HIV/AIDS Survey in Southern Angola

by Dr. Martin Chitsama, Joao Artur Dumba, Charlotte Mabhiza-Berejena and Nzola Dimbu
[ Demining HIV/Aids Partnership ] - view pdf

Deminers in Angola have a higher than average risk for HIV infection and transmission as a result of their work in border areas and their high mobility. The Demining HIV/AIDS Partnership conducted a Knowledge, Attitudes, Behaviors and Perceptions survey to explore deminers’ HIV/AIDS knowledge in Cassinga, southern Angola. Among other conclusions, the results stressed the need for an increase in HIV/AIDS education.

The necessary mobility of deminers across Angola may increase the spread of HIV/AIDS across a country with a low HIV-prevalence rate. This survey, conducted by the Demining HIV/AIDS Partnership in 2011, explores the HIV/AIDS-related knowledge, attitudes, behaviors and perceptions among deminers in southern Angola. The Demining HIV/AIDS Partnership is a coalition of international HIV/AIDS nongovernmental organizations comprised of the Demining HIV/AIDS Service Foundation (South Africa) and the Organization of National Humanitarian Aid (Angola).

The survey was conducted with the intention of stimulating evidence-based HIV/AIDS strategies targeting the landmine clearance sector and impacted communities around the world. The survey provides interesting and useful details about how lack of HIV knowledge leads to misconceptions and fear of people living with HIV, often resulting in stigma and discrimination. The results also provide key information regarding the interviewed deminers understanding of HIV/AIDS, and the ways in which their understanding (or lack thereof) affects their attitudes and behavior, including sexual associations while on demining contracts and attitudes toward HIV, HIV testing and people living with HIV.

According to the U.S. Agency for International Development, “The countries of Southern Africa have some of the highest HIV prevalence rates in the world, and the region remains the global epicenter of the epidemic… According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), nine countries in Southern Africa continue to bear a disproportionate share of the global AIDS burden: All except Angola have an HIV prevalence greater than 10 percent and have some of the highest HIV prevalence rates in the world.”1

Issues relating to HIV/AIDS and deminers have international dimensions, which are reinforced by the Interagency Coalition on AIDS and Development's observations and recommended intervention programs for the sector published in a factsheet in 2002–2003.2 In Mozambique, the Accelerated Demining Programme claims it lost 10 deminers to HIV/AIDS, but only one deminer to a mine accident.3

Relatedly, the labor laws in some countries, such as Mozambique, reveal the legal difficulties that demining companies face regarding HIV tests. In June 2005, the Ministry of Public Administration, Labour and Social Security fined the U.S.-based demining company RONCO Consulting Corporation after discovering that RONCO required Mozambican sappers to take HIV tests when selecting them for a demining mission to Afghanistan.4

Demining and AIDS in Angola

The well-developed landmine clearance sector in Angola employs local and international deminers. Decades of war in Angola, from the 1970s to 2002, left an estimated 20 million landmines in Angolan soil. Norwegian Peoples Aid, Menschen gegen Minen (People Against Landmines), The HALO Trust, MAG (Mines Advisory Group), DanChurch Aid, Handicap International, Santa Barbara and other agencies trained thousands of deminers in Angola over the past two decades. The Instituto Nacional de Desminagem (National Institute of Demining) in Angola, supported by the United Nations Development Programme, trains thousands of Angolans in manual demining, mine detection dog handling and mechanical-demining support asset skills at the INAD School in Luanda. Angola has thousands of deminers removing landmines across the country. Clearance efforts are priorities in all of Angolas 18 provinces.

As a result of clearance needs, deminers are a highly mobile population. Angolan deminers are vulnerable to HIV infection and are in turn a potential vector of HIV transmission. According to the International Organization for Migration, “… mobile populations in general—have played a significant role in the initial spread of HIV in the southern African region. The largely seasonal or temporary character of migration in southern Africa, with migrants returning home to their families on a regular basis, has facilitated the rapid spread of the virus. However, the fact that population movement distributes HIV has become less relevant in the current stage of the AIDS epidemic in southern Africa (with extremely high HIV prevalence levels in the population in general). Migrants are no longer agents that help to spread HIV, but have become individuals at high risk. Several studies have shown that migrants are more vulnerable to HIV infection than their non-migrant counterparts.”5

USAID further explains the situation: “With an estimated 2 percent of the adult population living with HIV, Angola has one of the lower HIV prevalence rates in sub- Saharan Africa… Since the war, however, movement has become less restricted, and the likelihood of HIV reaching once-isolated communities has increased… Data collected from women attending antenatal clinics suggest the intensity of the HIV epidemic varies among Angolas different provinces, with the highest rates of infection occurring in the areas bordering Namibia, along the transport route to Luanda, and along the border of the Democratic Republic of the Congo; the lowest rates are found in the center of the country.”6

Methodology

To examine the HIV/AIDS realities and risks to deminers in Angola, the Demining HIV/AIDS Partnership conducted a targeted survey. The survey included 45 indepth interviews with deminers in Cassinga in southern Angola. All respondents were male Angolan deminers employed by Vanguard Demining Services on the Tchamutete Demining Project in the Huila province. The interviews were conducted at the VDS Tchamutete Base Camp in a six-week period from August to October 2011. All interviews were conducted in Portuguese, and each interview took approximately three hours to complete. Joao Artur Dumba translated the research tool and the survey responses into English.

Demographics

The respondents were between the ages 20 and 49 and self-identified as sexually active. They came from the Benguela, Cunene, Huila, Kuando Kubango, Kwanza Sul and Malanje provinces. The following shows the respondents education:

Image 1. Dog, handler and supervisor; observer with camera in the background. All photos courtesy of the authors.Figure 1. Participants' ages.
All photos courtesy of the authors.
Image 1. Dog, handler and supervisor; observer with camera in the background. All photos courtesy of the authors.Figure 2. Participants' number of wives.

The mean duration of demining work experience in the survey population was eight years. Only 25 percent of participants believed their salary levels to be poor, while 75 percent of participants found their salary levels satisfactory.

Over the past five years, 31 of the deminers said they spent nine months each year living in demining camps, and 14 deminers reported that they lived in camps for at least six months each year. All respondents lived in tents, returning home once every three months for two weeks. Their work conditions did not allow their spouses to visit. All 45 respondents also said they would opt out of demining if alternative, closer-to-home opportunities arose.

All respondents said they were circumcised through cultural initiation rites. The deminers reported their marital status as follows:

Six deminers said they had no sexual partners outside marriage, 36 deminers had one regular sexual partner outside marriage and three said they had at least two regular sexual partners outside marriage. Nearly all (43) of the 45 interviewed deminers said they had sexual partners while on demining contracts. Two respondents said they never had sexual partners while on demining contracts. More than half, 28 deminers, said they had a sexually transmitted infection previously.

Results

Basic HIV/AIDS knowledge. All interviewed deminers confirmed that HIV and AIDS exist, and all respondents said that no treatment exists for AIDS. The following shows the breakdown of responses when asked about the transmission of HIV/AIDS:

All stated that prolonged coughing, diarrhea, weight loss and hair changes are AIDS symptoms. The respondents identified these high-risk groups:

The deminers reported their sources for HIV/AIDS information:

Deminers attitudes toward HIV prevention, testing and stigma. To prevent HIV infection, the respondents listed the following actions:

The majority, 43 of the deminers, said they get condoms from health centers, 37 said they buy condoms from shops, six said they get them from their partners. Two deminers said they get condoms from the demining workplace.

Regarding other HIV transmission methods, 28 deminers said they do not share shaving kits. Most, 39 of the 45 deminers interviewed, said they had evacuated a landmine-injured colleague in the past. All deminers involved said they had not worn gloves during the casualty evacuation process.

HIV testing and stigma. Of those interviewed, 32 said they had HIV tests in the past, were prepared to take regular HIV tests and would encourage their sexual partners to test for HIV as well. Deterred by fear of what their sexual history could mean for HIV test results and the stigmas and responsibilities that come with a positive result, 12 deminers said they had not taken HIV tests in the past. All of the interviewed deminers said they would visit a health center for advice if they suspected they became HIV-infected.

Seven deminers said they would separate from a sexual partner exhibiting AIDS symptoms, while 25 said they would continue with the relationship but advise their partner to visit a health center. Slightly more than one-third, 17 deminers, said they would abandon sexual relationships with a partner if HIV test results are discordant, while 28 said they would seek advice from health centers. Twenty-nine of the deminers accept HIV/AIDS-affected people as normal, while 16 said HIV-positive people should be avoided. Twenty-one of the deminers said they discuss HIV/AIDS issues with their families; 24 said they do not.

HIV/AIDS Facts

  • HIV is a virus that attacks the immune system. AIDS is a syndrome where the body has a reduced ability to fight infection and disease.
  • HIV cannot be transmitted by touching another infected person or through kissing, unless one or both people has an open mouth sore that is bleeding
  • HIV can be transmitted through interchange of blood or bodily fluids with an HIV infected person, primarily in cases of:
    • Unprotected sex (vaginal, anal or oral)
    • Sharing needles with other people
    • Transmission between mother and child during pregnancy, childbirth or nursing
  • 34 million people live with HIV in the world
  • There are therapy programs that can stop HIV virus from reproducing in the body.9

Analysis

The responses reveal that deminers would prefer to work closer to home. However, due to limited employment options, they are compelled to continue with this trade.

Almost all surveyed deminers admitted having sexual partners while on demining contracts. The history of STIs in 66 percent of the study population adds up to a high-risk HIV-transmission scenario. Persons with STIs are more susceptible to HIV infection and are more likely than uninfected persons to spread HIV to their sexual partners. The majority of deminers admitted to earning sufficient funds, making possible the purchase of sexual favors. While most deminers mention condom usage as a means of protecting oneself against HIV/AIDS, condoms are largely unavailable at the demining workplace. Additionally, 10 percent of the interviewed deminers mentioned that they never use condoms. Safe sex education needs to be conducted regularly for deminers, including provision of workplace condoms.

The deminers main sources of HIV/AIDS information are the media and health centers, which 42 of the 45 deminers identified as their greatest source of information. However, these resources are often not easily accessible to deminers. Comparatively, only 20 of the 45 deminers identified the demining workplace as a resource center for information about HIV/AIDS. The respondents demonstrate a limited understanding of the messages, considering that questions on HIV/AIDS existence, treatment, prevention and transmission resulted in typical answers. The demining workplace is clearly falling short in providing HIV/AIDS education and condoms to landmine clearance workers. Failure by all deminers who previously assisted in casualty evacuation to put on gloves demonstrates a high risk to HIV occupational exposure when deminers come in contact with blood and bone fragments during evacuation of injured colleagues.

All deminers who were interviewed were circumcised through cultural initiation rites, thus suggesting better protection from HIV transmission. According to the World Health Organization, “There is compelling evidence that male circumcision reduces the risk of heterosexually-acquired HIV infection in men by approximately 60% … WHO/UNAIDS recommendations emphasize that male circumcision should be considered an efficacious intervention for HIV prevention in countries and regions with heterosexual epidemics, high HIV and low male circumcision prevalence.”8 Voluntary male circumcision should be encouraged and supported among deminers and local communities in Angola. Keeping employees healthy is in the best interest of demining companies, and this could be accomplished with a policy change that incorporates the procedure into medical and surgical care already provided by the company.

The majority, 72 percent of the deminers, said they took HIV tests in the past. This positive attitude toward HIV testing needs sustainment through continued HIV/ AIDS education for deminers. With 30 percent of deminers saying they would avoid HIV/AIDS-affected persons, stigmatization of HIV/AIDS and of the positive HIV state among deminers is apparent. HIV/AIDS-destigmatization advocacy needs promotion in the demining sector. This challenge of stigma and discrimination in the deminers is reflected in broader Angolan society: “A 2003 KAP [knowledge, attitudes and practices] study reported nearly half of all young people (and more than two-thirds of those with no education) said they would refuse to buy food from a local shopkeeper whom they knew to be HIV positive. Similarly, more than one-third of all young people (and nearly two-thirds of those with no education) would refuse to share a meal with an HIV-positive person. According to the 2005–2006 KAP study, 80 percent of youth interviewed showed some discriminatory tendencies toward HIV-positive individuals.”6

Conclusion

Image 1. Dog, handler and supervisor; observer with camera in the background. All photos courtesy of the authors.
Figure 3. Map of Angola: The borders for international routes A and B have been opened up. Deminers working in southern
and eastern Angola are part of the emerging HIV/AIDS hot spots along the Namibian and Zambian border regions. Apart from
deminers, there is a huge presence of international workers, truckers, the military, informal traders and construction workers
in these regions.
Map courtesy of the authors/CISR.

According to USAID, “Other conditions that increase the risk of continuing the spread of the virus in Angola include mobility among the 4 million people currently internally displaced by the war; high levels of civilian contact with military personnel; low levels of education; extreme poverty; limited female autonomy; weak social networks and public services; and cross-border interaction with Namibia and Zambia, where HIV prevalence rates are 13.1 percent and 13.5 percent, respectively, according to UNAIDS.”6

This study attempted to identify an occupation that exhibits traits characteristic of a high-risk HIV group. The demining workplace has insufficient HIV/AIDS prevention and education services for deminers. Deminers need continuous education on safe sexual practices, and demining companies must deliver HIV/AIDS services to their workers and local communities. HIV/AIDS hot spots emerging in Angola are illustrated in Figure 3.

Hard-to-reach mobile groups such as deminers, which are often invisible and inaccessible to the public-health eye, partly drive the HIV/AIDS pandemic. With HIV/AIDS programs hardly reaching deminers, they are silent HIV transmission vectors. Such groups threaten to reverse gains made in the global HIV/AIDS mitigation drive. Efforts must be made to identify such HIV high risk groups and engage them in traditional HIV/AIDS intervention efforts.

Reprinted with permission from Demining HIV/AIDS Partnership. The authors appreciate the permission and support they received from Vanguard Demining Services Project Manager Johannes Van Schalkwyk and Technical Adviser Johan Strydom to conduct the survey. They would like to thank the deminers who participated in the survey for their consent and for the time donated by Farirai Berejena, Demining Supervisor Joao Bango, Dr. Tamuka Chivonivoni (Elizabeth Glaser Pediatric AIDS Foundation), Dr. Desire Mangama (Zagope-Brazil), Dr. Silence Gavi (Zimplats), Dr. Panganai Dhliwayo (Centers for Disease Control) and Kinirosi Dimingo for giving valued advice on the study.

 

Biographies

Dr. Martin ChitsamaDr. Martin Chitsama holds Bachelor of Medicine and Bachelor of Surgery medical degrees and attained an Executive Certificate in Strategic HIV/AIDS Project Management from the University of Zimbabwe. He has 14 years experience working as a medical advisor in landmine clearance operations in Africa (Angola, Eritrea, Mozambique, Somalia, Sudan and Zimbabwe). Dr. Chitsama is a member of the Board of Trustees of the U.K.-based Landmines HIV/AIDS Trust. He is also the director for the Global Landmines HIV/AIDS Program.



Joao Artur DumbaJoao Artur Dumba has worked in demining for the past 13 years. In mine action he holds an international qualification diploma for IMAS Level 3 Explosive Ordnance Disposal acquired at the International Mine Action Training Centre in Kenya and a demining supervisor diploma from Norwegian Peoples Aid Angola. He has held positions as Deputy Director of the NPAs Mine Dog Training Centre Angola and as a Technical Advisor in Sudan working with Norwegian People’s Aid, Vanguard Demining Services/MECHEM and the UNDP.

Charlotte Mabhiza-BerejenaCharlotte Mabhiza-Berejena has a Bachelor of Business Management and Information Technology (Honors) degree from the Catholic University in Zimbabwe and a postgraduate diploma in International Development Studies from Bindura University of Science Education. She has seven years of information technology and computer networking experience. Her interest in community development grew while working in the telecommunications industry in Namibia and Zimbabwe, where she realized how technology enriched people's lives.



Nzola DimbuNzola Dimbu is a qualified clinical officer trained by Norwegian People's Aid Angola. He was formerly the deputy program manager of the Comité Regional Sul Para O Desenvolvimento (Demining Committee for Southern Regional Development) in Angola. He is a founding member of and technical advisor to the National Demining Society and Mineral Protection in Angola. Dimbu has vast experience working in HIV/AIDS projects in public and private sectors and nongovernmental organizations in Angola and the Democratic Republic of the Congo. Dimbu is the President of the Organization for National Humanitarian Aid in Angola.



Contact Information

Dr. Martin Chitsama
Director Global Landmines HIV/AIDS Program
Landmines HIV/AIDS Trust UK
310 Hitchen Road
Henlow Camp
Bedfordshire SG16 6DP / United Kingdom
Tel: +244 93 2268 772
Email: martin@landmineshivaids.ws
Website: http://landmineshivaids.ws

Joao Artur Dumba
Public Relations Officer
Vanguard Demining Services
Rua Albano Machado No. 6
Luanda / Angola
Tel: +244 92 6199 553
Email: joaodumba@yahoo.com.br

Charlotte Mabhiza-Berejena
Service Desk Analyst
Pomeroy IT Solutions
2D 786 Ravine Circle
Southgate, KY 41071 / USA
Tel: +1859 444 0328
Email: cmabhiza@gmail.com

Nzola Dimbu
President
Organization for National Humanitarian Aid
Bairro Tchioco Zona 1
Lubango / Angola
Tel: +244 939 145 735
Email: ondah92@yahoo.com.br

 

Endnotes

  1. “USAID HIV/AIDS Regional Health Profile for Southern Africa - February 2011.” USAID (February 2011). http://transition.usaid.gov/our_work/global_health/aids/Countries/africa/southernafrica_profile.pdf. Accessed 3 June 2012.
  2. “Implementing the UN’s Declaration of Commitment on HIV/AIDS: A Guide for Canadian AIDS Service Organizations.” Interagency Coalition on AIDS and Development. http://www.icad-cisd.com/pdf/e_ungass_factsheet_revised_May_23_2003_final.pdf. Accessed 8 October 2012.
  3. “Landmine Removal: Restoring Land, Restoring Lives.” United Methodist Committee on Relief. http://gbgm-umc.org/umcor/stories/landmineremoval.stm. Accessed 29 April 2012.
  4. “Strengthening the demining sector response to HIV/AIDS in Sub-Sahara Africa.” The Journal of ERW and Mine Action, Issue 14.3 (2010). Chitsama, Martin. http://www.maic.jmu.edu/
    journal/14.3/notes/chitsama/chitsama.htm
    . Accessed 29 May 2012.
  5. “Mobile Populations and HIV/AIDS in the Southern African Region.” International Organization for Migration (August 2002). Brummer, Daan. http://www.sarpn.org/documents/d0000587/Labour_migration_HIV-AIDS.pdf. Accessed 01 June 2012.
  6. “USAID Health: HIV/AIDS, Countries, Angola.” USAID (January 2011). http://transition.usaid.gov/
    our_work/global_health/aids/Countries/africa/angola_profile.pdf
    . Accessed 3 June 2012.
  7. “Sharps” refer to any object capable of puncturing or lacerating the skin. For more information see: http://www.ehs.ku.edu/Files/Forms/Lab_Safety/Sharps%20disposal%204.pdf. Accessed 1 October 2012.
  8. “Male Circumcision for HIV Prevention.” http://www.who.int/hiv/topics/malecircumcision/en/index.html. Accessed 23 May 2012.
  9. “10 Facts on HIV/AIDS.” World Health Organization. http://www.who.int/mediacentre/
    factsheets/fs360/en/index.html.
    Accessed 26 October 2012.

 

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