Why Has HIV Declined More in Zimbabwe than in Other Southern African Countries?
One question arising from this review is why similarly high AIDS mortality and extensive coverage of HIV prevention programs (resulting in similarly high levels of reported condom use, early and large reductions in STI incidence, etc.) in several other countries in the region have not yet led to substantial declines in HIV prevalence (or multiple sexual partner- ships) [3,7,9,21]. Our comparative anal- ysis of eight southern African countries revealed few patterns of association.
The HIV epidemic in Zimbabwe is somewhat older than in some other countries in the region, yet HIV prevalence has been declining markedly for over a decade now, which has not occurred to nearly the same extent, for example, in Malawi and Zambia (where HIV arrived even earlier). In addition to the severe eco- nomic decline, where Zimbabwe does stand out is in having high levels of both secondary education and marriage, especially in urban men, among whom the greatest level of behavior change evidently has occurred [13,15,19] (Figures 2, S1).
It appears that this unique combination helped facilitate: 1) a clearer understanding and acceptance of how HIV is sexually transmitted (once such information became widely avail- able through various AIDS education and prevention programs commencing in the early 1990s ), as some studies of schooling levels and HIV determinants have suggested  and 2) a greater ability to act upon ‘‘be faithful’’ messag- es, given the stronger marriage pattern [28–30] in Zimbabwe than that in neighboring countries also having rela- tively well-educated populations, such as Botswana and South Africa.
In addition, national survey data sug- gest that between the mid-1990s and the early 2000s, Zimbabweans increasingly received information about AIDS from their friends, churches, and other inter- personal (as compared to official media) sources (Figure S4) [15,17]. A similar pattern has been linked to behavior change in Uganda [7,31]. Furthermore, the Zimbabwean government’s early adoption of a home-based care policy  may inadvertently have accelerated the process of behavior change. It has been hypothesized that, when people die at home, this direct confrontation with AIDS mortality is more likely to result in a tangible fear of death among family and friends than when patients are primarily cared for in clinical facilities, such as in Botswana .
It appears that the motivation for behavior change largely arose endoge- nously from within the population, and may have been partly due to events specific to Zimbabwe, such as the drastic economic decline in recent years. Never- theless, it is unlikely that significant changes in behavior in response to the increasing levels of mortality could have occurred unless prevention programs had provided effective information and education about the link between risky sexual behavior and AIDS. We had hoped that our review would identify some particu- larly effective approaches, which could then be strengthened in Zimbabwe and inform prevention programs in other countries.
Perhaps one reason that most respondents failed to identify specific effective programs is because it was the cumulative exposure to many programs that helped create a ‘‘tipping point’’ leading to changes in behavioral norms. We also note that government and civil society did promote faithfulness (mainly in the context of a generic ‘‘ABC’’ message), although not as early or as vigorously as Uganda’s ‘‘zero grazing’’ campaign duringthe late 1980s [7,8,31]. Furthermore, findings from the qualitative research suggested the considerable impact of popular culture that occurred precisely around the key period of behavioral change of the late 1990s and early 2000s. For example, a (donor-sponsored) docu- mentary Todii (‘‘What shall we do?’’) and a related widely popular song released by the famous performer Oliver Mutukudzi addressed the behavioral risks and social consequences of HIV infection .
Daniel T. Halperin1*, Owen Mugurungi2, Timothy B. Hallett3, Backson Muchini4, Bruce Campbell5,
Tapuwa Magure6, Clemens Benedikt5, Simon Gregson3,7
1 Harvard University School of Public Health, Boston, Massachusetts, United States of America, 2 Ministry for Health and Child Welfare, Harare, Zimbabwe, 3 Imperial College London, London, United Kingdom, 4 Independent consultant, Harare, Zimbabwe, 5 United Nations Population Fund, Harare, Zimbabwe, 6 Zimbabwe National AIDS Council, Harare, Zimbabwe, 7 Biomedical Research and Training Institute, Harare, Zimbabwe