicators that accompanies this analysis, readers may also want to consult the 2003 indicators related to progress on Millennium Development Goals, which are published by UNDP . Colonialism and the Post-Independence Period In the 1970s, nationalists in what was then called Rhodesia fought a liberation war against the white-minority government. The struggle for independence claimed over 20,000 lives.[16] The British Government formally granted independence to Zimbabwe in April 1980 (whereas many African nations obtained independence in the 1960s).[16] After independence, Zimbabwe attained major social equity achievements, such that, by the end of the 1980s, it was a leader among African nations regarding access to health and education. (32) In October 1987, the constitution was amended to end the separate roll for white voters and to create an executive presidency to replace the whites whose reserved seats had been abolished. Robert Mugabe was the leader of the African nationalist group Zimbabwe African National Union (ZANU) and a key actor in the country's independence struggle. His Zimbabwean African National Union-Patriotic Front (ZANU-PF) Party has dominated the legislative and executive branches since independence in 1980.[16] In 1999, Zimbabwe began a period of major political and economic upheaval. Opposition to President Mugabe and the ZANU-PF had been growing rapidly, in part due to worsening economic and human rights conditions (see below). The opposition is currently led by the Movement for Democratic Change (MDC), established in September 1999.[16] In June 2000, parliamentary elections were marked by violence and claims of electoral irregularities and government intimidation of opposition supporters. However, the opposition MDC did capture 57 of 120 seats in the National Assembly. Presidential elections in March 2002, which President Mugabe won, were also marked by violence against opposition supporters, intimidation of the independent press and the judiciary, and other irregularities.[16] Governance Access to Information Zimbabwe's Access to Information and Protection of Privacy Act was passed in January 2002. The law established a media and information commission, appointed by the information ministry, with powers to license journalists¾all of whom must be Zimbabwean nationals, including correspondents for foreign newspapers¾and ensure that they possess appropriate "qualifications." The law prescribes penalties for "spreading rumors" and "false information," and defines a wide range of "protected information" to which reporting restrictions apply. The law also includes tight restrictions on foreign media. Another recent law, the Zimbabwe Public Order and Security Act, criminalizes criticism of the president and lays out sentences that include life imprisonment and death.[10] According to the Media Institute of Southern Africa, "Attempts to legalize repression of the media through the enactment of blatantly unconstitutional laws were the worst developments faced by Zimbabwean media during 2002." [11] Political Participation As mentioned above, the Zimbabwean presidential elections in 2002 were widely construed as unfair. In rural areas, 400,000 names were allegedly added to the register after the official closure of registration. Given significant discrepancies between the Electoral Supervisory Commission's results and the final count of the Registrar General, Commonwealth observers accused the ruling party of ballot box stuffing on a large scale. Nevertheless, SADC governments declared the outcome "legitimate."[10] Crime According to the U.N. Office on Drugs and Crime: "Paralleling a drastic drop in overall living standards and an uncertain political situation, serious crime levels in Zimbabwe appear to be on the increase. The number of reported homicides, for example, nearly doubled from 555 in 1996 to 1,045 in 2000. Criminal case clearance and conviction rates remain low. It appears the situation is ripe for an increase in substance abuse and drug trafficking as more and more marginalized citizens turn to drugs as a livelihood strategy."[12] Apart from the rise in reported homicides, there were also reported increases in serious assault, common assault, robbery, and vehicle hijacking during 1996-2000. Property crime also appears high and on the increase, with recorded cases of housebreaking rising from 53,524 in 1996 to 56,475 in 2000. All categories of organized crime have shown an increase between 1996 and 2000, but they have maintained their relative rank order, with drug trafficking (6,833 cases in 2000) first, followed by fraud and/or money laundering (5,060), vehicle thefts and hijackings (1,414), and armed robbery (513).(Zimbabwe Paper 2002).[12] Corruption Corruption is pervasive in Zimbabwe.[10] Zimbabwe is ranked at the top (most corrupt) of the SADC Afrobarometer ratings on public perception of the corruptibility of public officials.[12] According to Transparency International's Corruption Perceptions Index 2003, Zimbabwe's score has worsened since 2002 and now stands at 2.3 (perception of the degree of corruption as viewed by business people, academics, and risk analysts; ranges between 10 [highly clean] and 0 [highly corrupt].) [13] Transparency International Zimbabwe undertook a survey of 1,500 respondents in 2001, nearly 50 percent of whom blamed public and private sector corruption for the national economic crisis. In August 2001 the Human Rights Trust of Southern Africa in Zimbabwe published the results of a survey in which a representative sample of officials were asked about the extent of corruption within different professions. The survey found that politicians and police officers were perceived to be the most corrupt.[10] Currently, the government has no corruption prevention activities.[12] A major setback for civil society efforts to check official abuses in Zimbabwe was an amendment to the electoral law, which altered the status of domestic electoral monitors and curbed their powers. Under the new legislation, monitors during must be existing members of government services. Although Zimbabwe's supreme court declared the law unconstitutional, President Mugabe reinstated it. The legislation effectively rules out any possibility of civil society organizations mounting monitoring operations similar to that conducted by Transparency International Zimbabwe during the 2000 parliamentary elections.[10] Fast-Track Land Reform European colonizers displaced the majority of indigenous farming population onto unproductive lands called communal areas.[17] Historically, Zimbabwe's white minority owned most of the country's productive land through large-scale commercial farms, whereas the majority of the population lived on less-fertile land.[18] In 2000, about 4,500 large-scale commercial farmers still held 28 percent of the total land.[19] Many land restitution claims regarding forced removals under the white-minority government have never been addressed.[19] Both rural and urban areas continue to be spatially segregated along racial lines. Urban areas are characterized by separate, predominantly white, low-density neighborhoods and African high-density townships. In rural areas, there have historically been white commercial farms and African communal areas.[20] Many farm workers are descendants of Zambians, Malawians, or Mozambicans brought to Zimbabwe as indentured labor during the colonial era. They have little or no access to land on their own account; they are also vulnerable to arbitrary eviction from the accommodation that is tied to their employment by farm owners. Many poor and middle-income Africans in urban areas have viewed land as an alternative source of income and food security.[19] Most low- and middle-income urban Africans maintain dual residences: in the city where they work and in the rural/communal area where their families live. The need for land reform in Zimbabwe is widely acknowledged, even by representatives of the commercial farming sector.[19] In 2000, the government began a fast-track land redistribution program (under Section 8 of the Land Acquisition Act), which it maintains is meant to redress colonial era imbalances in land ownership.[21] Almost 95 percent of the country's commercial farmland is affected by this land reform program.[22] The fast-track process of resettlement is being carried out very rapidly, bypassing legal procedures. Consequently, there has been concern that title to land will be not secure. Some who wish to participate in resettlement have not done so because they lack the resources to plow the land and because there is little government support to assist new settlers.[19] Human Rights Watch posits that landless farm workers are the most disadvantaged group with regard to fast-track land reform. First, they have not been targeted to benefit from land reallocations. Second, many are of foreign descent and would have additional difficulty in accessing resettlement schemes. Finally, many have been laid off from paid work. HRW also believes that despite government commitments to addressing gender inequality in land distribution, women, whose rights to land under customary law are weak (see Gender section), have also failed to benefit proportionately from the fast-track process.[19] The Zimbabwean NGO Women Land and Lobby Group reports that between 1999 and 2001, only 16 percent of land was allocated to female-headed households. Concurrently, the number of female-headed households is increasing because of HIV/AIDS.[23] The process of allocating plots has also frequently discriminated against those believed to support opposition parties, and in some cases, those supervising the application process have required applicants to demonstrate support for the ZANUPF.[19] Moreover, there have been numerous reports of land going to President Mugabe's relatives and supporters.[14] Under the fast-track land reform, forced expulsion of white farmers and violence against both farmers and farm employees are occurring, often perpetrated by a loosely organized group (calling themselves war veterans).[18] The disruptions to commercial agriculture¾combined with severe drought¾have disrupted a significant portion of the commercial farm economy. Consequently, farm workers, settlers, youth brigades, and others are moving around the country. This population mobility can increase vulnerability to acquiring HIV. The Southern Africa AIDS Information Dissemination Service (SAfAIDS), for example, notes that fast-track land reform has been accompanied by large movements of people, regroupings of family units, and exposure to new sexual networks.[24] Uncertainty surrounding the farming sector has jeopardized the country's billion-dollar tea, coffee, sugar, flower, and vegetable export markets. There is also the risk of farmers' not making bond repayments, which would negatively affect the country's international credit rating.[22] These factors are contributing to the food crisis. Food Crisis Reports from aid agencies that have conducted missions in Zimbabwe concur that one of the key underlying factors contributing to the food crisis is HIV/AIDS. In August 2002, the U.N. reported that the causes of the food shortage were multifaceted and interconnected, primarily the result of: * inappropriate macroeconomic policy * fast-track land resettlement program * natural phenomena, e.g., drought * HIV/AIDS [43] At that time, the U.N. reported that over 6 million Zimbabweans¾half the population¾was at risk of starvation because of the worsening food shortage, estimated at 1.8 million metric tons. Health services were becoming increasingly difficult to access and basic drugs were in short supply.[43] In August 2002, the World Food Program (WFP) reported on the situation in Masvingo Province (which had the highest HIV prevalence among all provinces according to the 2000 ANC survey: 49.4 percent [2]). Communities that could afford to buy food still faced difficulties in accessing maize. The most vulnerable groups included child- and women-headed households, the elderly, and terminally ill people who cannot afford to buy food for themselves. Almost 95 percent of households visited lived on one meal only. Most had tea, sadza (porridge), wild fruits and roots, or vegetables as their only meal of the day. As supply of cattle currently exceeds demand, household assets such as cattle are not being sold, given low prices.[37] Preliminary indications from a joint August 2002 household economy assessment carried out by Zimbabwe's Ministry of Public Service and Social Welfare, Ministry of Lands, U.N. Relief and Recovery Unit, and Save the Children (U.K.) indicate that the food security situation is worsening. In Mashonaland East and West provinces, the mission noted that commercial farm workers, resettled farmers, and communal farmers were experiencing a severe shortage of food. Grain Marketing Board supplies are no longer sufficient to meet the increased demand.[37] A rapid assessment conducted in August 2002 by WFP and UNICEF in Tsholotsho District of Matabeleland North found that most respondents were relying exclusively on WFP-provided food in their community.[37] In September 2002, UNICEF reported that households already affected by HIV/AIDS, those that are poor, and/or those headed by women, children, or the elderly may have difficulty accessing food aid because of impaired mobility, ostracism, or stigma. Within households, the distribution of food may favor those perceived to be more healthy and productive; those who are HIV-positive may be given low priority. Water from unsafe sources is also more likely to be used, thereby increasing illness and death; its use also has a negative impact on infants who are bottle-fed.[44, 45] UNICEF also highlighted that vulnerable populations were adopting an array of survival strategies, including generating additional sources of food or income, migrating, dropping out of school, engaging in hazardous work, or exchanging sex for food or cash. For some young women, sex work provides the only way to support themselves and their families. UNICEF stressed that many of these strategies put young people¾especially women¾at high risk of acquiring HIV.[44, 45] Another factor involves the response to the food crisis, i.e., aid workers and truck drivers delivering food aid. UNICEF highlighted that some may offer sex to workers involved in transporting and distributing food aid to try and obtain preferential treatment in the distribution of supplies and services; women and children may be particularly vulnerable to sexual exploitation during humanitarian crises.[44, 45] A UN mission to Zimbabwe in January 2003 found that although food shortages were easing in other parts of southern Africa, the number of Zimbabweans at risk of starvation was rising.[15]: "Zimbabwe presents a substantially different set of challenges from those in other countries in the region. It does share some of the same problems with its neighbors - a high HIV/AIDS prevalence rate, erratic rainfall patterns, over -stressed social safety nets - but the current policy environment is preventing the international community from moving beyond pure emergency programming towards supporting longer-term development efforts. It is clear that the political situation has severely hampered the high-potential agricultural areas from operating at maximum capacity for this growing season, which will lead to a significant food deficit for the 2003/2004 marketing season. Impacts from the dire situation Zimbabwe will ripple through other southern African countries, amplifying any food security problems that those countries may experience."[16] "The situation in Zimbabwe is cause for serious concern, with over half the population currently in need of assistance. Along with continued political turbulence and economic decline, people in Zimbabwe will experience continuing food shortages in the coming year due to a combination of dry weather, lack of affordable food on the market, and a dramatically reduced amount of land under cultivation....The strong likelihood of severe food deficits in the 2003/2004 marketing season in Zimbabwe...represents an immediate threat to food security throughout the region and will need to be taken into account in recovery strategies."[16] In June 2003, the World Food Program and FAO reported that: "Zimbabwe faces acute food shortages, with some 5.5 million people in need of food aid. Food production in Zimbabwe has fallen by more than 50 percent, measured against a five-year average, due mostly to the current social, economic and political situation and the effects of drought...compounded by the marked reduction of the large-scale farm sector [a consequence of the ongoing land reform program], which produced only about one-tenth of their 1990s output. As a result, about half of the regional food deficit of 2.2 million mt is in Zimbabwe. The shortfall means that Zimbabwe will need to import almost 1.3 million mt of food, either commercially or through food aid, to meet the minimum food needs of its people."[17] Food Crisis and HIV/AIDS See also the Household Impact section below. The U.N. notes that drought is a normal part of the cycle in Zimbabwean agriculture and that poverty is the norm for the majority of Zimbabweans. Subsequently, households have an array of coping mechanisms.[43] Mutangadura notes that traditionally, strong family ties had been the "best social insurance against starvation" in Zimbabwe; she also outlines informal mechanisms beyond the extended family that have helped households cope.[95] Yet in 2002-03, because of HIV/AIDS, drought, fast-track land reform, and the deteriorating economic situation, most of these coping strategies are irrelevant, and the extended family safety net and local support networks are increasingly under pressure. For example, in the past, those with money could buy maize meal at the market when their stocks ran out. That is no longer possible; because of economic policies and fast-track land reform, there is very little maize meal on the market to satisfy the demand, and the price of other food commodities, such as rice, have become too expensive.[43] There is increasing reliance on dangerous or damaging survival strategies, many of which may contribute to increased AIDS-related illness and death and/or vulnerability to acquiring HIV. These include: * reduction in the number of meals: This is the first strategy employed when food becomes scarce. As mentioned, the World Food Program found that 95 percent of households in Masvingo Province had already reduced their food consumption to one meal per day. * sale of assets: large numbers of families are already selling their assets to buy food. * child labor: Poor families in both rural and urban areas are sending children to work as housemaids or cattle herders. In urban areas, children are used as vendors while in rural areas they may be used in piecework (where it can still be found). There are reports that some families have begun to exchange young girls for food. * sex work: The U.N. is finding that children currently involved in sex work often come from female- and child-headed households. * homelessness and near homelessness: In all urban areas, the number of squatters has increased tremendously. People displaced from rural areas and commercial farms move to high-density areas where they find low-cost or illegal accommodation. (See previous discussion of overcrowding.)[43] In late 2002, the Famine Early Warning Systems Network reported that: "The poverty that has accompanied Zimbabwe's economic crisis has driven many desperate rural people to prostitution, robbery and gold panning to survive. With maize and wheat being sold at eight times the government-set price, and oil, salt and rice prices escalating, income generating opportunities were diminishing for rural households. Cross border trading with neighbors Mozambique, Zambia and Botswana is also on the increase as households try to find any way they can to make ends meet. The demand for casual labor, which provided one of the few sources of cash, had declined in 90 percent of rural villages while 96 percent of villages reported a decrease in the flow of remittances from urban areas, researchers found. As a result, 80 percent of rural households reported eating wild foods they did not normally consume, which increased the risk of poisoning."[18] Human Rights Amnesty International has reported that state-sponsored militias are controlling the distribution of food supplies in rural areas and using food as a tool of repression against opposition Movement for Democratic Change supporters.[46] The U.N. also reports that in villages where government opposition is strong, residents are often denied state-provided food aid; many are surviving on wild berries and elephant dung.[47] In November 2002, the EU accused Zimbabwe's ruling party of using food aid as a political weapon against opposition supporters.[19] In December 2002, the Zimbabwe Human Rights NGO Forum released a report that cited increasing evidence that ZANU-PF was manipulating the distribution of food along political lines to gain and retain political support. [20] In 2002, Human Rights Watch reported that: The "fast track" land resettlement program implemented by the government of Zimbabwe over the last two years has led to serious human rights violations. Under the program, ruling party militias, often led by veterans of Zimbabwe's liberation war, have carried out serious acts of violence against farm owners, farm workers, and, using occupied farms as bases for attacks, against residents of surrounding areas. The police have done little to halt such violence, and in some cases are directly implicated in the abuses.[19] UNAIDS found a reported increase in rape of young girls living on farms that have been invaded following fast-track land reform.[38] Amnesty International has reported that state-sponsored militia are carrying out assaults and acts of sexual violence in reprisals against the political opposition.[46] Political violence has made public AIDS demonstration risky. The Men's Action Group in Zimbabwe reports that the main obstacles are: * Inability to organize activities with a politically mixed group, especially when participants know one another's political affiliation * Partisan politics: both in obstructing politically mixed gatherings and in claiming time of those who were once involved in mobilizing such gatherings * Lack of willingness on part of those are nonpartisan to be part of HIV/AIDS gatherings fearing victimization * Danger that mobilizations of people for HIV/AIDS activities may be perceived as political gatherings[83] Others have found that the effects of the political violence and economic hardship have had a negative impact on health and well-being through increased stress, little or no access to primary health care facilities, and a general sense of helplessness and hopelessness.[84] In March 2003, a strike to protest declining economic and political conditions and force the resignation of President Mugabe led to the arrest of over 400 citizens and a severe government backlash against political activity. The Movement for Democratic Change was prevented from undertaking normal campaign activities in the run-up to two parliamentary byelections, and party activists were harassed, detained, and beaten. In early June 2003, another protest stayaway was dismantled by state security forces in Harare.[21] In April 2003, Human Rights Watch criticized the lack of action by the UN Commission on Human Rights regarding alleged abuses in Zimbabwe.[22] In June 2003, HRW reported that human rights conditions in Zimbabwe had deteriorated dramatically over the last several months. HRW detailed the government's policy of repression and the harassment of opposition party members by state institutions and supporters of the ruling party, stressing that the direct involvement of ranking government officials and state security forces marks a new and worrisome trend in Zimbabwe's ongoing political crisis.[21] Not only have the army and police personnel failed to protect people from human rights abuses, but they are now carrying out abuses themselves. In addition, recent legislation has drastically curtailed citizens' rights to freedom of expression, assembly, and association (see above). The 2002 Public Order and Security Act bans public demonstrations.[21] HRW reports that the political violence prevalent in rural areas since 2000 has now become common in urban centers, and nonpolitical actors such as civic organizations and church leaders are increasingly targeted. Most of the recent violence has been committed by state security forces and youth militias.[21] In September 2003, Solidarity Peace Trust, chaired by Catholic Archbishop Pius Ncube of Bulawayo and Anglican Bishop Rubin Phillip of KwaZulu-Natal in South Africa, released a report on the Zimbabwe government's youth militia and its record of human right abuses: "Since it was set up in 2000, the youth militia, known locally as the "Green Bombers" from the color of their uniforms, have grown into one of the most commonly reported violators of human rights in Zimbabwe. Allegations of murder, torture, rape, arson, destruction of property and denial of food aid and health care to opposition members by the militia have been documented by Physicians for Human Rights, based in Denmark, and Amnesty International, among other rights groups."[23] "The National Youth Service, supposedly a voluntary training program for vocational skills, disaster management, patriotism and moral education, has become a paramilitary force for the ruling ZANU-PF. By the end of 2002, an estimated 9,000 youngsters had undergone formal militia training in five main camps, with up to 20,000 trained less formally in the districts."[23] "The government has repeatedly stated its intention to make youth service compulsory, with access to tertiary education and public sector positions linked to participation. In July the government announced plans for weapons training for the militia. Ministry of Defence Sydney Sekeramayi was quoted in the government press as saying that the National Youth Service could form a reserve force, under military command, to defend the nation."[23] "By announcing an 'intention' to train youth in weaponry, the minister had finally owned up to a 'de facto' government policy. It is now beyond doubt that the youth militia training is in fact paramilitary training under the guise of a national youth service. According to defected militia, it is often brutal and brutalizing."[23] "Children as young as 11 have reportedly been through the youth service program, whose stated catchment age is between 12 and 30 years. Such training could amount to creating child soldiers."{UN Office for the Coordination of Humanitarian Affairs, 2003 #974} "The militia has been deployed in force during local and national elections. They have been blatantly used by ZANU-PF as a campaign tool, being given impunity and implicit powers to mount roadblocks, disrupt MDC rallies and intimidate voters."[23] Population Mobility Part of Zimbabwe's colonial legacy involves gender-segregated, inter- and intracountry labor migration.[17] Moreover, excombatants who fought to attain independence returned to Zimbabwe during the 1980s; this movement may have facilitated HIV transmission.[12] Zimbabwe's paved roads link major urban, industrial, and mining centers, and rail lines tie it into an extensive central African railroad network.[18] There is high mobility among urban, rural, mining, and port areas, within Zimbabwe as well as within the southern Africa subregion.[24] Much of this movement is dominated by men. Migrant labor separates men from their families, places them in close proximity to "high-risk" sexual networks, and may result in their having an increased number of sexual contacts. Concurrently, it may also lead to women's reliance on sex to supplement their incomes while their male partners are away for long periods.[24] Food shortages, fast-track land reform, and the political and economic situation are also spurring population dislocation. Intercountry mobility is also high. For example, statistics released by Britain's Home Office indicated that more Zimbabweans sought asylum in Great Britain during 2002 than any other Africans. [25] Almost half the nurses trained in Zimbabwe are lost annually to better paying jobs in South Africa, the U.K., Australia, and the U.S.[7] Zimbabwe's 2000 ANC survey found that HIV prevalence was highest in commercial farming and mining areas, followed by border posts, growth points, other urban areas, and other rural areas.[1] In November 1999, Family Health International undertook research in four towns along the Durban-Lusaka highway, including Beitbridge. The findings epitomize the intersection of mobility, gender, sex work, and violence (see box 2). Moreover, some studies in southern African have found that female cross-border traders are particularly vulnerable to HIV infection. Many female traders report exchanging sex for transport. They also report rape and sexual harassment.[26, 27] The Tiripamwechete Study Group (comprising researchers from, inter alia, the University of Zimbabwe, University College London, and London School of Hygiene and Tropical Medicine) found that sex workers near mining and farming communities in Mashonaland West living close to paved roads reported a higher number of partners and clients, charged more per sex act, and had higher HIV prevalence than those women who lived in less accessible areas.[28] Researchers from Zimbabwe, the Netherlands, and U.K. examined the relationship between population mobility and HIV prevalence in rural Manicaland during 1998-2000. They found that men and women who moved into the study area in the last 10 years had a higher HIV prevalence than residents. Adjusting for number of lifetime partners, in-migration retained an association with HIV infection. Having an in-migrant spouse was associated with higher levels of HIV infection in men, but not in women.[29] Trafficking According to the U.S. State Department, Zimbabwe is a source country for men, women, and children trafficked to South Africa for farm labor and commercial sexual exploitation, as well as a transit country for persons trafficked from Asia, Malawi, Zambia, and Mozambique to South Africa. As a result of Zimbabwe's recent economic downturn and a growing number of HIV/AIDS orphans and child-headed households, internal trafficking of young women for commercial sexual exploitation is growing. The State Department reports that although the Government of Zimbabwe does not fully comply with the minimum standards for the elimination of trafficking, it is making significant efforts to do so despite severe resource constraints.[26] The UN notes that illegal entry into South Africa by Zimbabwean nationals is a longstanding phenomenon, and that the economic downturn has increased trafficking and smuggling of human beings.[12] Box 2. Beitbridge: HIV/STI Vulnerability in a Zimbabwean Border Town Zimbabwe's 2000 ANC survey found that HIV prevalence in Beitbridge was 41.4 percent. Beitbridge's stable population is 20,000. Each month, an estimated 5,000 to 10,000 truckers pass through the town. Beitbridge has many more female than male residents, reflecting the legacy of rural male migration to South Africa and female migration to the town. Women often come to Beitbridge hoping to enter or find work in South Africa, but many do not succeed. Stranded in the town without income, they are compelled to engage in sex work. Others rely on vending or cross-border trading for income. Since the decline in Zimbabwe's currency and the imposition of prohibitive tariffs, however, the import trade has declined dramatically. The town also has a higher proportion of informal traders than other Zimbabwean towns. At peak periods, 500 informal traders may cross the border daily. Some traders exchange sex with truckers for free rides and with customs officials for duty exemption. Without contacts at borders, however, women may face harassment. The sex industry in Beitbridge is the largest and most explicit in Zimbabwe. Many women work as vendors by day and sex workers by night. Female vendors as young as 14 are thus drawn into sex work. Young boy vendors describe them as chihure chesadza, or selling themselves for maize flour. The girls tell their families they work at night to sell produce to late-night bus passengers. Up to two-thirds of sex workers may be under age 18. In addition, female school enrollment has fallen steeply in Beitbridge. Sex workers in Beitbridge fall into three socioeconomic categories. Upper-income sex workers work from home, serving a smaller number of stable clients and boyfriends. Middle-income sex workers, who constitute the largest group, usually seek clients in bars. Lower-income sex workers seek clients on the highway or streets, sometimes exposing themselves to passing drivers. Sex workers come primarily from the arid southern provinces of Masvingo and Matabeleland South. Their rural origins provide them with support in Beitbridge because they can usually stay with people from their home areas until they are settled. Condoms are relatively accessible, and sex workers are willing to use them but unable to insist on their use. Those who do so risk violence. Sex workers are aware that many truckers have STIs, but say they have no choice: lacking their clients' willingness to use condoms, the sex workers accept that they will contract STIs and use their earnings to have them treated. Many sex workers prefer to use traditional healers, because of the greater discretion and better interpersonal quality of the service. Attitudes towards AIDS are fatalistic. As elsewhere, truckers are preferred clients, especially South African drivers. Smugglers, with their disposable income, are also popular. Police and customs officers often do not pay, but use coercion to elicit free sex. The average trucker is about 40 years old and spends up to 20 days each month away from home. Most reported that they have wives, girlfriends, and sex-worker partners, thus providing a bridge for widespread STI and HIV transmission. Border clearance is lengthy, forcing truckers to make stops of up to 10 days while paper work is processed. Most transport companies provide no accommodation, expecting truckers to sleep in their trucks at borders. Others give drivers a fixed allowance, which they are motivated to save. One trucker noted that a night with a sex worker costs less than half the price of a hotel room. Truckers receive money for road toll fees, which they can sometimes avoid or minimize, increasing their disposable income. Sources: AIDS & TB Program, Zimbabwean Ministry of Health and Child Welfare (with support from Zimbabwe-CDC AIDS Program). "National Survey of HIV Prevalence Among Women at Antenatal Clinics in Zimbabwe, 2000." PowerPoint presentation, 2001; Family Health International. Corridors of Hope in Southern Africa: HIV Prevention Needs and Opportunities in Four Border Towns. Arlington, Va.: 2000 Economy At independence, the Zimbabwean economy was more industrialized than most in Africa, with a diversified productive base, well-developed infrastructure, and a relatively sophisticated financial sector.[18] Zimbabwe's economy relies heavily on agricultural crops. Corn (maize) is the largest and staple crop. Tobacco is the largest export crop followed by cotton. Related manufacturing industries such as textiles and sugar production are also important. Mining, primarily gold, is also a major activity. Zimbabwe has an important percentage of the world's known reserves of chromite; other commercial mineral deposits include coal, asbestos, copper, nickel, and iron ore. Major growth industries include steel and steel products, heavy equipment, transportation equipment, ferrochrome, textiles, and food processing.[16, 18] According to the Reserve Bank of Zimbabwe, at the end of 2001, agricultural products account for 44 percent of total merchandise exports, with mining and manufacturing contributing 24 and 32 percent, respectively, to national exports.[30] In the early 1970s, the economy experienced a modest boom. Real per capita earnings for blacks and whites reached record highs, although the disparity in incomes between blacks and whites remained, with blacks earning only about one-tenth as much as whites. However, after 1975, the economy was undermined by the cumulative effects of sanctions, declining earnings from commodity exports, worsening guerilla conflict, and increasing white emigration.[16] Following independence, Zimbabwe experienced an economic recovery. Real growth for 1980-81 exceeded 20 percent. However, depressed foreign demand for the country's mineral exports and drought decreased the growth rate during 1982-84. In 1985, because of a 30 percent increase in agricultural production, the economy rebounded. However, given, inter alia, drought and a foreign-exchange crisis, it fell again in 1986. Growth in the late 1980s averaged 4.5 percent.[16] In 1991, Zimbabwe undertook an IMF-guided structural adjustment program. During the 1990s. poverty in Zimbabwe increased significantly. In the mid-1990s, for example, over 60 percent of Zimbabwean households fell below the national poverty line. The World Bank attributes this increase in poverty to the poor performance of the economy and to flaws in the structural adjustment program. Under structural adjustment, for example, budgetary cutbacks reduced the availability of public sector jobs. For those with formal sector jobs, their salaries lagged behind inflation, and formal sector employment no longer prevented people from being poor.[31] Since 1999, the country has been experiencing a socioeconomic crisis, resulting from poor economic policies, falling prices for key exports, a decrease in farm outputs following farm invasions and expulsion of white farmers and farm workers, increased deficit, drought, and loss of investor confidence due to uncertainty about domestic policies. Economic deterioration was also exacerbated by military involvement in the Democratic Republic of Congo from 1999 to 2002.[18] In 2000, Zimbabwe's gross national income per capita was US$460.[32] In 2001, GNI per capita was US$480; GDP growth during 2000-01 contracted by 8.4 percent.[27] Given the current political and economic situation, some donors have suspended funding, citing violence and abrogation of the rule of law. Others have reduced their operations to activities in social sectors (including HIV/AIDS), social protection, and human rights/governance programs. Increased donor support is contingent upon progress in orderly land reform and macroeconomic stabilization. However, a large number of international NGOs remain active with community-level programs.[18] In 2001, overall donor assistance to Zimbabwe was US$37.5 million, compare to US$219 million in 1999.[41] The World Bank suspended disbursements to Zimbabwe on May 15, 2000, due to overdue service payments.[18] On June 13, 2002, the IMF adopted a declaration of noncooperation regarding Zimbabwe's overdue financial obligations to the fund and suspended the provision of technical assistance to the country.[42] Inflation In August 2002, Zimbabwe's Central Statistics Office reported that inflation had reached 123.5 percent. The increase was due largely to rises in the prices of food and clothing.[36] During the same month, Zimbabwe's Food Security Trends Report found that that the prices of beef, milk, bread, and cooking oil have been increasing continuously and dramatically. This scenario is negatively affecting vulnerable populations' ability to purchase food.[37] Given the drought, fast-track land reform, and economic and political crises, basic food items remain scarce.[36] And poor economic management and low foreign currency reserves have led to serious fuel shortages.[16] Among other effects, the fuel shortages are affecting the ability of AIDS organizations to reach families with needed support, counseling, food, and other supplies.[38] In July 2003, the U.N. reported that inflation had reached 364 percent and is forecast to reach 500 percent by the end of 2003.[7] Unemployment In 1997, Zimbabwe's unemployment rate was estimated at around 30 percent by the government and at 44 percent by the Zimbabwe Congress of Trade Unions. There has been a declining trend in formal sector employment growth since independence. Among women, 55 percent were without paid employment in 1997.[39] (More recent, reliable unemployment figures are unavailable. Collection and analysis of unemployment data in developing countries are difficult [see UNDP's Human Development Report 2002 for a related discussion.[40]] Zimbabwe's political, economic, and food crises may be rendering such data collection even more difficult.) Widespread poverty, high rates of unemployment, and generally low returns from informal sector income-generating activities have been associated with high-risk sexual behavior and the spread of HIV.[25] Declining Human Development One method of tracking human development in Zimbabwe is to analyze trends in its Human Development Index. The HDI was created by UNDP to measures average achievements in life expectancy at birth; adult literacy and secondary, and tertiary gross enrollment ratios; and GDP per capita. An HDI of 0.800 or above = high human development; 0.500 - 0.799 = medium human development; less than 0.500 = low human development. In 2001, Zimbabwe's HDI was 0.496, placing it among "low-human development" countries and ranking it 145 of 175 countries for UNDP calculated an HDI.[28] Zimbabwe's HDI has been declining since the mid-1980s. Between 1975 and 1985, the HDI rose from 0.544 to 0.626, a reflection of, inter alia, the government's concrete efforts to increase educational attainment and health outcomes. From 1985 onward, however, the HDI has been falling, mirroring the country's socioeconomic decline. In 1990, the HDI was 0.614, falling to 0.567 in 1995 and to 0.551 in 2000. In 2001, it fell still farther, to 0.496. In 2000, Zimbabwe's HDI value was ranked 128 out of 173 countries; by 2001, it had fallen to 145 of 175 countries.[40][28] This decline doubtlessly reflects the enormous impact of AIDS mortality (see Impact section), which drastically reduced the life expectancy component of the HDI value. A critical indicator of the well-being of children is the under-five mortality rate (probability of dying between birth and exactly five years of age, expressed per 1,000 live births). According to UNICEF, Zimbabwe's under-five mortality rate in 2001 was 123. This figure is below that for all least-developed countries (157) as well as the sub-Saharan African region (173); however, it is the world's 38th highest (of 193 countries). [29] Another critical human development indicator is the maternal mortality ratio (MMR), the number of deaths to women per 100,000 live births that result from conditions related to pregnancy, delivery, and related complications. According to UNFPA, Zimbabwe's MMR has increased, from 610 in 2001 [30] to 654 in 20002.[31] Health System In 2000, public expenditures on health represented 3.1 percent of GDP, whereas private health expenditures represented 3.6 percent of GDP.[28] As previously mentioned, after independence, the Government of Zimbabwe made great strides in improving access to social services.[48] By the end of the 1980s, the country was one of Africa's leaders in terms of overall access to health and education.[32] However, in 2001, the U.N. reported that: Zimbabwe's crumbling health sector, with its under-funded and overcrowded hospitals and crammed mortuaries, is an eloquent testimony to the more far-reaching decline of a nation that a decade ago was a showcase of social service provision. At independence in 1980, along with promises of education and housing for all, the then avowedly socialist government of President Robert Mugabe made universal health by the year 2000 its pledge to its people.[49] Some examples of how the current crises are affecting health care delivery: In the past, 80 percent of rural Zimbabweans lived within 5 km of a rural health center; however, access declined in 2002 as a result of fast-track land reform, which has led to new settlements in areas with no clinics. [33] In 2003, WHO reported that poor infrastructure in new settlements impeded access to TB treatment.[33] Zimbabwe's public health sector has been severely affected by an array of problems, including drug shortages and the exodus of skilled medical personnel.[34] In July 2003, the U.N. reported on the serious shortage of professional health care staff in Zimbabwe, including nurses, doctors, and pharmacists. As mentioned above, almost half the nurses trained in Zimbabwe seek better paying jobs in South Africa, the U.K., Australia, and the U.S. [7] In September 2003, Bulawayo City Council's directorate of health services announced that 20 health clinics, as well as its referral hospital, had been severely affected by the exodus of qualified health staff and were operating with only half the required staff complement. [35] Zimbabwe's parliament has acknowledged the impact of staff shortages on the country's health centers. However, Health Minister David Parirenyatwa has argued that the country's economic crisis renders it difficult for the government to invest in health. He concedes that the situation is unlikely to improve in the near future that the hemorrhage of skilled staff abroad will continue.[7] Zimbabwe imports most of its medication requirements, and the shortage of foreign currency in the mainstream economy has forced suppliers to source foreign currency in the parallel market. In October 2003, medical drug suppliers and pharmacies raised prices by over 1,000 percent, citing an increase by the same margin in import costs. A recent survey of pharmacies in Bulawayo found that the price of paracetemol rose from Z$110 in August 2003 to Z$1,100 by October 2003.[34] Tuberculosis WHO ranks Zimbabwe a "high TB burden" country. In 2001, it had the world's 17th highest burden of TB in terms of new cases. In 2001, the TB incidence rate was 628 cases per 100,000 population (an increase from 584 cases per 100,000 population in 2000[36]) . An estimated 67 percent of adult (ages 15-49) TB cases are HIV-positive, and an estimated 1.9 percent of new cases are multidrug-resistant. [33] The DOTS strategy was adopted in 1997.[36]) The number of cases notified continues to increase, probably in response to the high rates of HIV infection. The case detection rate under DOTS has changed little since 1998 and was estimated at 47 percent for 2001. Given poor laboratory facilities, smear microscopy results are not available for 20 percent of cases notified. Only 69 percent of patients registered in 2000 were successfully treated, a decline from 73 percent in 1999. The death rate was high (12 percent), probably the result of a combination of HIV coinfection and late diagnosis.[33] A draft strategic plan for DOTS expansion exists but has yet to be approved by the government. Decentralization has been accepted in principle, and provinces are managing and financing TB programs, although financing is insufficient. An acting TB manager was recruited, and provincial and district TB coordinators are in place, but there is still no national TB program coordinator and no staff to support the acting national program manager at the national level.[33] Major constraints to achieving TB targets include * weak political commitment to TB control * lack of TB manager and other staff * funding gaps * low access to treatment because of poor infrastructure in new settlements * limited community involvement in TB control[33] Sexual and Reproductive Health According to UNFPA, Zimbabwe's past achievements in sexual & reproductive health have eroded and the reproductive health status of Zimbabweans has deteriorated. The country's contraceptive prevalence rates¾though much higher than the regional averages¾have stagnated.[37] The MMR has increased, from 610 in 2001 [30] to 654. [31] Family planning services have been available in Zimbabwe since 1953. After independence in 1980, the family planning association was dismantled. In 1985, the ruling party congress resolved to promote family planning not just for child spacing and welfare reasons but to limit family size. In the same year, the Child Spacing and Family Planning Council was renamed the Zimbabwe National Family Planning Council (ZNFPC) which became a state agency. At one point, the ZNFPC had 34 clinics and 800 trained community-based distribution agents covering about 30 percent of the rural population.[50] Funding for ZNFPC by central government has declined over the last five years; consequently, ZNFPC has reduced the number of clinics it operates as well as the number of community-based distributors it employs. Responsibility for most rural family planning services has devolved to rural district councils, but without any concomitant or specific funding for reproductive health provided.[4] Sexually Transmitted Infections It is unclear whether the reported number of STIs is decreasing. Decosas and Padian cite data that demonstrate that the number of reported STIs is falling, though not rapidly.[17] However, recent data from Harare find that a 2.4 percent increase in the number of STIs reported by clinics, from 48,026 in 2000 to 49,166 in 2001.[53] It appears that viral, rather than bacterial, STIs, are driving the epidemic. For example, in a national survey conducted in 32 rural growth point villages, researchers from the University of Zimbabwe and Battelle Memorial Research Institutes of the U.S. found that rates of gonorrhea, chlamydia, and syphilis were low (1 to 2 percent), whereas prevalence of herpes simplex virus-2 was 44 percent. Prevalence of HIV was 26 percent (N = 1,601; female mean age = 23; male mean age = 22).[54] The Tiripamwechete Study Group recruited 363 sex workers from two mines and five farms in rural Mashonaland West. The prevalence of bacterial STIs was low, but herpes simplex virus-2 prevalence was 80.8 percent (95% CI 76.7 - 84.0). HIV prevalence was 55.7 percent (95% CI 50.6 - 60.9).[28] Awareness and Knowledge of HIV/AIDS Knowledge of HIV/AIDS is high in Zimbabwe. In the 1999 Zimbabwe Demographic and Health Survey, 96.5 percent of women and 99.1 percent of men had heard of HIV or AIDS. However, 16.8 percent of women and 7.4 percent of men could not cite a way to avoid HIV/AIDS; among rural women and men, these figures were 21.4 and 9.7 percent, respectively. There was also wide variation among provinces. (The methodology used in the 1999 ZDHS to estimate knowledge of HIV/AIDS was relatively new and rendered comparisons with the 1994 ZDHS difficult.)[7] When asked whether a "healthy looking person can have the AIDS virus," 76 percent of women and 85 percent of men correctly responded yes. The women and men least likely to respond correctly tended to be young, sexually inexperienced, rural, and less educated. Women in all rural provinces were uniformly less knowledgeable on this issue than women in Harare and Bulawayo.[7] Despite almost universal knowledge of HIV/AIDS, research in, for example, Manicaland, has found differences in the way male and female respondents construct their HIV risk. Female respondents still perceived their own personal protection as secondary to their role as a wife, service-provider, or girlfriend. Their vulnerability to HIV acquisition was thus related more to their social roles than lack of awareness or condom availability.[55] Research was presented in Barcelona in July 2002 on a rapid assessment formative study conducted in 32 rural growth point villages in Zimbabwe; this assessment was undertaken to prepare for an international trial of the Community Popular Opinion Leader (CPOL) intervention. Knowledge about transmission of HIV and condoms affording protection was high. Individuals believed that access to condoms was adequate, yet few used condoms, especially with main partners. Condom use was perceived to prevent infections but also seen as a "not nice (sweet) thing." Respondents reported that married couples who "know each other" do not need condoms, and delay of sex is difficult when "one feels ready for sex." They also reported that it is difficult to "control one's feelings" regarding sex. They viewed monogamy as something that cannot be discussed with partners because of trust issues.[56] Stigma and Discrimination Despite high levels of awareness of HIV/AIDS, it remains highly stigmatized. Consequently, there is tremendous fear around being tested for HIV. Over 90 percent of those infected are unaware of their HIV status.[57] Traditionally, sickness and disease were considered punishment by one's ancestors for immorality and unfaithfulness.[58] People with HIV are perceived as having done something wrong, something of which they and their families should be ashamed. Zimbabwe's Tsungirirai AIDS Service Organization reports that "HIV/AIDS is a disease of shame. People with HIV are shunned and treated with contempt and described as immoral."[59] Even in recent years, when a sizable number of PWHA are open about their condition, stigma remains and tends to prevent PWHA from receiving adequate care and treatment. A case study of a 22-year old HIV-positive woman participating in a perinatal HIV transmission trial in Zimbabwe highlighted that HIV-positive women may experience considerable levels of psychological morbidity. Numerous stress factors include experience of discrimination upon disclosure of HIV status and inadequate support networks.[60] The Eden Home Health Center has reported on AIDS-related stigma and discrimination in communal farming communities and found that community leaders, chiefs, headmen, and others are making discriminatory statements during their graveside messages at funerals. The center stresses the need for HIV/AIDS education (in local languages) targeting traditional leaders in remote areas.[61] Sexual Behavior Sexual behaviors driving the HIV/AIDS epidemic in Zimbabwe are influenced by a complex interplay of social, economic, and cultural factors. For women, casual sex before marriage is not socially sanctioned. It is, however, expected that men will have had several sexual partners before marriage. [17] Decosas and Padian note that in most Zimbabwean studies, 30 to 50 percent of men report having several concurrent sex partners, whereas this figure is less than 5 percent for women. Studies from rural areas have found that there is a large degree of tolerance for men's having concurrent sex partners, but none for women. Because of these social norms, Decosas and Padian posit that the number of sex partners among women may be underreported.[17] Data from Zimbabwe's DHSs find that sexual abstinence is much more commonly reported for young women than for young men, and underreporting by women (and possible overreporting by men) may partly account for these patterns.[1] The Shona are the predominant ethnic group in Zimbabwe. It is culturally acceptable for Shona men to have more than one wife or girlfriend, although women are expected to be monogamous with their husbands. And given that children are highly valued in Shona society, men are unlikely to use condoms with their wives.[62] Moreover, prostitutes and casual partners are considered "dirty," but wives are "clean" and thus a condom is not necessary with a wife.[62] Some ethnic groups in Zimbabwe encourage sexual abstinence between a husband and wife for several weeks before and after the birth of a child; this is perceived by some as socially sanctioned infidelity (on the part of the husband). [62] Open discussion about sex is difficult. Traditionally, couples in Zimbabwe communicated about sex and sexuality through third parties such as uncles and aunts.[63] Decosas and Padian note that such communication is now rare and that most adolescents learn about sex from peers or the media.[17] Age at First Sex According to the 1999 ZDHS, among women, the median age at first sex is 18.7; among men, this figure is 19.7.[7] Zaba et al. note that in Zimbabwe, men and women consistently report a later initiation of sex than respondents in other southern African countries; they posit that this may be because of reporting bias resulting from denial of any kind of sexual activity by adolescents.[64] The Regai Dzive Shiri Study Group (comprising researchers from, inter alia, the University of Zimbabwe, University College London, and London School of Hygiene and Tropical Medicine) has found that in rural Zimbabwe there is poor correlation between biological evidence of sexual experience and questionnaire responses, due to concerns about confidentiality.[65] (See box 2.) And in a study by Chinake et al. cited below, male and female respondents reported much lower ages of sexual debut. Condom Use The 1999 ZDHS found that among women who had sex in the past year, 4.3 percent used a condom during last sexual intercourse with a spouse or cohabiting partner; 42 percent used a condom during last sex with a non-cohabiting partner. Among men, these figures were 6.5 and 70.2 percent, respectively. Urban men and women were more likely to use a condom at last sex with any partner than their rural counterparts. The urban-rural differential was particularly strong for condom use with non-cohabiting partners; women in urban areas were 50 percent more likely to use a condom during sex with non-cohabiting partners than women in rural areas.[7] A significant decline in condom use within marriage occurred during the latter half of the 1990s. A May 2002 report from Zimbabwe's National AIDS Council and several of its partners posit that this decline may be explained by the increasing level of stigma associated with condoms in Zimbabwe and the subsequent difficulty, for both men and women, in negotiating their use.[1] The most widely mentioned specific ways of avoiding HIV/AIDS by both men and women are condom use and limiting sexual activity to one partner. However, the 1999 ZDHS found that 28.2 percent of women and 16.7 of men could not cite a source where they could obtain a male condom. Among those ages 15 to 19, 50 percent of women and 31.7 percent of men did not know where to obtain a condom. Between 1994 and 1999, knowledge of a source for condoms improved in all age groups except 15-19, within which it worsened.[7] A May 2002 National AIDS Council report examined the discrepancy between number of condoms distributed (about 55 million at the time of the 1999 DHS) and those used (an estimated 11.3 million). Possible explanations include: * overstatement of the number of condoms distributed * understatement of condom use * build-up of inventories at facility level * build-up of personal inventories * wastage and loss; most condoms in Zimbabwe are distributed free of charge and are thus considered more likely to go unused or wasted[1] Researchers from SAfAIDS, Population Council, University of Zimbabwe Medical School, WHO, and the Women and AIDS Support Network Harare investigated whether female condoms are acceptable to sex workers in Harare and whether improved access to male and female condoms increases the proportion of protected sex episodes with clients and boyfriends. Sex workers were randomized to receive either male and female condoms (group A, n = 99) or male condoms only (group B, n = 50) and were followed prospectively for about 3 months each. The researchers found a considerable burden of HIV and STIs in the cohort at enrollment (86 percent tested positive for HIV and 34 percent had at least one STI). Consistent male condom use with clients increased from 0 to 52 percent in group A and from 0 to 82 percent in group B between enrollment and first followup two weeks later and remained high throughout the study. Few women in group A reported using female condoms with clients consistently (3 to 9 percent), and use of either condom was less common with boyfriends than with clients throughout the study (8 to 39 percent for different study groups, visits, and types of condom). Unprotected sex occurred, as evidenced by an STI incidence of 16 episodes per 100 woman-months of followup. Although survey data indicated high self-reported acceptability of female condoms, focus group discussions revealed that a main obstacle to female condom use was client distrust of unfamiliar methods.[38] Researchers from the University of Zimbabwe sought to identify condom negotiation strategies used by HIV-seronegative Zimbabwean women after a prevention intervention. Study participants were age 18 and above, sexually active with men at least 10 times during the previous three months, using contraception or otherwise not able to become pregnant, and willing to be tested for HIV and receive the result. Women were excluded if they reported condom use at more than 50 percent of all sexual episodes in the previous three months; were HIV-seropositive; or were unable to speak English or Shona. Altogether, 359 women were eligible for the study and 339 were enrolled. Of these, 260 women completed all four study visits, yielding a retention rate of 77 percent. The average age of participants was 29 years. Most participants (96 percent) were married and had at least one child (99 percent). The intervention achieved high levels of self-reported consistent condom use, increasing from zero pre-HIV test to 42 percent posttest and intervention to 63 percent at booster intervention and 55 percent at the two month followup. Six strategies were identified and used by at least 10 percent of women. Forty-seven percent of the participants used a strategy of remarking that condoms prevent HIV/AIDS. Twenty-five percent mentioned participation in the study. Another, alluding to one's own negative HIV test result, was used by 15 percent of respondents. Strategies involving efforts to exonerate their partners of blame were used by 12 percent. A fifth strategy, reported by 11 percent of women, based the request on the high prevalence of HIV/AIDS in their community. Finally, 11 percent of women mentioned their partner's earlier infidelities or their own lack of trust in him. Of the six negotiation strategies identified, only one, mentioning HIV prevalence in the community, was significantly associated with consistent condom use two months after the intervention ended.[39] Youth Zimbabwe has a very young population; 40 percent of Zimbabweans are under age 15.[30] In 2000, the median age in the country was 17.5.[6] During 2002, the U.S.-based Center for Reproductive Law and Policy (CRLP) and the Zimbabwe-based Child and Law Foundation (CLF) issued a report entitled State of Denial: Adolescent Reproductive Rights in Zimbabwe. The report is based on interviews conducted with over 800 Zimbabwean adolescents, parents, family members, government officials, and service providers. The report contends that through contradictory laws and policies, the Zimbabwean government is denying adolescents their human right to access the services and information to protect themselves from unwanted pregnancy and HIV/STIs. Consequently, adolescents' rights are being violated and they are vulnerable to dangerous, potentially life-threatening health risks.[40] The report posits that the Zimbabwean government has failed to adopt laws and policies that ensure young people the right to access the information and methods to protect themselves from unwanted pregnancy and HIV/STIs ("dual protection"). The Zimbabwean government has made parents the gatekeepers for their children's access to reproductive health services, and as a result, health workers have tended to turn away adolescents seeking dual protection information and services. In addition, young people tend to lack confidence that health workers will keep their requests confidential.[40] A 2003 report from the Population Council states that: "Clearly, a conflict is apparent in how condom use and abstinence are promoted in government and civic environments in Zimbabwe. These opposing strategies are part of an ideological battle in which morality, religion, cultural identity, and Western influences all play a role."[41]: "The Ministry of Health and Child Welfare's Reproductive Health Guidelines and Policy (1998) states that the Ministry aims to address issues related to adolescent sexuality by developing youth-friendly services. This policy identifies abstinence rather than condom use as a risk-reduction strategy among young unmarried people. A similar message is evident in the National Youth Policy (1999) of the Ministry of Youth, Gender, and Employment Creation. In both of these documents, what is striking is not the advocacy for abstinence per se, but rather the absence of any promotion of condom use as an alternative and complementary strategy for HIV prevention. As in other government policy documents, the unwillingness to accept that sex occurs among young unmarried people and that they need effective protection is clear."[41] "The National Population Policy, developed with support from UNFPA, provides general guidelines for promoting adolescents' reproductive health through attitudinal change, creation of gender equity, and removal of obstacles. Although this policy includes abstinence as part of responsible sexual behavior for young people, condom use is not mentioned. No practical details are provided about how to meet the goals of promoting sexual health; the burden for defining responsible sexual behavior among young people is left to health-care service providers.[41] "The National AIDS Policy aims to coordinate all AIDS-prevention and reproductive and sexual health activities in Zimbabwe. This policy emphasizes abstinence among young people as the sole strategy for HIV prevention. The policy is moralistic in tone and advocates long-term abstinent relationships among young people. This advice may sound irrelevant to young people who are sexually active and who recognize the need to protect themselves."[41] The Regai Dzive Shiri Study Group (comprising researchers from, inter alia, the University of Zimbabwe, University London, and London School of Hygiene and Tropical Medicine) highlighted that in Zimbabwe, adolescents are culturally deemed children and have few rights. The group found that in rural Masvingo, adolescents' access to reproductive health services was poor, partly because nurses were reluctant to provide such services. This reluctance stemmed from a lack of clarity in Zimbabwean legislation and policies: the law defines sex below age 16 as rape, but policy permits provision of contraception to anyone who is sexually active with no age limitations specified. Nurses fear that provision of contraception will be perceived as condoning of adolescent sexual activity. Though adolescents interviewed praised nurses' clinical skills, they found that service delivery was judgmental and confidentiality and privacy lacking.[42] Using a sample of 2,250 ever-married women age 15-49 years selected from 6,828 households in rural and urban Zimbabwe, Moyo found that reporting a boyfriend, compared to a husband, as their last sex partner was the strongest independent predictor of condom use at last sex.. Being separated or divorced (OR=2.67; 95% CI 1.55-4.62), reporting secondary education and above (OR=1.93; 95% CI 1.31-2.85) and self-perceived high risk for HIV infection (OR=1.5; 95% CI 1.02-2.21) were also significant independent predictors of condom use at last sex. Women who perceived themselves to be at high risk for HIV infection were younger, less educated, unemployed or employed in informal or agriculture sectors, currently married, and more likely to report husband as last sex partner (p<0.05). Moyo concluded that women of childbearing age in Zimbabwe are likely to report condom use for STI prevention, contraception, or both if they perceive themselves at high risk of infection with HIV. His data suggest that health education enhancing the perception of HIV risk with husbands and primary partners will promote condom use for many women. Further research is needed to explore how to involve husbands and steady partners.[66] The Harare Youth Forum also conducted interviews and focus group discussions conducted men and women ages 15 and 25 in the western district of Harare. It found that 43 percent of respondents reported having an STI in the past 18 months and 7 percent believed that they could be HIV-positive. Although condoms were believed to provide protection against STIs by most (97 percent), only 19 percent reported having used a condom. Of them, half used condoms to prevent pregnancy. Focus group discussions revealed that notion of "manhood" encouraged multiple sexual partners and that condoms were perceived to affect male potency. Discussion of sex was reported as difficult.[67] Alcohol and Drug Use Consumption of and demand for harmful substances still center on alcohol and cannabis. Cultivation of illicit substances in Zimbabwe is confined to small-scale growers of cannabis in the west (e.g., Binga), east (e.g., Ruangwe, Nyanga, Chipinge and Chiredzi), and northeast (e.g., Mtolo). According to police estimates, however, this production satisfies only a small proportion of local consumption, as the bulk of cannabis consumed in Zimbabwe is imported from neighboring countries. There are reports that certain inhalants and over-the-counter stimulants are being abused. Anecdotal reports indicate an increase in the abuse of cannabis, cocaine, and ecstasy. Trafficking consists largely of cannabis being smuggled into the country or harder drugs being transshipped via Zimbabwe en route to South Africa.[12] Research conducted by the University of Zimbabwe's Medical School found that in rural areas, alcohol consumption plays an important part in community life as it is associated with ceremonies and rituals. It is also seen as an essential recreational activity, especially for some men. A variety of alcoholic beverages are consumed, but beer is the most frequent. Far more men than women drink alcohol, particularly in drinking establishments. For many, the purpose of drinking is to get drunk, and there is a high frequency of drunkenness among those who indicate they drink. Drinking is associated with casual and transactional sex.[68] The SAfAIDS-University of California San Francisco-San Francisco Department of Public Health-University of Zimbabwe research previously mentioned found that: * Nightclubs and bottle stores were highly valued by men and women under 21, but had potential to increase HIV transmission. * Youth commonly reported meeting sexual partners at drinking establishments, highlighting the role of alcohol in sexual disinhibition. * These drinking venues offer or enhance opportunities for engaging in sex for money, gifts, or alcohol. * The level of "always using condoms" with casual partners reported was high (94 percent among women, 75 percent among men) suggesting that HIV/AIDS awareness was high in the sample and that young people are reporting high levels of condom use with perceived riskier partners. * Self-reported condom efficacy, even when under the influence of alcohol, is also high. Participants in the study may have been overstating their ability to negotiate condom use and their actual use of condoms. Despite this potential bias, the data substantiate that condom use between young peers is lowest in steady relationships where there is little knowledge of the HIV status of one's partner.[69] In a related study, HIV testing and a behavioral survey were conducted with a cross-sectional sample of 324 men recruited at beerhalls in Harare to examine the relationship among alcohol use, high-risk sexual behavior, and HIV infection and evaluate the feasibility of using beerhalls as for male-centered HIV prevention activities: * Prevalence of HIV infection was 30 percent; prevalence of recent seroconversion was 3.4 percent. * Thirty-one percent of men reported having sex while intoxicated in the previous six months, a finding strongly associated with recent HIV seroconversion, unprotected sex with casual partners, and paying for sex.[70] Gender Shona and Ndebele societies are patriarchal and patrilineal. They impose strict controls on female sexual behavior, whereas the attitude toward male sexual behavior is more lenient.[43] Before independence, women were socially and legally minors, and their rights were subordinate to men (fathers, husbands, or brothers). Their active participation in the country's liberation struggle for independence demonstrated their capacity to fight against oppression. After Zimbabwe's independence in 1980, women struggled to liberate themselves socially, politically, and economically by lobbying the government through various women's organizations. Their major triumph was the passing of the Legal Age of Majority Act (1982), which made 18 the age of majority for both women and men.[71] However, Zimbabwe's constitution permits discrimination against women on the basis of customary law, under which women are designated minors.[23] Zimbabwean women become infected with HIV at younger ages than men for both biological and behavioral reasons (though the lifetime risk of acquiring HIV is about equal for both sexes [17]). A population-based survey of 10,000 participants in Manicaland between 1998 and 2000 found that HIV prevalence peaked among women at ages 23 to 25 and among men at ages 30 to 34. Women ages 17 to 24 were four time more likely to be HIV-positive than men in the same age group.[17] The U.S. Bureau of the Census projects that by 2020, there will be more men than women in each of the five-year-age cohorts between the ages of 15 and 44, which may push men to seek partners in increasingly younger age cohorts. This factor in turn may increase HIV infection rates among younger women.[8] Also, fear of HIV drives some men to seek very young partners believing that these younger girls are more likely to be uninfected.[72] Finally, men's sexual "buying power" is low at young ages, but increases as they enter the labor force and acquire greater socioeconomic status; most of this "buying power" is directed at women who are economically vulnerable, and most of these women are relatively young.[14] High male-to-female transmissibility of HIV is considered likely to play a significant role. Age mixing is another crucial factor (discussed in depth below). Many young girls have sex with older men, who have been sexually active for many years and are thus more likely to be infected. Many women are unable to insist on condom use and negotiate the timing of sex and the conditions under which it occurs. Even when women know that their husbands are at high risk of HIV, many do not raise the issue of condoms as to do so might be perceived as accusing their husbands of infidelity or depriving them of sexual pleasure. Women who do suggest condom use may be at increased risk of physical violence and/or economic abandonment. A study conducted by UNIFEM found that even when Zimbabwean women were educated about HIV/AIDS, their economic dependence on men left them feeling "helpless" to negotiate safer sex.[5] Women's subordinate socioeconomic status affects their vulnerability to acquiring HIV and, once infected, accessing care and support services. According to UNDP: Zimbabwean women are the hardest hit by poverty and their situation is especially difficult in rural areas. Women constitute the majority of communal farmers and yet they have no land rights in accordance with customary law. Women in rural areas have lower education levels than men, which often means that they have more limited capacity to access new technology and market/farming knowledge that could enhance their productivity. It is quite rare for women to participate in community development decision-making, and there are few women in positions of influence at the local and central levels. This means that women have little opportunity to establish development priorities that meet their needs. Gender inequalities are apparent in all social, political and economic spheres.[39] There has been much study of female-controlled technologies to prevent transmission of HIV and other STIs in Zimbabwe (see below). The female condom has been widely introduced, phase 2 clinical trials of a vaginal microbicide are under way, and acceptability of the diaphragm as an HIV prevention tool is being studied. A high value is placed on procreation; thus, development of nonspermicidal microbicides will be crucial.[62] Other projects that seek to address HIV through young women's economic position are also being undertaking (see Response section).[62] Gender-related Development Index UNDP measures gender inequality by using the unweighted average of three component indices: life expectancy, education, and income. Its Gender-related Development Index (GDI) value ranges from 0 (lowest gender equality) to 1 (highest gender equality). In 2000, UNDP calculated Zimbabwe's GDI value at 0.545, ranking it 107 out of 146 countries for which UNDP calculated a GDI.[44] By 2001, Zimbabwe's GDI had fallen to 0.489, ranking it 113 out of 144 countries.[28] Polygyny According to the 1999 ZDHS, 14.3 percent of married women reported being in a polygynous union. Prevalence of polygyny ranged from 0.0 in Matabeleland South to 5.0 percent in Bulawayo to 29.9 percent in Mashonaland Central. Polygyny decreased as women's education increased.[7] Intravaginal Practices Studies have suggested that Zimbabwean women regularly insert a wide array of herbal and nonherbal preparations inside their vaginas. Excessive vaginal secretions are viewed as dirt that must be removed to provide a clean environment in which fertilization may occur. Zimbabwean women believe that intravaginal practices promote cleanliness, fertility, and good health. However, the most important reason for intravaginal practices is to provide sexual satisfaction for one's husband to maintain his fidelity. Studies of men's opinions about dry sex indicate that friction and warmth in the vagina increases their sexual pleasure and that they dislike vaginal secretions for an array of reasons.[76] There is limited evidence of an association between intravaginal practices and vaginal infections, which in turn may be associated with HIV acquisition.[77] Some studies have suggested that intravaginal practices may increase heterosexual transmission of HIV and other STIs by: 1. drying out and irritating the vaginal and cervical mucosa 2. disturbing the normal vaginal flora, eliminating lactobacilli that form a natural barrier against colonization of STI pathogens and transmission of HIV 3. interfering with the acceptability and efficacy of barrier methods of HIV/STI prevention [76] The University of California San Francisco, the Population Council, and the University of Zimbabwe have collected detailed information on intravaginal practices in Harare. Sixty percent of study participants practiced vaginal cleansing and drying/tightening; the most common practice was vaginal cleansing with water, or water and soap, using a finger. The association between vaginal practices and vaginal infections was not statistically significant in Zimbabwe. Vaginal insertion of traditional substances appeared to be less common than previously assumed. The researchers found few difference in demographic and sexual behavior characteristics between users and nonusers of intravaginal practices. Although users were significantly more likely to live in poorer accommodation (renting a room in some one else's house or staying with relatives, compared to owning or renting a house or living in a company house), there were no other statistically significant differences in educational level or demographic characteristics. The researchers recommended further study on: 1. whether there is a direct link between intravaginal practices and transmission of HIV and other pathogens 2. effect of intravaginal practices on the acceptability and efficacy of male and female condoms 3. interplay between intravaginal practices and topical vaginal microbicides[76, 77] Age Mixing There are many data on age mixing in Zimbabwe. Summaries of recent studies are listed below: * Using data from a longitudinal study examining the effect of hormonal contraception on HIV acquisition in Zimbabwean women, researchers from the University of California San Francisco and University of Zimbabwe found that early age of coital debut was associated with an increased risk of HIV, independent of condom use. In addition, among seronegative women, having a male partner 10 or more years older increased the risk of never having used a male condom.[73] * The University of California San Francisco and the University of Zimbabwe have held group discussions with in- and out-of-school youth ages 16 to 19 year old from urban/periurban sites. Girls reported that having "boyfriends" more than five years older is the norm, and that about two thirds of their peers are involved with "older partners" (a term reserved for the stereotypical "sugar daddy" over age 30). The primary motivation for having boyfriends is the prospect of marriage (although monetary/material gifts are also expected), whereas for older partners it is money and material support. Within relationships, the power to negotiate safe sex diminishes with the increased age of the partner; older men reportedly became violent if girls proposed condom use or refused sex. The majority of boys reported at least one sexual experience with a woman at least 10 years older. The primary reason for having sex with older women was to gain sexual experience, although additional benefits (such as food, alcohol, and money) were also cited. Condom use within relationships with older women was reportedly common. The researchers concluded that involvement with older partners is the norm for adolescent females in Zimbabwe, and also common among adolescent males. Girls particularly are at risk of HIV infection in relationships with older partners because of a lack of power to negotiate safe sex and the threat of violence.[74] * Researchers from the Southern Africa AIDS Information Dissemination Service (SAfAIDS), University of California San Francisco, San Francisco Department of Public Health, and University of Zimbabwe conducted a quantitative and qualitative study of alcohol use and high-risk sexual behavior among adolescents and young adults ages 15 to 21 in Harare. They found that women tend to become infected with HIV at a younger age than men, most likely by having older male partners upon whom they are often financially dependent. (Exchanging sex for money was reported by 63 percent of women.) The study suggested that these relationships may be initiated at drinking establishments, especially nightclubs located in more affluent areas, which attract young women from poor areas.[69] * The previously mentioned research conducted by the University of London and Zimbabwe's Biomedical Research and Training Institute found empirical evidence that the substantial age difference between female and male sexual partners was the major behavioral determinant of the more rapid rise in HIV prevalence in young women than in men. Older age of sexual partner was associated with increased risk of HIV-1 infection in men (odds ratio 1.13 [95% CI 1.02-1.25]) and women (1.04 [1.01-1.07]). Young women form partnerships with men five to 10 years older than themselves, whereas young men have relationships with women of a similar age or slightly younger. Greater number of lifetime partners is also associated with increased risk of HIV (1.03 [1.00-1.05]). Young men report more partners than do women, but infrequent coital acts and greater use of condoms. These behavior patterns are underpinned by cultural factors including the expectation that women should marry earlier than men. A strong gender effect remains after factors that affect exposure to infected partners are controlled (6.04 [1.49-24.47]).[75] Sexual Violence According to the U.N. Office on Drugs and Crime, reported violence against Zimbabwean women has risen dramatically. During 1996 to 2000, there was an increase in reported rape cases from 3,034 to 4,408.[12] In studies cited by the World Bank, 10 percent of Zimbabwean girls reported that their first sexual intercourse was forced. In urban Zimbabwe, half of all reported rape cases involved girls younger than 15, who were most likely to have been abused by male relatives, neighbors, or schoolteachers.[85] Hindin of Johns Hopkins University notes that Zimbabwean women are vulnerable to abuse because of their low status and lack of power in the family, and because violence within marriage is widely tolerated. Zimbabwean women lack substantial legal recourse if they experience abuse. Although women in traditional (i.e., customary) marriages can cite domestic violence as grounds for separation or divorce, police often treat domestic violence as a "family" rather than as a criminal problem and few women are even aware of their limited legal rights.[45] Using data from the 1999 DHS, Hindin found that 53 percent of women in Zimbabwe believed that wife beating was justified in at least one of five situations. Respondents were most likely to find wife beating justified if a wife argued with her spouse (36 percent), neglected her children (33 percent), or went out without telling her spouse (30 percent). Women who were in partnerships (n=3,077), younger, living in rural areas, had lower household wealth, schooling at a lower level than secondary, and lower occupational status were associated with reporting that wife beating is justified. Women who reported that they make household decisions jointly with their partners were less likely to state that wife beating is justified. Hindin underscores that "given the current social and political climate in Zimbabwe, finding means to negotiate rather than settle conflict through violence is essential from the household level to the national level."[45] The Musasa Project is a Harare-based NGO established in 1988 and affiliated with women's advocacy groups such as the Women's Action Group (WAG), Women and AIDS Support Network (WASN), and Zimbabwe Women's Resource Center and Network (ZWRCN). It offers counseling and shelter to women experiencing domestic violence. Most of the women also receive free legal advice and representation from members of the Women Lawyers Association. A report from the Musasa Project based on its findings from 1995-97 indicated the extent and type of violence experienced by wives at the hands of their husbands. Forced sex was most likely to occur among women who were formally married, had their own income, knew that their partner had a girlfriend, and whose partner used alcohol or drugs. Withdrawn sex was associated with important changes in a relationship, such as impending separation, or with an effort by men to protect their wives from STIs, including HIV. The report notes that there are mixed feelings in Zimbabwe about the acceptability of either form of sexual coercion.[86] As previously discussed, since 2000, human rights groups¾including Amnesty International, Human Rights Watch, the International Crisis Group, and Physicians for Human Rights¾have documented systematic rape and sexual torture of women in the context of the country's political violence. Tony Reeler, regional human rights defender with the Institute for Democracy in South Africa, describes a new pattern of sexual violence in Zimbabwe: During 2000 and early 2001, human rights groups documented widespread torture of opposition supporters, of whom about 40 percent were women. These women were beaten, stripped naked, and humiliated, but few were raped or sexually abused. After June 2001, however, rape and sexual torture of women became more prevalent and brutal.[46] Research from the Institute of Education at the University of Sussex investigated the nature and pattern of abuse of girls in three coeducational junior secondary schools and an all-girls secondary school in one region of Zimbabwe. Findings include: * Abuse of girls (sexual and nonsexual) in schools is widespread, including aggressive sexual behavior, intimidation and physical assault by older boys; sexual advances by male teachers; and corporal punishment and verbal abuse by both female and male teachers (directed at boys as well as girls). * Male sexual aggression in schools is institutionalized and considered "normal," and girls generally respond with resignation and passivity. * Schools are complicit in the abuse in that they fail to discipline the perpetrators (whether pupils or teachers), deny that abuse exists, and foster an authoritarian culture in which the behavior of teachers cannot be questioned. * School-based abuse is a reflection of abuse found elsewhere¾in the home and in the community.[47] Sex Work A study conducted during 1994-95 found that 86 percent of sex workers tested in Harare were HIV positive.[78] The Tiripamwechete Study Group found that HIV prevalence among sex workers (n=363) from a mining and farming community in rural Mashonaland West was 55.7 percent (95% CI 50.6 - 60.9).[28] Decosas and Padian note that there is a "large gray area" between "commercial" and "compensated" sex. They cite evidence that the deteriorating economic situation is rendering sex in exchange for money or material good more common. [17] In the 1999 ZDHS, 81.5 percent of men who paid for sex in the last year reported using a condom at last paid intercourse.[7] The Tiripamwechete Study Group also calculated the percent of HIV infection among miners and farm workers attributable to sex work (see Mining section). Male Circumcision There is very limited male circumcision in Zimbabwe. Male circumcision is practiced by a Xhosa ethnic group known as amaFengu in Zimbabwe. The amaFengu are originally from South Africa and live in some areas of Matabeleland. Some observational studies from sub-Saharan Africa have indicated that male circumcision may reduce the risk of HIV acquisition,[79, 80] though circumcision does not appear to affect transmission from HIV-positive men to their partners.[81] The limitations of these studies have been highlighted, and further study is needed on both biomedical and sociobehavioral issues before promoting male circumcision as a public health intervention. Other Issues * Overcrowding: Urban housing is severely limited and this scenario leads to severe overcrowding.[88] Carol Coombe of the University of Pretoria, for example, highlights how poor, overcrowded housing facilitates transmission of tuberculosis. She also notes that such housing conditions may facilitate sexual abuse and harassment, particularly of young girls.[89] Overcrowding in prisons is also a major problem, as noted in Zimbabwe's HIV/AIDS policy.[24] * Decosas and Padian note that Zimbabwean decolonization "has been a protracted and sometimes violent process characterized by political instability and ethnic tension. As a consequence, community cohesion in many rural areas is low."[17] Added to this scenario are HIV/AIDS, economic crisis, drought, food shortage, and political turmoil; these are contributing to the deteriorating welfare and social service systems (at a time when they are most needed), lack of other safety nets, and breakdown of traditional coping mechanisms. A study from Zimbabwe's Biomedical Research and Training Institute highlights an association between social cohesion and risk of HIV acquisition. It found that 60 percent of men and 83 percent of young women were members of well-functioning social groups. Members were more likely to have avoided HIV among both men (OR=1.41, p<0.001) and women (1.33, 0.04); this effect was restricted to those with secondary school education. Greater education was positively associated with group membership and more educated female members were more likely to report that their groups functioned well (1.44, p=0.058). For the more educated, church group membership was associated with HIV-avoidance in men (1.86, p<0.001) and women (1.47, p=0.02). Fewer of the men in church groups had begun to have sex, had multiple sexual partners, or reported condom use with their casual partners. For women, youth (2.17, p=0.06) and women's (3.21, p=0.06) group membership was associated with HIV-avoidance; group members knew more about HIV and had greater self-efficacy.[87] Impact At a Glance Demographic * During 2000-2005, Zimbabwe will have the world's second-lowest life expectancy at birth (33.1). During 2000-05, life expectancy would have been 67.6 without AIDS. For 2010-15 and 2045-50, life expectancy would have been 70.5 and 76.2, respectively, without AIDS. These figures represent a 40 to 55 percent reduction during 2000-50. * Zimbabwe's population will be 61 percent smaller in 2050 than it would have been in a "no-AIDS" scenario. * General mortality figures have been radically eroding in Zimbabwe. * There were approximately 1.1 million cumulative AIDS deaths in Zimbabwe through 2000, with AIDS increasing mortality by 67 percent. Between 2000 and 2015, there will be 4.2 million AIDS deaths, representing a 311 percent increase in mortality in Zimbabwe. The number of AIDS deaths is projected to rise to 6.0 million during 2015-50, a 119 increase in mortality during this period. Welfare * HIV/AIDS has already resulted in welfare losses equivalent to 76.0 percent of GDP. Households * HIV/AIDS has further strained coping mechanisms through its enormous and complex impact on households. Women are traditional caregivers and thus take on additional responsibilities when family members become ill. * When an adult Zimbabwean woman dies, her children are likely to be fostered by an elderly woman. Major problems faced by older Zimbabweans caring for HIV-infected children and/or orphans include: ? loss of economic support, loss of remittances from sick or dead adult children ? lack of access to basic needs such as food and clothing ? limited access to and utilization of health care services because of transport difficulties and high cost of services ? financial hardships, leading to inability to pay for medical or school fees ? negative attitudes of health workers toward older persons, as well as toward people living with HIV/AIDS ? stigmatization of those with HIV/AIDS by community and service providers ? physical and emotional stress resulting from increasing levels of violence and abuse (often as a result of witchcraft accusations) Orphans and Other Vulnerable Children * At the end of 2001, UNAIDS estimated that 780,000 AIDS orphans (ages 0 to 14) were living in Zimbabwe. The percent of Zimbabwe's orphans due to AIDS rose from 16.0 percent in 1990 to 76.8 percent in 2001; it projected that this percentage would rise to 85.7 percent in 2005 and 88.8 percent in 2010. * Fewer than 4,000 of Zimbabwe's orphans are living in the country's 45 registered orphanages. Maintaining a child in one of these orphanages is far costlier than other forms of care. Some researchers have posited that increased resources for AIDS orphans would be optimally targeted to strengthen existing community groups at the local level. Agriculture * According to FAO, between 1985 and 2020, Zimbabwe will have lost 23 percent of its agricultural labor force because of AIDS. Health * Seventy percent of hospital admissions are HIV-related. * Demand for the time and services of trained health care providers is increasing; concurrently, those working in the health sector are also affected by HIV/AIDS. Education * Between 2000 and 2010, 2.1 percent of Zimbabwe's teachers will die annually because of AIDS. On the demand side, there will a 0.25 percent reduction in Zimbabwe's school-age population (ages 5-14). * Of new teachers who needed to be trained in Zimbabwe in 2000, 54.3 percent replaced teachers lost to AIDS; for 2010, a projected 82.6 percent of newly trained teachers will replace teachers who have died because of AIDS. Mining * Mining companies operating in Zimbabwe offer family accommodation, schools, and health clinics. Unlike in South Africa, male miners' wives and families usually live with then in company-provided housing. Demographic Life Expectancy at Birth According to the U.N. Population Division, during 2000-2005, Zimbabwe will have the world's second-lowest life expectancy at birth (33.1), following Zambia (32.4). The division projects that Zimbabwe's life expectancy will rise to 45.7 during 2045-50, ranking as the world's fourth-lowest life expectancy during that period (only Swaziland, Botswana, and Lesotho are projected to have lower life expectancies).[6] Life expectancy is projected to decline to 31.8 during 2010-15, thereafter increasing to 45.7 during 2045-50. The division estimates that during 2000-05, life expectancy would have been 67.6 without AIDS. For 2010-15 and 2045-50, life expectancy would have been 70.5 and 76.2, respectively, without AIDS. These figures represent a 40 to 55 percent reduction during 2000-50 (table 1).[6] Table 1. Life Expectancy with and without AIDS, 2000-2005, 2010-2015, and 2045-2050 Period 2000-2005 2010-2015 2045-2050 With AIDS Without AIDS Reduction in Life Expectancy Percentage Reduction With AIDS Without AIDS Reduction in Life Expectancy Percentage Reduction With AIDS Without AIDS Reduction in Life Expectancy Percentage Reduction 33.1 67.6 34 51 31.8 70.5 39 55 45.7 76.2 30 40 Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. World Population Prospects: The 2002 Revision. Highlights. New York: February 2003 Population The U.N. Population Division also examined population under a "no-AIDS" scenario. Tables 2 and 3 indicate that Zimbabwe's population will be 61 percent smaller in 2050 than it would have been in a "no-AIDS" scenario.[6] Table 2. Projected Population with and without AIDS, 2000, 2015 AND 2050 (Thousands) Period 2000 2015 2050 With AIDS Without AIDS With AIDS Without AIDS With AIDS Without AIDS 12 650 13 948 13 031 19 895 12 658 32 432 Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. World Population Prospects: The 2002 Revision. Highlights. New York: February 2003 Table 3. Projected Population Reductions, 2000, 2015 AND 2050 Period 2000 2015 2050 Population Reduction (Thousands) Percentage Reduction Population Reduction (Thousands) Percentage Reduction Population Reduction (Thousands) Percentage Reduction 1 298 9 6 865 35 19 775 61 Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. World Population Prospects: The 2002 Revision. Highlights. New York: February 2003 Mortality See also the Epidemiology section above. General mortality figures have been radically eroding in Zimbabwe. For example, during 1995-2000, the probability at birth of not surviving to age 40 (percentage of cohort) was 51.6 percent;[44] for the period 2000-05, this figure has increased to 74.8 percent.[28] Probability at birth of surviving to age 65 (percentage of cohort) has fallen: during 1995-2000, this figure stood at 24 percent for females and 22 percent for males; for 2000-05, it has fallen to 8.3 and 9.2 percent, respectively. By comparison, for the sub-Saharan African region, the 2000-05 figures are 36.1 and 32.0, respectively.[28] (See accompanying indicator table.) Using data from the U.N. Population Division, tables 4 and 5 indicate that there were approximately 1.1 million cumulative AIDS deaths in Zimbabwe through 2000, with AIDS increasing mortality by 67 percent. The division projects that between 2000 and 2015, there will be 4.2 million AIDS deaths, representing a 311 percent increase in mortality in Zimbabwe. The number of AIDS deaths is projected to rise to 6.0 million during 2015-50, a 119 increase in mortality during this period.[6] (NB: These projections assume that HIV/AIDS dynamics remain unchanged until 2010. Thereafter, prevalence levels are assumed to decline. By 2050, prevalence levels are lower but still substantial in the most highly affected countries.)[6] Table 4. Projected Number of Deaths with and without AIDS, 1980-2000, 2000-2015, and 2015-2050 (Thousands) Period 1980-2000 2000-2015 2015-2050 With AIDS Without AIDS With AIDS Without AIDS With AIDS Without AIDS 2 715 1 623 5 563 1 355 11 032 5 029 Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. World Population Prospects: The 2002 Revision. Highlights. New York: February 2003 Table 5. Deaths Because of AIDS, 1980-2000, 2000-2015, and 2015-2050 Period 1980-2000 2000-2015 2015-2050 Excess Deaths (Thousands) Percentage Increase Excess Deaths (Thousands) Percentage Increase Excess Deaths (Thousands) Percentage Increase 1 092 67 4 208 311 6 003 119 Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. World Population Prospects: The 2002 Revision. Highlights. New York: February 2003 Research undertaken by UNAIDS and WHO found that for Zimbabwe, the HIV-attributable under-5 mortality rate (per 1,000), corrected for competing causes of mortality (i.e., under-5 mortality attributable to HIV/AIDS), was 42.2 during 1990-99. The HIV-related population proportional attributable risk of dying before age 5 (i.e., the proportion of all-cause under-5 mortality attributable to HIV) was 35.1 percent. Of the 39 African countries studied, only Botswana's rates surpassed those of Zimbabwe.[9] Fertility Desires Research presented in Barcelona found that perceived high risk for HIV infection was not associated with lower desire for future pregnancy by the Zimbabwean women surveyed. Rather, the data suggest an increased desire for future pregnancy to replace childhood deaths or spontaneous abortions that may result from HIV infection.[92] Macroeconomic According to a June 2003 report from the World Bank, previous studies have grossly seriously underestimated the economic impact of the AIDS epidemic, failing to factor in the impact of education and parenting on the economy. The authors underscore that by killing primarily young adults, AIDS does more than destroy the human capital embodied in them; it also deprives their children of the requirements to become economically productive adults: their parents' care, knowledge, and capacity to finance education. This weakening of the mechanism through which human capital is transmitted and accumulated across generations becomes apparent only after a long time lag, and it is progressively cumulative in its effects. [48] Previous estimates of macroeconomic impact include those published in 2002 by Haacker of the IMF. He estimated that in the medium term, Zimbabwe will experience a 7.3 percent reduction in GDP per capita because of HIV/AIDS; of this percentage, 1.3 percent is due to total factor productivity, 2.2 percent to the capital/labor ratio, and 3.9 percent to "experience" (aggregate knowledge and skills of the workforce, lost due to AIDS mortality and to new entrants in labor force lacking such experience). In the long term, he projected a 2.3 percent decreased in GDP per capita because of HIV/AIDS. The lower figure for the long-term reflects, partly, that the decline in experience will be partly reversed as the weight of younger cohorts in the working-age population declines, reflecting lower birth rates.[49] Welfare Crafts and Haacker of the IMF have sought to quantify the welfare losses associated with HIV/AIDS. They used estimates and projections of the impact of the epidemic on mortality and life expectancy, as well as existing studies on the value of statistical life. They estimated welfare loss as the loss in per capita income that would have the same effect on lifetime utility as the increase in mortality, expressed in percentage of GDP. They do note numerous limitations of their study. For Zimbabwe, they found that HIV/AIDS has already resulted in welfare losses equivalent to 76.0 percent of GDP.[50] Households (See also the previous Food Crisis section) HIV/AIDS has further strained coping mechanisms through its enormous and complex impact on households. As AIDS severely affects the most economically active members of the household, income and consumption patterns are changing dramatically, reducing or depleting income, savings, and remittances, and increasing expenditures on care and funerals. Families may have to sell assets or increase their labor to pay for care (e.g., a private doctor or traditional healer); transport to reach care providers; burials; and household necessities. Household income often declines though (1) illness and death of the breadwinner, (2) wages lost by other household members who stop (or reduce) working to care for the sick, and/or (3) wages lost by (or opportunity cost of) attending funerals. Lost employment may be accompanied by loss of insurance and medical benefits. Household members - including its oldest and youngest members -- may have to enter or remain in the workforce longer to compensate for the loss of the main breadwinner's earnings. Exacerbating this scenario is that more than one household member is often infected with HIV/AIDS.[94] In households in which the father dies first, the widow often suffers severe financial difficulties, particularly when relatives claim all the husband's property. Women often do not have marriage certificates or other documentation to protect their rights (and wills are rarely written).[95] Household food security is imperiled by HIV/AIDS. When an adult dies, food consumption of all surviving household members often declines, due to reduced family income as well as the increased number of household members that may arise from fostering orphans and hosting and caring for sick relatives.[96] Households that are headed by a single parent, have only one breadwinner, and/or have more than one HIV-infected member are also vulnerable to economic (and psychosocial) shocks. Female-headed households tend to be poorer than those headed by men and thus have fewer resources with which to respond to HIV/AIDS. In Zimbabwe, 35 percent of households are headed by women or girls. The number is increasing as a result of HIV/AIDS.[23] Women are traditional caregivers and thus take on additional responsibilities when family members become ill. And in single-parent households or those in which one parent has already died, girls are more likely than boys to provide care. When family breadwinners become ill or die, girls are often the first to be taken out of school -- to help care for those who are ill, carry out household chores, and/or undertake income-generating activities.[97] Research presented at the Barcelona AIDS conference in July 2002 found that as a result of male mortality, Zimbabwean women are seeking new means of economically supporting themselves and their families. The researchers also found that communities are creating self-help networks to care for orphans and those who are ill, as well as to provide economic support for families.[98] UNAIDS also reports that in parts of Zimbabwe, women are moving into the traditionally male carpentry industry.[5] Dr. Gladys Bindura Mutangadura of the University of North Carolina Chapel Hill reports that there are very limited forms of formal social protection to lessen the impacts of adult death in Zimbabwean households. The main protection measures include public assistance, social development funds, free food distribution, grain loan schemes, and child supplementary feeding programs. The effectiveness of these public projects, however, is undermined by inadequate funding and constrained access to them.[95] Burden on Elderly Zimbabweans In Zimbabwe, Mutangadura found that when an adult female dies, her children are likely to be fostered by an elderly woman whose main business activity is informal.[51] In early 2001, WHO worked with partners in Zimbabwe to undertake a study involving households headed by adults who were either caring for their sick children, or had cared for such children in the past and were now living with AIDS orphans. Final data analysis concentrated on 685 individuals age 50 or older; 84 percent of these individuals were the main caregivers within the household and 71 percent were female.[52] The study identified the following major problems faced by older Zimbabweans caring for HIV-infected children and/or orphans: * loss of economic support, loss of remittances from sick or dead adult children * lack of access to basic needs such as food and clothing * limited access to and utilization of health care services because of transport difficulties and high cost of services * financial hardships, leading to inability to pay for medical or school fees * negative attitudes of health workers toward older persons, as well as toward people living with HIV/AIDS * stigmatization of those with HIV/AIDS by community and service providers * physical and emotional stress resulting from increasing levels of violence and abuse (often as a result of witchcraft accusations) The three key areas identified for policy and program action were: 1. enhancing the care-giving capacity of older people 2. improving access to and utilization of services, and 3. ensuring economic independence and income support.[99] Orphans and Other Vulnerable Children At the end of 2001, UNAIDS estimated that 780,000 AIDS orphans (ages 0 to 14) were living in Zimbabwe.[5] Children on the Brink 2002, a report on AIDS orphans commissioned by USAID, estimated that the percent of Zimbabwe's orphans due to AIDS rose from 16.0 percent in 1990 to 76.8 percent in 2001; it projected that this percentage would rise to 85.7 percent in 2005 and 88.8 percent in 2010.[100] Research presented in Barcelona in July 2002 found that in Manicaland, orphans live in poorer conditions. Part of this explanation is that more are cared for in rural, elderly, and female-, and adolescent-headed households, which themselves tend to be poorer.[101] Preliminary findings of another study found that for those providing care to AIDS orphans in rural Zimbabwe, the main problems are poverty and lack of resources. All study participants reported lack of adequate food, shelter, clothing, and school fees for the orphans.[102] The World Bank has examined the impact of orphaning on school enrollment and found the data inconclusive. What is clear is that HIV/AIDS reduces girls' access to education. Girls are highly vulnerable to contracting AIDS because of social, cultural, economic, and physiological reasons, and compared with boys are more often retained at home when household income and/or labor supply falls. Girls' lower educational levels are related to lower formal labor force participation and decreased earnings and thus lessened economic autonomy. This situation may increase women's economic dependence on men and inability to refuse sex or insist on condom use -- all factors that can increase vulnerability to HIV.[103] The Southern African AIDS Training Program (SAT) stresses that traditional attitudes and practices to care for and support children who have experienced death in their family are no longer functional in the context of the high mortality of young adults in Zimbabwe. SAT conducted focus group discussions with children who were living with a terminally ill relative or who had a recent death in the family and found that many children affected by AIDS are experiencing neglect, exploitation, psychological trauma, and physical abuse. Many children care for dying relatives without preparation and support. There is little meaningful communication between adults and children about death and dying. Many children are separated from their dying parent and lose contact with one part of their family. They are excluded from the mourning process. They have no voice in family decisions about their future, and easily fall victim to exploitation or abuse. The basic survival needs of most orphans are met, but many suffer psychological and emotional trauma. Cultural taboos about death and dying, and the traditionally defined role of children within families contribute to the trauma they experience.[104] The economic and social effects of HIV infection and AIDS on children include malnutrition, reduced access to education and health care, migration, and homelessness. Psychological effects include depression, guilt, and fear, possibly leading to long-term mental health problems. The combination of these effects on children increases their vulnerability to a range of consequences, including HIV infection, illiteracy, poverty, child labor, exploitation, and unemployment when they reach adulthood.[105] The situation of Zimbabwe's AIDS orphans has been exacerbated by the current food crisis and land reform policies.[47] Zimbabwe's National Orphan Care Policy establishes a six-tier safety net: 1. orphans first remain in biological nuclear families 2. when both parents die, the extended family assumes care 3. the community designates guardian(s) 4. children may be placed in formal foster care 5. children may be placed for adoption 6. orphans may be institutionalized as a last resort The Department of Social Welfare promotes informal foster care of orphans through traditional care systems such as community or extended family care.[24] Researchers from the University of Zimbabwe note that fewer than 4,000 of Zimbabwe's orphans are living in the country's 45 registered orphanages. Maintaining a child in one of these orphanages is far costlier than other forms of care. Although establishment of small, family-based orphanages has reduced some of the adverse psychological and social effects associated with institutionalization, children's homes also undermined traditional models of care and alienated children from their families and culture.[106] Dr. Geoff Foster of the Mutare Provincial Hospital has worked extensively with AIDS orphans. In a June 2002 New England Journal of Medicine commentary, he proposed that increased resources for AIDS orphans be used to strengthen existing community groups at the local level whose mission is to support orphans and other vulnerable children and that these resources be committed for the long term. He stresses that smaller amounts of money will be needed to supplement community safety nets for decades.[105] Agriculture According to FAO, between 1985 and 2020, Zimbabwe will have lost 23 percent of its agricultural labor force because of AIDS. [53] UNAIDS highlights that Zimbabwean farm workers do not own the land on which they reside; for families living on commercial farms, their livelihood and accommodation are tied to the father's employment. Thus, when fathers or breadwinners die because of AIDS, families may lose their homes, in addition to the other impacts described above.[38] A 1997 study sponsored by the Zimbabwe Farmers' Union compared production levels of various crops in a small sample of households that both had and had not experienced an AIDS death. Results indicated that the death of a breadwinner due to AIDS decreased the marketed production of maize in small-scale farming and communal areas by 61 percent. Similar results were obtained for other crops, such as cotton, vegetables, groundnuts, and the number of cattle owned. The main reasons given for the decline in production were a lack of labor input, shortage of purchased inputs, and lack of time available from the surviving members of the household. The households citing an AIDS death also reported a loss of remittance income.[25] (NB: These figures do not take account of the current food and land reform crises.) Health See also the Health System section above. In January 2003, Zimbabwe's health minister stated that 70 percent of hospital admissions are HIV-related. [16] According to USAID, Zimbabwe spends 60 percent of its health budget on HIV/AIDS.[107] Zimbabwe's health care system has been experiencing a deterioration in the quality of services. Part of this is because of the economic and political situation. Many health care professionals have emigrated from the country. Nurses, on whom the health care system relies heavily, have been emigrating in large numbers.[12] Concurrently, demand for the time and services of trained health care providers will increase further as a result of HIV/AIDS. With regard to supply, those working in the health sector are also affected by HIV/AIDS. Haacker of the IMF notes that if Zimbabwe were to maintain its current numbers of doctors and nurses, and assuming HIV prevalences for health sector staff are similar to those of the general population, training of doctors and nurses would have to increase by about 25 to 40 percent between 2000-10.[10] Haacker has examined the costs of HIV/AIDS-related health services in nine southern African countries. To provide a common indicator to compare data across countries, his analysis was based on the assumption that the coverage rate for palliative care and prevention of OIs is 30 percent, coverage rate for clinical treatment of OIs is 20 percent, and the coverage rate for HAART is 10 percent. In Zimbabwe, he found that total HIV-related health services, assuming these rates of coverage, would account for 2.1 percent of GDP in 2000 and 3.5 percent of GDP in 2010.[10] Compare total health expenditure for 1998: 3 percent of GDP (and this percentage has been declining).[32] (The HIV/AIDS-related costs were broken down as follows: Costs for palliative care and prevention of OIs were estimated at 0.2 percent of GDP for 2000 and 0.3 percent for 2010; for clinical treatment of OIs: 0.8 and 1.1 percent of GDP, respectively; and for HAART: 1.1 and 2.2 percent of GDP, respectively. NB: These estimates were published in February 2002.)[10] Education Educators may be particularly vulnerable to HIV infection given their comparatively high incomes, sometimes remote postings, and geographic and social mobility--all of which may increase their number of sexual partners and contacts with different sexual networks.[85] A recent study in Manicaland, Zimbabwe, found that 19 percent of male teachers and almost 29 percent of female teachers were infected with HIV.[5] Morbidity and mortality are also affecting education sector administrators, finance and planning officials, inspectors, and managers in many African countries.[89] HIV/AIDS has a direct impact on the supply of and demand for education. On the supply side, budgets are having to accommodate higher teacher hiring and training costs to replace teachers who have died of AIDS, as well as the payment of full salaries to sick teachers who are absent and additional salary costs for substitute teachers. The World Bank projects that 2.1 percent of Zimbabwe's teachers will die annually because of AIDS between 2000 and 2010 (NB: Based on the assumption that teachers have the same infection rate as estimated for the general population.) The comparable figures for Zambia, Kenya, and Uganda are 1.7, 1.4, and 0.5 percent, respectively.[85] According to researchers from the University of Sussex, projected AIDS-related deaths for primary and secondary school teachers in Zimbabwe during 2000-2008 will be 16,200 and 7,600, respectively. (This projection is based on three assumptions: teachers have the same age and HIV profiles as the rest of the adult population, adult HIV prevalence from 1999 will not increase, and teachers are unable to access life-prolonging ARVs.)[54] On the demand side, the World Bank projects that there will a 0.25 percent reduction in Zimbabwe's school-age population (ages 5-14) between 2000 and 2010. The number of children of primary school age will be 20 percent lower by 2010 than pre-AIDS projections. Lower demand for education may also be the result of children dying of AIDS because of mother-to-child transmission (see Mortality section above).[85] Haacker from the IMF projects a decline in the number of pupils by 2010 and a decline in the absolute numbers of new teachers needed. However, he estimates that of new teachers who needed to be trained in Zimbabwe in 2000, 54.3 percent replaced teachers lost to AIDS; for 2010, he projects that 82.6 percent of newly trained teachers will replace teachers who have died because of AIDS.[10] Military In 1999, the Government of Zimbabwe sent a sizeable military force into the Democratic Republic of Congo to support the government of then President Laurent Kabila.[16] Most of those forces have since been withdrawn. In December 2002, the Southern Africa HIV/AIDS Information Dissemination Service reported that 50 percent of Zimbabwe's soldiers are HIV-positive. [55] (NB: This reference is a popular press report and so should be viewed with caution.) Prisons Official data on HIV prevalence and AIDS mortality in Zimbabwean prisons have not been released. Zimbabwe's national HIV/AIDS policy mentions overcrowding in prisons. It recommends improved surveillance and supervision to prevent both consensual and coerced sexual activity in prisons. The policy states that prisoners have a right to information about HIV/AIDS (though not condoms) and that HIV testing should be voluntary and accompanied by pre- and posttest counseling.[24] Mining Mining companies operating in Zimbabwe offer family accommodation, schools, and health clinics. Unlike in South Africa, male miners' wives and families usually live with then in company-provided housing.[110] The Tiripamwechete Study Group (comprising researchers from, inter alia, the University of Zimbabwe, University College London, and London School of Hygiene and Tropical Medicine) conducted a survey among 1,405 male miners and farm workers in Mashonaland West. They found that overall HIV prevalence was 27.3 percent (95% CI 24.8 - 29.5 percent). Prevalence of chlamydia and gonorrhea were low (1.5 and 0.5 percent, respectively) and not significantly associated with HIV infection. 48.4 percent of men reported ever having sex worker contact and 29.3 percent reported contact with a sex worker in the last year. HIV infection was 1.5 times more likely in men who reported ever having had sex worker contact. Rates of sex worker contact were highest in unmarried men, 20 percent of whom reported that their last sexual contact was with a sex worker.[111] The researchers attributed 18.6 percent of HIV infections to ever having had contact with a sex worker, though they stress that they were not able to relate sex worker contact to HIV acquisition chronologically and thus other factors may to some extent confound the association they did find. They note that the deteriorating economic situation in Zimbabwe may be leading young men to delay marriage and thus perhaps widening the time period when they are more likely to have contact with sex workers. They also note that it may forcing an increasing number of women to resort to sex work.[111] These data are not meant to demonize sex workers, but rather to underscore the benefits of family accommodation for miners and other workers who migrate from their home villages to seek employment. The Tiripamwechete Study Group also recruited 363 sex workers from the same community. HIV prevalence among the sex workers was 55.7 percent (95% CI 50.6 - 60.9).[28] Other Industries * Studies in Zimbabwe have found that increased benefit claims, absenteeism, and expenditures on recruitment and training are among the highest HIV-related costs faced by companies.[112] * One study of a bus company in Zimbabwe indicated that AIDS-related absenteeism accounted for 54 percent of all AIDS-related costs, followed by HIV-related illness (35 percent).[5] * The National Railways of Zimbabwe (NRZ) is the largest transport company in Zimbabwe and employed 17,000 workers in 1997. In 1990, the company reported operational problems due to an absenteeism rate over 15 percent. A later impact study estimated the company's AIDS costs at Z$39million, equal to 20 percent of the company's profits. In 1997, absenteeism costs increased further to Z$80 million. In the mid- to late 1990s, the annual budget for the direct costs of managing HIV/AIDS prevention was close to Z$1.5 million. Further direct costs comprise an additional 10 percent staff complement to cover for absentees in certain work areas. Training costs to replace skilled workers (direct training and lower productivity) are projected to increase fivefold due to AIDS between 1991 and 2000. Railmed, the company's medical aid society, observed an 18 percent increase in medical related costs (Z$5.6 million in 1995 to Z$6.8million in 1996). Because the costs of the medical scheme are shared by NRZ and employees, costs for both are likely to continuously increase.[113] Response At a Glance Government * After the first AIDS case in Zimbabwe was identified in 1985, the government's initial response involved the introduction of universal screening of blood and blood products for HIV. This initiative has been a great success, as HIV transmission via blood transfusion is rare. * In 1987, the Ministry of Health and Child Welfare established the National AIDS Coordination Program (NACP). * In 1991, the government implemented a program of HIV sentinel surveillance. * Between 1988 and 1998, the government created several short- and medium-term plans to address HIV/AIDS, the implementation of which was the responsibility of NACP. * Increasing levels of HIV infection, especially among youth, coupled with the many impacts of epidemic, forced the Zimbabwean government to acknowledge that its actions against HIV/AIDS had been inadequate and limited in scope and effectiveness. Among other things, the government had no HIV/AIDS policy until 1999. * In addition, the government had faced criticism that although the enormity of the HIV/AIDS epidemic in Zimbabwe has been recognized for some time, the government was slow to acknowledge the scale of the problem and take appropriate action. Prior to 2000, for example, President Mugabe rarely mentioned HIV/AIDS publicly; when he did so, it was deemed newsworthy. * The government introduced the National Policy on HIV/AIDS in December 1999. The National AIDS Council was created in May 2000 to implement the policy. * The government has been criticized for insufficient consultation with all stakeholders, especially PWLHA. * To what degree the national HIV/AIDS policy is being implemented is unclear. NAC, for example, is constrained by inadequate capacity (human and financial resources), overwhelming and competing demands for its services, internal struggles for visibility and power, denial and stigma around HIV/AIDS, and difficulty in bringing different stakeholders together. Zimbabwe's HIV/AIDS policy is also unclear regarding how a multisectoral response will be implemented. More generally, given the country's myriad and interrelated crises, the government's motivation and/or ability to focus on and support HIV/AIDS policy implementation is impeded. * In March 2003, the UN Relief and Recovery Unit reported that "a vigorous response" to HIV/AIDS within the context of the current humanitarian crisis in Zimbabwe was lacking, citing, inter alia, limited coverage and quality of interventions, as well as weak coordination at all levels. * An AIDS levy was introduced in 1999 to supplement the MOHCW's HIV/AIDS budget. * The government has taken steps to make the disbursement of funds from the AIDS levy more transparent. However, donors and local AIDS committees continue to raise concerns that disbursements are not reaching local committees and have been politicized (i.e., are being disbursed through ZANU-PF-affiliated channels). * In June 2002, the government enacted a declaration of a six-month period of emergency (HIV/AIDS) to increase availability of and access to generic AIDS drugs. Human Rights * Zimbabwe's Labor Relations Regulations on HIV/AIDS bar employers from requiring HIV testing as a precondition to employment, termination, or benefit eligibility. However, to what degree preemployment HIV testing and HIV/AIDS-related workplace discrimination are occurring is unknown. * In accordance with international guidelines, Zimbabwe's policy places no restriction on travel of HIV-positive persons. * Many other laws and policies are not sufficiently up-to-date or comprehensive to address the myriad impacts of HIV/AIDS. Donors * Zimbabwe relies heavily on funding from international donors for its HIV/AIDS programs. * Because of the political situation -- and because Zimbabwe is not servicing its debt -- most multi- and bilateral donor resources are being withdrawn or reduced. Many donors, however, are continuing to fund HIV/AIDS programs, often through NGOs. Major donors for HIV/AIDS include the U.K., U.S., European Union, Germany, and Japan. Norway, Sweden, and the Netherlands sponsor smaller programs. U.N. agencies remain active in Zimbabwe in several sectors, including HIV/AIDS, famine relief, health, education, environment, and governance. * The Global Fund to Fight AIDS, Tuberculosis & Malaria awarded Zimbabwe two grants in April 2002; HIV/AIDS funds, however, have not yet been disbursed. Civil Society * Zimbabwean civil society, including NGOs, CBOs, religious and academic organizations, and private industry, provide a significant amount of HIV/AIDS prevention, care, and support. VCT * Zimbabwe's national HIV/AIDS policy considers counseling to be a vital component of HIV/AIDS prevention and care and addresses VCT in depth. The Zimbabwe AIDS Prevention and Support Organization (ZAPSO) opened the first VCT center in Zimbabwe in 1998. * Almost 12 percent of Zimbabwean women report having been tested for HIV; among those not tested, 59.1 percent would like to be tested. Among men, 9.2 percent report having been tested for HIV; of those not tested, 56.8 percent would like to be tested. Among women who have not been tested for HIV, 63.4 percent do not know a source for HIV testing. Among men, the comparable figure is 66.5 percent. * USAID, in collaboration with PSI and the Government of Zimbabwe, launched 10 New Start VCT centers at strategic locations throughout the country. In 2001, these 10 sites counseled and tested over 50,000 clients. * New Start has expanded into a network of 14 centers throughout the country, serving over 5,000 clients each month. Female-controlled Prevention Technologies * The female condom was launched in Zimbabwe in 1997. It was initially sold through selected pharmacies and clinics at a heavily subsidized retail price of US$0.24 for a box of two; distribution has since expanded to other urban outlets, including large supermarkets and convenience stores. The high cost of the female condom (vis-à-vis the male condom) is leading many Zimbabwean women, particularly sex workers, to reuse it to save money. * Although users of the female condom perceive it to be effective and reliable both as an STI/HIV and pregnancy prevention method, 30 percent of men and 57 percent of women reported some difficulty with use, such as problems with insertion, discomfort during sex, noise or squeakiness during use, and excess lubrication. * A study of married Zimbabwean women found that offering them multiple prevention options increased the reported percentage of sex acts protected by any method. Most women preferred the male condom and least liked the female condom. * Based on a phase I clinical trial of Buffergel that found that it appeared to be safe and well tolerated, a phase 2/2B study of the safety and effectiveness of BufferGel and PRO 2000/5 Gel (P) is currently taking place in Zimbabwe. * Preliminary findings indicate that both Zimbabwean men and women generally accept the diaphragm. Although the majority preferred male condoms because of their known efficacy against HIV, most women felt protected and empowered through use of the diaphragm. In August 2002, the Gates Foundation awarded US$28 million to the University of California San Francisco to continue testing the diaphragm as a potential prevention method for HIV/other STIs. * There are numerous HIV prevention interventions under way that have an economic/livelihoods focus. PMTCT * WHO estimated that as of the end of 2001, only 4 percent of Zimbabweans in need of PMTCT services was receiving them. With GFATM financing, the government's target for 2002 was to have 30,000 pregnant women counseled and tested for HIV; by 2004, this figure would rise to 70,000. The GFATM grant would also fund expansion of ART for PMTCT. * In January 2002, the government launched the PMTCT Program, through the MOHCW and NAC (using funds from the AIDS levy). MOHCW funds 60 to 70 percent of PMTCT activities and coordinates all PMTCT programs. Donors either support individual sites or provide resources to the national office to enhance capacity to implement and coordinate activities. The program offers free VCT to pregnant mothers and free nevirapine at the time of labor in a single dose. * Because of personnel and training constraints, the PMTCT program is not yet available in all maternity units. Treatment of OIs and ART * Currently, between 200 and 2,000 Zimbabweans are receiving some form of ART (of highly variable quality and with highly variable levels of adherence) through the private sector and clinical trials. * Zimbabwe's Antiretroviral Therapy Subcommittee has produced draft ART guidelines. The government's (draft) Plan for the Nationwide Provision of ART calls for detailed implementation strategy to be developed for all aspects of ART. * In its 2002 GFATM proposal, the government requested US$2.2 million for antiretroviral drugs and US$1.5 million for logistics and training support for 2002-04. This support is intended to assist with: * In September 2002, Zimbabwe's Antiretroviral Therapy Subcommittee estimated that the cost of ART ranged from US$25 to US$50 per person per month. * As of late 2002, three major local companies-Datlabs, CAPS, and Varichem-were negotiating with foreign companies to manufacture generic ARVs under license. * Pfizer has donated Diflucan to government for free provision to patients. * A 2000 study from Zimbabwe described ART prescribing practices as "therapeutic anarchy"; lack of treatment guidelines, links between private practitioners and specialists, and access to research evidence were all factors contributing to this scenario. Government Initial Response After the first AIDS case in Zimbabwe was identified in 1985, the government's initial response involved the introduction of universal blood screening for HIV. The National Blood Transfusion Service (NBTS) is mandated by the government to collect, test, store, and distribute blood and blood products in Zimbabwe. NBTS has seven centers located in five towns, with headquarters in Harare. It is also one of the two WHO Regional Quality Training Centers in sub-Saharan Africa. HIV transmission via blood products is rare. HIV prevalence in all blood donations decreased from 2.48 percent in 1992 to 0.61 percent in 2001. NBTS recruits most of its donors from high/senior schools (16-19 age group). NBTS also operates two HIV prevention initiatives: Schools Peer Education Program, in which it encourages school-age blood donors to talk about the importance of donating blood and HIV/AIDS issues with their peers, and Pledge25Club for out-of-school youth blood donors who join and pledge to make 25 donations.[114] In 1988, the government created a one-year Short Term Plan (1987-88) that outlined measures to create public awareness about HIV/AIDS and train health workers on prevention and control of HIV. This involved establishment of the National AIDS Coordination Program (NACP) in 1987 by the Ministry of Health and Child Welfare. A five-year Medium-Term Plan (MTP1, 1988-93) outlined plans for behavior change, counseling and care for people with HIV/AIDS, and epidemiological surveillance. (HIV sentinel surveillance was initiated in 1991.) A second Medium Term Plan (MTP2, 1994-98) outlined strategies to reduce HIV/STI transmission and the personal and socioeconomic impact of HIV/AIDS/STI. All these programs of action were the responsibility of NACP. HIV voluntary counseling and testing (VCT) was later introduced to complement and reinforce other behavior change interventions (see below). During this period, the government began to work with several stakeholders such as the public and private sectors, NGOs (national and international), faith-based organizations, and other community groups. Increasing levels of HIV infection, especially among youth, coupled with the many impacts of epidemic, forced the Zimbabwean government to acknowledge that its actions against HIV/AIDS had been inadequate and limited in scope and effectiveness. Among other things, the government had no HIV/AIDS policy until 1999. In addition, the government had faced criticism that although the enormity of the HIV/AIDS epidemic in Zimbabwe has been recognized for some time, the government was slow to acknowledge the scale of the problem and take appropriate action[43, 115, 116] Prior to 2000, for example, President Mugabe rarely mentioned HIV/AIDS publicly; when he did so, it was deemed newsworthy.[117] National HIV/AIDS Policy and National AIDS Council of Zimbabwe (NAC) The government introduced the National Policy on HIV/AIDS in December 1999. According to the government, this followed a broad-based consultative process involving discussions with expert groups and public debate at provincial and district levels over a period of three years. However, SAfAIDS notes that when government created this policy -- as it established the National AIDS Council to implement it (see below) -- there was little consultation with all stakeholders, especially people living with HIV/AIDS.[24] The National Policy on HIV/AIDS encompasses 43 guiding principles, upon which strategies are built. In sum, these principles state that: * HIV/AIDS should be addressed through a multisectoral approach that will be coordinated by the National AIDS Council. All sectors, organizations, and communities should participate actively in the fight against HIV/AIDS utilizing their comparative advantages. * Information and behavior change are the cornerstones of prevention. * The human rights and dignity of all people regardless of their HIV status should be respected. Avoidance of discrimination against PWHA should be promoted. However, because of the stigma still attached to HIV/AIDS, the rights of PWHA need special consideration. It must be recognized that with rights come responsibility. The responsibility to protect oneself and others from HIV infection should be upheld by all people including PWHA. * Providing care and counseling is essential to minimizing the personal and social impact of HIV/AIDS. * Sensitivity to gender and commitment to promoting gender equality should be integrated into policies. * Research should be an integral part of the effort to combat HIV/AIDS.[118] The National AIDS Council of Zimbabwe (NAC) was established as a parastatal body in May 2000 under an Act of Parliament. It is managed by a multisectoral board that was appointed in August 2001. The board comprises representatives from government, NGOs, faith-based groups, the private sector, and the media. NAC's mandate is "to mobilize, coordinate, facilitate and monitor an expanded national multisectoral response to HIV/AIDS as well as ensure maximum transparency and accountability in the management and utilization of resources raised to combat the epidemic." The National Strategic Framework on HIV/AIDS 2000 - 2004, published in November 1999, focuses on district/community response initiatives on HIV/AIDS through community-driven planning, implementation, and monitoring processes. The rationale for formulating a national strategic framework was based on the extent of the HIV/AIDS epidemic in Zimbabwe. The strategic framework calls for greater mobilization of commitment to fight HIV/AIDS from political, civil, economic, and traditional leaders. It argues for an integrated response through a multisectoral participatory mechanism involving relevant sectors and interest groups to ensure accessibility of resources to communities. The community is regarded as the key to addressing HIV/AIDS through sustainable initiatives. To date, NAC has established 10 provincial AIDS action committees (PAACs) and 83 district AIDS action committees (DAACs). (Some districts have gone further to decentralize coordination and financial management to rural administrative wards through ward AIDS action committees.) NAC reports that 83 AIDS Action Plans are being implemented. NAC is also responsible for disbursing funds from the National AIDS Trust Fund through these action committees. Monies for the AIDS trust come from an AIDS levy introduced in 1999 (see sections below). To what degree the national HIV/AIDS policy is being implemented is unclear. NAC, for example, is constrained by inadequate capacity (human and financial resources), overwhelming and competing demands for its services, internal struggles for visibility and power, denial and stigma around HIV/AIDS, and difficulty in bringing different stakeholders together. More generally, given the country's myriad and interrelated crises, the government's motivation and/or ability to focus on and support HIV/AIDS policy implementation is impeded. Zimbabwe's HIV/AIDS policy is also unclear regarding how a multisectoral response will be implemented.[24] In March 2003, the UN Relief and Recovery Unit reported that "a vigorous response" to HIV/AIDS within the context of the current humanitarian crisis in Zimbabwe was lacking: "Despite a supportive environment that has been created for HIV/AIDS prevention, mitigation and care, the vigorous response that is commensurate with the size of the epidemic is not observable - specifically in preventing new infections, extending care for People Living with HIV/AIDS (PLWHA), responding to needs of orphans and vulnerable children ... [or] mitigating the economic and social impacts on communities....The coverage and quality of the HIV/AIDS response was limited and varied, there was also a lack of a sense of urgency and ... weak coordination among partners (government, donors, UN agencies and NGOs) at all levels."[56] Budgets Ministry of Health The Ministry of Health and Child Welfare (MOHCW) was allocated a total budget of Z$22 billion for 2002. This allocation has been inadequate, only meeting health costs for the first eight months of the year; a Z$3billion supplementary budget has since been awarded by the Treasury. However, according to Minister of Health and Child Welfare, Dr. David Parirenyatwa, the supplement is inadequate. The ministry needs an additional Z$5.6 billion to meet the total cost of providing health through the end of 2002. Minister Parirenyatwa states that most of the money would go toward purchasing medical supplies (drugs and equipment) for the country's health institutions and to fighting HIV/AIDS AIDS Levy An AIDS levy is administered by the National AIDS Council. Introduced in 1999 to supplement the MOHCW's HIV/AIDS budget, the AIDS levy is an added tax on all employees and corporations. It is calculated at 3 percent of corporate tax and 3 percent of individuals' income tax. The National AIDS Trust Fund (NATF) was created to disburse the levy revenue to address issues pertaining to HIV/AIDS in general (vs. solely for AIDS treatment and care). To date, the MOHCW has received Z$966 million from these funds to procure and subsidize drugs for opportunistic infections. This support does not cover HAART. The AIDS levy has been a contentious issue. When the government introduced it, objections were raised regarding instituting a levy on taxpayers already experiencing economic hardship. There was concern about whether funds would reach deserving beneficiaries at the grassroots level and avoid being absorbed by government overhead or corruption. Some felt strongly about contributing to a fund from which they would never benefit. Some blamed PLWA for having become infected with HIV "through their own promiscuity." The government responded to these concerns by establishing the National AIDS Fund Trust for disbursement of funds generated by the AIDS levy. Disbursement of the funds was initially haphazard until establishment of provincial and district AIDS committees. Each district is allocated an initial Z$5 million, after which subsequent disbursements are made on submission of satisfactory progress and financial reports. Funds are targeted to prevention, care, support, and mitigation for community members. Some of the funds are used for technical support regarding capacity building, coordination, and monitoring activities at district level. NAC also disburses monies directly to NGOs, research institutes, and government ministries and agencies (e.g., MOHCW, AIDS & TB Program, NECTOI [discussed below], defense, education). For accountability purposes, NAC has made public its disbursements to various sectors and institutions. This information is periodically printed in newspapers. Since the AIDS levy was established, NAC reports that Z$3 billion has been collected as revenue from the tax. Between April 2000 and July 2002, NAC disbursed Z$1.4 billion.[120] However, donors and local AIDS committees continue to raise concerns that disbursements are not reaching local committees and have been politicized (i.e., are being disbursed through ZANU-PF-affiliated channels).[107, 121] For example, in October 2002, Zimbabwe's AIDS Network voiced concerns that the NAC had become politicized.[57] Constraints to School-based AIDS Education * The Ministry of Education, Sports, and Culture plays a critical role in defining the policies that guide efforts directed at HIV prevention. The "AIDS Action Plan in Schools" provides guidelines for all HIV-prevention activities in schools. It promotes abstinence as the exclusive risk-reduction strategy for preventing the spread of HIV/AIDS. According to the Population Council, the document is reluctant to acknowledge that some youth people are sexually active and may choose to use condoms to prevent HIV infection. No public or religious schools in Zimbabwe provide students with condoms on school premises.[41] * The AIDS Action Plan in Schools was initiated by the Ministry of Education, Sports, and Culture in 1992 in collaboration with UNICEF. The program targets students and teachers in all primary (grades 1 to 6) and secondary (grades 4 to 7) schools. A 1995 review of the program found that only one-third of teachers had received in-service training, that teachers were unfamiliar with the new participatory techniques, and that they found topics of sex and HIV embarrassing and difficult to teach.[58] * In the 1990s, Zimbabwe developed the Auntie Stella health education pack for secondary school students. Auntie Stella is a classroom-based pack of question and answer cards that address students' concerns or gaps in knowledge (identified through baseline participatory research) on reproductive health, including rape, sexual harassment, STIs, HIV/AIDS, unwanted pregnancy, and lack of money leading to commercial sex. Students analyze behaviors and participate in exercises to devise action plans for behavioral change and risk reduction. Following field-testing in eight pilot schools, Auntie Stella was slated to be expanded to the national level. However, the Ministry of Education has not approved it for use in schools.[58] Human Rights * Zimbabwe's Labor Relations Regulations on HIV/AIDS were drafted by the Intersectoral Committee on AIDS and Employment, chaired by the Ministry of Public Service, Labor and Social Welfare; Employers' Confederation of Zimbabwe; Zimbabwe AIDS Coordination Program; and several NGOs. The regulations (Code of Conduct on AIDS and the Workplace) were adopted in 1998. They establish the rights and responsibilities of both employers and employees with regard to the prevention and management of HIV/AIDS and its employment consequences. They specifically bar employers from requiring HIV testing as a precondition to employment, termination, or benefit eligibility.[24] * The Labor Relations Regulations on HIV/AIDS provide a minimum standard to which employers may be held accountable. They place the burden of implementation on the employer without discussing ways in which the government and other actors can assist in HIV/AIDS prevention and treatment within the labor force.[24] Moreover, to what degree preemployment HIV testing and HIV/AIDS-related workplace discrimination are occurring is unknown. * In accordance with international guidelines, Zimbabwe's policy places no restriction on travel by HIV-positive persons.[24] * Sexually transmitted infections are a notifiable disease under the Public Health Act (Chapter 15:09). This means that personal details of people found to be HIV-positive are systematically recorded.[24] * The Sexual Offences Act, passed in August 2001, makes marital rape an offence. The act states that persons charged with any sexual offence that could involve the risk of HIV transmission should be required to take a test. The assaulted person should be offered voluntary testing and, where appropriate, treatment by the state. Although the act outlines stiff penalties for, inter alia, marital rape and child trafficking, few test cases have been taken to court as a result of the legislation.[24, 122] * Part V of the Sexual Offences Act addresses the deliberate transmission of HIV. It states that "Any person who, having actual knowledge that he is infected with HIV, intentionally does anything or permits the doing of anything which he knows or ought reasonably to know (a) will infect another person with HIV; or (b) is likely to lead another person becoming infected with HIV; shall be guilty of an offence, whether or not he is married to that person, and shall be liable to imprisonment for a period not exceeding twenty years." In principle, this legislation has been lauded mainly by women and advocacy groups as a positive action by the government to protect vulnerable women. However, there are a number of challenges that prevent the act's implementation, for example, most of those infected with HIV do not know their status, and there may be negative consequences -- especially for women -- who disclose their status. As yet, there has been no test case in the courts for this legislation. * The Children's Act (formerly The Children's Protection and Adoption Bill) provides for the protection, welfare, and supervision of children and juveniles. However, the act's mechanisms for adoption and guardianship are insufficient in light of the children orphaned and otherwise made vulnerable by HIV/AIDS. The act also requires stiff penalties for not sending children to school, but does not take into account the economic burden placed on most families by HIV/AIDS. The Southern Africa AIDS Information Dissemination Service (SAfAIDS) notes that this legislation must be updated and made more comprehensive to address AIDS orphans and OVC.[24] * The Deceased Estates Act provides for maintenance out of the estate of a deceased person for certain members of his/her family. Amendments to the Deceased Estates Succession Act and the Deceased Persons Family Maintenance Act included improved provisions that benefit wives and children. However, the act does not consider grandparents, who may be the only surviving guardians of children, and de facto guardians. Furthermore, the justice system has not been able to enforce the law.[24] * The Class Action Act is designed to assist a group or groups of people to take collective legal action to initiate change. This act can be used to lobby authorities to initiate legislation that takes the interests of PWHA into consideration. Unfortunately, notes SAfAIDS, few people are aware of this law.[24] * As discussed in the Land Reform section, Section 8 of the Land Acquisition Act (fast-track land reform) is resulting in large-scale displacement of populations. The resettlement of large numbers of people has been accompanied by regroupings of family units and exposure to new sexual networks.[24] Declaration of Period of Emergency (HIV/AIDS) Notice, Mid-2002 In June 2002, the government enacted a declaration of a six-month period of emergency (HIV/AIDS) in terms section 34 of the Patents Act [Chapter 26:03]. The declaration notice enables the state or a person authorized by the state to: * make or use any patented drug, including any antiretroviral drug, used in the treatment of persons suffering from HIV/AIDS or HIV/AIDS-related conditions * import generic drugs used in the treatment of persons suffering from HIV/AIDS or HIV/AIDS-related conditions In January 2003, Zimbabwe extended the declaration of emergency on HIV/AIDS by a further five years.[59] Box 3. Role of the Media The Southern Africa AIDS Information Dissemination Service (SAfAIDS) is a center for print and media resources on HIV/AIDS. SAFAIDS also has a resource center at its premises with a database on HIV/AIDS information. SAfAIDS also conducts monthly discussion forums in Harare where HIV/AIDS researchers are invited to present their research (ongoing or complete studies) to share information with peers and the general public. SAfAIDS publishes a news bulletin quarterly and freely distributes it to the public. SAfAIDS analyzed coverage of HIV and AIDS in 570 articles drawn from nine Zimbabwean newspapers over four three-month periods (Nov. 1998-Jan. 1999; Apr. 1999-Jun. 1999; Nov. 1999-Jan. 2000; Apr.00-Jun.00). During the first two collection periods, the prominent themes were (1) prevention and awareness, (2) support for children and orphans, and (3) lack of government policies concerning HIV/AIDS. In the last two collection periods, the major themes were 1) AIDS levy and government strategies for HIV/AIDS, (2) accessing treatment, and (3) women and HIV. The volume of articles decreased over the data collection periods. Although few articles were published on the front page, feature articles and columns on HIV were given greater prominence. The language used to describe HIV/AIDS was frequently negative and stigmatizing. Metaphors of war, disaster, and plagues continue to be used, yet new metaphors such as "AIDS as a business" reveal a change in the HIV/AIDS discourse. HIV/AIDS themes in news articles reflect the concerns of the public in relation to changes in the epidemic. The language and statistics influence the stigmatization of HIV and AIDS. Communicators developing information for the media need to consider new approaches to incorporating HIV/AIDS information in the news media. (Source: Page S. " The coverage of HIV and AIDS in nine Zimbabwean newspapers: A content analysis." Abstract no. TuPeE5096. XIV International Conference on AIDS, Barcelona, July 7-12, 2002.) Donors and Collaborating Institutions Zimbabwe relies heavily on funding from international donors for its HIV/AIDS programs. As previously mentioned, the Government of Zimbabwe is not currently servicing its debt, and most multilateral and bilateral donor resources are being withdrawn or reduced. However, many HIV/AIDS projects continue to be financed by donors. Many bilateral donors have reduced or ended government-to-government assistance, opting to channel aid through NGOs. Major donors for HIV/AIDS include the U.K., U.S., European Union, Germany, and Japan. Norway, Sweden, and the Netherlands sponsor smaller programs. U.N. agencies remain active in Zimbabwe in several sectors, including HIV/AIDS, famine relief, health, education, environment, and governance.[41] The World Bank has suspended disbursements to Zimbabwe.[124] More detail on donor activities is found in the Links section. Global Fund to Fight AIDS, Tuberculosis & Malaria (GFATM) The Government of Zimbabwe has pledged US$1 million to the GFATM.[125] Zimbabwe's 2002 HIV/AIDS proposal was approved for US$10 million over two years (US$14 million maximum over five years). However, Zimbabwe and the GFATM have not yet signed an agreement for the HIV/AIDS grant, and no funds have yet been disbursed.[60] Civil Society Grassroots efforts provide a significant amount of care and support to persons living with HIV/AIDS and their families. NGOs operating in Zimbabwe must register with the Department of Social Welfare under the Ministry of Public Services, Labor and Social Welfare, in compliance with the Private Voluntary Organization Act. The National Association of Nongovernmental Organizations (NANGO) registers both national and international NGOs. There were 62 registered HIV/AIDS service organizations listed in the NANGO Zimbabwe NGO Directory 2000, although this list is far from exhaustive. The Zimbabwe AIDS Network (ZAN) is the coordinating body for HIV/AIDS programs in carried out by NGOs, the government, AIDS service organizations, and private industry. ZAN compiled the Zimbabwe HIV/AIDS Directory 2001, which is a register of NGOs and commercial organizations involved in care and support of HIV/AIDS persons. The Zimbabwe National Traditional Healers Association (ZINATHA) represents herbalists, spirit mediums, faith healers, and traditional midwives. Under the auspices of NAC, it has developed a national HIV/AIDS prevention project using traditional care systems to provide support to those affected by HIV/AIDS, develop traditional methods aimed at reducing HIV transmission, increase awareness of HIV/AIDS for prevention and care of people with AIDS, and create a supportive environment for PLWHA.[126] In April 2003, the Futures Group International, with funding from USAID, launched the Zimbabwe AIDS Policy and Advocacy (ZAPA) Project. The goal of ZAPA is to mitigate the impact of AIDS by strengthening the capacity of civil society organizations to advocate for more effective HIV/AIDS policies.[61] Religious Organizations About 80 percent of Zimbabwe's population is Christian; evangelical denominations have been growing rapidly.[41] Many religious organizations (e.g., Catholic Relief Services, Salvation Army, Zimbabwe Association of Church-Related Hospitals, Organization of African Instituted Churches, German Catholic Bishops Organization for Development Cooperation, World Council of Churches) are carrying out HIV/AIDS projects. Their projects are present in almost every community and play an important role in the emotional, social, and spiritual aspects of the Zimbabwean population. They are active in home-based care, education and awareness, HIV and bereavement counseling, supplementary nutrition feeding schemes for orphans and deprived children, special youth programs, income-generating projects, among many others. Most churches promote abstinence among young people.[41] In their responses to HIV/AIDS, many religious organizations in Zimbabwe need to address stigma and discrimination toward PLWHA. Many still find it difficult to engage in: * discussion about sexual behavior, sexuality, and HIV/STIs * discussion on preventing the spread of HIV, especially condom use * work with marginalized groups, e.g., sex workers and street people[128] Academic and Research Institutes The University of Zimbabwe and other Zimbabwean research institutes collaborate with numerous partners around the world. (See the Links section.) Industry See the discussion of the HIV/AIDS Labor Relations Regulations above. The Southern African Development Community (SADC) has also developed a code of practice on HIV/AIDS and the workplace for its 14 member countries (including Zimbabwe). NAC has established a Business Council on AIDS that is supposed to examine the impact of HIV/AIDS in the private sector and plan appropriate responses. Most employers in both the private and public sector have launched HIV/AIDS education and awareness programs for their employees, including disbursement of free male condoms at the workplace. Peer education programs are being undertaken in collaboration with some HIV/AIDS organizations and/or training institutes. For instance, the Zimbabwe AIDS Prevention Project (ZAPP), a research project of the University of Zimbabwe's Department of Community Medicine, offers HIV surveillance, HIV counseling, and condom distribution in the workplace through peer education. Zimbabwe's Delta Corporation is providing ART to 10 employees.[62] De Beers Zimbabwe Prospecting plans to introduce ART coverage for its southern African employees in 2003.[133] Zimbabwe's National Employment Council for the Transport Operating Industry (NECTOI) is a quasigovernmental organization under the Ministry of Labor. In 1992, it established an HIV/AIDS program, which involves increasing AIDS awareness, promoting condom use, and supporting and strengthening the capacity of transport companies to respond to the epidemic. NECTOI also participates in HIV/AIDS research with various institutions such as the University of Zimbabwe. NECTOI received funding from the national AIDS levy. Other firms involved in HIV/AIDS programs (from the Zimbabwe HIV/AIDS Directory 2001): * Astra Holdings Limited: annually funds STI/HIV/AIDS activities, e.g., peer education training, counseling, and home-based care. * Commercial Farmer's Union (CFU): funded by the Royal Netherlands Embassy and other fund-raising activities, CFU supports programs focusing on HIV prevention among commercial farm workers, e.g., IEC materials, peer education for in- and-out-of-school youth, workplace counseling, condom procurement and distribution, research, and home-based care. * David Whitehead Textiles (DWT): With a Z$3 million clinic budget, focuses primarily on AIDS awareness through peer education in the workplace and other activities such as counseling, research, support groups for PLWA, and condom procurement and distribution. * Financial Holdings (FINHOLD): Funds workplace activities on HIV prevention through awareness campaigns, counseling, condom procurement and distribution, home-based care, and general IEC. Donated $10 million to the National Aids Council through the Zimbabwe National Chamber of Commerce for AIDS awareness programs.[134] * National Railways of Zimbabwe (NRZ): AIDS budget of Z$1.5 million funds HIV/AIDS/STI prevention in the workplace through peer education. HIV Prevention Trials Network Current studies include: * HPTN 052: A Randomized Trial to Evaluate the Effectiveness of Antiretroviral Therapy Plus HIV Primary Care versus HIV Primary Care Alone to Prevent the Heterosexual Transmission of HIV-1 in Serodiscordant Couples * * HPTN 046: Phase III Trial to Determine the Efficacy and Safety of an Extended Regimen of Nevirapine in Infants Born to HIV Infected Women to Prevent Vertical HIV Transmission During Breastfeeding * HPTN 039: Phase III, randomized, double-blind, placebo-controlled trial of acyclovir for the reduction of HIV acquisition among high risk HSV-2 seropositive, HIV-seronegative individuals * HIVNET 016A: Condom Promotion and Counseling Study * HPTN 035: Phase II/IIb Safety and Effectiveness Study of the Vaginal Microbicides BufferGel and 0.5% PRO2000/5 Gel (P) for the Prevention of HIV Infection in Women[63] Voluntary Counseling and Testing (VCT) Zimbabwe's national HIV/AIDS policy considers counseling to be a vital component of HIV/AIDS prevention and care and addresses VCT in depth.[24] The Zimbabwe AIDS Prevention and Support Organization (ZAPSO) opened the first VCT center in Zimbabwe in 1998. Its Chitungwiza center manages four VCT centers in and around Harare, with support from UNFPA. ZAPSO is currently extending VCT services to rural areas through Catholic mission hospitals.[64] A report published by WHO in July 2002 estimated that 97,375 people in Zimbabwe received VCT in 2001, with 16 public/NGO VCT sites operating. WHO estimated that only 10 percent of the population in need of VCT services was receiving them.[135] According to Zimbabwe's 1999 DHS, 11.8 percent of women report having been tested for HIV (urban: 16.8 percent; rural: 8.6 percent). Among those not tested, 59.1 percent would like to be tested. Among men, 9.2 percent report having been tested for HIV (urban: 13.1 percent; rural: 6.3 percent). Of those not tested, 56.8 percent would like to be tested. Among women who have not been tested for HIV, 63.4 percent do not know a source for HIV testing. Among men, the comparable figure is 66.5 percent.[65] In 1998, the Government of Zimbabwe asked USAID to help identify best practices from countries that had achieved declining HIV infection rates. Missing elements in Zimbabwe were VCT services and sustained messages on behavior change. USAID, in collaboration with Population Services International (PSI) and the Government of Zimbabwe, launched 10 New Start VCT centers at strategic locations throughout the country.[136] USAID established and continues to support 10 VCT sites in Zimbabwe. These 10 New Start sites counseled and tested over 50,000 clients in 2001.[136] Since launching the first center, New Start has expanded into a network of 14 centers throughout Zimbabwe. The average number of people visiting the centers increased from 230 a month in 1999 to over 5,000 a month in 2002. [66]The VCT program is complemented by a USAID-supported media campaign that encourages individuals and couples to learn their HIV status and uses posttest services to promote and maintain positive behavior change.[136] USAID reports that in Zimbabwe, VCT has achieved the highest client return rate of any USAID-supported VCT program, due, in part, to the high quality of counseling and the relatively low fee of US$0.75 that clients pay for pre and posttest counseling, and three follow-up visits. The newest independent VCT site is managed by PSI using "business franchise" techniques. It is located in downtown Harare near a bus terminal, open 12 hours a day, seven days a week, including public holidays.[136] According to PSI, New Start VCT centers will be expanded to reach more rural areas and will offer outreach services in partnership with other NGOs.[67] Other research on VCT: * Researchers from the University of California and the University of Zimbabwe conducted a randomized, controlled study to assess the impact of a short counseling session on partner referral was conducted at two large public clinics in Harare. The intervention comprised an individualized confidential session with a trained counselor; standard care (control) relied on the treating clinician to discuss partner referral. The intervention increased notification of spouses for both men and women: 90 percent reported that they notified spouses, 53 percent notified regular partners, 22 percent notified casual partners, and 18 percent notified sex work partners. Motivating factors for women to notify their partners were to prevent reinfection, prevent infection to fetuses, address infidelity, and access money for treatment. Men were motivated to notify partners to avoid infertility, stop recurrence of painful sores, and because they felt unable to use condoms with regular partners. Both men and women mentioned fear of accusation of infidelity as a barrier to partner notification.[137] * In scaling up VCT, the Zimbabwe AIDS Prevention and Support Organization (ZAPSO) adopted a participatory approach in the planning and implementation stage of the project cycle. ZAPSO found that the high response rate and attendance showed a great willingness to participate in HIV prevention initiatives at a community level.[138] * Tsungirirai AIDS Service Organization, in collaboration with Pact Zimbabwe, undertook a posttest support services program known as the "Moving On ..." Club. The aim was to reduce stigma and discrimination surrounding HIV/AIDS. Membership in the Moving On... Club is open to anyone who takes an HIV test. Club members meet on fixed days to share experiences and support one other.[59] Female-controlled Prevention Technologies Female Condom In 1993, the University of Zimbabwe's Department of Community Medicine received funding from WHO to conduct an acceptability study of the female condom in Zimbabwe. In 1996, based on the findings of acceptability trials and as a result of advocacy efforts by the Women and AIDS Support Network, the Zimbabwe National AIDS Coordination Program invited Population Services International (PSI) to initiate a five-year female condom social marketing program in Zimbabwe. USAID and DFID provided funding for the program, which was launched in July 1997. The female condom was marketed as a family planning product or contraceptive sheath under the brand name care. The female condom was initially sold through selected pharmacies and clinics at a heavily subsidized retail price of US$0.24 for a box of two; distribution has since expanded to other urban outlets, including large supermarkets and convenience stores. An assessment of the female condom conducted by the Horizons Project of the Population Council and PSI found that the users of the female condom were generally in their mid- to late twenties and, compared to male condom users and nonusers of either method, had higher levels of education and access to household resources. Use of the female condom was higher within the context of marriage or regular partnerships, rather than casual or commercial partnerships. Married women were more likely than single women to encounter partner resistance to the female condom and less likely to report future use. They also were less likely than single women to have used male condoms prior to trying the female condom and less likely to be consistent female condom users. Novelty or experimentation and pregnancy prevention were primary reasons for initial use of the female condom. However, one-third of men and one-fifth of women reported STI/HIV prevention as a motivator for trying the female condom. Both male and female users agreed that women, more so than men, initiate dialogue about using the female condom, decide on its use, and procure it. Users of the female condom often continue using male condoms. Choice of method was often driven by the context of the situation. Although users of the female condom perceived it to be effective and reliable both as an STI/HIV and pregnancy prevention method, 30 percent of men and 57 percent of women reported some difficulty with use, such as problems with insertion, discomfort during sex, noise or squeakiness during use, and excess lubrication. Thirteen percent of women reported using the female condom without their partners' knowledge. Although this suggests that for some women the female condom can be totally under their control, in most cases the female condom requires communication with and cooperation from a woman's partner.[139] The University of California San Francisco, University of Zimbabwe, and CDC conducted a study of married Zimbabwean women recruited from family planning clinics in Harare to examine use of and preference for three HIV/STD prevention methods (male condom, female condom, and spermicide). They found that offering women multiple prevention options increased the reported percentage of sex acts protected by any method. Most women preferred the male condom (58 percent) and least liked the female condom (48 percent).[140] The 1999 ZDHS found that 82.1 percent of women and 83.4 percent of men did not know where to find the female condom.[7] Zimbabwe's Women's AIDS Support Network reports that the current cost of the female condom is Z$55 and that it is primarily available in pharmacies. Three male condoms cost Z$5 (or are available for free) and are more widely available. WASN found that the high cost of the female condom is leading many Zimbabwean women, particularly sex workers, to reuse it to save money. WASN found that female condoms were reused after being cleaned with beer, urine, water, or detergents.[141] Family Health International has provided a useful, detailed discussion of reuse of the female condom.[142] Microbicides A phase I clinical trial of Buffergel has been completed. In total, 98 women (30 sexually abstinent and 68 sexually active) were enrolled. Overall compliance with product use was 93 percent. Epithelial abnormalities detected by pelvic examination or colposcopy were uncommon (8 cases in 271 examinations). Approximately one-quarter of participants (0.58 events per woman-week) reported irritation, but this was generally mild and of short duration. The prevalence of bacterial vaginosis fell significantly, from 30 percent at enrollment to 6 percent at one week, and 7 percent at two weeks of BufferGel use. Thirty-two women acquired microscopically detectable yeast during BufferGel exposure, but only three developed symptomatic vaginitis. Given that BufferGel appeared to be safe and well tolerated by the cervicovaginal epithelium[68], a phase 2/2B study of the safety and effectiveness of BufferGel and PRO 2000/5 Gel (P) is currently taking place in Chitungwiza, Harare.[69] Diaphragm UCSF, UZ, and CDC have also been examining acceptability of the diaphragm http://www.uz-ucsf.co.zw/research/researchprojects/current/diaphragm.html as potential HIV prevention tool. Preliminary findings presented in Barcelona in July 2002 indicated both Zimbabwean men and women generally accepted the diaphragm with K-Y Jelly. Although the majority preferred male condoms because of their known efficacy against HIV, most women felt protected and empowered through use of the diaphragm. All participants reported that they were willing to use the diaphragm if proven effective against HIV.[144] In August 2002, the Gates Foundation awarded US$28 million to the University of California San Francisco to continue testing the diaphragm as a potential prevention method for HIV/other STIs.[145] Prevention Interventions with an Economic Component Aimed at Young Women * The University of California San Francisco and University of Zimbabwe are undertaking the Adolescent Livelihood Study http://www.uz-ucsf.co.zw/research/researchprojects/current/adolescent.html to examine the socioeconomic and behavioral determinants of participating in compensated sexual relationships. * The International Labor Organization is integrating an AIDS education component to its microfinance and entrepreneurial skills training projects for women in Zimbabwe (as well as Malawi, Mozambique, and Tanzania).[5] * Findings from a project in which girls are given scholarships ($US6 a year per girl) to attend a local high school in rural Zimbabwe were presented in Barcelona in July 2002. The girls also worked with HIV/AIDS patients in the local rural hospital and were matched with older women hospital employees to talk about sexual decisions. Girls from the program report later sexual debut and less sexual abuse and feel they have more options concerning sexual encounters, birth control, and HIV/AIDS than girls who must drop out of school after grade 7.[146] * The Horizons Council of the Population Council has examined microfinance interventions aimed at households coping with chronic illness and death. The study centered on Zambuko Trust, a Zimbabwean NGO that provides small loans and training to established microentrepreneurs, most of whom are women. Findings suggested that Zambuko client households (which may include HIV-infected members) had a greater number of income sources and improved savings patterns. These results may be partly attributable to participation in Zambuko's business management training. However, the study also highlighted that microloans can be an added burden for households struggling with chronic illness and death.[147] * The United Nations Foundation has launched a youth and HIV/AIDS prevention initiative in southern Africa, with local NGOs and donor agencies. In Zimbabwe, adolescent girls are provided with peer education and access to microcredit information. The project has also provided enhanced community support for orphans. Orphans and Other Vulnerable Children There are numerous NGOs and CBOs providing support to orphans and other vulnerable children. Projects encompass psychosocial and economic support. See the list of NGOs and CBOs in the Links section. Other sources of information on orphans and OVC include: * Association François-Xavier Bagnoud, AIDS Orphans Assistance Database http://orphans.fxb.org/db/index.html * World Bank, Early Child Development Team, Children and Caregivers Affected by HIV/AIDS Resources http://www.worldbank.org/children/hiv.html Care and Support Numerous CBOs in Zimbabwe provide care and support services to PLWHA. Recently, Zimbabwe launched an HIV/AIDS Quality of Care Initiative. The main purpose is to work in partnership with government, NGOs, the private sector, religious groups, and others to improve the quality of care of those infected with or affected by HIV/AIDS.[148] Prevention of Mother-to-Child Transmission (PMTCT) WHO estimated that as of the end of 2001, only 4 percent of Zimbabweans in need of PMTCT services was receiving them.[135] According to Zimbabwe's GFATM proposal, submitted in January 2002, four districts had PMTCT services in 2001 and services across the country were deemed negligible. With GFATM financing, the government's target for 2002 was to have 30,000 pregnant women counseled and tested for HIV; by 2004, this figure would rise to 70,000. The GFATM grant would also fund expansion of ART for PMTCT.[70] Zimbabwe's first PMTCT project was a short-course, AZT pilot project initiated by the U.N. and Government of Zimbabwe in 1999 in three urban maternity clinics (Bulawayo, Chitungwiza, and Harare). The core activities involved VCT, provision of AZT, safe obstetrical practices, and a modified breast-feeding (no formula) regimen. Some of the outcomes of the pilot project included low uptake of testing, poor compliance with AZT, confusion regarding infant feeding, and overburdening of health workers. Both participants' partners and the local community felt excluded from project decision-making; there was inadequate information about PMTCT; the existing infrastructure at clinics was not conducive to confidential VCT; and there was no follow-up of babies. Subsequently, the MOHCW extended PMTCT activities to other areas in Zimbabwe, such as Epworth (a periurban residential area 20 km from Harare) and rural areas of Murambinda and St. Alberts. Other PMTCT projects include: * In 1999, ZAPP launched a PMTCT pilot project in Chitungwiza at Seke North and St Mary's clinics (collaborators include University of Zimbabwe's Department of Pediatrics, and Stanford University School of Medicine). The project offered free VCT services to pregnant women and their partners, a free short-course AZT regime to HIV-positive mothers, and subsidized formula for the mothers who opted not to breastfeed. Pre- and posttest counseling is provided by community volunteers trained by the project. ZAPP's Chitungwiza PMTCT project is now funded by the Elizabeth Glaser Pediatric AIDS Foundation/Call to Action. * Since May 2001, the Kapnek Charitable Trust has been working with MOHCW on a PMTCT project in Epworth, This project has experienced some constraints, including poor infrastructure (sanitation, water, roads); unaffordable maternity fees; and lack of easy access to the clinic. * A PMTCT project was launched in August 2001 at the Murambinda Mission Hospital (Buhera District). It is funded by the Elizabeth Glaser Pediatric AIDS Foundation. Currently, the EGPAF is supporting PMTCT activities in: ? Buhera District: Birchenough Bridge Hospital, Buhera Rural Hospital and Nyashanu Clinic ? Chitungwiza: Seke North Clinic, Seke South Clinic, St Mary's Clinic, and Zengeza Clinic ? Epworth: Epworth Clinic ? Harare: National Expansion/Training and Training Manual Development ? Murambinda: Murambinda Mission Hospital ? Murewa District: Murewa District Hospital, Murewa Polyclinic, Musame Mission Hospital and Madamombe Clinic ? National: Chivu, Kariba, Makoni, Mudzi, Nyanga, Rusape, and Sadza[71] * The Zimbabwe Vitamin A for Mothers and Babies Project (ZVITAMBO) is managed by Johns Hopkins University and funded by USAID. It includes an infant feeding component that addresses costs associated with feeding options, availability of replacement foods, potential stigmatization of women who choose not to breastfeed, and caregivers' ability to properly breastfeed, express and heat-treat breastmilk, and prepare commercial infant formula. In January 2002, the government launched the PMTCT Program, through the MOHCW and NAC (using funds from the AIDS levy). MOHCW funds 60 to 70 percent of PMTCT activities and coordinates all PMTCT programs. Donors either support individual sites (see examples below) or provide resources to the national office to enhance capacity to implement and coordinate activities. The program offers free VCT to pregnant mothers and free nevirapine at the time of labor in a single dose. The supplies of VCT HIV testing kits are donated by CDC. Nevirapine is provided free by the manufacturer, Boehringer-Ingelheim, through at least 2005. Because of personnel and training (counseling and testing) constraints, the program is not yet available in all maternity units. However, in Harare, all public and private sector maternity units have access to free nevirapine. All sites offering PMTCT must be approved and registered by the AIDS & TB Unit within MOHCW. In September 2002, the Minister of Health and Child Welfare announced that nevirapine to prevent MTCT was being administered at 34 institutions (of the 59 that had qualified for the PMTCT program).[149] In October 2002, Dr. Inam Chitsike, head of the MOHCW's MTCT Prevention Unit, reported that although 90 percent of pregnant women agree to be tested for HIV during a prenatal visit, many women do not return to or call the clinic to learn their test results. According to Chitsike, many women fail to learn their results because they are "too frightened" of the reaction they might receive from spouses or their communities.[150] Another constraint is that knowledge of NVP is limited, both among pregnant women and some health care providers.[151] Other challenges include: * improving counseling strategies * mobilizing communities to support the program (ensuring community ownership, overcoming stigma) * addressing human resource shortages * identifying an appropriate infant feeding method * providing care beyond PMTCT (as of October 2003, there were no Zimbabwean sites participating in MTCT-Plus, http://www.mtctplus.org/project.html) To resolve some of these challenges, the MOHCW has established a Partner's Forum, where all partners of women participating in PMTCT meet monthly to discuss pertinent issues.[152] Treatment of OIs and ART Currently, between 200 and 2,000 Zimbabweans are receiving some form of ART (of highly variable quality and with highly variable levels of adherence) through the private sector and clinical trials. The 2000 Essential Drugs List of Zimbabwe (EDLIZ) provides treatment guidelines for the most common health conditions, including OIs. The European Union provides support for NatPharm, the national pharmaceutical agency, and for essential drug supplies to NatPharm. The EU does not finance ARVs, but does fund many medications for OI prophylaxis and care, including TB treatment. In 2003 and 2004, the EU anticipates supplying 26 million euros worth of essential drugs to Zimbabwe. Zimbabwe's National Drugs and Therapeutics Policy Advisory Committee established the Antiretroviral Therapy Subcommittee, which has produced draft ART guidelines, including laboratory tests and recommendations for patient monitoring. The government's (draft) Plan for the Nationwide Provision of ART calls for detailed implementation strategy to be developed for all aspects of ART. It recommends that ART be introduced initially at a limited number of central sites and gradually decentralized to provinces as more health personnel receive in-service training. The first four suggested pilot sites are Harare and Mpilo Central hospitals, Wilkins Infections Diseases Hospital, and the Genitourinary Center in Bulawayo. Under this plan, an estimated 7,500 patients would begin treatment at these four sites in the first three months. After three months, ART would be initiated in a further three hospitals (Parirenyatwa, United Bulawayo, Chitungwiza), followed three months later by provincial hospitals (sites not yet specified).[72] In October 2002, a USAID-supported mission implemented by JSI/DELIVER conducted a comprehensive assessment of technical requirements for Zimbabwe's National AIDS Treatment Program. In May 2003, DELIVER presented its findings. "There is tremendous interest at the national level and within specific facilities to expand HIV care to include the full spectrum of care and support, including ART. The public and private sectors have a great depth of experience that will serve as an excellent foundation for initiating and expanding ART....Given the success of the TB program, the ever-increasing number of clients visiting VCT sites in both urban and rural areas, and especially the willingness to improve logistics systems, Zimbabwe is well ahead of many countries in its capacity to implement a national ART program." [62] GFATM In its 2002 GFATM proposal, the government requested US$2.2 million for antiretroviral drugs and US$1.5 million for logistics and training support for 2002-04. This support is intended to assist with: * operational research to scale up HAART in urban Zimbabwe and pilot implementation in rural districts * establishment of clinical reference center of excellent and national referral center * establishment of national HIV reference lab[70] With GFATM financing, the government is aiming to have 1,000 PWLHA on ART by 2004 (NB: that was stated objective in January 2002 proposal; given ART price reductions, increased availability of generics, inflation, other economic factors, these target figures may change).[70] CDC Since August 2000, CDC has provided support for: 1. PMTCT efforts, including development of warehousing and logistic contract for rapid HIV test kits and ARVs used for PMTCT (mainly NVP donated by Boeringer-Ingelheim) 2. development of draft patient monitoring forms and software for clinical management of ARV patients 3. provision of equipment and training for HIV testing, PCR, CD4+ count monitoring, and HIV viral load determination at National Microbiology Reference Laboratory and agreement to support laboratory testing for an intensive first-year of training, monitoring, and evaluation of national protocols and operations of NATP 4. development of cooperative agreement with Sharing Health Empowerment (SHE), trust formed to support HIV Clinicians Association (subcommittee of Zimbabwe Medical Association) for training of Zimbabwe practitioners to promote improved HIV care, especially ARV treatment[73] * general, palliative, and home-based care: 1. cooperative agreement with UZ Clinical Epidemiology Unit for HIV/AIDS Quality of Care Initiative (HAQOCI) 2. collaboration with Island Hospice, Hospice Association of Zimbabwe, and other groups to support strengthening of home-based and palliative care 3. provision of immediate equipment and commodity needs of AIDS service providers [73] * Tuberculosis care and prevention[73] * Other OIs 1. Support through HAQOCI of new OI Infection Prevention Clinic at Harare Central Hospital 2. collaboration with Pfizer as key technical partner assisting in development of Diflucan Partnership Program [73] CDC has committed US$450,000 to work with MOHCW on pilot implementation of the National Antiretroviral Therapy Program at Harare Central and Mpilo hospitals involving 400 patients over one year.[73] Since October 2001, UZ and MOHCW have been working with CDC on the HIV/AIDS Quality of Care Initiative. Its objectives: 1. develop clinical epidemiology infrastructure 2. develop broad and specific framework and partnership strategies 3. develop baseline assessments for HIV/AIDS quality of care 4. provide support for research projects on health services and operational research addressing questions re: HIV/AIDS quality of care improvement 5. strengthen training in clinical epidemiology, focusing more on capacity building for HIV/AIDS research and care[74] University of Zimbabwe The University of Zimbabwe is providing leadership and expertise in HIV care and training and clinical research involving ARVs and other aspects of HIV care. It will play a major role in the national ART program with laboratory support, monitoring, pharmacy and logistics expertise, and specialty consultation. UZ and the HIV Clinicians Association, a private practitioners' organization, are currently developing centers of excellence on HIV/AIDS care.[72] The Rockefeller Foundation supports UZ's Department of Community Health's DART study, which aims to treat 1,000 PWLHA in Harare with ART.[72] Other Partners * The J.F. Kapnek Charitable Trust finances the Pediatric AIDS Fund-Zimbabwe, a pilot PMTCT project utilizing nevirapine, implemented in conjunction with MOHCW, NAC, ZAPP, Global Strategies for HIV Prevention, and the Elizabeth Glaser Pediatric AIDS Foundation/Call to Action Program. [72] Cost * In September 2002, GlaxoSmithKline announced that it had reduced the price for several HIV/AIDS and malaria drugs in Zimbabwe by 15 to 33 percent. In September 2002, Zimbabwe's Antiretroviral Therapy Subcommittee estimated that the cost of ART ranged from US$25 to US$50 per person per month.[72] * As of late 2002, three major local companies-Datlabs, CAPS, and Varichem-were negotiating with foreign companies to manufacture generic ARVs under license.[62] * Pfizer has donated Diflucan to government for free provision to patients. [62] * Both private distributors and NatPharm considering importation of generic ARVs. Some private distributors, such as Independent Health Care and Geddes, have significant experience importing them. [62] * There is long-term prospect of regional pooling through entities such as SADC, wherein countries in subregion buy drugs in bulk.[62] * See Appendix D of the JSI/DELIVER report for list of ARVs registered in Zimbabwe: Clinical Criteria for Starting ART * Per the latest draft of Zimbabwe's Plan for the Nationwide Provision of ART (September 2002): "If the patient's CD 4 lymphocyte count is less than 300/mm3 then treat with ART as described above. If the patient's CD 4 lymphocyte count is more than 500/mm3 then do not start ART but follow the patient on a regular basis at least 3 to 6 monthly and perform CD 4 lymphocyte counts every 3 to 6 months. Should the CD 4 counts fall below 300/mm3 then commence ART as described. If the patient's CD4 counts are between 300 and 500/mm3 and the patient wishes to consider taking antiretroviral therapy then refer him for specialist opinion and discussion of the pros and cons of taking ARVs at this time. This may apply to some patients who have already commenced on ARVs prior to this programme being implemented."[72] Current Challenges in Prescribing Brugha highlights that recent reductions in the price of ARVs and rapid increase in legal distribution will inevitably increase illegal leakage into the private sector. He cites examples of uncontrolled use private sector. For example, a 2000 study from Zimbabwe reported that one-quarter of 68 private physicians were prescribing ARVs and one-quarter of 80 pharmacies were dispensing them to patients, although insurance companies did not reimburse for their use. The authors described prescribing practices as "therapeutic anarchy," with prescribers and dispensers using "any ARV that they could lay their hands on." Monotherapy, stocked by 82 percent of pharmacies, was prescribed to 17 percent of patients. Most of the 92 patients interviewed believed that ARVs cured HIV infection. Lack of treatment guidelines, links between private practitioners and specialists, and access to research evidence were all factors contributing to this scenario.[75] Links Queries concerning links may be sent to the project director: Lgarbus@psg.ucsf.edu References 1. Zimbabwe National AIDS Council, AIDS in Africa during the Nineties: Zimbabwe: A Review and Analysis of Surveys and Research Studies, http://www.cpc.unc.edu/measure/publications/special/zimbabwe_aids.pdf. 2002, Zimbabwe Ministry of Health and Child Welfare, The MEASURE Project, and CDC/Zimbabwe. 2. AIDS & TB Programme, National Survey of HIV Prevalence Among Women at Antenatal Clinics in Zimbabwe, 2000. PowerPoint presentation. 2001, Zimbabwe Ministry of Health and Child Welfare (with support from Zimbabwe-CDC AIDS Program). 3. Kububa, P., et al. First Suggestion of a Decline in HIV Prevalence in Zimbabwe? in XIV International Conference on AIDS. 2002. Barcelona. 4. Personal Communication with Dr. Tsungai Chipato, senior lecturer, Department of Obstetrics and Gynecology, University of Zimbabwe. 2002. 5. UNAIDS, Report on the Global HIV/AIDS Epidemic, http://www.unaids.org/barcelona/presskit/barcelona%20report/table.htm. 2002, UNAIDS: Geneva. 6. UNAIDS, Report on the Global HIV/AIDS Epidemic, http://www.unaids.org/epidemic_update/report/Epi_report.htm. 2000: Geneva. 7. Zimbabwe Central Statistical Office, Zimbabwe Demographic and Health Survey 1999. 2000, Macro International: Calverton, Md. 8. Stanecki, K.A. The AIDS Pandemic in the 21st Century. Draft report, http://www.usaid.gov/pop_health/aids/Publications/docs/aidsdemoimpact.pdf. in XIV International AIDS Conference. 2002. Barcelona. 9. Walker, N., B. Schwartländer, and J. Bryce, Meeting international goals in child survival and HIV/AIDS, http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12147371&dopt=Abstract. Lancet, 2002. 360(9329). 10. Haacker, M., The Economic Consequences of HIV/AIDS in Southern Africa, http://www.imf.org/external/pubs/ft/wp/2002/wp0238.pdf. 2002, IMF Working Paper 02/38: Washington, DC. 11. Gregson, S., B. Zaba, and S.C. Hunter, The Impact of HIV 1 on Fertility in Sub-Saharan Africa: Causes and Consequences. Background paper prepared for the Expert Group Meeting on Completing the Fertility Transition, http://www.un.org/esa/population/publications/completingfertility/Zabapaper.PDF. 2002, Population Division, Department of Economic and Social Affairs, United Nations Secretariat, March 11-14, 2002: New York. 12. Personal communication with Dr. Godfrey Woelk, professor, Department of Community Medicine, University of Zimbabwe. 2002. 13. Personal communication with Dr. William McFarland, director, HIV Seroepidemiology Unit, San Francisco Department of Public Health. 2002. 14. Johnson, L. and D. Budlender, HIV Risk Factors: A Review of the Demographic, Socio-economic, Biomedical and Behavioural Determinants of HIV Prevalence in South Africa. 2002, University of Cape Town, Center for Actuarial Research. 15. Bloom, S., et al., Community effects on the risk of HIV infection in rural Tanzania, http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12181463&dopt=Abstract. Sex Transm Infect, 2002. 78(4): p. 261-66. 16. Bureau of African Affairs, Background Note: Zimbabwe, http://www.state.gov/r/pa/ei/bgn/5479.htm. 2002, U.S. Department of State. 17. Decosas, J. and N. Padian, The profile and context of the epidemics of sexually transmitted infections including HIV in Zimbabwe, http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12083446&dopt=Abstract. Sex Transm Infect, 2002. 78(Suppl 1): p. i40-6. 18. WB, Zimbabwe Country Brief, http://www.worldbank.org/afr/zw2.htm. 2001, World Bank. 19. Human Rights Watch, Fast Track Land Reform in Zimbabwe, http://www.hrw.org/reports/2002/zimbabwe/. 2002. 20. WB, Republic of Zimbabwe: Urban Sector and Regional Development Project, http://www-wds.worldbank.org/servlet/WDSContentServer/WDSP/IB/2002/08/16//000094946_02071104014987/Rendered/PDF/multi0page.pdf. 2002, World Bank. 21. Zimbabwe: Mugabe says white farmers must go. 2002, IRIN/UN Office for the Coordination of Humanitarian Affairs. 22. Zimbabwe: Farming uncertainty continues. 2002, IRIN/UN Office for the Coordination of Humanitarian Affairs. 23. Association for Women's Rights in Development, How Can Zimbabwe's Land Resettlement Program Be Made Gender Sensitive? Interview with Ms. Abby Mgugu of Zimbabwe's Women Land and Lobby Group, http://www.awid.org/fridayfile/msg00065.html. 2002. 24. The POLICY Project/The Futures Group International, National And Sector HIV/AIDS Policies In The Member States Of The Southern Africa Development Community, http://www.policyproject.com/pubs/countryreports/SADC.pdf. 2002, Southern African Development Community (SADC),. 25. POLICY Project, HIV/AIDS in Southern Africa: Background, Projections, Impacts and Interventions, http://www.policyproject.com/pubs/countryreports/SoAf10-01.pdf. 2001, The Futures Group International: Washington, DC. 26. Muzvidziwa, V., Forging new identities: Globalization, cross-border women traders and regional integration, in Towards an African Economic Community, S. Asante, F. Nwonwu, and V. Muzvidziwa, Editors. 2001, Institute of South Africa: Pretoria. 27. Ntseane, P.G., Informal women's cross-border networks in the Southern African region: The case of Botswana small businesswomen, in Pan-Africanism and Integration in Africa, I. Mandaza and W. Nabudere, Editors. 2002, SAPES: Harare. 28. Cowan, F., L. 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