AFRO-NETS> HIV/AIDS in Zimbabwe

[AIDS Analysis Africa <aaasa@iafrica.com>]

HIV/AIDS in Zimbabwe
--------------------

by Russell Kerkhoven and Memory Sendah

In February 1999 Dr Timothy Stamps, Minister of Health and Child Wel-
fare in Zimbabwe, announced that 220 Zimbabweans per day are dying, and 
most of these deaths are due to AIDS or AIDS-related illnesses. This 
means a total of 80,000 deaths per annum. 

For the first time this year, Zimbabwe produced a human development re-
port, and although the issue of HIV/AIDS was mentioned, it was not 
really taken on board, despite mounting evidence from the NACP, the 
World Bank and the US Bureau for the Census which suggests that the im-
pact on future human development will be significant. Figures and 
statements that reach the print and broadcast media receive one day's 
attention, then the focus is diverted to political events unfolding in 
the country. What is the possible relation between all this?

HIV/AIDS data
Zimbabwe's last sentinel surveillance survey of women attending antena-
tal clinics was undertaken in 1997, and relevant data were released at 
the end of 1998. Reported HIV prevalence rates varied from 7% in the 
rural area of Karirangwe, to a high of 50.8% in Buhera, another rural 
area. Rates in the main border towns (Beitbridge: 46%, Mutare: 37.7% 
and Victoria Falls: 42.6%) confirm that border towns and adjacent areas 
remain significant epicentres of the epidemic. On the basis of these 
results, the NACP estimates that national HIV prevalence is at least 
24%.

As before, the survey sample size varied considerably from a low of 99 
to 601. Only 11 out of 26 sites had the required sample size of at 
least 300 antenatal clinic attenders. Out of these 11 sites, nine re-
ported HIV prevalence levels above 25%. Within these 11 sites, rural 
HIV prevalence rates range from 19.1% (Mutoko) to 50.8% (Buhera); urban 
localities have a narrower range, between 28% (Harare) and 46% (Beit-
bridge, a border post). The fact that the highest prevalence rate is 
found in a rural area indicates that HIV is spreading throughout the 
country, and confirms the mobility of the Zimbabwean population. From 
this, it is painfully obvious that HIV prevalence rates in Zimbabwe 
continue to rise, which will lead to rising morbidity and mortality in 
years to come.

Although a sentinel surveillance system has been in place since 1990, 
there is little consistency in the way the sites are chosen and in the 
frequency or sampling method with which sentinel surveys are carried 
out per site. The emerging pattern suggests that there is little sys-
tematic effort committed to the execution of sentinel surveys. Data not 
reflected here are products of convenience sampling and generally show 
an upward trend in HIV infection rates. The NACP acknowledges that the 
system does not work as it should, attributing this to shortages of 
testing kits and inadequate human resources. As a result, data compari-
son and national calculation of HIV prevalence and AIDS case totals re-
main problematic. In addition, there is no conscious effort by govern-
ment to comply with methodological requirements that will stand up to 
scientific scrutiny.

Other health-related data
Not only are HIV/AIDS data a cause for concern; TB cases rose more than 
100% during 1993-97. In 1982 the TB incidence rate was 60/100 000; by 
1996 this had risen to 299/100 000. Clinical malaria cases rose from 
40.4/1 000 in 1982 to 139.9/1 000 in 1996. In recent weeks, the country 
has faced a growing cholera epidemic, with over 57 deaths recorded 
within one week, confirming that the health services are failing to 
cope with critical health issues.

Recent data show that domestic violence against women by their sexual 
partners is experienced by one in four women, revealing a widespread 
pattern of abuse involving women from all socio-economic backgrounds. 
In one province, 42% of the women interviewed had experienced physical 
violence! 73% of women who had sought outside assistance and support in 
these circumstances reported forced sexual intercourse. The vast major-
ity of married women, over 95%, do not use condoms within the marriage, 
implying that they are exposed to considerable risk of HIV infection. 
Even though these data are known, domestic violence and in particular 
marital rape are largely taboo subjects in Zimbabwean society.

The current response
Since 1990, a wide variety of HIV/AIDS-related prevention activities 
have been developed in Zimbabwe. Surveys have indicated that more than 
90% of both sexes are aware of HIV, condoms are reported to be avail-
able in 88% of the peripheral health centres, and condom usage has in-
creased. However, less than 10% of women who have a regular partner in-
sist on the use of a condom.

Zimbabwe implemented its second Medium-Term Plan for HIV/AIDS during 
1994-98. An in-depth review of this plan was conducted, and consulta-
tive efforts are currently underway to formulate the next medium-term 
plan. As yet, there is no subsequent national HIV/AIDS plan indicating 
how the government sees the country responding to the increasing HIV 
prevalence and its associated mortality. The NACP is heavily dependent 
on external donor funding, and has been faced with a high turnover of 
professional personnel. Staff have generally opted for a more conducive 
work environment and improved conditions. In 1997, rumours suggested 
that the institutional position of the NACP was to be upgraded, but, to 
date, this has not materialised. With the mounting problems that the 
unit is facing, its institutional position and capacity can only be de-
scribed as weak.

The government response to HIV/AIDS in Zimbabwe has been lacklustre. A 
significant number of innovative prevention and care programmes have 
been undertaken outside the government realm by NGOs, churches, school 
authorities, trade unions and, of late, the private sector. Work on 
peer education with sex workers has been supported by local government 
structures, has proved effective, and has the potential to be sustain-
able. Single women's associations have been established, who take on a 
supporting and economic empowerment function. Innovative care ap-
proaches are being developed with active community involvement in vari-
ous parts of the country. In addition, Zimbabwe's involvement with pol-
icy development around HIV/AIDS has shown that the NACP can work with 
limited means and mobilise diverse groups and individuals. The emphasis 
placed on consultation and involvement of all interested parties is an 
equally important component of this response. Sadly, the Persons with 
AIDS (PWA) response continues to be weak, and is affected by debilitat-
ing factionalism, personal agendas and societal stigma.

How is society responding?
It is clear that Zimbabwean society is responding in different ways 
with regard to the spread of HIV/AIDS. The diversity of initiatives is 
noteworthy, but these are by no means an adequate response, as is indi-
cated by the continued high HIV prevalence levels in Harare, its border 
towns and the country as a whole. Important human development indica-
tors paint a complex and increasingly negative picture of a nation that 
is not developing progressively. It is virtually impossible to even be-
lieve that society is coping: a visit to chronically ill people in any 
of the high-density residential areas, home to the majority of the ur-
ban population, reveals a grim picture of suffering, poverty and bur-
den.

Knee-jerk reactions continue to steal the limelight, as is clear from 
the recent front-page announcement in the national daily newspaper that 
the ZANU (PF) Politburo has decided to reduce the retirement age to 40 
to ensure that people benefit from their pension contributions. Further 
details of this proposal and instructions are to be expected shortly! 
Perhaps the most significant indicator of such a sad response is that 
in 1998 the Department of Social Welfare announced that more than 1,000 
"paupers' burials" were being conducted weekly and funded by the De-
partment. Paupers' burials are "routine" burials without ceremony, in 
which bodies are buried wherever there is space. The death toll is so 
high that mortuaries are filled beyond capacity due to the failure of 
families to collect bodies. For most Zimbabweans, attachment to and 
burial in the home area, kumusha, signifies linkage to ancestors and 
the spiritual world. To bypass such an important ceremony signifies 
high social and cultural costs and implies lack of coping.

Several key human development indicators show negative trends for the 
first half of this decade. Projected data indicate that these recent 
negative trends will continue well into the next century. NACP used 
1994 as the base year for projections and since then, HIV prevalence 
has continued to rise, meaning that the full impact of the current 
prevalence will exceed what is presently expected. What this will mean 
for the society as a whole is difficult to say. There is a large under-
15 age group who are potentially HIV-free. The effectiveness of preven-
tion activities must be questioned if we realise that the current HIV 
prevalence rate amongst women aged 15-24 in Harare, the capital city, 
is still 32% - well above the estimated national average!

Zimbabwe in 1999
During the past 12-18 months, Zimbabwe has experienced unprecedented 
economic change and political turmoil. The currency lost more than 75% 
of its value in US dollar terms, and basic food prices and general cost 
of living expenses have increased significantly beyond wage increases. 
Health, education and other services essential for sustainable develop-
ment are slowly being crippled. A governmental emphasis on macro-
economic indicators and benchmarks has not led to improved quality of 
life for a vast majority of households who are forced to carry the 
costs of the HIV epidemic. In addition, the political situation is in-
creasingly volatile due to mounting discontent with the current govern-
ment. Food riots at the beginning of 1998 were violently suppressed by 
the army, which has been fighting a "budget-neutral" intervention in 
the DRC during the past six months. The independent and state-
controlled media have resorted to a daily 'cold war', relegating the 
all-important issue of HIV/AIDS to the bottom of their agendas. Other 
events mirror a government struggling to deal with fundamental changes 
in the economic, judicial and political sphere, and resorting to fire-
fighting and an ad-hoc style of governance. Such a response appears to 
be particularly inappropriate to deal with the mounting HIV/AIDS epi-
demic.

Sustained prevention, care and mitigation require long-term investment 
in human development, effective targeting and a concerted public effort 
The current economic problems affect household income and spending 
power and force people to focus on daily survival and short-term plan-
ning and decision-making. Combined with the extremely high HIV preva-
lence figures, it is inevitable that this scenario will widen the gap 
between affluent and poor. Equitable human development, the crux of a 
fair and just society, will increasingly become a distant dream.

References:
Central Statistical Office (1995), Zimbabwe Demographic Health Survey: 
1994.

Central Statistical Office (1998), Zimbabwe: 1997 Inter-Censal Demo-
graphic Survey Report.

Ministry of Health and Child Welfare (1998), Zimbabwe National Health 
Profile.

Ngwenya, T.L., D.N. Matanhire, T.A. Makadzange and L.B. Ncube (unpub-
lished), An Investigation into the Relationship Between Domestic Vio-
lence and Women's Vulnerability to Sexually Transmitted Infections and 
HIV/AIDS, a study undertaken by Musasa Project.

NACP (1997), Annual Report.

NACP (1998), HIV/AIDS, STD and TB Fact Sheet.

NACP (1998), Projections of the HIV/AIDS Epidemic and its Demographic 
Impact in Zimbabwe.

UNDP (1998), Zimbabwe Human Development Report: 1998.

--
Russell Kerkhoven and Memory Sendah work for the Southern Africa AIDS 
Information Dissemination Service (SAfAIDS) as Deputy Director and As-
sistant Programme Officer respectively. This article was written in 
their personal capacity.


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