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Zambia, in southern Africa, has one of the world’s most devastating HIV and AIDS epidemics. More than one in every seven adults in Zambia is living with HIV and life expectancy at birth has fallen to just 42 years¹. This has compounded Zambia’s existing economic problems. In 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 proportion of people living with HIV (prevalence). Although Zambia has received hundreds of millions of dollars from rich country governments toward HIV programmes, prevalence rates are not dropping and have remained more or less stable since the nineties, at as high as 25% in urban areas².

History of AIDS in Zambia

Zambia’s first AIDS case was reported in 1984³. Only one year later 17.5% of hospital patients in the capital Lusaka were found to be HIV-positive. Within two years of the first report of AIDS in the country 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 AIDS⁴ 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. The Health Minister did not favour this idea; it was felt that the government was preoccupied with reconstructing the bankrupt economy and paying off the country's debt ⁵. According to Stephen Lewis, the 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 problem⁶.

In 1999, The Post newspaper wrote in an editorial,

"we feel [there] has been a very poor approach to the HIV/AIDS problem by our government – especially cabinet ministers, including President Chiluba. A look at what our government has allocated to the AIDS/HIV fight in this year's budget clearly reveals this irresponsibility." ⁷

The new millennium signalled a marked change in political attitude and, according to Stephen Lewis, ‘an entirely new level of determination’⁸ 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.

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. Additionally, 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.

The Impact of HIV/AIDS in Zambia

Unlike in some countries, HIV in Zambia is not primarily a disease of the most underprivileged; infection rates are very high among wealthier people and the better educated. However, it is the poorest who are least able to protect themselves from HIV or to cope with the impact of AIDS.

HIV has spread throughout Zambia and to all parts of society. However, some groups are especially vulnerable - most notably young women and girls. At the end of 2006, UNAIDS/WHO estimates that 15% of people aged 15-49 years old were living with HIV or AIDS. Of these million adults, 57% were women⁹. AIDS has worst hit those in their most productive years, and, as families have disintegrated, thousands have been left destitute.

Desperate people will inevitably turn to risky occupations - such as sex work - or migration. There is a saying among women in Zambia: "AIDS may kill me in months or years, but hunger will kill me and my family tomorrow".

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"¹⁰. According to the Zambia Business Coalition, 82% of known causes of employee deaths are HIV-related and 17% of staff recruited are to replace people who have died or left because of HIV-related infections¹¹.

Agriculture, from which the vast majority of Zambians make their living, is also affected by AIDS. In particular, the loss of a few workers 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.

Children have been much affected by the AIDS epidemic in Zambia. In 2007 there were 600,000 AIDS orphans in the country. Thousands of these children are abandoned due to stigma or to simple lack of resources, while others run away because they have been mistreated and abused by foster families.

"In the days before the full impact of the HIV and AIDS pandemic, street children were a very rare sight in Zambian cities and towns. Now they are everywhere … sleeping under bridges, behind walls, and in shop corridors." - Dr Mannasseh Phiri¹².

Many of the most tragic stories connected with HIV transmission involve the sexual abuse of children. Men are targeting increasingly younger sexual partners whom they assume to be HIV-negative, and the "virgin cure" myth (which wrongly claims that sex with a virgin can cure AIDS) fuels much of the abuse. An increased proportion of the abusers are HIV-positive and many transmit their infection to their victims. Police handled more than 200 cases of child rape in the second quarter of 2003, and some experts believe that for every case published another ten go unheard¹³.

HIV Prevention

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". 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"¹⁴.

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. There are encouraging signs that efforts to educate young people about avoiding HIV have had some success¹⁵, as although prevalence rates in Zambia have remained stable overall, HIV prevalence among certain groups is falling.

The most notable finding concerns pregnant women aged 15-19 years surveyed in Lusaka. Among this group, the proportion living with the virus almost dropped from 30% in 1994 to 24% in 2004. Over the same period, there appears to have been a general decline in prevalence among young women in urban areas¹⁶. It is thought that the falling prevalence levels indicate a drop in the number of new infections, possibly as a result of behavioural change.

But despite signs of behaviour change, many misconceptions remain. As of 2005, although almost all adult Zambians know that HIV/AIDS exists, still 8.8% of the population do not know that it can be avoided. Over a quarter of adults think that mosquitoes can transmit HIV; 22% think they can be infected by witchcraft; and 15% believe that sharing a meal with an infected person puts them at risk. The level of understanding is lower in rural areas than in towns, and women are less knowledgeable than men¹⁷.

There is clearly a need for continued, comprehensive education, although this of itself is not enough. The real challenge is to change people's attitudes and behaviour, so as to prevent new infections and to stop stigmatisation. This means not only making people better informed, but also empowering them with life skills that enable them to have safe and responsible sexual relationships.

AIDS education

If behaviour is to be changed then young people must be the highest 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 5 and 14 years old; 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, 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 2000¹⁸.

In recent years the Ministry has sought to better integrate HIV/AIDS education into more parts of the school curriculum. Without doubt, a very vigorous government campaign is essential to protect the nation's future, and changes cannot come too soon.

Unfortunately, national policies are one thing and implementation on the ground is quite another. Anecdotal reports suggest that some schools still do not teach pupils anything about AIDS because of the belief that sex should only be discussed between parents and their children, and that to do otherwise would increase sexual activity.

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 Impact¹⁹.

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"²⁰. In Chiluba's opinion, "the only answer is abstinence"²¹.

Although total condom sales more than doubled from 4.7 million in 1993 to 10.6 million in 2002²², the use of condoms remains very infrequent, especially in rural areas. One issue is availability and affordability: many villages are miles from the nearest outlet. However, what is more significant is that, while condom adverts adorn shops and bars throughout the nation, the issues of stigma, lack of knowledge and gender inequality present major obstacles to people using them. Less than half of Zambian women believe that a woman can insist on using condoms²³.

Several major national surveys investigating sexual behaviour have seen evidence of favourable trends with regard to increased use of condoms. However, one particular report adjusted the data to compensate for differences in surveillance methods, and arrived at an interesting conclusion. The proportion of men engaging in the highest-risk activity – sex with a non-cohabiting partner in the last year without using a condom last time – fell from 25% in 1996 to 12% in 2003. Yet it seems that this trend is not due to greater use of condoms: in each survey, about 40% of men having sex with non-cohabiting partners reported using a condom on the last occasion. The change has in fact occurred because fewer men are having sex, and of those who are not abstaining an increased proportion are remaining faithful to one cohabiting partner. There is also evidence of a rise in the average age at which men first have sex²⁴. It seems that, in recent years, messages promoting abstinence and fidelity may have had a greater impact on levels of high-risk behaviour than those advocating condom use.

The evidence of increased abstinence and fidelity is encouraging. However, promoting these two strategies alone is not enough. While the exact statistics may be open to debate, what is clear is that much more needs to be done to encourage the full ABC including consistent condom use.

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. By 2004 it had expanded so that 74 health facilities in four provinces offered antiretroviral drugs (primarily nevirapine) to expectant mothers and newborn infants.

Preventing mother-to-child transmission is a high priority of the United States' PEPFAR initiative. In 2007, through PEPFAR funding some 31,600 HIV infected pregnant women received drugs to prevent transmission of the virus, meaning that approximately 6,000 infant infections were averted²⁵.

UNAIDS estimates that in 2007 47% of pregnant women received treatment to reduce mother-to-child transmission²⁶.

AVERT is calling for a greater global effort on preventing mother-to-child transmission in our Stop AIDS in Children campaign.

Other strategies

Other prevention campaigns in Zambia include:

• Targeting truck drivers: Truck drivers have been identified as key players in the spread of AIDS as the infection is carried along the main transport routes. A number of campaigns have been launched by the Zambian Association of Truck Drivers to raise educate the drivers and distribute condoms.
• Music, drama, group discussions and role play exercises have been used 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 staff²⁷.
• 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% of urban and 37% of rural youth saw at least some of the HEART television campaigns in 2000, and it seems that their behaviour was influenced as a result²⁸.
• In the late 1980s, one school in Zambia became perhaps the first in the world to set up an Anti-AIDS club²⁹, a concept that has since become very popular. 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.

HIV Testing

Just 13% of Zambian adults have volunteered to be tested for HIV and know their status³⁰. Those who do not know they are infected can spread the virus to many others before they become ill, and without early diagnosis may not get the care they require. Many people are reluctant to come forward to be tested because they fear stigma, or because they think that knowing their status is of no advantage – especially if they are unlikely to receive antiretroviral therapy. However, even those who want to be tested may find that accessing services is difficult or costly, and 20% do not even know where they can go for HIV tests³¹.

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. The survey found that 18% of the 8,532 employees tested were HIV-positive³².

Opt-out testing (which means that a person will be tested for HIV whenever they visit a health centre, unless they specifically ask not to be) was introduced in Zambia in 2005 following joint UNAIDS and World Health Organization guidance which suggests this way of testing is the gateway to HIV treatment and an essential component of prevention programmes. Although opt-out testing has received criticism from some groups who believe non-voluntary testing may infringe human rights, it is generally felt that this is outweighed by the advantages of early diagnosis and therefore treatment for people high prevalence African countries.

HIV and AIDS Treatment

State provision of antiretroviral therapy began Zambia in late 2002, although initially very few people could afford the monthly payments towards the drugs. Provision of free treatment started in June 2004³³, 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.

By forming collectives, people living with HIV can share their problems, pool their strength, and campaign for change.

A the end of 2007, 46% of the 330,000 people in Zambia needing ARV treatment were receiving it³⁴, which is above the African average.

Ultimately, Zambia aspires to provide universal 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 WHO³⁵.

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 nurses³⁶. ‘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.

Zambia's health system, having suffered years of under-investment, has now been brought to the brink of collapse by the AIDS epidemic. Success or failure in this area could be the critical factor in determining the future rate of scale-up.

There are many ways to help people living with HIV besides treatment. Some organisations run loan schemes that enable groups of HIV-positive people to set up small businesses, so they can provide for themselves and their families. Other projects distribute food or establish cooperative vegetable plots - good nutrition is essential for everyone living with HIV.

By forming collectives, people living with HIV can share their problems, pool their strength, and campaign for change. The largest of all such groups is the Network of Zambian People Living with AIDS (NZP+).

Conclusion

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.

And as scale up of treatment proceeds, it is vital that prevention programmes are not neglected, but are instead likewise 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 problem of HIV and AIDS is not going to go away. Because those who receive treatment will live longer, the number of people living with HIV is likely to rise unless there is a significant fall in the number of new infections. Zambia will continue to face colossal challenges in the fields of HIV/AIDS prevention and care, and will suffer the epidemic's terrible impact for many years to come.

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