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HIV & AIDS in Zimbabwe
With around 15 percent of the population living with HIV1 Zimbabwe is experiencing one of the harshest HIV and AIDS epidemics in the world. In a country that has had a tense political and social climate over the last few decades, it has been difficult to respond to the crisis. The country has had to confront a number of severe crises in the past few years, including an unprecedented rise in inflation (in January 2008 it reached 100,000percent2), a severe cholera epidemic, high rates of unemployment, political violence, and a near-total collapse of the public health system.3
However, regarding HIV and AIDS the country is currently seeing some progress and improvements; Zimbabwe is one of the few countries where incidence has declined by 50 percent between 2001 and 2011.4 This is partially due to efforts among the population to prevent the spread of HIV, some of which have been remarkable in the context of such immense challenges:
- Between 2002 and 2006, the population is estimated to have decreased by four million people.5 The country is now seeing an annual growth rate of 2.2 percent.6
- Average life expectancy is just under 53.7
- By 2011, there were one million children living in Zimbabwe who had been orphaned as a result of parents dying from AIDS.8
HIV prevention in Zimbabwe
Efforts to prevent the spread of HIV in Zimbabwe have been spearheaded by the NAC, non-governmental, religious and academic organisations. Prevention schemes have been significantly expanded since the turn of the millennium, but remain critically under-funded. Although mortality rates have played a large part in reducing the number of people living with HIV among the population of Zimbabwe, it is believed prevention programmes aimed at behaviour change and the prevention of mother to child transmission have also been instrumental in bringing about a decline in HIV prevalence.9 10 Increases in safer sex and HIV prevention among individuals have also been spurred by the fear attached to such a high rate of AIDS-related mortalities. It has been reported that certain behaviours, such as paying for sex, are now considered less normal than they used to be, due to the associated HIV-risk.11
Children in Zimbabwe are currently taught about HIV and AIDS in schools. In 2006 the Ministry of Education, Sport and Culture, and UNICEF initiated an in-service training scheme of primary and secondary school teachers in HIV and AIDS life-skills and counselling. By the end of 2007 around 2753 primary and secondary schools had been reached by the scheme.12 Outside of school, efforts to educate and inform people about HIV and AIDS (which are often organised by NGOs) have used a number of different means to convey prevention messages, including leaflets,13 television and radio, drama, and community groups.
With around half of the people living with HIV in Zimbabwe becoming infected during adolescence or young adulthood14, education campaigns have primarily targeted young people. As a result, knowledge about HIV and AIDS is higher than the average for sub-Saharan Africa.15 A greater understanding and awareness of HIV and AIDS is thought to lead to changes in sexual behaviour, which has been shown to reduce the number of new HIV infections. However, it has been reported that the proportion of young women with multiple sexual partners has increased recently, suggesting that the pattern of safer sex practices is not all encompassing and education needs to continue to reach more young people.16 As 75 percent of deaths among hospitalised adolescents are attributed to HIV and AIDS,17 it is important that more young people understand the importance of knowing their status so they can access life-saving drugs if needed.
Voluntary counselling and testing
The government emphasised the importance of voluntary counselling and testing for HIV (VCT) in its National AIDS Policy in 1999. Between 2005 and 2010 the total number of health facilities offering HIV testing and counselling increased from 395 to 121818 19, with 1.8 million people testing in 2011.
Whilst the increase in testing centres is great progress, a diverse approach is necessary to ensure that the specific testing needs of the population are met. Evidence shows that the implementation of community based VCT can significantly increase the number of people accessing treatment for the first time. A study of communities with access to both community based and standard clinic based VCT found that more than half of individuals testing for HIV had never been tested before, compared with only 5 percent of those being tested in communities with only standard clinic based VCT.20This suggests that community based VCT is a viable option for increasing HIV testing in areas where uptake of testing is low.
However, there is still a strong reluctance to access testing amongst much of the population. People living with HIV face a particularly high level of discrimination in Zimbabwe, and many people fear that if they are found to be HIV-positive they will be victimised. In places where there is little access to ARVs, some see testing as pointless, as one HIV-positive woman described to reporters in 2006:
“I said [to the doctor]: "Why have you tested me - you have just put me on a death sentence because I'm scared now because I know I am HIV positive. If you test me, it was to give me tablets." Here in Zimbabwe we don't have something like that. We don't have tablets”21
In 2007, the government shifted focus from voluntary testing to provider-initiated testing, meaning that whenever a person visits a healthcare facility, they will be offered HIV testing as part of the hospital service. Dr Mugurungi, Head of the AIDS and TB Unit in the Ministry of Health and Welfare, believes that the new testing regulation will mean that a greater number of people will know their status, which will help "both the service provider and the infected person to plan effectively on either living positively or maintaining a negative status."22
However, consultation fees charged in state public health institutions are deterring people from accessing any health services, including HIV testing and treatment, until their immune systems have become very weak.23 This is problematic not only for the patient, but for efforts to prevent further HIV transmission. In 2010, Mugabe advocated for testing the entire population. However, there are currently laws against implementing forced testing and human-rights based arguments against such an approach.24
The fear of being tested for HIV also has implications for the national blood supply. It has been reported that most of the country's blood supply is donated by school children, as many adults are afraid of finding out they are HIV positive, and therefore do not donate blood.25
HIV prevalence among pregnant women (aged 15-49) is 16 percent and mother-to-child transmission accounts for the highest number of HIV infections, after heterosexual sex (the primary route of transmission).26 27 In Zimbabwe, around 14,600 children are infected with HIV every year,28 the majority through mother-to-child transmission. As with VCT, the provision of services to prevent the transmission of HIV between mothers and their children during pregnancy is gradually being scaled up. The prevention of mother-to-child transmission (PMTCT) pilot programme was launched at four sites in 1999 and today the programme is nationwide. It aims to provide pregnant women with free VCT and give them access to antiretroviral drugs, which significantly decrease the chance of transmission occurring.
The provision of drugs to prevent MTCT rose from 6.6 percent in 2005 to 52 percent in 2011.29 30 Today, 81 percent of pregnant women are receiving antiretroviral treatment for PMTCT.31 Approximately 25 percent of infants born to HIV infected mothers are also infected32 and an estimated 200,000 children are living with HIV in Zimbabwe, most of whom became infected through mother-to-child transmission.33 This number has declined since 2009, when 220,000 children were living with HIV.34
One of the reasons for failure of PMTCT is that some mothers do not attend follow-up appointments.35 Possible reasons for this are financial constraints, the long distance between home and clinics and the fear of stigma attached to taking antiretrovirals. Another potential contributor to mother-to-child transmission is Zimbabwe’s low rates of exclusive breastfeeding, with less than 6 percent of infants exclusively breastfed through six months of age.36
Read more about mother-to-child transmission of HIV worldwide.
Increased condom use has been recognised as a major factor in the recent decline in Zimbabwe’s HIV prevalence.37 The number of free condoms distributed by the government, NGOs and social marketing campaigns tripled during the 1990s, and further increased in subsequent years. The number of condoms sold through the private sector has also increased dramatically, and most condoms are now purchased rather than acquired for free, suggesting that condom use has become more accepted in Zimbabwean society.38
Additionally, female condom sales and distribution in Zimbabwe are among the highest in the world.39 The use of this prevention method has been partly implemented by hairstylists from 500 salons in low-income settings, who have been trained to distribute female condoms and answer women’s questions about them.40
Voluntary medical male circumcision
There have been efforts in Zimbabwe to scale up voluntary medical male circumcision (VMMC) as a prevention method. Circumcision can reduce the chance of a man becoming infected with HIV through heterosexual transmission by up to 60 percent.41 Although only a small proportion of the Zimbabwean population practice circumcision as a cultural rite,42 following large-scale campaigns about the preventative effects of circumcision, a survey showed that 52 percent of men would be prepared to undergo the procedure. The government have set a target to circumcise 1.2 million men by 2015 and Zimbabwe has had one of the largest increases in VMMC of any country, with the number of operations done increasing from 2,801 in 2009 to 36,742 in 2011.43 44 The country’s Health Minister commented on the success of the roll-out:
“The success to date of this programme is due to the fact that Zimbabweans are quick to adapt to new ideas. We have rural chiefs encouraging their people to get circumcised – that is a good sign” - Madzorera, Health Minister45
In 2012 the government announced that 175 parliamentary workers and MPs would lead the way in promoting this prevention technique. The group would either be circumcised, or if female, encourage male partners to undergo VMMC. The campaign was accompanied by a call from the Zulu King Goodwill Zwelithini to restore the traditional rite of circumcision, but with the practice adapted to be a safe, medical procedure.46
HIV and AIDS treatment in Zimbabwe
Largely as a result of Zimbabwe’s declining economy, there has been a shortage of antiretroviral drugs (ARVs) over the last decade. In 2002 the government declared the treatment shortage as a national emergency, allowing Zimbabwe to produce and purchase generic AIDS drugs locally under international law, and thereby reducing their cost. Various issues over the last decade have affected the consistency of access to treatment, causing many people’s ARV treatment courses to be interrupted, which can lead to drug resistance, declining health, and in some cases death.
There have been huge improvements recently with a 118 percent increase between 2009 and 2011 in the number of people taking ARVs, the largest of any country.47 By 2012, an estimated 79 percent of people in need of treatment were receiving it in Zimbabwe.48 However, the challenges in accessing treatment are still very apparent, particularly among children in need of ARVs, of which only 45 percent had access in 2012.49
Barriers in accessing treatment
In October 2005 it was reported that the cost of antiretroviral drugs had quadrupled in the previous three months.50 This increasing cost led to a number of problems, such as the selling of fake drugs at flea markets.51 An article published in 2006 even reported that government officials who were HIV positive had been given priority access to the drugs. While doing so, they had intercepted drugs for their own use that were actually meant for public hospitals.52 One study found that Zimbabweans on the government free ARV programme are often expected to pay bribes for drugs and services that are supposed to be free under the programme.53 Three quarters of those studied had been asked to pay a bribe, either for enrolment, diagnostic services or drugs despite the fact that the majority were unemployed and could not afford basic necessities. Health workers low salaries and a lack of public accountability were partly to blame for the widespread occurrence of bribery.
More recently there has also been the severe threat brought about by interruptions of regular supplies of ARVs, partly due to reported breakdowns in drug delivery and theft of drugs by government officials. Physicians have been forced to switch patients to different regimens due to drug shortages even if it is known that this may lead to drug resistant HIV strains developing.54 In early 2010 the Ministry of Health and Child Welfare responded by introducing a new monitoring system and a range of other strategies to ensure early warnings of any threats of stock-outs. As a result, there were no reports of stock-outs of first line regimens between February and December 2010.55
Women and children who live in rural areas reportedly find it very difficult to obtain ARVs.56 As the income for rural households tends to be low, and rural women often rely upon husbands working in urban areas for financial support, women cannot afford the cost of the drugs.57 They also have to travel long distances to health centres in order to receive ARVs, which is another financial burden. Even at sites where treatment has been made accessible, a severe national shortage of healthcare workers has led to long waiting lists and administration problems.
Displaced people and treatment access
There have been various examples where people have been displaced due to political disruption, and this has impacted on access to treatment for people living with HIV. During the land reforms that began in 1999, there was a decrease in access to education and healthcare due to the deterioration of the economy.58
Another specific case of population displacement that impacted on treatment access was ‘Operation Murambatsvina’. Translating roughly to ‘operation to clean up the filth’, the operation was initiated in May 2005 with the aim of redistributing people from urban to rural areas. Large numbers of homes and businesses were demolished and their tenants forcibly removed.
By July 2005, it was estimated that the people who had been displaced included over 79,500 adults living with HIV.59 A number of these people had previously been receiving antiretroviral drugs (ARVs) to delay the onset of AIDS, but now had no access to them as treatment centres and clinics had been demolished. Other HIV and AIDS-related services such as home based care and prevention programmes were also disrupted. Several home-based care programmes for people living with HIV indicated a 15-25 percent reduction in the number of patients accessing their services.60
One year after Operation Murambatsvina, Lynde Francis – co-ordinator of The Centre, an HIV and AIDS non-governmental organisation (NGO) with 4,500 clients that was disturbed by the campaign – described the difficulties her organisation was facing in re-establishing connections with people living with HIV:
“We still haven't traced some clients ... they've vanished as far as we're concerned. Others disappeared for weeks and were homeless and incomeless, which means they were not eating, and that's a problem when taking [ARVs]”61
Migration for treatment
Reports have revealed that people living with HIV and AIDS in Zimbabwe have crossed the border in order to receive ARVs which are more readily available in neighbouring countries.62 Many of those migrating to access treatment are children, with increasing numbers travelling to neighbouring Botswana and South Africa.63
“I have to buy my drugs from South Africa since it has been difficult to transact in Zimbabwe due to the ever spiralling inflation. I cannot also have regular CD4 count and viral load tests because of the cost.” C.M.64
This was made easier in South Africa with a two-year suspension of any arrests and deportations of Zimbabwean migrants due to the unstable political situation in Zimbabwe. However, the suspension was lifted in 2011, and the fear of deportation has acted as a barrier to healthcare and treatment access for Zimbabwean people living with HIV in South Africa.65
Other major issues
Despite a high level of awareness, HIV and AIDS remain highly stigmatised in Zimbabwe. People living with HIV are often perceived as having done something wrong, and discrimination is frequently directed at both them and their families. Many people are afraid to get tested for HIV for fear of being socially alienated, losing their partner or losing their job. Those who do know their status rarely make it publicly known, which often means they do not have access to sufficient care and support.
Men who have sex with men (MSM) are a group who are particularly marginalised within society. As homosexuality is illegal in Zimbabwe, it is difficult for prevention programmes to reach MSM and MSM who are living with HIV are often unable to access HIV treatment, care and support. The Zimbabwean government has been instrumental in discriminating against MSM; President Mugabe once reportedly described MSM as "worse than pigs and dogs".66
There is a feeling in Zimbabwe that the stigma surrounding HIV is gradually diminishing, although it remains a significant problem. Various attempts have been made to improve the situation, such as the 2005 “Don’t be negative about being positive” campaign. Organised by PSI-Zimbabwe, this campaign encouraged people to reveal their HIV-positive status and to share their stories. The organisers won the 2005 Global Media Award for their work.67 However, many people find that the stigma surrounding HIV heavily impacts on their lives:
“i have been living with hiv for the past 4 years… and i am finding it difficult to engage in a relationship with anyone having to hide the fact that im positive.” Tafadzwa, Zimbabwe, 2368
There are large social and economic gaps between women and men in Zimbabwe, and these inequalities have played a central role in the spread of HIV. Constrictive attitudes towards female sexuality contrast with lenient ones towards the sexual activity of men, resulting in a situation where men often have multiple sexual partners and women have little authority to instigate condom use. Sexual abuse, rape and coerced sex are all common, and as the economy deteriorated more women turned to sex work as a means of survival.69
Prevention campaigns that emphasise safe sex and abstinence often fail to take into account these realities, and are more applicable to the lives of men than those of women. Women are likely to be poorer and less educated than men, predisposing them to HIV infection and making it harder for them to access treatment, care and information.70 According to Zimbabwe's National AIDS Council, an estimated 60 percent of Zimbabwean adults living with HIV at the end of 2011 were female.71
Gender norms and expectations of how people should behave also affect men negatively. Having multiple partners and taking risks, behaviour that is associated with masculinity, can make men more likely to become infected with HIV. Men are less likely to seek medical care when ill,72 which potentially contributed towards the disparity in treatment access during 2009: 64 percent of eligible females have access to treatment compared to only 36 percent of males.73
In recent years, Zimbabwe has suffered from a severe lack of human resources. Whilst the proportion of adults (over 25 years) in employment increased to 89 percent in 2011, only 65 percent of people (15-64 years) were employed in 2008.74 75
In many cases this problem is a direct result of the HIV epidemic, as workers are either caring for family members or unwell themselves. In the healthcare sector, the deficiency of workers has hindered efforts to treat and care for people living with HIV. Estimates in 1998 suggested that there was only one doctor for every 12,000 people,76 and in 2009 it was reported that within the public sector there were no functioning critical care beds.77
Additionally, large numbers of health personnel migrate to other countries once they are trained, and there are reports of low levels of care in the health system among those who remain caused by health workers' disillusionment due to low wages.78
Famine and malnutrition
As the economy deteriorated and farming communities struggled to recover from the economic downturn triggered by land reforms, food shortages escalated. Sickness and death from HIV-related illnesses caused a reduction in agricultural output. The expectation of women to provide care for relatives that need it, forced many to abandon their agricultural work.
As Zimbabwe’s workforce deteriorated, the resulting food shortages increased the number of deaths from AIDS.79 Malnutrition can cause people living with HIV to develop AIDS faster, and decreases the effectiveness of ARVs for those who are receiving treatment.80 81
"[We] want to ensure there is food on the table so that when we give them ARVs we know that those tablets will make them well” Thokozani Khupe, Deputy Prime Minister of Zimbabwe82
While it is essential that those on ARVs are receiving adequate nutrition for the drugs to work effectively, there have been reports of HIV-positive patients selling ARV medication in order to buy food.83
The availability of food has improved recently, but is still comparatively high-priced. Some people in Harare and Bulawayo are benefiting from an electronic voucher scheme that has been implemented to help overcome the issue. Patients on antiretrovirals who are malnourished are identified and given vouchers to receive monthly basic food provisions.84
Inconsistencies with international aid
While campaigns to prevent and treat HIV in other African nations benefit from international aid, the political situation in Zimbabwe has somewhat deterred foreign donors. In mid-2000s the government became increasingly hostile towards foreign non-governmental organisations (NGOs), to the extent where they threatened to pass a law that would give the government the power to interfere with how NGOs are run.85 It has been hard for NGOs to operate consistently since this period. In 2008, there was a total ban on all NGO activity in the weeks leading up to the disputed 2008 elections, and in 2012 the Governor of Masvingo Province banned twenty-nine NGOs on the basis that they had failed to register with his office.86
Despite this hostility, Zimbabwe is still receiving international aid - the main donors are the UK and the US departments for international development (DFID and USAID), and the European Commission (EC). DFID pledged to provide Zimbabwe with nearly £40 million over five years to help tackle HIV and AIDS in 2010.87 At the beginning of 2008 USAID donated US$26.4 million for HIV and AIDS. However, put into context, this was 10 times less than Zambia received and a quarter of what Namibia received.88
Zimbabwe has accused foreign donors of being ‘politically motivated’ whereas foreign donors such as the Global Fund cite ‘technical’ reasons for not providing as much as the Zimbabwean government requests. In 2008, the Zimbabwean government diverted US$7 million from its Round 5 grant, which further soured the relationship between foreign donors and Zimbabwe. However, the government subsequently returned the money and Zimbabwe was included in Round 8 of the Global Fund’s grants.89
In 2009, the Global Fund decided that it would no longer provide money through the NAC and instead it granted US$37.9 million to be channelled through the UNDP.90 Contributions from international funding sources increased markedly in 2010 and 2011; total contributions reached over $150 million, compared with less than $50 million in the years 2007-2009. In 2011, international donors such as the global fund contributed 86 percent of Zimbabwe’s treatment programme.91 92 Increasing insecurity relating to international funding during the global economic crisis could provide further challenges and the need for Zimbabwe to rely more on domestic funding. Indeed, reports have suggested that by 2018, HIV services in Zimbabwe could face a US$ 227 million deficit.93 Like many countries that rely heavily on international donors, Zimbabwe is cutting back on civil-society led, community initiatives around HIV.94 As the Health Minister stated:
“The consequences of the global economic meltdown will be catastrophic to our programmes and will take us back many years” - Dr Henry Madzorera, Zimbabwe Health Minister95
The government’s response
When HIV and AIDS first emerged in Zimbabwe, the government was slow to acknowledge the problem and take appropriate action. Discussion of HIV and AIDS was minimal and President Mugabe rarely addressed the subject in speeches.96
Although the National AIDS Co-ordination Programme (NACP) was set up in 1987 and several short term and medium term HIV and AIDS plans were carried out over the following years, it was not until 1999 that the country’s first HIV and AIDS policy was announced.97 This policy was implemented the following year by the newly formed National AIDS Council (NAC), which took over from the NACP. At the same time, the government introduced an AIDS levy on all taxpayers to fund the work of the NAC.98 The levy had a minor impact for years due to the economic crisis, but between 2009 and 2010 there was a large increase of 259 percent in collections, making the levy a promising source of funding.99
While these measures have had a positive impact, the government’s response to HIV and AIDS has ultimately been compromised by numerous other political and social crises that have dominated political attention and overshadowed the implementation of the national AIDS policy.100 The NAC has also been constrained by poor organisation and a lack of resources.
HIV and AIDS prevention and treatment initiatives have been scaled up and the national HIV prevalence seems to have declined.101
Yet in the context of such a fragmented political and economic background, the fight against HIV and AIDS has been unable to make substantial progress. HIV prevalence is still one of the highest in the world and many of those in need of antiretroviral treatment are not receiving it.
HIV and AIDS is just one of many crises in Zimbabwe and, despite optimism following the establishment of a Government of National Unity in late 2008, each day thousands of Zimbabweans are still crossing the borders to neighbouring countries, as a matter of survival.102
The history of HIV and AIDS in Zimbabwe
The first reported case of AIDS in Zimbabwe occurred in 1985. By the end of the 1980s, around 10 percent of the adult population were thought to be infected with HIV.103 This figure rose dramatically in the first half of the 1990s, peaking at 26.5 percent in 1997.104 But since this point the HIV prevalence is thought to have declined, making Zimbabwe one of the first African nations to witness such a trend. According to government figures, the adult prevalence was 23.7 percent in 2001, and fell to 14.3 percent in 2010.105 The decreasing number of new infections appears to have played a part in this decline. In Harare, the capital, transmission rates peaked when 5.5 percent of the city became infected in 1991 but slowed to 1 percent in 2010.106
Yet although survey results indicate a fall in Zimbabwe’s adult HIV prevalence, caution should be taken when interpreting the data available. Given the large number of homeless and displaced people living in Zimbabwe who are not likely to have been surveyed, the results cannot be taken as wholly representative of the situation. A rise in the number of people dying from AIDS is thought to have played a role in the decline, as well as an increase in the number of people (HIV-positive or otherwise) who have migrated to other countries.
Brian Nyathi, a Zimbabwean health practitioner in South Africa, is among those questioning the official statistics:
“Many people have left Zimbabwe and the ones that are left are so struck down by poverty and the collapse of the health delivery system such that they can not access hospitals. We wonder if these figures can be trusted.”107
Nonetheless, there have been some moves towards safer sexual behaviour over the last few years. In 2005 it was found that condom use had increased, a higher number of young people were delaying first sex and many people had reduced their number of sexual partners, with some men reporting more recently that having multiple sexual partners is less respected than it used to be due to its association with HIV.108 109
It is thought that an increased awareness of HIV and AIDS has influenced these changes. In many cases, people may have changed their behaviour after witnessing the effects of the epidemic first hand, through the deaths of friends or relatives. One young Zimbabwean told reporters:
“I'm not sure if sexual attitudes are changing altogether, but I tell you around the streets of Harare you will see lots of used condoms on the ground”.110
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