Community peer education to prevent STD/HIV/AIDS among women in Zimbabwe and Zambia
Presented by Dr David Wilson, Department of Psychology, University of Zimbabwe, Harare
Zimbabwe and Zambia have both experienced an explosive increase in the HIV epidemic in recent years. In Zimbabwe, HIV prevalence among STD patients is estimated to be between 25 and 55% and the overall female-to-male ratio is one-to-one: heterosexual and perinatal transmission are the major modes of transmission in that country. In Zambia, in the age group 15 to 39, HIV prevalence is estimated to be 34% in urban areas and 13% in rural areas. The consequences of such high prevalence rates, affecting all members of society, can only be prevented or mitigated by concerted, coordinated, nation-wide efforts.
Such a far-reaching initiative is taking place in Zimbabwe and Zambia in a partnership of 20 Community peer education projects (14 and 6 respectively in each country). They are coordinated by their National AIDS Programme, with technical support from their national communities. The projects work primarily with single women in low-income areas. Men whose sexual behaviour contributes to the rapid spread of HIV transmission are also targeted (e.g. men with mobile lifestyles, men who visit bars and men who seek STD care). The importance of educating men in bars is illustrated by a study in which 100 men in Harare were tracked over 21 days for their alcohol consumption, sexual behaviour and condom use. They reported 271 commercial sexual relations over this period, 98% of which were preceded by consuming alcohol.
The peer education intervention itself focuses on education, condom distribution and promotion of STD care. The peers distributed condoms (some projects distribute as many as 60,000 a week) in their own social networks, in markets, bars, workplaces and STD centres. HIV/AIDS education takes place in these same places, where an average of five community meetings are held by each peer educator per week. Many projects provide free STD “cards” to sex workers and in Bulawayo, to all women. All projects begin with rapidly conducted formative research that looks at the social and economic organization, community dynamics and concerns, and health and social service utilization. Community norms and behaviour patterns as regards sexuality and condom use are also assessed.
This research takes place in project sites which have been mapped. Health and social services, churches and other community organizations, neighbourhoods where single women live, transport routes, business areas and market places, and areas where mobile men cluster such as construction sites, military bases, truck-stops, hotels and bars are situated on a ‘zone’ map (see below). As each site is mapped and assessed, the coordinator (often with health, education, social service or pastoral experience), is recruited and she in turn recruits 30 to 150 peer educators, depending on the size, dispersion and complexity of each site. Most are informal community leaders among single women, who are identified using observational and other techniques and who are subsequently trained in STD/HIV/AIDS prevention, participatory education techniques, and community mobilization. Peer educators operate in zones, which function as cohesive units with internal responsibility for organizing, motivating and supervising their members and participating in weekly meetings with other peer educators. Each zone chooses a group leader, who receives intensive leadership training. Experienced peer educators share their skills with the less experienced through tailored site visits, structured field placements, mentor relationships and skills and competency building networks.
Although the projects began by emphasizing STD/HIV/AIDS education and condom distribution, their objectives have been broadened to meet the requests of the community for medical, psychosocial and economic support. Neighbourhood support associations of single women who never married, are widowed, divorced, separated or have been deserted, have been formed to meet these requests. Each association elects its own chairwoman, treasurer and secretary and provides services, for example, child care services, care during illness and bereavement, small loans and revolving credit funds.
Although peer education programmes are now widely accepted as an effective approach to STD/HIV prevention, questions remain about the feasibility of large-scale implementation. Evidence from this initiative suggest that expansion and wide coverage with peer education is possible. In Zimbabwe alone, 10 million people were reached (including repeat contacts), 200000 community meetings were held, and over 30 million condoms were distributed over a two-year period. The average unit costs of the activities carried out in Bulawayo in 1994 were US$ 0.02 per person reached through face-to-face education, and US$ 0.01 per condom distributed and $1.24 per community meeting held.
Results indicate that these activities have led to changes in behaviour and condom use. In Bulawayo, reported condom use among commercial sex workers rose from 18% to 66% after two years. In Mutare, Zimbabwe, although there are no baseline data, during the second year of the project, 78% of a random sample of commercial sex workers, and 82% of a sample of men in bars, reported using condoms with their last commercial partner. In addition to reported condom use, projects track the number of STD consultations at health centres. The information should be interpreted with great caution, but it is worth noting that in both Bulawayo and Mutare, the declines were significant: in Bulawayo, the number of reported STD cases fell from 22878 in July-September 1991 to 11836 in April-June 1994 (see Figure 5) and the number of cases reported from Mutare fell from 5345 in July-September 1990 to 2552 in October-December 1994.
STD cases in Bulawayo (1991 -1994) (thousands)
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