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NYU Master's Program in Global Public Health Capstone Program UNDERSTANDING THE CONTEXT OF HIV RISK IN ZAMBIA A Study of Mongu, Senanga, and Kaoma Districts.

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Presentation on theme: "NYU Master's Program in Global Public Health Capstone Program UNDERSTANDING THE CONTEXT OF HIV RISK IN ZAMBIA A Study of Mongu, Senanga, and Kaoma Districts."— Presentation transcript:

1 NYU Master's Program in Global Public Health Capstone Program UNDERSTANDING THE CONTEXT OF HIV RISK IN ZAMBIA 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

2 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 Identify problem 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

3 RESEARCH QUESTIONS Define Research Questions The following research questions were agreed: NYU partnered with Concern Worldwide Zambia in collaboration with ARHA, DAPP, DHMTs and DATFs to undertake a qualitative exploratory study in 2010 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? Concern Worldwide began working in Zambia in 2002 - HIV Prevention, Livelihood Protection and Emergency Response

4 STUDY DESIGN Define the Problem Design Study Study Design Qualitative study utilizing rapid assessment techniques Study Setting Mongu, Senanga & Kaoma Districts in Western Province Methods Key Informant Interviews In-depth Interviews Focus Group Discussions

5 Individual Factors Structural Factors Social Factors HIV Transmission Dynamics HIV Incidence Social Capital Cultural Context Social Networks Structural Violence & Discrimination Policy Environment Legal Structures Behavior Individual Characteristics Socioeconomic Position POVERTY Source: Adapted from Poundstone, Strathdee & Celentano, 2004 THEORETICAL FRAMEWORK

6 DATA COLLECTION Data Collection MonguSenangaKaoma Focus Group Discussions 622 No. of FG Participants 461314 In-depth Interviews 800 Key Informant Interviews 1017 Total Participants541421 Data collection took place over a two-week period Focus Group Participants 47Average Age (years) 54% Male 46% Female 48% Married 30% of participants who reached secondary level education Interviews NGO leaders Government officials Local/tribal leaders Traditional healers Church leaders Community Health Workers

7 A tree provides shade for a focus group in Itufa, Senanga District.

8 Analysis ANALYSIS Secondary Data Zambian DHS Other studies Focus Group Discussions In-depth and Key Informant Interviews Triangulation

9 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: Traditional Norms & Practices Gender, Power & Inequality Social Factors Prevention & Disconnected Messages Infrastructure & Service Delivery

10 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 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 TRADITIONAL NORMS & PRACTICES

11 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 …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 GENDER, POWER & INEQUALITY

12 …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 SOCIAL FACTORS

13 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 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

14 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 INFRASTRUCTURE & SERVICE DELIVERY

15 Pervasiveness Risk Low Medium High Low MediumHigh Female initiation Polygamy Traditional leader influence Religious influence Migration Venues for sex Stigma HIV Risk Factors in the Western Province Gender inequality Dry sex Multiple sexual partners Sex workers Rural-urban gap: service & practices Poverty School prevention programs Sexual cleansing Multiple circumcisions with one knife Widow inheritance Media influence Traditional medicine Misconceptions of condoms Alcohol abuse Early sexual debut Inability to negotiate condom use Lack of government support Limited access to HIV testing Lack of access to ART Lack of access to condoms MSM Lack of family dialog on HIV

16 RECOMMENDATIONS INDIVIDUAL STRUCTURAL SOCIAL Increase HIV education efforts, targeting misconceptions and considering the local context Introduce programs that address gender norms and empower women Increase commitment and cooperation among leaders at all levels Increase condom distribution partnered with education and directed at HIV “hot spots” Expand reach of HIV testing and treatment services

17 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 PROGRAMME RESPONSES

18 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 N’itumezi (thank you)

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