In 2013, over 54,000 adults and 12,000 children became newly infected with HIV in Zambia.1 These figures represent the plateau of HIV prevalence in the country since the mid-nineties; HIV prevalence is neither increasing or decreasing. At its height, HIV prevalence in Zambia was 14.5%, and as of 2013 is still high at 12.5%.2
One in every eight people in the country are living with HIV, and life expectancy is just 58.1 years.3 However, this is a considerable increase from the 2012 life expectancy of 49.4 years, partly thanks to improved access to antiretroviral treatment.4
Unprotected heterosexual sex drives the Zambian HIV epidemic, with 90% of new infections recorded as a result of not using a condom. Zambia's national HIV response is keen to address this in their future plans.5
Key affected populations in Zambia
Zambia's national response has not systematically collected data, or monitored the impact of HIV and AIDS on key affected populations. Despite this, it does recognise that certain groups of people, specifically sex workers, men who have sex with men, prisoners and mobile populations are more vulnerable to HIV in the country. Two large-scale studies are being undertaken in 2015 to determine the extent, impact, HIV prevalence and distribution of these key affected populations.6
Men who have sex with men (MSM) and HIV in Zambia
Same sex intercourse is illegal in Zambia.7 For this reason alongside many others, data on Zambian men who have sex with men (MSM) is almost non-existent, with little knowledge of the HIV epidemic among this population.
What is known, is that MSM in Zambia experience a heightened vulnerability to HIV for a multitude of reasons including alcohol abuse, low levels of education, being subjected to discrimination and low economic status.8
The Zambian government's own progress report alludes to one small-scale study in 2008, which put MSM HIV prevalence at just 1%. However, much higher HIV prevalence is being reported elsewhere, such as 33% by MSMGF.9 The illegal status, stigma and discrimination that MSM experience makes them a population that is difficult to reach with HIV prevention messages.
Sex workers and HIV in Zambia
The number of sex workers in Zambia is disputed, as is the HIV prevalence among this population, with studies reporting vastly different statistics.
One study in 2012 records 7-11% of all new HIV infections in the country among sex workers, their clients and clients' partners.10 Some reasons why HIV is so virulent among sex workers include the fact that only 62% of urban men who bought sex in 2007 used a condom, dropping to 50% in rural areas. It is hoped that ongoing studies will shed more light on HIV among sex workers in Zambia.11
One Zambian study investigated the link between the scale-up of voluntary medical male circumcision (VMMC), and sex workers' vulnerability to HIV. It found that many sex workers were ill informed about VMMC and its HIV prevention benefits. Also, many sex workers experience circumcised clients buying sex before their wounds have healed and try to negotiate unprotected sex because they are circumcised and therefore a condom is not necessary; both of these actions directly put sex workers at risk of HIV.12 Outreach work with sex workers in Zambia needs to educate them about VMMC and how to negotiate with a circumcised client who does not want to use a condom.
Migrants and HIV in Zambia
Many Zambians of both sexes move around the country seeking work. There are certain regions where this is more common, such as Lusaka and Copperbelt, alongside the main transport routes, where HIV prevalence is higher than other regions.
Strikingly, Zambia reports a higher vulnerability to HIV among its female migrants than male. This is due to them experiencing exploitation, abuse and gender-based violence both on their journey and at their destination which is more likely when classed as a temporary migrant with few employment rights.13
One other study found varying condom usage depending on whom the male migrant was having sex with. The results showed that of the men questioned, condom usage was at 96% with sex workers, 80% with non-regular partners, 60% with a regular partner and just 3% with their wife. This suggests that migrants understand the benefits of condom use but wrongly think they are not necessary with their wives.14
Women and HIV in Zambia
In 2012, 500,000 of the 960,000 people living with HIV in Zambia were women.15 The most recent statistics available put prevalence higher among women (16%) than men (12%) overall. However, it is much higher among younger women than younger men, but much lower among older women than older men. This reflects three main factors:
- Education attainment is higher among young men than young women. Therefore men are more likely to be exposed to HIV education.
- Women are much more likely to have a partner much older than themselves who may already be living with HIV.
- Women experience their first sexual intercourse at a younger age than men.16
Zambian society and culture is extremely patriarchal, limiting the power of women in relationships. Women are often taught never to refuse their husbands sex or to insist their partner uses a condom.
In response to this, the enactment of the Anti-Gender Based Violence Act took place in 2011 with a view to changing the unequal structure of society.17 In the coming years it is hoped that this change in law will stop women being disproportionately affected by HIV.
Children, orphans and HIV in Zambia
Children have been severely affected by the HIV epidemic in Zambia, where 150,000 children are estimated to be living with HIV, alongside 600,000 children orphaned by AIDS.18
However, these figures are declining and Zambia is expected to reach its target of reducing new child infections by 90% by the end of 2015.19
A huge part of this progress is due to the implementation of a rigorous prevention of mother-to-child transmission (PMTCT) programme, which has seen the percentage of children born HIV-positive drop by 51% between 2011 and 2012.20 Over 96% of women received PMTCT support in 2013, meeting universal target levels.
HIV testing and counselling (HTC) in Zambia
Targets for HIV testing and counselling (HTC) in Zambia have been reached, with over 2 million Zambians tested for HIV and received their results in 2013. However, last known actual figures suggest only 15% of the general population had an HIV test and received their results in 2011.21
Latest data also shows that 60% of men under the age of 50 have never been tested for HIV, and only 33% of young people have tested.22 Couples counselling and testing is also extremely low in the country, despite this being an effective route to testing more people for HIV elsewhere.
A study in 2012 found a combination of reasons explaining why people were not testing, including a fear of stigma, rejection by their sexual partner, a fear of antiretroviral treatment, and a belief that traditional medicine would keep them healthy if they became ill. These beliefs are ill-informed, but also reflect the continued stigma around HIV in Zambia.23
Despite low uptake, increased provision of HIV testing has been evident, with access now available at many VMMC, PMTCT, STI testing and blood testing sites. Mobile outreach, community-based testing and door-to-door HTC initiatives are also increasing uptake of HIV testing in Zambia.24
Antiretroviral treatment (ART) in Zambia
At the end of 2013, over 60% of people in need antiretroviral treatment (ART) were receiving it, based on the 2013 World Health Organisation (WHO) treatment guidelines.25
Considering the huge increase in the number of people eligible for treatment under these new guidelines, Zambia has shown commitment to increasing ART coverage. Between 2010 and 2013, 5.6 million new people were put on ART across the world, 4% of whom were in Zambia alone.26
It is thought that 80% of Zambians are still on treatment after one year. Efforts need to be stepped up to ensure people who start treatment continue to take it as interrupted or stopped treatment causes illness, drug resistance and further transmission.27 Enhanced efforts also need to be made for children, as currently only 33% of those needing antiretroviral treatment (ART) are receiving it.28
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 2013.29 Task-shifting has also been implemented, whereby HIV nurse practitioners can now administer ART for non-complicated HIV, and community health workers can now perform rapid HIV testing.30
HIV prevention programmes in Zambia
Zambia has a rigorous combination prevention strategy, focusing on five main action points:
- reduce exposure to HIV: heterosexual sexual intercourse and within a healthcare setting
- reduce the likelihood of HIV becoming established in the body after exposure to the virus; prevention of mother-to-child transmission (PMTCT) and post-exposure prophylaxis (PEP)
- encourage behaviour change: discuss and educate about high-risk sexual activities and stigma against people living with HIV
- thread HIV prevention messages throughout society: keep girls in school, empower women and encourage men to respect women
- ensure money and resources for the HIV response are well utilised: roll out cost-effective strategies and evaluate progress.31
The latest detailed statistics in 2007 suggest that of people who have had more than one sexual partner in the last 12 months, only 33% of women and 28% of men used a condom last time they had sex.32 However, among young people the average is 47%. This suggests that youth-centred education around condom use is positively changing behaviour among this age group.33
Zambians are most likely to use condoms with non-regular partners.34 This suggests knowledge and awareness around the preventative benefits of condoms as they are choosing to use them in these high-risk circumstances. However, further work is needed to educate and persuade people to use condoms with all sexual partners, especially if they are in multiple concurrent partnerships, or change partners regularly.
There are still many misconceptions about HIV and AIDS in Zambia. Latest data suggests that just 39% of people have comprehensive knowledge of HIV, despite 90% having heard of the virus.35
If behaviour is to be changed, young people must be a priority target as 46% of all Zambians are between 0 and 14 years old.36 This provides a fantastic opportunity to ensure HIV education is included in the national school curriculum which will help to tackle the HIV epidemic effectively.
Life skills education in schools is catering to this demand, where students can learn about HIV, condom use, inter-generational sex and gender relations. However, the effects of unbalanced gender relations in society continue to prevent young girls attending school where they could learn about these topics, contributing to their disproportionate vulnerability to HIV.37
Prevention of mother-to-child transmission (PMTCT)
Zambia's prevention of mother-to-child transmission (PMTCT) programme has been very successful. The overall percentage of pregnant women attending antenatal clinics and receiving HIV testing is 94%, with 97% of those testing positive receiving antiretroviral treatment (ART). This impressive scale-up and achievement of universal coverage has enabled the halving of transmissions from mother-to-child between 2009 (24%) and 2012 (12%), and a huge reduction in infant deaths.38
Despite this, less than 60% of women attend four antenatal appointments, and 53% of women deliver their babies at home, where medical staff are not present to help with the birth and make important decisions regarding HIV risk for the child.39
Although Zambia is striving to implement Option B+ (where all pregnant women living with HIV receive ART for life), the country is having to implement it in phases due to concerns over drug availability. There is also concern over knowledge about antiretroviral treatment among pregnant women and new mothers, as only 43% are still taking their treatment when breastfeeding.40 More research needs to be conducted to find out whether this is due to loss to follow up, a poor retention rate in treatment and care once the baby has been born or simply a lack of knowledge.
Voluntary medical male circumcision (VMMC)
VMMC coverage is increasing in Zambia since the programme was launched in 2009, albeit not at the speed set out by the targets which aimed for 80% of men circumcised by 2015.41 At the end of 2012, just 17% of the target had been reached.42
Elevated numbers of sites offering the procedure are now available, at 287 in 2011. This has enabled the large increase in the number of males circumcised from 84,604 in 2011, to 221,845 in 2013.43
60% of circumcised men in Zambia are thought to be 15-19 years old. Further awareness raising work needs to be carried out to increase the number of older men coming forward for VMMC.
Barriers to HIV prevention in Zambia
Social and cultural barriers
Multiple concurrent partnerships are commonplace in Zambia, heightening the risk of HIV to all involved. However, campaigns are being implemented to raise awareness of this issue, such as the 'One Love Kwasila' campaign which aims to get people talking about the issue. The televised series firstly aimed to target men, as they are seen as the dominant decision maker when it comes to sex, and the second aim was to empower women.44
The patriarchal society of Zambia remains a barrier to reducing the disproportionate burden of HIV on women and young girls.
Legal and data collection barriers
Young people face increased barriers due to a lack of services targeted at young people, and those under the age of 16 are also still required to gain parental consent. This is globally recognised as a fundamental barrier to HIV testing.45
Lack of data on key affected populations make it impossible to determine the size, vulnerability and solutions to HIV prevention for these groups. This is especially the case for men who have sex with men and female sex workers, although large-scale studies are underway in 2015 in an attempt to fill this gap in knowledge.
HIV testing remains complex and dysfunctional, especially where access is limited by restrictive opening times at HCT facilities, and a lack of testing equipment. A lack of drug resources has also led to rationing, stock-outs, inadequate ART regimes for people living with HIV and a severe lack of drugs for children. Not only does this pose serious health issues for people living with HIV, but also increases the likelihood of onwards HIV transmission to others.46
Finally, human resources remain a serious impediment to addressing HIV in Zambia. Health staff shortages, a lack of highly-trained medical staff, and capacity issues mean that even when physical resources are available, there is often not the healthcare personnel to administer them.47
HIV and AIDS funding in Zambia
Whilst Zambia's domestic spending on HIV and AIDS has risen dramatically in recent years, it still remains at just 4% of the overall budget.48 90% of these funds are spent on ARVs. PEPFAR funds the majority of the Zambian HIV response, at 84% in 2012.49
Discussions are on-going as to the possibility of integrating HIV into a National Health Fund via a Social Health Insurance Scheme, which would expand funding and therefore access to HIV services for Zambia's population.50
The future of HIV and AIDS in Zambia
Zambia needs to fully integrate behaviour change communication into all aspects of its HIV response. Providing ARVs, testing facilities and PMTCT services will not yield results when people are not counselled, informed and educated about the need to adhere to treatment, or get tested regularly.
The success of PMTCT in the country is extremely positive, but with so many mothers not continuing to take their ART when breastfeeding and so many children not receiving ART at all, the initial efforts are not being seen through.
Above all, the results from the 2015 studies about key affected populations will enable better understanding and targeting of future efforts to curb the Zambian HIV epidemic. Without this knowledge it is impossible to develop robust HIV prevention programmes.
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