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A widely used demographic model of fertility, based on the proximate determinants, is described. The model is fitted for three contrasting countries, using data from 1980s round of demographic and health surveys. Regional variations in the relative significance of the different proximate determinants are noted, and considered in a discussion of the mechanisms through which HIV could influence future fertility levels. (DSE)

AbstractIntroductionSexual behaviour change contributed to reductions in HIV incidence in eastern and southern Africa between 1990 and 2010. More recently, there are indications that non‐regular partnerships have increased. However, the effect of these increases on population‐level risks for HIV and other sexually transmitted infections could have been reduced by simultaneous increases in condom use. We describe recent trends in sexual behaviour and condom use within the region and assess their combined effects on population levels of sexual risk.MethodsNationally representative Demographic and Health Survey data on sexually active males and females (15 to 49 years) were used for 11 eastern and southern African countries (≥3 surveys for each country; 1999 to 2016) to describe trends in sexual behaviour (multiple, non‐regular, and casual sexual partnerships; condom use; age at first sex). Logistic regressions tested for statistical significance of changes. Analyses were stratified by sex.ResultsRecent increases in multiple, non‐regular, and/or casual partnerships can be found for males in 10 countries and, for females, in nine countries; five countries exhibited recent decreases in age of sexual debut. Reduction in sex without condoms with non‐regular partners was observed in six countries for males and eight for females. Changes in the proportion of the overall population reporting condomless sex with non‐regular partners varied between countries, with declines in six countries and increases in three.ConclusionsExtensive change in sexual behaviour occurred across eastern and southern Africa during the period of scale‐up of antiretroviral therapy programmes. This includes increasing multiple and non‐regular partnerships, but their potential effects on population‐level sexual risks were often offset by parallel increases in condom use. Strengthening condom programmes and reintegrating communication about behavioural dimensions into combination prevention programmes could help countries to meet international targets for reductions in HIV incidence.

AbstractHIV is widely regarded as a disease of poverty and ignorance. However, within sub‐Saharan Africa, more developed countries and sub‐populations appear to have higher levels of HIV prevalence. This paper considers the evidence and possible reasons for this, by focusing on the relationships between education and the spread of HIV at the macro and micro levels. It is concluded that more educated populations are initially particularly vulnerable to HIV but are also better equipped to mount effective responses. Expanding provision of and access to secondary education could facilitate HIV control but is severely hampered by the morbidity and mortality effects of HIV epidemics. Efforts to sustain and increase education levels and to reduce HIV infections should therefore be mutually re‐enforcing but will require extensive resources. Copyright © 2001 John Wiley & Sons, Ltd.

BackgroundSocial constructions of masculinity have been shown to serve as an obstacle to men's access and adherence to antiretroviral therapies (ART). In the light of women's relative lack of power in many aspects of interpersonal relationships with men in many African settings, our objective is to explore how male denial of HIV/AIDS impacts on their female partners' ability to access and adhere to ART.MethodsWe conducted a qualitative case study involving thematic analysis of 37 individual interviews and five focus groups with a total of 53 male and female antiretroviral drug users and 25 healthcare providers in rural eastern Zimbabwe.ResultsRooted in hegemonic notions of masculinity, men saw HIV/AIDS as a threat to their manhood and dignity and exhibited a profound fear of the disease. In the process of denying and avoiding their association with AIDS, many men undermine their wives' efforts to access and adhere to ART. Many women felt unable to disclose their HIV status to their husbands, forcing them to take their medication in secret, and act without a supportive treatment partner, which is widely accepted to be vitally important for adherence success. Some husbands, when discovering that their wives are on ART, deny them permission to take the drugs, or indeed steal the drugs for their own treatment. Men's avoidance of HIV also leave many HIV‐positive women feeling vulnerable to re‐infection as their husbands, in an attempt to demonstrate their manhood, are believed to continue engaging in HIV‐risky behaviours.ConclusionsHegemonic notions of masculinity can interfere with women's adherence to ART. It is important that those concerned with promoting effective treatment services recognise the gender and household dynamics that may prevent some women from successfully adhering to ART, and explore ways to work with both women and men to identify couples‐based strategies to increase adherence to ART

Background: Partnerships are core to global public health responses. The HIV field embraces partnership working, with growing attention given to the benefits of involving community groups in the HIV response. However, little has been done to unpack the social psychological foundation of partnership working between well-resourced organisations and community groups, and how community representations of partnerships and power asymmetries shape the formation of partnerships for global health. We draw on a psychosocial theory of partnerships to examine community group members' understanding of self and other as they position themselves for partnerships with non-governmental organisations. Methods: This mixed qualitative methods study was conducted in the Matobo district of Matabeleland South province in Zimbabwe. The study draws on the perspectives of 90 community group members (29 men and 61 women) who participated in a total of 19 individual in-depth interviews and 9 focus group discussions (n = 71). The participants represented an array of different community groups and different levels of experience of working with NGOs. Verbatim transcripts were imported into Atlas.Ti for thematic indexing and analysis. Results: Group members felt they played a central role in the HIV response. Accepting there is a limit to what they can do in isolation, they actively sought to position themselves as potential partners for NGOs. Partnerships with NGOs were said to enable community groups to respond more effectively as well as boost their motivation and morale. However, group members were also acutely aware of how they should act and perform if they were to qualify for a partnership. They spoke about how they had to adopt various strategies to become attractive partners and 'supportable' – including being active and obedient. Conclusions: Many community groups in Zimbabwe recognise their role in the HIV response and actively navigate representational systems of self and other to showcase themselves as capable actors. While this commitment is admirable, the dynamics that govern this process reflect knowledge encounters and power asymmetries that are conditioned by the aid architecture, undermining aspiring efforts for more equitable partnerships from the get-go.

IntroductionRecent debates on how to achieve an optimal HIV response are dominated by intervention strategies that fail to recognize children's role in the community response to HIV. Whilst formal responses are key to the HIV response, they must recognize and build on indigenous community resources. This study examines adult's perspectives on the role of children in the HIV response in the Matobo District of southern Zimbabwe.MethodsThrough a mix of individual interviews (n=19) and focus group discussions (n=9), 90 community members who were active in social groups spoke about their community response to HIV. Transcripts were subjected to a thematic analysis and coding to generate key concepts and representations.FindingsIn the wake of the HIV epidemic, traditional views of children's social value as domestic "helpers" have evolved into them being regarded as capable and competent actors in the care and support of people living with HIV or AIDS, and as integral to household survival. Yet concurrent representations of children with excessive caregiving responsibilities as potentially vulnerable and at risk suggest that there is a limit to the role of children in the HIV response.ConclusionCommunity volunteers and health staff delivering HIV services need to recognize the "behind the scene" role of children in the HIV response and ensure that children are incorporated into their modus operandi – both as social actors and as individuals in need of support.

How realistic is the international policy emphasis on schools 'substituting for families' of HIV/AIDS-affected children? We explore the ethic of care in Zimbabwean schools to highlight the poor fit between the western caring schools literature and daily realities of schools in different material and cultural contexts. Interviews and focus groups were conducted with 44 teachers and 55 community members, analysed in light of a companion study of HIV/AIDS-affected pupils' own accounts of their care-related experiences. We conceptualise schools as spaces of engagement between groups with diverse needs and interests (teachers, pupils and surrounding community members), with attention to the pathways through which extreme adversity impacts on those institutional contexts and social identifications central to giving and receiving care. Whilst teachers were aware of how they might support children, they seldom put these ideas into action. Multiple factors undermined caring teacher-pupil relationships in wider contexts of poverty and political uncertainty: loss of morale from low salaries and falling professional status; the inability of teachers to solve HIV/AIDS-related problems in their own lives; the role of stigma in deterring HIV/AIDS-affected children from disclosing their situations to teachers; authoritarian teacher-learner relations and harsh punishments fuelling pupil fear of teachers; and lack of trust in the wider community. These factors undermined: teacher confidence in their skills and capacity to support affected pupils and motivation to help children with complex problems; solidarity and common purpose amongst teachers, and between teachers and affected children; and effective bridging alliances between schools and their surrounding communities–all hallmarks of HIV-competent communities. We caution against ambitious policy expansions of teachers' roles without recognition of the personal and social costs of emotional labour, and the need for significant increases in resources and institutional recognition to enable teachers to adopt support roles. We highlight the need for research into how best to create opportunities for teacher recognition in deprived and disorganised institutional settings, and the development of more culturally appropriate notions of caring

IntroductionIntensified poverty arising from economic decline and crisis may have contributed to reductions in HIV prevalence in Zimbabwe.ObjectivesTo assess the impact of the economic decline on household wealth and prevalent HIV infection using data from a population‐based open cohort.MethodsHousehold wealth was estimated using data from a prospective household census in Manicaland Province (1998 to 2011). Temporal trends in summed asset ownership indices for sellable, non‐sellable and all assets combined were compared for households in four socio‐economic strata (small towns, agricultural estates, roadside settlements and subsistence farming areas). Multivariate logistic random‐effects models were used to measure differences in individual‐level associations between prevalent HIV infection and place of residence, absolute wealth group and occupation.ResultsHousehold mean asset scores remained similar at around 0.37 (on a scale of 0 to 1) up to 2007 but decreased to below 0.35 thereafter. Sellable assets fell substantially from 2004 while non‐sellable assets continued increasing until 2008. Small‐town households had the highest wealth scores but the gap to other locations decreased over time, especially for sellable assets. Concurrently, adult HIV prevalence fell from 22.3 to 14.3%. HIV prevalence was highest in better‐off locations (small towns) but differed little by household wealth or occupation. Initially, HIV prevalence was elevated in women from poorer households and lower in men in professional occupations. However, most recently (2009 to 2011), men and women in the poorest households had lower HIV prevalence and men in professional occupations had similar prevalence to unemployed men.ConclusionsThe economic crisis drove more households into extreme poverty. However, HIV prevalence fell in all socio‐economic locations and sub‐groups, and there was limited evidence that increased poverty contributed to HIV prevalence decline.

Abstract Background This paper examines the potential for community conversations to strengthen positive responses to HIV in resource-poor environments. Community conversations are an intervention method through which local people work with a facilitator to collectively identify local strengths and challenges and brainstorm potential strategies for solving local problems. Methods We conducted 18 community conversations (with six groups at three points in time) with a total of 77 participants in rural Zimbabwe (20% HIV positive). Participants were invited to reflect on how they were responding to the challenges of HIV, both as individuals and in community groups, and to think of ways to better support openness about HIV, kindness towards people living with HIV and greater community uptake of HIV prevention and treatment. Results Community conversations contributed to local HIV competence through (1) enabling participants to brainstorm concrete action plans for responding to HIV, (2) providing a forum to develop a sense of common purpose in relation to implementing these, (3) encouraging and challenging participants to overcome fear, denial and passivity, (4) providing an opportunity for participants to move from seeing themselves as passive recipients of information to active problem solvers, and (5) reducing silence and stigma surrounding HIV. Conclusions Our discussion cautions that community conversations, while holding great potential to help communities recognize their potential strengths and capacities for responding more effectively to HIV, are not a magic bullet. Poverty, poor harvests and political instability frustrated and limited many participants' efforts to put their plans into action. On the other hand, support from outside the community, in this case the increasing availability of antiretroviral treatment, played a vital role in enabling communities to challenge stigma and envision new, more positive, ways of responding to the epidemic.