HIV Clinical Research: Realities on the Ground in Zimbabwe
Dr Michael Silverman’s presentation of his study showing HIV rates decline and his hypothesis of the reasons causing that decline at the July 2009 IAS Pathogenesis conference in Cape Town, South Africa has caused quite a stir in my country, with strong sentiments expressed from different quarters. Dr Silverman’s study was around HIV prevalence trends in Zimbabwe, and sampled women attending ante-natal care at a rural mission hospital. That HIV prevalence and incidence in Zimbabwe has declined dramatically is something that has been categorically studied and stated in the Demographic Health survey of 2007, and validated by both the Center for Diseases Control (CDC) and the Joint United Nations HIV/AIDS Program (UNAIDS). Despite this well-researched evidence, the notion that Zimbabwe can achieve such a remarkable feat has baffled many – Zimbabweans and non-Zimbabweans alike. However, the reasons given for the decline in Dr. Silverman’s study have been categorically called into question especially among well-known HIV and AIDS researchers who have studied trends in Zimbabwe for a number of years. A Zimbabwean newspaper, The Sunday Mail of 26 July 2009, described Dr Silverman’s theory as “ludicrous”; going on to say, “Why are they not writing about the resourcefulness, resilience and never-say-die spirit of our people? These virtues have played a crucial role in lessening the impact of HIV on our population”. Dr Paul Chimedza, medical practitioner and past president of the Zimbabwe Medical Association, writing in the Sunday Mail of 2 August 2009, said the presentation demeans Zimbabweans.
Zimbabwe has achieved some significant successes in the response to HIV and AIDS – this despite many challenges that have led to a general resilience of in a climate with a potential to cause much despondency. Zimbabwe has borne the brunt of a severe socio-economic and political decline within the last ten years. From the time the first HIV-infection case was acknowledged and reported in Zimbabwe, there was a rapid increase in incidence and prevalence that saw the prevalence rates reaching a high of 34%, with the country earning an infamous world ranking as the fourth highest. This was mostly attributed to the poverty that was associated with the economic decline. The economic decline also saw the basic social and health services diminishing, unemployment rising and thus contributing to a myriad of intertwining factors that turned the increasing prevalence into an epidemic, which fast turned into a pandemic. The political environment also deteriorated, resulting in a mass exodus by donors and funding partners all turning their backs on Zimbabwe.
The impact on HIV and AIDS was that there was a general lack of comprehensive treatment, care and support, worsened by the shrinking public support for the health care system, and a mass exodus of the many highly qualified health-care workers.
The challenges faced in such a scenario left Zimbabwe with no option but to find strategies from within in order to mitigate the alarming rate of deaths due to AIDS, and the general decay of the health care system that resulted in the most needy and vulnerable failing to access basic health care services. The response therefore saw several players on the ground intensifying strategies and efforts towards this cause. These included civil society organizations and faith-based groups many of which based their activities in rural areas where the need was perceived to be greatest. Other players complemented these efforts through massive awareness and education campaigns around HIV transmission, prevention, treatment and health literacy, and the care of those bed-ridden with AIDS. To these were added the massive distribution of both male and female condoms. The government on its part responded to a call by people living with HIV to set up a fund to respond to the needs, particularly health-related, of those who were diagnosed positive. The National AIDS Trust Fund (NATF) was duly set up through an act of parliament, which also enacted the setting up of the National AIDS Council (NAC) to administer the funds and coordinate the national response. The funding for this came from within the country by levying each worker three percent (3%) of their income, which the revenue authority would duly deposit into the NATF. This resulted in a coordinated multi-sectoral response that, as the years went by, began to show results in 2006 with the first report of a decline in prevalence.
Based on the first reports of a decline in prevalence rates, several factors have been noted as most significant contributors. First, it appears that due to the many deaths and massive awareness campaigns and behavior change programs, there are signs that many people in Zimbabwe have changed their behaviors discarding harmful traditional practices, amongst other things. Second, the number of deaths from AIDS-related illnesses has been very high due to a combination of a lack of adequate nutrition and sufficient anti-retroviral drugs for all those in need of treatment in effect creating a decline in prevalence rates. Lastly, it has been noted that there has been a large migration of Zimbabwean citizens to other countries due to economic and political factors, also potentially impacting the prevalence rate. Despite all these factors contributing to a significant decline in prevalence, poverty has remained a challenge considered responsible for the still high prevalence of 15.6%. And this is probably where Dr Silverman’s research findings have seemingly caused a big offense to many Zimbabweans, and an affront to their intelligence and reasoning capacity.
Completely ignoring any of the contributing factors outlined above, Dr. Silverman reported that the HIV prevalence and incidence decline was probably caused by poverty as the men in Zimbabwe no longer had the financial capacity to sustain “small houses”. Small house is the term Zimbabweans use for women who are in a long-term relationship with a married man. Many times the man has no intention of ending his marriage partnership, but intends to maintain both relationships. Silverman said he concluded that "a lot of the effect (of the decline in HIV infections) is from the collapsing economy." AIDS experts have long noted that the richest countries in Africa are also those with the highest infection rates."You can't pay the sex worker if you have no currency," he said. "It's hard to have a concurrent relationship if you're always in earshot of your spouse, because you can't afford to travel. Because of the economic collapse, people are forced to stay home, like being in quarantine."
I have discussed with several colleagues and friends at work and on social networking sites, and also followed what other experts in Zimbabwe have had to say over this, and so far have not heard any of my country folk taking a positive stance on the reasons proffered for the decline. There have been accusations that the learned doctor is insulting the intelligence of Zimbabweans, and insinuates that as long as any Zimbabwean male has some financial clout, they are unable to remain faithful to one partner. There was also an assumption that these findings meant Dr Silverman had not bothered to study the findings of the Zimbabwe Demographic Health Survey and other studies that have shown that there is generally increased awareness, consciousness and responsibility around HIV and AIDS, and intimate relationships. Studies have shown that there is delayed sexual debut among young women, as the trend now is for young girls to delay early sexual relations. Ms Michelle Faul from the Associated Press cites Simon Gregson, a professor at Imperial College London and a demographer and epidemiologist who has worked half time in Zimbabwe since 1998: “We have found that it is not just that more people are dying than are becoming newly infected; it's not just because the death rate is very high; but the rate of new infections have been coming down and that is because people have been changing their behavior and adopting safe practices." The studies show people, particularly men, are having fewer partners, and condom use is quite high, Gregson said in an interview from his office in Zimbabwe. "What's not so clear is what caused them to change their behavior and why there is more of a change in Zimbabwe than in other neighboring countries?"
The discussions from my friends, the different opinion pieces written in the media have been telling in the way the general population have received this research study. I have been involved in HIV and AIDS and treatment access activism in Zimbabwe for around six years now. I was also taken by surprise by the findings of this study. When one radio station phoned to ask for my opinion on the study looking at women attending ante-natal services, my immediate reaction was that that would mean a rate in a smaller fraction of the population who actually can afford to reach a health facility – the barriers being transport costs and user fees which are now in United States dollars, South African rand, and Botswana pula. User fees usually have some stages such as consultation, diagnostic tests, and delivery fees. The majority of Zimbabweans do not have this kind of money. There is surely need to bring all the issues at hand together and give an adequate analysis. The most baffling point has been how all the studies in the past have shown poverty to be a key driver of the epidemic in most countries with high prevalence rates, and all of a sudden this one study for Zimbabwe states poverty as the cause of the decline in rates of infection.
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