Condoms Are a Key to Reducing HIV Transmission in Zimbabwe

HARARE, Zimbabwe — Cathy Nyarai is an ebony, svelte, almost frail-looking 22-year-old woman. She is often described as anerunako, a beauty, in the local Shona language. In other cities, she might be sauntering down catwalks. But in Harare, she is only one among a growing legion of young women and girls to walk the streets near major hotels hoping to snare a client. And no, she does not consider herself a sex worker. She is a second-year university student, forced by the exigencies of poverty and a family of nine—two parents and seven siblings—to do what she can to make ends meet.

In Zimbabwe and many other African countries, a deepening economic crisis, growing poverty and high unemployment, have left many women with little choice but to exchange sex for money or basic commodities. It is a dangerous venture, Cathy readily admits. She has to think on her feet and detect and ward off violent and dangerous clients while keeping an eye out for police dragnets. It’s all in a night’s work.

Cathy also knows what AIDS can do to young women. Today, HIV prevalence rates are high among young women aged 21 to 23. One in five already carries the virus. Some of her colleagues have already succumbed to AIDS. But Cathy is confident that she can stay safe. It is soon evident why. She flips out a packet of condoms from her bag, saying: “If there is one thing I must leave home with in the evening, it is this. This is my protector.”

And, apparently, she is not alone. Condoms, as it turns out, protect many Zimbabweans against sexually transmitted infections, including HIV, chlamydia, gonorrohea, herpes, human papilloma virus, and syphilis. Condoms have become a critical component of broader

HIV prevention strategies in Zimbabwe, especially among groups with high rates of partner change, such as sex workers.

While UNFPA is a staunch advocate – and a major supplier – of both male and female condoms, it also strongly promotes a more comprehensive and rights-based approach to HIV prevention, treatment and care for sex workers. This includes addressing the lack of options that so often play a role in individuals engaging in sex work and providing a range of educational and life skills, as well as economic supports, to allow for an exit route from sex work for those who chose to take it.

Zimbabwe is one of the three African countries showing a drop in HIV prevalence rates—down from 24.6 per cent in 2003 to 20.1 per cent in 2005, according to UNAIDS. Nevertheless, the country still has one of the highest HIV prevalence rates in the world. The practices that account for Zimbabwe’s continued high prevalence are still widespread. In addition to underlying factors such as unequal gender dynamics and stigma, these include multiple partnering, concurrent sexual relations with different partners, wide age disparities between partners, widows being ‘inherited’ by relatives of the deceased spouse, and young girls being forced into early marriage.

A comprehensive review undertaken by UNAIDS attributes the decline to a number of factors—in particular, partner reduction and condom use. One factor that complicates HIV prevention in places with generalized epidemics, like Southern Africa, is that much of the transmission is occuring in the context of stable marriages and long-term relationships. Condom use within these relationships remains very low in all African countries, including Zimbabwe.

Although researchers have noticed a decline in the reported number of partners, experts believe there is a need to look more closely at concurrent, or longer-term parallel relationships. These relationships, which give rise to overlapping partners and sexual networks, can be particularly risky because newly infected persons develop a very high viral load, which makes transmission more likely, in the absence of condom use.

"Partner reduction has already started in Zimbabwe, but we believe there is still much potential in further promoting faithfulness in marriage,” explains Clemens Benedikt, prevention programme manager in the Zimbabwe Country Office of UNFPA, the United Nations Population Fund. "Condom programmes have also been a successful element of HIV prevention in Zimbabwe. Since the mid-1990s, condom use with non-regular partners, including commercial sex workers, in Zimbabwe has been among the highest in Africa."

An exact causal relationship linking condom use to the HIV decline is hard to trace. However, trend data show that as condom distribution has expanded dramatically — from just over 20 million in 1994 to over 80 million in 2004 — the HIV infection rate has slowed and even declined among certain groups.

Studies in Zimbabwe show that the condom is the prevention method of choice among single, sexually active men. They appear to be relying on condoms within non-marital, short-term relationships to serve a dual purpose—both as a contraceptive and as a prophylactic.

But the male condom is still widely associated with infidelity and commercial sex work, a perception that can undermine a spouse’s willingness to use the male condoms. This is one of the reasons high hopes are being pinned on the possibilities afforded by the female condom, which offers women a greater degree of control and is becoming increasingly accepted within marital unions. The number of female condoms publicly distributed and socially marketed increased from about 200,000 in 2000 to a peak of 1.4 million in 2002—before declining to just under 1.2 million in 2005. Today, the female condom is widely available in Zimbabwe’s urban areas, and the Government is now seeking to meet the needs of women living in more remote, rural regions.

A user perspectives study on the female condom undertaken by the Ministry of Health and Child Welfare in 1998 revealed high rates of acceptability among both men (74 per cent) and women (91 per cent). The study included men and women from rural and urban areas. While a few clients found it difficult to use, the difficulty diminishes with practice. “It’s thin and does not affect sex, you just feel as if there is nothing,” a female respondent from the study said.

The dramatic uptake of the female condom has been aided by innovative distribution strategies introduced by PSI-Zimbabwe, the local branch of the US-based Population Services International. These include the home-meeting initiative, during which trained markers visit potential clients in the privacy of their homes to promote the female condom. PSI is training hairdressers to help raise awareness among clients by chatting about the efficacy of the female condom and providing information on where to obtain it.

Daisy Nyamukapa, condom programming specialist in the Zimbabwe Country Office of UNFPA, maintains that popularity has to do not only with HIV prevention but also with the broader issue of female empowerment—especially with regard to contraception and sexual negotiation. “The female condom is a tool that can be used to start discussion about women’s issues: empowerment, anatomy and negotiation for safer sex.”

The largely supportive political, legislative and public environment has aided the creation of a strong partnership between the public, social marketing and private sectors as well as the international donor community. The Government of Zimbabwe has also developed a national strategic framework on HIV and AIDS, a National AIDS Policy, a National AIDS Council, and has introduced an AIDS levy, which garners 3 per cent of taxable income from individuals and corporate bodies to support the overall response to the epidemic.

These measures have assisted the sustained implementation of effective national condom programming strategies, whose main components include education, research, distribution, sales, forecasting, procurement, quality management, logistical and information systems. The Government established an office to coordinate and support condom programming in 1995, but it was vacated in 2000 owing to the economic challenges that face the country. UNFPA is now working with the Government to recruit staff and to scale up male and female condom programming. As part of this effort, in 2005 UNFPA facilitated the establishment of a Technical Support Group to improve access to both male and female condoms. The group—which is made up of representatives from the private sector, Government and other stakeholders as well as UNFPA and UNAIDS—is assisting the Government in developing a five-year national condom strategy.

While adequate supplies alone don’t mean that people will actually use condoms, making sure that they are available and accessible is a basic aspect of condom programming. Zimbabwe’s worsening economy, along with foreign exchange shortages are threatening to derail programming. The high cost of female condoms — 72 cents (US) compared to 3 cents for a male condom — is also taking its toll.

Although most religious organizations now champion condoms for HIV prevention, a few faith-based organizations continue to express strong reservations against them. Zimbabweans themselves have proposed a consensus solution: No stakeholders should make any negative statements about any effective HIV prevention method, including abstinence, faithfulness and condom use. If successes are to continue, this principle needs to become a reality — urgently.

— George Ngwa