HIV/AIDS in Zimbabwe Lisa Garbus, MPP Gertrude Khumalo-Sakutukwa, MSc, MSW AIDS Policy Research Center, University of California San Francisco Published November 2002 Last Updated October 2003 (c) 2003 Regents of the University of California All Rights Reserved. Table of Contents PREFACE 3 EXECUTIVE SUMMARY 5 EPIDEMIOLOGY 15 POLITICAL ECONOMY AND SOCIOBEHAVIORAL CONTEXT 22 IMPACT 59 RESPONSE 72 LINKS 96 REFERENCES 97 Preface The Country AIDS Policy Analysis Project is managed by the AIDS Policy Research Center at the University of California San Francisco. The project is funded by the U.S. Agency for International Development, Cooperative Agreement PHN-A-00-01-00001-00. Stephen F. Morin, PhD, is the project's principal investigator. The project receives additional support from the International Training and Education Center on HIV (I-TECH), a collaboration of the University of Washington and UCSF funded through a cooperative agreement with the HIV/AIDS Bureau of the U.S. Health Resources and Services Administration. The views expressed in the outputs of the Country AIDS Policy Analysis Project do not necessarily reflect those of USAID or I-TECH. The Country AIDS Policy Analysis Project is designed to inform planning and prioritizing of effective and equitable HIV/AIDS prevention and treatment interventions through multidisciplinary research on HIV/AIDS. The project evolved from the acute need for analysis of the epidemiology of HIV/AIDS in tandem with analysis of countries' political economy and sociobehavioral context¾at household, sectoral, and macro levels. This multidisciplinary analysis aims to: * help inform national HIV/AIDS policies * strengthen ability to plan, prioritize, and implement effective interventions * highlight the range of sectoral interventions that may affect or be affected by HIV/AIDS * facilitate multisectoral/interministerial coordination * facilitate intercountry information sharing * increase national and subregional capacity for effective partnerships The project develops and disseminates online, fast-download, continually updated analyses of HIV/AIDS in 12 USAID priority countries: Ethiopia, Kenya, Malawi, Senegal, South Africa, Uganda, Tanzania, Zambia, Zimbabwe, Brazil, Cambodia, and India Each analysis is linked with national strategic plans for HIV/AIDS prevention, care, and support. Analyses also include a comparative table of 70 key HIV/AIDS and socioeconomic. The primary audience for the country analyses is in-country HIV/AIDS planners, including those from government ministries and agencies, multi- and bilateral donors, international and local NGOs, health care institutions, prevention programs, academia, affected communities, and the private sector. International investigators and policymakers also report using the analyses in their work. All country analyses undergo peer review at the AIDS Research Institute of the University of California San Francisco. In addition, two in-country experts from each profiled country serve as peer reviewers. A scientific advisory board also reviews all analyses. Acknowledgments The following individuals served as peer reviewers and provided valuable inputs to this paper: Dr. Thomas J. Coates, Dr. William McFarland, and Dr. Nancy Padian, all of the University of California San Francisco; and Dr. Tsungai Chipato and Dr. Godfrey Woelk, both of the University of Zimbabwe. They are not responsible for any errors of fact or judgment. Note on Terminology All racial categorizations and nomenclature used in the data sources cited throughout this profile have been maintained; they do not constitute an endorsement of any particular terminology. Users please note that this version contains two bibliographies; we will post a corrected version shortly. Contact Information Because this analysis is continually updated, comments and suggested sources of new data are welcome and may be sent to the coinvestigator/project director at UCSF's AIDS Policy Research Center: Lgarbus@psg.ucsf.edu Executive Summary Epidemiology The first AIDS case in Zimbabwe was identified in 1985. HIV sentinel surveillance was initiated in 1991. In 2000, Zimbabwe undertook the first fully implemented ANC survey since 1997. It found that 35 percent of women attending ANCs were infected with HIV. The 2001 ANC findings appeared to indicate that ANC prevalence had fallen to 29.5 percent. In August 2003, Zimbabwe released a report presenting new national HIV/AIDS prevalence data, indicating that HIV prevalence in ANC surveys peaked in 2000 at 34 percent, fell in 2001 to 30 percent, and decreased further in 2002 to 25.7 percent. Using these figures, 24.9 percent of Zimbabwean adults are HIV-positive. Several Zimbabwean HIV/AIDS experts stated that the new figures did not represent a real decline in HIV prevalence, but rather a correction of flawed data from previous surveys. At the end of 2001, UNAIDS estimated that 2.3 million Zimbabweans were living with HIV/AIDS (range: 1.8 to 2.7 million) Of them, 2 million were adults (ages 15 to 49), with the adult prevalence at 33.7 percent. UNAIDS estimates that of adults infected with HIV at the end of 2001, 1.2 million (60 percent) were women. At the end of 2001, there were 240,000 Zimbabwean children (ages 0 to 14) living with HIV/AIDS. The epidemic is driven largely by heterosexual transmission, which accounts for 92 percent of infections. Mother-to-child transmission is also an important factor, accounting for 7 percent of infections. Transmission via blood transfusion is rare: Zimbabwe was one of the first countries in the world to implement universal screening of blood and the selection of all voluntary, low-risk donors. Transmission via men who have sex with men is probably underestimated, given the government's fervent antihomosexual stance. In 2001, UNAIDS estimated that there were 200,000 adult and child AIDS deaths. Among adult Zimbabwean women, CDC has found that mortality peaks at 5.7 percent for the 30-34 age group, with 5.5 percent dying because of AIDS. Among men, mortality peaks at 5.2 percent for the 40-44 age group, with 4.8 percent dying because of AIDS. ANC data currently serve as Zimbabwe's primary sentinel surveillance of HIV/AIDS. Though ANCs prevalence is widely used, they are imperfect. For example, antenatal data may underestimate HIV prevalence in women of reproductive age, as recent studies indicate that fertility among HIV-positive women is substantially lower than among uninfected women. That ANC surveys have not been conducted on an annual basis in Zimbabwe does constrains analysis. Another issue is the disparity in the number of antenatal clinics participating each year. This scenario may be related to reduced budgetary allocations for ANC surveys; famine and the political and economic crises may also be limiting the ability of researchers to conduct such surveys. In addition, they may be limiting the number of women who are able to attend ANCs, thus affecting samples. The August 2003 report appeared to confirm that laboratory errors regarding the Chiredzi and Musume data were made in the 2000 ANC survey, leading to overestimates of HIV prevalence and thus the very large prevalence declines observed in 2001. It appears that there may be a decline in HIV prevalence among women attending ANCs, particularly those in the youngest age cohorts. To what this decline can be attributed, however, remains unclear. Political Economy and Sociobehavioral Context The relationship between HIV prevalence and socioeconomic indicators is highly complex. Increasingly, risk of HIV infection is recognized as related to individual as well as community variables. Additionally, since 1999 the political and economic situation in Zimbabwe has dramatically deteriorated, and the country is currently undergoing a massive food shortage¾all these affect and are affected by HIV/AIDS. Recent laws passed in Zimbabwe put tight restrictions on access to information. Although the 2002 Zimbabwean presidential elections were widely viewed as unfair, SADC governments declared the outcome "legitimate." Paralleling a dramatic decline in overall living standards and an uncertain political situation, serious crime levels in Zimbabwe appear to be rising. Corruption is pervasive in the country. European colonizers displaced the majority of indigenous farming population onto unproductive lands called communal areas. Historically, Zimbabwe's white minority owned most of the country's productive land through large-scale commercial farms, whereas the majority of the population lived on less-fertile land. The need for land reform in Zimbabwe is widely acknowledged, even by representatives of the commercial farming sector. In 2000, the government began a fast-track land redistribution program, which is being carried out very rapidly, bypassing legal procedures. The allocation of plots has frequently discriminated against those believed to support opposition parties. There have been numerous reports of land going to President Mugabe's relatives and supporters. Under the fast-track land reform, forced expulsion of white farmers and violence against both farmers and farm employees are occurring. The disruptions to commercial agriculture¾combined with severe drought¾have disrupted a significant portion of the commercial farm economy. Uncertainty surrounding the farming sector has jeopardized the country's exports. Fast-track land reform has been accompanied by large movements of people, regroupings of family units, and exposure to new sexual networks. Reports from aid agencies that have conducted missions in Zimbabwe concur that one of the key underlying factors contributing to the food crisis is HIV/AIDS, as well as inappropriate macroeconomic policy, fast-track land resettlement program, and natural phenomena, e.g., drought. A UN mission to Zimbabwe in January 2003 found that although food shortages were easing in other parts of southern Africa, the number of Zimbabweans at risk of starvation was rising. It reported that the political situation has severely hampered the high-potential agricultural areas from operating at maximum capacity during the current growing season, leading to a significant food deficit for the 2003-04 marketing season. Drought is a normal part of the cycle in Zimbabwean agriculture and that poverty is the norm for the majority of Zimbabweans. Subsequently, households have an array of coping mechanisms. However, in 2002-03, because of HIV/AIDS, drought, fast-track land reform, and the deteriorating economic situation, most of these coping strategies are irrelevant, and the extended family safety net and local support networks are increasingly under pressure. Households already affected by HIV/AIDS, those that are poor, and/or those headed by women, children, or the elderly may have difficulty accessing food aid because of impaired mobility, ostracism, or stigma. Vulnerable populations are adopting an array of survival strategies, including generating additional sources of food or income, migrating, dropping out of school, engaging in hazardous work, or exchanging sex for food or cash. For some young women, sex work provides the only way to support themselves and their families. Another factor involves the response to the food crisis, i.e., aid workers and truck drivers delivering food aid. Some women and girls may offer sex to workers involved in transporting and distributing food aid to try and obtain preferential treatment in the distribution of supplies and services; women and children may be particularly vulnerable to sexual exploitation during humanitarian crises. Several aid agencies report that state-sponsored militias are controlling the distribution of food supplies in rural areas and using food as a tool of repression against opposition MDC supporters. Fast-track land reform has led to serious human rights violations, including serious acts of violence against farm owners and farm workers, and, using occupied farms as bases for attacks, against residents of surrounding areas. The police have done little to halt such violence, and in some cases are directly implicated in the abuses. There has also been an increase in rape of young girls living on farms that have been invaded following fast-track land reform. Part of Zimbabwe's colonial legacy involves gender-segregated, inter- and intracountry labor migration. Moreover, excombatants who fought to attain independence returned to Zimbabwe during the 1980s; this movement may have facilitated HIV transmission. There is high mobility among urban, rural, mining, and port areas, within Zimbabwe as well as within the southern Africa subregion. Much of this movement is dominated by men. Migrant labor separates men from their families, places them in close proximity to "high-risk" sexual networks, and may result in their having an increased number of sexual contacts. Concurrently, it may also lead to women's reliance on sex to supplement their incomes while their male partners are away for long periods. Food shortages, fast-track land reform, and the political and economic situation are also spurring population dislocation. Intercountry mobility is also high, as many Zimbabweans are emigrating. Zimbabwe's 2000 ANC survey found that HIV prevalence was highest in commercial farming and mining areas, followed by border posts, growth points, other urban areas, and other rural areas. At independence, the Zimbabwean economy was more industrialized than most in Africa, with a diversified productive base, well-developed infrastructure, and a relatively sophisticated financial sector. In 1991, Zimbabwe undertook a structural adjustment program. During the 1990s, poverty in Zimbabwe increased significantly. In the mid-1990s over 60 percent of Zimbabwean households fell below the national poverty line. The World Bank attributes this increase in poverty to the poor performance of the economy and to flaws in the structural adjustment program. Since 1999, the country has been experiencing a socioeconomic crisis, resulting from poor economic policies, falling prices for key exports, a decrease in farm outputs following farm invasions and expulsion of white farmers and farm workers, increased deficit, drought, and loss of investor confidence due to uncertainty about domestic policies. Economic deterioration was also exacerbated by military involvement in the Democratic Republic of Congo from 1999 to 2002. Given the current political and economic situation, some donors have suspended funding, citing violence and abrogation of the rule of law. Others have reduced their operations to activities in social sectors (including HIV/AIDS), social protection, and human rights/governance programs. Increased donor support is contingent upon progress in orderly land reform and macroeconomic stabilization. In 2000, public expenditures on health represented 3.1 percent of GDP, whereas private health expenditures represented 3.6 percent of GDP. After independence, the government made great strides in improving access to social services. By the end of the 1980s, the country was one of Africa's leaders in terms of overall access to health and education. However, the health care system is now deteriorating, exacerbated by the current crises. The public health sector has been severely affected by an array of problems, including drug shortages and the exodus of skilled medical personnel. WHO ranks Zimbabwe a "high TB burden" country. In 2001, it had the world's 17th highest burden of TB in terms of new cases. An estimated 67 percent of adult (ages 15-49) TB cases are HIV-positive. Zimbabwe's past achievements in sexual & reproductive health have eroded and the reproductive health status of Zimbabweans has deteriorated. The country's contraceptive prevalence rates¾though much higher than the regional averages¾have stagnated. The maternal mortality ratio has been increasing. It is unclear whether the reported number of STIs is decreasing. It appears that viral, rather than bacterial, STIs, are driving the epidemic. Knowledge of HIV/AIDS is high in Zimbabwe. However, there are profound gender differences in the way in which personal HIV risk is construed, which may affect policy and program interventions. And despite high levels of awareness of HIV/AIDS, it remains highly stigmatized. Sexual behaviors driving the HIV/AIDS epidemic in Zimbabwe are influenced by a complex interplay of social, economic, and cultural factors. For women, casual sex before marriage is not socially sanctioned. It is, however, expected that men will have had several sexual partners before marriage. Among women who had sex in the past year, 4.3 percent used a condom during last sexual intercourse with a spouse or cohabiting partner; 42 percent used a condom during last sex with a noncohabiting partner. Among men, these figures were 6.5 and 70.2 percent, respectively. A significant decline in condom use within marriage occurred during the latter half of the 1990s Twenty-eight percent of women and 16.7 of men cannot not cite a source for obtaining a male condom. Zimbabwe has a very young population; 40 percent of Zimbabweans are under age 15. In 2000, the median age in the country was 17.5. The Zimbabwean government has failed to adopt laws and policies that ensure young people the right to access the information and methods to protect themselves from unwanted pregnancy and HIV/STIs. The Zimbabwean government has made parents the gatekeepers for their children's access to reproductive health services, and as a result, health workers have tended to turn away adolescents seeking dual protection information and services. In addition, young people tend to lack confidence that health workers will keep their requests confidential. Consumption of and demand for harmful substances still center on alcohol and cannabis. There are reports that certain inhalants and over-the-counter stimulants are being abused. Anecdotal reports indicate an increase in the abuse of cannabis, cocaine, and ecstasy. In rural areas, alcohol consumption plays an important part in community life as it is associated with ceremonies and rituals. It is also seen as an essential recreational activity, especially for some men. A variety of alcoholic beverages are consumed, but beer is the most frequent. Far more men than women drink alcohol, particularly in drinking establishments. For many, the purpose of drinking is to get drunk, and there is a high frequency of drunkenness among those who indicate they drink. Drinking is associated with casual and transactional sex. Shona and Ndebele societies are patriarchal and patrilineal. They impose strict controls on female sexual behavior, whereas the attitude toward male sexual behavior is more lenient. Before independence, women were socially and legally minors, and their rights were subordinate to men. Their active participation in the country's liberation struggle for independence demonstrated their capacity to fight against oppression. After Zimbabwe's independence in 1980, women struggled to liberate themselves socially, politically, and economically by lobbying the government through various women's organizations. Their major triumph was the passing of the Legal Age of Majority Act (1982), which made 18 the age of majority for both women and men. However, Zimbabwe's constitution permits discrimination against women on the basis of customary law, under which women are designated minors. Zimbabwean women become infected with HIV at younger ages than men for both biological and behavioral reasons (though the lifetime risk of acquiring HIV is about equal for both sexes). Women's subordinate socioeconomic status affects their vulnerability to acquiring HIV and, once infected, accessing care and support services. Fourteen percent of married Zimbabwean women report being in a polygynous union. Studies on age mixing have found that older age of sexual partner was associated with increased risk of HIV infection in men and women. Zimbabwean women are vulnerable to domestic abuse because of their low status and lack of power in the family, and because violence within marriage is widely tolerated. Zimbabwean women lack substantial legal recourse if they experience abuse. Over half of Zimbabwean women believe that wife beating is justified in at least one of five situations. Abuse of girls (sexual and nonsexual) in schools is widespread. Reported violence against Zimbabwean women has been rising dramatically. Since 2000, human rights groups have documented systematic rape and sexual torture of women in the context of the country's political violence. A 1994-95 study found that 86 percent of sex workers tested in Harare were HIV-positive. The deteriorating economic situation is rendering sex in exchange for money or material good more common. There is very limited male circumcision in Zimbabwe. Male circumcision is practiced by a Xhosa ethnic group known as amaFengu in Zimbabwe. The amaFengu are originally from South Africa and live in some areas of Matabeleland. Impact During 2000-2005, Zimbabwe will have the world's second-lowest life expectancy at birth (33.1). During 2000-05, life expectancy would have been 67.6 without AIDS. For 2010-15 and 2045-50, life expectancy would have been 70.5 and 76.2, respectively, without AIDS. These figures represent a 40 to 55 percent reduction during 2000-50. Zimbabwe's population will be 61 percent smaller in 2050 than it would have been in a "no-AIDS" scenario. General mortality figures have been radically eroding in Zimbabwe. There were approximately 1.1 million cumulative AIDS deaths in Zimbabwe through 2000, with AIDS increasing mortality by 67 percent. Between 2000 and 2015, there will be 4.2 million AIDS deaths, representing a 311 percent increase in mortality in Zimbabwe. The number of AIDS deaths is projected to rise to 6.0 million during 2015-50, a 119 increase in mortality during this period. HIV/AIDS has further strained coping mechanisms through its enormous and complex impact on households. Women are traditional caregivers and thus take on additional responsibilities when family members become ill. When an adult Zimbabwean woman dies, her children are likely to be fostered by an elderly woman, who faces numerous material and psychosocial constraints in caring for HIV-infected children and/or orphans. At the end of 2001, UNAIDS estimated that 780,000 AIDS orphans (ages 0 to 14) were living in Zimbabwe. The percent of Zimbabwe's orphans due to AIDS rose from 16.0 percent in 1990 to 76.8 percent in 2001; it projected that this percentage would rise to 85.7 percent in 2005 and 88.8 percent in 2010. Fewer than 4,000 of Zimbabwe's orphans are living in the country's 45 registered orphanages. Maintaining a child in one of these orphanages is far costlier than other forms of care. Some researchers have posited that increased resources for AIDS orphans would be optimally targeted to strengthen existing community groups at the local level. According to FAO, between 1985 and 2020, Zimbabwe will have lost 23 percent of its agricultural labor force because of AIDS. Seventy percent of hospital admissions are HIV-related. Demand for the time and services of trained health care providers is increasing; concurrently, those working in the health sector are also affected by HIV/AIDS. Between 2000 and 2010, 2.1 percent of Zimbabwe's teachers will die annually because of AIDS. On the demand side, there will a 0.25 percent reduction in Zimbabwe's school-age population (ages 5-14). Of new teachers who needed to be trained in Zimbabwe in 2000, 54.3 percent replaced teachers lost to AIDS; for 2010, a projected 82.6 percent of newly trained teachers will replace teachers who have died because of AIDS. Response After the first AIDS case in Zimbabwe was identified in 1985, the government's initial response involved the introduction of universal screening of blood and blood products for HIV. This initiative has been a great success, as HIV transmission via blood transfusion is rare. In 1987, the Ministry of Health and Child Welfare established the National AIDS Coordination Program (NACP). In 1991, the government implemented a program of HIV sentinel surveillance. Between 1988 and 1998, the government created several short- and medium-term plans to address HIV/AIDS, the implementation of which was the responsibility of NACP. Increasing levels of HIV infection, especially among youth, coupled with the many impacts of epidemic, forced the Zimbabwean government to acknowledge that its actions against HIV/AIDS had been inadequate and limited in scope and effectiveness. Among other things, the government had no HIV/AIDS policy until 1999. In addition, the government had faced criticism that although the enormity of the HIV/AIDS epidemic in Zimbabwe has been recognized for some time, the government was slow to acknowledge the scale of the problem and take appropriate action. Prior to 2000, for example, President Mugabe rarely mentioned HIV/AIDS publicly; when he did so, it was deemed newsworthy. The government introduced the National Policy on HIV/AIDS in December 1999. The National AIDS Council was created in May 2000 to implement the policy. The government has been criticized for insufficient consultation with all stakeholders, especially PWLHA. In June 2002, the government enacted a declaration of a six-month period of emergency (HIV/AIDS) to increase availability of and access to generic AIDS drugs. To what degree the national HIV/AIDS policy is being implemented is unclear. NAC, for example, is constrained by inadequate capacity (human and financial resources), overwhelming and competing demands for its services, internal struggles for visibility and power, denial and stigma around HIV/AIDS, and difficulty in bringing different stakeholders together. Zimbabwe's HIV/AIDS policy is also unclear regarding how a multisectoral response will be implemented. More generally, given the country's myriad and interrelated crises, the government's motivation and/or ability to focus on and support HIV/AIDS policy implementation is impeded. In March 2003, the UN Relief and Recovery Unit reported that "a vigorous response" to HIV/AIDS within the context of the current humanitarian crisis in Zimbabwe was lacking, citing, inter alia, limited coverage and quality of interventions, as well as weak coordination at all levels. An AIDS levy was introduced in 1999 to supplement the MOHCW's HIV/AIDS budget. The government has taken steps to make the disbursement of funds from the AIDS levy more transparent. However, donors and local AIDS committees continue to raise concerns that disbursements are not reaching local committees and have been politicized (i.e., are being disbursed through ZANU-PF-affiliated channels). Zimbabwe's Labor Relations Regulations on HIV/AIDS bar employers from requiring HIV testing as a precondition to employment, termination, or benefit eligibility. However, to what degree preemployment HIV testing and HIV/AIDS-related workplace discrimination are occurring is unknown. In accordance with international guidelines, Zimbabwe's policy places no restriction on travel of HIV-positive persons. Many other laws and policies are not sufficiently up-to-date or comprehensive to address the myriad impacts of HIV/AIDS. Zimbabwe relies heavily on funding from international donors for its HIV/AIDS programs. Because of the political situation¾and because Zimbabwe is not servicing its debt¾most multi- and bilateral donor resources are being withdrawn or reduced. Many donors, however, are continuing to fund HIV/AIDS programs, often through NGOs. The Global Fund to Fight AIDS, Tuberculosis & Malaria awarded Zimbabwe two grants in April 2002; HIV/AIDS funds, however, have not yet been disbursed. Zimbabwean civil society, including NGOs, CBOs, religious and academic organizations, and private industry, provide a significant amount of HIV/AIDS prevention, care, and support. Zimbabwe's national HIV/AIDS policy considers counseling to be a vital component of HIV/AIDS prevention and care and addresses VCT in depth. The Zimbabwe AIDS Prevention and Support Organization (ZAPSO) opened the first VCT center in Zimbabwe in 1998. Almost 12 percent of Zimbabwean women report having been tested for HIV; among those not tested, 59.1 percent would like to be tested. Among men, 9.2 percent report having been tested for HIV; of those not tested, 56.8 percent would like to be tested. Among women who have not been tested for HIV, 63.4 percent do not know a source for HIV testing. Among men, the comparable figure is 66.5 percent. USAID, in collaboration with Population Services International (PSI) and the Government of Zimbabwe, launched 10 New Start VCT centers at strategic locations throughout the country. In 2001, these 10 sites counseled and tested over 50,000 clients. The female condom was launched in Zimbabwe in 1997. It was initially sold through selected pharmacies and clinics at a heavily subsidized retail price of US$0.24 for a box of two; distribution has since expanded to other urban outlets, including large supermarkets and convenience stores. The high cost of the female condom (vis-à-vis the male condom) is leading many Zimbabwean women, particularly sex workers, to reuse it to save money. Although users of the female condom perceive it to be effective and reliable both as an STI/HIV and pregnancy prevention method, 30 percent of men and 57 percent of women reported some difficulty with use, such as problems with insertion, discomfort during sex, noise or squeakiness during use, and excess lubrication. A study of married Zimbabwean women found that offering them multiple prevention options increased the reported percentage of sex acts protected by any method. Most women preferred the male condom and least liked the female condom. Based on a phase I clinical trial of Buffergel that found that it appeared to be safe and well tolerated, a phase 2/2B study of the safety and effectiveness of BufferGel and PRO 2000/5 Gel (P) is currently taking place in Zimbabwe. Preliminary findings indicate that both Zimbabwean men and women generally accept the diaphragm. Although the majority preferred male condoms because of their known efficacy against HIV, most women felt protected and empowered through use of the diaphragm. In August 2002, the Gates Foundation awarded US$28 million to the University of California San Francisco to continue testing the diaphragm as a potential prevention method for HIV/other STIs. There are numerous HIV prevention interventions under way that have an economic/livelihoods focus. WHO estimated that as of the end of 2001, only 4 percent of Zimbabweans in need of PMTCT services was receiving them. With GFATM financing, the government's target for 2002 was to have 30,000 pregnant women counseled and tested for HIV; by 2004, this figure would rise to 70,000. The GFATM grant would also fund expansion of ART for PMTCT. In January 2002, the government launched the PMTCT Program, through the MOHCW and NAC (using funds from the AIDS levy). MOHCW funds 60 to 70 percent of PMTCT activities and coordinates all PMTCT programs. Donors either support individual sites or provide resources to the national office to enhance capacity to implement and coordinate activities. The program offers free VCT to pregnant mothers and free nevirapine at the time of labor in a single dose. Because of personnel and training constraints, the program is not yet available in all maternity units. Currently, between 200 and 2,000 Zimbabweans are receiving some form of ART (of highly variable quality and with highly variable levels of adherence) through the private sector and clinical trials. Zimbabwe's Antiretroviral Therapy Subcommittee has produced draft ART guidelines. The government's (draft) Plan for the Nationwide Provision of ART calls for detailed implementation strategy to be developed for all aspects of ART. In its 2002 GFATM proposal, the government requested US$2.2 million for antiretroviral drugs and US$1.5 million for logistics and training support for 2002-04. In September 2002, Zimbabwe's Antiretroviral Therapy Subcommittee estimated that the cost of ART ranged from US$25 to US$50 per person per month. As of late 2002, three major local companies-Datlabs, CAPS, and Varichem-were negotiating with foreign companies to manufacture generic ARVs under license. Pfizer has donated Diflucan to government for free provision to patients. A 2000 study from Zimbabwe described ART prescribing practices as "therapeutic anarchy"; lack of treatment guidelines, links between private practitioners and specialists, and access to research evidence were all factors contributing to this scenario. Epidemiology At a Glance HIV Sentinel Surveillance * HIV sentinel surveillance was initiated in 1991. In 2000, Zimbabwe undertook the first fully implemented ANC survey since 1997. It found that 35 percent of women attending ANCs were infected with HIV. The 2001 ANC findings appeared to indicate that ANC prevalence had fallen to 29.5 percent. * The Zimbabwean MOHCW and CDC concluded that there seemed to be a decline in HIV among women attending ANCs between 2000 and 2001. They viewed the greater decline in prevalence among younger women and lower decline in older women as suggesting a declining incidence of HIV infection. As for the size of the decline, they believed that it was unclear whether the findings from 2000 were too high, or whether the 2001 findings reflected a true decline. * In August 2003, Zimbabwe released a report presenting new national HIV/AIDS prevalence data, indicating that HIV prevalence in ANC surveys peaked in 2000 at 34 percent, fell in 2001 to 30 percent, and decreased further in 2002 to 25.7 percent. Using these figures, 24.9 percent of Zimbabwean adults are HIV-positive. Several Zimbabwean HIV/AIDS experts stated that the new figures did not represent a real decline in HIV prevalence, but rather a correction of flawed data from previous surveys. UN Estimates * At the end of 2001, UNAIDS estimated that 2.3 million Zimbabweans were living with HIV/AIDS (range: 1.8 to 2.7 million) Of them, 2 million were adults (ages 15 to 49), with the adult prevalence at 33.7 percent. * UNAIDS estimates that of adults infected with HIV at the end of 2001, 1.2 million (60 percent) were women. HIV prevalence among women ages 15 to 24 ranged from 26.4 to 39.61 percent; the comparable range for men in the same age group was 9.9 to 14.85 percent.) * At the end of 2001, there were 240,000 Zimbabwean children (ages 0 to 14) living with HIV/AIDS. Transmission Patterns * The epidemic is driven largely by heterosexual transmission, which accounts for 92 percent of infections. Mother-to-child transmission is also an important factor, accounting for 7 percent of infections. Transmission via blood transfusion is rare: Zimbabwe was one of the first countries in the world to implement universal screening of blood and the selection of all voluntary, low-risk donors. Transmission via men who have sex with men is probably underestimated, given the government's fervent antihomosexual stance. AIDS Mortality * In 2001, UNAIDS estimated that there were 200,000 adult and child AIDS deaths. * Among adult Zimbabwean women, CDC has found that mortality peaks at 5.7 percent for the 30-34 age group, with 5.5 percent dying because of AIDS. Among men, mortality peaks at 5.2 percent for the 40-44 age group, with 4.8 percent dying because of AIDS. Data Quality Issues * ANC data currently serve as Zimbabwe's primary sentinel surveillance of HIV/AIDS. Though ANCs prevalence is widely used, they are imperfect. For example, antenatal data may underestimate HIV prevalence in women of reproductive age, as recent studies indicate that fertility among HIV-positive women is substantially lower than among uninfected women. * That ANC surveys have not been conducted on an annual basis in Zimbabwe does constrains analysis. Another issue is the disparity in the number of antenatal clinics participating each year. This scenario may be related to reduced budgetary allocations for ANC surveys; famine and the political and economic crises may also be limiting the ability of researchers to conduct such surveys. In addition, they may be limiting the number of women who are able to attend ANCs, thus affecting samples. * The August 2003 report appeared to confirm that laboratory errors regarding the Chiredzi and Musume data were made in the 2000 ANC survey, leading to overestimates of HIV prevalence and thus the very large prevalence declines observed in 2001. * It appears that there may be a decline in HIV prevalence among women attending ANCs, particularly those in the youngest age groups. To what this decline can be attributed, however, remains unclear. HIV Sentinel Surveillance The first AIDS case in Zimbabwe was identified in 1985. HIV sentinel surveillance was initiated in 1991, with subsequent HSS conducted in 1993, 1994, 1995, 1997, 2000, and 2001.[1] 2000 Findings In 2000, Zimbabwe undertook the first fully implemented antenatal clinic (ANC) survey since 1997 (with support from the U.S. Centers for Disease Control and Prevention).[1] For the 2000 ANC survey, anonymous, unlinked blood samples were collected over a three-month period from 6,121 women ages 15 to 44 at their first appointment at ANCs across 19 sentinel sites spanning all provinces (including urban center, municipalities, rural areas, commercial areas, farming areas, mining areas, growth points, and border posts). Of the 6,121 women studied, 22.6 percent were ages 15-19, 35.9 percent ages 20-24, 23.4 percent ages 25-29, and 11.4 percent ages 30-34 yrs, and 6.7 percent were over age 35. Fifty-five percent were from rural areas, 93 percent were married, and 66 percent had a secondary education.[2] The 2000 ANC survey found that 35 percent of women attending ANCs were infected with HIV.[2] Prevalences at the 19 sentinel sites ranged from 13.0 percent (Binga Kariyangwe) to 70.7 percent (Chiredzi). Prevalence was highest among women ages 30 to 34 (43.5 percent).[1] The 2000 ANC survey found that prevalence among married women was 34.5 percent. Provincial prevalences in 2000 ranged from 25.6 percent (Mashonaland Central) to 49.4 percent (Masvingo). Prevalences in Harare and Bulawayo were 30.0 and 31.1 percent, respectively. HIV prevalence was highest in clinics located in commercial farming and mining areas (53.9 percent), followed by border posts (48.7 percent), growth points (business centers servicing a collection of villages, including grocery shops, petrol station, bottle shop, nightclub, and sometimes a small hotel) (41.5 percent), urban areas (31.6 percent), and other rural areas (26.8 percent).[1] 2001 Findings At the XIV International AIDS Conference in Barcelona in July 2002, officials from Zimbabwe's Ministry of Health and Child Welfare (MOHCW) and the CDC presented preliminary findings. The 2001 ANC survey appears to have been carried out in the same 19 sites as in the 2000 ANC survey except that Banket was included and Hwange St. Patrick's was excluded in 2001. In 2001, data for 880 women attending ANCs were collected through anonymous, unlinked blood samples. The Genlavia MIXT HIV Assay was used to test specimens; EpiInfo 2000 and SAS were used to analyze the data.[3] The findings presented in Barcelona indicated that national HIV prevalence among ANCs had fallen to 29.5 percent (from 35 percent in 2000). HIV prevalence among the sentinel sites ranged from 19.2 percent (Binga and Karanda) to 41.9 percent (Gwanda). Thirteen sites registered decreases in HIV prevalence compared to 2000. In Chiredzi and Musume, absolute prevalence declines were greater than 25 percent; these two sites accounted for almost half of the total change in prevalence over 2000-2001. Excluding Chiredzi and Musume from the 2000 and 2001 data indicates that national ANC prevalence declined from 32 to 29.5 percent. Prevalence declines were observed in all age groups except those ages 40 to 44. Prevalence remained highest among those ages 30 to 34.[3] Based on these findings, the Zimbabwean MOHCW and CDC concluded that there seemed to be a decline in HIV among women attending ANCs in Zimbabwe between 2000 and 2001. They viewed the greater decline in prevalence among younger women and lower decline in older women as suggesting a declining incidence of HIV infection. As for the size of the decline, they believed that it was unclear whether the findings from 2000 were too high, or whether the 2001 findings reflect a true decline. They noted that an absolute difference in HIV prevalence greater than 5 percent in just one year appears to be too large to be a true epidemiologic change. They encouraged immediate validation and calibration of the 2001 ANC data using other population-based probability sampling, such as the young adult survey conducted in 2001 (the findings of which have not yet been released).[3] HSS Findings 1991 - 2001 Ten of the 19 sentinel clinics included in the 2000 survey were also part of the 1997 ANC survey. Comparing results from these 10 clinics only finds that HIV prevalence rose from 27.0 percent in 1997 to 35.0 percent in 2000. A comparison involving all participating clinics in 1997 (total 28) with the 19 that participated in 2000 finds that HIV prevalence rose from 29.0 percent in 1997 to 35 percent in 2000.[1] As mentioned, the 2001 ANC survey was carried out in the same 19 sites as in 2000 save for two sites. The preliminary findings from the 2001 ANC indicate that HIV prevalence fell from 35.0 percent in 2000 to 29.5 percent in 2001. [3] August 2003 Release of Revised HIV Figures On August 21, 2003, Zimbabwe officials released a report presenting new national HIV/AIDS prevalence data indicating a possible decline in the number of HIV-positive Zimbabweans. According to the report, 1.82 million are living with HIV/AIDS. The figures, compiled using surveys conducted by local experts with technical assistance from the CDC, WHO, UNAIDS, and the Imperial College of London, reported that 24.9 percent of Zimbabwean adults are HIV-positive, down from 33.7 percent in 2001, as reported by UNAIDS. Zimbabwe Health Minister David Parirenyatwa stated that the new data suggest that HIV prevalence in ANC surveys peaked in 2000 at 34 percent, fell in 2001 to 30 percent, and decreased further in 2002 to 25.7 percent. However, Parirenyatwa cautioned that "more work was needed" to determine whether the recent prevalence estimates marked a true decline. [1] Several Zimbabwean HIV/AIDS experts stated that the new figures did not represent a real decline in HIV prevalence, but rather a correction of flawed data from previous surveys.[2] For example, Dr. Godfrey Woelk of the University of Zimbabwe noted: "There were also some mistakes made in the testing in earlier surveys, which overestimated the prevalence....It is not a decline, simply a more accurate estimation. In one of the previous ANC sentinel surveillance surveys, there was probably a mistake in the lab testing (where Chiredzi and another area had rates of 70% HIV prevalence)."[3] Dr. Katherine Fritz of the UZ-UCSF Collaborative Research Program commented: "It could be that the epidemic peaked around 2000. I think it's also very possible that previous surveillance was flawed. The thing that worries me about the future is that with all the land redistribution over the past 18 months, people are on the move more than ever and husbands and wives spend more time apart. For example, men from Harare who have acquired land often send their wives to live on the land and tend it while men stay in the city."[4] HIV Incidence Reductions in HIV-1 prevalence, especially those in young adults, may indicate concomitant declines in HIV-1 incidence. However, other factors, such as mortality rates, migration, and survey coverage, also contribute to prevalence trends. Thus, incidence trends cannot be estimated directly from prevalence trends. Reductions in HIV-1 incidence trends would provide the most convincing evidence of a decrease in epidemic size, but large, long-term, longitudinal studies (cohort studies, which indicate both incidence as well as prevalence) are needed to obtain such evidence. [5] Since November 1999, women ages 18 to 35 years from family planning and STI clinics and community settings in Zimbabwe (as well as Thailand and Uganda) have been screened for and enrolled in a study of hormonal contraception and risk of HIV acquisition. Analysis of data from Zimbabwe through mid-August 2001 (n=1,600) found that HIV incidence was about 3.5 percent in Harare and Chitungwiza.[4] U.N. Estimates At the end of 2001, UNAIDS estimated that 2.3 million Zimbabweans were living with HIV/AIDS (range: 1.8 to 2.7 million) Of them, 2 million were adults (ages 15 to 49), with the adult prevalence at 33.7 percent.[5] (At the end of 1999, UNAIDS estimated adult prevalence at 25.06 percent.[6]).[5] The U.N. Population Division estimates that Zimbabwe's adult HIV prevalence peaked at 34.0 percent in 2000. By 2050, the division estimates that adult prevalence will have fallen to 18.3 percent. (This projection assumes that HIV/AIDS dynamics remain unchanged until 2010. Thereafter, prevalence levels are assumed to decline. By 2050, prevalence levels are lower but still substantial in the most highly affected countries.)[6] Gender and Age UNAIDS estimates that of adults infected with HIV at the end of 2001, 1.2 million (60 percent) were women. HIV prevalence among women ages 15 to 24 ranged from 26.4 to 39.61 percent; the comparable range for men in the same age group was 9.9 to 14.85 percent.) At the end of 2001, there were 240,000 Zimbabwean children (ages 0 to 14) living with HIV/AIDS.[5] Transmission Patterns The epidemic is driven largely by heterosexual transmission, which accounts for 92 percent of infections. Mother-to-child transmission is also an important factor, accounting for 7 percent of infections.[7] Transmission via blood transfusion is rare: Zimbabwe was one of the first countries in the world to implement universal screening of blood and the selection of all voluntary, low-risk donors (see Response section for more detail on the National Blood Transfusion Service). Transmission via men who have sex with men is probably underestimated, given the government's fervent antihomosexual stance. AIDS Mortality See also the Impact section below. In 2001, UNAIDS estimated that there were 200,000 adult and child AIDS deaths.[5] (The comparable figure for 1999 was 160,000.[6]) Zimbabwean health officials estimate that there are 2,500 HIV/AIDS-related deaths in the country each week.[1, 7] Among adult Zimbabwean women, CDC has found that mortality peaks at 5.7 percent for the 30-34 age group, with 5.5 percent dying because of AIDS. Among men, mortality peaks at 5.2 percent for the 40-44 age group, with 4.8 percent dying because of AIDS.[10] Data Quality Issues ANC data currently serve as Zimbabwe's primary sentinel surveillance of HIV/AIDS. Though ANCs prevalence is widely used, they are imperfect (see box 1). For example, antenatal data may underestimate HIV prevalence in women of reproductive age, as recent studies indicate that fertility among HIV-positive women is substantially lower than among uninfected women. Gregson et al. have found 25 to 40 percent lower fertility in women with HIV in high-prevalence African countries; they attribute about half of this "subfertility" directly to HIV infection.[11] There is also the possibility that women attending ANCs are significantly older or younger than women in the general population; however, when Zimbabwe's 2000 ANC data were adjusted to account for the age distribution among women in the general population, minimal differences in HIV prevalence were found.[12] That ANC surveys have not been conducted on an annual basis in Zimbabwe does constrains analysis. Another issue is the disparity in the number of antenatal clinics participating each year. For example, 28 clinics participated in the 1997 survey, but only 19 in 2000 and in 2001. The number of women surveyed has also decreased, from 6,121 in 2000 to 880 in 2001. This scenario may be related to reduced budgetary allocations for ANC surveys; famine and the political and economic crises may also be limiting the ability of researchers to conduct such surveys. In addition, they may be limiting the number of women who are able to attend ANCs, thus affecting samples. Finally, in 2001, women aged less than 15 and between 44 and 49 were included, whereas this does not appear to have been the case in 2000. The August 2003 report appeared to confirm that laboratory errors regarding the Chiredzi and Musume data were made in the 2000 ANC survey, leading to overestimates of HIV prevalence and thus the very large prevalence declines observed in 2001.[12] It appears that there may be a decline in HIV prevalence among women attending ANCs, particularly those in the youngest age groups. To what this decline can be attributed, however, remains unclear.[12, 13] Political Economy and Sociobehavioral Context At a Glance * The relationship between HIV prevalence and socioeconomic indicators is highly complex. Increasingly, risk of HIV infection is recognized as related to individual as well as community variables. Additionally, since 1999 the political and economic situation in Zimbabwe has dramatically deteriorated, and the country is currently undergoing a massive food shortage¾all these affect and are affected by HIV/AIDS. Governance * Recent laws passed in Zimbabwe put tight restrictions on access to information. * Although the 2002 Zimbabwean presidential elections were widely viewed as unfair, SADC governments declared the outcome "legitimate." * Paralleling a dramatic decline in overall living standards and an uncertain political situation, serious crime levels in Zimbabwe appear to be rising. * Corruption is pervasive in the country. Fast-Track Land Reform * European colonizers displaced the majority of indigenous farming population onto unproductive lands called communal areas. Historically, Zimbabwe's white minority owned most of the country's productive land through large-scale commercial farms, whereas the majority of the population lived on less-fertile land. * The need for land reform in Zimbabwe is widely acknowledged, even by representatives of the commercial farming sector. In 2000, the government began a fast-track land redistribution program, which is being carried out very rapidly, bypassing legal procedures. * The allocation of plots has frequently discriminated against those believed to support opposition parties. There have been numerous reports of land going to President Mugabe's relatives and supporters. * Under the fast-track land reform, forced expulsion of white farmers and violence against both farmers and farm employees are occurring. The disruptions to commercial agriculture¾combined with severe drought¾have disrupted a significant portion of the commercial farm economy. * Fast-track land reform has been accompanied by large movements of people, regroupings of family units, and exposure to new sexual networks. * Uncertainty surrounding the farming sector has jeopardized the country's exports. Food Crisis * Reports from aid agencies that have conducted missions in Zimbabwe concur that one of the key underlying factors contributing to the food crisis is HIV/AIDS, as well as inappropriate macroeconomic policy, fast-track land resettlement program, and natural phenomena, e.g., drought. * A UN mission to Zimbabwe in January 2003 found that although food shortages were easing in other parts of southern Africa, the number of Zimbabweans at risk of starvation was rising. It reported that the political situation has severely hampered the high-potential agricultural areas from operating at maximum capacity during the current growing season, leading to a significant food deficit for the 2003/2004 marketing season. * Drought is a normal part of the cycle in Zimbabwean agriculture and that poverty is the norm for the majority of Zimbabweans. Subsequently, households have an array of coping mechanisms. However, in 2002-03, because of HIV/AIDS, drought, fast-track land reform, and the deteriorating economic situation, most of these coping strategies are irrelevant, and the extended family safety net and local support networks are increasingly under pressure. * Households already affected by HIV/AIDS, those that are poor, and/or those headed by women, children, or the elderly may have difficulty accessing food aid because of impaired mobility, ostracism, or stigma. * Vulnerable populations are adopting an array of survival strategies, including generating additional sources of food or income, migrating, dropping out of school, engaging in hazardous work, or exchanging sex for food or cash. For some young women, sex work provides the only way to support themselves and their families. * Another factor involves the response to the food crisis, i.e., aid workers and truck drivers delivering food aid. Some women and girls may offer sex to workers involved in transporting and distributing food aid to try and obtain preferential treatment in the distribution of supplies and services; women and children may be particularly vulnerable to sexual exploitation during humanitarian crises. Human Rights * Several aid agencies report that state-sponsored militias are controlling the distribution of food supplies in rural areas and using food as a tool of repression against opposition Movement for Democratic Change supporters. * Fast-track land reform has led to serious human rights violations, including serious acts of violence against farm owners and farm workers, and, using occupied farms as bases for attacks, against residents of surrounding areas. The police have done little to halt such violence, and in some cases are directly implicated in the abuses. * There has also been an increase in rape of young girls living on farms that have been invaded following fast-track land reform. Population Mobility * Part of Zimbabwe's colonial legacy involves gender-segregated, inter- and intracountry labor migration. Moreover, excombatants who fought to attain independence returned to Zimbabwe during the 1980s; this movement may have facilitated HIV transmission. * There is high mobility among urban, rural, mining, and port areas, within Zimbabwe as well as within the southern Africa subregion. Much of this movement is dominated by men. Migrant labor separates men from their families, places them in close proximity to "high-risk" sexual networks, and may result in their having an increased number of sexual contacts. Concurrently, it may also lead to women's reliance on sex to supplement their incomes while their male partners are away for long periods. * Food shortages, fast-track land reform, and the political and economic situation are also spurring population dislocation. Intercountry mobility is also high, as many Zimbabweans are emigrating. * Zimbabwe's 2000 ANC survey found that HIV prevalence was highest in commercial farming and mining areas, followed by border posts, growth points, other urban areas, and other rural areas. Economy * At independence, the Zimbabwean economy was more industrialized than most in Africa, with a diversified productive base, well-developed infrastructure, and a relatively sophisticated financial sector. * In 1991, Zimbabwe undertook a structural adjustment program. During the 1990s, poverty in Zimbabwe increased significantly. In the mid-1990s over 60 percent of Zimbabwean households fell below the national poverty line. The World Bank attributes this increase in poverty to the poor performance of the economy and to flaws in the structural adjustment program. * Since 1999, the country has been experiencing a socioeconomic crisis, resulting from poor economic policies, falling prices for key exports, a decrease in farm outputs following farm invasions and expulsion of white farmers and farm workers, increased deficit, drought, and loss of investor confidence due to uncertainty about domestic policies. Economic deterioration was also exacerbated by military involvement in the Democratic Republic of Congo from 1999 to 2002. * Given the current political and economic situation, some donors have suspended funding, citing violence and abrogation of the rule of law. Others have reduced their operations to activities in social sectors (including HIV/AIDS), social protection, and human rights/governance programs. Increased donor support is contingent upon progress in orderly land reform and macroeconomic stabilization. Health System * In 2000, public expenditures on health represented 3.1 percent of GDP, whereas private health expenditures represented 3.6 percent of GDP. * After independence, the Government of Zimbabwe made great strides in improving access to social services. By the end of the 1980s, the country was one of Africa's leaders in terms of overall access to health and education. * However, the health care system is deteriorating, exacerbated by the current crises. The public health sector has been severely affected by an array of problems, including drug shortages and the exodus of skilled medical personnel. Tuberculosis * WHO ranks Zimbabwe a "high TB burden" country. In 2001, it had the world's 17th highest burden of TB in terms of new cases. An estimated 67 percent of adult (ages 15-49) TB cases are HIV-positive. * Major constraints to achieving TB targets include ? weak political commitment to TB control ? lack of TB manager and other staff ? funding gaps ? low access to treatment because of poor infrastructure in new settlements ? limited community involvement in TB control Sexual and Reproductive Health * Zimbabwe's past achievements in sexual & reproductive health have eroded and the reproductive health status of Zimbabweans has deteriorated. The country's contraceptive prevalence rates¾though much higher than the regional averages¾have stagnated. The maternal mortality ratio has been increasing. Sexually Transmitted Infections * It is unclear whether the reported number of STIs is decreasing. It appears that viral, rather than bacterial, STIs, are driving the epidemic. Awareness and Knowledge of HIV/AIDS * Knowledge of HIV/AIDS is high in Zimbabwe. However, there are profound gender differences in the way in which personal HIV risk is construed, which may affect policy and program interventions. Stigma and Discrimination * Despite high levels of awareness of HIV/AIDS, it remains highly stigmatized. Sexual Behavior * Sexual behaviors driving the HIV/AIDS epidemic in Zimbabwe are influenced by a complex interplay of social, economic, and cultural factors. For women, casual sex before marriage is not socially sanctioned. It is, however, expected that men will have had several sexual partners before marriage. * Among women who had sex in the past year, 4.3 percent used a condom during last sexual intercourse with a spouse or cohabiting partner; 42 percent used a condom during last sex with a noncohabiting partner. Among men, these figures were 6.5 and 70.2 percent, respectively. * A significant decline in condom use within marriage occurred during the latter half of the 1990s * Twenty-eight percent of women and 16.7 of men cannot not cite a source for obtaining a male condom. Youth * Zimbabwe has a very young population; 40 percent of Zimbabweans are under age 15. In 2000, the median age in the country was 17.5. * The Zimbabwean government has failed to adopt laws and policies that ensure young people the right to access the information and methods to protect themselves from unwanted pregnancy and HIV/STIs. The Zimbabwean government has made parents the gatekeepers for their children's access to reproductive health services, and as a result, health workers have tended to turn away adolescents seeking dual protection information and services. In addition, young people tend to lack confidence that health workers will keep their requests confidential. Alcohol and Drug Use * Consumption of and demand for harmful substances still center on alcohol and cannabis. There are reports that certain inhalants and over-the-counter stimulants are being abused. Anecdotal reports indicate an increase in the abuse of cannabis, cocaine, and ecstasy. * In rural areas, alcohol consumption plays an important part in community life as it is associated with ceremonies and rituals. It is also seen as an essential recreational activity, especially for some men. A variety of alcoholic beverages are consumed, but beer is the most frequent. Far more men than women drink alcohol, particularly in drinking establishments. For many, the purpose of drinking is to get drunk, and there is a high frequency of drunkenness among those who indicate they drink. Drinking is associated with casual and transactional sex. Gender * Shona and Ndebele societies are patriarchal and patrilineal. They impose strict controls on female sexual behavior, whereas the attitude toward male sexual behavior is more lenient. * Before independence, women were socially and legally minors, and their rights were subordinate to men. Their active participation in the country's liberation struggle for independence demonstrated their capacity to fight against oppression. After Zimbabwe's independence in 1980, women struggled to liberate themselves socially, politically, and economically by lobbying the government through various women's organizations. * Their major triumph was the passing of the Legal Age of Majority Act (1982), which made 18 the age of majority for both women and men. However, Zimbabwe's constitution permits discrimination against women on the basis of customary law, under which women are designated minors. * Zimbabwean women become infected with HIV at younger ages than men for both biological and behavioral reasons (though the lifetime risk of acquiring HIV is about equal for both sexes). * Women's subordinate socioeconomic status affects their vulnerability to acquiring HIV and, once infected, accessing care and support services. * Fourteen percent of married Zimbabwean women report being in a polygynous union. * Studies on age mixing have found that among seronegative women, having a male partner 10 or more years older increased the risk of never having used a male condom. Older age of sexual partner was associated with increased risk of HIV-1 infection in men and women. Sexual Violence * Zimbabwean women are vulnerable to domestic abuse because of their low status and lack of power in the family, and because violence within marriage is widely tolerated. Zimbabwean women lack substantial legal recourse if they experience abuse. * Over half of Zimbabwean women believe that wife beating is justified in at least one of five situations. * Reported violence against Zimbabwean women has been rising dramatically. Since 2000, human rights groups have documented systematic rape and sexual torture of women in the context of the country's political violence. * Abuse of girls (sexual and nonsexual) in schools is widespread, including aggressive sexual behavior, intimidation and physical assault by older boys; sexual advances by male teachers; and corporal punishment and verbal abuse by both female and male teachers (this last directed at boys as well as girls). Sex Work * A 1994-95 study found that 86 percent of sex workers tested in Harare were HIV-positive. * The deteriorating economic situation is rendering sex in exchange for money or material good more common. Male Circumcision * There is very limited male circumcision in Zimbabwe. Male circumcision is practiced by a Xhosa ethnic group known as amaFengu in Zimbabwe. The amaFengu are originally from South Africa and live in some areas of Matabeleland. In a paper prepared for the WHO Commission on Macroeconomics and Health, David Bloom of Harvard and his colleagues note that: Existing data provide some indication that the relationship between poverty and HIV is growing stronger over time, both between and within continents. But it is not possible to infer causality from these data. That is, it is difficult to tell whether poverty causes AIDS or vice versa¾or whether another variable, such as war, inadequate health, or poor education, explains the relationship....In sum, the link between economic status and AIDS is complex.[8] Håkan Björkman, senior adviser on HIV/AIDS to UNDP's Bureau for Development Policy, states that: HIV/AIDS is not strictly speaking a "disease of poverty" as it affects people at all income levels. But evidence from some countries at advanced states of the epidemic shows that new HIV infections disproportionately affect poor people, unskilled workers, and those lacking literacy skills¾especially young women in each of these categories. The relationship among poverty, gender, and HIV vulnerability has important policy implications.[9] Many of the factors discussed in this section exist in countries that, unlike Zimbabwe, have low HIV prevalence; these include poverty, gender inequality, and history of colonialism and political and economic disenfranchisement. The relationship between HIV prevalence and socioeconomic indicators is highly complex. Increasingly, risk of HIV infection is recognized as related to individual as well as community variables.[14, 15] Additionally, since 1999 the political and economic situation in Zimbabwe has dramatically deteriorated, and the country is currently undergoing a massive food shortage¾all these affect and are affected by HIV/AIDS. This section does not seek to demonstrate causality; rather, it aims to analyze key political economy and sociobehavioral contextual elements to highlight the range of sectoral policies and interventions that may affect or be affected by HIV/AIDS. In addition to the table of key HIV/AIDS and socioeconomic indicators that accompanies this analysis, readers may also want to consult the 2003 indicators related to progress on Millennium Development Goals, which are published by UNDP . Colonialism and the Post-Independence Period In the 1970s, nationalists in what was then called Rhodesia fought a liberation war against the white-minority government. The struggle for independence claimed over 20,000 lives.[16] The British Government formally granted independence to Zimbabwe in April 1980 (whereas many African nations obtained independence in the 1960s).[16] After independence, Zimbabwe attained major social equity achievements, such that, by the end of the 1980s, it was a leader among African nations regarding access to health and education. (32) In October 1987, the constitution was amended to end the separate roll for white voters and to create an executive presidency to replace the whites whose reserved seats had been abolished. Robert Mugabe was the leader of the African nationalist group Zimbabwe African National Union (ZANU) and a key actor in the country's independence struggle. His Zimbabwean African National Union-Patriotic Front (ZANU-PF) Party has dominated the legislative and executive branches since independence in 1980.[16] In 1999, Zimbabwe began a period of major political and economic upheaval. Opposition to President Mugabe and the ZANU-PF had been growing rapidly, in part due to worsening economic and human rights conditions (see below). The opposition is currently led by the Movement for Democratic Change (MDC), established in September 1999.[16] In June 2000, parliamentary elections were marked by violence and claims of electoral irregularities and government intimidation of opposition supporters. However, the opposition MDC did capture 57 of 120 seats in the National Assembly. Presidential elections in March 2002, which President Mugabe won, were also marked by violence against opposition supporters, intimidation of the independent press and the judiciary, and other irregularities.[16] Governance Access to Information Zimbabwe's Access to Information and Protection of Privacy Act was passed in January 2002. The law established a media and information commission, appointed by the information ministry, with powers to license journalists¾all of whom must be Zimbabwean nationals, including correspondents for foreign newspapers¾and ensure that they possess appropriate "qualifications." The law prescribes penalties for "spreading rumors" and "false information," and defines a wide range of "protected information" to which reporting restrictions apply. The law also includes tight restrictions on foreign media. Another recent law, the Zimbabwe Public Order and Security Act, criminalizes criticism of the president and lays out sentences that include life imprisonment and death.[10] According to the Media Institute of Southern Africa, "Attempts to legalize repression of the media through the enactment of blatantly unconstitutional laws were the worst developments faced by Zimbabwean media during 2002." [11] Political Participation As mentioned above, the Zimbabwean presidential elections in 2002 were widely construed as unfair. In rural areas, 400,000 names were allegedly added to the register after the official closure of registration. Given significant discrepancies between the Electoral Supervisory Commission's results and the final count of the Registrar General, Commonwealth observers accused the ruling party of ballot box stuffing on a large scale. Nevertheless, SADC governments declared the outcome "legitimate."[10] Crime According to the U.N. Office on Drugs and Crime: "Paralleling a drastic drop in overall living standards and an uncertain political situation, serious crime levels in Zimbabwe appear to be on the increase. The number of reported homicides, for example, nearly doubled from 555 in 1996 to 1,045 in 2000. Criminal case clearance and conviction rates remain low. It appears the situation is ripe for an increase in substance abuse and drug trafficking as more and more marginalized citizens turn to drugs as a livelihood strategy."[12] Apart from the rise in reported homicides, there were also reported increases in serious assault, common assault, robbery, and vehicle hijacking during 1996-2000. Property crime also appears high and on the increase, with recorded cases of housebreaking rising from 53,524 in 1996 to 56,475 in 2000. All categories of organized crime have shown an increase between 1996 and 2000, but they have maintained their relative rank order, with drug trafficking (6,833 cases in 2000) first, followed by fraud and/or money laundering (5,060), vehicle thefts and hijackings (1,414), and armed robbery (513).(Zimbabwe Paper 2002).[12] Corruption Corruption is pervasive in Zimbabwe.[10] Zimbabwe is ranked at the top (most corrupt) of the SADC Afrobarometer ratings on public perception of the corruptibility of public officials.[12] According to Transparency International's Corruption Perceptions Index 2003, Zimbabwe's score has worsened since 2002 and now stands at 2.3 (perception of the degree of corruption as viewed by business people, academics, and risk analysts; ranges between 10 [highly clean] and 0 [highly corrupt].) [13] Transparency International Zimbabwe undertook a survey of 1,500 respondents in 2001, nearly 50 percent of whom blamed public and private sector corruption for the national economic crisis. In August 2001 the Human Rights Trust of Southern Africa in Zimbabwe published the results of a survey in which a representative sample of officials were asked about the extent of corruption within different professions. The survey found that politicians and police officers were perceived to be the most corrupt.[10] Currently, the government has no corruption prevention activities.[12] A major setback for civil society efforts to check official abuses in Zimbabwe was an amendment to the electoral law, which altered the status of domestic electoral monitors and curbed their powers. Under the new legislation, monitors during must be existing members of government services. Although Zimbabwe's supreme court declared the law unconstitutional, President Mugabe reinstated it. The legislation effectively rules out any possibility of civil society organizations mounting monitoring operations similar to that conducted by Transparency International Zimbabwe during the 2000 parliamentary elections.[10] Fast-Track Land Reform European colonizers displaced the majority of indigenous farming population onto unproductive lands called communal areas.[17] Historically, Zimbabwe's white minority owned most of the country's productive land through large-scale commercial farms, whereas the majority of the population lived on less-fertile land.[18] In 2000, about 4,500 large-scale commercial farmers still held 28 percent of the total land.[19] Many land restitution claims regarding forced removals under the white-minority government have never been addressed.[19] Both rural and urban areas continue to be spatially segregated along racial lines. Urban areas are characterized by separate, predominantly white, low-density neighborhoods and African high-density townships. In rural areas, there have historically been white commercial farms and African communal areas.[20] Many farm workers are descendants of Zambians, Malawians, or Mozambicans brought to Zimbabwe as indentured labor during the colonial era. They have little or no access to land on their own account; they are also vulnerable to arbitrary eviction from the accommodation that is tied to their employment by farm owners. Many poor and middle-income Africans in urban areas have viewed land as an alternative source of income and food security.[19] Most low- and middle-income urban Africans maintain dual residences: in the city where they work and in the rural/communal area where their families live. The need for land reform in Zimbabwe is widely acknowledged, even by representatives of the commercial farming sector.[19] In 2000, the government began a fast-track land redistribution program (under Section 8 of the Land Acquisition Act), which it maintains is meant to redress colonial era imbalances in land ownership.[21] Almost 95 percent of the country's commercial farmland is affected by this land reform program.[22] The fast-track process of resettlement is being carried out very rapidly, bypassing legal procedures. Consequently, there has been concern that title to land will be not secure. Some who wish to participate in resettlement have not done so because they lack the resources to plow the land and because there is little government support to assist new settlers.[19] Human Rights Watch posits that landless farm workers are the most disadvantaged group with regard to fast-track land reform. First, they have not been targeted to benefit from land reallocations. Second, many are of foreign descent and would have additional difficulty in accessing resettlement schemes. Finally, many have been laid off from paid work. HRW also believes that despite government commitments to addressing gender inequality in land distribution, women, whose rights to land under customary law are weak (see Gender section), have also failed to benefit proportionately from the fast-track process.[19] The Zimbabwean NGO Women Land and Lobby Group reports that between 1999 and 2001, only 16 percent of land was allocated to female-headed households. Concurrently, the number of female-headed households is increasing because of HIV/AIDS.[23] The process of allocating plots has also frequently discriminated against those believed to support opposition parties, and in some cases, those supervising the application process have required applicants to demonstrate support for the ZANUPF.[19] Moreover, there have been numerous reports of land going to President Mugabe's relatives and supporters.[14] Under the fast-track land reform, forced expulsion of white farmers and violence against both farmers and farm employees are occurring, often perpetrated by a loosely organized group (calling themselves war veterans).[18] The disruptions to commercial agriculture¾combined with severe drought¾have disrupted a significant portion of the commercial farm economy. Consequently, farm workers, settlers, youth brigades, and others are moving around the country. This population mobility can increase vulnerability to acquiring HIV. The Southern Africa AIDS Information Dissemination Service (SAfAIDS), for example, notes that fast-track land reform has been accompanied by large movements of people, regroupings of family units, and exposure to new sexual networks.[24] Uncertainty surrounding the farming sector has jeopardized the country's billion-dollar tea, coffee, sugar, flower, and vegetable export markets. There is also the risk of farmers' not making bond repayments, which would negatively affect the country's international credit rating.[22] These factors are contributing to the food crisis. Food Crisis Reports from aid agencies that have conducted missions in Zimbabwe concur that one of the key underlying factors contributing to the food crisis is HIV/AIDS. In August 2002, the U.N. reported that the causes of the food shortage were multifaceted and interconnected, primarily the result of: * inappropriate macroeconomic policy * fast-track land resettlement program * natural phenomena, e.g., drought * HIV/AIDS [43] At that time, the U.N. reported that over 6 million Zimbabweans¾half the population¾was at risk of starvation because of the worsening food shortage, estimated at 1.8 million metric tons. Health services were becoming increasingly difficult to access and basic drugs were in short supply.[43] In August 2002, the World Food Program (WFP) reported on the situation in Masvingo Province (which had the highest HIV prevalence among all provinces according to the 2000 ANC survey: 49.4 percent [2]). Communities that could afford to buy food still faced difficulties in accessing maize. The most vulnerable groups included child- and women-headed households, the elderly, and terminally ill people who cannot afford to buy food for themselves. Almost 95 percent of households visited lived on one meal only. Most had tea, sadza (porridge), wild fruits and roots, or vegetables as their only meal of the day. As supply of cattle currently exceeds demand, household assets such as cattle are not being sold, given low prices.[37] Preliminary indications from a joint August 2002 household economy assessment carried out by Zimbabwe's Ministry of Public Service and Social Welfare, Ministry of Lands, U.N. Relief and Recovery Unit, and Save the Children (U.K.) indicate that the food security situation is worsening. In Mashonaland East and West provinces, the mission noted that commercial farm workers, resettled farmers, and communal farmers were experiencing a severe shortage of food. Grain Marketing Board supplies are no longer sufficient to meet the increased demand.[37] A rapid assessment conducted in August 2002 by WFP and UNICEF in Tsholotsho District of Matabeleland North found that most respondents were relying exclusively on WFP-provided food in their community.[37] In September 2002, UNICEF reported that households already affected by HIV/AIDS, those that are poor, and/or those headed by women, children, or the elderly may have difficulty accessing food aid because of impaired mobility, ostracism, or stigma. Within households, the distribution of food may favor those perceived to be more healthy and productive; those who are HIV-positive may be given low priority. Water from unsafe sources is also more likely to be used, thereby increasing illness and death; its use also has a negative impact on infants who are bottle-fed.[44, 45] UNICEF also highlighted that vulnerable populations were adopting an array of survival strategies, including generating additional sources of food or income, migrating, dropping out of school, engaging in hazardous work, or exchanging sex for food or cash. For some young women, sex work provides the only way to support themselves and their families. UNICEF stressed that many of these strategies put young people¾especially women¾at high risk of acquiring HIV.[44, 45] Another factor involves the response to the food crisis, i.e., aid workers and truck drivers delivering food aid. UNICEF highlighted that some may offer sex to workers involved in transporting and distributing food aid to try and obtain preferential treatment in the distribution of supplies and services; women and children may be particularly vulnerable to sexual exploitation during humanitarian crises.[44, 45] A UN mission to Zimbabwe in January 2003 found that although food shortages were easing in other parts of southern Africa, the number of Zimbabweans at risk of starvation was rising.[15]: "Zimbabwe presents a substantially different set of challenges from those in other countries in the region. It does share some of the same problems with its neighbors - a high HIV/AIDS prevalence rate, erratic rainfall patterns, over -stressed social safety nets - but the current policy environment is preventing the international community from moving beyond pure emergency programming towards supporting longer-term development efforts. It is clear that the political situation has severely hampered the high-potential agricultural areas from operating at maximum capacity for this growing season, which will lead to a significant food deficit for the 2003/2004 marketing season. Impacts from the dire situation Zimbabwe will ripple through other southern African countries, amplifying any food security problems that those countries may experience."[16] "The situation in Zimbabwe is cause for serious concern, with over half the population currently in need of assistance. Along with continued political turbulence and economic decline, people in Zimbabwe will experience continuing food shortages in the coming year due to a combination of dry weather, lack of affordable food on the market, and a dramatically reduced amount of land under cultivation....The strong likelihood of severe food deficits in the 2003/2004 marketing season in Zimbabwe...represents an immediate threat to food security throughout the region and will need to be taken into account in recovery strategies."[16] In June 2003, the World Food Program and FAO reported that: "Zimbabwe faces acute food shortages, with some 5.5 million people in need of food aid. Food production in Zimbabwe has fallen by more than 50 percent, measured against a five-year average, due mostly to the current social, economic and political situation and the effects of drought...compounded by the marked reduction of the large-scale farm sector [a consequence of the ongoing land reform program], which produced only about one-tenth of their 1990s output. As a result, about half of the regional food deficit of 2.2 million mt is in Zimbabwe. The shortfall means that Zimbabwe will need to import almost 1.3 million mt of food, either commercially or through food aid, to meet the minimum food needs of its people."[17] Food Crisis and HIV/AIDS See also the Household Impact section below. The U.N. notes that drought is a normal part of the cycle in Zimbabwean agriculture and that poverty is the norm for the majority of Zimbabweans. Subsequently, households have an array of coping mechanisms.[43] Mutangadura notes that traditionally, strong family ties had been the "best social insurance against starvation" in Zimbabwe; she also outlines informal mechanisms beyond the extended family that have helped households cope.[95] Yet in 2002-03, because of HIV/AIDS, drought, fast-track land reform, and the deteriorating economic situation, most of these coping strategies are irrelevant, and the extended family safety net and local support networks are increasingly under pressure. For example, in the past, those with money could buy maize meal at the market when their stocks ran out. That is no longer possible; because of economic policies and fast-track land reform, there is very little maize meal on the market to satisfy the demand, and the price of other food commodities, such as rice, have become too expensive.[43] There is increasing reliance on dangerous or damaging survival strategies, many of which may contribute to increased AIDS-related illness and death and/or vulnerability to acquiring HIV. These include: * reduction in the number of meals: This is the first strategy employed when food becomes scarce. As mentioned, the World Food Program found that 95 percent of households in Masvingo Province had already reduced their food consumption to one meal per day. * sale of assets: large numbers of families are already selling their assets to buy food. * child labor: Poor families in both rural and urban areas are sending children to work as housemaids or cattle herders. In urban areas, children are used as vendors while in rural areas they may be used in piecework (where it can still be found). There are reports that some families have begun to exchange young girls for food. * sex work: The U.N. is finding that children currently involved in sex work often come from female- and child-headed households. * homelessness and near homelessness: In all urban areas, the number of squatters has increased tremendously. People displaced from rural areas and commercial farms move to high-density areas where they find low-cost or illegal accommodation. (See previous discussion of overcrowding.)[43] In late 2002, the Famine Early Warning Systems Network reported that: "The poverty that has accompanied Zimbabwe's economic crisis has driven many desperate rural people to prostitution, robbery and gold panning to survive. With maize and wheat being sold at eight times the government-set price, and oil, salt and rice prices escalating, income generating opportunities were diminishing for rural households. Cross border trading with neighbors Mozambique, Zambia and Botswana is also on the increase as households try to find any way they can to make ends meet. The demand for casual labor, which provided one of the few sources of cash, had declined in 90 percent of rural villages while 96 percent of villages reported a decrease in the flow of remittances from urban areas, researchers found. As a result, 80 percent of rural households reported eating wild foods they did not normally consume, which increased the risk of poisoning."[18] Human Rights Amnesty International has reported that state-sponsored militias are controlling the distribution of food supplies in rural areas and using food as a tool of repression against opposition Movement for Democratic Change supporters.[46] The U.N. also reports that in villages where government opposition is strong, residents are often denied state-provided food aid; many are surviving on wild berries and elephant dung.[47] In November 2002, the EU accused Zimbabwe's ruling party of using food aid as a political weapon against opposition supporters.[19] In December 2002, the Zimbabwe Human Rights NGO Forum released a report that cited increasing evidence that ZANU-PF was manipulating the distribution of food along political lines to gain and retain political support. [20] In 2002, Human Rights Watch reported that: The "fast track" land resettlement program implemented by the government of Zimbabwe over the last two years has led to serious human rights violations. Under the program, ruling party militias, often led by veterans of Zimbabwe's liberation war, have carried out serious acts of violence against farm owners, farm workers, and, using occupied farms as bases for attacks, against residents of surrounding areas. The police have done little to halt such violence, and in some cases are directly implicated in the abuses.[19] UNAIDS found a reported increase in rape of young girls living on farms that have been invaded following fast-track land reform.[38] Amnesty International has reported that state-sponsored militia are carrying out assaults and acts of sexual violence in reprisals against the political opposition.[46] Political violence has made public AIDS demonstration risky. The Men's Action Group in Zimbabwe reports that the main obstacles are: * Inability to organize activities with a politically mixed group, especially when participants know one another's political affiliation * Partisan politics: both in obstructing politically mixed gatherings and in claiming time of those who were once involved in mobilizing such gatherings * Lack of willingness on part of those are nonpartisan to be part of HIV/AIDS gatherings fearing victimization * Danger that mobilizations of people for HIV/AIDS activities may be perceived as political gatherings[83] Others have found that the effects of the political violence and economic hardship have had a negative impact on health and well-being through increased stress, little or no access to primary health care facilities, and a general sense of helplessness and hopelessness.[84] In March 2003, a strike to protest declining economic and political conditions and force the resignation of President Mugabe led to the arrest of over 400 citizens and a severe government backlash against political activity. The Movement for Democratic Change was prevented from undertaking normal campaign activities in the run-up to two parliamentary byelections, and party activists were harassed, detained, and beaten. In early June 2003, another protest stayaway was dismantled by state security forces in Harare.[21] In April 2003, Human Rights Watch criticized the lack of action by the UN Commission on Human Rights regarding alleged abuses in Zimbabwe.[22] In June 2003, HRW reported that human rights conditions in Zimbabwe had deteriorated dramatically over the last several months. HRW detailed the government's policy of repression and the harassment of opposition party members by state institutions and supporters of the ruling party, stressing that the direct involvement of ranking government officials and state security forces marks a new and worrisome trend in Zimbabwe's ongoing political crisis.[21] Not only have the army and police personnel failed to protect people from human rights abuses, but they are now carrying out abuses themselves. In addition, recent legislation has drastically curtailed citizens' rights to freedom of expression, assembly, and association (see above). The 2002 Public Order and Security Act bans public demonstrations.[21] HRW reports that the political violence prevalent in rural areas since 2000 has now become common in urban centers, and nonpolitical actors such as civic organizations and church leaders are increasingly targeted. Most of the recent violence has been committed by state security forces and youth militias.[21] In September 2003, Solidarity Peace Trust, chaired by Catholic Archbishop Pius Ncube of Bulawayo and Anglican Bishop Rubin Phillip of KwaZulu-Natal in South Africa, released a report on the Zimbabwe government's youth militia and its record of human right abuses: "Since it was set up in 2000, the youth militia, known locally as the "Green Bombers" from the color of their uniforms, have grown into one of the most commonly reported violators of human rights in Zimbabwe. Allegations of murder, torture, rape, arson, destruction of property and denial of food aid and health care to opposition members by the militia have been documented by Physicians for Human Rights, based in Denmark, and Amnesty International, among other rights groups."[23] "The National Youth Service, supposedly a voluntary training program for vocational skills, disaster management, patriotism and moral education, has become a paramilitary force for the ruling ZANU-PF. By the end of 2002, an estimated 9,000 youngsters had undergone formal militia training in five main camps, with up to 20,000 trained less formally in the districts."[23] "The government has repeatedly stated its intention to make youth service compulsory, with access to tertiary education and public sector positions linked to participation. In July the government announced plans for weapons training for the militia. Ministry of Defence Sydney Sekeramayi was quoted in the government press as saying that the National Youth Service could form a reserve force, under military command, to defend the nation."[23] "By announcing an 'intention' to train youth in weaponry, the minister had finally owned up to a 'de facto' government policy. It is now beyond doubt that the youth militia training is in fact paramilitary training under the guise of a national youth service. According to defected militia, it is often brutal and brutalizing."[23] "Children as young as 11 have reportedly been through the youth service program, whose stated catchment age is between 12 and 30 years. Such training could amount to creating child soldiers."{UN Office for the Coordination of Humanitarian Affairs, 2003 #974} "The militia has been deployed in force during local and national elections. They have been blatantly used by ZANU-PF as a campaign tool, being given impunity and implicit powers to mount roadblocks, disrupt MDC rallies and intimidate voters."[23] Population Mobility Part of Zimbabwe's colonial legacy involves gender-segregated, inter- and intracountry labor migration.[17] Moreover, excombatants who fought to attain independence returned to Zimbabwe during the 1980s; this movement may have facilitated HIV transmission.[12] Zimbabwe's paved roads link major urban, industrial, and mining centers, and rail lines tie it into an extensive central African railroad network.[18] There is high mobility among urban, rural, mining, and port areas, within Zimbabwe as well as within the southern Africa subregion.[24] Much of this movement is dominated by men. Migrant labor separates men from their families, places them in close proximity to "high-risk" sexual networks, and may result in their having an increased number of sexual contacts. Concurrently, it may also lead to women's reliance on sex to supplement their incomes while their male partners are away for long periods.[24] Food shortages, fast-track land reform, and the political and economic situation are also spurring population dislocation. Intercountry mobility is also high. For example, statistics released by Britain's Home Office indicated that more Zimbabweans sought asylum in Great Britain during 2002 than any other Africans. [25] Almost half the nurses trained in Zimbabwe are lost annually to better paying jobs in South Africa, the U.K., Australia, and the U.S.[7] Zimbabwe's 2000 ANC survey found that HIV prevalence was highest in commercial farming and mining areas, followed by border posts, growth points, other urban areas, and other rural areas.[1] In November 1999, Family Health International undertook research in four towns along the Durban-Lusaka highway, including Beitbridge. The findings epitomize the intersection of mobility, gender, sex work, and violence (see box 2). Moreover, some studies in southern African have found that female cross-border traders are particularly vulnerable to HIV infection. Many female traders report exchanging sex for transport. They also report rape and sexual harassment.[26, 27] The Tiripamwechete Study Group (comprising researchers from, inter alia, the University of Zimbabwe, University College London, and London School of Hygiene and Tropical Medicine) found that sex workers near mining and farming communities in Mashonaland West living close to paved roads reported a higher number of partners and clients, charged more per sex act, and had higher HIV prevalence than those women who lived in less accessible areas.[28] Researchers from Zimbabwe, the Netherlands, and U.K. examined the relationship between population mobility and HIV prevalence in rural Manicaland during 1998-2000. They found that men and women who moved into the study area in the last 10 years had a higher HIV prevalence than residents. Adjusting for number of lifetime partners, in-migration retained an association with HIV infection. Having an in-migrant spouse was associated with higher levels of HIV infection in men, but not in women.[29] Trafficking According to the U.S. State Department, Zimbabwe is a source country for men, women, and children trafficked to South Africa for farm labor and commercial sexual exploitation, as well as a transit country for persons trafficked from Asia, Malawi, Zambia, and Mozambique to South Africa. As a result of Zimbabwe's recent economic downturn and a growing number of HIV/AIDS orphans and child-headed households, internal trafficking of young women for commercial sexual exploitation is growing. The State Department reports that although the Government of Zimbabwe does not fully comply with the minimum standards for the elimination of trafficking, it is making significant efforts to do so despite severe resource constraints.[26] The UN notes that illegal entry into South Africa by Zimbabwean nationals is a longstanding phenomenon, and that the economic downturn has increased trafficking and smuggling of human beings.[12] Box 2. Beitbridge: HIV/STI Vulnerability in a Zimbabwean Border Town Zimbabwe's 2000 ANC survey found that HIV prevalence in Beitbridge was 41.4 percent. Beitbridge's stable population is 20,000. Each month, an estimated 5,000 to 10,000 truckers pass through the town. Beitbridge has many more female than male residents, reflecting the legacy of rural male migration to South Africa and female migration to the town. Women often come to Beitbridge hoping to enter or find work in South Africa, but many do not succeed. Stranded in the town without income, they are compelled to engage in sex work. Others rely on vending or cross-border trading for income. Since the decline in Zimbabwe's currency and the imposition of prohibitive tariffs, however, the import trade has declined dramatically. The town also has a higher proportion of informal traders than other Zimbabwean towns. At peak periods, 500 informal traders may cross the border daily. Some traders exchange sex with truckers for free rides and with customs officials for duty exemption. Without contacts at borders, however, women may face harassment. The sex industry in Beitbridge is the largest and most explicit in Zimbabwe. Many women work as vendors by day and sex workers by night. Female vendors as young as 14 are thus drawn into sex work. Young boy vendors describe them as chihure chesadza, or selling themselves for maize flour. The girls tell their families they work at night to sell produce to late-night bus passengers. Up to two-thirds of sex workers may be under age 18. In addition, female school enrollment has fallen steeply in Beitbridge. Sex workers in Beitbridge fall into three socioeconomic categories. Upper-income sex workers work from home, serving a smaller number of stable clients and boyfriends. Middle-income sex workers, who constitute the largest group, usually seek clients in bars. Lower-income sex workers seek clients on the highway or streets, sometimes exposing themselves to passing drivers. Sex workers come primarily from the arid southern provinces of Masvingo and Matabeleland South. Their rural origins provide them with support in Beitbridge because they can usually stay with people from their home areas until they are settled. Condoms are relatively accessible, and sex workers are willing to use them but unable to insist on their use. Those who do so risk violence. Sex workers are aware that many truckers have STIs, but say they have no choice: lacking their clients' willingness to use condoms, the sex workers accept that they will contract STIs and use their earnings to have them treated. Many sex workers prefer to use traditional healers, because of the greater discretion and better interpersonal quality of the service. Attitudes towards AIDS are fatalistic. As elsewhere, truckers are preferred clients, especially South African drivers. Smugglers, with their disposable income, are also popular. Police and customs officers often do not pay, but use coercion to elicit free sex. The average trucker is about 40 years old and spends up to 20 days each month away from home. Most reported that they have wives, girlfriends, and sex-worker partners, thus providing a bridge for widespread STI and HIV transmission. Border clearance is lengthy, forcing truckers to make stops of up to 10 days while paper work is processed. Most transport companies provide no accommodation, expecting truckers to sleep in their trucks at borders. Others give drivers a fixed allowance, which they are motivated to save. One trucker noted that a night with a sex worker costs less than half the price of a hotel room. Truckers receive money for road toll fees, which they can sometimes avoid or minimize, increasing their disposable income. Sources: AIDS & TB Program, Zimbabwean Ministry of Health and Child Welfare (with support from Zimbabwe-CDC AIDS Program). "National Survey of HIV Prevalence Among Women at Antenatal Clinics in Zimbabwe, 2000." PowerPoint presentation, 2001; Family Health International. Corridors of Hope in Southern Africa: HIV Prevention Needs and Opportunities in Four Border Towns. Arlington, Va.: 2000 Economy At independence, the Zimbabwean economy was more industrialized than most in Africa, with a diversified productive base, well-developed infrastructure, and a relatively sophisticated financial sector.[18] Zimbabwe's economy relies heavily on agricultural crops. Corn (maize) is the largest and staple crop. Tobacco is the largest export crop followed by cotton. Related manufacturing industries such as textiles and sugar production are also important. Mining, primarily gold, is also a major activity. Zimbabwe has an important percentage of the world's known reserves of chromite; other commercial mineral deposits include coal, asbestos, copper, nickel, and iron ore. Major growth industries include steel and steel products, heavy equipment, transportation equipment, ferrochrome, textiles, and food processing.[16, 18] According to the Reserve Bank of Zimbabwe, at the end of 2001, agricultural products account for 44 percent of total merchandise exports, with mining and manufacturing contributing 24 and 32 percent, respectively, to national exports.[30] In the early 1970s, the economy experienced a modest boom. Real per capita earnings for blacks and whites reached record highs, although the disparity in incomes between blacks and whites remained, with blacks earning only about one-tenth as much as whites. However, after 1975, the economy was undermined by the cumulative effects of sanctions, declining earnings from commodity exports, worsening guerilla conflict, and increasing white emigration.[16] Following independence, Zimbabwe experienced an economic recovery. Real growth for 1980-81 exceeded 20 percent. However, depressed foreign demand for the country's mineral exports and drought decreased the growth rate during 1982-84. In 1985, because of a 30 percent increase in agricultural production, the economy rebounded. However, given, inter alia, drought and a foreign-exchange crisis, it fell again in 1986. Growth in the late 1980s averaged 4.5 percent.[16] In 1991, Zimbabwe undertook an IMF-guided structural adjustment program. During the 1990s. poverty in Zimbabwe increased significantly. In the mid-1990s, for example, over 60 percent of Zimbabwean households fell below the national poverty line. The World Bank attributes this increase in poverty to the poor performance of the economy and to flaws in the structural adjustment program. Under structural adjustment, for example, budgetary cutbacks reduced the availability of public sector jobs. For those with formal sector jobs, their salaries lagged behind inflation, and formal sector employment no longer prevented people from being poor.[31] Since 1999, the country has been experiencing a socioeconomic crisis, resulting from poor economic policies, falling prices for key exports, a decrease in farm outputs following farm invasions and expulsion of white farmers and farm workers, increased deficit, drought, and loss of investor confidence due to uncertainty about domestic policies. Economic deterioration was also exacerbated by military involvement in the Democratic Republic of Congo from 1999 to 2002.[18] In 2000, Zimbabwe's gross national income per capita was US$460.[32] In 2001, GNI per capita was US$480; GDP growth during 2000-01 contracted by 8.4 percent.[27] Given the current political and economic situation, some donors have suspended funding, citing violence and abrogation of the rule of law. Others have reduced their operations to activities in social sectors (including HIV/AIDS), social protection, and human rights/governance programs. Increased donor support is contingent upon progress in orderly land reform and macroeconomic stabilization. However, a large number of international NGOs remain active with community-level programs.[18] In 2001, overall donor assistance to Zimbabwe was US$37.5 million, compare to US$219 million in 1999.[41] The World Bank suspended disbursements to Zimbabwe on May 15, 2000, due to overdue service payments.[18] On June 13, 2002, the IMF adopted a declaration of noncooperation regarding Zimbabwe's overdue financial obligations to the fund and suspended the provision of technical assistance to the country.[42] Inflation In August 2002, Zimbabwe's Central Statistics Office reported that inflation had reached 123.5 percent. The increase was due largely to rises in the prices of food and clothing.[36] During the same month, Zimbabwe's Food Security Trends Report found that that the prices of beef, milk, bread, and cooking oil have been increasing continuously and dramatically. This scenario is negatively affecting vulnerable populations' ability to purchase food.[37] Given the drought, fast-track land reform, and economic and political crises, basic food items remain scarce.[36] And poor economic management and low foreign currency reserves have led to serious fuel shortages.[16] Among other effects, the fuel shortages are affecting the ability of AIDS organizations to reach families with needed support, counseling, food, and other supplies.[38] In July 2003, the U.N. reported that inflation had reached 364 percent and is forecast to reach 500 percent by the end of 2003.[7] Unemployment In 1997, Zimbabwe's unemployment rate was estimated at around 30 percent by the government and at 44 percent by the Zimbabwe Congress of Trade Unions. There has been a declining trend in formal sector employment growth since independence. Among women, 55 percent were without paid employment in 1997.[39] (More recent, reliable unemployment figures are unavailable. Collection and analysis of unemployment data in developing countries are difficult [see UNDP's Human Development Report 2002 for a related discussion.[40]] Zimbabwe's political, economic, and food crises may be rendering such data collection even more difficult.) Widespread poverty, high rates of unemployment, and generally low returns from informal sector income-generating activities have been associated with high-risk sexual behavior and the spread of HIV.[25] Declining Human Development One method of tracking human development in Zimbabwe is to analyze trends in its Human Development Index. The HDI was created by UNDP to measures average achievements in life expectancy at birth; adult literacy and secondary, and tertiary gross enrollment ratios; and GDP per capita. An HDI of 0.800 or above = high human development; 0.500 - 0.799 = medium human development; less than 0.500 = low human development. In 2001, Zimbabwe's HDI was 0.496, placing it among "low-human development" countries and ranking it 145 of 175 countries for UNDP calculated an HDI.[28] Zimbabwe's HDI has been declining since the mid-1980s. Between 1975 and 1985, the HDI rose from 0.544 to 0.626, a reflection of, inter alia, the government's concrete efforts to increase educational attainment and health outcomes. From 1985 onward, however, the HDI has been falling, mirroring the country's socioeconomic decline. In 1990, the HDI was 0.614, falling to 0.567 in 1995 and to 0.551 in 2000. In 2001, it fell still farther, to 0.496. In 2000, Zimbabwe's HDI value was ranked 128 out of 173 countries; by 2001, it had fallen to 145 of 175 countries.[40][28] This decline doubtlessly reflects the enormous impact of AIDS mortality (see Impact section), which drastically reduced the life expectancy component of the HDI value. A critical indicator of the well-being of children is the under-five mortality rate (probability of dying between birth and exactly five years of age, expressed per 1,000 live births). According to UNICEF, Zimbabwe's under-five mortality rate in 2001 was 123. This figure is below that for all least-developed countries (157) as well as the sub-Saharan African region (173); however, it is the world's 38th highest (of 193 countries). [29] Another critical human development indicator is the maternal mortality ratio (MMR), the number of deaths to women per 100,000 live births that result from conditions related to pregnancy, delivery, and related complications. According to UNFPA, Zimbabwe's MMR has increased, from 610 in 2001 [30] to 654 in 20002.[31] Health System In 2000, public expenditures on health represented 3.1 percent of GDP, whereas private health expenditures represented 3.6 percent of GDP.[28] As previously mentioned, after independence, the Government of Zimbabwe made great strides in improving access to social services.[48] By the end of the 1980s, the country was one of Africa's leaders in terms of overall access to health and education.[32] However, in 2001, the U.N. reported that: Zimbabwe's crumbling health sector, with its under-funded and overcrowded hospitals and crammed mortuaries, is an eloquent testimony to the more far-reaching decline of a nation that a decade ago was a showcase of social service provision. At independence in 1980, along with promises of education and housing for all, the then avowedly socialist government of President Robert Mugabe made universal health by the year 2000 its pledge to its people.[49] Some examples of how the current crises are affecting health care delivery: In the past, 80 percent of rural Zimbabweans lived within 5 km of a rural health center; however, access declined in 2002 as a result of fast-track land reform, which has led to new settlements in areas with no clinics. [33] In 2003, WHO reported that poor infrastructure in new settlements impeded access to TB treatment.[33] Zimbabwe's public health sector has been severely affected by an array of problems, including drug shortages and the exodus of skilled medical personnel.[34] In July 2003, the U.N. reported on the serious shortage of professional health care staff in Zimbabwe, including nurses, doctors, and pharmacists. As mentioned above, almost half the nurses trained in Zimbabwe seek better paying jobs in South Africa, the U.K., Australia, and the U.S. [7] In September 2003, Bulawayo City Council's directorate of health services announced that 20 health clinics, as well as its referral hospital, had been severely affected by the exodus of qualified health staff and were operating with only half the required staff complement. [35] Zimbabwe's parliament has acknowledged the impact of staff shortages on the country's health centers. However, Health Minister David Parirenyatwa has argued that the country's economic crisis renders it difficult for the government to invest in health. He concedes that the situation is unlikely to improve in the near future that the hemorrhage of skilled staff abroad will continue.[7] Zimbabwe imports most of its medication requirements, and the shortage of foreign currency in the mainstream economy has forced suppliers to source foreign currency in the parallel market. In October 2003, medical drug suppliers and pharmacies raised prices by over 1,000 percent, citing an increase by the same margin in import costs. A recent survey of pharmacies in Bulawayo found that the price of paracetemol rose from Z$110 in August 2003 to Z$1,100 by October 2003.[34] Tuberculosis WHO ranks Zimbabwe a "high TB burden" country. In 2001, it had the world's 17th highest burden of TB in terms of new cases. In 2001, the TB incidence rate was 628 cases per 100,000 population (an increase from 584 cases per 100,000 population in 2000[36]) . An estimated 67 percent of adult (ages 15-49) TB cases are HIV-positive, and an estimated 1.9 percent of new cases are multidrug-resistant. [33] The DOTS strategy was adopted in 1997.[36]) The number of cases notified continues to increase, probably in response to the high rates of HIV infection. The case detection rate under DOTS has changed little since 1998 and was estimated at 47 percent for 2001. Given poor laboratory facilities, smear microscopy results are not available for 20 percent of cases notified. Only 69 percent of patients registered in 2000 were successfully treated, a decline from 73 percent in 1999. The death rate was high (12 percent), probably the result of a combination of HIV coinfection and late diagnosis.[33] A draft strategic plan for DOTS expansion exists but has yet to be approved by the government. Decentralization has been accepted in principle, and provinces are managing and financing TB programs, although financing is insufficient. An acting TB manager was recruited, and provincial and district TB coordinators are in place, but there is still no national TB program coordinator and no staff to support the acting national program manager at the national level.[33] Major constraints to achieving TB targets include * weak political commitment to TB control * lack of TB manager and other staff * funding gaps * low access to treatment because of poor infrastructure in new settlements * limited community involvement in TB control[33] Sexual and Reproductive Health According to UNFPA, Zimbabwe's past achievements in sexual & reproductive health have eroded and the reproductive health status of Zimbabweans has deteriorated. The country's contraceptive prevalence rates¾though much higher than the regional averages¾have stagnated.[37] The MMR has increased, from 610 in 2001 [30] to 654. [31] Family planning services have been available in Zimbabwe since 1953. After independence in 1980, the family planning association was dismantled. In 1985, the ruling party congress resolved to promote family planning not just for child spacing and welfare reasons but to limit family size. In the same year, the Child Spacing and Family Planning Council was renamed the Zimbabwe National Family Planning Council (ZNFPC) which became a state agency. At one point, the ZNFPC had 34 clinics and 800 trained community-based distribution agents covering about 30 percent of the rural population.[50] Funding for ZNFPC by central government has declined over the last five years; consequently, ZNFPC has reduced the number of clinics it operates as well as the number of community-based distributors it employs. Responsibility for most rural family planning services has devolved to rural district councils, but without any concomitant or specific funding for reproductive health provided.[4] Sexually Transmitted Infections It is unclear whether the reported number of STIs is decreasing. Decosas and Padian cite data that demonstrate that the number of reported STIs is falling, though not rapidly.[17] However, recent data from Harare find that a 2.4 percent increase in the number of STIs reported by clinics, from 48,026 in 2000 to 49,166 in 2001.[53] It appears that viral, rather than bacterial, STIs, are driving the epidemic. For example, in a national survey conducted in 32 rural growth point villages, researchers from the University of Zimbabwe and Battelle Memorial Research Institutes of the U.S. found that rates of gonorrhea, chlamydia, and syphilis were low (1 to 2 percent), whereas prevalence of herpes simplex virus-2 was 44 percent. Prevalence of HIV was 26 percent (N = 1,601; female mean age = 23; male mean age = 22).[54] The Tiripamwechete Study Group recruited 363 sex workers from two mines and five farms in rural Mashonaland West. The prevalence of bacterial STIs was low, but herpes simplex virus-2 prevalence was 80.8 percent (95% CI 76.7 - 84.0). HIV prevalence was 55.7 percent (95% CI 50.6 - 60.9).[28] Awareness and Knowledge of HIV/AIDS Knowledge of HIV/AIDS is high in Zimbabwe. In the 1999 Zimbabwe Demographic and Health Survey, 96.5 percent of women and 99.1 percent of men had heard of HIV or AIDS. However, 16.8 percent of women and 7.4 percent of men could not cite a way to avoid HIV/AIDS; among rural women and men, these figures were 21.4 and 9.7 percent, respectively. There was also wide variation among provinces. (The methodology used in the 1999 ZDHS to estimate knowledge of HIV/AIDS was relatively new and rendered comparisons with the 1994 ZDHS difficult.)[7] When asked whether a "healthy looking person can have the AIDS virus," 76 percent of women and 85 percent of men correctly responded yes. The women and men least likely to respond correctly tended to be young, sexually inexperienced, rural, and less educated. Women in all rural provinces were uniformly less knowledgeable on this issue than women in Harare and Bulawayo.[7] Despite almost universal knowledge of HIV/AIDS, research in, for example, Manicaland, has found differences in the way male and female respondents construct their HIV risk. Female respondents still perceived their own personal protection as secondary to their role as a wife, service-provider, or girlfriend. Their vulnerability to HIV acquisition was thus related more to their social roles than lack of awareness or condom availability.[55] Research was presented in Barcelona in July 2002 on a rapid assessment formative study conducted in 32 rural growth point villages in Zimbabwe; this assessment was undertaken to prepare for an international trial of the Community Popular Opinion Leader (CPOL) intervention. Knowledge about transmission of HIV and condoms affording protection was high. Individuals believed that access to condoms was adequate, yet few used condoms, especially with main partners. Condom use was perceived to prevent infections but also seen as a "not nice (sweet) thing." Respondents reported that married couples who "know each other" do not need condoms, and delay of sex is difficult when "one feels ready for sex." They also reported that it is difficult to "control one's feelings" regarding sex. They viewed monogamy as something that cannot be discussed with partners because of trust issues.[56] Stigma and Discrimination Despite high levels of awareness of HIV/AIDS, it remains highly stigmatized. Consequently, there is tremendous fear around being tested for HIV. Over 90 percent of those infected are unaware of their HIV status.[57] Traditionally, sickness and disease were considered punishment by one's ancestors for immorality and unfaithfulness.[58] People with HIV are perceived as having done something wrong, something of which they and their families should be ashamed. Zimbabwe's Tsungirirai AIDS Service Organization reports that "HIV/AIDS is a disease of shame. People with HIV are shunned and treated with contempt and described as immoral."[59] Even in recent years, when a sizable number of PWHA are open about their condition, stigma remains and tends to prevent PWHA from receiving adequate care and treatment. A case study of a 22-year old HIV-positive woman participating in a perinatal HIV transmission trial in Zimbabwe highlighted that HIV-positive women may experience considerable levels of psychological morbidity. Numerous stress factors include experience of discrimination upon disclosure of HIV status and inadequate support networks.[60] The Eden Home Health Center has reported on AIDS-related stigma and discrimination in communal farming communities and found that community leaders, chiefs, headmen, and others are making discriminatory statements during their graveside messages at funerals. The center stresses the need for HIV/AIDS education (in local languages) targeting traditional leaders in remote areas.[61] Sexual Behavior Sexual behaviors driving the HIV/AIDS epidemic in Zimbabwe are influenced by a complex interplay of social, economic, and cultural factors. For women, casual sex before marriage is not socially sanctioned. It is, however, expected that men will have had several sexual partners before marriage. [17] Decosas and Padian note that in most Zimbabwean studies, 30 to 50 percent of men report having several concurrent sex partners, whereas this figure is less than 5 percent for women. Studies from rural areas have found that there is a large degree of tolerance for men's having concurrent sex partners, but none for women. Because of these social norms, Decosas and Padian posit that the number of sex partners among women may be underreported.[17] Data from Zimbabwe's DHSs find that sexual abstinence is much more commonly reported for young women than for young men, and underreporting by women (and possible overreporting by men) may partly account for these patterns.[1] The Shona are the predominant ethnic group in Zimbabwe. It is culturally acceptable for Shona men to have more than one wife or girlfriend, although women are expected to be monogamous with their husbands. And given that children are highly valued in Shona society, men are unlikely to use condoms with their wives.[62] Moreover, prostitutes and casual partners are considered "dirty," but wives are "clean" and thus a condom is not necessary with a wife.[62] Some ethnic groups in Zimbabwe encourage sexual abstinence between a husband and wife for several weeks before and after the birth of a child; this is perceived by some as socially sanctioned infidelity (on the part of the husband). [62] Open discussion about sex is difficult. Traditionally, couples in Zimbabwe communicated about sex and sexuality through third parties such as uncles and aunts.[63] Decosas and Padian note that such communication is now rare and that most adolescents learn about sex from peers or the media.[17] Age at First Sex According to the 1999 ZDHS, among women, the median age at first sex is 18.7; among men, this figure is 19.7.[7] Zaba et al. note that in Zimbabwe, men and women consistently report a later initiation of sex than respondents in other southern African countries; they posit that this may be because of reporting bias resulting from denial of any kind of sexual activity by adolescents.[64] The Regai Dzive Shiri Study Group (comprising researchers from, inter alia, the University of Zimbabwe, University College London, and London School of Hygiene and Tropical Medicine) has found that in rural Zimbabwe there is poor correlation between biological evidence of sexual experience and questionnaire responses, due to concerns about confidentiality.[65] (See box 2.) And in a study by Chinake et al. cited below, male and female respondents reported much lower ages of sexual debut. Condom Use The 1999 ZDHS found that among women who had sex in the past year, 4.3 percent used a condom during last sexual intercourse with a spouse or cohabiting partner; 42 percent used a condom during last sex with a non-cohabiting partner. Among men, these figures were 6.5 and 70.2 percent, respectively. Urban men and women were more likely to use a condom at last sex with any partner than their rural counterparts. The urban-rural differential was particularly strong for condom use with non-cohabiting partners; women in urban areas were 50 percent more likely to use a condom during sex with non-cohabiting partners than women in rural areas.[7] A significant decline in condom use within marriage occurred during the latter half of the 1990s. A May 2002 report from Zimbabwe's National AIDS Council and several of its partners posit that this decline may be explained by the increasing level of stigma associated with condoms in Zimbabwe and the subsequent difficulty, for both men and women, in negotiating their use.[1] The most widely mentioned specific ways of avoiding HIV/AIDS by both men and women are condom use and limiting sexual activity to one partner. However, the 1999 ZDHS found that 28.2 percent of women and 16.7 of men could not cite a source where they could obtain a male condom. Among those ages 15 to 19, 50 percent of women and 31.7 percent of men did not know where to obtain a condom. Between 1994 and 1999, knowledge of a source for condoms improved in all age groups except 15-19, within which it worsened.[7] A May 2002 National AIDS Council report examined the discrepancy between number of condoms distributed (about 55 million at the time of the 1999 DHS) and those used (an estimated 11.3 million). Possible explanations include: * overstatement of the number of condoms distributed * understatement of condom use * build-up of inventories at facility level * build-up of personal inventories * wastage and loss; most condoms in Zimbabwe are distributed free of charge and are thus considered more likely to go unused or wasted[1] Researchers from SAfAIDS, Population Council, University of Zimbabwe Medical School, WHO, and the Women and AIDS Support Network Harare investigated whether female condoms are acceptable to sex workers in Harare and whether improved access to male and female condoms increases the proportion of protected sex episodes with clients and boyfriends. Sex workers were randomized to receive either male and female condoms (group A, n = 99) or male condoms only (group B, n = 50) and were followed prospectively for about 3 months each. The researchers found a considerable burden of HIV and STIs in the cohort at enrollment (86 percent tested positive for HIV and 34 percent had at least one STI). Consistent male condom use with clients increased from 0 to 52 percent in group A and from 0 to 82 percent in group B between enrollment and first followup two weeks later and remained high throughout the study. Few women in group A reported using female condoms with clients consistently (3 to 9 percent), and use of either condom was less common with boyfriends than with clients throughout the study (8 to 39 percent for different study groups, visits, and types of condom). Unprotected sex occurred, as evidenced by an STI incidence of 16 episodes per 100 woman-months of followup. Although survey data indicated high self-reported acceptability of female condoms, focus group discussions revealed that a main obstacle to female condom use was client distrust of unfamiliar methods.[38] Researchers from the University of Zimbabwe sought to identify condom negotiation strategies used by HIV-seronegative Zimbabwean women after a prevention intervention. Study participants were age 18 and above, sexually active with men at least 10 times during the previous three months, using contraception or otherwise not able to become pregnant, and willing to be tested for HIV and receive the result. Women were excluded if they reported condom use at more than 50 percent of all sexual episodes in the previous three months; were HIV-seropositive; or were unable to speak English or Shona. Altogether, 359 women were eligible for the study and 339 were enrolled. Of these, 260 women completed all four study visits, yielding a retention rate of 77 percent. The average age of participants was 29 years. Most participants (96 percent) were married and had at least one child (99 percent). The intervention achieved high levels of self-reported consistent condom use, increasing from zero pre-HIV test to 42 percent posttest and intervention to 63 percent at booster intervention and 55 percent at the two month followup. Six strategies were identified and used by at least 10 percent of women. Forty-seven percent of the participants used a strategy of remarking that condoms prevent HIV/AIDS. Twenty-five percent mentioned participation in the study. Another, alluding to one's own negative HIV test result, was used by 15 percent of respondents. Strategies involving efforts to exonerate their partners of blame were used by 12 percent. A fifth strategy, reported by 11 percent of women, based the request on the high prevalence of HIV/AIDS in their community. Finally, 11 percent of women mentioned their partner's earlier infidelities or their own lack of trust in him. Of the six negotiation strategies identified, only one, mentioning HIV prevalence in the community, was significantly associated with consistent condom use two months after the intervention ended.[39] Youth Zimbabwe has a very young population; 40 percent of Zimbabweans are under age 15.[30] In 2000, the median age in the country was 17.5.[6] During 2002, the U.S.-based Center for Reproductive Law and Policy (CRLP) and the Zimbabwe-based Child and Law Foundation (C