From Panos Institute Southern Africa (PSAf), September 2014 - PSAf, in collaboration with the National HIV/AIDS/STIs/TB Council of Zambia and the Tropical Diseases Research Centre (TDRC), undertook a study on the existence of sexual minorities. The research aimed at establishing the characteristics of sexual minorities in Zambia, their risk to HIV infection and other reproductive health problems in order to identify opportunities for interventions.
This research was part of a three-country study HIV Prevention for Sexual Minorities in Botswana, Zambia and Zimbabwe, a project that was coordinated by the Biomedical Research Training Institute (BRTI) in Zimbabwe, in partnership with PSAf in Zambia, and University of Botswana in Botswana. The study targeted men who have sex with men (MSM) and women who have sex with women (WSW), regardless of their sexual orientation or how they identify themselves.
The specific objectives of the study were to:
- To describe the characteristics and behaviours of HIV high risk populations.
- To measure the extent to which high risk populations are being reached with HIV preventive and treatment services
- To identify inhibiting factors for effective HIV prevention among high risk populations
- To identify opportunities for inclusive interventions targeting high risk groups
- To determine HIV prevalence among high risk populations
- To provide recommendations for inclusive programming in the HIV/AIDS response.
Research was conducted in Ndola, Kitwe, Lusaka, Chingola, Chililabombwe and Livingstone. The selection of the study sites was based fact that these areas had registered and known MSM and WSW who were affiliated to the membership LGBTI [Lesbian, Gay, Bisexual, Transgender/Transexual and Intersexed] organisations in Zambia. This provided an entry point because these people were identified as seed respondents and would lead the process to their networks of people who are not affiliated to any organisation.
Quantitative and qualitative data collection methods were used. The quantitative methods were used for data that would quantify the results as well as make cross references of the variables to create a more definite picture on the sexual minority community in Zambia. These included private, face-to-face interviews using structured questionnaires. Qualitative data was collected through Focus Group Discussions to compliment the quantitative data and provide descriptions and explanations where necessary. The study also estimated the HIV prevalence of sexual minority groups by conducting HIV tests for all respondents using Dry Blood Spots (DBS). The DBS were collected by trained medical personnel from TDRC as part of the data collection process. The testing was done at the TDRC laboratory.
The key findings of the study were divided into a number of components, as follows:
a. Characteristics of sexual minorities
The study identified the characteristics of sexual minorities in Zambia in terms of sexual identity, sexual partners, and practices (including: sexual debut, condom use, type of sexual acts, and presence of transactional sex). The study reflected on a number of demographic characteristics in order to assess if there was any linkage between their demographic characteristics and their sexual behaviour or risk to HIV infection. The demographics included their age, marital status, education and employment status.
b. Sexual Practices
The study assessed the sexual behaviour of the sexual minorities specifically looking at what kind of partners they have sexual relations with, types of sexual acts and existence of risky behaviours. This was to assist with the assessment of the risks involved in the nature of their sexual behaviour to inform the development of relevant interventions. The sexual minorities portray multiplicity of partners as a significant aspect of their behaviour. The MSM bisexuals for instance indicated that they had more than 1-2 regular female partners in six months (54%) and an equal number of regular male partners within the same period. According to the respondents interviewed, it is difficult for sexual minority people to maintain monogamous relationships due to the scarcity of partners, and difficulty in maintaining committed relationships due to the unfriendly social and legal environment. This culture of multiple partnerships was one of the key findings of the four focus group discussions with the study group.
c. HIV Prevalence rates
From the Dry Blood Spot testing, the HIV prevalence rate for sexual minority was assessed with the aim of establishing the link between the characteristics of sexual minorities and their risk to HIV infection. According to the findings, HIV rates are highest among homosexual men (24.1% of the self-identified homosexual men tested positive) and bisexual women (23.6% of the self-identified bisexual women tested positive). HIV prevalence rate by sex of respondents present a higher rate in WSW because bisexual WSW prevalence rate was almost double that of bisexual MSM. Although the prevalence rate of male homosexuals was significantly higher than that of lesbians (24.1 homosexuals MSM and 17.9% for lesbians), the difference was not as high as that between male and female bisexuals.
d. Information and Knowledge levels on HIV Prevention
The study inquired into the access to and sources of information in relation to HIV prevention for the sexual minorities. The results showed that most of the information the respondents had received in the past 12 months on HIV was for heterosexual relationships. The common source was the mass media (Television, radio and newspapers) at 43% for male respondents and 53% for the females. The other reliable sources were health practitioners, peers/friends and school. HIV prevention information for same sex relations therefore seems to be almost non-existent. Those that indicated receiving information on HIV prevention in same-sex relations indicated receiving this information from peers or friends at 13% for males and 14% for the female counterparts.
e. Use of HIV prevention measures
The study also assessed the kind of HIV preventive measures that are accessible by the sexual minorities’ community and those that they use. The assessment was done in order to identify how easily accessible HIV prevention is for the community and identify challenges that require policy or programming redress. It was evident that condom use among sexual minorities was highly inconsistent posing a high risk to HIV infection. Generally, most MSM (79%) indicated that they sometimes use condoms for HIV prevention both with their female and male partners. 49% of those who reported using condoms indicated consistent use of condoms with their regular female partners, and 51.3% indicated consistent use of condoms with non-regular female partners. Condom use with regular male partners was relatively lower, only 32% of MSM reported consistent use of a condom with their regular male partners. In sexual relations with non-regular male partners 67% indicated consistent condom use. Although the consistent use of condoms with non-regular partners seemed fairly high at 67%, 68% of them reported that they did not use a condom at the most recent sexual encounter with their male partners.
f. Inhibiting factors
Having studied and characterised the sexual minorities of Zambia, established their risk to HIV infection and access to prevention services and information, the study made an assessment of potential and existing inhibiting factors to HIV prevention among this population in order to identify areas for interventions as well as opportunity for entry into this community. Some of the inhibiting factors to effective HIV prevention among sexual minorities in Zambia that were identified included: highly prevalent socio-legal homophobia, stigma against sexual minorities, unavailability of targeted services for sexual minorities, knowledge levels on HIV prevention and risk reduction methods, perceptions about HIV prevention, sexual violence, alcohol and drug use and limited access to HIV prevention information and services.
The study has recommendations that are expected to help in streamlining the specific intervention needs required for each sub-group. This would make it possible for the country health systems to develop interventions that would address the needs of this average but diverse population in the most effective ways. The study findings would be useful in advocacy efforts and promote the implementation of appropriate HIV prevention interventions in Zambia.
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