57060 Findings reports on ongoing operational, economic and sector work carried out by the World Bank and its member governments in the Africa Region. It is published periodically by the Knowledge, Information and Technology Center on behalf of the Region. PARTNERSHIPS AGAINST AIDS : A SOUTHERN AFRICAN EXPERIENCE IN CHANGING SEXUAL BEHAVIOR The University of Zimbabwe in cooperation with the Southern African Training (SAT) School Without Walls, assists community partners in Botswana, Malawi, Mozambique, South Africa, Tanzania, Zambia and Zimbabwe to mobilize against HIV. Thousands of meetings, dramas and "one on ones" initiated by educators within informal networks, are used to empower people at risk to avoid HIV infection. The hard work is beginning to pay off--condom use has increased and reported cases of sexually transmitted diseases have decreased. Rates of HIV infection in Southern Africa are reaching levels yet to be reported elsewhere in the world. HIV prevalence rates exceed 30 percent among pregnant women attending urban and peri-urban facilities in Botswana, Malawi, Zambia and Zimbabwe. The highest prevalence rates of HIV infection--40 percent--are among pregnant women at 24 and 25 years of age in Harare. Similar rates are believed to exist among military personnel. Like several other regions in the world, the vast majority of infected people in Southern Africa are infected as a result of their sexual behavior. Since sexuality is not easily discussed, changing sexual behavior at the individual level and norms at the community level requires substantial effort. Experience suggests however, that people do change their sexual behavior when empowered with the knowledge, skills and encouragement often provided in AIDS prevention programs. The Psychology Department of the University of Zimbabwe took a strategic decision in the late 1980s not to initiate its own AIDS prevention activities but to cooperate with organizations providing community-based health services in the region. The University's Project Support Group (PSG), as the SAT School Without Walls' primary partner, forms partnerships with universities, governments and NGOs in Southern Africa to plan, implement and evaluate effective community AIDS prevention. The Approach: Using Informal Social Networks PSG staff and partners are coaching communities on the "who, what, where, when and how's" of changing behaviors. The "who" is men and women making up specific groups such as female sex workers and their male clients, military personnel, miners and other migrants. Leaders from these groups are recruited and trained as `peer educators' to educate the others. The "what" is sexual knowledge, attitudes, beliefs, and practices that are influenced by a variety of social, cultural and economic factors. The "where" is homes, workplaces, markets, community halls, schools, hotels, bars, mines, plantations and under the tree. The "when" is anytime. However, since casual sex is often related to alcohol use, education activities for bar patrons need to occur before the alcohol takes effect. The "how" is the challenge. How do you change sexual behavior? PSG stresses the importance of informal social networks-- particularly in increasing condom use. Studies show that informal social networks, made up of friends, siblings, and trusted peers who have changed their behavior can be persuasive role models. Thus, PSG's emphasis is on the role of peer educators. Approaches that are genuinely participatory and challenge people to confront, reflect on, develop their own response to, and build a normative consensus concerning sexual behavior are also encouraged. Didactic and prescriptive approaches, PSG staff advise, should be abandoned. One- minute plays, 10-minute dramas, picture codes, games and other participatory exercises work best during community gatherings because they are portable, not dependent on expensive equipment, entertaining, and simple to use in the field. Working Within Commercial Sex and Bar Networks in Bulawayo In its first partnership, the PSG assisted the Bulawayo City Council Health Services Department to develop a community peer education program for HIV-vulnerable groups in Bulawayo, Zimbabwe's second largest city. Funding was provided by SAT and USAID. Targeting individuals who engage in frequent unprotected sex with multiple partners is the principal strategy to prevent HIV transmission in Bulawayo (as in most AIDS prevention programs). The program works primarily with single women in low-income areas and men who visit bars. Note here the different indirect causes of vulnerability to HIV: the women are at risk because they have low income and the men because of their alcohol use. It was not surprising, that research for the program in Bulawayo, showed commercial sex to be largely based out of bars. In a national study by the University of Zimbabwe on men's social and sexual behavior, participants reported that 98 percent of commercial sex acts were preceded by alcohol consumption. In addition to research and analysis of the socio-sexual culture, program activities in Bulawayo include mapping of strategic sites such as hotels, bars and health clinics, recruitment and training of approximately 70 peer educators, community education and outreach, condom distribution, and formation of single women's neighborhood support associations. With the assistance of the Bulawayo City Council, PSG partnerships have been expanded to 38 School Without Walls partnership sites: 14 in Zimbabwe, 10 in Zambia , 4 in Malawi and 2 each in Botswana, Malawi, Mozambique, South Africa and Tanzania. These partnerships are funded primarily by the respective country AIDS Control Programs, the SAT Programme of the Canadian Public Health Association and many others, including the World Bank's Special Grants Program. The Goals: Changing Behavior and Lowering Disease The PSG assists partners in setting up systems to monitor program inputs, outputs, unit costs, coverage, change in behaviors and reported STD cases. From 1989 to 1996, for about US $50,000 annually, the oldest program - the peer education program in Bulawayo - held approximately 189,000 community meetings attended by 6.5 million people (including repeat attenders) and distributed 28 million condoms (Figure 1). Bulawayo's 1994 unit costs averaged US $1.20 per meeting, US $0.02 per person reached and $0.01 per condom distributed. Unit costs for the other programs are comparable, with economies of scale affecting costs per activity. To determine program coverage in two cities in Zimbabwe, a random sample of sex workers in Bulawayo (705) and Mutare (204), and male bar patrons in Mutare (508) were interviewed after the second year of operation for both programs in Bulawayo and Mutare, in 1992 and 1993, respectively. Among sex workers in Bulawayo, 80 percent had attended project health education meetings (72 percent in the past month) and 91 percent of attenders had received condoms during the meetings. Among sex workers in Mutare, 98 percent had attended project health education meetings, (84 percent in the past month) and 93 percent of attenders had received condoms during meetings. Sex workers had attended an average of 4.8 meetings in Bulawayo and 10 meetings in Mutare. Among male bar patrons in Mutare, 92 percent had attended project health education meetings, 48 percent in the past month and 84 percent of attenders had received condoms. In Bulawayo, condom use rose from 18 percent at the program's outset in 1990 to 72 percent by 1992. Condom use was reported by 27 percent of respondents who had not attended any meetings, by 46 percent who had attended one meeting and by 77 percent of those who had attended 2 or more meetings (Figure 2) . Selected STD trends in PSG partnership areas in Mutare, Zimbabwe and George, Zambia are provided in Figures 3 and 4. In Mutare, STD cases declined by 41 percent between 1990 and 1995. Such declines have also been reported in PSG partnership areas in Bulawayo and Masvingo, Zimbabwe (48 and 56 percent respectively) . In the PSG partnership area in George, Zambia the percentage of pregnant women attending antenatal services who had a positive serological test for syphilis antibodies declined from 32 percent in October 1993 to 12 percent in December 1995. In another PSG partnership area, Kariba, Zimbabwe, the percentage of pregnant women with a positive serology declined from 46 percent in the first quarter of 1990 to 15.9 percent in the fourth quarter of 1994. Although caution must be exercised before asserting causal relationships between program interventions and reported data on STDs, the STD trends in Figures 3 and 4 are encouraging. Experts consider the work performed by PSG staff at the University of Zimbabwe noteworthy for several reasons. PSG and their partners reach persons at high risk of HIV with an approach that is participatory and community-based. PSG has developed simple and replaceable planning and management systems. These systems monitor their partners' extensive efforts which show that the approach is low in financial cost and effective in increasing condom use. Lastly, PSG staff, in cooperation with SAT's School Without Walls, have shared their experience with an impressive 38 partnerships throughout the region. Many people in Southern Africa are responsible for the successful efforts described above. In particular, acknowledgment is due to Patience Chirenda, David Wilson, Noleen Dube, Lucy Mavikeni, from the University of Zimbabwe; Rene Sabatier from the SAT Training Program; and Barnett Nyathi from the Bulawayo City Council. For more information on this topic, please contact Wendy Roseberry, Rm. J10-062, World Bank, 1818 H Street, NW, Washington D.C. 20433, e-mail: wroseberry@worldbank.org. For copies of the report , please contact P.C.Mohan, Rm. J5-171, World Bank, 1818 H Street NW, Washington, D.C. 20433. Tel. no.: (202) 474-4114. Internet address: pmohan@worldbank.org