Follow-up to the Declaration of Commitment on HIV/AIDS (UNGASS)

Transcription

1 NAC REPUBLIC OF ZAMBIA ZAMBIA NATIONAL AIDS COUNCIL NATIONAL HIV/AIDS/STI/TB COUNCIL Follow-up to the Declaration of Commitment on HIV/AIDS (UNGASS) 2005 ZAMBIA COUNTRY REPORT Reporting period: January-December st January 2005

2 TABLE OF CONTENTS I. STATUS AT A GLANCE...1 II. OVERVIEW OF THE HIV/AIDS EPIDEMIC Overall HIV Prevalence in Zambia HIV Prevalence Among Young People HIV Prevalence Among Infants...3 III. NATIONAL RESPONSE TO THE HIV/AIDS EPIDEMIC National Commitment and Action Multi-Sectoral Plan Development National Funds Disbursement National Composite Policy Index Assessment...6 IV. NATIONAL PROGRAMMES AND BEHAVIOUR Responses to HIV and AIDS in Education Workplace Policy Programs Prevention Care/Treatment...12 IV. MAJOR CHALLENGES FACED AND ACTIONS NEEDED TO ACHIEVE THE GOALS/TARGETS Coordination (NAC) Effective Leadership Capacity Monitoring and Evaluation...19 V. SUPPORT REQUIRED FROM ZAMBIA S DEVELOPMENT PARTNERS...20 VI. MONITORING AND EVALUATION ENVIRONMENT...22 Timeframe for Implementation of Data Collection Source...26 Summary of Methodologies for Major Data Collection Efforts...28 ANNEX 1: Preparation/Consultation Process for the National Report on Monitoring the Follow-up to the Declaration of Commitment on HIV/AIDS...28 ANNEX 2: National Composite Policy Index Questionnaire...30 ANNEX 3: Country M&E Sheet...36 ii

3 I. STATUS AT A GLANCE National Commitment & Action 1. Amount of national funds disbursed by governments in low and middle income countries Kwacha 148 billion Note: 1.53% of National budget for 2005 was used. 2. National Composite Policy Index 100% Compliance with Policy and Strategy Development (NPCI Assessment) National Programmes: 3. % of schools with teachers who have been trained in life-skills based HIV/AIDS education and who taught it during the last academic year 60% (2005 Educational Management Information System) 4. % of large enterprises/companies which have HIV/AIDS workplace policies and programmes 80% (Workplace Policy Survey, 2005) 5. % of women and men with STIs at health care facilities who are appropriately diagnosed, treated and counselled 10% (Health Facility Survey, 2000) 6. % of HIV positive pregnant women receiving a complete course of ARV prophylaxis to reduce the risk of MTCT 25% (CBoH, 2005) 7. % of women and men with advanced HIV infection receiving antiretroviral combination therapy 20% (CBOH, 2005) 8. % of orphans and vulnerable children whose households received free basic external support in caring for the child 13.4% (ZSBS, 2005) 9. % of transfused blood units screened for HIV 100% (Zambia National Blood Transfusion Services, 2005) Knowledge, Sexual Behaviour and Orphans school attendance 10. % of young women and men aged who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission 43.5% (ZSBS, 2005) ; Females = 40.5%, Males = 46.1% (Target: 90% by 2005; 95% by 2010) 11. Female and male median age at first sex Males=18.5 years ( 2005, ZSBS) Females=18.5 years ( 2005, ZSBS) 12.. % of young women and men aged who have had sex with a non-marital, non-cohabiting sexual partner in the last 12 months 18.6% (ZSBS, 2005) Males = 24%, Females = 13 %( ZSBS, 2005) 13. % of young women and men aged reporting the use of a condom the last time they had sex with a non-marital, non-cohabiting sexual partner Males = (38.4%), Females (26.1%) (2005) 14. Ratio of current school attendance among orphans to that among non-orphans, aged :5 (Ministry of Education, 2005) Impact 15. % of young women and men aged who are HIV infected 7.7%, (ZDHS, 2002) Target: 25% in most affected countries by 2005; 25% reduction globally by 2010) 16. % of adults and children with HIV still alive 12 months after initiation of antiretroviral therapy Not available 17. % of infants born to HIV infected mothers who are infected 39% (UTH, 1999) (Target: 20% reduction by 2005; 50% reduction by 2010) 1

4 II. OVERVIEW OF THE HIV/AIDS EPIDEMIC This section should cover the status of the HIV prevalence in the country during the period January-December 2005 based on sentinel surveillance and specific studies (if any) for Indicator 1 (HIV prevalence among young people) and estimates for Indicator 2 (HIV prevalence among infants). 1. Overall HIV Prevalence in Zambia Zambia, with a population of over 10.3 million and an annual growth rate of 2.9 % (Census 2000), is one of the Sub Saharan African countries worst affected by the HIV and AIDS pandemic. The country's first reported AIDS diagnosis in 1984 was followed by a rapid rise in HIV prevalence. Zambia is currently experiencing the health, economic and social impacts of a mature, generalised HIV/AIDS epidemic; with a national HIV prevalence rate of 16% among the years age group (ZDHS 2002). The epidemic has affected all aspects of social and economic growth in the country. HIV Prevalence rate=16% Ages 15 to Male 13%, Female 18% Urban 25% Rural 13% Luapula 11% Northern 8% Western 13% North-Western 9% 20% Copperbelt Central 15% Lusaka 22% Eastern 14% Southern 18% Overall, urban residents in Zambia are more than twice as likely to be infected as rural residents: 23% of urban residents were HIV positive compared to 11% of rural residents (ZDHS, 2002). The HIV prevalence rates vary significantly according to geography, with ranges from a low rate of 8% in Northern Province to a high of 22 % in Lusaka province. Women are overall 1.4 times more likely to be HIV-infected than men (17.8% for women and 12.6% for men). Prevalence among women is highest between the ages of 30 to 34 and this could be as a result of high levels of vulnerability, inadequate access to information on prevention, low levels of negotiation skills, and unequal protection under statutory and customary laws and traditions. In addition, older men having sexual relations with younger women may also contribute to problem. It is very likely that women are more vulnerable to other STIs as well, the presence of which probably contributes considerably to higher rates of HIV infections among women. 2

5 More recent data from the 2004 Sentinel Surveillance survey indicates that the overall prevalence from the 23 sentinel sites tracked in 2004 was 18.7%. The mean prevalence for urban sites was 25% and 11.8% for rural sites. Figure 1: HIV prevalence by age group and urban vs. rural sites, Zambia, Mean site rates (CBoH 2005) 40% 35% 30% % HIV+ 25% 20% 15% 10% 5% 0% Age Group 1994 Urb 1998 Urb 2002 Urb 2004 Urb 1994 Rur 1998 Rur 2002 Rur 2004 Rur 2. HIV Prevalence Among Young People Among young people, the Zambia Demographic and Health Survey (ZDHS, 2002) reports that 7.7 % in the year age group are HIV infected. According to the survey, young women years old are more likely to be HIV positive than men of the same age group, with infection rates among young women estimated as 4 times higher than those for young men in that age group. The table below highlights the gender differences in the prevalence between young men and young women. It split the age group as and years old and also shows the aggregate (15-24 years old) differences. Age Women % Men % Total % % 3. HIV Prevalence Among Infants Mother to Child transmission is one of the known modes of paediatric transmissions in Zambia. 39% of infants born to HIV infected mothers get HIV infections. 3

6 HIV prevalence at a glance % Young people years of age who are HIV infected 7.7% Source: (ZDHS, 2002) % of infants born to HIV infected mothers who are infected 39% Source: (UTH, 1999) III. NATIONAL RESPONSE TO THE HIV/AIDS EPIDEMIC 1. National Commitment and Action This sub-section should reflect the change in commitment made by national stakeholders in the fight against HIV/AIDS during the period January-December Commitment covers increased resources, expanded partnerships and multisectoral policy development. The vision of Government has been to prevent and control the spread of HIV and AIDS, promote care for those who are infected and affected, and reduce the personal, social and economic impact of the epidemic. As part of this commitment, Zambia finalized its National HIV/AIDS/STI/TB policy in 2005 and in the same year, took the policy decision to provide Antiretroviral Therapy (ART) free of charge to all in need of the treatment. Under considerable resource constraints, however, the target set for Zambia in the context of the WHO/UNAIDS-led global 3 by 5 initiative was the provision of ART to 100,000 people living with HIV/AIDS by the end of 2005, which would cater for only half of the 200,000 people who were in immediate need of treatment. In a more multi-sectoral context, the strengthening of the National HIV/AIDS/STI/TB Council (NAC) by recruiting key staff has come at an opportune time to reinforce efforts to coordinate and support the development, monitoring and evaluation of the multi-sectoral national response for the prevention and combating of the spread of HIV, STI and TB in order to reduce the personal, social and economic impacts of HIV, AIDS, STI and TB. To achieve these objectives, with effect from August 2004 to July 2009, Government declared HIV and AIDS a national crisis and put in place a number of national support structures: a high level Cabinet Committee of Ministers on HIV and AIDS, which provides policy direction, supervises and monitors the implementation of HIV and AIDS programmes. the NAC, established through an Act of Parliament in 2002, is a broad-based corporate body with government, private sector and civil society representation. The NAC is the national mechanism to coordinate and support the development, monitoring and evaluation of a Multi-Sectoral national response to HIV and AIDS whose overall mission is the prevention and combating of the spread of HIV and AIDS and reduce the personal, social and economic impacts of the HIV and AIDS epidemic. the National HIV/AIDS/STI/TB Policy of 2005 provides the directive and mandate for the national response. 4

7 At decentralised levels, NAC has established Provincial and District HIV and AIDS Task Forces (PATF and DATF). These are intended to operate as sub-committees of the decentralised development coordinating structures, the Provincial Development Coordinating Committees (PDCCs) and the District Development Coordinating Committees (DDCCs) respectively. Local level planning to support development of more strategic planning for HIV and AIDS at decentralised Districts level were initiated. The Zambia Multi-Sectoral Response is committed to controlling HIV and AIDS by mainstreaming HIV and AIDS into the business of every sector and the national development agenda. The 8 objectives included in the National HIV/AIDS Intervention Strategic Plan is shown below: The National HIV/AIDS Strategic Framework VISION A Nation free of HIV and AIDS GOAL: Reduce HIV/STD transmission among Zambians and reduce the socio economic impact of HIV/AIDS Objective 1: To promote the implementation of multisectoral behaviour change communication campaigns Objective 2: To decrease the MTCT rate by increasing access to quality prevention of mother-to-child transmission services in all the districts of the country Objective 3: Make all blood, blood products & body parts safe for transfusion & promote use of sterile syringes, blades, needles Objective 4: To improve quality of life of HIV/AIDS infected persons by encouraging positive living, good nutrition, prevention of OIs & avoiding high risk behaviour Objective 5: To provide appropriate care, support & treatment to HIV/AIDS infected persons and those affected by HIV/AIDS, TB, STIs and other opportunistic infections Objective 6: To provide improved care & support services for OVC & others affected & at risk such as refugees, prisoners & disabled people Cross Cutting objectives: Objective 7: To improve HIV/AIDS information management and decision making by developing well coordinated data bases by 2005 Objective 8: To assure impartial, transparent and effective programme operations by improving the coordination of multi-sectoral implementation of interventions 2. Multi-Sectoral Plan Development The Zambia Multi-Sectoral Response is committed to controlling HIV and AIDS by mainstreaming HIV and AIDS into the business of every sector and the national development agenda. There are plans to scale up the response aimed at intensifying prevention; expanding treatment, care and support and protecting the country s vulnerable children. Strategies are in place to work towards joint leadership and shared goals, coordinated by the NAC, to ensure that national actions are prioritised, rapid and sensitive to the needs of the local communities to be served. 5

8 Competence in dealing with HIV and AIDS related issues has been growing over the years through the determination of the various stakeholders and Cooperating Partners. The NDP HIV and AIDS Chapter and the new Strategic Framework represent an evolution of the previous plans, and of the continuing process to engage and include all sectors of the society to work together to achieve Zambia s collective vision and mission. The Country must continue to aspire to be better than it is by continually expecting and creating a culture of excellence. A culture of excellence will set the tone for our future, build on existing strengths, and recognize the commitment to quality in delivering on the HIV and AIDS interventions. Implementing partners are very active in the national multi-sectoral response, which include the districts and provinces, civil society, including the private sector, and line ministries. All partners have the opportunity to identify the specific thematic area, objectives and strategies in relation to their areas of comparative advantage to develop appropriate programmes, projects and interventions. In the spirit of partnership, this hierarchy of objectives have been built on the analysis of the various plans and intentions of the partners, and therefore does not intend to replace those more detailed plans but rather provides a summary of shared goals and collective action. 3. National Funds Disbursement National commitment at a glance National Commitment & Action 1. Amount of national funds disbursed by governments in low and middle income countries Kwacha 148 billion** Note: 1.53% of National budget for 2005 was used. 2. National Composite Policy Index 100% Compliance with Policy and Strategy Development (NPCI Assessment) ** This figure represents the amount committed in the 2005 Zambian budget to government ministries and the National AIDS Council. It does not capture other government counterpart funding and commitments to other agencies. The official statistics of the Ministry of Finance and National Planning indicate that in 2005 the Government allocated about ZK 148 billion (approximately US$ 32 million) for disbursement efforts to HIV and AIDS. This allocation was 1.53% of the Poverty Reduction Strategy Paper (PRSP) budget for It is important to note however that the allocation figure presented here represents the amount in the 2005 national budget to government ministries and NAC. It does not capture other government counter-part funding and commitments to other agencies. 4. National Composite Policy Index Assessment The National Composite Policy Index assessment was done during the second half of It attempted to assess progress in the development of national-level HIV/AIDS policies and strategies through the use of a country assessment questionnaire. The assessment report therefore summarizes the existing HIV/AIDS national policies, 6

9 strategies and plans in Zambia. The processes and findings of the National Composite Policy Index assessment, including civil society involvement are summarized below: Strategic Plan: Zambia has developed multi-sectoral strategies to combat HIV/AIDS Zambia has integrated HIV/AIDS into its general development plan Zambia has a functional national multi-sectoral HIV/AIDS management/coordination body Zambia has a functional national HIV/AIDS body that promotes interaction among government, the private sector and civil society Zambia has a functional HIV/AIDS body that assists in the coordination of civil society organizations Zambia has evaluated the impact of HIV/AIDS on its socio-economic status for planning purposes Zambia has a strategy that addresses HIV/AIDS issues among its national uniformed services Prevention: Zambia has a general policy or strategy to promote information, education and communication (IEC) on HIV/AIDS Zambia has a policy or strategy promoting reproductive and sexual health education for young people Zambia has a policy or strategy that promotes IEC and other health interventions for groups with high or increasing rates of HIV infection Zambia has a policy or strategy that promotes IEC and other health interventions for cross-border migrants Zambia has a policy or strategy to expand access, including among vulnerable groups, to essential preventative commodities Zambia has a policy or strategy to reduce Mother to Child Transmission Care and Support: Zambia has a policy or strategy to promote comprehensive HIV/AIDS care and support with emphasis on vulnerable groups Zambia has a policy or strategy to ensure or improve access to HIV/AIDS related medicines, with emphasis on vulnerable groups Zambia has a policy or strategy to address the additional needs of orphans and other vulnerable children Human Rights: Zambia has laws and regulations that protect against the discrimination of people living with HIV/AIDS Zambia has laws and regulations that protect against discrimination groups of people identified as being especially vulnerable to HIV/AIDS Zambia has a policy to ensure equal access for men and women to prevention and care, with emphasis on vulnerable groups Zambia has a policy to ensure that HIV/AIDS research protocols involving human subjects are reviewed and approved by an ethics committee IV. NATIONAL PROGRAMMES AND BEHAVIOUR 7

10 This sub-section should cover progress made during the period January-December 2005 in specific HIV/AIDS programmes broken down by prevention and care/treatment. 1. Responses to HIV and AIDS in Education The formal education system in Zambia has a three-tier structure comprising of the primary, secondary and tertiary levels of academic training. These are divided into: (a) primary schooling, which includes seven years of school, typically referred to as grades 1-7, with an official age range for schooling of 7-13 year; (b) secondary schooling, consisting of two levels, junior secondary (grades 8-9) and senior secondary (grades 10-12), with an official secondary school age range of years; and (c) tertiary education, including schooling at universities, colleges of commerce, technical colleges and teacher training colleges. The MOE has therefore been redefining the role of the education system in the fight against HIV/AIDS. Firstly, new central level structures are emerging: an HIV/AIDS Focal Point Unit has been established to deal with curriculum development for teaching about HIV/AIDS, monitoring and evaluation (M&E), coordination of workplace HIV/AIDS programmes, coordination of collaborative HIV/AIDS efforts with donors, etc. Secondly, MOE is introducing innovative solutions into the formal system: teaching of HIV/AIDS has been made an integral component of the curriculum for all educational levels, with all educators being mandated to follow the new curriculum. To help in the delivery of the right curriculum, guidelines have been developed for all educational levels in terms of handbooks (MOE 2003). Thirdly, with the assistance of local and international development partners the education system s mission is being extended beyond traditional academic training to include more attention to counselling and care for its members, and to promoting care and compassion for people with HIV/AIDS (Kelly 1999; MOE 2003). This change has been on many fronts, including the training of specialist for HIV/AIDS. Capacity building specifically for HIV/AIDS school programmes is being undertaken, and to date MOE has trained a total of about four thousand specialist educators on HIV/AIDS Interactive (participatory) Learning Methods. These specialists represent only about 9 % of the total teaching work force and are distributed among the 6,652 public schools 1 at a ratio of one specialist per school. Given the total number of 6,796 schools nationwide, this means about 59% of all schools have been serviced with one HIV/AIDS Interactive Learning Specialist. Conversely, there is an HIV/AIDS specialist resource gap in 40% of the schools nationwide. Also, it is not clear if having only one specialist per school is adequate to cater for the needs of every school, especially considering the variations in school sizes (in terms of enrolment and infrastructure). The 40% resource gaps may very well be a significant underestimation. 2. Workplace Policy Programs 1 A public school is defined here any school under the custody of MOH, including all GRZ schools, community schools and grant-aided schools, and excluding private schools and schools run by churches. 8

11 Public Sector Sectoral mainstreaming of HIV/AIDS in the public sector is being addressed. The capacity of the ministries of Agriculture, Health and Education respectively were assessed by a Public Service Management Division (PSMD) commissioned study in December The study indicates multiple factors limiting the capacity of the three ministries. Evidence of mainstreaming efforts are: There are 19 United Nations Volunteers (UNVs, 10 females and 9 males) for the line ministries. Focal point persons from a total of 30 line ministries and establishments were trained on HIV/AIDS mainstreaming in workplace. The table below indicates the number of Peer Educators, Counsellors so far trained in line ministries. In 2005 the Ministry of Community Development and Social Services (MCDSS) and Gender In Development Division (GIDD) developed a strategy for village banking and income generation for women s groups based on the Grameen model to 4 Districts. This component of the project will provide HIV/AIDS socio economic impact mitigation to women who are most affected by HIV/AIDS. Issues and challenges External mainstreaming has lagged behind. It is hoped that the plans in the 5 th National Development Plan and Funds from Global Fund would assist in accelerating external mainstreaming. More programmes like the one being done in Ministry of Community Development should be supported as they are a demonstration of the use of mandate of the Ministry in addressing HIV/AIDS issues Private sector In early 2004, the total formal employment in Zambia was estimated at 416,228 (CSO, March 2004). The Private Sector accounts for an estimated 58.5% of the formally employed workforce in Zambia, that is an estimated 243,645 employees. The design and implementation of workplace programmes in companies and businesses have been largely supported by a private sector network known as ZWAP (Zambia Workplace AIDS Partnership) comprising of four private sector NGOs: the Zambia Integrated Health Programme (ZIHP), Afya Mzuri (formerly known as the Zambia HIV/AIDS Business Sector Project); Zambia Health Education and Communications Trust (ZHECT); and the Zambia Business Coalition on HIV/AIDS (ZBCA). A workplace survey of 21 of the larger companies in Zambia was completed by NAC in 2005 in order to provide some preliminary information of the range of HIV and AIDS activities and the type of support that was needed to continue the development of the private sector response. There are many examples of Zambian companies undertaking innovative practices in the workplace across prevention, treatment care and support. While there is generally little sharing of these successful innovations and little cross-fertilisation between companies, companies have expressed interest in 9

12 improving communication and quality of technical support provided specifically to the private sector. Issues and challenges Companies with full time HIV/AIDS employees spearheading the implementation of company HIV/AIDS workplace policies are more coordinated and far much ahead in the fight than those that have part time focal persons Civil society response including Faith based Organisations Within the context of the NAC s participatory structures, civil society is considered to include the Media, Trade Unions, Traditional Healers and Youth Structures, as well as Non-Governmental Organisations (NGOs), Community-Based Organisations (CBOs) and Faith-Based Organisations (FBOs). In Zambia, civil society is considered to play a significant role in strengthening the multi-sectoral response to HIV/AIDS, TB and STIs, and civil society organisations (CSOs) are frequently key role-players in developing and implementing innovative, culturally-sensitive approaches that include elements of mainstreaming, decentralisation, outreach and community participation. A number of larger NGOs (such as CARE International and Oxfam) are now implementing cutting-edge multi-sectoral programmes that strengthen the linkages between HIV/AIDS, food security and income support. Others, such as SHARe, SNV and Concern International, are supporting the strengthening of decentralised planning and coordination structures, such as the PATFs and DATFs. There has also been considerable scaling-up and rolling out of prevention, care and support activities (including roll out of ARV services), particularly through US Government funding of FBOs, as well as through more traditional players, such as Development Aid from People to People (DAPP), the Copperbelt Health Education Project (CHEP) and the Kara Counselling and Training Trust (KCTT). There are a number of initiatives where consortia of CSOs have come together to strengthen outreach to hard to reach and vulnerable groups within a multi-sectoral framework (for example, the Corridors of Hope Programme targets truck drivers and sex workers in cross-border environments, whilst the C-Safe initiative operates regionally and targets farmers, farm workers and the rural poor). Meanwhile, there are a number of exciting new projects that focus on community mobilisation through thematic issues such as stigma (for example, the International HIV/AIDS Alliance s Stigma & Discrimination Project), treatment advocacy (for example, the Treatment Advocacy and Literacy Campaign (TALC)) and community-based ARV treatment literacy and compliance (for example, the ARV Community Education and Referral (ACER) Project). Zambia is now making considerable progress in strengthening its grant administration systems for CSOs, especially those in non-metropolitan areas. For example, the membership based Zambian National AIDS Network (ZNAN) is playing a key role in disbursement of accountable grants from the Global Fund, as well as from other cooperating partners (many of whom contribute to a basket fund through a Joint Financing Agreement (JFA)). Similarly, the Church Health Association of Zambia (CHAZ) and the Zambian Inter-Faith Networking Group (ZINGO) now have wellestablished systems for supporting grant-making to FBOs. Finally, the Community 10

13 Response to HIV/AIDS (CRAIDS) initiative was established under the World Bank s MAP II programme and has been particularly successful in disbursing grants to smaller CBOs. Nevertheless, it is acknowledged that grant making to CSOs can be bureaucratic and slow and there are significant human resource constraints in providing technical and monitoring support to funded projects. The role of Traditional Health Practitioners in strengthening the national response to HIV/AIDS, TB and STIs is increasingly acknowledged. The Traditional Health Practitioners Association of Zambia (THPAZ) held skills training and strategic planning workshops for their members in THPAZ has also been active in natural remedies research and income generating activities, such as crop production and community-based catering. Issues and challenges It has been observed that in order to be successful subprojects should respect timeframes, budget and quality It is important to assist communities identify viable IGAs that are profitable. The Monitoring and Evaluation tools greatly assist in capturing indicators while data auditing enhances accuracy of reports Linkage of subprojects to services in the local community (e.g. health facility, Agriculture, community development, learning and religious institutions) contribute greatly to effective implementation and sustainability of subprojects 3. Prevention: 3.1. VCT VCT services in Zambia are provided through two major models, stand alone sites, which are all currently private and attract a significant proportion of males, and integrated sites located in public health facilities that tend to attract more females than males. There are currently over 400 sites offering VCT services. The percentage of people who have gone for VCT and know thrie results now stands at 13% in Zambia (ZSBS, 2005) PMTCT As of the end of 2004, there were 136 PMTCT health facilities in Zambia, which increased to 256 sites by the end of The number of women attending ANC was 310,254 and 1 st ANC attendees was 144,025. The number of pregnant women who received Nevirapine was 21,156 which translates into 25 % coverage for the whole country.. Comment [cc1]: Data have been provided (19/1/06) but need to be extrapolated to end text will be updated and extended thereafter. 11

14 4. Care/Treatment ART The provision of ARV treatment though the public health system began in 2002 at two trial sites in Lusaka and Ndola. In 2003, the Government decided to make Antiretroviral Therapy (ART) available to its citizens nationwide. By the end of 2003, roughly 3000 people were accessing ART through the public sector, a figure that rose to 5,586 by April 2004 and dramatically to 24,000 by the end of In September 2005, the Government took the decision to make the provision of all ART related services (i.e., ARVs, laboratory procedures, etc) free of charge and by the end of 2005 there were 40,000 people on ART out of an estimated number of 200,000 people living with HIV/AIDS who were in need of the therapy in that year. This implies that ART services catered for only 20% of those in need. It is noteworthy however that the Zambian target for 2005 in the 3 by 5 initiative was to provide ART to 100,000 people living with HIV/AIDS. In terms of this target therefore, 40% of targeted persons were on ART in Validation of Traditional and Alternative Remedies Traditional and alternative remedies have been areas of considerable attention in Zambia. To date, 18 herbal formulations prepared by the traditional healers have been analysed for anti-hiv 1 activity. Two of these had shown to have some anti-hiv 1 activity, but not all the experiments have been conclusive pending further analysis. In 2005, clinic trials on traditional medicines and alternative remedies were conducted and finalised on 3 herbal medicines with 5 drug naive patients enrolled for each herbal drug Operational Research on Drug Resistance A total of 13 samples have so far been tested for HIV drug resistance in Zambia. Of the 13, 8 had mutations associated with drug-resistance targeting ARVs in the first line regimens. However, there is need for random sampling across the country in order to have a representative resistance figure. The challenges include insufficient global scientific work in this area, insufficient capacity of genotyping laboratories to accommodate nation-wide surveillance coupled with a lack of a mechanism of measuring quality and lack of skilled personnel. Identified research interests in Zambia are the following area: HIV/AIDS vaccine clinical trials Monitoring of the emergence of HIV-1 antiretroviral (ARV) drug resistance mutants in patients on ARVs and the general public in Zambia Monitoring of the circulating HIV-1 strains in Zambia Testing of traditional medicines and alternative remedies for anti HIV-activity Epidemiological survey to determine the impact of HIV/AIDS in the Line ministries 12

15 National programmes at a glance National Programmes: 3. % of schools with teachers who have been trained in life-skills based HIV/AIDS education and who taught it during the last academic year 60% (EMIS, 2005) 4. % of large enterprises/companies which have HIV/AIDS workplace policies and programmes 80% (Workplace Policy Survey, 2005) 5. % of women and men with STIs at health care facilities who are appropriately diagnosed, treated and counselled 10% (Health Facility Survey, 2000) 6. % of HIV positive pregnant women receiving a complete course of ARV prophylaxis to reduce the risk of MTCT 25% (CBoH, 2004) 7. % of women and men with advanced HIV infection receiving antiretroviral combination therapy 20% (CBOH, 2004) 8. % of orphans and vulnerable children whose households received free basic external support in caring for the child 15.6% (Ministry of Youth, Sport and Child Development, 2005) This section should also reflect any changes in behaviour as a result of programmes activities. According to the Zambia Sexual Behaviour Survey (2003 and 2005), awareness of HIV/AIDS has become universal in both urban and rural areas. 99% of men and 98% women have heard of HIV/AIDS, a slight increase from 96% recorded in However, in 2005 a slight decrease in knowledge among both men and women was recorded at 97%. Between 2000 and 2003, the proportion of people who thought HIV/AIDS could be avoided increased from 84% to 89% for men and from 79% to 81% for women. In 2005, 94% of men and 91% of women knew that HIV/AIDS could be avoided. In 2003, about 90% of men and 86% of women knew that a healthy-looking person could have HIV as compared to 2005 when an increase is reported to 93% for men and 89% for women. Knowledge of MTCT has remained the same between 2003 and 2005 where about 8 out of 10 men and women know about MTCT in both rural and urban areas. Misconceptions about HIV transmission (transmission by mosquitoes, witchcraft and sharing of meals) increased between 2003 and Within the same reference period it was observed that misconceptions about HIV transmission were slightly higher among females and rural dwellers than males and urban dwellers. Median Age at First Sex The age at first sexual debut among young people year old, has increased from the average of 16 years for either gender to a year later. This implies that young people delay the age of risky sexual behaviour: among males, from 16 years (1998) to 17.5 years (2003) to 18.5 years (2005); for females 17 years (1998), 17 years (2000), 13

16 17 years (2003) and 18.5 years (2005). There is need to continue targeting young people for abstinence messages to ensure that this pattern is not reversed. Table 3.1 Median Age at First Sex ZSBS 1998 ZSBS 2005 Males Females Total Years Number Median Age Number Median Age Number Median Age Age group Age group Source: Central Statistical Office, 2005 Sexual Partners among Young People There has been some positive trend on this indicator since Among males the proportion of those reporting to have a non regular sexual partner has reduced from 39% (year?) to 29% (2000) and stayed at 29% in Among females the proportion changed from 17% (1998), to 16% (2000 and 2003). But there is need for more results in partner reduction. FBOs are particularly well positioned to address this issue along with sexual abstinence. It is therefore important that NGOs make strategic partnerships with FBOs and with traditional leadership at community level. Condom Use among Young People Condom use during the most recent sexual act with a non regular sexual partner showed an increase between 1998 and However, a decrease has been recorded in Among males, it increased from 28% (1998) to 39% (2000) and then to 40% (2003). However, in 2005 it decreased to 38% among females it increased from 24% (1998) to 33% (2000) 35% 2003) and reduced to 26% in One contributing factor would be the median age at first sex had increased and therefore the demand for condom may be reduced. However, the 2004 Joint Annual Review revealed that total district, non-governmental organization (NGO) and line ministry demand for male condoms from Medical Stores Ltd (MSL) had declined from 16,308,580 pieces in 2003 to 14,855,148 in 2004 (indicator 23). This conceals sharp differences between provinces. In Southern, Lusaka, North Western and Central provinces condom demand went down by around 50%, whereas in Western, Eastern, Copperbelt and Northern provinces condom demand increased significantly, and in Luapula Province it nearly trebled. Reasons for these trends in both directions need to be analysed. Figures for socially marketed condoms also need to be considered. According to the 2003 NAC review the private sector sold 8.6 million pieces in 2001, 9.3 million in 2002, and 12.3 million in There seems to be no information readily available for

17 With respect to female condoms, the Society for Family Health (SFH) and the government successfully piloted female condoms in Zambia prior to a national launch in late This involved branded marketed condoms and free public sector ones. However, purchase, promotion and distribution have remained small-scale and erratic since, with very limited government involvement. In 2005 a new SFH and Population Services International (PSI) proposal seeks to scale up female condom supply (400,000 pieces per year) as a valuable HIV prevention strategy where male condoms are not utilized. The approach will involve marketing strategies and behavior change communication, as well as extensive further research into knowledge, attitudes and practices of target groups. Despite its potential, a major barrier to expanding female condom programming remains cost. Endorsement and promotion of appropriate cleaning and multiple uses of female condoms could reduce costs substantially. Regarding distribution logistics, problems experienced in Zambia include insufficient and inconsistent demand from districts and inadequate distribution to informal outlets within communities from local clinics. National behaviours at a glance % of respondents years of age who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission or prevention 33.5% (Source: ZSBS 2005) Males = 35.6%, Females = 31.3% % of people aged reporting the use of a condom during sexual intercourse with a non-regular sexual partner 32.2% (Source: ZSBS, 2005) Males = (38.4%), Females (26.1%) (Source: ZSBS 2005) Finally, this section should address national efforts in impact alleviation, with a focus on orphans. HIV/AIDS has left an estimated 750,000 orphans, most of whom will have no hope of obtaining formal education. This will affect the quality of the future labour force in Zambia. It has been estimated that 6% of these children are in the streets. Less than 1 % lives in orphanages. Significant achievements have been made in the area of orphans and vulnerable children. The Social Welfare under the Ministry of Community Development and Social Services (MCDSS) has also just established a mechanism to provide foster-parent households allowances of Zambian Kwacha 50,000 per child for providing a home to an orphan or any other vulnerable child. In Zambia, education for orphans and vulnerable children is a priority. The increase in community schools and the provision of bursaries for poor children have contributed to increasing access to basic education. In 2004 total orphan enrolment in schools, according to the Ministry of Education, was 536,672. In 2005, 507,425 orphans were enrolled. The ratio of orphaned pupils to non orphans in primary schools was 0.14 in In 2004 a situational analysis of Orphans and Vulnerable Children was conducted on behalf of the government in order to identify the challenges and issues facing orphans. Nine recommendations were provided to government and these recommendations will 15

18 form a plan of action for children for the next 5 years. In 2009, government is planning to carry out another situational analysis to report on the progress and identify next steps required for the further development of Zambian children. Throughout Zambia, there are initiatives to support orphans and vulnerable children implemented by government, international donors, NGOs, and several other groups. There are successful programs that keep children in the community rather than in orphanages. There are currently over 400 organizations with programs that work towards increasing income to vulnerable households. Other programs provide psychosocial and physical help to vulnerable families. Some other additional national achievements include: 1. The organization of two successful national consultative meetings on OVCs. 2. The current preparation of a situation analysis. 3. The development of a child policy that addresses OVC issues comprehensively. 4. A task force under the Ministry of Labour, to develop guidelines and implementation mechanisms for integrating street children. 5. The development of a five year national strategic plan. 6. The establishment of an OVC Steering Committee and its secretariat. 7. The establishment of district level coordinating mechanisms for OVCs in some districts. Impact alleviation at a glance Ratio of orphaned to non-orphaned children years of age who are currently attending school 1:5 (Ministry of Education, 2005) Whenever relevant, indicator scores should be reported by area of residence (urban/rural), gender, and the following age groups: 15-19, 20-24, Countries are encouraged to report on additional indicators that contribute to an expanded national response. IV. MAJOR CHALLENGES FACED AND ACTIONS NEEDED TO ACHIEVE THE GOALS/TARGETS 1. Coordination (NAC) In Zambia the HIV/AIDS arena is characterised by numerous local and international actors, including donors, UN agencies, international financial institutions, universities and research institutions, NGOs, FBOs, CBOs, etc. Much of the coordination efforts and coordination capacities of NAC are absorbed by managing numerous individual coordination processes associated with such a diverse group. The net result is that not enough action is realized on the ground. Stronger coordination mechanisms from national to the province and district are required to ensure that stakeholders at various levels are regularly communicating and therefore able to address specific, operational problems as they arise. Such a national 16

19 mechanism could bolster efforts to ensure that the technical support provided by various financing mechanisms and institutions is coordinated and is attuned to the needs of stakeholders at different levels. The National Development Planning processes presents a timely opportunity to address this institutional arrangement issue, and to reflect on the different mechanisms through which response coordination, financing and wider stakeholder participation could be achieved within broad mechanisms for integrating HIV/AIDS with all development efforts including coordinating workplace programmes, community Responses at the local level and for establishing coordination of interventions for Orphans and Other Vulnerable Groups, such as persons with disabilities, refugees and prisoners. Key issues under Coordination a. National Response i. National HIV/AIDS strategy ii. Integrating HIV/AIDS into the planning process (NDP) iii. Mainstreaming HIV/AIDS into sectoral programs iv. Decentralization v. Harmonization of policies vi. Information, Education and Communication b. Donor Support (MOFNP/NAC) i. Development assistance planning ii. Donor coordination and harmonization iii. Partnership development 2. Effective Leadership If Zambia has to achieve harmony and a well coordinated approach in combating HIV/AIDS, it is imperative that the country have an outstanding effective leadership that promotes a culture of excellence in multi-sectoral response to HIV/AIDS. Zambia has made considerable progress in building national leadership and ownership in the response to HIV/AIDS. Increasing numbers of national political and traditional leaders are voicing their support for efforts to tackle the disease, notwithstanding these efforts, considerable challenges still remain. NAC has been striving to provide support for effective leadership in four areas: 1) national level strategic planning and visioning, 2) technical and logistical support to an array of stakeholders, 3) monitoring the course of the epidemic and implementation programmes, and 4) resource mobilization. Taken together, these issues have reduced the effectiveness of Zambia s multisectoral response to HIV/AIDS. Despite previous efforts, there is not complete clarity on the division of responsibilities at national, provincial and district levels and among the partners. Any form of confusion at national level in turn plays out at provincial and district levels, as stakeholders and international agencies are not clear on who should be taking the lead on which activities, thus diminishing the possibilities of holding anyone accountable. For example, it is not very clear as to who should be held accountable over orphaned and vulnerable youths between the Ministries of 17

20 Community Development and Social Welfare, Youth Sport and Child Development and the Local Authorities in whose streets the street children and youths are found. The leadership challenge is thus to make inroads into tackling underlying issues such as advocacy, HIV/AIDS policy development and implementation, fiscal accountability, effective governance and human right issues and linkages with poverty, decision making and mobilization. Key Issues under Leadership a. Advocacy b. Legal and policy framework/national HIV/AIDS policy c. Budgetary provision d. Governance e. Linkages with poverty f. Decision making (e.g. in emergency situation) g. Mass mobilization at local levels 3. Capacity Low capacities and insufficient human resources as major barriers to rapidly scale up the response to AIDS at the district and community levels. The reasons for this are complex and vary considerably within the country, they including internal and external migrations, shifts from public to private or nongovernmental sectors (e.g., as a result of poor terms of service in the public sector and or the introduction of new HIV/AIDS initiatives that have attracted staff to the private and nongovernmental sectors), inadequate utilization of human resources (e.g., trained staff unable to be employed due to constraints on the public sector wage bill), and outright loss of staff (e.g., due to HIV-related morbidity and mortality). This human and technical capacity crisis being experienced in the country should underline the delicate balance that must be struck in the Fifth National Development Plan between the need to rapidly scale up AIDS interventions to respond to the urgency of the epidemic, and the need to promote longer-term sustainability and capacity-building at national and district levels. Currently there is a serious mismatch between the need for technical support and the financing available for it, as well as inefficiencies in the delivery of the support. Financing for programme activities has increased enormously, but this has not been accompanied by a concomitant rise in funding for technical support. Government s reliance on cooperating partners for technical support has generally not resulted in a sufficient volume of resources within grant agreements being devoted to technical support, and structurally it cannot address the financing of the upstream work of HIV/AIDS programme and proposal development. Thus while NAC is striving to scale up the response and is asking its implementing stakeholders to scale up the response, there is little or no capacity in some of these stakeholders and instead of building the capacity of these mandated stakeholders new structures are being established by cooperating partners in the form of international NGOs or parallel local level community based structures. Additionally, there is insufficient coordination of technical support, coupled with competition among cooperating partner institutions providing the support. 18

21 Further, only the health delivery system has gone through a thorough process of identifying the technical support needed to scale up their HIV/AIDS programmes to meet targets such as the Millennium Development Goals and the 3 by 5 Initiative for the rapid scale-up of antiretroviral treatment. Governments have a responsibility to improve capacities wherever needed for the campaign against HIV/AIDS. This includes their own effectiveness and accountability, so as to be able to fulfil their commitments to their citizens, and to be able to receive and dispense international assistance rapidly and efficiently. Key issues under Capacity a. Human Resource iv. Developing internal capacity at NAC (management and planning) v. Developing implementation capacity 1. for service delivery (health sector) 2. Monitoring and reporting 3. Financial management b. Institutional capacity vi. Institutional capacity development vii. Development of infrastructural capacity 4. Monitoring and Evaluation One of the key areas for an effective national response on the fight against HIV/AIDS is the establishment of an effective and sustainable Monitoring and Evaluation (M&E) system that can be used to report on results and impacts. The failure to share information between partners about planned activities, missions and reports produced leads to duplications and lessens the ability to build synergies between implementing and financing efforts. Multiple data systems exist in Zambia that have been developed for and by different groups, needs and paces. While the number of which naturally represent the nature of a quickly blooming multi-sectoral issue with the response of many, it is critical to expose all of these systems, their use, potential, and possible harmonization with other systems. Strong monitoring and evaluation is a prerequisite for oversight and accountability, yet it is an area that has not received adequate support from various stakeholders and cooperating partners. Finally, national oversight efforts are hindered by a failure by some international and national stakeholders to systematically share information with NAC. This fragments the national response and constrains national ability to identify problems when they are still nascent, instead allowing them to fester and grow. Further, tools that could assist in this process, such as an elaborate institutional arrangement with clear government legal support from the national level to the province and district have not been adequately utilised. The NAC must provide leadership with other national entities to proliferate solid M&E practice throughout provinces and districts in Zambia. Additionally, NAC has its own information needs such as tracking key HIV/AIDS-related activities, and facilitating the provision of data to global bodies (e.g. UNAIDS). 19