According to Kalichman, “nothing can account for AIDS in Africa other than a heterosexual HIV epidemic” (2009, p.83). Heterosexual transmission is prevalent in sub-Saharan Africa, hence the phrase ‘heterosexual epidemic’ (Bailey et al., 2001; NAC, 2011). A high prevalence of intergenerational sex has been found to be a key driver in this epidemic (Chikovore, Nystrom, Lindmark, & Ahlberg, 2009; Jackson, 2002). Research has demonstrated that age- disparate sexual liaisons increase young female adolescents’ vulnerability to HIV incidence (Abdool Karim, 2016), and importantly these young females continue to have relationships with boys of their age, thereby expanding the sex networks. Zimbabwe has been characterised by a harsh socio-economic and political atmosphere since 2000, resulting in an increase in transactional sex (Duri et al., 2013). As such, an increase in transaction and largely intergenerational sex was a pragmatic response to the unfavourable material conditions precipitated by the deteriorating economic atmosphere (Chikovore et al., 2009).
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The chapter provides a contextual overview of the country’s diverse responses to the HIV epidemic by reflecting on the general socio-economic and political context within which the epidemic evolved. It illuminates on key policies and programmes that guided the Government of Zimbabwe (GoZ hereafter) and other stakeholders such as local and foreign non-governmental organisations (LoNGOs and FoNGOs) in their concerted efforts to stem the epidemic. Furthermore, the conceptual framework informing the study is presented at the end of the chapter.
Certain specific factors make some population segments more vulnerable than others (Dutta, 2008). On a global scale, youth carry a huge burden of HIV infection annually and this is estimated at around 39% (Pettifor et al., 2015). According to Idele and colleagues (2014), owing to their age, social and economic status, adolescents (particularly those in developing countries) experience limited access to information and other important health resources. This obviously increases their susceptibility and vulnerability to HIV incidence. Research suggests that globally, adolescence is the sole age group that is experiencing a double burden of increasing HIV incidence and HIV related mortality (Bekker et al., 2015). As such, in-school adolescents in sub-Saharan Africa are designated as a key population for HIV prevention interventions (Abdool Karim et al., 2014). Without exception, Zimbabwean adolescents are equally vulnerable to HIV/AIDS (Nleya & Langa, 2014).
Research has shown that results for adolescent HIV prevention interventions targeting individual behaviour change have little or no impact on HIV incidence (Johnson, 2002). This has led to investing hope in those interventions seeking to address structural drivers of the epidemic (Bekker et al., 2015). Therefore, since this study focuses on preventing behaviourally transmitted HIV that is acquired through high-risk behaviours including unprotected sex (Lall et al., 2015), it may be argued that scaling up VMMC for HIV prevention and increasing condom access is one such strategy Zimbabwe’s youth urgently need.
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Bhana (2007) has argued that among the diversity of strategies to combat HIV, preventing new infections among those with increased vulnerability is critical. As indicated earlier that in-school adolescents are among young key populations (YKP), such an approach may pay significant dividends. Zimbabwe’s policy environment is squarely focused on abstinence as the sole answer to adolescence sexual and reproductive health (ASRH hereafter) challenges (Muparamoto & Chigwenya, 2009). This is unsustainable because sexual release does not occur only through will power (Johnson, 2002). Furthermore, research has shown that
“the vows of abstinence break far more easily than latex condoms” (Elders, 1999, p.14;
Johnson, 2002).
Risky sexual behaviour is widespread among the youth (Bekker et al., 2015; Tanser et al., 2013). This often culminates into STIs including HIV, unplanned teenage pregnancy, and adolescent maternal mortality (Guttmacher Institute, 2014). Often, young adults are ill- prepared for open communication with their sexual partners, hence early sexual encounters are mostly unplanned and unprotected (Lear, 1997). In Zimbabwe, efforts to stop an upsurge of maternal mortality among adolescents have recently prompted the government to consider providing pupils with hormonal contraceptives (The Herald, 2015). It is envisaged that contraceptive pills will mitigate the challenge of unplanned teenage pregnancies and the attendant negative health outcomes such as maternal mortality. However, this trajectory is severely criticised for failing to consider the need for prevention technologies that serve the dual purpose of preventing pregnancy and decreasing HIV incidence (Shumba, 2015).
The provision of contraceptives to in-school youth is important to reducing unplanned pregnancies thus key to sustainable human development (SHD). However, the strategy blatantly flies in the face of logic. It is critical to highlight that condoms are the sole contraceptive method with the potential to protect against both unintended pregnancy and HIV, among other STIs (Guttmacher Institute, 2014). Therefore, there is merit in arguing that barrier
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contraceptives such as the condom (both male and female), and other contraceptive methods controlled by women, that have proven to offer protection against STIs should be used (Baxter
& Abdool, 2016).
Research has shown that contraceptive use is often higher among sexually active young people with a background of sex education. However, sex education in Zimbabwe is in crisis, with little consensus on quality and content of the curricular (Jackson, 2002; Chikovore et al., 2009). In most cases, ASRH matters are woefully relegated to the margins of the curricular or they are non-existent at all. In Zimbabwe, school-based sex education is nothing more than mere rhetoric, not closer to being responsive to the pertinent and practical questions pertaining to adolescence, and despite glaring evidence of utter failure, abstinence remains a refrain, a dull normative chorus that does not appeal to most of the young people (Shumba, 2015).
Against this backdrop, the current VMMC programme for HIV prevention among in-school adolescents may have little impact on mitigating HIV incidence among this group of young key populations. Best practice recommends that VMMC should be accompanied by clear and consistent messages to avoid offsetting the benefits of partial protection conferred on those who are circumcised medically (Hankins, 2007).