What was missing from Dr. Murungi’s presentation was the time to discuss the sort of prevention messages that were being spread most in Zimbabwe in the late 90’s and early 2000’s — and who was doing it. This was not a prospective study so the association with programmes in operation there today is tenuous at best.
What is also interesting is that most of the data suggesting that there had been a change in behaviour come from the last five or six years, while the most recent data suggesting that there has been a decrease in incidence came from the years 2000 and 2001 suggesting that the incidence had in fact been falling over the course of the late 1990’s (while mortality was rising).
It would be useful for someone to compare and contrast what has happened in Zimbabwe with what is going on in Botswana, where despite massive efforts and funding spent on ABC-based prevention messages, the HIV prevalence in Botswana remains extremely high (38.5%) according to the UN report.
Again the effects of such a high mortality rate in Zimbabwe need to be considered. Over the course of the PEPFAR meeting, there was much talk about “creating enabling environments” that support and encourage people to abstain or be faithful or use condoms consistently. Well, history has shown that observing large numbers of people sick and dying of HIV can be a powerful motivator for changing behaviour. It is not a for-mula for enabling HIV prevention that any sane person would promote however.
There could also be a host of other negative “enabling” factors that played a part in the reported behaviour change. Its important to remember that this is, after all, Zimbabwe. Since the year 2000, Zimbabwe’s economy has ground to a halt; the country suffered from floods, followed by severe drought and endemic food insecurity. In this context it is odd, to say the least, that the official mortality rate reported peaked before all that trouble began. But even if famine and inflation didn’t increase the numbers of people dying, the calamity would have increased the costs of caring for a person with HIV tremendously.
People with AIDS have a tendency to return for care in their home villages but caring for a person with AIDS is difficult enough for a rural family in a time of plenty —during a time of hardship, the family can be strained to the breaking point. This usually increases stigma from which people with HIV suffer. In another study at the Implementers meeting, a team from Population Services International reported some of the challenges trying to work with and empower people living with HIV and AIDS (PLWHA) in Zimbabwe, who they reported experienced high levels of shame, blame and enacted stigma during this period. According to the presentation, in 2005, terms used to describe people with HIV in Zimbabwe included phrases such as “in the departure lounge,” “crossed the red robot,” and “bewitched by goblins.”
No wonder young people in Manicaland don’t want to go that route.
It can also be challenging to organise prevention work in Zimbabwe in the current political climate. For example, Catholic Relief Services has been working with orphan girls in Zimbabwe, who because of the disruption of normal patterns for their domestic and sexual education (loss of aunties to illness, etc.) are poorly informed about reproductive health and general protection issues. However, “local authorities can be politically sensitive to gatherings of youth,” a poster at the Implementer’s meeting reported, and any educational efforts they put together had to “work under the radar.” In fact, many foreign non-governmental organisations have complained about the difficulty of working in Zimbabwe over the last several years — which lends some credence to Dr.Mark Dybul’s (Acting US Global AIDS Coordinator) assertion (in a press conference at the meeting) that the church is often the only organisation with “reach” into some countries.
But the collapsing economy could have additional effects that could decrease mobility (and therefore risk of HIV infection). Unemployment has sky-rocketed in Zimbabwe, and there have been major petrol shortages. The commercial mining sector has collapsed, and factory work has evaporated. Cities no longer offer much work. (It would be interesting to know what has happened to HIV prevalence in the general population in the cities during this period.) So as a result of Zimbabwe’s economic contraction, many of the old hotspots for HIV trans-mission — near the factories and mines, at truck stops along the highway — could be dwindling or people no longer have a reason or the means to go there.
Finally, many of those with the means to get out and look for work have poured into neighbouring countries, including Botswana, and South Africa. Hundreds of thousands of adults in their prime working years (who may represent a substantial proportion of the sexually active and possibly HIV-infected population) have simply left the country. And yet, so far, no one has addressed what impact emigration might have had on Zimbabwe’s HIV prevalence and incidence — and what might happen should they all return home for treatment (see below) which is increasingly available.
These variables need to be explored fully in a multivariate analysis before building any case for prevention strategies upon the basis of what is going on in Zimbabwe. Dr. Murungi says that they still intend to do further analyses on the available data, and that results from a demographic health survey performed last year, should help fill in some of the missing data. Chances are there is still a lot to learn about what has happened in Zimbabwe — but again, it may not yield a formula that anyone would want to mimic.