Community resistance to a peer education programme in Zimbabwe.

BACKGROUND: This paper presents community perceptions of a state-of-the-art peer education programme in Manicaland, Zimbabwe. While the intervention succeeded in increasing HIV knowledge among men and condom acceptability among women, and reduced HIV incidence and rates of unprotected sex among men who attended education events, it did not succeed in reducing population-level HIV incidence. To understand the possible reasons for this disappointing result, we conducted a qualitative study of local perspectives of the intervention. METHODS: Eight focus group discussions and 11 interviews with 81 community members and local project staff were conducted. Transcripts were interrogated and analysed thematically. RESULTS: We identified three factors that may have contributed to the programme's disappointing outcomes: (1) difficulties of implementing all elements of the programme, particularly the proposed income generation component in the wider context of economic strain; (2) a moralistic approach to commercial sex work by programme staff; and (3) limitations in the programme's ability to engage with social realities facing community members. CONCLUSIONS: We conclude that externally-imposed programmes that present new information without adequately engaging with local realities and constraints on action can be met by resistance to change.

Social capital and HIV competent communities: the role of community groups in managing HIV/AIDS in rural Zimbabwe.

Community involvement is increasingly identified as a "critical enabler" of an effective HIV/AIDS response. We explore pathways between community participation and HIV prevention, treatment and impact mitigation in Zimbabwe, reviewing six qualitative studies in Manicaland. These find that community group membership is often (not always) associated with decreased HIV incidence, reduced stigma and improved access to some services, particularly amongst women. Participation in formal community groups (e.g., church or women's groups) and informal local networks (e.g., neighbours, families) provides opportunities for critical dialogue about HIV/AIDS, often facilitating renegotiation of harmful social norms, sharing of previously hidden personal experiences of HIV/AIDS, formulation of positive action plans and solidarity to action them. However, implementation of new plans and insights is constrained by poverty, social uncertainty and poor service delivery. Furthermore, dialogue may have negative effects, spreading false information and entrenching negative norms. The extent that formal groups and informal networks facilitate externally imposed HIV/AIDS interventions varies. They potentially provide vital practical and emotional support, facilitating service access, treatment adherence and AIDS care. However, they may sometimes play a negative role in prevention activities, challenging stereotypes about sexuality or gender. There is an urgent need for greater recognition of the role of indigenous community groups and networks, and the inclusion of "strengthening local responses" as a key element of interventions and policy. Such efforts require great sensitivity. Heavy-handed external interference in complex indigenous relationships risks undermining the localism and bottom-up initiative and activism that might be central to their effectiveness. Cautious efforts might seek to enhance the potentially beneficial effects of groups, especially for women, and limit potentially damaging ones, especially for men. Efforts should be made to facilitate contexts that enable groups to have beneficial effects, through nesting them within wider comprehensive responses, and supporting them through strong partnerships with service providers.

The role of community conversations in facilitating local HIV competence: case study from rural Zimbabwe.

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.

Obstacles to local-level AIDS competence in rural Zimbabwe: putting HIV prevention in context.

We explore the wider social context of an HIV-prevention programme in rural Zimbabwe. We make no comment on the programme itself, rather seeking to examine the wider community dynamics into which it was inserted, to highlight how pre-existing social dynamics may have influenced community "readiness" to derive optimal benefit from the intervention. Using the concept of "the AIDS competent community", we analysed 44 interviews and 11 focus groups with local people. Despite high levels of HIV/AIDS-related knowledge, there were several ways gender, poverty and low literacy may have undermined its perceived relevance to peoples' lives. Lack of opportunities for dialogue in the social milieu beyond the intervention may have limited opportunities for translating factual AIDS knowledge into action plans, or sharing hidden individual experiences of HIV/AIDS-affected family members or friends, given stigma and denial. The initiative of women and young people to respond effectively to AIDS was limited in a context dominated by adult males. People spoke of HIV/AIDS in a passive and fatalistic way, expecting outsiders to solve the problem. This tendency was exacerbated given the community's previous experiences of HIV/AIDS-related NGOs, which had often regarded local people as unpaid volunteer labour rather than building their capacity to make significant decisions and play leadership roles in health programmes. Despite obstacles, however, there were many potential community strengths and resources. There were high levels of HIV/AIDS-related knowledge. Public denial of HIV/AIDS masked huge reservoirs of private support and kindness to AIDS-affected family and friends. There were many strong community organisations and clubs, potentially forming the springboard for more empowered community responses to HIV/AIDS. HIV/AIDS programmers should pay greater attention to community readiness for interventions, especially around: (1) identifying and anticipating pre-existing obstacles to programme success and (2) mobilising the social assets that exist, even in contexts of poverty and gender inequality.

Social capital and women's reduced vulnerability to HIV infection in rural Zimbabwe.

Social capital­especially through its "network" dimension (high levels of participation in local community groups)­is thought to be an important determinant of health in many contexts. We investigate its effect on HIV prevention, using prospective data from a general population cohort in eastern Zimbabwe spanning a period of extensive behavior change (1998­2003). Almost half of the initially uninfected women interviewed were members of at least one community group. In an analysis of 88 communities, individuals with higher levels of community group participation had lower incidence of new HIV infections and more of them had adopted safer behaviors, although these effects were largely accounted for by differences in socio-demographic composition. Individual women in community groups had lower HIV incidence and more extensive behavior change, even after controlling for confounding factors. Community group membership was not associated with lower HIV incidence in men, possibly refecting a propensity among men to participate in groups that allow them to develop and demonstrate their masculine identities­often at the expense of their health. Support for women's community groups could be an effective HIV prevention strategy in countries with large-scale HIV epidemics.