Zambia

As much as 20 percent of Zambia's children will be orphaned by AIDS by 2015

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Background

Located in southeastern Africa, Zambia is a landlocked country bordered by the Democratic Republic of the Congo, Tanzania, Malawi, Mozambique, Zimbabwe, Botswana, Namibia and Angola.

For centuries, Zambia remained largely unexplored by Western powers. In the mid-19th century, famed British explorer David Livingstone was the first European to reach the Zambezi River's majestic waterfalls, which he later renamed Victoria Falls. Thirty years later, in 1888, Northern and Southern Rhodesia — named for their colonizer Cecil Rhodes — became part of the British sphere of influence.

Zambia is split into nine provinces. Lusaka is the capital city. The country is 35 percent urban and has more than 70 ethnic groups. Many of the groups speak Bantu, an African language, but the official language is English.

Formerly known as Northern Rhodesia, Zambia was renamed for the Zambezi River after gaining independence from Great Britain in 1964. For its first years of independence, Zambia was one of the most prosperous countries in Africa, mainly due to its copper exports. But the copper market crashed in the mid-1970s, and as a result, Zambia is now one of the poorest countries in the world.

The current president is Levy Mwanawasa, who was reelected to a second term in September 2006, despite his opponent's accusations of corruption.

The face of HIV

The first AIDS case in Zambia was diagnosed in 1984. Urban areas have infection rates two to four times as high as in rural areas. According to a study by the University of California, San Francisco, the disease is primarily transmitted by heterosexual intercourse, but mother-to-child transmission accounts for 30,000 new infections a year.

The study estimates that AIDS will reduce the life expectancy of a Zambian by 26 to 39 percent through 2050. By the same year, a cumulative 6.2 million people in Zambia will have died of AIDS-related deaths.

As in many of the "focus countries" funded by the President's Emergency Plan for AIDS Relief (PEPFAR), the five-year, $15 billion U.S. initiative to combat AIDS abroad, the HIV epidemic in Zambia disproportionately affects women. Fifty-nine percent of those living with HIV/AIDS are women, and 18 percent of all women are infected, compared with 13 percent of men. Approximately 30 percent of infants born to HIV-positive mothers are also HIV-positive.

The disease has taken its toll on children in other ways as well. About 750,000 to date have been orphaned. Estimates indicate that by 2015, as much as 20 percent of Zambia's children will be orphans.

"HIV has had a massive impact on Zambia," said Dr. Paul Zeitz, co-founder and executive director of the Global AIDS Alliance. He described it as "destroying the social and institutional fabric" of the country.

Challenges to fighting the HIV epidemic

The 2005 Country Operational Plan for Zambia calls HIV/AIDS the country's most "critical health, development and humanitarian crisis to date."

As in many other focus countries, extreme poverty is an obstacle to implementing HIV/AIDS programs. More than 70 percent of the population lives in poverty and more than 87 percent of the population lives on less than $2 a day. The country's Human Development Index rank, the U.N.'s measure of overall well-being, is 165 out of 177.

A key component of fighting the epidemic is testing, which alerts those infected to get treatment. But according to a 2005 report by the U.S. State Department's Office of the Global AIDS Coordinator, only 9.4 percent of women and 13.8 percent of men have been tested for HIV.

In addition, some traditional cultural practices contribute to the spread of HIV. One example of this is wife inheritance, a practice in which a widow becomes the spouse of her deceased husband's brother or other member of his family. The stigma against those infected is high, and there is little legal recourse for those discriminated against because of their HIV status.

Zambian government response

The government of Zambia began programs to fight HIV two decades ago, although early programs were largely ineffective.

The government implemented a national strategic plan for 2002 to 2005 to address HIV/AIDS as well as sexually transmitted infections and tuberculosis, and it set up a council to run the plan. The council includes members from government ministries and civil society organizations and is intended to help coordinate resources and support planning nationwide.

The government now tests pregnant women for HIV but allows them to decline if they choose. In a related but controversial plan to increase testing rates, the Ministry of Defense recently announced that it will require mandatory HIV testing of military recruits. All those who test positive will be barred from serving.

Since July 2005, the government has provided free antiretroviral (ARV) treatment services and as a result, the proportion of Zambians receiving treatment has risen significantly; the government estimates that treatment levels are near 25 percent. It is also conducting an AIDS vaccine trial. Antiretroviral drug treatment is credited with transforming HIV/AIDS from a fatal condition to a manageable illness.

"While we have made several strides towards fighting the epidemic, we still recognize that there is still more to be done," Minister of Foreign Affairs Ronnie Shikapwasha said in a statement given to the U.N. General Assembly Special Session on HIV in June 2006. "We need to do much if we are to reverse, and indeed to end, this pandemic."

U.S. government response

The U.S. government's approach to fighting the HIV epidemic in Zambia can be summed up in three words: strengthen, integrate, cooperate. Working within the context of Zambia's Strategic Plan, PEPFAR's main goals in Zambia include scaling up existing HIV programs and involving all levels of society in them.

In fiscal 2005, Zambia received $27.6 million for prevention activities, or 24.9 percent of the country's total PEFPAR funding for prevention, care and treatment. Another $29.3 million — or 26.4 percent — went to care, while treatment activities were allocated $53.8 million — or 48.7 percent.

But critics say some PEPFAR initiatives have been harmful.

Corridors of Hope was a prevention program funded by PEPFAR along Zambian trucking routes and border crossings, where commercial sex work is common and HIV infection rates in prenatal clinics have been as high as 50 percent. The program used to promote condoms and safe sex, but PEPFAR closed it down — only to reopen it, according to Zeitz, with a 60 percent focus on abstinence, an ineffectual policy when dealing with sex workers.

Zeitz also points out that condoms used to be readily available in bars and restaurants. Sexual health surveys have shown that condoms are no longer there.

But Zeitz also notes that the U.S. government has had some successes, particularly regarding ARV. Those medications were virtually unavailable to Zambians before the advent of PEPFAR. Today, however, more than 43,000 Zambians are receiving ARV, partly due to Zambian government efforts as well.

Additionally, the flow of funding into the country has dramatically increased.

"When I left Zambia in 2000," Zeitz said, "only about $5 million total was going into global AIDS. Now something close to $200 million is coming in. The whole response is being transformed, and … finally the tide of the epidemic is turning."

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