Given relatively high levels of adherence to HIV treatment in Africa, a Manicaland HIV Project team recently set out to explore what factors help facilitate Zimbabwean children’s adherence to HIV treatment, despite poverty, social disruption and limited health infrastructure. Through qualitative interviews they found that children, guardians, community members, health workers and NGOs - all of whom have a role to play in facilitating children's ART adherence - take advantage of the gradual public normalisation of HIV/AIDS and improved drug and service availability to construct new norms of solidarity and draw on an ethic of care/assistance to create health-enabling and supportive social environments. 

Want to know more? access the study here

"Ongoing investment in HIV prevention and treatment systems requires evaluation of the success of these systems and in particular, monitoring trends in deaths due to AIDS. This in turn requires accurate data on the causes of death, and reliable methods for identifying deaths due to AIDS. Many countries where AIDS is a major cause of death have poor or non-existent vital registration systems and cause-of-death certification. This makes it difficult to accurately determine the numbers of AIDS deaths in these countries." to continue reading, please access the 'Studies of HIV in African communities' bulletin from IDS here

With funding from the Tropical Health and Education Trust, the Manicaland Project will in 2011 strengthen AIDS Treatment and Care Services in Mutasa District, Zimbabwe. This will be done by upgrading local health centre infrastructure to increase capacity, by acquiring essential ART equipment (a CD4 Analyzer for use by the District Medical Officer), by increasing qualified human healthcare resources (through training in the diagnosis of HIV and the treatment of AIDS and opportunistic infections including TB and training in more effective methods of prevention of mother-to-child transmission of HIV), and by engaging with local communities to promote the timely uptake of HIV/AIDS and TB services. More specifically, in 2011 we will i) train 20 nurses in treatment of AIDS (ART) and opportunistic infections (OIs), ii) work to ensure that 30 nurses qualify in rapid testing for HIV infection, iii) train 30 nurses in PMTCT including MER, iv) purchase and make available a CD4 count machine at Bonda Mission Hospital, v) upgrade 6 rural health centres (RHCs) to provide follow-up ART drug supplies and facilitate 12 community meetings to promote ART uptake and sputum sampling.

In June 2001, the United Nations General Assembly Special Session (UNGASS) set a target of reducing HIV prevalence among young women and men, aged 15 to 24 years, by 25% in the worst-affected countries by 2005, and by 25% globally by 2010. We assessed progress toward this target in Manicaland, Zimbabwe, using repeated household-based population serosurvey data. We also validated the representativeness of surveillance data from young pregnant women, aged 15 to 24 years, attending antenatal care (ANC) clinics, which UNAIDS recommends for monitoring population HIV prevalence trends in this age group. Changes in socio-demographic characteristics and reported sexual behaviour are investigated.

We found that HIV prevalence among youth in the general population declined by 50.7% (from 12.2% to 6.0%) from round 1 to 3. Intermediary trends showed a large decline from round 1 to 2 of 60.9% (from 12.2% to 4.8%), offset by an increase from round 2 to 3 of 26.0% (from 4.8% to 6.0%). Among young ANC attendees, the proportional decline in prevalence of 43.5% (from 17.9% to 10.1%) was similar to that in the population (test for differences in trend: p value = 0.488) although ANC data significantly underestimated the population prevalence decline from round 1 to 2 (test for difference in trend: p value = 0.003) and underestimated the increase from round 2 to 3 (test for difference in trend: p value = 0.012). Reductions in risk behaviour between rounds 1 and 2 may have been responsible for general population prevalence declines.

Our study concludes that in Manicaland, Zimbabwe, the 2005 UNGASS target to reduce HIV prevalence by 25% was achieved. However, most prevention gains occurred before 2003. ANC surveillance trends overall were an adequate indicator of trends in the population, although lags were observed. Behaviour data and socio-demographic characteristics of participants are needed to interpret ANC trends. To read the article presenting these findings, click here

A recent study by the Manicaland team has found that men see HIV/AIDS as a threat to their manhood and dignity and effectively exhibit a profound fear of the disease. In the process of denying and avoiding their association with AIDS, many men undermine their wives' efforts to access and adhere to ART. We found that many women felt unable to disclose their HIV status to their husbands, forcing them to take their medication in secret, and act without a supportive treatment partner, which is widely accepted to be vitally important for adherence success. Some husbands, when discovering that their wives are on ART, deny them permission to take the drugs, or indeed steal the drugs for their own treatment. Men's avoidance of HIV also leave many HIV-positive women feeling vulnerable to re-infection as their husbands, in an attempt to demonstrate their manhood, are believed to continue engaging in HIV-risky behaviours. In this study we conclude that hegemonic notions of masculinity can interfere with women's adherence to ART. It is important that those concerned with promoting effective treatment services recognise the gender and household dynamics that may prevent some women from successfully adhering to ART, and explore ways to work with both women and men to identify couples-based strategies to increase adherence to ART. To read the article, please click here

Zimbabwe’s HIV epidemic has been one of the most severe in the world but, over the last decade, the burden of infection has declined more rapidly than in any other country in sub-Saharan Africa. Nationally, HIV prevalence amongst adults has been halved from a peak of 26.5% in 1997 to 13% in 2011.

Since the early 1990s, a team led by researchers from Imperial College London and the Biomedical Research and Training Institute in Harare has carried out prospective population-based studies to track trends in the spread, impact and control of the epidemic in Zimbabwe’s eastern province of Manicaland. This is one of only a handful of such studies in Africa.

In this lecture, Professor Gregson will describe how the ‘Manicaland Study’ has contributed to understanding of the HIV epidemic in Zimbabwe and will discuss the factors that have led to the drop in infection rates.

The lecture takes place June 8 from 18.00-19.30 in the Clore Lecture Theatre of Imperial College London. For further detail and for registration, click here

The big drop in the numbers of people infected with HIV in Zimbabwe is because of mass social change, driven by fear of infection, according to an international study reported today in the journal PLoS Medicine. The scientists unravelling the reasons behind this unexpected downturn now reveal what they hope are the most important lessons in the fight against the disease for the rest of Africa.

Zimbabwe’s epidemic was one of the biggest in the world until the number of people infected with HIV in Zimbabwe almost halved, from 29% to 16%, between 1997 and 2007. Remarkably, this occurred against a background of massive social, political, and economic disruption in the country.

Today’s findings strongly show that people in Zimbabwe have primarily been motivated to change their sexual behaviour because of improved public awareness of AIDS deaths and a subsequent fear of contracting the virus. The researchers found that other important drivers have been the influence of education programmes that have shifted people’s attitudes towards having multiple concurrent sexual partners in extramarital, commercial and casual relations and that have increased the acceptability of using condoms for casual sex.

Professor Simon Gregson, from the School of Public Health at Imperial College London, and senior investigator on the study, said: "Given the continuing, and worrying, trend for high HIV/AIDS infection rates in many sub-Saharan African countries, we felt it was important to understand why the disease has taken a such a dramatic downturn in Zimbabwe. Very few other countries around the world have seen reductions in HIV infection, and of all African nations, Zimbabwe was thought least likely to see such a turnaround. This is why there was such an urgent need to understand its direct and underlying causes."

Dr Timothy Hallett, also from the School of Public Health at Imperial College London and an investigator on the study, said: "The HIV epidemic is still very large, with more than one in ten adults infected today. We hope that Zimbabwe - and other countries in southern Africa - can learn from these lessons and strengthen programs to drive infections down even further."

The scientists say a change in peoples’ attitudes towards their numbers of partners was aided by HIV/AIDS prevention programs organised by the National AIDS Council through the mass media and church-based, workplace-based, and other interpersonal communication activities. The unfavourable economic situation in Zimbabwe from the early 2000s would also have driven down the number of concurrent partners a man could have, due to the constraints on his wallet, but occurred after behaviour had begun to change and would be unlikely to have altered his attitude towards infection. Other underlying factors found to distinguish Zimbabwe from neighbouring countries, and which may have contributed to the changes in behaviour, included its well-educated population and strong traditions of marriage.

The researchers reached their overall conclusions after investigating the results of studies from the last twenty years, which were also considered at a national public health meeting in the Zimbabwean capital, Harare, in 2008. Several other factors affecting HIV/AIDS infection were also discussed, including the age at which people first engaged in sexual behaviour, the introduction of HIV counselling and testing services, and transmission of the virus through means other than sex, such as blood transfusion and needle sharing. However these were ruled out following close examination of the medical and programme evidence.

The results of this study have been extensively and openly debated at the national meeting in Zimbabwe, where attendees reached a 'clear consensus' about the legitimacy of the findings. The researchers hope that, by making the data available more widely, the conclusions of the study can now be judged by other policy makers in the international community and that a clear message can be agreed about the factors driving a decline in HIV/AIDS.

Some of the studies upon which this paper is based were funded by the United Nations Population Fund (UNFPA), which provided some logistical support as well as helping with coordination between the studies. The United Nations HIV-AIDS Program (UNAIDS) and the Zimbabwean Ministry for Health and Child Welfare sponsored this study, along with funding from the Wellcome Trust.

A press release from Imperial College London | access

A recent study by the Manicaland Project has found that hegemonic notions of masculinity serve as a barrier to men's use of HIV services. The study found that men are required to be and act in control, to have know-how, be strong, resilient, disease free, highly sexual and economically productive. However, such traits were in direct conflict with the ‘good patient’ persona who is expected to accept being HIV positive, take instructions from nurses and engage in health-enabling behaviours such as attending regular hospital visits and refraining from alcohol and unprotected extra-marital sex. This conflict between local understandings of manhood and biopolitical representations of ‘a good patient’ can provide a possible explanation to why so many men do not make use of HIV services in Zimbabwe. However, once men had been counselled and had the opportunity to reflect upon the impact of ART on their productivity and social value, it was possible for some to construct new and more ART-friendly versions of masculinity. To read the publication, please click here