New infections dropped by 34% between 2005 and 2013, with behaviour change communication and high treatment coverage thought to be responsible for this decline.2 Yet there were still 69,000 new infections in 2013.1
In the same year, there were 64,000 deaths from AIDS-related illnesses, a 57% reduction since 2005. 890,000 children are orphaned due to AIDS.1
Key affected populations in Zimbabwe
The Zimbabwean HIV epidemic is largely driven by unprotected heterosexual sex. However, there are now growing epidemics among key populations who are at higher risk of HIV.3 National data on these populations is sparse, with data collection and reporting not featuring in national documents.
Men who have sex with men (MSM) and HIV in Zimbabwe
Homosexual acts are illegal in Zimbabwe for men who have sex with men (MSM), but legal for women who have sex with women.4 No national statistics are available for the number of MSM who are living with HIV, as a consequence of the punitive law.
However, there are organisations supporting the rights of MSM and their access to HIV services, such as Gays and Lesbians Zimbabwe (GALZ), but many are routinely punished, shut down or their members are arrested. This is what happened to GALZ in 2012.5 Marginalising MSM and people working with MSM drives this vulnerable group away from HIV services. As a result, many do not know their HIV status, let alone be able to access treatment.
International donors such as The Global Fund and PEPFAR have attempted to ensure some of their funding is directed towards MSM, but restrictions from the government mean this has not materialised.6
Sex workers and HIV in Zimbabwe
Around half of all sex workers in Zimbabwe are living with HIV.1 3 Smaller-scale studies have found much higher HIV prevalence among sex workers, such as between 50 and 70% in Victoria Falls, Hwange and Mutare. Half of those who tested positive during the study did not know they were positive. Only 25-30% of sex workers who tested positive during the study were accessing antiretroviral treatment.7 This is concerning in an environment where condoms are being confiscated and gender inequality makes condom negotiation difficult.
Sex work is illegal in the country, with police often using their powers to intimidate, arrest and harass sex workers. The possession of condoms is used as proof of sex work, with many sex workers reporting being arrested due to their work, or having their condoms confiscated. This hampers sex workers’ ability to negotiate condom use with clients, if they haven’t got any condoms of their own, heightening their risk of HIV.8
Sex workers, and the organisations representing them, are not involved in the Zimbabwean response to HIV, marginalising them and preventing them from accessing services. Including this group in HIV prevention initiatives would have a much greater outcome on the health of sex workers and the population as a whole.
Women and HIV in Zimbabwe
Gender inequality is present within relationships and marriages, with only 68% of men believing a woman has the right to refuse sexual intercourse if she knows he has sex with other women. Similarly, only 8 out of 10 women believe women have the right to ask their partner to use a condom if he has a sexually transmitted infection (STI).3
More than a quarter of women with a married or stable partner have experienced physical or sexual violence from their partner.10 This prevents women from being able to negotiate using a condom, and puts her at higher biological risk of HIV.
22% of women report that their first sexual intercourse was forced or against their will. This rises to 28% among women whose first sexual experience was under the age of 15.11
Young people and HIV in Zimbabwe
4.1% of young people aged 15-24 are living with HIV.1 However, with only 45% of young women and 24% of young men having ever tested for HIV, prevalence among this group is likely to be significantly higher.3
Only 52% of young women and 47% of young men have comprehensive knowledge about HIV, limiting their ability to engage in safer sex. However, young people who do not know where to get a condom are much less likely to have had sex, compared to those who do know where to get a condom. This suggests an understanding of the risks involved in not using a condom among this group.3
Relationships with large age-differences are common in sub-Saharan African countries, and 15% of young women aged 15-19 in Zimbabwe report having had sex with a man 10 years older. This ‘sugar-daddy’ culture can contribute to an elevated risk of HIV for young women as they are exposed to older men who may be more likely to have HIV, or have the power in the relationship.3
Some Zimbabweans hold the belief that promoting condoms to young people encourages them to experiment with sex at an early age. Indeed, more than half of adult respondents in the 2010/2011 Demographic and Health Survey felt it inappropriate to teach young people aged 12-14 about condoms.3 Avoiding education about condom use is detrimental to the health of young people and put them at greater risk of HIV, sexually transmitted infections (STIs) and unwanted pregnancy.
HIV testing and counselling (HTC) in Zimbabwe
Between 2007-2011, half of the male population aged 50-54 reported never having had an HIV test before.1 The DHS 2010-11 reports that across all age groups, 36% of men and 57% of women have ever been tested and received their results. These figures are much higher than the last DHS in 2005-06, when only 16% of men and 22% of women had ever been tested.3
The DHS 2010-11 found an increase in testing amongst both men and women, with around 90% of both sexes knowing where they could access HTC. However, of those who tested positive at the time of the survey, 36% did not know their status and were therefore unaware that they could transmit HIV to others if they had unprotected sex. The reason for this was a combination of never having tested or not having received the results of their last test.11
Greater effort needs to be made to ensure that people who test for HIV receive their results, and those who do must be linked to treatment and care.2
Antiretroviral treatment (ART) in Zimbabwe
Zimbabwe is part of the group of sub-Saharan African countries with the greatest access to antiretroviral treatment (ART), at more than 51% for adults. In fact, 5% of all people worldwide who began ART since 2010 were in Zimbabwe, showing that efforts to increase access are improving.1 It is thought that 9,000 people initiate treatment every month.2
However, among children, access to ART is only 27%. Greater effort needs to be made to retain mothers and their babies in treatment after birth, ensuring the child is able to access ART for the rest of its life.1
HIV prevention programmes in Zimbabwe
Zimbabwe’s National HIV and AIDS Strategic Plan 2011-2015 involves a Combination Prevention Strategy, meaning it is focusing on a number of areas to prevent new infections. These include prevention of mother-to-child transmission, voluntary medical male circumcision, behaviour change communication, condom programming and STI management.12
Prevention of mother-to-child transmission (PMTCT)
Availability of PMTCT services is high, with 95% of health facilities in Zimbabwe providing the service.2 Since 2009, there has been a 50% drop in the number of children born with HIV, with antiretroviral treatment coverage among pregnant women living with HIV now at 78%. It is thought to remain this high during the breastfeeding period.1
The country is rolling out Option B+ whereby HIV-positive mothers will receive antiretroviral drugs for life. This is in line with the most recent WHO treatment guidelines – a promising move for Zimbabwe’s HIV response.13
Voluntary medical male circumcision (VMMC)
Zimbabwe is one of the UNAIDS priority counties in terms of scaling up VMMC, and it is now one of the main prevention methods in the country’s National Combination Prevention Strategy.10 By 2018, the programme aims to reach 1.3 million men (80% of 13-29 year olds) in order for the programme to have a prevention benefit for the population.14
However, as of 2014, only 14% of the target had been reached, with limited human resources cited as the main reason.15 10 Moreover, HIV prevalence is slightly higher among men who are circumcised (14%) than those who are not (12%), although the reason for this is unknown.3
In order to increase motivation to circumcise, the country is now using the PrePex device (a non-surgical circumcision device) which speeds up the circumcision process and is less likely to lead to complications that need extra medical attention.2
One study in 2014 found that of all participants, only 68% of women and 53% of men had actually heard about VMMC as an HIV prevention method. 11% were circumcised at the time of the survey, and half of the remaining men said they would be willing to be circumcised, with the motivators being its HIV prevention benefit and improved hygiene. Barriers reported included perceived pain and 18% said they were not at risk of HIV.16
The study also found that answers varied by age group. To address these issues, it was suggested that VMMC education should focus more on the non HIV-related benefits, be tailored to different ages and address the expectation of pain.16
Another study made recommendations about how to encourage uptake among adolescents. They recommended promoting VMMC as a lifestyle choice rather than a medical intervention, and that it is intelligent and trendy. Various mass campaigns have been running in Zimbabwe over the last few years on radios, social media, in schools including celebrity endorsements. These should be scaled up.17
Behaviour change communication
The Zimbabwe National Behaviour Change Programme runs in all districts and has been successful at reaching all sectors of society. It targets sexually active people and members of key affected populations, and has scaled-up efforts to reach schools, workplaces and community-centred activities. In prisons for example, both staff and inmates have been trained in the programme in order to pass on knowledge to others.2
However, it is thought that only just over half of women and men in Zimbabwe have comprehensive knowledge about HIV and how to prevent it.3
Recent reductions in the number of new HIV infections in the country are however thought to be due to a reduction in the number of people with multiple sexual partners. This shows a shift towards making conscious behavioural changes in light of a serious HIV epidemic.18 Despite this, men are still 10 times more likely to have multiple sexual partners than women.3
The availability and distribution of condoms in Zimbabwe is good, with 100 million male condoms distributed in 2013. However, people tend to report not using condoms if they are in multiple concurrent partnerships, or if they are living with HIV.2
The 2010/2011 Demographic and Health Survey (DHS 2010-11) found that of respondents who had two or more sexual partners in the past 12 months, only 48% of women and 33% of men used a condom the last time they had sex. Those who did use a condom were more likely to be HIV-positive. However, it is likely that they already knew their status, or suspected it, and so were trying to prevent onwards transmission rather than protect themselves from infection.3
HIV education and knowledge
The DHS 2010-11 reported that 88% of women and 92% of men with education higher than secondary school level knew that the risk of HIV could be reduced if you use a condom and limit your sexual partners. This is in comparison to just 60% of women and 40% of men with little or no education. However, young people aged 15-24 still have lower levels of HIV knowledge than older people, suggesting school based HIV and sex education is inadequate.3
79% of women and 65% of men knew that HIV could be transmitted from mother-to-child, and that taking drugs would reduce this risk. Although this percentage is relatively high, many people did not know that this route of transmission can be prevented, and therefore are less likely to seek prevention of mother-to-child services.3
Barriers to HIV prevention in Zimbabwe
Social and cultural barriers
Polygamous relationships are commonplace in Zimbabwe, with 20% of those in such a relationship living with HIV compared to 16% of those in a monogamous relationship. Surprisingly, HIV prevalence among men in polygamous relationships was actually lower than those in monogamous relationships, although this may be due to dishonesty when answering survey questions.3
Gender-based violence persists among Zimbabwean society and within the household. The DHS 2010-11 found that 40% of women thought that their husband was justified in beating her for at least one of the following five reasons: burning the food, leaving the house without telling him, arguing with him, neglecting the children or refusing sex with him. The latter is the most concerning regarding HIV – 17% of women believe their husband has a right to beat them if they refuse sex, suggesting that they therefore would be unlikely to refuse sex. With such gender imbalances, condom negotiation is difficult for a woman.3
Alarmingly, young women are even more likely to believe men are justified to beat their wife. Interestingly, men are much less likely to believe wife-beating can be justified.3
Legal and data collection barriers
The illegal nature of sex work and homosexuality presents huge barriers for these populations in accessing HIV services to take care of their health. It also means that the country is unware of the demographics of people living with HIV, meaning targeted prevention, testing and treatment services are impossible. This allows HIV to continue as a public health issue when people who are living with HIV cannot access treatment to prevent onwards transmission.
Stigma and discrimination
Although people showed more accepting attitudes towards family members with HIV in the DHS 2010-11, they continued to show discriminatory attitudes towards shopkeepers or teachers who had HIV.3
Out of the four scenarios asked in the survey (willingness to buy vegetables from an infected shopkeeper, let others know the HIV status of a family member, take care of a family member with HIV, agree that a teacher with HIV should be allowed to continue teaching), only 40% of women and 39% of men showed accepting attitudes to all four situations.
However, 95% of respondents were willing to care for a family member with HIV, suggesting that personal beliefs about HIV may differ to beliefs expressed in society outside of the home. This reflected in the fact that only half of people said they would tell other people about a family member with HIV.3
HIV and AIDS funding in Zimbabwe
The Zimbabwean government collects an AIDS levy, which is made up of 3% payee and corporate tax which contributes considerably to the domestic share of funding for the national HIV response.2
The future of HIV and AIDS in Zimbabwe
PMTCT services are proving successful, and this effort must be maintained in order to end child infections. VMMC has the potential to make a dramatic difference in the transmission of HIV if it was scaled-up. The introduction of the PrePex device and further campaigning targeting young men should help to encourage uptake.
However, there are lots of avenues to pursue and scale up to tackle the Zimbabwean HIV epidemic. The fact that HIV prevalence is entirely unknown for most key affected populations is a major barrier to addressing Zimbabwe’s HIV epidemic. Without data, there is little evidence to inform prevention interventions, or how to encourage people to use HIV services. Ultimately, access to treatment could curb transmission among these groups and this must be recognized as a priority.
HIV education and knowledge could be more wide-reaching, with schools responsible for providing the education that young people need. This is especially important in a culture where patriarchy, gender inequality, polygamous relationships and a sugar-daddy culture persist.