Descriptive Results
The understanding and conceptions of HIV
Faith in God was central in the life of most participants. More than three quarters of participants reported that they had no doubt about the existence of God and one fifth that their relationship with God was their priority in life. Beliefs regarding spirits/spells were less prominent and more diverse. One third of participants said that they did not believe in the existence of spirits, and that spirits/spells had no power. However, only 7% said that ill health is never caused by spirits. One quarter said they believed that spirits/spells have power and 6% that ill health was always caused by spirits/spells. Some claimed that spirits/spells influenced them in the past (7%) or are influencing them now (3%). The beliefs about the origin of HIV were similarly diverse. Participants chose a combination of traditional/cultural, and spiritual/religious explanations. The most prominent beliefs were as follow: 22% said that HIV originated because of the mixing of blood of different age groups or races, 20% saw HIV as a punishment from God, and 15% believed HIV was brought by the West to weaken Africans. Participants were further asked why some people get infected with HIV and others do not. Most common were moralizing concepts of HIV. In this regard, 42% stated that HIV infection was a result of immoral sexual behaviour in the family or self, 12% perceived HIV as a result of personal sin, and 9% as result of sin in the family. 4% believe that HIV is the result of witchcraft/spells. Non-spiritual/-religious reasons for a HIV infection were chosen by 25% who believe that it is a result of a weak body. 11% cited bad luck as the reason why some get infected, and others do not.
Thus, for most participants, the belief in God and the perception of a transcendent influence on health are embedded in the experience of living with HIV and inform their health seeking behaviour.
Health seeking behaviour
Because HIV and HIV related illnesses are not merely seen as physical problems, but as having a spiritual or transcendent dimension, half of YPLHIV in our study wished to choose their health practitioner according to the cause of their illness and many freely moved between or within the three health systems (religious, traditional, biomedical). 40% of participants consulted religious healers. Of these, prophets (18%) were consulted most frequently. Two thirds of participants used religious rituals, of which prayer was the most common. 28% used prayer for healing and 14% used prayer for forgiveness. The following reasons were provided for consulting traditional healers: because they help holistically (physically and spiritually); they know the culture; they have access to ancestors; and they are affordable. Besides health concerns, traditional healers are consulted for various other issues including the preservation of morality, good luck charms, and dealing with relationship issues. Also, the use of herbal supplements was common, with two thirds of participants taking at least one supplement, and the highest reported number being seventeen different supplements. According to participants, the affordability of traditional medicine, especially relative to western medicine, is the primary reason for using it. Other important reasons included their accessibility, their natural/African origin, and because they are viewed as effective.
The parallel use of the biomedical, religious, and traditional health systems can lead to conflicting and compromising treatment approaches. This has also been found here: 10.5% of participants reported having at least once stopped taking ARVs for religious reasons. The following reasons were provided for having stopped ARVs: belief God/spirit would heal (42%); not wanting religious people to know that they are on ARVs (10%); belief that ARVs are not part of their culture/belief (9%); told by religious people to stop (6.3%); and belief that God was punishing them (4%). Besides these, the participants were also confronted with other religious reasons that oppose certain forms of treatment. 32% knew religious reasons that spoke against traditional medicine and 29% against western medicine. 26% had heard of or knew religious reasons that spoke against cervical cancer screening. Interestingly, the latter also had higher screening rates. The divergence between religious doctrine that speaks against (western) cervical screening and actual health seeking behavior highlight the complexity of the religion-health context within which participants operate. Not only do YPLHIV need to navigate three – at times - contrasting health systems, but additionally they are confronted with opposing views and approaches. Unsurprisingly, one third of participants wished that all healers (medical, traditional, religious) worked together. The importance of this wish is further underlined by our findings regarding risk behaviours, that highlight additional points of conflict, especially in regard to sexual practice.
Risk behaviours
UNICEF recently pointed out that child marriage is very common in Zimbabwe and that one in three women marry before the age of 18 (25). Among our participants, one third of participants started sexual activity before the age of 17, 17 were married before the age of 18, and 6 participants were sexually active before the age of 12. 41 participants (34 females, 7 males) younger than 18 had at least one child. 27% of all females reported at least one pregnancy and 6% of sexually active females had at least one abortion. Condom use was not popular, as less than half of those who reported being sexually active used a condom all the time. The higher the number of lifetime sexual partners, the higher the percentage of those who never use a condom. Condom use was slightly higher for males than for females. Furthermore, about one quarter of those who are sexually active had a minimum of five lifetime sexual partners and 11.4% had at least once sexual encounter with a person of the same sex.
In regard to the perception and experience of violence, 34% of participants experienced some form of non-sexual violence. Regarding non-sexual violence at home, nearly three quarters of respondents condoned the beating of children under certain circumstances. Much less accepted was beating one’s wife. In this instance, 73% of participants did not accept wife beating. Some however, saw some legitimate reasons for beating: arguing with husband (12%), going out without telling the husband (10%), neglecting their children (6%), or refusing sex (6%).
7% of participants reported that they had experienced sexual violence, while some preferred not to answer. Data collectors assumed that the majority of those responding with “don’t know” or “prefer not to answer” felt too uncomfortable to describe their experiences. However, due to the uncertainty associated with making this assumption, the “don’t know” and “prefer not to answer” answers were coded as “no”. In our study, there was only a small difference between genders.
Relative to other risk behaviours, participants reported the use of potentially harmful substances as follows: 7.5% of participants smoke, 15.6% of participants reported the consumption of alcohol, and 4.9% reported the use of drugs. Again, the data collectors felt that these relatively low numbers may be due to a perceived lack of privacy on the side of the respondents, who at times had to use their parents’ phone and were confined to their homes because of Covid-19.
Next, we looked at religious affiliations of participants.
Religious Affiliations
In this paper, the term “religion” refers to organised and/or shared faith practices or beliefs and the term “spirituality” refers to the way people relate to the transcendent, including traditional practices. In the questionnaire, participants were asked, “what is your religious affiliation?” and participants were allowed to choose multiple religious affiliations. Of these, Apostolic affiliation was the most frequently reported. Females reported a higher percentage of Anglican, Methodist, and Muslim religious affiliations, and males predominantly reported higher rates of Traditional religious affiliation. (Table 1)
Table 1: Religious affiliations with female/male percentage
Religious Affiliation
|
Overall %
|
Overall Female %
|
Overall
Male %
|
Traditional
|
3.62
|
2.4
|
5.5
|
Apostolic
|
24.31
|
|
|
Catholic
|
6.73
|
|
|
Pentecostal
|
19.33
|
|
|
Anglican
|
2.62
|
3.5
|
1.3
|
Baptist
|
1.62
|
|
|
Methodist
|
8.23
|
9.6
|
5.8
|
Muslim
|
1.25
|
1.8
|
0.3
|
Other
|
19.08
|
|
|
none
|
10.1
|
|
|
more than one religion
|
2.87
|
|
|
prefer not to answer
|
0.12
|
|
|
Health outcomes
The viral load result was described with three different variables, using the European Aids Clinical Society’s guidelines (26): Viral load with three different values corresponding to undetectable viral load, incomplete suppression, and treatment failure; TND (binary for undetectable viral loads); and Failure (binary) for viral load results indicating treatment failure. Nearly three quarters of all participants had an undetectable viral load, suggesting good treatment adherence. However, 16% of participants had a viral load that suggests poor treatment adherence and treatment failure. (Table 2) Out of the 804 participants only two had missing viral load results, all other viral load results were dated within 5 months of data collection.
42.8% of participants had at least one opportunistic infection. 9.2% had an average score of more than 8 in the Shona Symptom Questionnaire, indicating a risk for mental health problems. (Table 2)
Table 2: Viral load results, prevalence of opportunistic infections, mental health risk
Variable Name
|
Result
|
Definition
|
Viral load
(Three values 1-3)
|
74%
10%
16%
|
≤ 50 copies/ml
> 50 copies/ml ≤ 200 copies/ml
> 200 copies/ml
|
TND (binary)
|
74%
|
≤ 50 copies/ml
|
Failure (binary)
|
16%
|
> 200 copies/ml
|
Prevalence of opportunistic infections (binary)
|
42.8%
|
≥ 1 opportunistic infection
|
Mental Health risk (binary)
|
9.2%
|
> 8 in Shona Symptom Questionnaire (mean of 14 items)
|
Regression Results
The understanding and conceptions of HIV
Belief-based conceptions about the origin or reason for HIV had relevant relations to health outcomes and as such acted as facilitators or barriers to good health. Concepts without spiritual or religious connotation were linked to better health outcomes, while moralizing concepts of HIV were linked to a higher risk of opportunistic infections. This was also the case for the belief that HIV was brought by the West to weaken Africans. Seeing HIV as a result of witchcraft/spells was additionally linked to a higher risk of mental health problems. (Table 3)
Table 3: Concepts of HIV with relevant associations with health outcomes
Concept of HIV (binary)
|
Good Health Facilitator
|
Good Health Barrier
|
Not believing in the existence of spirits
|
Less opportunistic infections
(OR:0.7; CI:0.5-1; P: 0.037).
|
|
Only physical origin “weak body”
|
Lower risk for treatment failure (OR: 0.6; CI: 0.4-1.0; P: 0.063)
Higher chance for TND (OR: 1.4; CI: 1-2; P: 0.061)
Lower viral load (OR: 0.7; CI: 0.5-1; P: 0.067)
|
|
Brought by the West to weaken Africans
|
|
More Opportunistic Infections
(OR: 1.5; CI: 1-2.2; P: 0.061)
|
Result of immoral sexual behaviour in the family or self
|
|
More Opportunistic Infections
(OR:1.6; CI:1.2-2; P: 0.004)
|
Result of sin (family)
|
|
More Opportunistic Infections
(OR:1.8; CI:1.1-3; P: 0.018)
Higher risk of treatment failure
(OR: 1.7; CI: 0.7-1.1; P: 0.066)
|
Result of witchcraft / spells
|
|
More Opportunistic Infections
(OR:2.3; CI:1.1-4.6; P: 0.026)
Higher risk of mental problems
(OR: 2.6; CI: 1-6.3; P: 0.039)
|
Legend table 3: Regression controlled for gender, age, education, and location. Only significant (bold) and important relations are included.
Health seeking behaviour
Participants who experienced religious objections toward certain forms of therapy had a higher risk of mental health problems and in most cases also a higher prevalence of opportunistic infections. The consultation of religious and traditional healers was not related to health outcomes, except for those who consulted herbalists. None of the herbs had a direct significant link to health outcomes. However, those who consumed many different herbs had a higher prevalence of opportunistic infections. (Table 4)
Table 4: Health seeking behaviour with relevant associations with health outcomes
Beliefs about right treatment (binary)
Ever heard religious reasons …
|
Good Health Facilitator
|
Good Health Barrier
|
against Cervical Cancer Screening
|
|
Higher risk of mental problems
(OR: 2.2; CI: 1.35-3.68; P: 0.002)
More Opportunistic Infections
(OR:1.6; CI:1.1-2.1; P: 0.008)
|
against western Medicine
|
|
Higher risk of mental problems
(OR: 2.4; CI: 1.28-3.98; P: < 0.001)
More Opportunistic Infections
(OR:1.4; CI:1-2; P: 0.031)
|
against traditional Medicine
|
|
Higher risk of mental problems
(OR: 2.2; CI: 1.35-3.65; P: < 0.002)
|
Consultation of Healers:
Herbalists
|
|
Higher risk of mental problems
(OR: 4.2; CI: 1.7-10.2; P: 0.002)
|
Using of traditional medicine
|
|
The higher the number of herbal supplements the more opportunistic infections (OR:1.1; CI:1-2; P: 0.031)
|
Legend table 4: Regression controlled for gender, age, education, and location. Only significant (bold) and important relations are included.
Risk behaviours
Risk behaviours did not significantly relate to viral load, but some significantly increased the prevalence of opportunistic infections. (Table 5) In terms of sexual risk behaviours, the higher the age at which respondents first initiated sexual activity, the lower the risk of sexual violence, (OR: 0.8; CI: 0.7-1.0; P: 0.098) and the lower the number of sexual partners (OR: 0.8; CI: 0.7-0.9; P: 0.0).
Besides a higher prevalence of opportunistic infections, the experience of violence was additionally related to a higher risk of mental health problems. (Table 5) Accepting certain reasons for beating was linked to a higher prevalence of opportunistic infections, while the belief that beating is never justified was significantly linked to a lower risk of opportunistic infections (OR 0.7; CI 0.5-0.9; P 0.019).
Table 5: Risk behaviours with relevant associations to health outcomes
Risk Behaviour (binary)
|
Good Health Facilitator
|
Good Health Barrier
|
Substance use
Smoking
|
|
More Opportunistic Infections
(OR:2.6; CI1.5-4.8:1.5-4.8; P: 0.001)
|
Alcohol
|
|
Less TNDs
(OR:0.7; IC: 0.5-1.0; P: 0.090)
More Opportunistic Infections
(OR:1.6; CI:1-2.4; P: 0.017)
|
Drugs
|
|
More Opportunistic Infections
(OR: 2; CI: 1-4.2; P: 0.05)
|
Sexual risks
Minor Sex
|
|
More Opportunistic Infections
(OR:1.5; CI:1-2; P: 0.021
|
No condom
|
|
More Opportunistic Infections
(OR:1.2; CI:0.7-1; P: 0.012)
|
Many sex partners
|
Lower risk of mental problems
(OR: 0.85; CI: 0.7-0.99; P 0.041)
|
More Opportunistic Infections
(OR:1; CI: 1-1.2; P 0.054).
|
Teenage Parenting
|
|
Higher risk of mental problems
(OR: 2.5; CI: 0.9-6.5; P: 0.068)
|
Experience of non-sexual violence
|
|
Higher risk of mental problems
(OR: 2.4; CI: 1.5-3.9; P: 0.001)
More Opportunistic Infections (OR:1.8; CI:1.-2.5; P: < 0.001
|
Experience of sexual violence
|
|
Higher risk of mental problems
(OR: 2.7; CI: 1.3-5.4; P: 0.005)
More Opportunistic Infections
(OR: 2.5; CI: 1.3-4.6; P: 0.004)
|
Legend table 5: Regression controlled for gender, age, education, and location. Only significant (bold) and important relations are included.
So far, the regression results identified that belief-based conceptions about HIV, religious objections towards certain forms of therapy, the reliance on traditional practice, and individual risk behaviours were significantly related to physical and mental health and thus acted as barriers or facilitators to good health. Next, we explored the relationship between religious affiliations and health outcomes. Does religious affiliation significantly influence health outcomes?
The relation between religious affiliation and factors acting as facilitators and barriers of good health
In our study, we found that people do not disclose their HIV status to those outside their close family and friendship circles. Nearly one fifth of the participants explicitly said they did not want church leaders and church members to know. Nevertheless, certain religious affiliations significantly influenced specific conceptions of HIV, health seeking behaviour, and risk behaviours that have shown to act as facilitators or barriers to good health. There are some shared associations with health barriers, especially by no religious affiliation and Traditional religious affiliation. Both are significantly linked to the use of potentially harmful substances, the condoning of wife beating, and sexual activity below the age of 17 years. Apostolic religious affiliation is the only religious affiliation that significantly relates to both a good health facilitator, namely reduced risk of non-sexual violence, and a good health barrier, namely the belief that HIV was given by God as a punishment for sexual misconduct. Interestingly certain factors that act as barriers exclusively related to only one specific religious affiliation. For instance, having stopped ARVs for religious reasons only related to Traditional religion, and religious reasons against cervical cancer screening only related to no religious affiliation. (Table 6)
Table 6: Religious affiliations with significant associations with facilitators and barriers to good health
Religious affiliation (binary)
|
Good Health Facilitator
|
Good Health Barrier
|
Traditional
|
|
Prevalence of having stopped ARVs for religious reasons
Smoking, alcohol consumption, drug use
Condoning of wife beating
Sexual activity below 17 years
|
Apostolic
|
Reduced risk of non-sexual violence experience
|
Belief that HIV was given by God as punishment for sexual misconduct
|
Pentecostal
|
|
Belief that HIV is the result of immoral sexual behaviour in the family or self
Smoking
|
Anglican
|
|
Belief that HIV is the result of sin in the family
Experience of prostitution
Increased number of lifetime sexual partners
|
Muslim
|
|
Sexual activity below 17 years
|
None
|
|
Belief that HIV was brought by the West to weaken Africans
Religious objections against cervical cancer screening
Smoking and alcohol consumption
Condoning of wife beating
Sexual activity below 17 years
Increased number of lifetime sexual partners
|
Legend table 6: Regression controlled for gender, age, education, and location. Only significant (bold) relations are included. To improve readability regression values are not included.
While these findings show the indirect relationship between religious affiliation and health outcomes, we also identified direct significant relations between religious affiliations and health outcomes.
Religious affiliation and health outcomes
Traditional, Pentecostal, and Apostolic religious affiliations had direct significant links with current viral load results and, in the case of Traditional religion, with the prevalence of opportunistic infections. This means that religious affiliations may influence health outcomes in positive and negative ways. None of the religious affiliations were significantly linked to mental health. (Table 7)
Table 7: Religious affiliations with significant links to viral load and opportunistic infections
Religious affiliation (binary)
|
Good Health Facilitator
|
Good Health Barrier
|
Traditional
|
Lower viral load
(OR: 0.34; CI: 0.12-0.96; P: 0.042)
More TNDs
(OR: 2.04; CI: 0.9-6.08; P: 0.082)
|
More Opportunistic Infections
(OR: 2.2; CI: 1.1-4.4; P: 0.023)
|
Apostolic
|
|
More treatment failure
(OR: 1.52; CI: 1-2.3; P: 0.049)
|
Pentecostal
|
Less treatment failure
(OR: 0.53; CI: 0.32-0.95; P: 0.033)
|
|
Legend table 7: Only those religious affiliations with significant regression results (controlling for gender, age, education, and location) are included.
In summary, our findings support the idea that YPLHIV in Zimbabwe make use of parallel, and often incongruent biomedical, traditional, and religious health systems. We also identified the statistically significant influence of religious and traditional beliefs and practices on mental and physical health and showed how different religious affiliations act as predictors of health outcomes.