The prevalence of HIV in Zimbabwe has been declining over the years owing largely to positive behavioural change.
Our Senior Reporter Zororai Nkomo (ZN) caught up with the National Aids Council’s Chief Executive officer, Dr Bernard Madzima (BM), to discuss the status of HIV and AIDS in Zimbabwe and other issues.
Below are excerpts of the interview:
ZN: Has HIV prevalence gone down in Zimbabwe?
BM: Prevalence, which refers to the proportion of persons who have HIV at or during a particular time, should not go down but should stabilise.
In this country, it declined and then stabilised. Causes of decline in prevalence are mortality, proportional reduction in incidence of HIV and migration.
The decline in Zimbabwe, therefore, is real and caused by a positive behaviour change because there is a corresponding decline in incidence.
Although the HIV prevalence in Zimbabwe has been declining over time, it remains high.
According to estimates, prevalence among adults 15-49 years declined from 13.79% in 2015 to 12.78% in 2018.
Prevalence has been on a declining trend among all age groups, although HIV prevalence among young females is almost twice that among their male peers. With HIV prevalence among men who have sex with men (MSM) and transgender women gender queer individuals at 17.1% and 28% respectively, key populations have a higher HIV burden than in the general male population.
The same is true for female sex workers (FSW) at a 60% HIV prevalence rate.
ZN: Which province is mostly affected and which one is the least affected and what are the reasons for that?
BM: In terms of prevalence rate Matabeleland South has the highest with 17.6 followed by Matabeleland North with 14.9. Bulawayo province is ranked third with 14.0. The reasons for this may vary maybe because these provinces are closer to Botswana and South Africa which have high prevalence also. It also could be a behavioural issue. Prevalence is a factor of population.
Obviously when we consider absolute numbers affected, Harare has the highest, because 12.6 of Harare’s population is much higher than 17.6 of Matabeleland South population.
ZN: What have been the HIV trends in Zimbabwe over the past five years?
BM: AIDS-related mortality declined by 59.8% from 54,200 in 2010 to 21,800in 2018 largely due to success of the HIV treatment programme.
Whereas women are the face of the HIV epidemic, men are the face of the AIDS deaths as AIDS-related deaths are higher among males (52%) than females and among adults than children.
Some of the factors accounting for AIDS deaths are delay in initiation on ART, the “greying of AIDS” – the aging of PLHIV who benefit from ART and the emergence of age-related non-communicable diseases PLHIV not in care and limited psycho-social and nutrition support as well as undiagnosed and untreated TB co-infection among PLHIV. As is the case with new HIV infections, there is a need for deep dive into the factors accounting for AIDS deaths and to develop approaches to reduce AIDS deaths.
ZN: Key populations have been identified as major drivers of HIV in Zimbabwe. What are the prevalence of HIV in these groups?
BM: The key populations in Zimbabwe are the sex workers, men having sex with men, people with disability, prisoners although the recent study has shown that the prisoners are not the key populations in Zimbabwe, mobile populations and transgender. Key populations are defined as populations at higher risk of being infected with HIV, who play a role in how HIV is spread and whose involvement is vital for an effective response to HIV in Zimbabwe.
Other factors defining key populations are stigma and discrimination, criminalisation and lack of access to services.
The Modes of Transmission (MOT) study conducted in 2017 found that FSWs contribute about 4,000 new HIV infections while nearly 2,000 new infections occur among MSM annually. These numbers of new infections are significant when considered relative to the sex workers and MSM population.
In 2018, HIV prevalence among FSW was 57.1% and 31% among MSM while prevalence among prisoners in 2015 was estimated at 28% (26.8% males, and 39% females).
HIV prevalence data for the wider lesbian, gay, bisexual and transgender (LGBT) community is, however, lacking.
But, the country has made progress in improving HIV outcomes among key populations.
ZN: What are the possible challenges Zimbabwe might face in its attempt to end AIDS by 2030?
BM: Our target is ending AIDS by 2030 not ending HIV. HIV will remain with us beyond 2030 whereas AIDS will end, meaning that we will have achieved epidemic control. HIV and AIDS will be a public health issue and not an emergency anymore.
The challenges for ending AIDS by 2030 include, funding since Zimbabwe is still depended on donor funding, stigma and discrimination, drug resistance due to treatment interruption caused by lack of adherence.
Zimbabwe is on track to achieving the goal of ending AIDS by 2030, Gender issues, Lack of HIV testing.
Some people may not be willing to test for HIVZN: Faith Healers have been identified as a stumbling blocking fight against HIV.
ZN: What measures are you putting in place to curb the challenge?
BM: Faith Healers are not a stumbling block but they are a critical enabler.
In Zimbabwe most people belong to some religious grouping with various beliefs of which some may predispose to HIV. Some religious groups encourage members to stop taking ARVs when they feel better.
NAC is working with all religious groupings to give correct information about HIV and not to encourage the clients on treatment to stop treatment.
Faith healers can be used as means to spread HIV messages faster and effectively.
NAC also developed a manual to train all traditional healers on HIV and AIDS and they all have been trained.
ZN: What new programmes are you undertaking in Zimbabwe to end AIDS by 2030?
BM: Scale up of HIV testing which includes HIV self-testing, targeted HIV testing and Index testing, SASA programmes to deal with gender based violence, Integrating HIV with Covid 19, Non Communicable diseases, T-Band malaria, Resource mobilization, In-school HIV and AIDS programmes, Scale up of prevention of mother to child transmission, Scale up ARV treatment, Targeting key populations and other vulnerable groups.
ZN: What measures are you putting in place as NAC to fight stigma and discrimination?
BM: Another aspect of the HIV epidemic is stigma and discrimination.
The review of ZNASP III found that progress has been made to reduce stigma and discrimination, but stigma remains a major bottleneck to access to services among various populations particularly men, adolescents and young people and key populations.
While still unacceptably high, discriminatory attitudes towards PLHIV have declined. The 2015 Stigma Index Study report showed 65.5% of PLHIV experienced one or more forms of HIV-related stigma and discrimination.
There is paucity of data on stigma and discrimination. Data from stigma index carried out in 2014 found that 65% of people living with HIV experienced at least one form of discrimination.
The ZDHS of 2015 shows that 22% of women and 20% of men aware of HIV had discriminatory attitudes towards people living with HIV. 6% women and 9% men did not think children living with HIV should be allowed to attend school with HIV negative children.
About 19% women and 16% men would not buy vegetables from a trader with HIV.
A KP/PLHIV stigma study carried out in 2019 found deep rooted stigma and discrimination experienced by key populations (LGBT and sex workers). About 46% of the KPs reported gossip and discriminatory comments and 40.3% experienced verbal abuse at family level.
Majority of the KPs (62.7%) reported having difficulties telling others about their HIV status and 69.3% hide their HIV status from others. It was established that 45.9% of the KPs interviewed indicated that they had delayed HIV testing because they feared health worker’s attitude, 22.5% delayed HIV testing due to a bad experience with a health worker while only 37.5% reported having tested and started ART the same day.
Challenges KPs face at the health settings include verbal abuse, disclosure of their HIV status by health workers and general negative attitude.
Stakeholders observed that stigma and discrimination permeate communities and hinder access to services across all programmes.
Adolescents and young people have challenges accessing HIV and SRH services and adhering to treatment especially in school settings due to stigma; youths in tertiary institutions avoid college clinics to seek services in health facilities where they are not known; and stigma is a key hindrance for men seeking HIV services especially HTS. There have been attempts to address stigma and discrimination within HIV prevention and treatment programmes.
There is no comprehensive approach towards addressing stigma and discrimination holistically and data on stigma and discrimination is limited.
ZN: About 80% of Zimbabwe’s health budget is donor funded which is a threat in the event of the donors pulling out. What is the sustainable funding model for Zimbabwe to avoid over reliance on donors?
BM: AIDS Levy remains the best funding model ever. However, the Government should also allocate some funding from the treasury to reduce donor dependence.