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Zimbabwe: Reversing HIV/AIDS Prevalence Without Money?
Kennedy Mavhumashava
Extracted from PANOS Global AIDS Programme
August 2006

http://www.panosaids.org/issue2_4.htm

Many delegates gathered in Toronto have been complaining about the lack of funds to fight HIV/AIDS. Yet, the government of Zimbabwe – a crisis-ridden country grappling with an economic meltdown – appears to have notched up a quiet success. Alone in southern Africa, Zimbabwe’s rate of HIV/AIDS prevalence is actually falling. Kennedy Mavhumashava examines a ‘success story.’

HARARE – By any reckoning, ordinary Zimbabweans have had a pretty rough time since 1999. They have had to battle a deep socio-economic crisis, marked by political instability, the world’s highest inflation rate of 1184 per cent, and crippling shortages of foreign currency, fuel and food.

Joblessness has reached nearly 70 per cent and more than half the population of 13 million live in poverty.

In addition, raging policy differences between President Robert Mugabe’s government and the West have triggered a flight of donors and investors.

The World Bank says this southern African country today is facing the world’s worst economic crisis outside of the global war zones.

So when a sudden piece of good news emerged amid the gloom last year, there was understandable gloating. Studies showed that Zimbabwe had managed to bring down its HIV prevalence rate from about 24.6 percent in 2003 to 20.1 percent in 2005, making it the first country in southern Africa to reverse the trend of the HIV/AIDS epidemic.

Deputy Minister of Health and Child Welfare, Dr Edwin Muguti put down the decline to the "undying Zimbabwean spirit."

"Our people are very strong despite the challenges," he declared. "That is the major reason – not overflowing donor funds."

Some researchers attribute the decline to increased condom use, delayed sexual debut among the youth, and faithfulness among partners – ‘behaviour change’ in AIDS parlance. It is estimated that more than two million Zimbabweans are HIV positive, with 3,000 dying every week from AIDS-related illnesses.

News of the decline was met with initial scepticism in some quarters, as medical professionals, non-governmental organisations, donors and academics puzzled over how a country with a struggling economy and little foreign support could have notched up such a success.

Shortly after the figures were published after a national survey in 2005, the Joint United Nations Programme on HIV/AIDS (UNAIDS) commissioned a study to verify them. The UNAIDS review, conducted by a team that included researchers from Britain’s Imperial College, corroborated the government’s findings.

The data also showed that the HIV prevalence rate among pregnant women had dropped from 26 per cent in 2002 to 21 per cent in 2004 and that prevention programmes had played a role.

UNAIDS epidemiologist Dr Peter Ghys noted then that since Zimbabwe’s epidemic was older than that of other countries in the region, the country had had a "longer period of time to respond to the crisis."

But he also praised the government’s efforts to decentralise HIV/AIDS prevention and education programmes.

The real surprise for many observers was that unlike other countries in Africa, Zimbabwe has not received any meaningful financial assistance from the West for some time, and some Zimbabweans were quick to point to the government’s efforts at raising local funding.

As donor funding dried up, the Zimbabwean government imposed an AIDS levy in 2000, under which all workers in formal employment – in both public and private sectors – have to contribute three percent of their monthly salary to a statutory National AIDS Trust Fund.

"Money is not everything," said Benjamin Mazhindu, chairman of the Zimbabwe Network for People Living with HIV and AIDS (ZNNP+).

"It is like ZNNP+. We have not received any financial support for about two years, but we are still continuing with our programmes to educate people to be faithful, use condoms and to lobby for better treatment and care programmes for the infected. Money is very important, but if it is not there what can you do?"

Administered by the National AIDS Council, funds from the levy are used to bankroll prevention, treatment and care programmes. Although falling far short of the projected 300,000 people in immediate need of AIDS drugs, the tax has enabled the government to provide drugs to some 32,000 patients.

Now, the government says, it is likely to receive an amount of US$64 million from the Global Fund To Fight AIDS, Malaria and TB, representing the largest donor support for fighting HIV/AIDS in Zimbabwe. The government says the money will mainly be used to buy anti-retroviral (ARV) drugs and to fund further prevention programmes.

Zimbabwe has so far received only limited funding from the Global Fund and nothing at all from the United States President’s Emergency Plan for AIDS Relief (PEPFAR) or the World Bank’s Multi-country AIDS Programme initiative.

While donors spend an average of US$74 per per perosn living with HIV/AIDS every year in some African countries, Zimbabwe receives a paltry US$4.

But some international agencies and experts are cautioning against over-optimism and complacency.

"On the one hand the drop comes as a result of successful interventions in behaviour change on the part of Government, partners and donors," said UN Children’s Fund (UNICEF) representative in Zimbabwe, Dr Festo Kavishe, "though part of the drop must also be attributed to AIDS-related deaths."

"There is no doubting that a drop in the rate is good news," he added. "But a zero prevalence rate of 20 per cent remains extremely high and this is not the moment for complacency, but rather for putting even greater energy and resources into Zimbabwe’s fight against HIV and AIDS, particularly around girls."

UNICEF argues that without "substantial support" the current positive trends cannot be sustained.

Similarly, the UNAIDS study that confirmed the government figures argues that the decline resulted from a combination of declining HIV incidence and rising adult mortality occurring from the mid- and early-1990s.

Some critics say the large outward migration of Zimbabweans fleeing the desperate conditions at home is also a factor in the decline.

Although there are no reliable figures, some analysts claim that between three and five million Zimbabweans have left for South Africa, Zambia, Botswana, Britain, the United States and Australia among other countries since the start of the economic crisis.

Zimbabwean experts, while agreeing on the need to guard against complacency, reject the view that increasing mortality and outward migration are factors.

Government minister Muguti, for instance, said Zimbabwe’s high literacy rate of more than 80 percent was a factor behind the success of the national HIV/AIDS strategy.

"When you talk about anything to a reasonably literate person, the message tends to go down faster and more effectively."

He admitted that mortality and emigration had had a role, but said their impact was limited.

"These factors, especially mortality, are not applicable to Zimbabwe alone – they are applicable to all. We have some people who do not want to accept them, but the facts are there. The figures reveal that even if the mortality rate is high, the incidence rate is falling, which is good for us."

Dr Paul Chimedza, the secretary general of the Zimbabwe Medical Association does not believe that emigration is a factor at all. "The issue of emigration does not arise," he said. "The assumption here is that all the people who have emigrated are HIV positive, which is not necessarily the case."

Both donors and Zimbabwean experts agree on one point – that changes in individual behaviour are a major factor in the decline.

Lindiwe Chaza-Jakira, director of the Zimbabwe AIDS Network, said donor funding without accompanying behaviour change has not led to reductions in the HIV/AIDS burden in any country.

As examples, she said some countries which receive significant donor support still have high prevalence rates. Botswana, for example, had a prevalence rate of about 38 percent in a population of just over one million people.

"Behaviour change has been a major factor. But there is a need for more studies to find out the reasons why. If it is behaviour change, we must investigate further and if it is confirmed, we should strengthen that area."

Nevertheless, some critics of the Mugabe government remain unpacified. Human Rights Watch, the global rights group, warned in a report published in July that some of the government’s policies might end up reversing any gains.

"Zimbabwe has been hailed as a ‘success story’ in the fight against AIDS," said Joe Amon, director of the HIV/AIDS program at Human Rights Watch. "But abusive government policies are blocking treatment for those who desperately need it and making even more people vulnerable to infection."

Amon said the government’s eviction of thousands of people, which destroyed their livelihoods, exposed them to appalling living conditions and weakened their access to drugs could fuel the epidemic and increase vulnerability to infection.

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