Webster Mavhu

The Regai Dzive Shiri project: results of a randomized trial of an HIV prevention intervention for youth

Background:HIV prevention among young people in southern Africa is a public health priority. There is little rigorous evidence of the effectiveness of different intervention approaches. We describe findings of a cluster randomized trial of a community-based, multicomponent HIV, and reproductive health intervention aimed at changing social norms for adolescents in rural Zimbabwe. Methods:Thirty rural communities were randomized to early or deferred implementation of the intervention in 2003. Impact was assessed in a representative survey of 18–22-year-olds after 4 years. Participants self-completed a questionnaire and gave a dried blood spot sample for HIV and herpes simplex virus-2 (HSV-2) antibody testing. Young women had a urinary pregnancy test. Analyses were by intention-to-treat and were adjusted for clustering. Findings:Four thousand six hundred and eighty-four, 18–22-year-olds participated in the survey (97.1% of eligible candidates, 55.5% women). Just over 40% had been exposed to at least 10 intervention sessions. There were modest improvements in knowledge and attitudes among young men and women in intervention communities, but no impact on self-reported sexual behavior. There was no impact of the intervention on prevalence of HIV or HSV-2 or current pregnancy. Women in intervention communities were less likely to report ever having been pregnant. Interpretation:Despite an impact on knowledge, some attitudes, and reported pregnancy, there was no impact of this intervention on HIV or HSV-2 prevalence, further evidence that behavioral interventions alone are unlikely to be sufficient to reverse the HIV epidemic. The challenge remains to find effective HIV prevention approaches for young people in the face of continued and unacceptably high HIV incidence, particularly among young women.

Barriers and Motivators to Voluntary Medical Male Circumcision Uptake among Different Age Groups of Men in Zimbabwe: Results from a Mixed Methods Study

Background We conducted quantitative and qualitative studies to explore barriers and motivating factors to VMMC for HIV prevention, and to assess utilization of existing VMMC communication channels. Methods and Findings A population-based survey was conducted with 2350 respondents aged 15–49. Analysis consisted of descriptive statistics and bivariate analysis between circumcision and selected demographics. Logistic regression was used to determine predictors of male circumcision uptake compared to intention to circumcise. Focus group discussions (FGDs) were held with men purposively selected to represent a range of ethnicities. 68% and 53% of female/male respondents, respectively, had heard about VMMC for HIV prevention, mostly through the radio (71%). Among male respondents, 11.3% reported being circumcised and 49% reported willingness to undergo VMMC. Factors which men reported motivated them to undergo VMMC included HIV/STI prevention (44%), improved hygiene (26%), enhanced sexual performance (6%) and cervical cancer prevention for partner (6%). Factors that deterred men from undergoing VMMC included fear of pain (40%), not believing that they were at risk of HIV (18%), lack of partner support (6%). Additionally, there were differences in motivators and barriers by age. FGDs suggested additional barriers including fear of HIV testing, partner refusal, reluctance to abstain from sex and myths and misconceptions. Conclusions VMMC demand-creation messages need to be specifically tailored for different ages and should emphasize non-HIV prevention benefits, such as improved hygiene and sexual appeal, and need to address mens fear of pain. Promoting VMMC among women is crucial as they appear to have considerable influence over mens decision to get circumcised.

Enhancing psychosocial support for HIV positive adolescents in Harare, Zimbabwe.

Background There is a recognized gap in the evidence base relating to the nature and components of interventions to address the psycho-social needs of HIV positive young people. We used mixed methods research to strengthen a community support group intervention for HIV positive young people based in Harare, Zimbabwe. Methods A quantitative questionnaire was administered to HIV positive Africaid support group attendees. Afterwards, qualitative data were collected from young people aged 15–18 through tape-recorded in-depth interviews (n = 10), 3 focus group discussions (FGDs) and 16 life history narratives. Data were also collected from caregivers, health care workers, and community members through FGDs (n = 6 groups) and in-depth interviews (n = 12). Quantitative data were processed and analysed using STATA 10. Qualitative data were analysed using thematic analysis. Results 229/310 young people completed the quantitative questionnaire (74% participation). Median age was 14 (range 6–18 years); 59% were female. Self-reported adherence to antiretrovirals was sub-optimal. Psychological well being was poor (median score on Shona Symptom Questionnaire 9/14); 63% were at risk of depression. Qualitative findings suggested that challenges faced by positive children include verbal abuse, stigma, and discrimination. While data showed that support group attendance is helpful, young people stressed that life outside the confines of the group was more challenging. Caregivers felt ill-equipped to support the children in their care. These data, combined with a previously validated conceptual framework for family-centred interventions, were used to guide the development of the existing programme of adolescent support groups into a more comprehensive evidence-based psychosocial support programme encompassing caregiver and household members. Conclusions This study allowed us to describe the lived experiences of HIV positive young people and their caregivers in Zimbabwe. The findings contributed to the enhancement of Africaid’s existing programme of support to better promote psychological well being and ART adherence.

Prevalence and factors associated with knowledge of and willingness for male circumcision in rural Zimbabwe

Objective  To explore male circumcision (MC) prevalence, knowledge, attitudes and intentions among rural Zimbabweans.

Chronic cough and its association with TB-HIV co-infection: factors affecting help-seeking behaviour in Harare, Zimbabwe.

Objective  To qualitatively investigate reasons why individuals who reported chronic cough of 2 weeks or more in a cross‐sectional prevalence survey had not accessed community‐based outreach or other diagnostic services.

Acceptability and challenges of implementing voluntary counselling and testing (VCT) in rural Zimbabwe: evidence from the Regai Dzive Shiri Project

Abstract Voluntary counselling and testing (VCT) is an important component of HIV prevention and care. Little research exists on its acceptability and feasibility in rural settings. This paper examines the acceptability and feasibility of providing VCT using data from two sub-studies: (1) client-initiated VCT provided in rural health centres (RHCs) and (2) researcher-initiated VCT provided in a non-clinic community setting. Nurses provided client-initiated VCT in 39 RHCs in three Zimbabwean provinces (2004–2007). Demographic data and HIV status were collected. Qualitative data were also collected to assess rural communities’ impressions of services. In a second study in 2007, VCT was offered to participants in a population-based HIV prevalence survey. Quantitative data from clinic-based VCT show that of 3585 clients aged ≥18, 79.4% (95% CI: 78.0–80.7%) were female; young people (aged 18–24) comprised 21.1%. Overall, 32.9% (95% CI: 31.4–34.5%) tested HIV positive. Young people were less likely to be HIV positive 13.5% (95% CI: 11.1–16.1%) vs. 38.1% (95% CI: 36.3–39.9%). In the second study conducted in a non-clinic setting, 27.0% (n=1368/5052) of participants opted to test. Young people were as likely to test as adults (27.3% vs. 26.9%) and an equal proportion of men and women tested. Overall during the second survey, 18.8% (95% CI: 16.7–21.0%) of participants tested positive (youth = 8.4% (95% CI: 6.4–10.7%); adults = 29.1% (95% CI: 25.7–32.7%)). Qualitative data, unique to clinics only, suggested that adults identify RHCs as acceptable VCT sites, whereas young people expressed reservations around these venues. Males reported considering VCT only after becoming ill. While VCT offered through RHCs is acceptable to women, it seems that men and youth are less comfortable with this venue. When VCT was offered in a non-clinic setting, numbers of men and women testing were similar. These data suggest that it may be possible to improve testing uptake in rural communities using non-clinic settings.

What is 'sex' exactly? Using cognitive interviewing to improve the validity of sexual behaviour reporting among young people in rural Zimbabwe.

Self‐reporting of sensitive data is often unreliable, particularly when questions are asked about culturally or socially censured behaviours. This study aimed to improve the validity of questionnaire responses through cognitive interviewing of young people in Zimbabwe to better understand their underlying thought processes when responding to sexual behaviour questions. A questionnaire was developed in English and translated into Shona. Three rounds of cognitive interviewing were conducted with 65 young people. Data were coded and analysed using principles of grounded theory. Young women emphasised that they would not admit to having participated in sexual activities if questions were phrased in such a way that they could be seen as having initiated them. They suggested that in order to legitimise womens participation, the wording of their sexual questions should use the passive tense. The Shona term for ‘vaginal sex’ is used to refer to both consensual and non‐consensual sex. In Shona, there is no formal term for anal sex and phrasing this activity in a way that was both acceptable and understood proved particularly challenging. Cognitive interviewing is useful in exploring the underlying thought processes and the cultural context behind question responses. Examining the cultural and societal norms within a study population is key to obtaining valid responses.

Poverty, Food Insufficiency and HIV Infection and Sexual Behaviour among Young Rural Zimbabwean Women

Background Despite a recent decline, Zimbabwe still has the fifth highest adult HIV prevalence in the world at 14.7%; 56% of the population are currently living in extreme poverty. Design Cross-sectional population-based survey of 18–22 year olds, conducted in 30 communities in south-eastern Zimbabwe in 2007. Objective To examine whether the risk of HIV infection among young rural Zimbabwean women is associated with socio-economic position and whether different socio-economic domains, including food sufficiency, might be associated with HIV risk in different ways. Methods Eligible participants completed a structured questionnaire and provided a finger-prick blood sample tested for antibodies to HIV and HSV-2. The relationship between poverty and HIV was explored for three socio-economic domains: ability to afford essential items; asset wealth; food sufficiency. Analyses were performed to examine whether these domains were associated with HIV infection or risk factors for infection among young women, and to explore which factors might mediate the relationship between poverty and HIV. Results 2593 eligible females participated in the survey and were included in the analyses. Overall HIV prevalence among these young females was 7.7% (95% CI: 6.7–8.7); HSV-2 prevalence was 11.2% (95% CI: 9.9–12.4). Lower socio-economic position was associated with lower educational attainment, earlier marriage, increased risk of depression and anxiety disorders and increased reporting of higher risk sexual behaviours such as earlier sexual debut, more and older sexual partners and transactional sex. Young women reporting insufficient food were at increased risk of HIV infection and HSV-2. Conclusions This study provides evidence from Zimbabwe that among young poor women, economic need and food insufficiency are associated with the adoption of unsafe behaviours. Targeted structural interventions that aim to tackle social and economic constraints including insufficient food should be developed and evaluated alongside behaviour and biomedical interventions, as a component of HIV prevention programming and policy.

Systematic Monitoring of Voluntary Medical Male Circumcision Scale-Up: Adoption of Efficiency Elements in Kenya, South Africa, Tanzania, and Zimbabwe

Background SYMMACS, the Systematic Monitoring of the Voluntary Medical Male Circumcision Scale-up, tracked the implementation and adoption of six elements of surgical efficiency— use of multiple surgical beds, pre-bundled kits, task shifting, task sharing, forceps-guided surgical method, and electrocautery—as standards of surgical efficiency in Kenya, South Africa, Tanzania, and Zimbabwe. Methods and Findings This multi-country study used two-staged sampling. The first stage sampled VMMC sites: 73 in 2011, 122 in 2012. The second stage involved sampling providers (358 in 2011, 591 in 2012) and VMMC procedures for observation (594 in 2011, 1034 in 2012). The number of VMMC sites increased significantly between 2011 and 2012; marked seasonal variation occurred in peak periods for VMMC. Countries adopted between three and five of the six elements; forceps-guided surgery was the only element adopted by all countries. Kenya and Tanzania routinely practiced task-shifting. South Africa and Zimbabwe used pre-bundled kits with disposable instruments and electrocautery. South Africa, Tanzania, and Zimbabwe routinely employed multiple surgical bays. Conclusions SYMMACS is the first study to provide data on the implementation of VMMC programs and adoption of elements of surgical efficiency. Findings have contributed to policy change on task-shifting in Zimbabwe, a review of the monitoring system for adverse events in South Africa, an increased use of commercially bundled VMMC kits in Tanzania, and policy dialogue on improving VMMC service delivery in Kenya. This article serves as an overview for five other articles following this supplement.

A novel tool to assess community norms and attitudes to multiple and concurrent sexual partnering in rural Zimbabwe: participatory attitudinal ranking

Abstract Concurrent sexual partnerships are important in understanding the evolution and maintenance of the HIV heterosexual epidemic in sub-Saharan Africa. While it is possible to measure individual attitudes around sensitive behaviours through questionnaire surveys, studies suggest that responses may be subject to social desirability bias and may not reflect community norms. This study used a novel tool to collect data on community norms relating to the acceptability of concurrency in rural Zimbabwe. Six questions exploring general concurrency concepts and 28 scenarios in which multiple-partnerships might occur were developed and translated into Shona. Participatory attitudinal ranking (PAR), an approach adapted from participatory wealth ranking, was used to conduct group discussions (n=24) with 170 participants recruited in a household survey. Participants discussed and ranked scenarios according to the acceptability of the multiple-partnering described in the short accounts. Data analysis followed grounded theory principles. Qualitative data were examined against quantitative survey data collected from a representative sample of 18–44-year olds. While discussants indicated that concurrency was common among both males and females, self-reports from survey participants indicated that 37.1% of males (n=717/1931; 95% CI: 35.0–39.3%) and only 7.3% of females (n=215/2948; 95% CI: 6.4–8.3%) were in concurrent relationships suggesting under-reporting of this behaviour, particularly by women. We found that concurrency is an accepted community norm for men but never for women. Concurrency is considered more acceptable in specific social contexts, including infertility and lack of a male heir. Having protected rather than unprotected sex with a concurrent partner does not render this behaviour more acceptable. Using PAR, we managed to gain a more nuanced understanding of socially sanctioned concurrency, knowledge that could prove useful for improving behaviour change interventions targeting this behaviour. PAR allowed us to rank attitudes in terms of acceptability, which would enable us to compare attitudes between communities and evaluate changes over time.