PRB

(January 2003) With young people comprising a sizable proportion of Zimbabwe’s population, government officials, health workers, and community leaders face the overwhelming task of meeting the reproductive health needs for this special group. Even though many Zimbabwean youth become sexually active at an early age, they — like many others throughout the world — encounter social, cultural, and economic barriers to the information and health services they need to protect themselves against sexually transmitted infections (STIs) and other threats to their sexual and reproductive health.

Young people 15 to 24 years old in Zimbabwe are the group most vulnerable to HIV and other STIs. Factors that increase their risks of exposure include:

• Early sexual experimentation;
• Limited access to reproductive health services, including treatment for STIs, information about sexual health, and advice on responsible behavior;
• Harmful cultural practices;
• Social and urban changes in values;
• Loss of traditional support systems; and
• Economic insecurity.

Lack of Information Contributes to STI Rate Among Zimbabwe’s Young

More than 100 million sexually transmitted infections, not including HIV, occur every year around the world among people under age 25, according to the 2002 U.N. report, Young People and HIV/AIDS: Opportunity in Crisis. However, many infections go unnoticed. For biological reasons, women and girls may show no symptoms or the signs may be so mild that they are unrecognizable. In addition, young people have serious misconceptions about HIV and other STIs.

In Zimbabwe, adults generally have more knowledge than young people about STIs, according to Save the Children Zimbabwe, a 1999 Zimbabwe Demographic and Health Survey (ZDHS), and a May 2001 study by the United Nations Children’s Fund (UNICEF). The UNICEF study suggests that more than two-thirds of Zimbabwe’s adults have heard of gonorrhea and syphilis compared with 50 percent of out-of-school youth. The study also found that youth know little about STIs and the signs or symptoms of infection. Only 21 percent of women under age 20 were able to name two or more common STI symptoms, and their knowledge was confined to syphilis and gonorrhea.

This lack of knowledge among young people includes HIV. In a country where roughly one-third of adults have HIV, the National AIDS Council (NAC) estimates that more than 50 percent of all newly-reported HIV infections are among people under age 18. Yet the country’s young people are generally unaware of the risks of infection. The 1999 baseline study Youth Sexual and Reproductive Knowledge, Attitudes and Practices in Gweru, Zimbabwe found that 64 percent of youth in this central province felt their chances of contracting HIV in the next year were nil. Among 250 youth surveyed (125 boys and 125 girls, ages 12 to 24), only 4 percent assessed their risk to be high.

Health experts have found that preventing and treating STIs is a crucial part of the response toward HIV/AIDS. STIs facilitate the sexual transmission of HIV — particularly those STIs (such as syphilis, chancroid, and genital herpes) that produce genital ulcers. In Zimbabwe, the Ministry of Health’s 2001 National Survey of HIV and Syphilis Prevalence Among Women Attending Antenatal Clinics showed that HIV prevalence remained higher among women who tested positive for syphilis, compared with women who tested negative. Limiting the spread of STIs has therefore become increasingly urgent in countries like Zimbabwe with high HIV prevalence.

Among the other factors that increase the risk of HIV and other STIs is early sexual experience. Studies show that sexual activity begins at an early age throughout Zimbabwe — a particular concern in a country with a large and growing young population. Of Zimbabwe’s 12.6 million people, more than 36 percent are 10 to 24 years old, according to UN estimates. The UNICEF study suggests that in Bulawayo, Zimbabwe’s second largest city, 80 percent of in-school youth had their first sexual experience between ages 11 and 15. A 2000 baseline survey conducted by Africare in the Mashonaland Central districts of Bindura and Mount Darwin shows that sex is initiated between 9 and 15 years for both boys and girls.

Cultural, Social, and Economic Factors Increase Vulnerability

The unraveling of families because of urbanization and other factors has affected vital support networks for young people. In some situations, those leaving their villages for towns and cities include young people who are separating from grandparents and other relatives who had traditionally played a key role in their lives. The 1999 study Adolescents and AIDS Prevention: A School-Based Approach in Zimbabwe explains that traditional sources of sex education in Zimbabwe, including the paternal aunt (tete) and uncle (sekuru), are being lost in the process of urban migration. In Zimbabwean society, grandparents and other extended family members have traditionally passed on sexual and reproductive health information to their younger relatives.

Some religious and cultural practices may also place young women, in particular, at risk of exposure to HIV and other STIs. For example, a 2000 study titled A Dynamic Contextual Analysis of Young People’s Sexual and Reproductive Health in Zimbabwe indicates that the apostolic church (mapostori) expects girls to marry older polygamous men as part of a process of meeting God’s expectations. While this practice may offer parents increased financial security, it is potentially harmful since older men are associated with higher levels of HIV infection. Also, in the wider society, older men prefer to have sex with girls because of a myth that suggests that sleeping with a young virgin “cleanses” one of infection.

In addition, young women in Zimbabwe often face tremendous social and economic pressure to engage in sex. The 1997 article “Light on Learning: Using PRA to Explore School — Going Adolescents’ Views on Their Sex and Reproductive Health” found that girls have boyfriends for fun, financial security, kupusa (foolishness), and to keep up with their peers. Boys, on the other hand, have sex for pleasure, prestige, and proof of maturity.

Zorodzayi, a 13-year-old student from Harare’s suburb of Mbare, says she is not yet sexually active but knows her peers at school enjoy the company of “sugar daddies” — older, more financially stable men who offer girls gifts in exchange for sexual favors.

“It’s because [older men] give them the three Cs: cars, cash, and cell phones,” Zorodzayi explains, unclear about the implications of such risky relationships.

The same 1997 study shows that money plays a key role in teenage sex. “Both boys and girls assume without question that boys will pay for sex,” it notes. Similarly, economic insecurity drives young people into sex work for a living, and many end up in prison where they face higher risks of infection. An Umzingwane AIDS Network study in August 2000 showed that in Zimbabwe’s Umzingwane district of Matabeleland South province, schoolgirls were coerced into sex work with soldiers at nearby army camps simply to survive, thereby increasing their risk of infection.

Even those who know the dangers of unsafe sex still engage in high-risk sexual behavior because of cultural practices and social norms, notes the study Adolescents and AIDS Prevention: A School-Based Approach in Zimbabwe. Dry sex is a common practice in Zimbabwe: Women are forced to insert herbs and drying agents into their vaginas to sexually satisfy men. The resulting friction can injure the genital tract, increasing chances of STIs.

Limited Access to Care

Young Zimbabweans have limited access to reproductive health services, including treatment for STIs and information about sexual health. Social stigma and poor treatment from adults and health care workers are also major obstacles to care. Indeed, health workers are, by law, forbidden to provide reproductive health services to individuals younger than 16. At the same time, these young people “are excellent candidates for sexual health education,” notes a report on the Zimbabwe National Family Planning’s Promotion of Youth Responsibility Project.

Tafadzwa, a 16-year-old student of Churchill High School in Harare, explains that even at her age approaching nursing staff at a center for reproductive health services can be tricky: “They will give you an eye as if you have been up to something really bad… It’s like you are not allowed to go to places like that.”

Even though consistent condom use is essential for sexually active young people, sustainable free condom distribution is still largely confined to the country’s clinics, and distribution is facilitated by local nongovernmental organizations (NGOs) such as SAfAIDS as well as international NGOs like Population Services International (PSI). STI treatment is therefore constrained not only by a lack of public awareness but also by limitations related to service delivery.

Seventeen-year-old Kenneth, who is a senior student at Plumtree High School, 100 kilometers from Bulawayo, says he prefers not to visit a health center because “they only cater to bigger people.” He approves the use of condoms, but is secretive about where he obtains them.

Useful Youth Interventions

Some prevention programs in the country are geared toward developing positive and responsible attitudes and behavior among young people and recognize the influential role of the media.

• The Center for Disease Control (CDC) Zimbabwe is launching an entertainment-education radio serial that targets young people with the use of role models in January 2003. A “Talk Time” initiative has been successfully piloted among Zimbabweans at the Chinhoyi University of Technology (CUT), using youth-friendly materials that reinforce positive sexual behavior such as delaying the onset of sex, safe sex, testing, and care and support.
• Mark Fussell, operations director of CDC Zimbabwe explained that the radio serial will run alongside various youth reinforcement activities in communities. Key stakeholders identified from the formative research include faith-based organizations, pastors, unions, and teachers-integral partners in shaping youth attitudes and perceptions around sexual and reproductive health.
• A 1997-1998 multi-media campaign targeted Zimbabweans between ages 10 and 24. The national family planning center’s Promotion of Youth Responsibility Project was a six-month, multimedia strategy. It included 26 one-hour episodes of Youth for Real, a radio variety show broadcast nationally that was coupled with training for health providers on interpersonal communication.
• This weekly program that combined information with sexual and reproductive health advice and entertainment significantly increased use of health service facilities in Zimbabwe, according to The Impact Evaluation of the Youth Campaign on Reproductive Health in Zimbabwe. The report showed that 28 percent of young people at campaign sites visited health centers, compared with 10 percent at noncampaign sites. Also, 67 percent of those who had sex six months after the campaign reported using a modern contraceptive method, compared with 56 percent before the campaign. Phase 2 of the project is looking at broadcasting Youth for Real in local languages to reach a wider youth audience with increased focus on issues such as family planning and STIs.

Other prevention programs offer voluntary counseling and anonymous testing services to young people:

• Since 1999, PSI, the National AIDS Council, and the U.S. Agency for International Development (USAID) have provided voluntary counseling and testing services through “New Start” clinics at six sites in Zimbabwe: two NGO sites, one public sector health facility, two private sector workplace sites, and one site that is a partnership between an NGO and a public sector health facility. The New Start initiative tries to maintain a high quality of care through regular supervisory meetings, counseling reflection, direct observation, inservice training, stress management workshops, and exchange visits. Voluntary counseling and anonymous testing services are offered at a cost of Z$50 (approximately US$1), and the process aims to be client-centered and to offer same-day results.

Prevention and Care Strategies Need To Be Scaled Up

Despite the obvious threat of STIs for young people in Zimbabwe, the issue of sexual and reproductive health is still a topic that causes discomfort. Many here agree, however, that prevention programs for this vulnerable group need to be scaled up beyond the health arena with the full participation of young people, NGOs, government, educational institutions, international agencies, and faith-based organizations.

Addressing the growing problem of STIs means not only introducing education and communication strategies to promote healthy behaviors, but also addressing underlying social and cultural conditions to reduce individual risk-taking. Addressing the problem also means having health services offer a comfortable environment for young people to seek treatment and obtain advice, with services provided confidentially and sensitively.

Health experts recognize that more projects that target young people are essential for promoting increased access to information and services and that young men should be involved in interventions to support their partners and to understand the harmful implications of unprotected sex. Some experts argue that sex education needs to feature more prominently on school curricula, with messages reaching young people from an early age. Key to STI prevention efforts is the need to address policymakers’ perception of adolescent sexuality. Too often, youth needs are perceived as inappropriate for the national agenda, with leaders reluctant to support reproductive health programs for young people.

Aulora Stally is an independent media consultant based in Harare, Zimbabwe.

References

Africare, Adolescent Reproductive Health Project: Baseline Survey. Bindura and Mt. Darwin, Mashonaland Central, Zimbabwe (Harare, Zimbabwe: Africare, 2000).

Central Statistical Office, 1999 Zimbabwe Demographic and Health Survey (Harare, Zimbabwe: Central Statistical Office, 2000).

The Communication Initiative, “Promotion of Youth Responsibility Project — Zimbabwe,” accessed online at www.comminit.com/pdscc2001/sld-2121.html, on March 5, 2002.

M. Fuglesang, “Adolescent Sexuality Education, Counselling and Services,” Health Division Document Paper (Sweden: Swedish International Development Cooperation Agency, 1998).

Health Information and Surveillance Unit, Department of Disease Prevention and Control, National Survey of HIV and Syphilis Prevalence Among Women Attending Antenatal Clinics in Zimbabwe, 2000 (Harare, Zimbabwe: 2001).

Health Information and Surveillance Unit, Department of Disease Prevention and Control, National Survey of HIV and Syphilis Prevalence Among Women Attending Antenatal Clinics in Zimbabwe, 2001 (Harare, Zimbabwe: 2002).

M. Ki, C. Marangwanda, R. Nyakauru, and P. Chibatamoto, Zimbabwe National Family Planning Council, Johns Hopkins University, Center for Communication Programs, Impact Evaluation of the Youth Campaign on Reproductive Health in Zimbabwe, 1997-1998 (Baltimore, MD: Johns Hopkins University, July 1998).

Men’s Sexual Health Matters, “Common Sexual Problems,” Sexual Development and Function.

A. Runanga, A Dynamic Contextual Analysis of Young People’s Sexual and Reproductive Health in Zimbabwe (Harare, Zimbabwe: Human Behaviour Research Centre, 2000).

SAfAIDS Discussion Forum Review Newsflash, New Start HIV Counselling and Testing Initiative (Harare, Zimbabwe: SAfAIDS, May 2001).

Save the Children, Desk Study on Sexual Behaviour and Reproductive Health of Children and Young People in Zimbabwe (Harare, Zimbabwe: Save the Children Fund, March 2002).

J. Sherman, M. Bassett, “Adolescents and AIDS Prevention: A School-Based Approach in Zimbabwe,” Applied Psychology: An International Review (1999).

William Sambisa, Tim Williams, Lisa Mueller, Youth Sexual and Reproductive Health Knowledge, Attitudes, and Practices in Gweru, Zimbabwe: Results of a Baseline Survey (Washington, DC: Family Planning Service Expansion and Technical Support Project (SEATS), June 1999).

Umzingwane AIDS Network, Communication for Social Change Project (Umzingwane District, Zimbabwe: UAN, 2000).

UNAIDS, AIDS Epidemic Update, December 2002 (Geneva: UNAIDS 2002).

UNICEF, Countrywide KABP Baseline Survey on Tobacco, Alcohol and Drug Abuse and Other Health Related Behaviour Among 10–19-Year-Olds in Zimbabwe (Bulawayo, Zimbabwe: UNICEF, May 2001).

“Youth and HIV/AIDS: Can We Avoid a Catastrophe?” Johns Hopkins University Population Report, accessed online at www.jhuccp.org/pr/112/112chap4_2.shtml, on March 13, 2002.

For More Information

Africare www.africare.org

Auntie Stella www.auntiestella.org

Batsirai Group batsirai@mango.zw

Family AIDS Caring Trust www.fact.org.zw

Save the Children South Africa and Zimbabwe www.savethechildren.org.uk

Southern Africa AIDS Information Dissemination Service (SAfAIDS) www.safaids.org

Tsungirirai www.usafriends.org

Umzingwane AIDS Network (UAN) P.O. Box 112, Esigodini, Zimbabwe

Population Services International (PSI) www.psi.org

Zimbabwe AIDS Prevention Project (ZAPP) sostain@zappuz.co.zw

Zimbabwe AIDS Prevention and Support Organization (ZAPSO) zapso@zapso.org

Zimbabwe National Family Planning Council znfpc@ecoweb.co.zw