Demographic characteristics for 2015 ZDHS survey.
The demographic characteristics for the ZDHS 2015 are presented in Table 1. Approximately two-thirds (62% for females and 59% for males) of the population lived in rural areas. Two thirds, (66% for both sexes) of respondents had secondary education and approximately one percent for both sexes had no education. The Apostolic Sect was the largest religious group, constituting 40% of women and 30% of adult males. HIV knowledge factors associated with the apostolic sect
Table 1: Baseline frequencies for participant characteristics using ZDHS 2015-16 data
Variable
|
Female Frequency n (%)
|
Male frequency n (%)
|
Age group in years
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54 (Men only)
|
2156 (22)
1782 (17)
1656 (17)
1591 (16)
1209 (12)
966 (10)
595 (6)
|
2065 (25)
1376 (16)
1166 (14)
1104 (13)
932 (11)
797 (9)
578 (7)
378 (5)
|
Type of residence
Urban
Rural
|
4521 (38)
5434 (62)
|
3456 (41)
4940 (59)
|
Highest education level
None
Primary
Secondary
Higher
|
106 (1)
2385 (26)
6637 (66)
827 (7)
|
57 (1)
1855 (22)
5524 (66)
960 (11)
|
Marital status
Never in union
Married
Living with partner
Widowed
Divorced
Separated
|
2666 (25)
5700 (59)
315 (3)
430 (4)
488 (5)
356 (4)
|
3619 (43)
4267 (51)
70 (1)
66 (1)
163 (2)
211 (3)
|
Religion
Traditional
Roman catholic
Protestant
Pentecostal
Apostolic sect
Other Christian
Muslim
None
Other
|
60 (1)
670 (7)
1618 (16)
2679 (25)
3829 (42)
589 (5)
30 (0)
471 (5)
9 (0)
|
220 (3)
698 (8)
1272 (15)
1551 (18)
2507 (30)
606 (7)
53 (1)
1479 (18)
10 (0)
|
The results in Table 2 shows that the apostolic males and females were less likely to have ever heard about HIV when respectively compared to males and females of other religions (p<0.05). Ever tested for HIV percentages and knowledge of where to get tested and ever having tested were also lower in the apostolic groups. When compared to males and females of other religions the apostolic sect showed lower percentage of knowledge on the following questionnaire items: Knowing that HIV transmission can be reduced by having sex with one partner who is HIV negative, knowing that sexual HIV transmission can be reduced by consistent condom use, knowing that, men can reduce HIV transmission by being circumcised and that circumcised men who have sex without condom can get HIV/AIDS. Apostolic females would think that HIV can be obtained from sharing food with an HIV infected person and that one can get HIV by witchcraft or supernatural means. They did not know that, a healthy person can still be HIV infected. Comprehensive knowledge of HIV is a composite measure and indicates that an individual knows that consistent condom use and limiting sexual intercourse to one uninfected partner can reduce the risk HIV transmission, that a healthy-looking person can have HIV, and rejects the two most common local misconceptions about the transmission of HIV. In Zimbabwe, the two most common misconceptions are that HIV can be transmitted through mosquitoes and that a person can become infected with HIV by sharing food with a person who has HIV. Nationally, only 55% of women and 56% of men have comprehensive knowledge of HIV prevention and transmission [13]. Comprehensive knowledge on HIV was only 47% among females Apostolics compared to 60% among non Apostolics females. Similarly, comprehensive knowledge on HIV was only 51% among males Apostolics compared to 58% among non Apostolics males. Additionally, a larger percentage of the apostolic would be ashamed if a family member gets infected with HIV and would not buy vegetables from a vender with HIV infection. A slightly higher parentage of female Apostolics attest that children with HIV should not be allowed to attend school with children without HIV. Both apostolic males and females felt that a wife is not justified to ask her husband to use a condom if he has an STI. From the data, circumcision prevalence was low for the apostolic males.
Table 2: Factors associated with the apostolic sector analyzed separately for males and females from ZDHS 2015-16 data.
Variable
|
Females n (%)
|
Males n (%)
|
Apostolics
|
Other religion
|
P value
|
Apostolics
|
Other religion
|
P value
|
Ever heard about HIV
No
Yes
|
55 (1.4)
3774 (98.6)
|
34(0.6)
6092 (99.4)
|
0.011
|
27 (1.2)
2480 (98.8)
|
28 (0.5)
5861 (99.5)
|
0.002
|
Ever tested for HIV
No
Yes
|
805 (21.9)
3024 (78.1)
|
1085 (17.5)
5041 (82.5)
|
0.006
|
1016 (42.0)
1491 (58.0)
|
1873 (32.2)
4016 (67.8)
|
0.001
|
Know where to get tested
No
Yes
|
126 (3.6)
496 (96.4)
|
124 (2.3)
5947 (97.7)
|
0.001
|
150 (6.2)
2330 (93.8)
|
170 (3.0)
5691 (97.0)
|
0.001
|
HIV transmission can be reduced by having 1 sexual partner
No
Yes
Don’t know
|
7282 (7.6)
3434 (90.8)
58 (1.6)
|
330 (5.4)
5705 (93.5)
57 (1.1)
|
0.023
|
145 (5.8)
2312 (93.3)
23 (1.0)
|
251 (4.7)
5576 (94.7)
34 (0.7)
|
0.062
|
Condom use reduces HIV
No
Yes
Don’t know
|
519 (13.9)
3125 (82.1)
130 (4.0)
|
705 (11.8)
5282 (86.0)
105 (2.2)
|
0.006
|
300(11.8)
2146 (86.6)
34 (1.6)
|
517 (9.1)
5298 (90.1)
46 (0.8)
|
0.001
|
Men can reduce HIV transmission by being circumcised
No
Yes
Don’t know
|
672 (18.2)
2733 (71.1)
369 (10.7)
|
829 (13.7)
4794 (77.6)
469 (8.6)
|
0.001
|
446 (18.3)
1907 (76.5)
127 (5.3)
|
925 (15.5)
4694 (79.7)
242 (4.8)
|
0.016
|
Circumcised men who have sex without condom can get HIV/AIDS
No
Yes
Don’t know
|
981 (26.5)
2210 (56.1)
583 (17.4)
|
1029 (17.4)
4357 (68.7)
706 (12.9)
|
0.001
|
329 (13.2)
2016 (81.2)
135 (5.6)
|
626 (10.5)
5011 (85.1)
224 (4.4)
|
0.001
|
Can get HIV from sharing food
No
Yes
Don’t know
|
3371 (89.1)
312 (8.2)
91 (2.7)
|
5672 (93.2)
343 (5.3)
77 (1.5)
|
0.001
|
2197 (88.8)
220 (8.6)
63 (2.6)
|
5268 (90.0)
490 (8.1)
103 (1.9)
|
0.134
|
Can get HIV by witchcraft or supernatural means
No
Yes
Don’t know
|
3456 (91.8)
239 (6.0)
79 (2.2)
|
5696 (93.8)
306 (4.6)
90 (1.6)
|
0.001
|
2279 (92.2)
146 (5.5)
55 (2.4)
|
5403 (92.5)
353 (5.6)
105 (1.9)
|
0.442
|
A healthy person can be HIV infected
No
Yes
Don’t know
|
604 (15.7)
3131 (83.1)
39 (1.2)
|
680 (11.3)
365 (87.8)
47 (0.9)
|
0.001
|
311 (13.1)
2150 (85.9)
19 (1.0)
|
580 (10.3)
5242 (88.9)
39 (0.8)
|
0.005
|
Would be ashamed if a family member gets infected with HIV
Disagree
Agree
Don’t know
|
3253 (85.4)
511 (14.4)
10 (0.2)
|
5469 (89.0)
607 (10.7)
16 (0.3)
|
0.001
|
1946 (81.5)
523 (22.2)
11 (0.4)
|
4942 (77.4)
895 (16.0)
24 (0.56)
|
0.001
|
Would buy vegetables from a vendor with HIV
No
Yes
Don’t know
|
61 (23.4)
2888 (76.0)
25 (0.6)
|
968 (16.4)
5093 (82.9)
31 (0.7)
|
0.001
|
464 (18.3)
2002 (81.2)
14 (0.5)
|
923 (15.3)
4879 (83.7)
59 (1.0)
|
0.001
|
Children with HIV should be allowed to attend school with children without
No
Yes
Don’t know
|
324 (8.7)
3409 (90.1)
41 (1.2)
|
312 (4.6)
5741 (94.6)
39 (0.8)
|
0.001
|
245 (9.2)
2211 (89.9)
24 (0.9)
|
486 (8.1)
5341 (91.2)
34 (0.7)
|
0.201
|
Wife justified to ask husband to use a condom if he has an STI
No
Yes
Don’t know
|
509 (12.9)
3240 (84.8)
80 (2.3)
|
662 (10.2)
5372 (88.2)
92 (1.6)
|
0.040
|
397 (16.0)
2076 (82.6)
34 (1.4)
|
670 (12.3)
5164 (86.7)
55 (1.0)
|
0.001
|
Responded circumcised
No
Yes
Don’t know
|
|
|
|
2196 (88.7)
306 (11.2)
5 (0.2)
|
4861 (84.2)
1021 (15.7)
7 (0.1)
|
0.001
|
Adjusted regression model results for females
In multivariate stepwise regressing models, compared to women of other religions, women belonging to the Apostolic sect continued to fair negatively in the following items. They are less likely to know where to get an HIV test adjusted odds ratio (aOR) (95% confidence interval [CI]) = 0.665 (0.503-0.880), p=0.004, they are less likely to know that men can reduce their chance of getting HIV by being circumcised, aOR (95%CI) = 0.863 (0.781-0.955), p=0.004. They were less likely to know that circumcised men who do not use condoms during sex can still get HIV, aOR (95%CI) = 0.633 (0.579-0.693), p=0.001. They are less likely to know that it is possible for a healthy-looking person to have, aOR (95%CI) = 0.814 (0.719-0.921), p=0.001. They would not buy vegetables from a vendor with HIV, aOR (95%CI) = 0.817 (0.729-0.915), p=0.001 and are unfortunately less likely to support the fact that children with HIV should be allowed to attend school with children without HIV, aOR (95%CI) = 0.804 (0.680-0.950), p=0.011. Apostolic women were likely to show misconception that one can get HIV from sharing food OR (95%CI) = 1.203 (1.012-1.429), p=0.036. On a positive note apostolic females had higher rate of HIV testing aOR 1,283 (95% CI 1.134-1.451).
Adjusted regression model results for males
In multivariate stepwise regressing models, compared to men of other religions, men belonging to the apostolic sect were less likely to have been tested for HIV, aOR (5%CI) = 0.825 (0.743-0.916), p=0.001, or know where to get an HIV test, aOR (5%CI) = 0.637 (0.502-0.809), p=0.001. The men were less likely to know that circumcised men who have sex without a condom can get HIV aOR (5%CI) = 0.771 (0.665-0.895), p=0.001. There men are less likely to concur with the fact that a wife is justified to as her husband to use a condom if he has an STI, aOR (5%CI) = 0.851 (0.748-0.967), p=0.014. Apostolic men were less likely to be circumcised aOR (5%CI) = 0.773 (0.675-0.885), p=0.001.
Trend of risk perception
From data analysis results of the three rounds of ZDHS surveys, Apostolics male and females performed poorly in most questionnaire items related to their understanding of HIV and associated risk factors, see supplementary tables 1a, 1b, 2a, 2b, 3 and 4.
With regard to data on previous rounds of ZDHS, we also performed chi-square tests for various factors comparing the apostolic sect and people of other religions using the ZDHS 2010-2011 data (supplementary table 3) and ZDHS 2005-2006 data (supplementary table 4).
From this analysis presented in supplementary table 3, female Apostolics are significantly, in terms of the proportions, less likely to know where to get an HIV test, to know that HIV transmission can be reduced by having one sexual partner who is HIV negative, to know that condom use reduces HIV transmission risk, more likely to think HIV is transmitted by sharing food with someone who is HIV positive, are more likely to think that one can get HIV from witchcraft or through supernatural means, are less likely to know that a healthy looking person can be having HIV infection, would want HIV infection in the family to remain a secret, would not want to but vegetables from a vendor with HIV, would not want a male teacher with HIV to continue teaching and finally although not statistically significant they are more likely to feel that a wife is not justified to ask her husband to use a condom if the husband has an STI. Similarly, male Apostolics are significantly less likely to have ever heard about HIV or to have ever been tested or to know where to get an HIV test, less likely to know that condom use reduces HIV transmission risk, are more likely to think that one can get HIV from sharing food with a person who is infected, are less likely to know that a healthy looking person can be having HIV infection, would want HIV infection in the family to remain a secret, would not likely buy vegetables from a vendor with HIV, thinks a male teacher with HIV should not be allowed to teach, thinks a wife is not justified to ask her husband to use a condom if the husband has an STI and finally are less likely to be circumcised.
From this analysis presented in supplementary table 4, female Apostolics are significantly, in terms of the proportions, less likely to have ever heard of AIDS or to have been tested or know a place where one can get an HIV test. They are significantly less likely to know that HIV transmission can be reduced by having one sexual partner who is HIV negative, or to know that condom use reduces HIV transmission risk. They are likely to think that HIV can be transmitted by sharing food with an infected person and that one can get HIV from witchcraft or natural means. They are less likely to know that a healthy-looking person can be having HIV infection and are also less likely to buy vegetables from a vendor with HIV infection and do not think a person with HIV should be allowed to continue teaching. They are less likely to think that a wife is justified to ask her husband to use a condom if the husband has an STD. Similarly, apostolic males are less likely to have ever heard of AIDS or to have been tested or know a place where one can get an HIV test. Interestingly the male Apostolics are more likely to know that HIV transmission can be reduced by having one sexual partner who is HIV negative and this is something positive for this group. However, they do not think a person with HIV should be allowed to continue teaching. Although not statistically significant male Apostolics are less likely to know that condom use reduces HIV transmission risk and would think that HIV can be transmitted by sharing food with an infected person and are also less likely to buy vegetables from a vendor with HIV infection. Also, of statistical borderline significance is the fact that they are less likely to know that a healthy looking person can be having HIV infection and are less likely to say it is justified for a wife to ask her husband to use condoms if the husband has an STD infection
In supplementary table 1a chi-square test of proportions was used to compare various factors across the various religious groups among females. From table supplementary 1a, the proportions show religious groups with the poorest performance for each question item. We used religious groups with sufficient samples sizes, notably Roman Catholics, Protestant, Apostolic Sect, Other Christians and None, to explore how religious groups are performing by ranking each factor for these religious groups using rating scores number 1 to 6 with 6 being the worst, see supplementary table 1b. These ranks were based on proportions shown for each variable from the preceding table of comparison of factors across various religious groups using chi-square tests. In the analysis, we summed the-scores to assess the overall performance of the groups. This analysis showed that female Apostolics performed worst, followed by people of no religion then other Christians. The other three in that sequence are Protestant and Roman Catholic then the Pentecostal fared best with regards to risk factors and understanding of HIV issues. Statistical comparison of the scores using oneway analysis of variance showed some difference (p<0.001). The Bonferroni posthoc tests shows that, the actual difference exists between the worst three and any member of the best three religions (p<0.001). This similar approach described above was conducted for males (see supplementary tables 2a and 2b). The ranking results from males follows a similar trend from worst to best that being Apostolics followed by No religion, Other Christians, Protestant, Roman Catholic and then Pentecostal (p<0.001).
Table 3: Multivariate stepwise backward elimination model results for females: final model using ZDHS 2015 data.
Variable
|
Adjusted Odds Ratio
|
95% CI
|
P Value
|
Ever tested for HIV
|
1.283
|
1.134-1.451
|
0.001
|
Know where to get tested
|
0.665
|
0.503-0.880
|
0.004
|
HIV transmission can be reduced by having 1 sexual partner
|
0.900
|
0.765-1.059
|
0.205
|
Men can reduce HIV transmission by being circumcised
|
0.863
|
0.781-0.955
|
0.004
|
Circumcised men who have sex without condom can get HIV/AIDS
|
0.633
|
0.579-0.693
|
0.001
|
Can get HIV from sharing food
|
1.203
|
1.012-1.429
|
0.036
|
Can get HIV by witchcraft or supernatural means
|
1.134
|
0.943-1.362
|
0.181
|
A healthy person can be HIV infected
|
0.814
|
0.719-0.921
|
0.001
|
Would be ashamed if a family member gets infected with HIV
|
1.110
|
0.970-1.270
|
0.129
|
Would buy vegetables from a vendor with HIV
|
0.817
|
0.729-0.915
|
0.001
|
Children with HIV should be allowed to attend school with children without HIV
|
0.804
|
0.680-0.950
|
0.011
|
Table 4: Multivariate stepwise backward elimination model results for males: final model using ZDHS 2015 data
Variable
|
Adjusted Odds Ratio
|
95% CI
|
P Value
|
Ever tested for HIV
|
0.825
|
0.743-0.916
|
<0.001
|
Know where to get tested
|
0.637
|
0.502-0.809
|
<0.001
|
Circumcised men who have sex without condom can get HIV/AIDS
|
0.771
|
0.665-0.895
|
0.001
|
Would be ashamed if a family member gets infected with HIV
|
0.709
|
0.616-0.816
|
0.001
|
Wife justified to ask husband to use a condom if he has an STI
|
0.851
|
0.748-0.967
|
0.014
|
Responded circumcised
|
0.773
|
0.675-0.885
|
0.001
|