Did national HIV prevention programs contribute to HIV decline in eastern Zimbabwe? Evidence from a prospective community survey. Sexually Transmitted Diseases

Abstract Objective: To add to the evidence on the impact of national HIV prevention programmes in reducing HIV risk in sub-Saharan African countries. Methods: Statistical analysis of prospective data on exposure to HIV prevention programmes, relatives with AIDS and unemployment, and sexual behaviour change and HIV incidence, in a population cohort of 4,047 adults, collected over a period (1998)(1999)(2000)(2001)(2002)(2003) when HIV prevalence and risk-behaviour declined in eastern Zimbabwe. Results: Exposure to HIV prevention programmes and relatives with AIDS -but not unemployment -increased from 1998-2003. Men and women exposed to media campaigns and HIV/AIDS meetings had greater knowledge and self-efficacy, attributes that were concomitantly protective against HIV infection. Women attending community HIV/AIDS meetings before recruitment were more likely than other women to adopt lower-risk behaviour (96.4% versus 90.8%; aOR 3.09; 95% CI, 1.27-7.49) and had lower HIV incidence (0.9% versus 1.8%; aIRR 0.63; 95% CI, 0.32-1.24) during the inter-survey period. Prior exposure to relatives with AIDS was not associated with differences in behaviour change. More newly unemployed men than employed men adopted lowerrisk behaviour (84.2% versus 76.0%; aOR 2.13; 95% CI, 0.98-4.59). Conclusion: Community-based HIV/AIDS meetings reduced risk-behaviour amongst women who attended contributing to HIV decline in eastern Zimbabwe

Household-based cash transfer targeting strategies in Zimbabwe: are we reaching the most vulnerable children?

Census data, collected in July 2009, from 27,672 children were used to compare the effectiveness, coverage and efficacy of three household-based methods for targeting cash transfers to vulnerable children in eastern Zimbabwe: targeting the poorest households using a wealth index; targeting HIVaffected households using socio-demographic information (households caring for orphans, chronicallyill or disabled members; child-headed households); and targeting labour-constrained households using dependency ratios. All three methods failed to identify large numbers of children with poor social and educational outcomes. The wealth index approach was the most efficient at reaching children with poor outcomes whilst socio-demographic targeting reached more vulnerable children but was less efficient.publishedVersio

Effects of unconditional and conditional cash transfers on child health and development in Zimbabwe: a cluster-randomised trial

SummaryBackgroundCash-transfer programmes can improve the wellbeing of vulnerable children, but few studies have rigorously assessed their effectiveness in sub-Saharan Africa. We investigated the effects of unconditional cash transfers (UCTs) and conditional cash transfers (CCTs) on birth registration, vaccination uptake, and school attendance in children in Zimbabwe.MethodsWe did a matched, cluster-randomised controlled trial in ten sites in Manicaland, Zimbabwe. We divided each study site into three clusters. After a baseline survey between July, and September, 2009, clusters in each site were randomly assigned to UCT, CCT, or control, by drawing of lots from a hat. Eligible households contained children younger than 18 years and satisfied at least one other criteria: head of household was younger than 18 years; household cared for at least one orphan younger than 18 years, a disabled person, or an individual who was chronically ill; or household was in poorest wealth quintile. Between January, 2010, and January, 2011, households in UCT clusters collected payments every 2 months. Households in CCT clusters could receive the same amount but were monitored for compliance with several conditions related to child wellbeing. Eligible households in all clusters, including control clusters, had access to parenting skills classes and received maize seed and fertiliser in December, 2009, and August, 2010. Households and individuals delivering the intervention were not masked, but data analysts were. The primary endpoints were proportion of children younger than 5 years with a birth certificate, proportion younger than 5 years with up-to-date vaccinations, and proportion aged 6–12 years attending school at least 80% of the time. This trial is registered with ClinicalTrials.gov, number NCT00966849.Findings1199 eligible households were allocated to the control group, 1525 to the UCT group, and 1319 to the CCT group. Compared with control clusters, the proportion of children aged 0–4 years with birth certificates had increased by 1·5% (95% CI −7·1 to 10·1) in the UCT group and by 16·4% (7·8–25·0) in the CCT group by the end of the intervention period. The proportions of children aged 0–4 years with complete vaccination records was 3·1% (−3·8 to 9·9) greater in the UCT group and 1·8% (−5·0 to 8·7) greater in the CCT group than in the control group. The proportions of children aged 6–12 years who attended school at least 80% of the time was 7·2% (0·8–13·7) higher in the UCT group and 7·6% (1·2–14·1) in the CCT group than in the control group.InterpretationOur results support strategies to integrate cash transfers into social welfare programming in sub-Saharan Africa, but further evidence is needed for the comparative effectiveness of UCT and CCT programmes in this region.FundingWellcome Trust, the World Bank through the Partnership for Child Development, and the Programme of Support for the Zimbabwe National Action Plan for Orphans and Vulnerable Children

The distribution of sex acts and condom use within partnerships in a rural sub-Saharan African population

Introduction In an HIV/AIDS epidemic driven primarily by heterosexual transmission, it is important to have an understanding of the human sexual behaviour patterns that influence transmission. We analysed the distribution and predictors of within-partnership sexual behaviour and condom use in rural Zimbabwe and generated parameters for use in future modelling analyses. Methods A population-based cohort was recruited from a household census in 12 communities. A baseline survey was carried out in 1998–2000 with follow-up surveys after 3 and 5 years. Statistical distributions were fitted to reported within-partnership numbers of total, unprotected and protected sex acts in the past two weeks. Multilevel linear and logistic regression models were constructed to assess predictors of the frequency of unprotected sex and consistent condom use. Results A normal distribution of ln(sex acts+1) provided the best fit for total and unprotected sex acts for men and women. A negative binomial distribution applied to the untransformed data provided the best fit for protected sex acts. Condom use within partnerships was predominantly bimodal with at least 88% reporting zero or 100% use. Both men and women reported fewer unprotected sex acts with non-regular compared to regular partners (men: 0.26 fewer every two weeks (95% confidence interval 0.18–0.34); women: 0.16 (0.07–0.23)). Never and previously married individuals reported fewer unprotected sex acts than currently married individuals (never married men: 0.64 (0.60–0.67); previously married men: 0.59 (0.50–0.67); never married women: 0.51 (0.45–0.57); previously married women: 0.42 (0.37–0.47)). These variables were also associated with more consistent condom use. Discussion We generated parameters that will be useful for defining transmission models of HIV and other STIs, which rely on a valid representation of the underlying sexual network that determines spread of an infection. This will enable a better understanding of the spread of HIV and other STDs in this rural sub-Saharan population. Figures Table 3Table 1Figure 1Figure 2Figure 3Table 2Figure 4Table 3Table 1Figure 1Figure

Involving communities in the targeting of cash transfer programs for vulnerable children: opportunities and challenges

We used baseline data, collected in July–September 2009, from a randomized controlled trial of a cash transfer program for vulnerable children in eastern Zimbabwe to investigate the effectiveness, coverage, and efficiency of census- and community-based targeting methods for reaching vulnerable children. Focus group discussions and in-depth interviews with beneficiaries and other stakeholders were used to explore community perspectives on targeting. Community members reported that their participation improved ownership and reduced conflict and jealousy. However, all the methods failed to target a large proportion of vulnerable children and there was poor agreement between the community- and census-based methods

Household-based cash transfer targeting strategies in Zimbabwe: are we reaching the most vulnerable children?

Census data, collected in July 2009, from 27,672 children were used to compare the effectiveness, coverage and efficacy of three household-based methods for targeting cash transfers to vulnerable children in eastern Zimbabwe: targeting the poorest households using a wealth index; targeting HIVaffected households using socio-demographic information (households caring for orphans, chronicallyill or disabled members; child-headed households); and targeting labour-constrained households using dependency ratios. All three methods failed to identify large numbers of children with poor social and educational outcomes. The wealth index approach was the most efficient at reaching children with poor outcomes whilst socio-demographic targeting reached more vulnerable children but was less efficient

Observed and fitted distributions of the number of sex acts in the last two weeks.

<p>Panels A, C and E represent the numbers of sex acts (total, unprotected and protected) reported by men and B, D and F represent the same for women. A normal approximation of ln(sex acts+1) is used for A–D, and a negative binomial approximation of the untransformed data is used for E and F.</p

Overlaid histograms showing the distributions of the numbers of sex acts (total, unprotected and protected) with a specified partner within the last two weeks for (A) men and (B) women.

<p>Note that the line for total sex acts is lower than that for either unprotected or protected sex acts at zero because individuals reporting either zero unprotected or protected sex acts did not often report zero sex acts in total (due to the observed bimodal pattern of condom use described later).</p

Summary of data.

<p>NOTE. NA, not applicable, as individuals may be resampled from round to round but partnerships are not; hence the number of individuals in each round also does not sum across all rounds.</p><p>* Data on up to two recent partners was collected in rounds 1 and 2, and up to three for round 3. For consistency, the third reported partner was omitted for the calculated mean partners per individual and standard deviation for round 3, where one existed (n = 34 for men and n = 2 for women).</p

Generalised multivariable mixed model showing the determinants of consistent condom use within a partnership.

<p>Odds ratios refer to the odds of always using condoms compared to sometimes or never using condoms during sex acts for the previous two weeks with a single partner, estimated by adaptive Gauss-Hermite approximation using ten integration points. The modal group (denoted by a stop mark) was selected as the reference for all categorical variables.</p><p>NOTE. CI, confidence interval.</p>†<p><i>P</i>-values are estimated by Wald test.</p><p>*<i>P</i>-values estimated by Likelihood Ratio Test.</p><p>All <i>P</i>-values are reported to three decimal places. All other results are reported to two significant figures.</p