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HIV & AIDS in Zambia
Zambia, in southern Africa, has one of the world’s most devastating HIV and AIDS epidemics. More than one in every seven adults in the country are living with HIV1 and life expectancy at birth has fallen to just 49.4 years.2 In 2011, nearly 42,000 adults and 9,500 children were newly infected with HIV, that is about 115 new infections each day.3 After four decades of independence, Zambia has found peace but not prosperity and today it is one of the poorest and least developed nations on earth.
Zambia's first reported AIDS diagnosis in 1984 was followed by a rapid rise in the number of people living with HIV. Although Zambia has received hundreds of millions of dollars for HIV programmes from rich country governments, HIV prevalence has not dropped significantly, remaining more or less stable since the mid-nineties. As of 2011, overall HIV prevalence was 13 percent, however, it has been reported as considerably higher in some urban areas.4 5
The impact of HIV in Zambia
Unlike in some countries, HIV in Zambia does not primarily affect the most underprivileged; infection rates are very high among wealthier people and the better educated. HIV is most prevalent in the two urban centres of Lusaka and the Central Province, rather than in poorer rural populations.6 7
The collapse of copper prices in the 1970's weakened Zambia's economy and saw an increase in the number of men seeking work away from home. The movement of miners, seasonal agricultural workers and young men between rural areas and urban centres has been shown to spread HIV to new areas.8 Zambia is now the most urbanised country in sub-Saharan Africa, with only a third of its population living in rural areas.9
The impact on women
Although the HIV epidemic has spread throughout Zambia and to all parts of its society, some groups are especially vulnerable - most notably young women and girls. Among young women aged 15-24, HIV prevalence is more than twice that of men in this age category.10
A number of factors resulting from gender inequality contribute to the higher prevalence among women. Women are often taught never to refuse their husbands sex or to insist their partner uses a condom. In a Zambian behavioural survey, around 15 percent of women reported forced sex, although this may not reflect the true number as many women do not disclose this information.11 In addition, young women in Zambia typically become sexually active earlier than men, with partners who will be on average five years their senior and who may already have had a number of sexual partners.12 An estimated 15 percent of men and women aged 15-24 years, were younger than 15 years the first time they had sex.13
In 2011, a long awaited law protecting women from gender violence was enacted.14 It is hoped the Anti Gender Based Violence Act, outlawing gender-based violence, such as, physical, sexual, economic and psychological violence, will reduce the increased risk of HIV infection faced by women.
The impact on economic productivity
The impact of AIDS has gone far beyond the household and community level. All areas of the public sector and the economy have been weakened, and national development has been stifled. As Zambia's Poverty Reduction Strategy Paper acknowledges, "the epidemic is as much likely to affect economic growth as it is affected by it".15
The loss of workers due to AIDS can lead to a large reduction in a nations economic productivity. Agriculture, from which the vast majority of Zambians make their living, is particularly affected by the impact of AIDS. A decline in the number of individuals able to work at the crucial periods of planting and harvesting can significantly reduce the size of the harvest. AIDS is believed to have made a major contribution to the food shortages that hit Zambia in 2002, which were declared a national emergency.16 17
The impact on children
Children have been much affected by the AIDS epidemic in Zambia, where 170,000 children are estimated to be living with HIV.18 However, being HIV infected is not the only way that children are affected by HIV and AIDS. In 2009 there were 690,000 AIDS orphans in the country19 and AIDS orphans made up half of all orphans in the country.20 Children may be abandoned due to stigma or a simple lack of resources, while others run away because they have been mistreated and abused by foster families.21
In 2003, it was revealed that increasing numbers of child rape cases were being fuelled by the "virgin cure" myth (which wrongly claims that sex with a virgin can cure AIDS).22 A 2005 study by the Applied Mental Health Research Group (part of the John Hopkins School of Public Health) reported that child sexual abuse was "a major problem" among the HIV-affected population of mothers and children studied in Lusaka, Zambia.23
HIV prevention in Zambia
HIV and AIDS prevention through awareness-raising began early in Zambia. An American journalist in 1988 reported, "Zambia is waging one of the world's most aggressive educational campaigns against AIDS, surpassing anything being done in the United States".24 Much of the early campaign involved pamphlets and posters that warned of the dangers of AIDS and promoted abstinence before marriage, for example: "Sex thrills, but AIDS kills".25 Over the years, a wide range of media has been used to carry messages about AIDS, and children have been taught at least the biological facts in school.
Condoms and abstinence
It has been conclusively proven that condoms are highly effective at preventing sexual HIV transmission, when used correctly and consistently. Nevertheless, the role of condoms in curbing the spread of Zambia's epidemic has been a subject of prolonged controversy in this mainly Christian nation. In 2002 the three main churches in Zambia passed a resolution endorsing condom use for preventing HIV transmission between married couples. In all other cases the churches encourage abstinence only, which many AIDS experts consider to be an ineffective approach:
"We do appreciate the crucial role the Church has continued to play in building good moral values in our society and its active role in home-based care; however, the Church could do even more if it stops treating the condom as an instrument of immorality but a life saving device." - Chris Zimba of Youth Change Impact.26
Additionally, top government officials have publicly criticised condom use. Near the end of his presidency, Frederick Chiluba said, "I don't believe in condoms myself because it is a sign of weak morals on the part of the user".27
Although total condom sales more than doubled from 4.7 million in 1993 to 10.6 million in 2002,28 the use of condoms remains infrequent, especially in rural areas. One issue is availability and affordability: many villages are miles from the nearest outlet. Issues of stigma, lack of knowledge, and gender inequality also present major obstacles to people using them. More recently, total condom distribution has been dropping in Zambia, particularly in non health facilities where condom distribution dropped by 46 percent in 2007 and then a further 10 percent in 2008.29 Although condom distribution from health facilities went up by 13 percent in the same period, this general decline does not bode well for efforts to promote better sexual health in a country where condom use is not widespread. Only 1 in 10 men and women who engaged in higher risk sex (those had more than one sexual partner in the last 12 months) reported using a condom with their last partner.30
There are still many misconceptions about HIV and AIDS in Zambia. In 2009 only around one third of young people aged 15-24 had comprehensive HIV/AIDS knowledge.31
If behaviour is to be changed, young people must be a priority target. It is often said that Zambia's youth offer the nation a "window of hope" – the hope of an AIDS-free future. Nearly half of all Zambians are between 0 and 14 years old;32 relatively few of these young people have HIV, and they are all eager to learn. Effective education therefore has the power to change attitudes and behaviour for life.
Unfortunately, the government has not always taken the lead:
"It must be acknowledged that the Ministry of Education has made a late start on interventions, mainly because HIV/AIDS was generally viewed as a Health issue." - Ministry of Education, September 200033.
In recent years the Ministry has sought to better integrate AIDS education into more parts of the school curriculum. A government case study in 2009 showed that about two thirds of teachers had knowledge about HIV and AIDS education and could integrate them into their lessons but that many did not, and lacked sufficient resources or the skills to use them.34 In those schools where life based skills HIV and AIDS education was provided, the response has been very positive. However, 17 percent less 15-24 year olds were reached with HIV and AIDS education in 2008 compared to 2006, so there is obviously a need to step up these efforts if sustainable prevention efforts are to succeed.35
Preventing mother-to-child transmission
Zambia's prevention of mother-to-child transmission (PMTCT) initiative was launched in 1999, beginning with a three-year pilot programme in Copperbelt Province. In 2004 it had expanded so that 74 health facilities in four provinces offered antiretroviral drugs (primarily nevirapine) to expectant mothers and newborn infants, increasing to 939 by the end of 2008. In 2007 an estimated 47 percent of pregnant women living with HIV received ARVs for preventing mother-to-child transmission. By the end of 2011, 95 percent of pregnant women received the most effective antiretroviral regimens (i.e. not single-dose nevirapine, which is no longer recommended by WHO) to prevent transmission to their baby.36
Zambia's commitment to providing antiretroviral prophylaxis to HIV-positive pregnant women has been rewarded; a vast reduction in annual new HIV infections among children is evident between 2009, when 21,000 children were newly infected, and 2011, when 9,500 children were newly infected.37
Other strategies (past and present) :
- In the late 1980s, one school in Zambia became perhaps the first in the world to set up an Anti-AIDS club, and by 1992 there were 1,150 registered clubs.38 Members are encouraged to spread messages about safer behaviour and compassion for those living with HIV. So long as their influence extends beyond their membership and reaches the most vulnerable children, Anti-AIDS clubs can be very effective.
- Television, radio and the press have also proved to be influential in raising awareness, even though not all people have direct access to them. Some 71 percent of urban and 37 percent of rural youth saw at least some of the HEART television campaigns in 2000, and it seems that their behaviour was influenced as a result.39
- Music, drama, group discussions and role play exercises have been employed by the Copperbelt Health Education Project (CHEP) to raise AIDS awareness, particularly in rural areas. In 2003, through its in-school youth programme, the CHEP educated some 25,000 students using these methods. Peer-centred education also reaches sex workers, street children and soldiers, and the CHEP has established youth-friendly health services, in which trained peer educators work alongside clinic staff.40
- Truck drivers have been identified as key players in the spread of HIV due to the high levels of mobility along main transport routes. Prevention programmes targeting this high-risk group seem to have had a positive effect on behaviour: reported condom use for truck drivers increased from around 50 percent in 2000 to almost 70 percent in 2006.41 'Corridors of Hope' is a project funded by USAID and implemented by RTI International and Family Health International. It aims to reduce HIV transmission among transportation corridor communities in seven countries, including Zambia.42
HIV testing in Zambia
Just 15 percent of Zambian adults aged 15-49 received a test in the last 12 months and know their HIV status.43 Those who do not know they are infected with HIV can spread the virus to others before they become ill. Moreover, those who are not diagnosed early may not get the treatment and care they need. Because they fear stigma and social rejection many people are reluctant to come forward to be tested, waiting instead until they fall ill. People may also not go for testing because they cannot see the advantage of knowing their status – especially if they are unlikely to receive antiretroviral therapy.44 Even those who want to be tested may find that accessing services is difficult or costly. The extremely low level of HIV testing in Zambia has been highlighted as one of the main reasons people are failing to access HIV treatment.45
In early 2001, Zambia's largest mining company, Konkola, caused much controversy by forcing hundreds of its employees to undergo anonymous HIV tests. Many groups complained that the miners might suffer discrimination as a result. However, the company insisted that without this action it would be unable to plan its future operations and improve the health of its workers. Results from the testing programme found that 18 percent of the 8,532 employees were infected with HIV.46
In 2004 Zambia's National AIDS Council called for mandatory HIV/AIDS testing in all hospitals in an effort to control the epidemic. Their views provoked strong criticism from human rights activists and people living with HIV, who saw mandatory testing as a breach of human rights.47 In 2005, the Zambian government stated that it would not encourage anonymous (without consent) testing and it would discourage mandatory testing for employment and scholarships.48 It would, however, encourage (VCT) voluntary counselling and testing, and promote universal routine counselling and testing (i.e. routine opt-out testing) of all at-risk patients entering a health facility.
As of 2009, all 1,563 private and public health facilities in the country offered VCT services. In that year more than one and a half million people aged 15 and over were tested for HIV and received their results; double that of the previous year and quadruple that of 2006.49 In 2010, the number of HIV testing and counselling facilities expanded further to a total of 1,689. Unfortunately, this increase in facilities did not result in an overall increase in the uptake of HIV testing and counselling in 2010, with reports showing that the number of people who received HIV testing and counselling was 200,000 people less than in 2009.50
HIV and AIDS treatment in Zambia
State provision of antiretroviral therapy began in Zambia in late 2002, although initially very few people could afford the monthly payments towards the drugs. Provision of free treatment started in June 2004,51 made possible by an unprecedented amount of funding from the Global Fund (in 2004 it committed $254 million over 5 years), PEPFAR (Zambia is one of the programme’s most highly funded focus countries, receiving $149 million in 2006 alone) and other sources. The delivery of the programme relies on the involvement of many NGOs, churches and communities.
At the end of 2011, 82 percent of the 510,000 people in Zambia needing ARV treatment were receiving it.52 This estimation of treatment coverage is based on the 2010 WHO guidelines. Although access to antiretroviral treatment is high and increasing among adults, coverage among children remains worryingly low, with only 1 in 3 children in need of treatment receiving it in 2011.53 However, the Ministry of Health has further increased access to treatment by creating 68 new antiretroviral therapy (ART) sites in addition to supplying drugs to all existing ART sites nationwide in 2013. As a result of this, and support from the Global Fund, approximately 400,000 people now have access to free treatment. 54
Ultimately, Zambia aspires to provide universal treatment access, so that ARV therapy is equally available to everyone who is clinically eligible. However, some current schemes try to make it easier for particular groups to gain access, including civil servants, teachers, university students and mothers and children (through "PMTCT Plus"). Additionally, some employers run private schemes – particularly the mining companies. In general, accessing treatment is a great deal easier for city-dwellers than for those living in rural areas.
The treatment programme's greatest handicap is the inadequacy of the healthcare system, which suffers from high patient numbers, lack of physical space and infrastructure, and – most critically – too few staff. There is a critical shortage of doctors (in 2006 there were only 646 doctors in a country of almost 12 million people), nurses, lab technicians and other health professionals. Zambia currently has under a third of the doctor-patient ratio recommended by the WHO.55
The crisis stems from a variety of factors, most notably a large-scale emigration of trained professionals to other countries in Africa and abroad, where salaries and conditions are more favourable. Zambia is now trying to recruit as many health workers as it possibly can, and has implemented a variety of initiatives to retain health staff, expand the workforce, and improve the wellbeing of doctors and nurses.56 ‘Task-shifting’ is a strategy that has been introduced to delegate certain health-care duties to lay people or community workers to reduce the workload of doctors and nurses. Still, human resource challenges are continually cited as a major impediment to effective treatment programmes.
An analysis by USAID found that the gap in finances available to achieve Zambia's country targets (increase the number of people on ART by 24 percent from 2010 to 2015) was likely to be $8.2 billion in 2011, increasing to $57 billion in 2015.57 According to 2006 data, Zambia's funding for HIV treatment comes mainly from international sources, raising the concern that Zambia's increasing level of treatment coverage may not be sustainable without consistent foreign donor support.58
HIV and AIDS funding in Zambia
In 2009, after it was revealed that donor aid to the Zambian Ministry of Health had been embezzled, Sweden and the Netherlands suspended $30 million in aid for health programmes.59 The Global Fund for HIV/AIDS, Malaria and TB also suspended more than $137 million later that year.60 In 2010, it was revealed that around $7 million from the Health Ministry had been stolen in total. The Canadian International Development Agency (CIDA) responded by suspending a $14.5 million aid program for the Health Ministry.61 Although the Zambian government reimbursed the Swedish and Dutch governments for their stolen funds, and partly reimbursed Canada, these countries had not resumed their health aid as of August 2010. They insisted that funding would not resume until certain internal reforms and audits were carried out. The Global Fund on the other hand, resumed its funding but is instead channelling it through the United Nations Development Program (UNDP).62
Almost three quarters of funding for HIV and AIDS Zambia is from foreign donors, and it has been reported that HIV programmes are amongst some of the worst affected by the corruption scandal and resulting disruptions in donor funding.63 64 The majority of Zambia's donor funding comes from PEPFAR (50 percent), followed by the Global Fund and the World Bank.65 Concern about this reliance on donor funding has been voiced by the Southern African AIDS Trust which has urged the Zambian government to scale up its funding for HIV and AIDS programmes.66
So far, Zambia has had notable success in scaling up ARV treatment. The government can take much of the credit for providing strong leadership while at the same time recognising that they cannot succeed alone. They have involved faith-based organisations, civil society and NGOs, and have also entered into a partnership with the private sector to administer some of the treatment. Zambia must continue to strive to make ARV therapy equally accessible to all those in need; the abolition of user charges was a crucial step towards this goal. However, the scale up of treatment faces serious challenges due to human resource and funding shortages.
Even if treatment scale up proceeds, it is vital that prevention programmes are also expanded. The ARV programme itself can help this process because it offers an incentive to be tested, and those who know they have HIV are less likely to infect others.
The decline in HIV prevalence among some young women suggests that some prevention campaigns may be working. However, it is clear that stigma, gender inequality and opposition to condoms remain deeply entrenched. All sectors of society must fight their hardest to change attitudes.
The history of HIV and AIDS in Zambia
Zambia’s first AIDS case was reported in 1984.67 Within two years the National AIDS Surveillance Committee (NASC) and National AIDS Prevention and Control Programme (NAPCP) were established to coordinate HIV/AIDS-related activities.
In the early stages of the epidemic much of what was known about HIV prevalence was kept secret by the authorities under President Kaunda. Senior politicians were reluctant to speak out about the growing epidemic (the President’s announcement in 1987 that his son had died of AIDS68 was a notable exception), and the press did not mention AIDS.
By the early nineties it was estimated that as many as 1 in 5 adults had been infected with HIV, leading the World Health Organization to call for the establishment of a National AIDS Advisory Council in Zambia. According to Stephen Lewis, the former UN's Special Envoy for HIV/AIDS in Africa, throughout the 1990s the government was ‘disavowing the reality of AIDS’ and doing ‘nothing’ to combat the problem.69
The new millennium signalled a marked change in political attitude and, according to Stephen Lewis, ‘an entirely new level of determination’70 to confront the epidemic. The National HIV/AIDS/STD/TB Council (NAC) became operational in 2002 when Parliament passed a national AIDS bill that made the NAC a legally-established body able to apply for funding (the prospect of a large World Bank grant provided much of the necessary motivation). At the passing of this bill, the NAC became the single, high-level institution responsible for coordinating the actions of all segments of government and society in the fight against HIV and AIDS and is in charge of guiding the implementation of the National HIV and AIDS Strategic Framework (2006-2010).
In 2004, President Mwanawasa declared HIV/AIDS a national emergency and promised to provide antiretroviral drugs to 10,000 people by the end of the year. Having exceeded this target, he set another to provide free treatment for 100,000 by the end of 2005.
Government ministers and officials at all levels are now much more willing and able to talk about the epidemic. Even former president Kaunda has changed – he is now one of the most vocal and committed AIDS activists in the country. In 2008 UNAIDS reported a stabilising of Zambia's epidemic and some evidence of favourable behaviour change.71
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