Policy Forum

A Surprising Prevention Success: Why Did the HIVEpidemic Decline in Zimbabwe?

Daniel T. Halperin

, Owen Mugurungi

, Timothy B. Hallett

, Backson Muchini

, Bruce Campbell

,Tapuwa Magure

, Clemens Benedikt

, Simon Gregson

3,7

Harvard University School of Public Health, Boston, Massachusetts, United States of America,

Ministry for Health and Child Welfare, Harare, Zimbabwe,

ImperialCollege London, London, United Kingdom,

Independent consultant, Harare, Zimbabwe,

United Nations Population Fund, Harare, Zimbabwe,

Zimbabwe NationalAIDS Council, Harare, Zimbabwe,

Biomedical Research and Training Institute, Harare, Zimbabwe

Background

While dramatic gains in the availabilityof antiretroviral medications in developing countries have been achieved [1], there isgrowing consensus that, unless preventionefforts can be made more effective, therewill ultimately be no victory in the fightagainst HIV/AIDS [1–4]. Maintaining tens of millions of people on treatmentthroughout their lifetimes will not besustainable or affordable, particularly asdrug resistance may increasingly result inthe need for much more expensive secondand third line medications. Although therehave been promising breakthroughs in afew other areas, notably male circumcisionand prevention of mother-to-child trans-mission (PMTCT) [1,2,5], it is widelyrecognized that behavior change mustremain the core of prevention efforts [2–4].While the often cited prevention successstories of Thailand [6] and Uganda [7,8] areinspiringandinformative,someofthespecificsocio-cultural, historical, and other factors inthe southern African regionnow the globalepicenter of the HIV pandemicare distinc-tive. In these ‘‘hyper-endemic’’ settings,where adult HIV prevalence ranges from12% to 26% [1], HIV transmission is highlygeneralized, whereas Thailand’s epidemicwas much more concentrated. There, HIVtransmission was driven mainly by brothel-based sex workenabling the aggressive‘‘100 percent condom’’ programs to befeasible, enforceable, and effective [6,9].The unprecedented HIV decline and associ-ated behavior change in Uganda, mainlyinvolving large reductions in multiple sexualpartnerships [2,7–10], occurred some 20years ago and under rather different contex-tual and programmatic circumstances.MorerecentexamplesofHIVprevalencereduction are emerging, including fromKenya, Haiti, the Dominican Republic,Malawi, and Ethiopia [1–3,10–12]. Giventhe severe HIV epidemics that continue toplague parts of sub-Saharan Africa, there isan urgent need for studies identifying theproximate as well as underlying causes forthese encouraging trends. In this paper, wereview and summarize the principal find-ings of our comprehensive interdisciplinaryanalysis (commissioned by two UnitedNations agencies, the United Nations Pop-ulations Fund [UNFPA] and United Na-tions HIV-AIDS Program [UNAIDS]) of the causes behind the considerable HIVdecline in Zimbabwe, including evidencefor changes in patterns of sexual behaviorand the contextual and possible program-matic reasons for these changes, which wehave published in other peer-reviewedjournals [13–15]. Here we also considersome policy implications of these findings.

Synthesis of Data

Data

HIV prevalence data from nationalantenatal clinic surveillance and thehousehold-based 2005/6 Demographicand Health Survey (DHS) were used tofit a mathematical model to estimatetrends in HIV incidence and AIDS deathsin Zimbabwe (Figure 1A) [14]. Data fromthe DHS and other longitudinal surveys[13,14,16–18] were used to examine thepossible contributions of changes in sexualbehavior to reductions in HIV infection.Published data from focus group discus-sions with 90 adult men and 110 womenin diverse urban and rural sites and severaldozen in-depth key informant interviewsas well as an extensive historical mapping of prevention programs [15], were exam-ined in assessing the contributions of different contextual and programmaticfactors to observed changes in behavior.Finally, DHS data on various potentialproximal and contextual determinants of behavior change for Zimbabwe werecompared with similar data for sevenother southern African countries to iden-tify distinctive patterns that might help toexplain the earlier and faster HIV declineobserved in Zimbabwe (Figures 2, S1).

Process

Interpretation of data on the causes of HIV declines in other countries (e.g.,

The Policy Forum allows health policy makersaround the world to discuss challenges andopportunities for improving health care in theirsocieties.

Citation:

Halperin DT, Mugurungi O, Hallett TB, Muchini B, Campbell B, et al. (2011) A Surprising PreventionSuccess: Why Did the HIV Epidemic Decline in Zimbabwe? PLoS Med 8(2): e1000414. doi:10.1371/journal.pmed.1000414

Published

February 8, 2011

2011 Halperin et al. This is an open-access article distributed under the terms of the CreativeCommons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium,provided the original author and source are credited.

Funding:

Some of the studies upon which this paper is based were funded by the United Nations PopulationFund (UNFPA), which provided some logistical support as well as helping with coordination between thestudies. Two of the authors of this paper (Benedikt and Campbell) are employed by UNFPA and helped edit themanuscript. The United Nations HIV-AIDS Program (UNAIDS) and the Zimbabwean Ministry for Health andChild Welfare also sponsored this study. TBH and SG thank the Wellcome Trust for funding support. Thefunders had no other role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing Interests:

The authors have declared that no competing interests exist.

Abbreviations:

DHS, Demographic and Health Survey; PMTCT, prevention of mother-to-child transmission;STI, sexually transmitted infection; VCT, voluntary counseling and testing* E-mail: dhalperi@hsph.harvard.edu

Provenance:

Not commissioned; externally peer reviewed.

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Uganda) has proved to be contentious andproblematic when drawing conclusions forpolicy. Therefore, to establish a consensusamong key stakeholders on the roles of different potential causes of HIV decline inZimbabwe, a national stakeholders meet-ing was held in Harare in May 2008 toexamine the evidence assembled during this study. Stakeholders from a broadrange of backgrounds attended the meet-ing, including high-level representatives of civil society and international organiza-tions as well as senior non-political ap-pointees within the Ministry of Health andChild Welfare and the National AIDSCouncil (participants and agenda listed inText S2). At the meeting, the proximateand underlying contextual and program-matic factors that could have contributedto Zimbabwe’s declining HIV epidemicwere ranked systematically according towhether they were considered likely,plausible, or unlikely to be major contrib-utors to the HIV decline, based upontriangulation of the data described aboveand from other relevant studies [13–19](see Table 1 and Text S1). Four tests wereapplied in determining this ranking: 1)whether the factor could, based on theepidemiological literature, have been ef-fective in reducing HIV risk at thepopulation level; 2) for underlying factors,the existence of a clear causal pathway tothose proximate factor(s) considered to beeffective in reducing risk; 3) the extent orcoverage of the factor; and 4) the consis-tency of timing between the primarychange or amplification of the factor andthe period of most significant risk reduc-tion as estimated by the epidemiologicalmodel (about 1999–2003) [14]. Thosefactors considered effective that had al-ready reached high levels of coveragebefore the period of most rapid risk reduction and continued to maintain highlevels throughout this period were consid-ered possible contributors to the HIVdecline, as theoretically they could havehelped to curb transmission (without animmediate impact on prevalence) so thatlater behavioral changes had a greaterimpact [20].

Trends in HIV Prevalence andIncidence and Sexual Behaviorin Zimbabwe

HIV prevalence in Zimbabwe increasedrapidly in the early to mid-1990s, beforereaching a plateau in the late 1990s(peaking at an estimated 29% adultprevalence in 1997 [13]), and declining after 2000 (down to 16% estimatedprevalence in 2007). Mathematical mod-eling fitted to surveillance data [14](Figure 1A) estimates that HIV incidencepeaked around 1991 and (as in many otherAfrican countries [21]) declined graduallythereafter, mainly as part of the naturalcourse of the epidemic, primarily due tosaturation of infection in high-risk popu-lations [11,14,22]. Between about 1999and 2003, the pace of incidence declineaccelerated considerably, which empiricaldata [13,14] and modeling [14] suggestcorresponded to reduced levels of riskysexual behavior.As illustrated in Table 1 (and see TextS1), the unanimous conclusion from thestakeholders meeting (Text S2) held toassess, triangulate, and interpret the evi-dence assembled in the review [13–18]was that a reduction in multiple sexualpartnerships was the most likely proximatecause for the recent decline in HIV risk.Although the DHS surveys indicate therewas little change in age of sexual debutbetween 1999 and 2005/6, an approxi-mately 30% reduction in the proportion of men reporting extra-marital partners oc-curred (Figure 1B). Similar or largerreductions in multiple partnerships among adults have been reported in other nation-al surveys [13,18]. Since presumablynearly all married people would have sexat least occasionally with their spouses(and given that most adults in Zimbabweare married), this implies a sizeablereduction in the level of concurrentpartnerships, which is a key epidemiolog-ical factor [23]. At a rural easternZimbabwean research site, where HIVprevalence fell substantially between1998–2000 and 2001–2003, the fractionof men (and women; data not shown here)reporting concurrent partnerships de-clined by about 40% (Figure 1B) [16]. Inaddition, there were considerable reduc-tions reported around this time in thenumber of Zimbabwean men paying forsex (Figure 1B) [13]. Participants in focusgroups and key informant interviewsconducted in various rural and urbanareas similarly reported that major chang-es in norms of sexual behavior hadoccurred, especially after the late 1990s[15]. For example, many informantsrecounted that, whereas in earlier years itwas commonplace for men gathering atlocales such as beer halls to be surroundedby women/sex workers, by the late 1990sthis norm had changed and it was nowtypical for men to gather strictly among themselves at such places. Moreover, whileearlier it had been considered a proof of masculinity to acquire a sexually transmit-ted infection (STI), more recently getting an STI (and visiting sex workers) istypically said to be embarrassing or evenshameful for Zimbabwean men [15].

Reasons for HIV Decline andAssociated Behavior Change

In fact, the prevalence of other STIs wasgreatly reduced during the early 1990s,mainly due to widespread syndromicmanagement services [15]. Although STIcontrol remains an important publichealth measure, the data from clinicaltrials regarding the population-level im-pact on HIV incidence are increasinglyunconvincing (Text S1) [2,24]. However,it has been hypothesized that STI treat-ment during the early phases of an HIVepidemic may help to reduce transmission

Summary Points

There is growing recognition that primary prevention, including behaviorchange, must be central in the fight against HIV/AIDS. The earlier successes inThailand and Uganda may not be fully relevant to the severely affectedcountries of southern Africa.

We conducted an extensive multi-disciplinary synthesis of the available data onthe causes of the remarkable HIV decline that has occurred in Zimbabwe (29%estimated adult prevalence in 1997 to 16% in 2007), in the context of severesocial, political, and economic disruption.

The behavioral changes associated with HIV reductionmainly reductions inextramarital, commercial, and casual sexual relations, and associated reductionsin partner concurrencyappear to have been stimulated primarily by increasedawareness of AIDS deaths and secondarily by the country’s economicdeterioration. These changes were probably aided by prevention programsutilizing both mass media and church-based, workplace-based, and other inter-personal communication activities.

Focusing on partner reduction, in addition to promoting condom use for casualsex and other evidence-based approaches, is crucial for developing moreeffective prevention programs, especially in regions with generalized HIVepidemics.

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(although this is unconfirmed by observa-tional evidence; e.g., given the absence of HIV declines in several other Africancountries that had also implemented earlyand aggressive STI control programs).Reported condom use increased steadilyduring the 1990s (reaching 59% among men for last non-marital sexual encounterin the 1994 DHS), but did not increasefurther between 1999 and 2005/6(Figure 1B), and remained very low forregular partnerships [13]. However, thereis some evidence for modest improvementin the

consistency

of condom use among women in casual partnerships [13,16], amore important measure for reducing infection risk than reported use at lastsex [9].In assessing the underlying factors forthe national prevalence decline (Table 2,Figure S2), high AIDS mortality appearsto have been the dominant factor forstimulating behavior change. Both empir-ical and modeling-derived estimates indi-cate that AIDS deaths increased dramat-ically during the mid-to-late 1990s, beforestabilizing after 2000 [13,14]. Moreover,men and women in focus groups andinterviews repeatedly and consistentlyreported personal exposure to AIDSmortality and the resulting fear of con-tracting the virus to be the primarymotivation for changes in sexual behavior,particularly reductions in casual sex andother multiple sexual partnerships [15].The severe economic decline, taking hold in the late 1990s/early 2000s,appears to have played a considerablesecondary role in amplifying patterns of behavior change, particularly partner re-duction. Gross domestic product in Zim-babwe began to slump in the late 1990s,declining by about 40% between 1999 and2005, with average real earnings plum-meting by 90% during the same period.And many men in focus groups andinterviews reported that having less dis-posable income has increasingly led toreduced ability to purchase sex or main-tain multiple sexual relationships [15].However, the most severe financial de-clines occurred after 2002, i.e., after thebulk of HIV incidence decline hadevidently already occurred [13,14](Figures 1A, S3). The severe economicand political instability in the country alsoled to extensive international migrationfrom Zimbabwe around this time. To havecontributed substantially to the HIVdecline, migration also would have neededto have been highly concentrated among individuals with HIV [13]. In fact, theavailable data suggest that the oppositewas probably the case; e.g., HIV preva-lence among pregnant Zimbabwean wom-en living in the United Kingdom peaked at12%, less than half the equivalent figureseen among pregnant women living inZimbabwe itself [13]. Therefore, althoughthe political and economic crises inZimbabwe have been (especially in morerecent years) extremely turbulent and of grave concern for humanitarian and otherreasons, these factors do not appear to bethe

predominant

ones for explaining the HIVdecline that occurred.In considering the potential impact of prevention programs on the HIV decline(Table 2, Figure S2), condom distributionand promotion efforts commencing in theearly 1990s may have contributed throughhelping build high levels of condom use forcommercial and casual sex [13,15]. (And itappears that condoms were usually notpromoted in the often highly ‘‘sexy’’manner as occurred in some neighboring countries such as Botswana, but generallyas a strictly ‘‘protective’’ public healthintervention.) Voluntary counseling andtesting (VCT) and PMTCT programswere, however, unlikely to have contrib-uted significantly to HIV incidence decline

Figure 1. Summary of epidemiological findings.

(A) Estimated trends in HIV prevalence,incidence, and AIDS deaths using a mathematical model of HIV transmission fitted to antenataland household-based estimates of HIV prevalence, 1980–2010. HIV incidence peaks around 1991and declines as part of the natural course of epidemic maturation; incidence decline isaccelerated between about 1999 and 2003 due to reductions in sexual risk behavior [14]. (As hasbeen noted [14], incidence declined a little earlier in urban areas. The model suggests behaviorchange could have continued partly into 2004 in rural areas, but the majority of changes wereconcentrated within the 1999–2003 period [14].) (B) Changes in key indicators of sexualpartnership formation taken from the nationally representative DHSs (1999 and 2005/6) andsurveys in Manicaland, rural eastern Zimbabwe (1998–2000 and 2001–2003) [13,16].doi:10.1371/journal.pmed.1000414.g001PLoS Medicine | www.plosmedicine.org 3 February 2011 | Volume 8 | Issue 2 | e1000414