NYU Master's Program in Global Public Health Capstone Program

1. UNDERSTANDING THE CONTEXT OF HIV RISK IN ZAMBIA NYU Master's Program in Global Public Health Capstone Program A Study of Mongu, Senanga, and Kaoma Districts in the Western Province Rebecca Adeskavitz, MPA Donovan Jones, MA Moneesha Kamani, MSc, MS Erin Murphy, MMS, PA-C Janet Vessotskie, MS, PhD Report May 2010

2. HIV and AIDS IN ZAMBIA Identify problem The 2007 Zambia Demographic Health Survey revealed that HIV prevalence rates in the general population have dropped from 16% to 14% However… Young women have been especially hard hit; 16% of women aged 20-24 are infected compared to just 4% of men in the same age group 3out of 9 provinces have a rising HIV prevalence, including the Western Province The causeof these new infections is not yet known, though many point to cultural practices such as: • Sexual Cleansing • Widow Inheritance • Dry Sex • Polygamy • Female Initiation • Male Circumcision

3. RESEARCH QUESTIONS Concern Worldwide began working in Zambia in 2002 - HIV Prevention, Livelihood Protection and Emergency Response Define Research Questions NYU partnered with Concern Worldwide Zambia in collaboration with ARHA, DAPP, DHMTs and DATFs to undertake a qualitative exploratory study in 2010 The following research questions were agreed: • What are the sexual practices in Zambia’s Western • Province that are putting people at risk for HIV? • What are the contextual factors that influence the • continuation of these practices?

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

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

6. DATA COLLECTION Data collection took place over a two-week period • Interviews • NGO leaders • Government officials • Local/tribal leaders • Traditional healers • Church leaders • Community Health Workers Data Collection

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

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

9. RESULTS What are the factors driving the epidemic? In-depth analysis of interview and focus group transcripts revealed a number of social and structural factors that act as both barriers and facilitators for HIV risk behaviors. 5meaningful themes emerged: POVERTY Traditional Norms & Practices Gender, Power & Inequality Social Factors Prevention & Disconnected Messages Infrastructure & Service Delivery

10. TRADITIONAL NORMS & PRACTICES It is a symbol in our culture that if you have more that one wife, you must be a very powerful person or a very rich person who is able to look after those wives —Senior Government Official, Mongu • Major Findings - Learning: • Cultural norms and practices are contributing to the spread of HIV in the Western Province • Some traditional practices have a positive effect and are helping to protect against HIV transmission • Harmful practices are slowly changing in response to HIV

11. GENDER, POWER & INEQUALITY …Wearing a condom is regarded as taboo even for family planning. Women are unable to negotiate condom use even when the partners are HIV positive —Grace Hamukwala, Mongu District HIV Manager, Concern Worldwide • Major Findings - Learning: • Women are socially and economically disadvantaged in the Western Province • Gender inequality is manifested in sexual coercion, reduced condom negotiating power and partnering with older men, all practices that heighten risk for HIV • Transactional sex is widespread

12. SOCIAL FACTORS …It is normal for a man to have multiple sexual relationships. The community will not say anything. It is just normal that you have a girlfriend apart from your wife - these cultural issues are still being highly practiced in rural areas —Brian Kayongo, Executive Director, Adolescent Reproductive Health Advocates • Major Findings - Learning: • Multiple partnerships are generally accepted in Zambia (more for men than women) and are practiced widely in the Western Province • Widespread alcohol use contributes to risky behavior, particularly lack of condom use

13. PREVENTION & DISCONNECTED MESSAGES Apart from coming out on radio supporting HIV and AIDS programs they have not been proactive…if the King stands and says no one will marry a 11 year girl no one will do that because there is so much respect for the King —Brian Kayongo, Executive Director, Adolescent Reproductive Health Advocates • Major Findings - Learning: • Prevention messages are coming from all levels of society and are often contradictory • Tension exists between abstinence-only messages and messages promoting condom use • There has been a lack of leadership on a number of issues

14. INFRASTRUCTURE & SERVICE DELIVERY In terms of accessibility, most of our rural areas do not have access to condoms. They are only concentrated in the township area. —Senior Health Official, Mongu • Major Findings - Learning: • Condom access is inconsistent and misconceptions are pervasive • HIV Testing services have increased, but gaps still exist • Community members report adequate ART coverage, community leaders report rural gaps • Lack of communication / coordination between NGOs, Church leaders and Local Government departments

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

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

17. PROGRAMME RESPONSES • Increasing involvement of Traditional Leaders • Increasing sensitization of young women in rural areas on HIV risk reduction • Expanding HIV mainstreaming responses through existing community structures – community action teams (CATs) using the ‘community conversation’ methodology • S/BCC through HH approach – focusing on: • - VCT information • - service referral • - increasing male involvement • - reducing stigma and discrimination • Establishing Western Province NGO Forum for advocacy to national level

18. to the people of Zambia and all participants who agreed to take part in this study We are also grateful to the entire Concern Zambia staff for their support. We would particularly like to thank Maurice Sadlier, Friday Mwamba, Nalisa Mufuzi, Francis Wakumelo, Grace Hamukwala and Edna Kalaluka A special thank you to Dr. Kristin Bright of New York University N’itumezi (thank you)