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The rise and fall of HIV prevalence in Zimbabwe: the social, political and economic context a

Stephen O'Brien & Alex Broom

a

a

School of Social Science , The University of Queensland , Campbell Road, St Lucia Qld, 4072, Australia Published online: 13 Oct 2011.

To cite this article: Stephen O'Brien & Alex Broom (2011) The rise and fall of HIV prevalence in Zimbabwe: the social, political and economic context, African Journal of AIDS Research, 10:3, 281-290, DOI: 10.2989/16085906.2011.626303 To link to this article: http://dx.doi.org/10.2989/16085906.2011.626303

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ISSN 1608–5906 EISSN 1727–9445 doi: 10.2989/16085906.2011.626303

The rise and fall of HIV prevalence in Zimbabwe: the social, political and economic context Stephen O’Brien* and Alex Broom

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The University of Queensland, School of Social Science, Campbell Road, St Lucia Qld 4072, Australia *Corresponding author, e-mail: [email protected] For more than 10 years Zimbabwe has experienced social, political and economic instability, including the near collapse in 2008 of its health system. Paradoxically, this period has also seen a fall in estimated HIV prevalence, from 25.6% in 1996 to 13.7% in 2009. This article examines this development in a socio-political and historical context. We focus on the complex interplay of migration, mortality, individual behaviour change, and economic patterns in shaping the presumed epidemiological waning of HIV prevalence in Zimbabwe and explore the evolution and management of the country’s HIV/AIDS response. Our assessment of the role that the Zimbabwean state has played in this development leads to the conclusion that a decline in HIV prevalence has been as much an artefact of dire social, political and economic conditions as the outcome of deliberate interventions. Lastly, we propose the need to contextualise available epidemiological data through qualitative research into the social aspects of HIV and the everyday lives of individuals affected by it. Keywords: behaviour change, HIV incidence, qualitative research, social theory, socio-economic and political issues, southern Africa

Introduction Between 1996 and 2009, during a period of political instability and economic turbulence in Zimbabwe, HIV prevalence is estimated to have dropped from 25.6% to 13.7% (ANC HIV Estimates Technical Working Group Zimbabwe, 2009). Given Zimbabwe’s largely negative international reputation, it is perhaps surprising that the country is now cited as one of the ‘success stories’ for tackling HIV (UNAIDS, 2010a and 2011). This article examines how this situation has arisen and explores a number of social and political issues relating to the evolution and management of the country’s HIV/AIDS response. Specifically, this includes an examination of the various factors feeding into the decline in the country’s HIV prevalence and an assessment of the role of the Zimbabwean state in this development. Before doing this it is worthwhile to briefly explore the history of the HIV epidemic in Zimbabwe. The geopolitical and historical context After appearing in the human population of Central Africa sometime around the 1930s, by 1959 HIV had reached the Democratic Republic of the Congo (Denis & Becker, 2006; Epstein, 2007). These decades were a time of increased population movement facilitated by the expansion of transportation routes, rural to urban drift, and migrant labour. This period also saw the transition from colonialism, a process that was complicated in the 1970s to 1990s by war and civil conflict in southern Africa. Back calculations of epidemiological data suggest that HIV was present in the population of Rhodesia in the 1970s, so that by 1980

(the year of Zimbabwe’s independence) over 20 000 people were already infected (ANC HIV Estimates Technical Working Group Zimbabwe, 2009). Sequencing the genetic makeup of HIV has indicated that Zimbabwe experienced “multiple introductions” of the virus by the late 1970s (Dalai, De Oliveira, Harkins, Kassaye, Lint, Manasa, Johnston & Katzenstein, 2009, p. 2523). The region’s geopolitical history helps explain the HIV epidemic’s swift expansion. During 1953 to 1963, the Federation of Rhodesia and Nyasaland facilitated inter-regional migration to blend the populations of what would eventually become Zimbabwe, Zambia and Malawi (Dalai et al., 2009). Another wave of population mobility, a factor that increases exposure to HIV (UNAIDS, 2001), occurred after this political unity collapsed when, in order to forestall majority rule, the white minority of Rhodesia declared its ‘independence’ (for the period 1965 to 1980) and was increasingly drawn into a violent war against the Zimbabwe African People’s Union and the Zimbabwe African National Union–Patriotic Front (ZANU-PF). As a result of the conflict over 400 000 refugees and liberation fighters decamped to what were known as the frontline states, especially Botswana, Mozambique, Zambia and Tanzania, before liberation was finally achieved in 1980 (Kriger, 1992). By 1985 the first AIDS death was recorded in Zimbabwe, but over 70 000 people were probably infected at that time, and 20 000 might have already died (ANC HIV Estimates Technical Working Group Zimbabwe, 2009). Denialism and denigration A manifestation of the government’s formal recognition of HIV and AIDS was the introduction of universal blood

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screening (National AIDS Council [NAC], 2004) and the implementation of certain measures like the establishment of a series of medical committees and short-and medium-term HIV/AIDS control plans. However, the government concealed HIV/AIDS statistics and this contributed to a failure to alert the population to the true danger of the epidemic (Houston, 1990; Rödlach, 2006). In addition, some of the early HIV-awareness campaigns coincided with a police offensive against alleged sex workers and homosexuals, which had the effect of driving so-called ‘carriers’ of the virus underground (New African, 1987). Some posters from the time depicted AIDS as a female vampire on the prowl for men (New African, 1987). These morally-driven campaigns created the impression that HIV and AIDS was only something a small number of people had to be concerned about, and that social ‘deviance’ was a leading reason for the presence of the virus. Such actions and attitudes made it more difficult for people at risk, such as sex workers and their clients, to access HIV-prevention and sexual health services. Denialism about the nascent HIV epidemic was widespread in Africa in the 1980s (De Waal, 2006; Denis & Becker, 2006) and the fact that HIV was first isolated in the metropolis may have shaped perceptions that AIDS was a ‘foreign’ disease (Denis & Becker, 2006) — and thus an issue of no great concern. During the 1980s most international research was concerned with the impact of HIV on Western societies and was largely unaware of the adversity that was about to occur in Africa (Fourie, 2005; Denis & Becker, 2006; Epstein, 2007). Two countries in Africa did react with swiftness and apparent effectiveness to the potential threat. In Senegal, broad community engagement in HIV prevention has kept prevalence below 2% (Echenberg, 2006; UNAIDS, 2010b), and ‘mass education’ in Uganda was followed by a substantial reduction in HIV prevalence there (Tumushabe, 2006). The rise and rise of HIV: factors combine to produce an epidemic In the 1980s and 1990s a mix of ingredients having the potential to generate a severe HIV epidemic was in place. Increased travel along Zimbabwe’s good transport routes, more disposable income, and changes in social attitudes and gender relations all facilitated the spread of HIV (Poverty Reduction Forum Institute of Development Studies, 2004). In addition, Zimbabwean males had low rates of circumcision, a procedure that can reduce chance of infection by up to 75% (Southern African Development Community [SADC], 2006). Some cultural attitudes may have also played a role. For example, sexually transmitted (STIs) were socially acceptable among men in the sense that they were regarded as an indication of manhood. The practice of ‘dry sex,’ an activity that can cause genital lesions, as well as the custom of ‘wife inheritance,’ whereby the brother of a deceased man is obligated to marry this brother’s widow, are traditional practices associated with increased HIV risk (Lopman, Nyamukapa, Hallett, Mushati, Preez, Kurwa et al., 2009). However, the issue of multiple concurrent sexual partnerships has also been identified as a significant facilitator of HIV transmission (Ministry of

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Health and Child Welfare [MOHCW], NAC & USAID, 2004; Halperin & Epstein, 2007). Most Zimbabweans live in rural areas (Government of Zimbabwe, 2010) and, as a legacy of the country’s colonial economy, many people have long worked in towns, cities, mines, farms and plantations while maintaining close ties with their rural homes (Stoneman, 1981; UNAIDS, 2005). In the past, male workers might have multiple sexual partners in both locations (home and work), and, with their partners often absent, women were more likely to be involved in polygamous relationships. If a ‘married’ couple both had extra sexual partners and if those partners also had partners, a complex web of “local sexual networks” (UNAIDS, 2005, p. 5) would evolve. Newly HIV-infected individuals have a high viral load for a few months, thus sex during this time has a higher risk of transmitting HIV, especially when it occurs within a sexual network (NAC, 2006). By 1989 Zimbabwe had one of the worst HIV epidemics in the world (Buvé, 2006). Half a million people were already infected, over 20 000 were dying of AIDS annually, and with HIV incidence at about 5%, one in 20 adults were becoming infected each year (ANC HIV Estimates Technical Working Group Zimbabwe, 2009). Such was the visibility of HIV and AIDS that this period saw the establishment of what would amount to several hundred HIV/AIDS service organisations (ASOs). By the time Timothy Stamps became health minister in 1990, deaths from AIDS were too visible to ignore. The subsequent national response was enhanced and gradually shifted away from a biomedical approach (disease control) to social and behavioural change (Poverty Reduction Forum Institute of Development Studies, 2004). Health Minister Stamps had already been outspoken on HIV and AIDS and one of his first acts was to escort President Robert Mugabe on a tour of rural hospitals to see the problem first-hand (The Herald, 1990). In a televised address to launch national HIV/AIDS awareness week in 1990, Mugabe declared that HIV and AIDS had placed Zimbabwe in ‘great jeopardy’ (Sunday Mail, 1990). Despite such high level recognition this coincided with the introduction of a structural adjustment programme that shifted expenditure away from education and health (Renfrew, 1996; Paediatric Association of Zimbabwe, 1997) and thus weakened the state’s capacity to deal with the epidemic. Rural hospitals were closed, medical treatment fees increased, and a proposed school HIV curriculum was not resourced (Renfrew, 1996; Poverty Reduction Forum Institute of Development Studies, 2004; NAC, 2006). Since then individuals have increasingly carried the cost of their own healthcare to the point where private contributions are now the main source of heath financing in Zimbabwe (Kwenda, 2010; Mundawarara & Mapanda, 2010). Government policies requiring the discharge of HIV patients from hospitals into home-based care exacerbated this new situation (Hansen, Woelk, Jackson, Kerkhoven, Manjonjori, Maramba et al., 1998; Halperin, Mugurungi, Hallett, Muchini, Campbell, Magure et al., 2011). The responsibility of caring for the sick has fallen on family members and volunteer home-based carers, and this in turn has literally brought the burden of the HIV epidemic home to people. Such a move from institutional to domestic care, and the realities

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of HIV-related illness progression, may have in turn contributed to behaviour change (Halperin et al., 2011). Estimating prevalence and incidence Just when it appeared that the HIV epidemic was unchecked in Zimbabwe, underlying factors began to drastically reduce the number of people living with the virus. At this juncture it is useful to briefly explain how HIV indicators are derived. HIV prevalence is the percentage of people in the adult population who have tested positive to the presence of HIV antibodies in their blood. As a high proportion of expectant mothers in Zimbabwe visit antenatal care (ANC) clinics during their pregnancy (Zimbabwe National Statistics Agency & Measure DHS, 2011), this group provides a convenient and representative sample of sexually active adults (i.e. 15–49-year-olds). Nineteen specified clinics around the country are programmed to anonymously test for HIV as pregnant women present for a medical examination. When correlated with information from other sources, such as voluntary counselling and testing (VCT) centres and demographic and health surveys, this data is used to estimate HIV prevalence in the adult population. HIV incidence is the number of people who become infected in a given time period and is therefore a measure of the how fast the epidemic is spreading. HIV incidence is derived from studies that follow the health of specific populations, including new HIV infections recorded by VCT centres and by the blood transfusion services, as well as through mathematical modelling that analyses HIV prevalence data. Epidemiological data along with demographic information can be synthesised using specialised software (i.e. Estimation and Projection Package [EPP] and Spectrum) to further chart the evolution, direction and impact of the HIV epidemic. In general, statistical methods have become more accurate as technologies and procedures have improved; this has led to a body of evidence indicating that HIV prevalence in Zimbabwe fell from 25.6% in 1996 to 13.7% in 2009. This corresponds with estimates that HIV incidence also dropped, from 551 new infections per 10 000 people in 1993, to 85 new infections per 10 000 in 2009 (ANC HIV Estimates Technical Working Group Zimbabwe, 2009; Government of Zimbabwe, 2010; Gregson, Gonese, Hallett, Taruberekera, Hargrove, Lopman et al., 2010; Muchini, Benedikt, Gregson, Gomo, Mate, Mugurungi et al., 2010). Statistical declines in HIV To provide context, there are counter arguments to the evidence that HIV incidence and prevalence have fallen in Zimbabwe. First is the position that Zimbabwean agencies are not capable of collecting accurate data. This must be situated within the context of the condition of Zimbabwe’s health services, such as when hyperinflation and political crisis meant that many health centres ceased to function (Policies of the Movement for Democratic Change, 2008; Whiteside, 2008; Sollom, 2009). Gathering statistics in such a context is hardly a priority. Yet, it is also the case that international agencies are known to have prioritised, even during these times of crisis, support for data-collection logistics, technology and staffing (Peersman & Sikipa, 2002; Measure DHS, 2010). In addition, one legacy of the

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immediate post-independence period was a primary healthcare network, including ANC clinics. In addition, the initial scepticism that greeted the news of the positive epidemiological data shifted as the international donors started to take some credit for this development, thereby implying some level of confidence in the health statistics (O’Brien & Broom, 2010). A second critique of the country’s HIV prevalence and incidence statistics is that large numbers of HIV-positive people have migrated. Estimates indicate that anywhere between two and four million Zimbabweans have left Zimbabwe (United Nations Development Programme [UNDP], 2008; International Organization for Migration, 2010), some legally and others illegally, to live in neighbouring countries, or further afield, including in the United Kingdom and Australia. Gregson et al. (2010) conclude that even allowing for the possibility that HIV-positive people may be more likely than non-infected people to migrate perhaps due to the country’s economic decline, there is no evidence that this would have been substantial enough to dramatically impact on the country’s HIV-prevalence estimate. Indeed, it is not certain that HIV status would make a person any more likely to leave: a cohort of pregnant Zimbabwean women living in the United Kingdom between 2000 and 2006 had half the level of HIV infections as compared to their counterparts in Zimbabwe (Gregson et al., 2010). The third point is more obvious and clearly concerning. That is, the death of over two million HIV-positive Zimbabweans has certainly caused overall HIV prevalence to decline. As the epidemic accelerated, hundreds of thousands of people became infected and died. As noted, this is reflected in the rising rates of mortality in urban and rural areas in the late 1980s. By the 1990s, once many of the most vulnerable people had become infected, a point of ‘saturation’ was reached and the number of new and existing cases of HIV infection started to fall. But, between 1999 and 2003, this reduction occurred at a much faster rate than what could be explained as a natural occurrence, strongly suggesting that human actions mediated the decline (Lopman, Lewis, Nyamukapa, Mushati, Chandiwana & Gregson, 2007; Hallett, Gregson, Mugurungi, Gonese & Garnett, 2009; Halperin et al., 2011). In other words, having perceived the risk of HIV and AIDS, people started to counter this through behaviour change, such as reducing the number of sexual partners and using protection when they had sex. Sites of influence for declining HIV prevalence An examination of underlying factors that may have fed into this reduction in HIV prevalence and/or incidence in Zimbabwe reveals an at times tense dynamic between the state, international donors, non-governmental organisations (NGOs) and people living with HIV. Funding One consequence of Zimbabwe’s post-1999 political, social and economic crisis was a collapse in the level of external financial support (Bond & Manyanya, 2003).

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After 2000, among southern African countries, Zimbabwe received the lowest amount of donor funding for its national HIV/AIDS programme (Nyahoda, 2006; UNICEF, 2006; Loewenson & Masotya, 2008). At that time the international profile and funding of HIV/AIDS country responses was otherwise increasing following the 2001 United Nations General Assembly Special Session (UNGASS) Declaration of Commitment on HIV/AIDS. Zimbabwe still received external aid from sources such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Expanded Support Programme Zimbabwe (a basket-funding mechanism supported by several countries), and the United States Presidents Emergency Plan for AIDS Relief (PEFPAR). However, most of this funding was channelled through United Nations agencies, NGOs and faith-based organisations (FBOs), and only indirectly disbursed to relevant government ministries (Government of Zimbabwe, 2010). However, by 2000, NGOs and FBOs had started to partially fill gaps in service provision left by the government’s structural adjustment programme of the 1990s (Saunders & Spicer, 2000). National coordination According to the ‘Three Ones’ principles for strengthening national HIV/AIDS responses at the country level (promoted by UNAIDS), national coordination should be carried out under the aegis of a unitary framework, one coordinating authority (e.g. the National AIDS Council) and a single monitoring and evaluation system (UNAIDS, 2004). The proliferation of ASOs, with their competing priorities, duplication of effort, and parallel administration systems regardless of the benefits of their programmes, would have made national coordination more difficult (Biesma, Brugha, Harmer, Walsh, Spicer & Walt, 2009) and the overall “managerial burden” more onerous (Van de Walle, 2001, p. 200). Towards the end of the 1990s, the government of Zimbabwe started to emphasise the need to build partnerships with civil society as part of a more participatory and systematic approach to the national response (Mugurungi, Gregson, McNaghten, Dube & Grassly, 2007). The intention behind this strategy was to address the social conditions that were placing individuals and communities at risk of HIV. Thus, a national policy (in 1999), an AIDS levy (1999), HIV/ AIDS strategy (2000), the National AIDS Council (NAC) (2000) and the declaration of an HIV emergency (in 2002) were formulated. Mugurungi et al. (2007, p. 208) describe this effort as “pioneering,” but by that time the ruling party’s political and social prestige was waning and it had less capacity to lead, let alone coordinate, in response to important social issues such as HIV and AIDS (Poverty Reduction Forum Institute of Development Studies, 2004). One consequence of this development was that many NGOs, whose growth was significant after 2000 (Muchini et al., 2010), were reticent to disclose their funding sources and to fully report their activities and programmes to the government (NAC, 2004; Government of Zimbabwe, 2010). For its part, the state was either unwilling or unable to share key sentinel HIV/AIDS data which could have identified the areas of most need and made interventions more effective

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(Poverty Reduction Forum Institute of Development Studies, 2004). Perhaps the most serious illustration of such mistrust occurred in 2008 when the government banned field operations by NGOs for several months during an election period marked by violence (IRIN News, 2008). In addition, limited capacity in monitoring and evaluation meant that assessments of many non-governmental interventions were inadequate (Poverty Reduction Forum Institute of Development Studies, 2004). The limitations of interventions As well as lacking coordination and strategic targeting, the activities of NGOs and FBOs tended to be shaped by the priorities of their external donors and not necessarily by the needs of people living with HIV. The NGOs in the country mostly preferred to operate in the cities and towns where they were based, whereas the FBOs tended to provide services in the countryside, where 70% of the population lives. In fact, most HIV/AIDS-services programmes in the rural areas were provided by the FBOs, particularly through the network of church hospitals and missions. Organisations with a faith orientation, rather than social orientation, had more facility to operate with less state surveillance and control (Smart, 2006). As an aside, one feature of their anti-HIV work has been a tendency to emphasise faithfulness within marriage and to downplay the efficacy of condoms (Poverty Reduction Forum Institute of Development Studies, 2004). A critical observation of the interventions of ASOs in Zimbabwe is that, in some instances, they may have engendered passivity in the target communities by delivering services without ever building the local capacity necessary for sustainable and ongoing HIV-prevention activities (Nhamo, Campbell & Gregson, 2010). This is not to suggest that the work of NGOs and FBOs has been counterproductive; but, as reporting and coordination at the national level were generally haphazard, it is not possible to fully evaluate their contribution to the national HIV/AIDS response. Factors affecting the national HIV/AIDS response Considering the contradictions and tensions inherent in the national HIV/AIDS response in Zimbabwe, it is not surprising that there is a lack of certainty among researchers and commentators about which specific programmes have worked, at least in terms of raising awareness and preventing new infections. However, general trends can be seen. Gregson et al. (2010) cite data from successive demographic and health surveys that track respondent’s perceptions on issues such as HIV risk and multiple partnerships. These major surveys (which have been conducted on a large scale in Zimbabwe every five years since 1988) indicate that people have become more informed over time and began to adjust their sexual behaviour. Social attitudes towards sex workers and STIs appear to have shifted negatively (Halperin et al., 2011); by 2005 there were half as many reported STI cases as there had been in 1991 (Muchini et al., 2010). A study by Gregson, Nyamukapa, Schumacher, Mugurungi, Benedik, Mushati

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et al. (2011) analysed HIV-related views and experiences in a rural cohort, between 1998 and 2003. The participants who reported having attended community-based HIV/ AIDS meetings were found to have reduced their sexualrisk behaviour and had a lower incidence of HIV than those who did not attend meetings — however, they were not able to identify any particular HIV-prevention programmes as effective. Some context for understanding this behaviour change is provided by indications that HIV and AIDS became increasingly discernible in the late 1990s. The collective remembrance and community trauma of seeing relatives and friends suddenly become ill and die heightened the cultural visibility of HIV and AIDS and brought the reality and consequences of the epidemic home to individuals and their families (Muchini et al., 2010; Halperin et al., 2011). Historical mapping of the HIV/AIDS activities of various government, NGO and church agencies showed that people’s experiences coincided with an intensification of the various initiatives and activities. The programmes carried messages which, while not often remembered in specific terms, reinforced a national dialogue about HIV and AIDS. Overall, there are indications that post-1999 there was a proliferation of community awareness activities, constructive conversations, and more home-based nursing and palliative care efforts — all of which could have fed into behaviour shifts in terms of how people engaged in sexual relationships. Also at that time, lowered incomes made paid sex less affordable for men, healthcare more expensive, and political and community activity more problematic. While people heard the HIV/AIDS messages, they seem to have not paid particular attention to who delivered these; at the same time, more frequent conversations about HIV and AIDS occurred among families, friends and neighbours (Muchini et al., 2010; Halperin et al., 2011). Economic collapse, land reform and economic/political disadvantage One factor that contributed to people changing their sexual behaviour was economic hardship, such as via land-reform initiatives. Zimbabwe’s economic implosion began in 1997 and accelerated after 1999. Male respondents in qualitative studies recalled that after 1999 they no longer had the money to entertain several sexual partners or to keep multiple households, referred to as ‘small houses’; hence, Muchini et al. (2010) and Halperin et al. (2011) argue that the economic decline should not be overemphasised in contextualising HIV-incidence patterning. They base this conclusion on the fact that the worst of the economic crisis occurred after 2002, when most of the decline in HV incidence had already occurred. However, the two years before (2000 and 2001) did see major economic problems, with 10% negative growth in GDP and a 15% drop in the real earnings index (UNDP, 2008); even though this was not as extreme as what was to come, it represents a dramatic fall in economic activity and standards of living. A second, indirect contribution of government policy to the decline in HIV prevalence is ZANU-PF’s post-2000 land reform. Estimates vary, but possibly up to one million farm workers and their families were dislocated by this

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operation (Sachikonye, 2003; Hammar, 2008, Scoones, Marongwe, Mavedzenge, Mahenehene, Murimbarimba & Sukume, 2010). Given that farming estates were areas of high HIV prevalence (Poverty Reduction Forum Institute of Development Studies, 2004; Sachikonye, 2004; UNAIDS, 2005; Sadomba & Helliker, 2010), such a mass displacement would have broken links between sexual networks and thereby prevented some new HIV infections. Women’s economic and cultural vulnerabilities Although certain aspects of women’s legal situation in Zimbabwe are more progressive than in the rest of southern Africa (Cawthorne, 1999; Mvududu, 2002), interpersonal and structural violence directed against women and girls continue to interplay with experiences of HIV. As of 2009, about 60% of one million HIV-positive adults were females and HIV prevalence among young women was double that among males (ANC HIV Estimates Technical Working Group Zimbabwe, 2009; Government of Zimbabwe, 2010). Intergenerational sex has been a key route of HIV transmission. Older men with disposable income are more prone to being HIV-infected due having had a longer sexual history and a tendency to not use condoms during sex with younger women and adolescents (Gregson, Nyamukapa, Garnett, Mason, Zhuwau, Caraël et al., 2002; Hallett, Gregson, Lewis, Lopman & Garnett, 2007; Lopman et al., 2009). Poverty can play other roles in addition to reducing Zimbabwean men’s capacity to keep ‘small houses’ and to engage in casual sex. In the case of women and girls their low socio-economic status often makes them dependent on men for shelter and food and therefore less able to refuse sex or to insist on the use of condoms (UNICEF, 2004; Gregson et al., 2011). In addition, a double standard exists where partner concurrency is acceptable for men but is not tolerated for women (Mavhu, Langhaug, Pascoe, Dirawo, Hart & Cowan, 2011). Condoms in the socio-cultural landscape: the limitations of usage Since 1989, a key HIV-prevention message in Zimbabwe has been the so-called ABCs (abstain, be faithful and condomise), an approach embedded with divergent assumptions about sexual practices. Accordingly, the various actors within the HIV/AIDS response emphasise different ‘letters’ of the ABC approach. FBOs, for example, tend to shy away from promoting condoms to instead favour the abstain and be faithful aspects. Despite the ambivalence about promoting condoms, they are a crucial HIV-prevention technology in Zimbabwe and their usage has been high by African standards. Between 1990 and 2005, the number of condoms distributed increased fourfold (Muchini et al., 2010); and, in 2009, 95 million were sold or supplied (Government of Zimbabwe, 2010). A number of recent studies have suggested that Zimbabweans have not only used more condoms but have done so in a way that has had an epidemiological impact. Muchini et al. (2010) found that people started to use condoms in casual or transactional sexual relationships especially in the mid-1990s, and by 1997 the extent of usage among males (estimated for the last time they had sex with a casual partner) was as high as

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72%. Gregson, Garnett, Nyamukapa, Hallett, Lewis, Mason et al. (2006) and Gregson et al. (2010) have also reported that most men consistently used condoms when engaging in casual or commercial sex. Even though the epidemiological impact of condoms is ‘plausible’ (Halperin et al., 2011), this is not to suggest that they are the key to solving the problem of HIV transmission since this form of protection also has a gendered dimension. In Zimbabwe, females and young people in general are less likely than older males to use condoms (NAC, 2006) — and these are precisely the populations with accelerated rates of new infections (Marunda, 2009). The 2010 Millennium Development Goals Status Report for Zimbabwe notes that adult males showed 68% condom usage for last instance of higher-risk sexual activity, whereas this was only 42% for adult females (National MDG Taskforce, 2010). The report also notes that condoms tended to be used by men engaging in casual or commercial sex, albeit an activity that males practised less frequently. The cultural and social negativity associated with condoms means that they are less frequently used in long-term relationships, as indicated by trials that saw usage drop off once the research ended (Van der Straten, Cheng & Minnis, 2010). The role of the state in HIV/AIDS management Stigma and deviance: policy/practice disjunction The Zimbabwe government’s inadequate management of HIV and AIDS has been acknowledged by many commentators and academics, as well as by President Mugabe (1999). While HIV/AIDS policies have been developed across a range of sectors, their implementation has often been hampered by shortcomings in capacity, coordination and political will. An example of the disjunction between policy and government practice/rhetoric is manifest in the anti-homosexual public stances of both President Mugabe and Prime Minister Morgan Tsvangirai (Mail & Guardian, 2010). While the National Behaviour Change Strategy Policy recognises the need to be inclusive of the gay and lesbian community (NAC & UNFPA Zimbabwe, 2009) the rhetoric of these two government leaders reflects a tendency to portray the HIV epidemic as casually linked to marginalised groups. Literacy, HIV/AIDS education and antiretroviral therapy The Zimbabwe state is due credit in relation to the impact of its post-independence investment in education (UNDP, 2010) and its contribution to people’s knowledge and understanding of HIV and AIDS. Zimbabweans are relatively well-educated by southern African standards, with an adult literacy level around 90% (The World Bank, 2011) and this is reflected by almost universal HIV/AIDS awareness (98%) as reported in the latest demographic and health survey (see: Zimbabwe National Statistics Agency & Measure DHS, 2010, p. 21). The country’s school-based HIV/AIDS education, which commenced in the 1990s, would have contributed to this situation (NAC, 2006; Halperin, Muchini, Gomo, Mate, Magure, Mugurungi et al., 2008; Muchini et al., 2010). In addition, the intensification of government and donor-sponsored HIV/AIDS-related activities, reinforced by mass communication and popular culture, possibly created

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a synergy that helped reinforce the relevant messages, such as conveyed in rural and community meetings (Gregson, Terceira, Mushati, Nyamukapa & Campbell, 2004; Gregson et al., 2011). Education plays a vital role in containing the epidemic; for instance, the more schooling a girl child or adolescent receives reduces her chances of becoming HIV-infected (Gregson et al., 2004). This should be noted in consideration of the fact that it is increasingly more difficult for the parents and carers of Zimbabwe’s 1.6 million orphans and vulnerable children to meet the cost of school fees (United Nations, 2010). A further qualification is noted by Nhamo et al. (2010, p. 1667) who observed that while rural people often knew about HIV and AIDS they did not internalise its significance due to “gender, poverty and low levels of literacy.” It should be noted that rural Zimbabweans, and rural females in particular, have significantly higher illiteracy rates that people living in urban areas (see Ministry of Education, Sport and Culture, 2007, p. 1). Zimbabwe’s rollout of antiretroviral therapy (ART) is also an achievement for which the state can take partial credit, even though it is mainly financed by external donors. In 2010, over 320 000 adults and children were receiving ART (National AIDS Council, 2011). As ART prolongs lives this will eventually lead to a greater number of people living with HIV, working against a further decline in HIV prevalence. Governance and the HIV epidemic The impacts of HIV-prevention activities by government or any other stakeholder are largely unclear because such actions have coincided with a time of intense political division when both civil society and the state have been at loggerheads. Some post-1999 policies have been controversial. The National Trust Fund, which is financed by the AIDS levy (a 3% tax on income to fund HIV/AIDS activities), has been frequently accused of misspending or distributing funds according to a political agenda (Garbus & KhumaloSakutukwa, 2003; Price-Smith & Daly, 2004; Batsell, 2005; Rödlach, 2006 and 2009); this has added to the perception that AIDS Action Committees (established by the National AIDS Council at the provincial and village levels) are partisan bodies. Such experience has contributed to mistrust between the state and civil society. There have also been numerous allegations concerning the misappropriation of ARV drugs (Mundawarara & Mapanda, 2010), which suggests that even healthcare is another means for party/ state elites to amass wealth (Moore & Mawowa, 2010). The government’s HIV/AIDS response may thus have contributed to the national consciousness of the HIV epidemic in a positive fashion, by creating public awareness and discussion, but also in a negative way as allegations of political favouritism and corruption, such as in the ART programme, are not politically positive for the state. In his foreword to the 2010 Millennium Development Goals Status Report, President Mugabe (2010, p. iv) claims that “halting and reversing the spread of HIV” is an example of the “pro-poor” policies pursued by his government. Some scholars apologise for Mugabe’s record and propose that Zimbabwe is a radical or progressive state pursuing anti-neoliberal policies — such as land reform and the local manufacture of ART drugs (Moyo & Yeros, 2007).

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The reported decline in HIV prevalence has certainly been deployed as a political device by both the government and its opponents (O’Brien & Broom, 2010). Such contentions about the state are part of a broader debate concerning issues around state legitimacy, national sovereignty and historical interpretation, as expressed by scholars such as Campbell (2003), Bond & Manyanya (2003), Mamdani (2008), Moore & Mawowa (2010) and Raftopolous & Mlambo (2009), Scoones et al. (2010). Overall responsibility for a nation’s health must lie with its government — and any defence of the record of the ZANU-PF-dominated state, in health or any other matter, has to contend with that political party’s well-documented capacity to act with disregard for the welfare and wellbeing of Zimbabwe’s citizens (Tibaijuka, 2005; Catholic Commission for Justice and Peace & Legal Resources Foundation, 2006; Sollom, 2009). One would also have to recognise that, despite apparent epidemiological advances, HIV and AIDS in Zimbabwe is becoming “a disease of the poor” (Lopman et al., 2007, p. S58) and, additionally, the epidemic impacts disproportionately on the country’s females (Gregson et al., 2010). Conclusions Prevalence and incidence are main facets of the epidemiology of disease, such as for estimating the extent and rate of spread of HIV. Yet, such measures can be without context, revealing little about the social and cultural production of new infections, and the respective roles of social change, mortality rate, and shifting notions of, and attitudes towards, risk. This article is unique in exploring the apparent decline of HIV prevalence in Zimbabwe as embedded in the country’s social, economic and political contexts. While previous commentary has reassessed, critiqued and presented various forms of ‘evidence’ for the decline in HIV in the country, we have adopted an integrative approach that draws together aspects of the economy, population movement, behavioural change, and political actions. Each of these may influence epidemiological patterning — a situation, we argue, that provides a better understanding of how the HIV epidemic in Zimbabwe has developed and evolved. A key ambition of the research was to describe different levels of influence on HIV prevalence, from the structural to the micro level. That is, to examine sites of change, such as: at the level of the individual (e.g. condom use and sexual activity); at the level of social norms (e.g. attitudes toward STIs and multiple sexual partnerships); and, at the level of governance (e.g. the management of the HIV epidemic in policy and practice). By not including all these levels we reduce the HIV epidemic to particular things which become worsened or improved by particular people, organisations and actions. The grassroots reality reveals that the ‘social life of HIV’ has a variety of elements or causes, and no single shift, whether at the individual, community or state level, is responsible for the epidemic’s persistent impact on Zimbabweans. Thus, the article has presented a broad picture to illustrate different levels of influence on HIV prevalence in Zimbabwe — particularly, how political,

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economic and social upheaval might feed into behaviour change. In conclusion, we argue that the estimation of HIV prevalence is ultimately an important, but reductive, representation of a plethora of influences. Further research is needed to explore how social, cultural and economic processes and shifts continue to shape the everyday lives of people in Zimbabwe (that is, how such things as individual desire, poverty, cultural norms, gender, mortality, government policy, and international interventions influence the trajectory of the HIV epidemic). Structural variations in any of these social relations and cultural values further shape how HIV is transmitted, represented and contained. While the estimations of HIV prevalence and incidence in Zimbabwe are extremely useful indicators of broader shifts, they do not provide the context. As an artefact, these numeric estimates remain vulnerable to being used (possibly out of context) for political purposes, as seen in the Zimbabwean state’s co-option of the so-called ‘HIV decline.’ For balance, it is important to point out that the Zimbabwean state is not alone in terms of the use of rhetoric or the actual manipulation of health statistics. Most governments exercise control over the production (‘what is collected’) and presentation (‘what is said’) of health statistics. It is important to recognise that misrepresentations (e.g. Zimbabwe as a ‘success story’) and misconceptions (e.g. HIV is on the decline) do little to address the needs of the large population still living with HIV in Zimbabwe. Examination of social and cultural factors must augment statistical representations; especially, there is a need for in-depth and rigorous exploration of the ‘social life of HIV’ and how the virus continues to impact on the daily lives of people. This implies the need for a research programme in Zimbabwe involving qualitative and ethnographic explorations of HIV — in context, and post-‘HIV decline,’ and from the perspectives of those who have lived through periods of high AIDS mortality or who are now living with a virus that is having a persistent and high impact on communities. The authors — Stephen O’Brien is a PhD candidate at the School of Social Science, University of Queensland, and is undertaking a qualitative study of people’s experiences and perceptions of HIV in Harare, Zimbabwe. Alex Broom is an associate professor of sociology and an Australian Research Council future fellow at the University of Queensland. His research interests include the sociology of health and illness; the sociology of traditional, complementary and alternative medicines; health in developing countries; and social theory as applied to health.

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