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 is living with HIV¹ and life expectancy at birth has fallen to just 39 years.² In 2009, nearly 83,000 adults were newly infected with HIV, that is about 200 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 proportion of people living with HIV. Although Zambia has received hundreds of millions of dollars for HIV programmes from rich country governments, prevalence rates are not dropping and have remained more or less stable since the nineties, at as high as 25% in some urban areas.⁴

The history of HIV and AIDS in Zambia

Zambia’s first AIDS case was reported in 1984.⁵ 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 AIDS⁶ 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 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.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 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.⁹

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.^10 11

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.¹² Zambia is now the most urbanised country in sub-Saharan Africa, with only a third of its population living in rural areas.¹³

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 nearly four times that of men in this age category.¹⁴

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.¹⁵ In addition, young women in Zambia typically become sexually active earlier than men, with a partner who will be on average five years her senior, who may already have had a number of sexual partners.¹⁶

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".¹⁷

Agriculture, from which the vast majority of Zambians make their living, is also affected by AIDS. 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.  

The impact on children

Children have been much affected by the AIDS epidemic in Zambia, where over 30,000 children are HIV positive.¹⁸ However, being HIV infected is not the only way that children are affected by HIV and AIDS. In 2007 there were 600,000 AIDS orphans in the country and AIDS orphans made up half of all orphans in the country.^19 20 Thousands of these children are abandoned due to stigma or a simple lack of resources, while others run away because they have been mistreated and abused by foster families.

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 unheard.²¹

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".²² 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".²³ 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.²⁴

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".²⁵ 

Although total condom sales more than doubled from 4.7 million in 1993 to 10.6 million in 2002,²⁶ 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% in 2007 and then a further 10% in 2008.²⁷ Although condom distribution from health facilities went up by 13% 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; less than half of 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.²⁸

AIDS education

There are still many misconceptions about HIV and AIDS in Zambia. In 2007 almost two thirds of young people aged 15-24 could not both reject major misconceptions about HIV transmission and correctly identify ways of preventing sexual transmission of HIV.²⁹

If behaviour is to be changed, 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 0 and 14 years old;³⁰ 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 2000 ³¹.

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.³² In those schools where life based skills HIV and AIDS education was provided, the response has been very positive. However, 17% less 15-24 year olds were reached in 2008 compared to 2006 so there is obviously a need to step up these efforts if sustainable prevention efforts are to succeed.³³

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% of pregnant women living with HIV received ARVs for preventing mother-to-child transmission.³⁴ By the end of 2009 this estimate had increased to 61%.³⁵

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.³⁶  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% 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 result.³⁷
• 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.³⁸
• 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% in 2000 to almost 70% in 2006.³⁹ '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.⁴⁰

HIV testing in Zambia

Just 28% of Zambian adults aged 15-49 know their HIV status.⁴¹ Those who do not know they are infected with HIV can spread the virus to many others before they become ill, and without early diagnosis may not get the treatment and care they require. Many people are reluctant to come forward to be tested, waiting instead until they fall ill, because they fear stigma and social rejection, or because they think that knowing their status is of no advantage – especially if they are unlikely to receive antiretroviral therapy.⁴² Even those who want to be tested may find that accessing services is difficult or costly.

 

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% of the 8,532 employees were infected with HIV.⁴³

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.⁴⁴ 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.⁴⁵ 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 a million people aged 15 and over were tested for HIV and received their results; double that of the previous year and quadruple that of 2006.⁴⁶

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 2004,⁴⁷ 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.

A the end of 2009, 68% of the 330,000 people in Zambia needing ARV treatment were receiving it and a third of all health facilities in the country were able to offer treatment.⁴⁸

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.⁴⁹

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.⁵⁰ ‘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. Most staff work extended hours with no compensation - Zambia's 2010 Country Progress report to UNAIDS notes that there "are no non-monetary incentives for overworked health providers in place or being planned for."⁵¹

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.

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.

As scale up of treatment proceeds, it is vital that prevention programmes are not neglected, but are instead 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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