DRIVERS OF THE HIV EPIDEMICS IN THE CAPRIVI REGION, NAMIBIA AGNES MWILIMA NAMIBIA 45th International Course in Health Development September 22, 2008 œ September 11, 2009 KIT (ROYAL TROPICAL INSTITUTE) Development Policy & Practice/ Vrije Universiteit Amsterdam A thesis submitted in partial fulfillment of the requirement for the degree of Master of Public Health By Agnes Mwilima Namibia Declaration: Where other people‘s work has been used (either from a printed source, internet or any other source) this has been carefully acknowledged and referenced in accordance with departmental requirements. The thesis Drivers of the HIV Epidemics in the Caprivi Region, Namibia is my own work. Signature:…………………………………………… 45th International Course in Health Development (ICHD) September 22, 2008 œ September 11, 2009 KIT (Royal Tropical Institute)/ Vrije Universiteit Amsterdam Amsterdam, The Netherlands September 2009 Organized by: KIT (Royal Tropical Institute), Development Policy & Practice Amsterdam, The Netherlands In co-operation with: Vrije Universiteit Amsterdam/ Free University of Amsterdam (VU) Amsterdam, The Netherlands Table of Contents able of Contents................................................................................. i List of Tables, figures and graphs ......................................................... iii Acknowledgement .............................................................................. iv List of abbreviations ............................................................................ v Glossary ...........................................................................................vii Executive Summary...........................................................................viii Introduction ...................................................................................... ix CHAPTER 1....................................................................................... 1 1.1 Background of Namibia ................................................................ 1 1.2 The Caprivi Region ...................................................................... 2 CHAPTER 2 ....................................................................................... 4 2.1 Statement of the problem ............................................................ 4 2.2 Justification................................................................................ 5 2.3 Limitations ................................................................................. 6 2.4 Aim and Objectives ..................................................................... 6 2.4.1 General Objectives................................................................. 6 2.4.2 Specific Objectives ................................................................. 6 2.5 Methods..................................................................................... 6 2.5.1 Search Strategy..................................................................... 6 2.5.2 Inclusion Criteria ................................................................... 7 2.5.3 Process for reviewing articles................................................... 7 2.5.4 Table 1 Outcome of the reviewing process................................. 7 CHAPTER 3: Findings........................................................................ 8 3.1 Figure 1, Conceptual framework.................................................... 8 3.2 Analysis of the drivers of the HIV epidemic and their contribution to (HIV) infection in Caprivi. .................................................................. 9 3.2.1 Personal Factors .................................................................... 9 3.2.2 Proximal factors................................................................... 15 E.2.3 Distal Factors ...................................................................... 20 CHAPTER 4 Responses for prevention............................................. 33 4.1 Present responses and gaps in the responses ................................ 33 4.2 Other gaps in addressing the drivers............................................ 36 CHAPTER 5: DISCUSSION............................................................... 37 5.1 Personal factors ........................................................................ 37 5.2 Proximal factors ........................................................................ 38 5.3 Distal factors ............................................................................ 39 5.4 Interrelation between factors ...................................................... 41 5.5 Responses for Prevention ........................................................... 41 CHAPTER 6: Conclusions and Recommendations............................. 42 6.1 Conclusions .............................................................................. 42 6.2 Recommendations..................................................................... 42 6.2.1 Policy recommendations ....................................................... 42 6.2.2 Research recommendations................................................... 43 6.2.3 Intervention recommendations .............................................. 43 REFERENCES.................................................................................. 45 Appendices.................................................................................... 51 Appendix 1: Map of the Caprivi......................................................... 51 Appendix 2: Map of Namibia ............................................................ 52 Appendix 3: Wildfire Simulation Technique ......................................... 53 Appendix 4: Occupational Risk.......................................................... 65 Appendix 5: HIV prevalence in Districts ............................................. 67 Appendix 6: National testing day results ............................................ 69 Appendix 7: Number of public sector male and female condoms distributed to the region April 2006 œ March 2007............................................... 70 List of Tables, figures and graphs Tables able 1 Outcome of the literature reviewing process ........................ 7 Table 2 Percentage of men aged 15-49 who paid for sex in the last 12 months ................................................................ 28 Figures Figure 1 Conceptual framework...................................................... 8 Graphs Graph 1 Trend of HIV prevalence in Caprivi region and Namibia ......... 4 Graph 2 Multiple concurrent sexual partnership in selected regions in Namibia ........................................................... 13 Graph 3 Comparison of circumcision rates and HIV prevalence in some regions in Namibia ............................................... 24 Graph 4 HIV prevalence rate by urban/rural residence and age groups ..................................................................... 27 Acknowledgement I wish to extend my gratitude to the Ministry of Health and Social Services, in particular the Division of Special Programs and the Caprivi Regional Health Management team, for according me the opportunity to pursue this course. Sincere gratitude to the ICHD course management, thesis advisor, back stopper and Secretariat for their support during the course, and throughout the process of thesis writing. Much appreciation to all my course mates and my workmates for technical and moral support rendered during the course. Finally, my special thanks go to my family for the encouragement and support. List of abbreviations AHFS Adolescent Health Friendly Services AIDS Acquired Immunodeficiency Syndrome CACOC Constituency AIDS Coordination Committee CDC Centre for Disease Control COMBI Communication for Behavioural Change Interventions HAART Highly Active Antiretroviral Treatment HIV Human Immunodeficiency Syndrome IEC Information Education & Communication KAP Knowledge, Attitudes and Practice MDGs Millennium Development Goals MET Ministry of Education and Technology MFMC My Future is My Choice MIB Ministry of Information and Broadcasting MTP Medium Term Plan MOHSS Ministry of Health and Social Services NANASO Namibian Network of AIDS Service Organisation NASOMA Namibia Social Marketing Association NDHS Namibia Demographic and Health Survey NDP National Development Plan NPC National Planning Commission NYC National Youth Council PLHIV People Living with HIV PMTCT Prevention of Mother to Child Transmission RACOC Regional AIDS Coordination Committee RSV Regional Support Visit SIAPAC Social Impact Assessment & Policy Analysis Cooperation SMA Social Marketing Association STIs Sexually Transmitted Infections SW Sex worker TB Tuberculosis TCE Total Control of the Epidemic UNAIDS Joint United Nations Programme on HIV/AIDS VCT Voluntary Counselling and Testing VSO Volunteer Services Oversee WHO World Health Organisation Glossary Gini Coefficient Measures equity of wealth distribution among socioeconomic classes (NPC, 2004a) Drivers of HIV Structural and social factors that are not easily measured that increases people‘s risk and vulnerability to HIV infection (UNAIDS, 2008) Vulnerability The social context that affects an individual‘s ability to protect her/his self from HIV infection (KIT, 2009 Basic HIV Module) Susceptibility The probability of someone will contract HIV ( KIT, 2009 Basic HIV module) Structural factors Are physical, social, cultural, organizational, community, economic, legal or policy aspect of the environment that impede or facilitate