This is one of a set of three related pages, which also includes a history of HIV & AIDS in Zambia and an account of prevention and care programmes.
The Republic of Zambia is a large country at the heart of sub-equatorial Africa. More than a quarter of its 10.5-11 million people live in two urban areas near the centre: in the capital Lusaka and in the industrial towns of the Copperbelt. The rest of Zambia is very sparsely populated, particularly the west and the northeast, and the majority of people make their living as subsistence farmers.
In its four decades of independence, the Republic has found peace but not prosperity. Zambia is today one of the poorest and least developed nations on earth, and has a crippling national debt. Around two-thirds of the population lives on less than a dollar a day.
Zambia's problems have since the mid 1980s been compounded by one of the world's most devastating HIV and AIDS epidemics. The statistics alone are appalling:
HIV has spread throughout Zambia and to all parts of society. However, some groups are especially vulnerable - most notably young women and girls, who suffer inequality and abuse. AIDS has worst hit those in their most productive years, and, as families have disintegrated, thousands have been left destitute.
The impact of AIDS has gone far beyond the individual level; all areas of the public sector and the economy have been weakened, and national development has been stifled.
Responses to HIV and AIDS in Zambia have for many years aimed to prevent HIV transmission; to care for those who are infected and affected; and to reduce the personal, social and economic impact of AIDS. Since late 2002, the state has been engaged in an ambitious antiretroviral (ARV) treatment programme. Today, HIV prevalence remains at a shockingly high level. Reducing the number of new infections while scaling-up the provision of treatment to so many thousands in need poses a massive challenge to the government and the international community. Yet it is a challenge that must be met if Zambia is ever to have a better future.
Zambia's first reported AIDS diagnosis in 1984 was followed by a rapid rise in HIV prevalence (that is, the proportion of people who are living with HIV). By 1993, surveys of pregnant women had found infection rates of 27% in urban areas and 13-14% elsewhere. These levels have remained relatively stable ever since.3
At the end of 2003, UNAIDS/WHO estimates that 16.5% of people aged 15-49 years old were living with HIV or AIDS. Of these 820,000 adults, 57% were women.4 Young women aged 15-19 are around six times more likely to be infected than are males of the same age.5
Nearly half of Zambia's population is under 15 years old. According to UNAIDS/WHO estimates, 85,000 of these children were living with HIV or AIDS at the end of 2003.
Unlike in the USA or Western Europe, HIV in Zambia is not primarily a disease of the most underprivileged. Infection rates very high among wealthier people and the better educated. However, it is the poorest who are least able to protect themselves from HIV or to cope with the impact of AIDS.
A little under 40% of Zambians live in towns or cities, and HIV prevalence is considerably higher in these urban areas than elsewhere. Among pregnant women, the highest rates have been recorded in the capital, Lusaka (home to 10% of the population); the industrial towns Kabwe and Ndola; Western Province's capital, Mongu; and the cross-border trading centres Chipata and Livingstone (Livingstone is also a tourist resort). It has been estimated that urban areas contain 54% of all adults living with HIV or AIDS.6
Prevalence data on HIV in Zambia come from testing pregnant women at antenatal clinics and population-based surveys in selected areas. Since 1990, some 36 sites have been included in national antenatal surveillance on at least one occasion. It should be noted that this does leave substantial gaps, including some of the larger towns.
There is good evidence of a significant fall in HIV prevalence among young Zambian women in the 1990s. The most dramatic finding concerns pregnant women aged 15-19 years surveyed in Lusaka. Among this group, the proportion living with the virus almost halved from 28.4% in 1993 to 14.8% in 1998. Over the same period, there appears to have been a general decline in prevalence among young women in urban areas, and to a lesser extent among teenage women in rural areas. The greatest reductions were found among well-educated women, while prevalence among the least educated remained stable or increased. It is thought that the falling prevalence levels indicate a drop in the number of new infections, possibly as a result of behavioural change. This is an encouraging sign that efforts to educate young people about avoiding HIV have had some success.7
The trends among young women have not had a noticeable impact on Zambia's national prevalence level, which appears to have stabilized in the range 13.5-20%. This means that the annual number of new infections is roughly equal to the number of deaths. Falling prevalence among young people might well indicate lower incidence of infection, but a more general decline would not necessarily be a good sign. In fact, if more people receive antiretroviral treatment, and there is no great drop in the number of new infections, then fewer people will die of AIDS each year and prevalence may rise.
In Zambia, most HIV infections are the result of unprotected heterosexual sex. People who have many sexual relationships increase the risk to both themselves and their partners.
A number of factors can greatly increase the risk of HIV transmission during unsafe sex. Among these is the presence of a sexually transmitted disease (STD) in one or other partner. STDs are very common in Zambia: it is estimated that around a million cases occur each year. The high-risk, traditional practice of "dry sex" is also widespread. During dry sex, plant extracts are used to reduce lubrication, often causing genital ulcerations through which HIV can more easily enter the body.
Many thousands of sexual transmissions could be avoided if people consistently used condoms. However, for a lot of people to do so requires overcoming substantial practical, cultural or religious obstacles.
Most non-sexually transmitted HIV infections are passed from mother to child. Without access to preventative drugs, nearly 40% of HIV-positive mothers give birth to infected babies.
An estimated 30,000 infants contract the virus each year in Zambia, either during pregnancy, at the time of birth or while breast-feeding. Most of these children die before they are 5 years old. Around a half of all transmissions during pregnancy and birth could be avoided if every mother received a short course of antiretroviral treatment.
Other mechanisms of transmission such as contaminated blood and reuse of needles are thought to be relatively insignificant but are nonetheless important. All district, provincial and central referral hospitals have blood transfusion facilities that screen for HIV. However, it is not certain that safety can be absolutely assured outside of the capital, Lusaka. People might also be put at risk by some traditional practices such as tatooing.
In any discussion of Zambia's HIV and AIDS epidemic, the significance of gender inequality cannot be overstated. Men play a dominant role in most relationships, while women and girls are generally expected to be submissive. Females also have less access to education and mass media. As a result, women can lack the confidence, skills and knowledge necessary to negotiate safe relationships with men and to make independent lifestyle choices. Usually, a woman is taught that she must obey her husband and that it is wrong to refuse sex with him. Less than two-thirds of adults (of either gender) believe that a woman can refuse sex if she suspects that her husband has HIV.
Various aspects of traditional Zambian culture make women more vulnerable to HIV infection. Not least among these is sexual cleansing - a very common ritual in which a deceased man's relative has sex with his widow, in the belief that this will dispel evil forces. The HIV status of either person involved is usually not taken into consideration. Various alternative, risk-free rituals do exist, and traditional leaders in some areas have saved lives by encouraging change.
Most Zambians become sexually active at quite a young age. In 2003, among young people 15-19 years old, 28% of boys and 44% of girls reported having had sex within the last twelve months. The average age for first sex is around 17 in females and 17.5 in males.8
It is normal for men to be older than their partners; the average age difference is around 5 years. For many girls, their first sexual encounter is with an older boy or elderly man, some of whom entice them with money or gifts. This is one reason why girls aged 15-19 are six times more likely to have HIV than are boys of the same age.
Many of the most tragic stories connected with HIV transmission involve the sexual abuse of children. The high prevalence of HIV has increased the level of sexual violence and coercion, and not just because many of the victims are vulnerable AIDS orphans. Men are targeting increasingly younger sexual partners whom they assume to be HIV-negative, and the "virgin cure" myth (which 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.
Like most countries, Zambia does have laws against child abuse. However, orphans who inform against their guardians risk abandonment or violent punishment, and families will often go to great lengths to conceal what is going on. It is no surprise that the vast majority of perpetrators go unreported, unpunished and free to abuse again:
"To report a crime of sexual violence or abuse, a girl would face a police department that is rarely child- or gender-sensitive, health service providers that may scold her for being promiscuous, a court system lacking any facilities for youths, and a societal structure that teaches girls to be submissive to men. Even if she did report abuse, chances that officials would act against the abuser are minimal." - Human Rights Watch.9
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 10 go unheard.10
There are thousands of female sex workers in Zambia, and men pay a premium to engage in unprotected sex with them. The limited data available suggest that around two-thirds of such women are HIV-positive.11
Besides regular sex workers, many other women are compelled by poverty to occasionally accept money or gifts in return for sex. According to a 2003 survey, 19% of women and 29% of men have taken part in commercial sex.12 There is a saying among desperate women in Zambia: "AIDS may kill me in months or years, but hunger will kill me and my family tomorrow".
Much of Zambia's population is mobile. Risk of infection is often higher among these people and among those whom they contact.
Infection is carried along the main transport routes by truck drivers, hundreds of whom regularly pay for sex. (The Zambian Association of Truck Drivers is very aware of this problem, and is running awareness campaigns to try to counter it.) Elsewhere, large numbers of seasonal workers and fishermen/women, during long periods away from their regular partners, engage in short-term relationships and "temporary marriages", thus spreading the virus from pockets of high prevalence into the general population. Women and girls involved in cross-border trading may exchange sex for transport or other favours, and are very vulnerable to exploitation.
Homosexuality is a taboo subject in Zambia. No-one knows how many people are infected through homosexual sex, which is officially illegal. What is known is that sex between men occurs frequently in prisons, yet the government refuses to lift its ban on distributing condoms to prisoners.
Because HIV can be sexually transmitted, it is often presumed that those living with the virus have brought disease upon themselves by having many sexual partners, and moral judgements are made. Women are especially vulnerable to this prejudice, and they may also be blamed for infecting their children (even though the father is often the first to be infected). Victims of stigma suffer physical and social isolation from their family, friends and community; they are made to feel guilty, ashamed and inferior. Those associated with people living with HIV also suffer from stigma, as do those thought to be responsible for spreading infection, such as sex workers, traders and migrant workers (even if they are not themselves known to be infected).13
Stigma does not just cause pain to individuals, it also hampers prevention and care programmes. Those who fear becoming stigmatised will be unwilling to volunteer for an HIV test; even purchasing condoms or discussing safer sex may be seen as an indication of infection and so be stigmatised. People who know or suspect that they are HIV-positive are generally reluctant to reveal their status - even to their partners and family - or to come forward for treatment.
Tragically, some of the worst discrimination occurs in clinics and hospitals. Patients known or suspected to have HIV are sometimes given very low priority and may be subjected to degrading treatment and breaches of confidentiality; they may even be denied drugs and treatment.14
The majority of people who develop AIDS are in their productive years and are often the sole breadwinners in their households. When an adult falls ill, other family members - in particular children kept home from school - must try to raise money or tend crops as well as looking after their ailing relative. Much of the cash they are able to obtain is spent on medical care and, ultimately, funeral costs. When a parent dies, survivors can be left destitute.
People in need have traditionally been supported by their extended families, but the toll of the epidemic is now so great that family structures can no longer cope. Stigma compounds the problem, as many of those affected by AIDS become socially excluded. And to make matters worse, when the male head of a household dies it is common for his entire property to be "grabbed" by his relatives (despite laws meant to prevent this), leaving his widow and children with nothing. Desperate people will inevitably turn to risky occupations or to migration.
Thousands of children are abandoned due to stigma or to simple lack of resources, while others run away because they have been mistreated and abused by foster families. Many such children congregate in the big cities, where they live by begging, stealing and prostitution:
"In the days before the full impact of the HIV and AIDS pandemic, street children were a very rare sight in Zambian cities and towns. Now they are everywhere… sleeping under bridges, behind walls, and in shop corridors." - Dr Mannasseh Phiri.15
In 2003, it was estimated that 630,000 surviving children had lost at least one parent to AIDS16 (around one in every five children). It is projected that the number of AIDS orphans in Zambia could rise to 974,000 by 2014.17 See our orphans page to learn more.
The crippling effect of AIDS on Zambia's healthcare system is perhaps the greatest problem the government faces. In some hospitals, more than 50% of beds are occupied by patients with AIDS-related illnesses. Not only has the epidemic increased the number of people seeking medical services, but it has also greatly increased costs as most AIDS-related conditions are especially expensive to treat. There is consequently less money available to treat other conditions.18
Zambia's health system, having suffered years of under-investment, has now been brought to the brink of collapse. Almost all health facilities lack adequate personnel, drugs, and/or equipment, and physical infrastructure is deteriorating. Under such conditions, carers must struggle to cope with the rise in demand - just as their own number is being depleted by illness and AIDS deaths.
In 2001, a nationwide survey found that just two-thirds of primary-school-age children attended primary school, and less than a quarter of those aged 14-18 years attended secondary school. Twelve percent of all respondents said that a child in their own family did not attend school because a parent or guardian was suffering from AIDS or had died from AIDS.19 In 1999, the government launched a programme called BESSIP, which envisages education for all by 2015. However, it is acknowledged that, "the global spread of HIV/AIDS may make the attainment of some of the BESSIP goals difficult if not impossible".20
Teachers have been disproportionately affected by the epidemic and are now in short supply; more than two thousand teachers died in 2002, while teaching colleges produced fewer than a thousand new graduates.21 Rural postings are unpopular, and those who accept them tend to move away when they become ill, so as to be closer to clinics.22
Those children and teachers who are able to attend school face further challenges, as AIDS-related illness, stress and malnutrition make learning very difficult.
The AIDS epidemic severely damages every sector of Zambia's economy. In the first place, employers bear the direct costs of absenteeism, medical care, funerals and extra recruitment; according to the Zambia Business Coalition, 82% of known causes of employee deaths are HIV-related and 17% of staff recruited are to replace people who have died or left because of HIV-related infections.23 But what is even more significant is that, as AIDS kills people in the prime of life, the workforce is stripped of valuable skills and experience. The situation becomes yet worse as there are fewer people to teach the next generation. All of this means that production costs rise, while at the same time consumer spending falls because people affected by AIDS have less money to spare. Zambia has been one of the world's poorest countries since the late 1970s, and AIDS has made a bad situation even worse.
Agriculture, from which the vast majority of Zambians make their living, is also affected by AIDS. In particular, 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.
Negative trends in the economy and food production fuel the epidemic that helped to create them. Poor nutrition makes HIV-positive people more vulnerable to infections, and hastens the progression of AIDS; and when people are poorer they are more likely to turn to risky occupations, and are less able to pay for medical care or school fees. As Zambia's Poverty Reduction Strategy Paper acknowledges, "the epidemic is as much likely to affect economic growth as it is [to be] affected by it".24
Clearly an epidemic on such a scale demands a powerful and wide-ranging response. AVERT.org has two more pages that continue the story of HIV and AIDS in Zambia:
History and Funding - Was the government slow to mount a strong response to the HIV and AIDS epidemic? What is the current attitude and how are the programmes funded?
Prevention and Care - What efforts are being made to prevent new HIV infections? Who is receiving life-saving AIDS drugs?
Author: Rob Noble.
Last updated August 16, 2005