15 August 2006
HARARE, Zimbabwe — Cathy Nyarai is an ebony, svelte, almost frail-looking 22-year-old woman. She is often described as anerunako, a beauty, in the local Shona language. In other cities, she might be sauntering down catwalks. But in Harare, she is only one among a growing legion of young women and girls to walk the streets near major hotels hoping to snare a client. And no, she does not consider herself a sex worker. She is a second-year university student, forced by the exigencies of poverty and a family of nine—two parents and seven siblings—to do what she can to make ends meet.
In Zimbabwe, a deepening economic crisis, growing poverty and high unemployment, have left many women with little choice but to exchange sex for money or basic commodities. It is a dangerous venture, Cathy readily admits. She has to think on her feet and detect and ward off violent and dangerous clients while keeping an eye out for police dragnets. It’s all in a night’s work.
Cathy also knows about what AIDS can do to young women. Today, HIV prevalence rates are highest among young women aged 21 to 23 with one in four already infected with the virus. Some of her colleagues have already succumbed. But Cathy is confident that she can stay safe. It is soon evident why. She flips out a packet of condoms from her bag, saying: “If there is one thing I must leave home with in the evening, it is this. This is my protector.”
And, apparently, she is not alone. Condoms, as it turns out, protect many Zimbabweans against sexually transmitted infections, including HIV, chlamydia, gonorrohea, herpes, human papilloma virus, and syphilis. Condoms have become a critical component of broader HIV prevention strategies in Zimbabwe, especially among groups with high rates of partner change, such as sex workers.
While UNFPA is a staunch advocate – and a major supplier – of both male and female condoms, it also strongly promotes a more comprehensive and rights-based approach to HIV prevention, treatment and care for sex workers. This includes addressing the lack of options that so often play a role in individuals engaging in sex work and providing a range of lifestyle and educational skills, as well as economic supports, to allow for an exit from sex work for those who chose to do so.
Zimbabwe is one of the three African countries showing a drop in HIV prevalence rates—down from 24.6 per cent in 2003 to 20.1 per cent in 2005, according to UNAIDS. Nevertheless, the country still has one of the highest HIV prevalence rates in the world. The practices that account for Zimbabwe’s continued high prevalence are still widespread. These include multiple partnering, concurrent sexual relations with different partners, wide age disparities between partners, polygamy, widows being ‘inherited’ by relatives of the deceased spouse, and young girls being forced into early marriage.
A comprehensive review undertaken by UNAIDS attributes the dip to a number of factors—including partner reduction, abstinence, faithfulness and condom use. Experts caution that the first three factors are based on anecdotal evidence only.
Although researchers have noticed a decline in the reported number of partners, there is little data on concurrent relationships. “Faithfulness in marriage has not proven to be the holy grail of HIV prevention,” explains Clemens Benedikt, HIV/AIDS project manager in the Zimbabwe Country Office of UNFPA, the United Nations Population Fund. “Polygamy, as a causal factor, seems to have stabilized. It is decreasing but does not seem to be a key factor in the decline.” The biggest development, he contends, appears to be increased condom use and HIV awareness.
Although measuring condom use is difficult, many studies in Zimbabwe show that the condom is the prevention method of choice among single, sexually active men. They appear to be relying on condoms as the prevention method of choice for non-marital relationships. Condoms also serve a dual purpose—both as a contraceptive and as a prophylactic.
Although a causal relationship linking condom use to the HIV decline is hard to trace, trend data show that as condom distribution has expanded dramatically -- from just over 20 million in 1994 to over 80 million in 2004 — the HIV infection rate has slowed and even dipped among certain groups
The female condom has also been enormously successful since women’s advocacy groups lobbied for its introduction in 1997. The number of female condoms publicly distributed and socially marketed increased from about 200,000 in 2000 to a peak of 1.4 million in 2002—before declining to just under 1.2 million in 2005. Today, the female condom is widely available in Zimbabwe’s urban areas, and the Government is now seeking to meet the needs of women living in more remote, rural regions.
A user perspectives study on the female condom undertaken by the Ministry of Health and Child Welfare in 1998 revealed high rates of acceptability among both men (74 per cent) and women (91 per cent). The study included men and women from rural and urban areas. While a few clients found it difficult to use, the difficulty diminishes with practice. “It’s thin and does not affect sex, you just feel as if there is nothing,” a female respondent from the study said. Users claim it is also reliable—both as a method of contraception and as a means of preventing sexually transmitted infections, including HIV.
The dramatic uptake of the female condom has been aided by innovative distribution strategies introduced by PSI-Zimbabwe, the local branch of the US-based Population Services International. These include the home-meeting initiative, during which trained markers visit potential clients in the privacy of their homes to promote the female condom. PSI is training hairdressers to help raise awareness among clients by chatting about the efficacy of the female condom and providing information on where to obtain it.
Daisy Nyamukapa, condom programming specialist in the Zimbabwe Country Office of UNFPA, maintains that popularity has to do not only with HIV/AIDS prevention but also with the broader issue of female empowerment—especially with regard to contraception and sexual negotiation. “The female condom is a tool that can be used to start discussion about women’s issues: empowerment, anatomy and negotiation for safer sex.”
The largely supportive political, legislative and public environment has aided the creation of a strong partnership between the public, social marketing and private sectors as well as the international donor community. The Government of Zimbabwe has also developed a national strategic framework on HIV/AIDS, a National AIDS Policy, a National AIDS Council, and has introduced an AIDS levy, which garners 3 per cent of taxable income from individuals and corporate bodies to support the overall HIV/AIDS response.
These measures have assisted the sustained implementation of effective national condom programming strategies whose main components include education, research, distribution, sales, forecasting, procurement, quality management, logistical and information systems. The Government established an office to coordinate and support condom programming in 1995, but it was vacated in 2000 owing to the economic challenges that face the country. UNFPA is now working with the Government to recruit staff and to scale up male and female condom programming. As part of this effort, in 2005 UNFPA facilitated the establishment of a Technical Support Group to improve access to both male and female condoms. The group—which is made up of representatives from the private sector, Government and other stakeholders as well as UNFPA and UNAIDS—is assisting the Government in developing a five-year national condom strategy.
While adequate supplies alone don’t mean that people will actually use condoms, making sure that they are available and accessible is a basic aspect of condom programming. Zimbabwe’s worsening economy, along with foreign exchange shortages are threatening to derail programming. The high cost of female condoms -- 72 cents (US) compared to 3 cents for a male condom -- is also taking its toll.
Furthermore, as Ms. Nyamukapa points out, while the female condom has been accepted as a dual-protection method among married couples, the male condom is still widely associated with infidelity and commercial sex work. This perception presents a huge challenge because it can undermine a spouse’s willingness to use the male condoms.
Although most religious organizations now champion condoms for HIV prevention, a few faith-based organizations continue to express strong reservations against them. Zimbabweans themselves have proposed a consensus solution: No stakeholders should make any negative statements about any effective HIV prevention method, including abstinence, faithfulness and condom use.
