A rural HIV epidemic in Zimbabwe? Findings from a population-based survey.

The aim of the study was to use population-based data from 689 adults to describe the socio-demographic, behavioural and biomedical correlates of HIV infection and aid identification of effective HIV control strategies for rural Zimbabwe. Dried blood spot and urine samples were collected for HIV and sexually transmitted disease (STD) testing and participants were interviewed on socio-demographic characteristics, sexual behaviour and experience of STD symptoms. HIV seroprevalence was 23.3% and was higher in females, divorcees, widows, working men, estate residents, and respondents reporting histories of STD symptoms. Female HIV seroprevalence rises sharply at ages 16-25. A third of sexually-active adults had experienced STD-associated symptoms but there were delays in seeking treatment. Herpes simplex virus type 2 (HSV-2) and Trichomonas vaginalis are more common causes than syphilis, gonorrhoea, and chlamydia, and are strongly associated with HIV infection. Local programmes promoting safer sexual behaviour and fast and effective STD treatment among young women, divorcees and working men could reduce the extensive HIV transmission in rural communities.

Apostles and Zionists: the influence of religion on demographic change in rural Zimbabwe.

Religion has acted as a brake on demographic transition in a number of historical and contemporary populations. In a study in two rural areas of Zimbabwe, we found substantial differences in recent demographic trends between Mission and Independent or "Spirit-type" churches. Birth rates are higher in some Spirit-type churches and, until recently, infant mortality was also higher. Recent increases in mortality were seen within Mission churches but not in Spirit-type churches. Missiological and ethnographic data indicate that differences in religious teaching on healthcare-seeking and sexual behaviour and differences in church regulation could explain this contrast in demographic patterns. More restrictive norms on alcohol consumption and extra-marital relationships in Spirit-type churches may limit the spread of HIV and thereby reduce its impact on mortality. These contrasting trends will influence the future religious and demographic profile of rural populations in Zimbabwe.

Is there evidence for behaviour change in response to AIDS in rural Zimbabwe?

This article reports on evidence for behaviour change in response to AIDS among women in two rural areas of Manicaland Province, Zimbabwe. It examines self-reported data on two overlapping areas of behaviour: (1) actions taken to avoid HIV-1 infection; and (2) fertility practices. The latter were used to assess the validity of the former, given that self-reported behaviour data are notoriously problematic. It is concluded that while self-reported behaviour change is exaggerated, the true level of change has nonetheless been significant and includes delayed onset of sexual relations, increased use of condoms and, possibly, increased monogamy. Reported actions taken to avoid HIV-1 infection and differentials in fertility practices were correlated with data on demographic, social and psychological factors. Differentials in fertility practices were associated with heightened risk perception--particularly when based on personal acquaintance with AIDS patients--but not with greater knowledge of HIV-1/AIDS. Results from the study suggest that effective behaviour change in Manicaland is facilitated by greater knowledge, experience and personal risk perception but obstructed by low female autonomy, marital status and economic status, and by male labour migration and alcohol consumption. Gaps in knowledge included misconceptions about the distinction between HIV-1 and AIDS, the influence of STDs, perinatal transmission, and incorrect modes of transmission. Better knowledge was associated with education, religion, travel and media exposure Personal risk perception was quite high (42%) and correlated with non-marriage, media exposure and contact with medical services. Few respondents knew close relatives with HIV/AIDS (4%) but nearly a quarter of those who felt in danger of infection said this was because friends and relatives were dying of AIDS. Many reported credible behavioural responses, some of which would only be effective given their partner's co-operation. Intensified behaviour interventions are needed which should include peer-education initiatives targeting men and individuals without access to modern media. The epidemic may accelerate fertility decline in rural Zimbabwe through behavioural as well as biological change.

Recent upturn in mortality in rural Zimbabwe: evidence for an early demographic impact of HIV-1 infection?

OBJECTIVES: To describe recent mortality trends in rural Zimbabwe and to assess the impact of HIV-1 infection. METHOD: Comparative, cross-sectional, retrospective, demographic survey with 1-year follow-up. Parallel HIV-1 surveillance. Comparison of results with 1992 national census and vital registration data and results from mathematical model-based population projections. SETTING AND PARTICIPANTS: Residents of 929 (745 revisited in 1995) households in two rural areas of Manicaland Province, Zimbabwe, with contrasting HIV-1 prevalence: Honde and Rusitu valleys. Subjects gave information on parental survival for 2320 resident children. Female residents aged 13-49 years (n = 1237) provided information on birth histories and child survival. Consenting women attending local antenatal clinics (n = 487) provided blood samples for HIV-1 screening and demographic information. MAIN OUTCOME MEASURES: HIV-1 prevalence in pregnant women; per capita death registration rates; incidence of parental death for children aged under 8 years; infant mortality and age-specific death probabilities. RESULTS: HIV-1 prevalence was high in each study area. Death registration and age-specific mortality have begun to rise. The largest increases were seen in the area of higher HIV-1 prevalence (Honde) and among younger adults, particularly men. Incidence of parental death was observed to be rising. Increases in registered deaths were concentrated among HIV-1-associated causes. CONCLUSIONS: The observed increases in mortality by age, sex and cause of death were consistent with those expected early in a severe HIV-1 epidemic, on the basis of mathematical model projections and observations elsewhere in Africa. Further rises in mortality, particularly among women and young children, and consequent increases in orphanhood, are to be expected in rural areas of Zimbabwe.

The early socio-demographic impact of the HIV-1 epidemic in rural Zimbabwe.

PIP: This situational analysis provided information on the sociodemographic context and impact of the HIV-1 epidemic in rural areas of Zimbabwe. Demographic, sociological, and epidemiological methods were used to gather data on the levels of HIV-1 prevalence; the impact of the epidemic on mortality; and knowledge, attitudes, and behavior in relation to AIDS and fertility. Findings revealed that one-sixth of women of childbearing age were infected with HIV, divorced pregnant women were five times as likely to be infected as married women, and single mothers were over three times as likely to be infected. Data on HIV knowledge, attitudes, and behavior suggested that fewer than 2% recognized the role of sexually transmitted diseases (STDs) in HIV transmission and misconceptions about its spread was rampant. The study findings recommend that greater awareness of the links between other STDs and risk of HIV transmission, together with strengthened STD screening, diagnosis, and treatment services could help reduce the incidence of new infections in Zimbabwe.^ieng

Age and religion selection biases in HIV-1 prevalence data from antenatal clinics in Manicaland, Zimbabwe.

Sera from 487 women attending antenatal clinics in two areas of Manicaland were tested for the presence of HIV-1 infection. In the Honde Valley and Rusitu Valley areas, 24,3 pc and 14 pc respectively, were found to be infected. HIV-1 infection was found to be associated with age, marital status and location. Younger women, non-married women and women living in the Honde Valley were all more likely to be infected. There was also a weak association with level of education, with women with secondary education being at greater risk of being infected. The unadjusted overall figures for HIV-1 prevalence from the antenatal clinics were shown to provide a poor indication of the relative levels of prevalence of infection in the two study areas because of differences in the age structure and religious affiliations of the antenatal clinic and study populations. Similar problems may exist in sentinel surveillance data and would distort comparisons between locations and over time, especially during periods of rapid fertility change. In particular, the age bias is liable to exaggerate differences between urban and rural populations in developing societies. Where comparable information is available for the general population and sample sizes permit, this problem may be overcome by collecting basic socio-demographic data on the individuals tested and then applying standardization techniques. In the Honde Valley and Rusitu Valley example, the levels of HIV-1 prevalence after adjusting for age differences are 18,4 pc and 13,2 pc respectively.

PIP: The results of two human immunodeficiency virus (HIV) seroprevalence surveys conducted among pregnant women in rural Zimbabwe during 1993-94 suggest that selection biases can limit the general relevance such surveys. Screening of sera from 487 women attending antenatal clinics in Honde Valley and Rusitu Valley, Manicaland, Zimbabwe, revealed HIV prevalence rates of 24.3% and 14.0%, respectively. Infection rates were highest among unmarried women in their 20s living in the Honde Valley; also observed were weak associations with a secondary school education and low parity. When logistic regression was used, only marital status and age retained statistical significance. Women 25-30 years old were 50% more likely to be HIV-positive than those in the broader 15-30 year age group. However, a comparison of this data set with data from parallel, unlinked sociodemographic surveys (4961 respondents) conducted in the study areas in 1994 indicates that women in their 20s were over-represented in the antenatal clinic group. After the HIV rates in Honde Valley and Rusitu Valley were adjusted for age differences, they fell to 18.4% and 13.2%, respectively. Religion comprised a second potential source of bias. 28% of women in the Honde Valley were Marange Apostolic; they were less likely than women from other religions to visit a health clinic and thus be covered in antenatal clinic surveys.