UNDERSTANDING THE
CONTEXT OF HIV RISK IN
ZAMBIA
NYU Master's Program in Global Public Health Capstone Program
A Study of Mongu, Senanga, and Kaoma Districts in the Western Province
Rebecca Adeskavitz, MPA
Donovan Jones, MA
Moneesha Kamani, MSc, MS
Erin Murphy, MMS, PA-C
Janet Vessotskie, MS, PhD
Report May 2010
HIV and AIDS IN ZAMBIA
The 2007 Zambia Demographic Health Survey
revealed that HIV prevalence rates in the general
population have dropped from 16% to 14%
However…
Young women have been especially hard hit; 16%
of women aged 20-24 are infected compared to
just 4% of men in the same age group
3 out of 9 provinces have a rising HIV prevalence,
including the Western Province
The cause of these new infections is not yet known,
though many point to cultural practices such as:
• Sexual Cleansing
• Widow Inheritance
• Dry Sex
• Polygamy
• Female Initiation
• Male Circumcision
Identify
problem
RESEARCH QUESTIONS
Concern Worldwide began working in Zambia in 2002
- HIV Prevention, Livelihood Protection and Emergency Response
NYU partnered with Concern Worldwide Zambia in
collaboration with ARHA, DAPP, DHMTs and DATFs to
undertake a qualitative exploratory study in 2010
The following research questions were agreed:
•What are the sexual practices in Zambia’s Western
Province that are putting people at risk for HIV?
• What are the contextual factors that influence the
continuation of these practices?
Define
Research
Questions
STUDY DESIGN
Study Design
Qualitative study utilizing
rapid assessment techniques
Define
the
Problem
Study Setting
Mongu, Senanga & Kaoma
Districts in Western Province
Methods
• Key Informant Interviews
• In-depth Interviews
• Focus Group Discussions
Design
Study
THEORETICAL FRAMEWORK
Policy Environment
Social Capital
Legal Structures
Cultural Context
Structural Violence &
Discrimination
Structural
Factors
Social Networks
Social
Factors
Socioeconomic
Position
Individual
Characteristics
Behavior
Individual
Factors
POVERTY
Source: Adapted from Poundstone, Strathdee & Celentano, 2004
HIV
Transmission
Dynamics
HIV
Incidence
DATA COLLECTION
Data collection took place over a two-week period
Interviews
•NGO leaders
• Government officials
• Local/tribal leaders
• Traditional healers
• Church leaders
• Community Health Workers
Focus Group Participants
47 Average Age (years)
54 % Male
46 % Female
48 % Married
30 % of participants who reached
secondary level education
Mongu
Senanga
Kaoma
Focus Group
Discussions
6
2
2
No. of FG
Participants
46
13
14
In-depth
Interviews
8
0
0
Key Informant
Interviews
10
1
7
Total Participants
54
14
21
Data
Collection
A tree provides shade for a focus group in Itufa, Senanga District.
ANALYSIS
Secondary Data
Zambian DHS
Other studies
Triangulation
Focus Group
Discussions
In-depth and
Key Informant
Interviews
Analysis
RESULTS
What are the factors driving the epidemic?
In-depth analysis of interview and focus group transcripts revealed a
number of social and structural factors that act as both barriers and
facilitators for HIV risk behaviors.
5 meaningful themes emerged:
P
O
V
E
R
T
Y
Traditional Norms & Practices
Gender, Power & Inequality
Social Factors
Prevention & Disconnected Messages
Infrastructure & Service Delivery
TRADITIONAL NORMS & PRACTICES
It is a symbol in our culture that if you have more that one
wife, you must be a very powerful person or a very rich
person who is able to look after those wives
—Senior Government Official, Mongu
Major Findings - Learning:
• Cultural norms and practices are contributing to the spread of HIV in
the Western Province
• Some traditional practices have a positive effect and are helping to
protect against HIV transmission
• Harmful practices are slowly changing in response to HIV
GENDER, POWER & INEQUALITY
…Wearing a condom is regarded as taboo even for family
planning. Women are unable to negotiate condom use
even when the partners are HIV positive
—Grace Hamukwala, Mongu District HIV Manager, Concern Worldwide
Major Findings - Learning:
• Women are socially and economically disadvantaged in the Western
Province
• Gender inequality is manifested in sexual coercion, reduced condom
negotiating power and partnering with older men, all practices that
heighten risk for HIV
• Transactional sex is widespread
SOCIAL FACTORS
…It is normal for a man to have multiple sexual relationships.
The community will not say anything. It is just normal that you
have a girlfriend apart from your wife - these cultural issues
are still being highly practiced in rural areas
—Brian Kayongo, Executive Director, Adolescent Reproductive Health Advocates
Major Findings - Learning:
• Multiple partnerships are generally accepted in Zambia (more for
men than women) and are practiced widely in the Western Province
• Widespread alcohol use contributes to risky behavior, particularly
lack of condom use
PREVENTION & DISCONNECTED MESSAGES
Apart from coming out on radio supporting HIV and AIDS
programs they have not been proactive…if the King stands
and says no one will marry a 11 year girl no one will do that
because there is so much respect for the King
—Brian Kayongo, Executive Director, Adolescent Reproductive Health Advocates
Major Findings - Learning:
• Prevention messages are coming from all levels of society and are
often contradictory
• Tension exists between abstinence-only messages and messages
promoting condom use
• There has been a lack of leadership on a number of issues
INFRASTRUCTURE & SERVICE DELIVERY
In terms of accessibility, most of our rural areas do not
have access to condoms. They are only concentrated in the
township area.
—Senior Health Official, Mongu
Major Findings - Learning:
• Condom access is inconsistent and misconceptions are pervasive
• HIV Testing services have increased, but gaps still exist
• Community members report adequate ART coverage, community
leaders report rural gaps
• Lack of communication / coordination between NGOs, Church leaders
and Local Government departments
HIV Risk Factors in the Western Province
Pervasiveness
High
Female initiation
School prevention
programs
Sexual cleansing
Medium
Multiple circumcisions
with one knife
Widow inheritance
Low
Low
Traditional leader
influence
Dry sex
Multiple sexual partners
Poverty
Sex workers
Media influence
Lack of access to ART
Traditional medicine
MSM
Gender inequality Alcohol
Misconceptions of
Rural-urban gap:
abuse
condoms
service & practices
Limited access to
Lack of access to
Stigma
Polygamy condoms
HIV testing
Venues for sex
Lack of government
Migration
Early sexual
support
Religious
Lack of family influence Inability to debut
dialog on HIV
negotiate condom use
Medium
Risk
High
RECOMMENDATIONS
STRUCTURAL
Increase commitment and
cooperation among leaders
at all levels
Introduce programs that
address gender norms and
empower women
Expand reach of HIV testing
and treatment services
SOCIAL
Increase condom distribution
partnered with education and
directed at HIV “hot spots”
Increase HIV education efforts,
targeting misconceptions and
considering the local context
INDIVIDUAL
PROGRAMME RESPONSES
• Increasing involvement of Traditional Leaders
• Increasing sensitization of young women in rural areas on HIV
risk reduction
• Expanding HIV mainstreaming responses through existing
community structures – community action teams (CATs) using the
‘community conversation’ methodology
• S/BCC through HH approach – focusing on:
- VCT information
- service referral
- increasing male involvement
- reducing stigma and discrimination
• Establishing Western Province NGO Forum for advocacy to
national level
N’itumezi (thank you)
to the people of Zambia and all participants who agreed
to take part in this study
We are also grateful to the entire Concern Zambia staff for their support.
We would particularly like to thank Maurice Sadlier,
Friday Mwamba, Nalisa Mufuzi, Francis Wakumelo,
Grace Hamukwala and Edna Kalaluka
A special thank you to Dr. Kristin Bright of New York University