Attitude Adjustment

This, by Megan Brooks, has been sent to me by a subscriber to Medscape Medical News:

February 9, 2011 — Mass changes in behavior are credited with helping to remarkably reduce the number of people infected with HIV in Zimbabwe in recent years, concludes a report published online February 8 in PLoS Medicine.

These behavioral changes — primarily declines in extramarital, commercial, and casual sexual relations, as well as a decline in multiple partners — appear to have been stimulated primarily by increased awareness of AIDS deaths and fear of infection, and secondarily by the country's economic deterioration. Other important drivers have been the influence of ongoing education and prevention programs.

"Some HIV experts think the main reason for the decline in Zimbabwe is the economic collapse," first author Daniel Halperin, PhD, lecturer on global health at Harvard University School of Public Health in Boston, Massachusetts, noted in a statement.

"While we think that it's an important factor, it appears to be a secondary one. As in Uganda, behavior change (and mainly partner reduction), due mainly to fear of dying of AIDS, seems to be the most important factor," Dr. Halperin said.

HIV Prevalence Almost Halved

HIV prevalence in Zimbabwe increased rapidly in the early to mid-1990s, reaching a plateau in the late 1990s. By 1997, the estimated adult prevalence of HIV in the country was 29%. However, HIV prevalence declined after 2000, and in 2007 it was estimated to be 16%.

The goal of the international study, commissioned by the United Nations Population Fund and the United Nations HIV-AIDS Program, was to unravel the reasons for the marked decline in HIV rates in Zimbabwe in the context of social, political, and economic disruption.

"Given the continuing, and worrying, trend for high HIV/AIDS infection rates in many sub-Saharan African countries, we felt it was important to understand why the disease has taken such a dramatic downturn in Zimbabwe," Simon Gregson, DPhil, from the School of Public Health at Imperial College London, United Kingdom, and senior investigator on the study, said in a statement.

"Very few other countries around the world have seen reductions in HIV infection, and of all African nations, Zimbabwe was thought least likely to see such a turnaround. This is why there was such an urgent need to understand its direct and underlying causes," he noted

The study pinpoints significant declines in multiple sexual partners as "the most likely proximate cause" for the recent declines in HIV.

Data from nationally representative Demographic and Health Surveys from 1999 and 2005/2006 suggest an approximately 30% reduction in the proportion of men reporting extramarital partners. The data also suggest substantial reductions in the proportion of men reporting concurrent partnerships, as well in the number paying for sex.

"High AIDS mortality," the researchers report, "appears to have been the dominate factor for stimulating behavior change." In interviews and focus groups, Zimbabweans "consistently reported personal exposure to AIDS mortality and the resulting fear of contracting the virus to be the primary motivation for changes in sexual behavior, particularly reductions in casual sex and other multiple sexual partnerships."

Attitude Adjustment

Prevention programs also get some of the credit. It is unlikely, the researchers say, that significant changes in behavior could have occurred unless prevention programs had provided effective and widespread information and education about sexual behavior and AIDS.

Their findings also suggest that attitudes about sexually transmitted infections have changed. Although contracting a sexually transmitted infection or visiting a sex worker was once considered proof of masculinity, it is now typically thought of as embarrassing, or even shameful.

The severe economic decline, which took hold in the late 1990s and early 2000s, probably played a secondary role in amplifying these behavior changes: Men had less disposable income to pay for sex or maintain multiple relationships.

Other underlying factors found to distinguish Zimbabwe from neighboring countries and that have contributed to changes in behavior include the nation's well-educated population and high rates of marriage, especially among urban men, among whom the greatest level of behavior change seems to have occurred.

"It appears that this unique combination helped facilitate a clearer understanding and acceptance of how HIV is sexually transmitted and a greater ability to act upon 'be faithful' messages," the researchers say.

The results of the study were extensively and openly debated at a meeting in Zimbabwe, where attendees reached a "clear consensus" on the legitimacy of the findings. The researchers hope their findings "may provide important insights for HIV control within the region."

Some of the studies on which this paper is based were supported by the United Nations Population Fund, which provided some logistical support as well as helping with coordination between the studies. The United Nations HIV-AIDS Program and the Zimbabwean Ministry for Health and Child Welfare sponsored this study, along with funding from the Wellcome Trust. The authors have disclosed no relevant financial relationships.