Region focus: Africa

Country focus: Zimbabwe. Gray map of Africa with Zimbabwe highlighted in green.
61 percent of Zimbabweans are 25 years old or younger, which means that they are entering the age when they are most at risk of infection.

Geoff Garnett

The data
Three future scenarios for Zimbabwe’s HIV epidemic

Geoff Garnett

Deputy Director, HIV, Bill & Melinda Gates Foundation
Among the tragedies of HIV is that it strikes in the prime of life, when young people should be completing their education, starting businesses, raising families, and building strong communities. At the height of the HIV epidemic in Zimbabwe, in 1997, an estimated one in four adults was infected. HIV devastated Zimbabwe.
Chart showing the projected decrease in new cases of HIV (from 2017 to 2050) if things stay the same, if current prevention tools are scaled up, and if new prevention tools are introduced.

Since then, however, Zimbabwe’s government and civil society, with the support of international donors, have demonstrated a remarkable commitment to preventing and treating the disease. Since 2010, new HIV infections are down by 49 percent, and AIDS-related deaths are down by 45 percent.

The challenge is to build on this success, because with 61 percent of Zimbabweans under 25 years old, more than half the population is entering the age when they are most at risk for infection. The youth boom has the potential to drive economic growth in Zimbabwe, but only if these young peole are healthy, educated, and economically active. That will not happen if another generation is decimated by the HIV epidemic.

We asked a team from Imperial College London to consider what Zimbabwe’s HIV epidemic, and therefore Zimbabwe’s future, might look like in 2050, by analyzing three alternative scenarios.

The model includes three sets of interventions:

  • Treatment: Antiretroviral therapy can be effective, but it depends on three key metrics that go together. Are people aware of their HIV status? If they are aware, are they on treatment? If they are on treatment, are they adhering to that treatment so that the virus is suppressed in their bodies?
  • Currently available prevention methods: This includes condoms; voluntary medical male circumcision (VMMC), which decreases men’s risk of acquiring HIV; and pre-exposure prophylaxis (PrEP), which involves drug treatment for people in high-risk populations, such as sex workers.
  • Prevention methods that may be available in the medium and long term : This includes long-acting PrEP and a 70 percent effective vaccine.

SCENARIO #1: The black line
Status quo of treatment and prevention 1
Zimbabwe’s current efforts are impressive. If they are sustained, the number of new infections will continue to decline. However, this decline will be gradual, and there will still be almost 16,000 new infections each year by 2050.

SCENARIO #2: The green line
Further scale-up of current prevention tools
The curve would bend sharply if Zimbabwe further scaled up currently available prevention tools over the next five years. New infections would drop by another third within a decade and to roughly 5,000 in 2050, a significant improvement over the status quo scenario. This scenario uses optimistic but reasonable assumptions for short-term scale-up, based on past trends and coverage levels in nearby countries.

There are two important caveats with this scenario. First, despite the rapid decline in new infections, the virus would remain widely present in 2050, threatening resurgence. More importantly, it would be nearly impossible to sustain this combination of treatment and prevention at such high levels of coverage for 30 years.

SCENARIO #3: The orange line
Scale-up plus new prevention tools
This is where long-acting PrEP and a vaccine could come in. We’re confident that long-acting PrEP, which is not only longer acting but more effective than current PrEP, will be introduced soon. The model assumes 2024. The model also assumes a vaccine by 2030. That’s more optimistic, but it’s why the world (and the Bill & Melinda Gates Foundation) are investing so much in R & D. If we succeed in introducing these tools, the number of infections would tumble. Long-acting PrEP and especially a vaccine would also be much easier for a stretched health system to deliver at scale.

In spite of political and economic disruptions, Zimbabwe has done an exemplary job of controlling HIV. However, this modeling exercise shows that redoubled efforts can make a big difference. It’s reasonable to forecast an epidemic that would still sap the strength of Zimbabwean society. It’s also reasonable to forecast an epidemic that is firmly under control.

It depends on Zimbabwe’s continued commitment to ending its HIV crisis. In addition to continuing to invest, Zimbabwe must innovate to reach those most at risk with tools that work for them. Zimbabwe has just agreed to be one of the leaders of the Global HIV Prevention Coalition, so indications are positive.

Progress also depends on the world’s continued commitment to R & D. A strong pipeline of new and better products, and eventually a vaccine, will ensure that countries like Zimbabwe can succeed.

The story
Stigma & the sisterhood

Busani Bafana

Storyteller and journalist based in Zimbabwe
Across Africa, female sex workers’ odds of having HIV are estimated to be 11 times higher than those of women in the general population. In Zimbabwe, a growing number of sex workers are learning how to protect themselves.

I am lost in a packed Oportunistic Infections health center. Hundreds of eyes are glued on me, seemingly questioning the object of my visit. I am not a regular here.

In a panic, I hurry down a long corridor to an unmarked open door and ask for Bathabile Nyathi. “Oh,” says a kind nurse, reading the confusion on my face, “you mean Sisters.” She points me to a staircase.

At the bottom of the stairs, I find 27-year-old Bathabile at her desk in the neat, airy Sisters with a Voice clinic. Prim in a white dress, her shiny locks neatly tied back, she looks every inch an administrator, a teacher, even a banker. She has a welcoming grin and a firm handshake. As she begins to talk, I chide myself for my prejudice. What had I expected a sex worker to look like?

Members of the Women Against All Discrimination performance group conduct an edutainment session. (Bulawayo, Zimbabwe)

According to Zimbabwe’s National AIDS Council, thanks to a combination of targeted awareness campaigns, higher rates of condom use, more comprehensive testing, and antiretroviral therapy, Zimbabwe’s HIV rate has been halved from a peak 28 percent in 1997. Nevertheless, more than 30,000 Zimbabweans die of AIDS-related causes annually, and 1.3 million are living with HIV.

What’s more, female sex workers’ odds of having HIV are estimated to be 11 times higher than those of women in the general population, and modeling suggests that across Africa, 40 percent of new infections are likely attributable to unsafe sex work. Despite these risks, sex work is a source of employment for more than 45,000 women in Zimbabwe. Many of them are adolescents and young women—a group already experiencing a rise in HIV prevalence—pushed into the trade by growing poverty and pulled by a ready market.

The attitude at Sisters is a shift from the norm: here, sex workers are number-one customers

Busani Bafana

Storyteller and journalist based in Zimbabwe

But as Bathabile explains, most health institutions in Zimbabwe do not welcome sex workers seeking clinical services. Instead, she says, doctors and nurses judge their young patients, accusing them of “spreading HIV and AIDS.”

Bathabile knows this firsthand. In 2006, at 16 years old, she rushed to the hospital in her home area of Gwanda, 126 kilometers south east of Bulawayo, Zimbabwe’s second major city. The reason: a debilitating sexually transmitted illness.

“I was undressed and questioned as to where I got the illness and was told I would be treated once I brought along the person who had infected me,” Bathabile tells me. “My ulcer was the point of discussion among the nurses, and I could not explain that I was a sex worker; worse, when the nurses found out I had a child, they had more questions but still would not treat me.”

Eventually, she tells me, she found Sisters with a Voice, which was founded in 2009 by Zimbabwe’s Centre for Sexual Health, HIV and Aids Research (CeSHHAR). The attitude of program and support staff at the Sisters clinic is a shift from the norm: Here, sex workers are the number-one customers.

Bathabile appreciated this open-door approach. “I confessed to having unprotected sex, I was on drugs and a heavy drinker, but Sisters Clinic did not judge me,” she said. “They welcomed me like family. Through counseling and the information they shared about practicing and negotiating safe sex, I realized sex work can be done safely. I have not had an STI since then.” She is still doing sex work—but always safely.

Since then, Nyathi has taken the crusade for sex workers’ rights across the globe. She is the founder and chairperson of Women Against All Forms of Discrimination, an advocacy association formed two years ago.

Two women standing outside and talking.

An outreach worker visits a sex worker at her home. (Mbare, Zimbabwe)

“Sex work is an option, bridge, and an easy way to get by. Sex work does not require an ID, birth certificate, or qualifications,” Bathabile says. “Women are stigmatized for selling sex but no one understands why they have resorted to selling sex in the first place.”

Bathabile also leads an “edutainment” group whose performances educate communities about sex work “so we are not stigmatized and discriminated against but supported and cared for like anyone else,” she says. I watch her group perform a song with complicated lyrics:

I met new friends, to me they were good, only to discover later that they were nothing but bad news
They talked about money, men, smart phones and ipads
There I was l didn’t know what an ipad was I only knew sanitary pads
They talked about leggings stilettoes, there I was wearing my torn dress and shoes I could easy count my toes
Pizzas, fruit juice that was their lunch, my only choice was coke and plain bun or nothing
They laughed at me and mocked at me and said I am a fool
Then angels came into my life, sugar daddies
They said they deserve a lot, they said I am beautiful, I am sexy. I am unique
Then I realized that I should use what I have to get what I wanted
Selling sex became my weapon to fight my poverty
My only tool to solve my problems….

As Bathabile’s song makes clear, shifting the narrative around sex work in Zimbabwe is no easy task. Fortunately, she’s not the only one doing it.

In 2014, in partnership with CeSHHAR, sex workers founded the Determined Resilient Empowered AIDS-free Mentored and Safe (DREAMS) project, an advocacy group focusing only on young women selling sex—that is, young women who have sex with older men, often called “sugar daddies.” (By contrast, the Sisters clinics serve sex workers of all kinds.)

“While the HIV programs in Zimbabwe have focused on clinical services, our program looks at the wellbeing of the individual and not just the treatment of HIV,” says DREAMS project coordinator Rumbidzai Mapfumo Makandwa. Adolescent girls and young women who participate in the DREAMS program get a package of services, including HIV prevention, testing, counseling services, gender-based–violence counseling, family planning, and social protection. The program also provides socioeconomic empowerment interventions, including transport vouchers and grants.

A woman relaxing on her couch and smiling at the camera.

Bathabile relaxes at home. (Bulawayo, Zimbabwe)

“Our mandate is ensuring sex workers are safe and healthy,” says Makandwa, “because if they are safe, everyone is safe. Who are their clients? Our sons, brothers, fathers, and husbands.”

Makandwa, a social worker, says the secret to the success of the program is its ownership by sex workers. “We have sex-worker peer educator and outreach workers. We have sex-worker interns who are attached to the program for three months. They own the program, making it easier to sell to other sex workers.”

During the first year of the DREAMS program, one third of the sex workers who participated were referred for pre-exposure prophylaxis (PrEP), an HIV prevention method, and 97 percent of those who tested positive for HIV were successfully referred for treatment. Initial results of CeSHHAR’s impact evaluation suggest that sex workers who participated know more about HIV than before and that more are practicing safe sex.

Negotiating safe sex has been a key weapon in the sex workers’ arsenal, according to Juliet Makondora, an outreach worker at CeSHHAR office in Gweru, an identified HIV hotspot in central Zimbabwe. “We have built the capacity of the women selling sex,” she says. “They know their rights: that they are people first before they are sex workers.”

The sex workers I speak with at a roundtable meeting at the Sisters clinic in Gweru agree. Fungai, 20, lives in Gweru and has been a sex worker since her teens. She came to the Sisters clinic to be treated for an STI. “I got more than treatment,” Fungai tells me. “I learned to conduct sex work safely.”

Fungai is ambitious. She has a day job and is also running a business selling clothes, which she hopes to expand to include high-value goods like cars. She will soon pay off a parcel of land where she plans to build a house.

“I do not plan to leave sex work,” says Fungai, who supports her parents and a sibling, “but I do not want to depend on it.”

I meet Kudzi, 24, at the Sisters clinic in Mbare, one of the oldest high-density suburbs in Zimbabwe, located six kilometers southeast of Harare. Kudzi turned to sex work to give herself time to look after her two sons when she divorced her husband after years of physical abuse. “Through counseling and training,” Kudzi says, “I am independent and have been empowered to negotiate safe sex with my clients. More importantly, I know how to remain healthy as a sex worker. I am on PrEP and use family planning.”

It’s pretty simple: Bathabile and her colleagues (and their clients and their families, too) will only stay safe and healthy if they can visit any public-health center without fear or stigma. That’s what programs like DREAMS and Sisters, and organizations like CeSHHAR, are working so hard to accomplish. It’s a break from the past, and it’s the future of HIV control in Zimbabwe.