Frameworks, Conventions and Resolutions: The protection of Children affected by HIV/AIDS

by Anthony Pringle

Societies are often judged on how well they protect their more vulnerable members. The protection of the less fortunate people in society is a feature of any advanced democratic system, characterised by a constitutional framework reflecting and protecting human rights, an impartial judicial system and a stalwart social services network. These key features are the culmination of social evolution, the contemporary pinnacle of a social contract in which the general populace has abdicated special privileges onto a core of decision makers who are thus compelled to act in the best interest of all people and to afford them the best protections. Governments are thus obliged to take special measures to ensure that their most vulnerable subjects, the children, are accorded their full rights both as individuals and as equals.

Zimbabwe’s legal system is a dualist legal system, which draws on customary law and statutory law. Today these legal frameworks are being challenged primarily by the HIV/AIDS epidemic. HIV/AIDS manifests as a chimera of threats to children, including abuse, exploitation, and jeopardy of education, nutrition and equality. The HIV/AIDS crisis has challenged the Zimbabwean Government in its role as a protector of children, and has called for ever more innovative strategies to tackle the issue. It is ever imperative in this current crisis that the Government should play a more acute role and be increasingly vigilant to ensure that the child’s rights are accorded in full. This article will look at how Zimbabwe’s legal frameworks are coping during this crisis. I will initially look at Zimbabwe’s legal system and the national and international legal frameworks set up to protect the rights of the child. Following this I will look at the current HIV crisis, its impact on children and the subsequent discharging of jurisprudence. Finally I wish to offer some of my own thoughts on the legal system and its role in the protection of children.

Zimbabwe’s legal system

Zimbabwe’s constitutional law contains a legal framework and two key national policies, which are directly concerned with the rights of Zimbabwean children (1). The constitutional legal framework also includes the Children’s Protection and Adoption Act, which was adopted in 2001 (2). This Act is a broad and encompassing statute with a stated aim “to make provision for the protection, welfare and supervision of children and juveniles” (3). The two key national policies are more inclusive, informed and appropriate as they directly take into account the impact of HIV on children. These two key national policies, the National Orphan Care (NOC) policy and the National AIDS Policy (NAP) both adopted in 1999 (4).

Zimbabwe also must adhere to both regional and international frameworks and conventions that the country has ratified as a signatory state. The most important International legal document that Zimbabwe is a signatory state to, is the UN Convention on the Rights of the Child (UNCRC), of September 2nd, 1990 (5). This international convention is the most encompassing and inclusive legal text, which clearly delineates children’s rights and the State’s obligation in upholding such rights. Regional frameworks include the African Charter on the Rights and Welfare of the Child 1999 (6). This document is uniquely important as it recognises and accounts for the unique threat of HIV/AIDS on the African continent. In my view, the key principles which underpin these national, regional and international legal frameworks include

• Equality & Non discrimination
• Best interest of the Child
• A child’s right to life, survival and developmen
• Respect for the views of children

Furthermore, in the face of the HIV/AIDS crisis the Zimbabwean Government has attempted an innovative working of Zimbabwe’s legal system, in an effort to coordinate a targeted response to negate the impact of AIDS. The resulting policy was the National Plan of Action for Orphans and Other Vulnerable Children (NPA for OVC) which was adopted by the Cabinet Committee on Social Services in 2004. With the NPA for OVC, NAPS, NOC and the UNHCR there is a wide array of legal protections afforded to Zimbabwean children with clear State obligations, of which there is no clearer enunciation than in the UNHCRC Article 6 section 2 which states that “States Parties shall ensure to the maximum extent possible the survival and development of the child.”

Jeopardized Jurisprudence: HIV&AIDS

HIV/AIDS has changed every aspect of life in Zimbabwe. Because of the radical shift in all spheres of life many now argue that the original key legal texts are now antiquated and inappropriate to the contemporary social terrain of Zimbabwe (7). One of the acute social transformations due to HIV/AIDS is the changing of children’s lives (8). Due to the restructuring of children’s lives the child now faces an unprecedented scale and scope of risks, which the government and legal frameworks had not anticipated.

The impact of HIV/AIDS on children is both direct and collateral. The direct impact of HIV/AIDS is the predisposition of Zimbabwe’s children to the contraction of HIV, be it pre or post natal. Demographic charts show that in Zimbabwe there are an estimated 160,000 children living with HIV/AIDS (9). Even more harrowing is the estimate that more than 60 per cent of 15-year-old boys today can expect to become infected during their lifetime. For the infected children there can be no real quality of life, education nor nutrition, which all are facets of life guaranteed in national and international legal frameworks.

The collateral impact is just as destructive, with poverty being the biggest threat. In Zimbabwe currently 20.5% (10) of the economically active population have contracted HIV, thus constraining household income for food, education and other child appropriate activities. Often the obligation to work and feed the family then falls to the children who are forced to turn to agriculture, industrial work, prostitution or any other employment that may be available, regardless of risk, in order to provide for the family. Research carried out by Global March (11) in 2000 indicated that in Zimbabwe there were 427,000 children between the ages of 10-14 who are economically active, of which 187,000 are girls and 240,000 boys (12). Furthermore, with declining economic conditions, and the unprecedented number of children entering waged labour, schooling for many has suffered. UNHCR Article 28 that “State Parties recognize the right of the child to education“. Whilst ‘recognition’ is important actual quality education is paramount. According to UNICEF statistics for the period 1996 to 2004, only 44% of boys and 42% of girls registered in Zimbabwe’s secondary schools actually attended classes (13). Many parents said that their children had to drop out of school to help support the family (14). The pragmatism of child labour is a serious detriment to the Zimbabwean Government, challenging it’s obligations under UNHCRC Article 32 which states that;

States Parties recognize the right of the child to be protected from economic exploitation and from performing any work that is likely to be hazardous or to interfere with the child’s education, or to be harmful to the child’s health or physical, mental, spiritual, moral or social development (15).

Another distinct impact of HIV/ AIDS is the increasing incidence of child abuse. UNHCR Article 34 states that States should;

undertake to protect the child from all forms of sexual exploitation and sexual abuse (16 & 17).

Governments are obliged to take all appropriate national, bilateral and multilateral measures to prevent:

(a) The inducement or coercion of a child to engage in any unlawful sexual activity;

(b) The exploitative use of children in prostitution or other unlawful sexual practices.

HIV/AIDS can weaken a family due to the loss of one or both parents, creating unprecedented orphan numbers. With the decline of structured families and the denigrating socio-economic conditions children are more vulnerable to neglect as well as emotional, physical and sexual abuse.

Due to the diverse spectrum of the HIV/AIDS impact, the Government has a myriad of issues to tackle and as such needs to be innovative in framing legislation in practical, tangible and attainable ways.

Legal Innovation by the Zimbabwean Government

The rise in the number of orphans, the new phenomenon of households headed by children and grandparents, children entering waged labour, and the deteriorating education conditions were not anticipated when Zimbabwe’s child protection laws were originally framed. The Zimbabwean Government has attempted to update and overhaul the legal system to accommodate for this manifestation of HIV/AIDS. One such innovative and encouraging step was their tailoring of the NPA for OVC so as to more pragmatically address the direct and collateral impacts of HIV/AIDS. The NPA for OVC was born of recognition that widespread consultation and devolution of power was required to tackle HIV/AIDS (18). The NCA for OVC planned to devolve decision-making to grass roots level and empower sectors of the community under a legal framework.

The NPA for OVC sought to overcome these issues with a stated aim to “identify all orphans and other vulnerable children and to have reached out with service revising to at least 25 of OVC” (19). The Government has also set up a number of key bodies within the Department of Health & Education in an attempt to strengthen the legal frameworks protecting children’s rights threatened by HIV/AIDS. The NPA for OVC, the National Orphan Care (NOC) policy and the National AIDS Policy (NAP) also demonstrate the commitment of Zimbabwe’s Government to upholding international standards on adoption, as set out in UNHC Article 21

States Parties that recognize and/or permit the system of adoption shall ensure that the best interests of the child shall be the paramount consideration (20).

These policy initiatives (NPA for OVC and NOC) which directly address the HIV/AIDS crisis , are encouraging steps taken by the government to adapt to the changing social terrain of Zimbabwe.

Whilst creating and shaping legal documents and Frameworks is important, upholding these texts is paramount. One of the key impediments to enforcing the protection of children’s rights as called for by the legal frameworks, is the lack of adequate resources to counteract the contemporary difficulties faced by children (21). By its own admission, the NPA recognised this when ZimRelief (22) reported that the NPA would require unforeseen funding (23). The report also stated that;

Although Zimbabwe has a well defined legislative and policy framework to support children, lack of resources have prevented full implementation of key national policies. There is an urgent need to mobilise and coordinate resources for full implementation of national policies benefit ting children.

Getting the balance right

On a primordial level the Zimbabwean Government’s commitment to assisting children appears contradictory in light of some of its developmental policies. UNHCR Article 16 (24) states that;

1. No child shall be subjected to arbitrary or unlawful interference with his or her family, home or correspondence
2. The child has the right to the protection of the law against such interference or attacks

Yet with developmental policies like Operation Murambatsvina(Clear the filth) which began on May 25, 2005 the lives and modality of life of many children was jeopardized (25). The UN estimated that 700,000 people, 6% of the total population, lost their homes, livelihoods or both as a result of the operation. The UN SPCA envoy reported that the government;

provided little to no assistance to displaced children living with their parents or guardians, children separated from their families, or child headed households (26).

According to ActionAid, 22% of the children affected by the operation, dropped out of school after the operation because evictions forced them to relocate to extensive distances away from their schools (27). Human Rights Watch noted in June 2005 that many NGOs could not effectively disseminate Anti-Retro-Virals (ARVs) to the displaced persons, many of whom were children (28). These actions clearly contradict the State’s obligation as stated in Article 3 section 1;

In all actions concerning children, whether undertaken by public or private social welfare institutions, courts of law, administrative authorities or legislative bodies, the best interests of the child shall be a primary consideration (29).

Clearly, this disruption will perpetuate the direct and indirect impacts on all spheres of the child’s life. State obligations to protect the child as enshrined in national, regional and international legal frameworks are compromised in the face of such of the Government’s development operations. When viewed at the macro-level, the government has struggled to uphold its own legal obligations to providing due protections to the children, due to economic stagnation, challenges in effectively allocating resources and in attempting to uphold social networks.

In conclusion the scope of legal protections afforded to Zimbabwean children is broad, a fact which indirectly acknowledges the impact of HIV/AIDS on contemporary Zimbabwean life. With Zimbabwe being a signatory state to many international treaties on children, like the OAU’s African Charter on the Rights and Welfare of the Child and the UN Convention on the rights of the Child, and in view of key statutes in the constitution of Zimbabwe, there is a strong body of legal protections afforded to Zimbabwean children. In the face of HIV/AIDS, Zimbabwe’s government has attempted many innovative strategies, most notably, the NPA for OVC, in a bid to uphold the rights of the child. HIV and AIDS have redrawn the economic, social and cultural terrain of Zimbabwe, resulting in a serious strain on the available resources needed to protect children’s rights. While attempting to address the country’s economic decline, the Government must be cognisant of the impacts of such developmental policies as Murambatsvina, and should always attempt to maintain an appropriate balance in this developmental rubric. The government has faced some challenges, and so has attempted to empower sectors of the society through the NPA for OVC in a bid to maximise the “survival and development of the child” (30). There however remains a need for a larger investment in tackling the manifestations of AIDS which impact Zimbabwe’s children in a variety of ways; namely poverty, abuse and labour. Education also plays a key role and should in the future drive Zimbabwe’s economy. By achieving the right balance in directing proportional resources into different strategies and drawing civil society into a continual consultation process there will hopefully be a strengthening in the enforcement of the legal frameworks and an improvement in the quality of life of the Zimbabwean child.

References:

(1). Statute Law Of Zimbabwe, Revised edition.
(2). Childrens Protection and Adoption Act (Amendeded Act).
(3). ibid
(4). Zimbabwe National AIDS Council
(5). Full text of UN Convention of the Rights of the Child.
(6). African Charter on the Rights and Welfare of the Child, CAB/LEG/24.9/49 (1990), entered into force Nov. 29, 1999.
(7). Youth Net : Adolescents : Orphaned and Vulnerable in the time of AIDS.
(8). Pringle, A. The Commercialization of Childhood. HAZ PUBLICATIONS, Lexington, KY. (MAY 1, 2006)
(9). Figures for the e nd of 2005
(10). Guardian On line: Dramatic fall in Zimbabwe HIV Infections 2005.
(11). Global March Against Child Labour.
(12). International Labour Organisation (ILO): ILO, International Labour Office – Bureau of statistics, Economically Active Population 1950-2010, STAT Working Paper, 1997
(13). IRIN Africa-Zimbabwe: Fees Hike Likely to force more children out of school.
(14). Ibid
(15). Article 32 UNHCR.
(16). Article 34 UNHCR.
(17). Article 28 UNHCR.
(18). ZimRElief Npa for OVC, full text.
(19). ibid
(20). UNHCR Article 21 UNHCR
(21). ibid
(22). The Zimbabwe Situation
(23). The original plan estimated yearly funding costs of US$33 million but due to a number of factors ,escalated up to a speculated US$55 million per : Based on calculations from the original NPA for OVC charter and updated reports from Zimwatch & Kubatana annum.
(24). Article 16 UNHCR.
(25). Human Rights Watch Operation Murambatsvina Zimbabwe: Evicted and Forsaken Internally displaced persons in the aftermath of Operation Murambatsvina.
(26). U.N. Special Envoy on Human Settlement Issues in Zimbabwe, “Report of the Fact-Finding Mission”.
(27). Action Aid International, November 2005, An in-depth study on the impact of Operation Murambatsvina/restore order in Zimbabwe.
(28). Human Rights Watch (HRW), December 2005, Zimbabwe: Evicted and Forsaken: Internally displaced persons in the aftermath of Operation Murambatsvina.
(29). UNHCR Article 3.
(30). UNHCR, Article 6.

Perspective: Zimbabwe observes a reduction in HIV prevalence, but why?

by Theo Smart:

This article was originally posted on the AIDSMAP web site, on July 5th 2006.

In 2005, a substantial reduction in national HIV prevalence during the previous year was observed in Zimbabwe. This has been heralded by some as evidence that HIV prevention efforts, particularly strategies based upon Abstinence, Be Faithful and use Condoms (ABC), are having an impact.

However, while this may be true in a general way – there does appear to be some evidence of recent behavioural change, such as a decline in number of partners and casual sex; and greater use of condoms with casual partners -other factors, such as an extremely high rate of mortality, contributed greatly to Zimbabwe’s reduction in prevalence.

Zimbabwe is being held up as an example of the early success of PEPFAR’s ABC approach, but do findings from the field really support that claim?

The Ministry of Health and Child Welfare investigates

A report on what happened in Zimbabwe was presented at the PEPFAR Implementers meeting last month in Durban, South Africa, by Dr. Owen Murungi from Zimbabwe’s Ministry of Health and Child Welfare (MoHCW) during a session on ABC.

According to Dr. Murungi, after the dramatic decline in HIV prevalence during 2004 was registered in Zimbabwe, nearly everyone was shocked. “The big question to all of us was, is this real? What’s happened?” he said.

So a review was conducted to determine whether other available data corroborated the finding, and whether the cause for the decline was due to high mortality rates or an actual decrease in incidence. Then, if there was a decline in incidence, could it be explained by natural dynamics of the epidemic or by behaviour changes.

The Ministry pulled together data from 30 different sources including every available survey, records from antenatal clinics, PMTCT and VCT programmes, census data, and clinical trials such as the ZVITAMBO (a large vitamin study) and the Manicaland studies (from rural Zimbabwe). Then working with experts from the UNAIDS reference group, they held a meeting to review the data with all the local stakeholders from government, research and donor groups (including the US Centers for Disease Control, USAID, the UK Department for International Development, UNFPA, UNICEF, London’s Imperial College and the teams from the major local clinical trials).

All the data seem to agree that the fall in HIV prevalence was indeed real. According to antenatal clinic (ANC) data, in the year 2000, the HIV prevalence in Zimbabwe was 32.1% and in the following two years it hovered around 30%. No data were available for 2003 but in 2004 the HIV prevalence had fallen to 23.8% and the test for the trend was statistically significant (p<0.001). This trend was corroborated by data from the ZVITAMBO study, which included pregnant and post-natal women from Harare followed over several years. In this study population the HIV prevalence actually peaked around 1996 (at over 36%) and had been falling ever since (to somewhere around 21% in the middle of 2004).

Rural populations tend to have a lower general HIV prevalence, but the downward trend was similar from the two time periods of 1998-2000 and 2001-2003 in the Manicaland studies. In women between the ages of 15-44 years old, ANC data suggested that the HIV prevalence fell from 21.1% to 19.2% (p value not significant) with declines in most age groups except for women over 30. Another survey from that study looked at women in households, and found that the prevalence was actually much higher. Even so, in the household survey, the prevalence also fell from 25.9% to 22.3% (p3D0.015).

The Manicaland study also looked at men between the ages of 17 and 44 years old, where there was also a decrease in prevalence, from 19.5% to 18.2% (p3D0.01), with declines in all age groups except men over 35. It is interesting to note that very few of the younger men are infected, but in the years 1998-2000 close to 50% of the men between the ages of 30-34 were HIV-infected, falling to around 40% in the next survey.

Reasons for reduced HIV prevalence in Zimbabwe

Decreased incidence or cumulative mortality? Even though this study is being touted as proof that ABC works, the data that Dr. Murungi presented paint a much more complex picture. A very large part of the reduction in HIV prevalence was actually due to the very high mortality rate for people with HIV in the country.

According to Dr. Murungi, all deaths are recorded in Zimbabwe, and beginning as early as the mid-80′s, there was a steep rise in mortality which Dr. Murungi attributed to AIDS, but which he believes began to level off, although at very high rates, around the year 2000. A closer investigation of the data from Harare suggests that this has indeed been the case in the capital, although the most recent data from Bulawayo shows mortality still rising.

Of course, many people with HIV return to their home villages to die. So looking at the Manicaland study sites (again in rural Zimbabwe), the death rates in men appeared to peak in the year 2000 at around 31-32 deaths per 1000 person years falling to around 26 deaths per 1000 person years in 2002/3 (However, the confidence intervals for these findings are quite similar, so we cannot judge with certainty if this represents a true decrease).

In women, rural death rates peaked in 2001, at just below 25 deaths per 1000 person years, falling to around 23 deaths per 1000 person years, although again, the confidence intervals overlap.

Overall, the yearly mortality rate for people with HIV in Zimbabwe was somewhere over 4% per year. However, by itself, the mortality rate could not effect a reduction in prevalence unless there had also been a reduction in incidence of HIV infection (from the peak incidence rate). In other words, at some point in the last several years, people with HIV began dying at a higher rate than new people were becoming infected.

Over the years, a number of studies have looked at HIV incidence in Zimbabwe. In the first one, Mbizvo et al., in 1993, the incidence was around 5% in antenatal women. Around the year 2000, the ZVITAMBO study observed an incidence that was around 3.6%. Among men, a survey in male factory workers, that the Zimbabwe AIDS prevention survey (ZAPS) conducted in 1994, found the incidence to be about 3.5%. Seven years later (2001), a similar survey in male factory workers reported an incidence of less than 2%.

Although these are cross-study comparisons, the data do suggest a falling incidence – at least between 1993/4 and 2001. If the current incidence is roughly around 2%, at the current mortality rate, the prevalence would decrease substantially each year.

Are changes in incidence due to the natural dynamics of the disease or behaviour change?

Reductions in HIV incidence could be the result of natural dynamics of the HIV epidemic or due to behaviour change (people having less risky sex). For example, over time, any epidemic is somewhat self limiting. Mortality plays more than one part in this, because it doesn’t only decrease prevalence directly, it can decrease incidence as well, by decreasing the pool of infectious individuals who can spread the infection. This is particularly the case when most of those who have died are men (because infected men are much more likely than women to spread the infection to more than one partner).

However, although he didn’t exclude natural dynamics during his presentation, in a conversation afterwards, Dr. Murungi said that colleagues at Imperial College in London had run simulations suggesting that other factors besides natural dynamics were needed to explain the changes in incidence observed in Zimbabwe.

So the MoHCW investigated what the available data sources could tell them about the contribution of behaviour change to the decrease in incidence and prevalence. Several surveys have explored age of first sex among 15-24 year olds over the last 20 years. Dr. Murungi believes they show that the age of sexual debut has increased over the last several years, although the data he presented were difficult to scrutinise closely (a dozen or so studies’ findings scattered both up and down across a graph, which made it difficult to evaluate the trends or determine how comparable the data were).

However, over the last several years, there did appear to be a clear and substantial fall in the percentage of young men who reported having had sex during the last 12 months with non-regular partners. Reported condom use with non-regular partners had also increased in the last five years. Dr. Murungi noted that there has also been a steady increase in the number of condoms in circulation, particularly socially marketed condoms (rather than public sector condoms).

In the Manicaland study, statistically significant changes in reported sexual behaviour were observed for both males and females in 1) the age of sexual debut, 2) new partners in the last year/month and 3) the number of current partners. The data supporting positive behaviour changes in these rural settings are convincing but it should be kept in mind that most new infections occur when people leave the rural settings to find work away from their families in urban or industrial areas. Whether they take the sex behaviour changes with them to other settings is another matter.

Problems with attribution and intervening variables

What was missing from Dr. Murungi’s presentation was the time to discuss the sort of prevention messages that were being spread most in Zimbabwe in the late 90′s and early 2000′s – and who was doing it. This was not a prospective study so the association with programmes in operation there today is tenuous at best.

What is also interesting is that most of the data suggesting that there had been a change in behaviour come from the last five or six years, while the most recent data suggesting that there has been a decrease in incidence came from the years 2000 and 2001 suggesting that the incidence had in fact been falling over the course of the late 1990′s (while mortality was rising).

It would be useful for someone to compare and contrast what has happened in Zimbabwe with what is going on in Botswana, where despite massive efforts and funding spent on ABC-based prevention messages, the HIV prevalence in Botswana remains extremely high (38.5%) according to the UN report.

Again the effects of such a high mortality rate in Zimbabwe need to be considered. Over the course of the PEPFAR meeting, there was much talk about “creating enabling environments” that support and encourage people to abstain or be faithful or use condoms consistently. Well, history has shown that observing large numbers of people sick and dying of HIV can be a powerful motivator for changing behaviour. It is not a for-mula for enabling HIV prevention that any sane person would promote however.

There could also be a host of other negative “enabling” factors that played a part in the reported behaviour change. Its important to remember that this is, after all, Zimbabwe. Since the year 2000, Zimbabwe’s economy has ground to a halt; the country suffered from floods, followed by severe drought and endemic food insecurity. In this context it is odd, to say the least, that the official mortality rate reported peaked before all that trouble began. But even if famine and inflation didn’t increase the numbers of people dying, the calamity would have increased the costs of caring for a person with HIV tremendously.

People with AIDS have a tendency to return for care in their home villages but caring for a person with AIDS is difficult enough for a rural family in a time of plenty -during a time of hardship, the family can be strained to the breaking point. This usually increases stigma from which people with HIV suffer. In another study at the Implementers meeting, a team from Population Services International reported some of the challenges trying to work with and empowering people living with HIV and AIDS (PLWHA) in Zimbabwe, who they reported experienced high levels of shame, blame and enacted stigma during this period. According to the presentation, in 2005, terms used to describe people with HIV in Zimbabwe included phrases such as “in the departure lounge,” “crossed the red robot,” and “bewitched by goblins.”

No wonder young people in Manicaland don’t want to go that route.

It can also be challenging to organise prevention work in Zimbabwe in the current political climate. For example, Catholic Relief Services has been working with orphan girls in Zimbabwe, who because of the disruption of normal patterns for their domestic and sexual education (loss of aunties to illness, etc.) are poorly informed about reproductive health and general protection issues. However, “local authorities can be politically sensitive to gatherings of youth,” a poster at the Implementer’s meeting reported, and any educational efforts they put together had to “work under the radar.” In fact, many foreign non-governmental organisations have complained about the difficulty of working in Zimbabwe over the last several years – which lends some credence to Dr.Mark Dybul’s (Acting US Global AIDS Coordinator) assertion (in a press conference at the meeting) that the church is often the only organisation with “reach” into some countries.

But the collapsing economy could have additional effects that could decrease mobility (and therefore risk of HIV infection). Unemployment has sky-rocketed in Zimbabwe, and there have been major petrol shortages. The commercial mining sector has collapsed, and factory work has evaporated. Cities no longer offer much work. (It would be interesting to know what has happened to HIV prevalence in the general population in the cities during this period.) So as a result of Zimbabwe’s economic contraction, many of the old hotspots for HIV trans-mission – near the factories and mines, at truck stops along the highway – could be dwindling or people no longer have a reason or the means to go there.

Finally, many of those with the means to get out and look for work have poured into neighbouring countries, including Botswana, and South Africa. Hundreds of thousands of adults in their prime working years (who may represent a substantial proportion of the sexually active and possibly HIV-infected population) have simply left the country. And yet, so far, no one has addressed what impact emigration might have had on Zimbabwe’s HIV prevalence and incidence – and what might happen should they all return home for treatment (see below) which is increasingly available.

These variables need to be explored fully in a multivariate analysis before building any case for prevention strategies upon the basis of what is going on in Zimbabwe. Dr. Murungi says that they still intend to do further analyses on the available data, and that results from a demographic health survey performed last year, should help fill in some of the missing data. Chances are there is still a lot to learn about what has happened in Zimbabwe – but again, it may not yield a formula that anyone would want to mimic.

This is success?

This is not to say that the ABC strategies aren’t working, but teams building effective prevention programmes need better information about best practices and how to create enabling environments that can be replicated in their home countries. While a balanced prevention campaign featuring the ABC approach may indeed reduce the number of new HIV infections, the defenders of PEPFAR’s prevention package may be in too much of a haste to vindicate the approach before their critics.

Adopting Zimbabwe as a poster child for ABC also seems unwarranted especially as the teams that PEPFAR is working with now are carefully gathering data and putting it together in such a way that other groups will be able to learn from their successes. It may take a little longer but it should be far more effective.

Finally, Dr. Murungi stressed that Zimbabwe still has a long way to go “We acknowledge the fact that the prevalence rates are still very high in Zimbabwe. We still have a lot to do. 20% is still very, very high.”

And it might not even be as low as that. Until recently only a very low percentage of Zimbabweans were willing to be tested for HIV. According to another presentation at the Implementer’ meeting, national testing and counselling centres were set up across the country, but as of the first quarter of 2003, HIV prevalence was only 18.3%, which suggested to the authors that they were drawing primarily the “worried well.” Then in April 2004, the Zimbabwean government, with support from the US government began rolling out antiretroviral therapy, which by February 2006 was available at 65 sites nationwide. The rollout has been associated with an increase in the percentage of symptomatic people and people at higher risk of infection who come in for test-ing so that by the fourth quarter of 2005, the HIV prevalence at the national testing sites had increased to 28.9% (p3D0.05) – which is much closer to the HIV prevalence reported in earlier this decade.

Finally, more Zimbabweans on ART should mean improved survival – which could increase HIV prevalence. In fact, ART could be one of the major reasons why neighbouring Botswana continues to see a stable rather than a falling HIV prevalence.

References

1. Gregson S and Murungi O. HIV decline accelerated by reductions in unprotected casual sex in Zimbabwe? Evidence from a comprehensive epidemiological review. The 2006 HIV/AIDS Implementers Meeting of the President’s Emergency Plan for AIDS Relief, Durban, South Africa, Abstract 29.
2. Karin Hatzold and Taruberekera N. Effect of perceived treatment availability on HIV prevalence among T&C clients in Zimbabwe. The 2006 HIV/AIDS Implementers Meeting of the President’s Emergency Plan for AIDS Relief, Durban, South Africa, Abstract 155.
3. Madan Y, Taruberekere N, Chatora K. Active involvement of PLAs to design and develop mass media campaigns to address stigma and discrimination related to HIV and AIDS. The 2006 HIV/AIDS Implemen-ters Meeting of the President’s Emergency Plan for AIDS Relief, Durban, South Africa, Abstract.