1

Danuta Kasprzyk, PhD and Daniel Montaño, PhD

University of Connecticut, CHIP

March 17, 2011

Zimbabwe: A Decade of HIV Prevention Research

University of Zimbabwe

2

Overview

• Zimbabwe Background

• Behavior Change Research: Applying the Integrated Behavioral Model (IBM)– CPOL

– Male Circumcision

• Strategies to Improve Family Functioning Among Families with HIV Positive Parents– Family Health Study

3

Zimbabwe: Basic demographics

• 11.39 Million people

• Median Age: 17.6 (M=16.3; F=18.8)

• 5.95 Million 15-49 year olds

• 41% children under 5 years of age

• 70% live in rural areas

• 70% of population is women and children

• Two majority ethnic groups– 70% Shona; 30% Ndebele

• English, Shona and Ndebele are the official languages2007 – 2008 UN estimates/CIA Factbook estimates

4

5

Zimbabwe: Basic demographics

• Annual population growth = 0.6

• Adult Literacy 90%: – women 87.6%;

– men 93.7% • Percent of primary school enrollment

– boys 88%,

– girls 87%

• Per capita expenditure on health = $146 US

2007 – 2008 UN estimates/CIA Factbook estimates

6

Zimbabwe: Public Health Indicators

Statistics from ZDHS/Multiple Indicator Monitoring Survey 2009/Maternal and Perinatal Mortality Study; * 2007 data

Indicator 1999 2005 2009 MDG target

Infant Mortality Rate 65 60 63 22

Under 5 Mortality 102 82 119 34

Exclusive breastfeeding (6 mos.) 27 22 26 70

Children immunized 67 53 46 90

Skilled delivery attendance 73 68 65 100

TB Incidence 355 1047 782* 178

Malaria incidence 122 124 94 62

Crude death rate 17 20

Life expectancy at birth 45 43 43

7

HIV prevalence (%) in adults (15–49) in Africa, 2007

8

The Zimbabwe AIDS Epidemic• First reported case: 1984 • Prevalence peaked in 1998 at

over 30%

• 1.1 M PLWHA (2009 est.)

– 10% children; 60% women

• ~1.3 million orphans

• ~135,000 new infections/year

HIV and AIDS Indicators 1999 (%) 2005 (%) 2009 (%)

HIV and AIDS prevalence (ages 15-49)

28 18 13.7

Adult ART coverage 0 4 54

Pediatric ART coverage 0 .1 57

9

Zimbabwe HIV Prevalence

Overall Adult2005

(ZDHS)

Urban: 17%Rural: 15%

Total Prevalence %

15.2 – 16.7

16.7 – 18.4

<15.2

18.5 – 19.7>19.7

10

Zichire Origin• ZiCHIRe formed in July 2000 after obtaining funding

to join NIMH Collaborative HIV/STD Prevention Trial

• We operate with a formal Memorandum of Understanding with Battelle and University of Zimbabwe (UZ)

• 2 collaborating institutions:– Battelle, Centers for Public Health Research and

Evaluation

– UZ, Medical School, Department of Community Medicine

– UZ, Department of Psychology

11

University of ZimbabweZichire office

12

Research in Zimbabwe• Ten studies conducted since 2000

– RCT HIV/STD Prevention Trial, 8 yrs, NIMH

– Alcohol and risky behavior, 4 yrs, NIAAA

– Male Circumcision uptake in, 4 yrs, NIMH

– Family Health Study: psychosocial support intervention, 6 yrs, NINR

– Neuro-cognitive effects of HIV, UW grant, Pilot study

– STD Etiology Study, pilot, NIMH

– UNICEF: Male Champions rapid assessment evaluation– CDC:

- Mopani Junction Radio Drama formative research and pilot impact evaluation

- Young Adult Survey development

- Health educational pamphlet design technical assistance

13

BEHAVIOR CHANGE RESEARCH:

APPLICATION OF THE INTEGRATED

BEHAVIORAL MODEL (IBM)

14

Origin and Application of the IBM

• In USA– Project SAFER

• In Zimbabwe – Project SAFER

– CPOL Trial

– Male Circumcision

15

Experiential Attitude

Instrumental Attitude

Injunctive Norm

Self-Efficacy

Perceived Control

Feelings about Behavior

Behavioral Beliefs

Normative Beliefs –Others’ expectations

ControlBeliefs

Efficacy Beliefs

Integrated Behavioral Model

Personal Agency

Attitude

Descriptive Norm

Other

Factors

Perceived Norm

Normative Beliefs –Others’ behavior

16

HIV/STD Prevention Trial• NIMH funded, Multi-national Collaborative 2-armed RCT

to test HIV/STD prevention intervention

• First multi-national test of the Community Popular Opinion Leader (CPOL) Model Intervention:

• Multi-site: Conducted in 5 countries

– China/UCLA; India/JHU; Peru/UCSF-UCLA; Russia/Medical College of WI; Zimbabwe/Battelle

Peru

ChinaIndia

Peru

17

HIV/STD Prevention Trial• Accrued cohort through purposive selection of

approximately 185 individuals (30 Growth Points)

• Conduct Baseline (N=5,547)

• Personal Interview Assessment:– Demographic, Behavioral Risk, IBM

– Health Assessment, including STD symptoms

– Biologic samples (Bacterial and Viral STDs)

• Implement intervention (15 growth points randomly assigned)

• Follow-ups at 12 and 24 months (30 growth points)

18

19

Local women selling vegetables outside a store at Nedziwa Growth Point

People shopping at Gokwe Growth Point

Men drinking Chibuku at a bottle store in Mamina Growth Point

Growth Point Recruitment Sites

Shops at Dema Growth Point

20

.

21

CPOL Behavioral Intervention• Diffusion of Innovation Theory

• Uses Community Popular Opinion Leaders–Deliver persuasive messages to peers to

encourage behavior change

–Opinions and behavior diffuse through community to become norm

• CPOLs trained to have conversations with peers–Focus on effective conversation skill training–Use self as example of behavior change–Assumes CPOLs will target the right issues

- Attitudes, norms, self efficacy

22

Application of IBM: Original intent • Apply IBM to:

–Inform content of CPOLs’ messages

–Structure CPOL conversations with community members

–Measure intermediate outcomes- Determine whether behavior change can be explained by change in IBM constructs

• Collaborative Trial decisions:–These plans were not implemented across 5

study sites

23

Additional NIAAA funding• Allowed us to apply the IBM to:

–Identify appropriate targets for intervention messages

–Assess whether those targets were impacted

• Qualitative elicitation interviews to identify:–Underlying issues/beliefs for each IBM construct

–8 behaviors: condom use with different partners, monogamy, talking to partners about sex, sex in context of alcohol use, transactional sex

• Develop culturally appropriate IBM construct measures for each behavior

24

Final IBM Survey

• Measured constructs for each behaviour–Behavioural intention/motivation–Attitude: 9-14 behavioural beliefs–Perceived Norm: 4-6 normative beliefs

- All three measured with 5-pt Strongly disagree – Strongly agree

–Self-Efficacy: 6-11 self-efficacy beliefs- 5-pt Certain I could not – Certain I could

• Translated and back-translated to Shona and Ndebele

• Conducted survey – Baseline, 12-mo, 24-mo

25

Results: STI Incidence

Results: Unprotected sex

CPOL Trial Main Outcome Results

26

CPOL Trial Results Summary

• Equal change in behavior in both Intervention and Control sites

–Unprotected sex with non-spousal/live-in partners reduced by 33%

• Incidence in combined STD/HIV outcome declined equally

• CPOL Intervention did not add anything over and above the counseling and testing intervention

• Why no differential effect?

27

IBM Analysis

• Computed model constructs – mean of beliefs underlying construct

• Correlation of constructs with Intention

• Correlation to identify construct beliefs that best explain Intention and behavior:–Behavioral beliefs underlying Attitude

–Normative beliefs underlying Perceived Norm

–Efficacy beliefs underlying Self-Efficacy

28

CONDOM USE – STEADY PARTNER

29

Correlations IBM Constructs with Intention to Use Condoms with Steady

All correlations significant with p < 0.01;

Multiple R significant with p < 0.01;** beta weight significant with p < 0.01

.49**

.17**

.16**

beta

.69

r

Multiple R

.65Self Efficacy

.49Perceived Norm

.46Attitude

Condom Use - Steady

(n=2,212)

30

Behavioral Beliefs: Rs with Condom Use Motivation (Steady Partner)

Behavioral Beliefs: Motivation

Make partner angry -.37

Show lack of respect for partner -.40

Show you think partner is unclean/diseased

-.37

Show that you are unclean/diseased -.37

Be embarrassing -.29

Make partner think you don’t love her/him

-.37

Spoil the relationship -.36

Show you don’t trust her/him -.38

You would get less pleasure -.21

Make partner think you have other partners

-.39

Unnecessary - partner has no other partners

-.31

You will not have sexual release -.24

Encourage promiscuity in partner -.29

All correlations significant with p < 0.001

31

Normative Beliefs: Rs with Condom Use Motivation (Steady Partner)

Normative Beliefs:

Motivation

Your family .25

Your closest friends

.29

Radio shows or radio dramas

.20

Your partner .56All correlations significant with p <

0.001

32

Efficacy Beliefs: Rs with Condom Use Motivation (Steady Partner)

Efficacy Beliefs: Motivation

Carried away and can’t wait to have sex

.57

You drink before sex .52

Partner drinks before sex .53

Use another method of birth control

.59

Partner doesn’t want to use condom

.56

Believe AIDS will affect you .43

Having condom with you .57

Know how to use a condom .59

Condom availability in community .60

Had to talk about it with her .56

You think she had other partners .45

All correlations significant with p < 0.001

33

Was there differential impact?

• Computed change score for each measure

–24-month minus Baseline

• Tested for significant difference:

–Intervention vs. Control

–If constructs were targeted appropriately, expected greater change for Intervention vs Control

34

Differential Change (Steady Partner Condom Use)

Condom Use:

Mean Change

Sig.ControlInterventio

n

Behavior .70 1.24 NS

Motivation .38 .49 NS

35

Differential ChangeBehavioral Beliefs (Steady Partner Condom Use)

Behavioral Beliefs:Mean Change

Sig.Control Intervention

Make partner angry -.42 -.76 NS

Show lack of respect for partner -.46 -.61 NS

Show you think partner is unclean/diseased

-.71 -.95

Show that you are unclean/diseased -.56 -.80 NS

Be embarrassing -.14 -.14 NS

Make partner think you don’t love her/him

-.72 -.82 NS

Spoil the relationship -.43 -.38 NS

Show you don’t trust her/him -.87 -.81 NS

You would get less pleasure -.70 -.68 NS

Make partner think you have other partners

-.95 -1.04 NS

Unnecessary - partner has no other partners

-.28 -.72

You will not have sexual release -.34 -.42 NS

Encourage promiscuity in partner -.73 -.75 NS

36

Differential ChangeNormative Beliefs (Steady Partner Condom Use)

Normative Beliefs:

Mean Change

Sig.

ControlInterventio

n

Your family .13 .40 NS

Your closest friends -.03 .09 NS

Radio shows or radio dramas

-.12 -.09 NS

Your partner .42 .59 NS

37

Differential ChangeEfficacy Beliefs (Steady Partner Condom Use)

Efficacy Beliefs:Mean Change

Sig.Control

Intervention

Carried away and can’t wait to have sex

.11 .31 NS

You drink before sex .36 .46 NS

Partner drinks before sex .17 .34 NS

Use another method of birth control

.13 .37 NS

Partner doesn’t want to use condom

.28 .60

Believe AIDS will affect you -.02 .00 NS

Having condom with you -.17 .09 NS

Know how to use a condom -.12 .03 NS

Condom availability in community -.13 .06 NS

Had to talk about it with her -.14 -.03 NS

You think she had other partners -.37 -.14 NS

38

STICKING TO ONE PARTNER - MONOGAMY

39

Behavioral Beliefs: Rs with Monogamy Motivation

Behavioral Beliefs: Motivation

means you would not get the variety in sexual partners you need -.12means you would not be sexually satisfied -.28does not fit into our culture -.09*is difficult because you have a high sex drive -.32is difficult since it is traditional for men to have multiple partners -.20makes men less manly -.12means you will not have HIV .05*is something that you cannot commit to -.30means men would get sick -.12means men would lose prestige or standing in the community -.13means women will not get ahead in their jobs -.12

All correlations significant with p < 0.004, except *

40

Normative Beliefs: R with Monogamy Intention

Normative Beliefs: Intention

your spouse or steady partner .21your family .15your closest friends .20your culture .20your church .12radio shows or radio dramas .13

All correlations significant with p < 0.001

41

Efficacy Beliefs: Rs with Monogamy Intention

Efficacy Beliefs: Intention

If you could talk about it with your partner .55If you trusted that your partner was also monogamous .46If you and your partner were a part a lot .41If your partner didn’t want sex as often as you did .40MEN ONLY: If you spot a beautiful girl .44MEN ONLY: If commercial sex workers entice you .39MEN ONLY: If your wife, main or steady partner was pregnant .48WOMEN ONLY: If men offer you gifts or money .48

All correlations significant with p < 0.001

42

Differential Change – Monogamy

Condom Use:

Mean Change

Sig.ControlInterventio

n

Intention .09 .07 NS

43

Differential Change Behavioral Beliefs (Monogamy)

Behavioral Beliefs:Mean Change

Sig.Control Intervention

means you would not get the variety in sexual partners you need

-.39 -.36 NS

means you would not be sexually satisfied

-.06 -.05 NS

does not fit into our culture -.18 -.15 NS

is difficult because you have a high sex drive

-.07 -.08 NS

is difficult since it is traditional for men to have multiple partners

-.37 -.30 NS

makes men less manly -.16 -.10 NS

means you will not have HIV -.38 -.40 NS

is something that you cannot commit to -.28 -.25 NS

means men would get sick -.12 -.05 NS

means men would lose prestige or standing in the community

-.10 -.04 NS

means women will not get ahead in their jobs

-.12 -.05 NS

44

Differential Change Normative Beliefs (Monogamy)

Normative Beliefs:Mean Change

Sig.

ControlInterventio

n

your spouse or steady partner

.01 .02 NS

your family .05 -.01your closest friends .10 .08 NS

your culture .02 .00 NS

your church .09 .05 NS

radio shows or radio dramas

.04 .00 NS

45

Differential Change Efficacy Beliefs (Monogamy)

Efficacy Beliefs:Mean Change

Sig.

ControlInterventio

n

If you could talk about it with your partner

.12 .11 NS

If you trusted that your partner was also monogamous

.17 .15 NS

If you and your partner were apart a lot .36 .39 NS

If your partner didn’t want sex as often as you did

.32 .33 NS

MEN ONLY: If you spot a beautiful girl .35 .27 NS

MEN ONLY: If commercial sex workers entice you

.26 .17 NS

MEN ONLY: If your wife, main or steady partner was pregnant

.24 .17 NS

WOMEN ONLY: If men offer you gifts or money

.15 .16 NS

46

Impact and Process Evaluation• CPOLs had conversations

• CPOLs expressed frustration:

–Did not know what to target in conversations

• Data shows CPOLs did not target/impact critical beliefs

–Training successful in motivating conversations and conversation skills

–Not successful in teaching CPOLs how to target and change beliefs shown to be key in changing behavior

47

Enhanced CPOL Intervention

• IBM complements CPOL– CPOL provides channel of persuasive

communication– IBM provides behavioral theory to identify targets

of persuasive messages

• Train CPOLs in IBM conceptualization• Train CPOLs to have guided conversations

– Use IBM conversation guide to systematically identify beliefs to target for each person

– Target issues identified

• Train CPOLs to develop messages for target beliefs identified in this research

48

Enhanced CPOL intervention

• Used in roll-out to comparison sites

• Trainers and CPOLs extremely positive

–CPOLs understood IBM conceptualization

–Expressed greater confidence in:- Having targeted conversations with peers

- Having an impact on behavior

• Not evaluated

49

Closing the Gap in Male Circumcision Uptake

Environmental and Behavioral Factors Shaping Male Circumcision Decisions in Zimbabwe

Funded by: National Institute of Mental Health

50

Why Circumcision: Ecological Studies

Caldwell

Strong potential impact

51

Three Clinical Trails

South Africa

Uganda Kenya

HIV incidence for MC group

0.85 (20) 0.66 (22) 2.1 (22)

HIV incidence for Control group

2.1 (49) 1.33 (45) 4.2 (47)

Percent protection (Intent-to-treat)

60% 51% 53%

As treated analysis

76% 60% 60%

Adverse Events 54 (3.8%) 178 (7.7%) 27 (1.7%)

Results

52

The Problem

• Consensus (WHO, UNAIDS) that MC be included in comprehensive HIV prevention programs where–HIV prevalence > 15%

–Heterosexual transmission

–Large proportion men (> 80%) not circumcised

• High prevalence countries are implementing MC programs

53

Scaling Up MC

Scaling up of MC to reach 80% of adult and newborn males in 14 African countries by 2015 would require:

• Almost 12 million MCs to be performed in the peak year, 2012 alone (206,000 done since 2008)

• Over 1.1 million MCs in Zimbabwe in peak year, 2012

– 4,583 MCs per day

– 150 to 200 doctors + nurse teams (each doing 30/day)

54

Operations Research Needed

• RCT study sites– Some success in scaling up

– Encountered barriers to MC adoption

- Kenya, Orange Farm

• Research is needed to:– Determine factors affecting

- MC uptake and adoption

– Investigate

- Environmental and policy implications

- Behavioral determinants

– Include all stakeholders / target groups

55

Overall Goals

• Identify and understand factors affecting motivation to adopt MC

• Seven main study groups:– Policy makers and stakeholders – who may promote MC

– Clinicians – who may recommend or perform MC

– Adolescent boys (13-17) – who may adopt MC

– Adult men (18-30) – who may adopt MC

– Women – who may impact men’s MC decisions

– Expectant parents – who may decide for infants re MC

– Parents of young boys (13-17) – who may decide for teen sons re MC

56

Self-Efficacy

Perceived Control

Personal Agency

Experiential Attitude

Instrumental Attitude

Attitude

Environmental Factors

Injunctive Norm

Descriptive Norm

Social Influence

Individual Factors

Behavioral Beliefs

Beliefs aboutOthers’ Expectations

Beliefs aboutOthers’ Behavior

Beliefs about Barriers and Facilitators

Efficacy Beliefs

Feelings about Behavior

Integrated Behavioral Model

Motivation or Intention to Perform the

Behavior

Capacity (knowledge and

skills) to Perform the behavior

Salience of the Behavior

Structural/Systems

Constraints

Socio-Cultural Factors

57

MC Behaviors Being Studied

Study Group Circumcision Behaviors

Policy-makers and Stakeholders -including traditional leaders and traditional healers

Promote or not promote male circumcision

Clinicians and health care workers

Recommend male circumcision to: - Parents of neonates - Parents of adolescent boys - Adolescent boys (aged 13-17) - Adult males (aged 18-30)Motivation for training regarding circumcision

Adolescent males aged 13-17 Getting circumcised

Males aged 18-30 Getting circumcised

Females aged 18-30 Encourage men to get circumcised

Parents of adolescent boys Have boy age 13-17 circumcised

Expectant parents Have neonate circumcised

58

O = MC sites

O Mutoko

O Bulawayo

O Matobo

59

Study Design

• Three main study phases, each including:– Data collection

– Analysis

– Each following from prior phase

• Integrated Behavioral Model guides all three phases

• Carried out in 4 sites:– Two urban (Harare, Bulawayo)

– Two rural (Mutoko, Matobo)

• Results will be provided to policy-makers– Throughout each phase

– At conclusion of each phase

60

Three Phases and Progress to Date• Qualitative Study

– Individual semi-structured interviews

– 320 interviews conducted with study groups

• Quantitative Survey– 7460 face-to-face interviews with study groups

– Interviews in process

• Message development and testing– Design messages targeting issues identified in survey

analysis

– Test MC message impact on small samples

– To be done after survey data shows us most important issues to focus messages on

61

Adolescents who may be targets of MC

Circumcision Center

Interviewing clinicians

Interviewing Adults and Parents

62

Operations Research will:Close the gap in uptake through:

Evidence-based message design

Evidence-based community mobilization

63

The Zichire Family Health Study

Psychosocial Support to HIV/AIDS Affected Children in Zimbabwe

Funded by: National Institute of Nursing Research

64

Percentage of distribution of deaths by age in southern Africa, Percentage of distribution of deaths by age in southern Africa, 1985–1990 and 2000–20051985–1990 and 2000–2005

0–4 5–19 20–29 30–39 40–49 50–59 60+

40

35

30

25

20

15

10

5

0

1985-1990 2000-2005

Percentage of total deaths

Age-groups:

Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat (2005). World Population Prospects: The 2004 Revision. Highlights. New York: United Nations. 4.2

Background

65

Impact of HIV• HIV rates are still high in Zimbabwe

– Approximately 1.4 million PLWHA (aged 15-49)

– Approximately 180,000 new infections a year

• Treatment is still fairly rare• About 35,000-40,000 individuals

on ART

• Mortality is high– Over 3,200 individuals die a

week

• Individuals, children and families are highly impacted

• Little research on psychosocial effects conducted in high prevalence countries

66

Family Health Study

• Why this Study?– Knowledge about HIV/AIDS high, infections continue, 1 in

5 individuals has HIV

– Some evidence that behavior change is occurring (2001 - 1 of 3 infected; 2005 – 1 of 5 infected)

– While behavior has changed somewhat, the reduction in prevalence of HIV is also due to mortality associated with infections maturing

– Mortality rates continue to be high

– Individuals, children and families are highly impacted, but little research on psychosocial effects is conducted in high prevalence countries

67

68

Meeting needs of Families living with HIV and AIDS

• Most interventions focused on meeting needs of orphans and vulnerable children, target basic needs

• Some teach skills such as home-based care

• Support groups for PLWHA exist

• Support groups for families do not

• Very few programs target the psycho-social needs of children or families who are living with the consequences of HIV, especially in SSA

69

AIDS the Endless Song of SorrowIn our heart is a song A voice that forever singsA cry for the pain it brings For in the world we are living Is full of sorrow AIDS the eternal song of sorrowChildren’s emotions despair To the serenity of lonelinessSo hurtful of our heartsDeprived of all the happinessFor a tear will forever be shedIn the pain of today and tomorrowTo the part that singsAIDS the endless song of sorrow

70

Project TALC Results• Research by Mary Jane Rotheram and colleagues

demonstrated that:

– HIV has a long term negative impact on adjustment of both parents and their adolescent children;

– Impact is intergenerational (is experienced by the offspring of the adolescents of parents living with HIV);

– A coping skills intervention can improve outcomes (4-year follow-up) for both parents and their adolescent children

– Has a positive impact (6 year follow-up) on the adolescent child’s offspring

• The team also established that among adolescents, young adults, and parents living with HIV about:

– 33%-50% maintain transmission acts,

– 33% do not take recommended medications, and

– 70% experience mental health problems

71

Project TALC Zimbabwe

• The primary goal in this project is to provide psychosocial support to children living with a parent who has HIV/AIDS

• We will do this by:– Implementing a Randomized Control Phase II

Community-based Trial to evaluate an intervention (Project TALC)

• Working in 4 residential areas (Harare, Bulawayo) with a cohort of at least 400 families where a parent has HIV/AIDS

72

Comparative Effectiveness Trial Design

Baseline 6 month

6 monthBaseline 12 month 24 month

12 month 24 month

Intervention

Coping Intervention

group

Capacity Intervention

group

73

Study Phases and Goals

• Census– To Identify families with 12-18 year olds

• Health Screening– To identify HIV + parents

• Baseline– To obtain pre-intervention measures

• Intervention implementation

• Follow-ups– 6-mo, 12-mo, 24 mo

– To assess impact of intervnetion

74Zichire Mobile Office: Starting the Health Assessment

75

Census Results• Housing Units identified: 9,442

• Housing Units enumerated: 8,256 (87%)

• Family Units enumerated: 14,205

- average families per HU: 1.7

- Average family size: 3.8

• Families with children (12-18 yrs) in residence identified: 5 972 (40%)

• Families with resident parent and biological child (12-18): 4,297

• 35% of children (12-18) do not live with biological parent

76

Approaching a housing unit

Results on site:

Getting ready:

Testing

Results

77

Health Screening Results• Harare and Bulawayo Health Screening

–6,570 adults eligible for Health Screening

–2,548 (39%) adults had Health Screening

–1,823 (72%) had blood draw for HIV test

–363 HIV positive

–234 (9%) self-reported HIV+- 34% males and 24% females reported HIV+ status

–20% individuals HIV positive

–32% had previously been tested

78

FHS Participant Accrual and Data Collection Flow DiagramADULTS

Not enumerated: 1,186

Housing Units: Total: 9,442

Enumeration: HU: 8,256

Families: 14,205

Families with 12-18 yo:5,972 (42%)

Families without 12-18 yo:8,233

Health Screening Eligible:6,570 Adults

Health Screening NO:3,534 Adults

Tested HIV POSITIVE: 363 Adults

Tested HIV NEGATIVE:1,447 Adults

Self-report HIV POSITIVE:218 Adults

HIV Positive Eligible Adults: 581

Health Screening YES: 3,036 Adults

HIV tested YES: 1,810

HIV tested NO:1,226 Adults

1,482 individuals Adults and 12-18 yo Children in families eligible for accrual into Baseline

NO HS, Volunteered HIV POSITIVE:48 Adults

79

Baseline Methods • Approached families identified via Census and

Health Screening• Explained we were in final phase of the study • Explained we identified them in the first phases of

the study• Confirmed that families have:

– At least one parent living at home – At least one child aged 12-18 living at home (not in

boarding school)• Explained that Baseline may make families

eligible for a program we were implementing in their neighborhood

• Scheduled Baseline Assessment with each parent• Recruited adolescent with parental permission

80

Baseline Recruitment and Assessment

81

Baseline• 1,482 individuals Adults and 12-18 yo Children in

families eligible for accrual (of this, n=38 were HIV- spouses)

• 1,007 individuals were interviewed

• One adult and one child aged 12-18 in family

• Measures: Adults– Demographics– Psychosocial: stress, depression, anxiety, family

functioning and communication, QOL, social support, HIV knowledge, disclosure of HIV status, coping with illness

– Parenting skills– Behavioral risks: substance use, sexual risk– Health: clinical assessment, treatment documentation

82

Measures – child level

• Demographics, including living situation

• Index of school involvement/success: – School attendance, grade level attained, performing at

grade level, academic grades,

– educational aspirations, truancy, suspensions/expulsions, behavioral problems at school

• Psychological symptoms of emotional distress

• Family interactions and communication

• Global self-esteem

• Sexual behavior

• Alcohol and substance use

83

Intervention• Implemented intervention in 4 residential areas,

among our families

• 717 individuals participated in our interventions– Adult HIV + parents (354), teen children (363)

– Half went through the ‘coping’, half through the ‘capacity’ intervention

• Adult Intervention: 14 sessions

• Adolescents’: 10 sessions

• Assessed psychosocial, behavioral and HIV endpoints at 6- and 12- and 24- month FUs

84

Baseline Results

• 431 parents assessed

–398 Index parents

–33 spouses

• 478 children assessed

• All assessments included:

–Health and symptom assessment (HSA)

–Psychosocial assessment (PSA)

85

Parent sample

• Mostly female (83%)

• Mean age 41 years

• Mean of 3.6 children

• 98% attended school

• 90% go to church or place of worship

• Importance of religion

• 91% Very important

• 8% Somewhat important

• 1% Not important at all

86

Health

• General Health

• Satisfaction with Health

PARENTS Poor Fair Good Very Good

Excellent

% 13 34 20 7 26

PARENTS

Very Dissatisfied

Dissatis-fied

Neither Satisfied Very Satisfied

% 14 25 5 36 20

87

Use of Health Care: Last 6 months

• 1.3 (mean) visits to a doctor or other health care worker

• 67% had no visits to a doctor or other health care worker

• 1% saw a traditional healer

• 2.3 (mean) visits to a health clinic

88

Sexual Practices and Sexual History

• 24% of men and 49% of women had no sexual partner in the past year

• 63% men and 48% women had one partner

• 7% men and 1% women had 2 partners,

• 6% men and 2% women had 3+ partners

• 63% of men and 47% of women reported using a condom at last sex

89

Shona Symptom Scale (11 items) (α=.88)

Symptoms % Yes

Thinking deeply/thinking about many things 52

Lose temper or get annoyed over trivial things 23

Nightmares or bad dreams 28

Stomach was aching 34

Run down and tired 42

Generally unhappy 36

Moments life was so hard, felt like crying, or cried

38

90

General Health Quest (12 items) (α=.94)Items Below Scaled: 1=much more than usual; 2=little more than usual; 3=no more than

usual; 4=not at all

Item Mean

Lost sleep over worry 3.23

Constantly felt under strain 3.31

Felt couldn’t overcome difficulties 3.30

Been feeling unhappy and depressed 3.24

Thinking yourself as a worthless person 3.47

Items Below Scaled: 1=much less than usual; 2=less than usual; 3=same as usual; 4=more so than usual

Item Mean

Felt playing a useful part 2.82

Able to enjoy normal day-to-day activities 2.80

Able to face up to problems 2.79

Feeling reasonably happy, all things considered 2.79

Been able to concentrate on what you are doing 2.80

91

Disclosure

Disclosure of HIV results to at least one person is: 87%

• sister (35%) or daughter (30%)

• spouse (29%)

• mother (21%) or father (8%)

• brother (19%) or son (23%)

• best female friend (15%) or best male friend (8%)

• aunt (8%)

• ministers (3%)

92

How did your family react to results?

• They: – were supportive after hearing you had HIV (98%)

– wanted to make sure you are all right (96%)

– said it was your partner’s fault that you had HIV (31%)

– said your partner is a bad person (26%)

– asked if you or your partner had had sex with others (19%)

– said it was your fault you had HIV (7%)

– said you are a bad person (3%)

93

Family Relationships and InteractionsParents report overall good relationships

with their children age 12-18 years97% of mothers and 94% of fathers report good

relationships with all of their teenage childrenTalk about: Mothers Fathers

Delay of sex 81% 72%

Abstinence/avoiding sex 82% 72%

Boy/girlfriend relationships 75% 66%

Sex and sexuality 58% 54%

Condom use 35% 39%

HIV/AIDS 79% 70%

94

Children’s Demographics• Mean age: 14.9

• 51% males

• 90% live with mother; 40% live with father

• 83% in school; –96% 12-15 year olds; 57% 16-19 year olds

• 92% go to church, mosque, or other place of worship

• 96% learned about HIV and AIDS in school

95

Family Relationships and Interactions

Children report overall good relationships with family members, esp. mothers– 97% of teens report good relationships with mother

– 83% of teens report good relationships with fatherTalk about: Mothers Fathers

Delay of sex 83% 30%

Abstinence/avoiding sex 63% 29%

Boy/girlfriend relationships 50% 30%

Sex and sexuality 38% 15%

Condom use 25% 12%

HIV/AIDS 68% 34%

96

Children’s Measures• Youth Risk Behavioral Surveillance System

(YRBSS)– Assessed risk

• Shona Symptom Scale (11 items)– α = .70

• General Health Questionnaire (12 Items)– Assesses stress, anxiety, depression

– α = .85

• Edinburg Depression Scale (12 items)– α = .84

97

Children’s Risk Behaviors

• 19% have boy/girlfriend

• 7% (22) had sex (age range 14-20)• 90% who had sex were 16-18 years old

• 4 had forced sex

• Sexual activity in last 3 months• 5 teens, with 1 partner each

• 53% used a condom at last sex

• Less than 10% have tried alcohol, cigarettes, or other substances (marijuana, glue sniffing)

98

Shona Symptom Scale (11 items)

Symptoms % Yes

Thinking deeply/thinking about many things 17

Lose temper or get annoyed over trivial things 15

Nightmares or bad dreams 13

Stomach was aching 26

Run down and tired 17

Generally unhappy 13

Moments life was so hard, felt like crying, or cried

12

99

General Health Questionnaire (12 items)

Item Mean

Lost sleep over worry 3.82

Constantly felt under strain 3.83

Felt couldn’t overcome difficulties 3.83

Been feeling unhappy and depressed 3.76

Thinking yourself as a worthless person 3.85

Item Mean

Felt playing a useful part 3.00

Able to enjoy normal day-to-day activities 3.00

Able to face up to problems 2.94

Feeling reasonably happy, all things considered 2.98

Been able to concentrate on what you are doing 2.97

Items Below Scaled: 1=much more than usual; 2=little more than usual; 3=no more than usual; 4=not at all

Items Below Scaled: 1=much less than usual; 2=less than usual; 3=same as usual; 4=more so than usual

100

School Issues• 83% are in school

• 32% have been bullied, intimidated or pushed around– About two thirds 1 or 2 times

• 16% have been in a physical fight– 70% once

• 52% have had property stolen or damaged– About three quarters between 1-3 times

• Felt so sad and hopeless in past year, stopped usual activities– 7%

101

Conclusions• Research shows teens can be vulnerable to negative

effects if parents have HIV/AIDS• These teens in Zimbabwe are not exhibiting high risk

behavior, high stress• Many may not be aware of parental HIV; but two thirds

of coping arm teens went through the teens “Aware of parental status” intervention

• School tribulations may be a sign of difficulty• Teens are picked on at fairly high rates• Unfortunately, we don’t know if this is due to living with

a parent with HIV, or if this is normative in Zimbabwe• Research among teens in schools to establish

normative numbers for risk is needed

102

Explanations

• School may be protective• Other research from Zimbabwe confirms that

teens in school have low risk behavior on average

• Targeting teens in schools with efficacious evidence-based HIV prevention programs may be important

• Parenting is protective; most teens lived with mothers, and had good relationships with mothers

103

Explanations

• These children are used to hardship, given what they have been growing up with

• Zimbabwean culture is protective of children– Not discussing problems so as to not burden children

• Zimbabwean culture also has family solidarity values– One does not discuss problems outside the family

104

HIV Research in Zimbabwe: Future Directions

• Family Health Study continued among grandparents who end up fostering AIDS orphans

• HIV prevention targeting youth 13-19 • Neuro-cognitive effects of HIV acute infection• Other Sexually transmitted diseases (STI etiology study)

– Herpes, Syphilis, Human Papillomavirus (HPV)

• Male circumcision device testing• Prevention with Positives• Monitoring and evaluation of public health programs and

approaches• Continued capacity building

– STI Annual Workshop

105

Zimbabwe

Victoria Falls – “the smoke that thunders”

106

Zimbabwe

Great ZimbabweBuilt 1100 – 1400

107

Zimbabwe

108

ACKNOWLEDGEMENTSFunded by: NIMH, NINR, NIAAA - Battelle Team: Terry Johnson, Bill Grady, Ed Liebow, Hunter Handsfield, Lisa Cubbins, April

Greek, Diana Echeverria, Kasia Alderman, Gary Chovnick, Carolina Mejia, Susan Hauth, Kate Blessing, Burk Dowell, Peter Klein

- ZiCHIRe Team: Mufuta Tshimanga, MD, MPH, director Zichire Godfrey Woelk, PhD (Site PI CPOL intervention) Sally-Nyandiya Bundy (Site PI FHS intervention) Tinashe Muromo, BSc (Hon), MPhil., PhC Rachel Gatsi, Office Manager Philani Moyo and Ethnography Team Reggie Mutsindiri and Nurses Team Patrick Mateta, Luanne Rodgers and Lab Team Walter Chikanya and Intervention Team Pesenai Chatikobo and Process Evaluation Team Gay Hendrikse, Admin Staff, Transcription Team, Security Team Gift Mutepfe and Driving Team

- All Study Participants