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2008 PEPFAR Country Profile Update: Zambia

 

Administered by the Office of the Global AIDS Coordinator, the President’s Emergency Plan for AIDS Relief (PEPFAR) provides $15 billion dollars over 5 years for AIDS, Malaria and Tuberculosis programs globally. A majority of funds are allocated to 15 focus countries: Botswana, Cote d’Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam and Zambia.

(The following document is a 2008 update to the status of PEPFAR funding and related issues in Zambia.  Click Here to Read Zambia's 2005 Original Country Profile)
 
Introduction
 
In 2005, SIECUS published PEPFAR Country Profiles: Focusing on Prevention and Youth, an in-depth look at the then-new funding stream opened up through the President’s Emergency Plan for AIDS Relief (PEPFAR).  
 
PEPFAR directed $15 billion over five years, primarily to 15 focus countries and to a lesser extent to over one hundred other countries.  PEPFAR gave voice to the concern of the people of the United States to care for those around the world affected by HIV /AIDS and demonstrated the political will to put that concern into action.  At the outset, advocates were hopeful that this generous funding stream would offer a meaningful contribution to the fight against HIV/AIDS at a time when millions were dying.  Still, much of the language in the legislation gave advocates cause for concern, and it was unclear how the implementation of this program would play out.  
 
Advocates were particularly concerned with some of PEPFAR’s policies regarding prevention. First, a maximum of 20 percent of the funds could be spent on prevention efforts.  Moreover, 33 percent of those funds that were spent on prevention were earmarked for abstinence-until-marriage programs.  Together these made a glaring statement about the program’s priorities. PEPFAR also made funds available to faith-based organizations (FBOs), taking advantage of the vast social service networks already in place in many countries around the world. While these organizations often displayed expertise in areas such as care for orphans and hospice for the dying, they were, and still are, entitled to exclude information, particularly as relates to programs for the prevention of sexual transmission of HIV, that they believed to be inconsistent with their religious teachings. 
 
In the early years of PEPFAR very little was known about how these provisions, among others, impacted the efforts of national and international organizations. To fill this gap in information, SIECUS did what we have done in the United States for many years; we followed the money. For the original Country Profiles, we drew together information to create a more cohesive picture of the nature of each epidemic in the 15 focus countries and how PEPFAR responded to those epidemics, with a particular eye to the prevention and youth components. Specifically, we tracked prevention funds: how much money was distributed, who it went to, and how it was used. These were all elusive pieces of information at the time. 
 
Unfortunately, this type of information remains elusive. SIECUS conducted follow up research in 2008 to provide an update to those original Country Profiles. Each update features recent demographic data pertinent to the epidemic in that country, a breakdown of funding allocations for prevention, care, and treatment, and a list of those PEPFAR grantees that are implementing prevention programs. Wherever possible we also include additional information on grantees and the type of programs they are running with PEPFAR funds. 
 
In addition to this data, each update also offers further analysis on particular items of note in the country.  And, we follow this analysis with our recommendations for moving forward with PEPFAR to ensure truly comprehensive prevention strategies in the focus countries.  While these updates can be read independently of the original profiles, reading them together, affords an even richer perspective. 
 
Overview
 
Zambia has an estimated population of less than 12 million people with a slight (2.9 percent) annual population growth. With an estimated HIV prevalence of 15.2 percent, it is one of the sub-Sahara African countries most affected by the HIV/AIDS pandemic.[1] In addition, it is one of the more urbanized African countries with approximately 39 percent of its population living in urban areas.[2]The highest HIV prevalence, over 17.6 percent, is found in cities and towns along major transportation routes such as in the capital area of Lusaka, a region next to Zimbabwe, and the Copperbelt area, a region next to the Democratic Republic of Congo.[3]  Zambia remains one of the poorer countries in Africa with 87.4 percent of its people receiving less than two dollars a day.[4] 
 
Zambia’s first AIDS case was reported in 1984. In 1990, Zambia’s HIV prevalence was less than 10 percent, this increased to 15 percent by 1993 and has remained stable ever since. However, the estimated number of Zambians living with HIV has increased by roughly 20,000 each year since the mid 1990s.[5] As of 2007, 980,000 adults and 120,000 children under the age of 15 were living with HIV and 600,000 children had lost one or both parents to the disease.[6] Since 1990 roughly one million Zambians have died from AIDS-related illnesses.[7] While there is good news that the number of AIDS-related deaths has been declining since 2003, about 56,000 adults and children died from AIDS-related causes in 2007 alone.[8]
 
Women currently make up over half of all people living with HIV in Zambia.[9] HIV prevalence among women is roughly three to four times than in men, and prevalence among pregnant women ranges from less than 10 percent in some regions to 30 percent in others.[10]  Young women ages 15–24 are most affected with prevalence rates nearly four times that of men of a similar age group (11.3 versus 3.6 percent).[11] In addition, certain cultural practices that perpetuate gender inequity in Zambia put women at greater risk of HIV infection. For instance, women are taught never to refuse sex with their husband regardless of the number of extra-marital partners he may have, his unwillingness to use condoms, or if he is suspected of having HIV or other STDs.[12]
 
Zambia’s health system does not adequately cover the impact of the epidemic. While the number of sites providing antiretroviral therapy (ART) has increased from less than 110 in 2005 to 322 in 2007, less than half (46 percent) of people eligible for ART received it in 2007.[13] It is not known what the geographic distribution of the ART sites is currently; in 2005 the majority of ART facilities were in the Lusaka and Copperbelt regions with as few as one facility responsible for an entire province in other areas.[14] In addition, nearly all pregnant women (93 percent) in Zambia have access to and receive antenatal care, however, only 53 percent of antenatal clinics provide HIV testing and counseling, and less than half (47 percent) of pregnant women who are living with HIV received ART to prevent mother-to-child transmission in 2007.[15] It is estimated that there are a total of 646 physicians, 9,000 nurses, and 97 hospitals in the entire country and they are expected to deal with regular healthcare needs as well as the burden of 1.1 million Zambians living with HIV.[16]
 
The chart below offers a snapshot of some of the key facts and figures which highlight the particular landscape of the epidemic in Zambia. The stories behind the statistics are fleshed out in greater detail following the chart.
 
PORTRAIT OF ZAMBIA IN NUMBERS
 
Total population (2006)[17]
11,668,000
Percentage of the population under the age of 24
N/A
Gross national income in purchasing power parity (GNI PPP) per person (Int’l$, 2006)[18]
$890
Per capita total expenditure on health (Int’l$, 2006)[19]
$26
Secondary school enrollment rate (1999–2005)[20]
25% Females
31% Males
Estimated number of people ages 15 and over living with HIV (2007)[21]
980,000
HIV prevalence in people ages 15–49 (2007)[22]
15.2%
HIV prevalence in people ages 15–24 (2007)[23]
14.2% Female upper estimate
5.2% Male upper estimate
 
8.5% Female lower estimate
1.6% Male lower estimate
Median age of first intercourse
N/A
Median age of first marriage
N/A
Young people ages 15–24 who have had sex before age 15 (2007)[24]
14% Females
16% Males
Percentage of women and men ages 15–49 who have had sexual intercourse with more than one partner in the last 12 months (2007)[25]
1% Females
14% Males
Percentage of women and men ages 15–49 who had more than one sexual partner in the past 12 months reporting the use of a condom during their last sexual intercourse (2007)[26]
37% Females
50% Males
Contraceptive prevalence rate (2004)[27]
34% Any method
23% Modern methods
Percentage of couples using condoms for family planning (2005)[28]
3.8%
Number of births per 1,000 women ages 15-19(2005–2010)[29]
122
Percentage of females (20–24) who have given birth by age 18 (2005)[30]
35%
Young people ages 15–24 who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission (2007)[31]
34% Females
37% Males
Schools with teachers trained in life-skills-based HIV/AIDS education who taught this during the last academic year (2007)[32]
60%
 
Zambia attempted to respond to its AIDS epidemic shortly after the first case was reported in 1984. In 1986, Zambia established the National AIDS Surveillance Committee and the National AIDS Prevention and Control Programme. Zambia is a signatory to many important commitments related to ending HIV and AIDS, including the ‘Three Ones’ principle that provides a useful framework for the ongoing response to HIV/AIDS in Zambia:
 
  1. One agreed HIV and AIDS Strategic Framework that provides the basis for coordinating the work of all partners
  2. One National AIDS Coordinating Authority, with a broad-based multi-sectoral mandate
  3. One agreed country-level Monitoring and Evaluation System[33]
 
Zambia has developed and disseminated a Fifth National Development Plan (FNDP 2006–2010) and a related National HIV and AIDS Strategic Framework (NSF 2006–2010). The main goal of Zambia’s NSF 2006–2010 is to “prevent, halt and begin to reverse the spread and impact of HIV and AIDS by 2010.” Implementation of this goal is guided by several principles, including the adoption of a human rights approach, the greater and meaningful involvement of people living with HIV/AIDS, and that the “national response to HIV and AIDS be guided by ethically sound, current scientific and evidence based research bringing out best practices and using a public health approach to guide prioritization and selection of the most cost effective interventions.”[34]
 

Key Themes of the National Strategic Framework 2006–2010
  1. Intensifying Prevention
  2. Expanding Treatment, Care and Support
  3. Mitigating the Socio-economic Impact
  4. Strengthening the Decentralized Response and Mainstreaming HIV and AIDS
  5. Improving the Monitoring of the Response
  6. Integrating Advocacy and Coordination of the Multi-Sectoral Response
 


Through legislation, the government of Zambia established the National HIV/AIDS/STI/TB Council (NAC), which is comprised of broad representation from several government ministries and civil society. The NAC Board and Secretariat’s purpose is to oversee, drive, and convene a multi-sectoral national response. Unfortunately, a lack of resources, a lack of political commitment to battling the epidemic, and the perpetuation of stigma surrounding the disease prevented true implementation of HIV/AIDS-prevention policies. Though the NAC was created in 2000, it was not until 2002 that it was officially recognized.  The legal recognition of the NAC allowed the organization to apply for funding and to start implementing the National Strategic Framework (NSF) developed in 2000. This first NSF covered the period 2001–2003 and has formed the basis for successive NSFs, including the most recent one that covers 2006–2010.
 
In addition, the NAC developed a Monitoring and Evaluation (M&E) Framework and Plan for 2006–2010 for improved decision-making, advocacy, policy direction, and targeting of resources and planning in combating the epidemic. M&E maintains a central database of all HIV/AIDS national data to ensure better knowledge of the epidemic for implementing concerted strategies. However, many challenges beset M&E including late reporting to the central database, financial constraints on implementing reporting, and inexperience among M&E staff of data-use on the epidemic.[35]
 
While Zambia has made some progress in addressing the themes of the NSF it still has a long way to go in each category, particularly in prevention. Although it was one of the first sub-Saharan African countries to launch behavior change communication programs using HIV- prevention messaging, there is still a general lack of knowledge about HIV prevention among youth and the Zambian population as a whole. About 16 percent of Zambians have sexual intercourse before the age of 15.[36] And, statistics show that young people are woefully under-educated about protecting themselves from risk. As of 2007, less than half of young adults ages 15–24 could correctly identify ways of preventing sexual transmission of HIV and reject major misconceptions about HIV transmission.[37] Alarmingly, only 50 percent of men and 37 percent of women ages 15–49 report using a condom with a non-regular partner in 2007.[38]
 
In addition, continued stigma of HIV/AIDS in Zambia is an ongoing barrier to expanding voluntary HIV counseling and testing. In 2007, only a quarter of the general population ages 15–49 reported receiving HIV test results and knowing their results.[39] The promotion of human rights, especially of people living with HIV/AIDS (PLWHA) is explicitly mentioned in the NSF and yet there are no clear mechanisms for recording, documenting, and addressing cases of discrimination against PLWHA. While Zambia has general anti-discrimination legislation in place contained in various acts and in Article 23 of its Constitution, there are no explicit legal protections against HIV-based discrimination.[40] 
 
Like many other sub-Saharan countries, Zambia has been economically devastated by HIV/AIDS and has nowhere near the resources necessary to combat the epidemic without external assistance. Zambia does not finance the majority of its HIV/AIDS expenses but relies heavily on foreign governments and international agencies for funding. According to the most recent funding data from the Joint United Nations Programme on HIV/AIDS, Zambia’s domestic funds only covered 15 percent of all HIV/AIDS expenditures in 2006. Additional funding comes mainly from the President’s Emergency Plan for AIDS Relief (PEPFAR) which accounted for over 90 percent of all international aid directed to HIV/AIDS in 2006.[41] Several other major international donors have stepped in to assist Zambia, including the Global Fund to Fight AIDS, Tuberculosis, and Malaria, the World Bank, and the UK Department for International Development (DfID).

 
President’s Emergency Plan for AIDS Relief (PEPFAR)
 

Key Terms to Understanding PEPFAR Prevention Programs and Funds
 
ABC: ABC stands for “Abstain, Be-Faithful, and Correct and Consistent Condom Use.” ABC is PEPFAR’s guiding principal for HIV-prevention programs. PEPFAR requires that a minimum of one-third of all prevention funds be spent on abstinence programs and it limits the promotion and marketing of condoms to specific groups outlined in PEPFAR’s ABC guidance. No discussion or promotion of condoms is permitted with youth under the age of 14 using PEPFAR funds.
 
Country Operation Plan (COP): A yearly program and budget plan developed for each PEPFAR focus country. The COP is developed by U.S. staff in conjunction with country governments. It divides programs into three main categories of prevention, care, and treatment: Abstinence-Be-Faithful (AB), Other Prevention (OP), and Prevention of Mother-to-Child Transmission (PMTCT). A country’s COP is not the same as its National Strategic Plan/Framework (NSP/F). Unlike a NSP/F, a COP is specific to PEPFAR programs and funds, and is developed annually. In comparison, the NSP/F is a multi-year, country-wide strategy on HIV/AIDS that is developed by each country’s government. Although the NSP/F may make reference to PEPFAR and other international donors, it is not limited to a description of activities funded by international donors, and an NSP/F may or may not be developed with input from the United States or other donors. 
 
Abstinence-Be-Faithful (AB): One category of prevention programs and funding under PEPFAR. Grantees that provide AB programs focus on education and promotion of abstinence-until-marriage and be-faithful messages. Grantees that receive OP funds, such as those to promote condom use, are listed in both sections of the COP.
 
Other Prevention (OP): One category of prevention programs and funding under PEPFAR. The OP category includes any prevention program that is not an AB program or a PMTCT program. This category includes surveillance programs, programs aimed at reducing stigma and discrimination, training for healthcare workers, and the promotion and marketing of correct and consistent condom use. Grantees that receive funds for OP programs in addition to AB funds are listed in both sections of the COP.
 
Prevention of Mother-to-Child Transmission (PMTCT): One category of prevention programs and funding under PEPFAR. The PMTCT category includes routine rapid HIV-testing in antenatal and maternity settings, counseling and support for infant feeding, and linking to care, treatment, and support services.
 
 

 
 
Funding
 
PEPFAR began implementing its HIV/AIDS programs in Zambia starting in 2004 with an initial grant of nearly $82 million dollars, making Zambia one of the most well-funded sub-Saharan African countries. As mentioned, Zambia relies heavily on foreign governments and international agencies for funding and PEPFAR covers the majority of those funds. In 2008, PEPFAR has almost tripled the initial allocation from 2004 with funding nearing a quarter of a billion dollars.
 
The following chart details the allocated funds from PEPFAR to the different areas of funding. Within the prevention framework, PEPFAR promotes an ABC message, which signifies: Abstinence-only, Be faithful, and Correct and Consistent Condom Use. Abstinence-only/Be-faithful (AB) programming utilizes an AB-only message, while Other Prevention (OP) includes AB programming as well as messages that address correct and consistent condom use (ABC).

Allocated PEPFAR Funds 2004–2008*
 
2004[42]
2005[43]
2006[44]
2007[45]
2008[46]
Total Funds Allocated**
$81,786,638
$110,662,813
$130,752,016
$190,050,254
$224,206,594
Total Prevention Funds Allocated
N/A
$27,573,776
$25,645,997
$45,147,479
$56,457,157
Total AB Funds Allocated
N/A
$6,957,390
$8,619,058
$15,042,012
$20,794,658
Total Other Prevention Funds Allocated (includes condom funding)
N/A
$7,949,600
$5,960,000
$8,874,500
$12,077,000
Total Treatment Funds Allocated
N/A
$ 53,835,934
$ 68,619,022
$88,719,179
$99,706,179
Total Care Funds Allocated
N/A
$ 29,253,103
$ 39,906,213
$61,367,596
$68,043,258
* The Office of the U.S. Global AIDS Coordinator (OGAC) only releases data on the funds that are allocated to each country. No data is available on the PEPFAR funds that are disbursed per country.  
** Total funding allocated to Field Programs only, excludes Agency costs.
 
Of the $224 million allocated in 2008, $56 million (25.2 percent) was allocated for prevention programs, $68 million (30.3 percent) was allocated for care services, and $99 million (44.5 percent) was allocated for treatment services. Between 2005 and 2006, the total prevention budget decreased as did funding for OP programs, a subset within the prevention budget that includes condom programs. The current amount of OP funding represents 5.4 percent of the total budget compared to the 9.3 percent of the total budget given to AB prevention programs.
PEPFAR’s funding seems to be at odds with the government’s national plan to combat the epidemic which prioritizes comprehensive prevention programs. 
 
 
Prevention Programming
 
Prevention programming under PEPFAR utilizes an “Abstain, Be faithful, and when appropriate use Condoms” (ABC) approach. However, programs which promote abstinence and fidelity are the predominant intervention used with the general population. Programs addressing correct and consistent condom use are most often used with specific target populations that the PEPFAR guidance identifies as being most at-risk. Programs that support a comprehensive ABC approach are calculated into “Other Prevention” (OP) funding. 
 
The most comprehensive data available on PEPFAR funding for each focus country is in the 2007 Country Operational Plan (COP). The COP delineates the total amount, according to program area, that each grantee or organization is given for that fiscal year. While general program descriptions are listed with the information about funding allocations, details on the specific activities that each grantee carried out and how these activities were executed are rarely included in the COP. This lack of detail on program content makes it difficult to conduct a thorough analysis of each program or of PEPFAR’s overall impact on prevention programming in the country. 
 
According to the 2007 Country Operation Plan, within the area of prevention PEPFAR funded a total of 13 organizations to implement only AB programs, 9 organizations to implement both AB and OP programs, and 5 organizations to implement only OP programs. Only 7 organizations promoted the correct and consistent use of a condom.[47]
 
The following is a list provided of PEPFAR grantees receiving prevention funding as reported by the Office of Global AIDS Coordinator in the 2007 Country Operational Plan for Zambia. This list indicates whether grantees received only Abstinence-only/Be faithful (AB) funding, only Other Prevention (OP) funding or both. While there is a summary of funding projections available through 2008, the breakdown of funding according to recipient and amount granted in the full Country Operational Plan is only available for 2007.[48]
 
Organizations that received AB funding only:

  • Academy for Educational Development
  • American Institutes for Research
  • American International Health Alliance
  • Children’s AIDS Fund
  • Cooperative League of the USA
  • Copperbelt University
  • Development Alternatives, Inc
  • International Executive Service Corp
  • International Youth Foundation
  • National Arts Council of Zambia
  • Pact, Inc.
  • University of Zambia
  • World Vision International

 
Organizations that received AB and OP funding:

  • Jhpiego
  • John Snow Research and Training Institute
  • Johns Hopkins University Center for Communication Programs
  • Population Services International
  • Project Concern International
  • Research Triangle Institute
  • Tulane University
  • United Nations High Commissioner for Refugees
  • U.S. Peace Corps

 
Organizations that received OP funding only:

  • Central Contraceptive Procurement
  • Elizabeth Glaser Pediatric AIDS Foundation
  • Provincial Health Office - Eastern Province & Western Province
  • University Teaching Hospital
  • U.S. Centers for Disease Control and Prevention

 
 
In 2007, Zambia received a total of $15,042,012 in funding for AB programs which were estimated to reach over one million people through community outreach.[49] World Vision International received the most funding for AB-only activity ($2,066,700), and was set to reach 43,189 people through community outreach.[50] World Vision International is part of a consortium of organizations that trains “local pastors, teachers, and peer educators to promote primarily abstinence messages for youth. The program will promote AB messages at community meetings, schools, church meetings, in one-to-one counseling, sporting events, during visits to home-based care clients, and in work with youth… [World Vision International] seek[s] to reduce HIV transmission by promoting abstinence among unmarried young people aged 10–24 years and by encouraging faithfulness among young married couples.”[51] World Vision International includes “like skills trainings” to ensure young people have accurate knowledge about things from relational power dynamics to proper nutrition.
 
The organization that received the most combined AB/OP funding was Johns Hopkins University Center for Communication Programs, which in partnership with Health Communication Partnership, received $3,302,016 ($630,000 in OP funds, $2,672,016 in AB funds).[52]  Within its AB activity Johns Hopkins runs the “Helping Each Other Act Responsibly Together” (HEART) campaign which was designed in 1999 specifically for “youth and by youth, and informs young people about the Abstinence, Be faithful, and correct and consistent Condom use (ABC) approach to prevention.”[53] HEART holds creative arts contests among youth to engage people in educating themselves and others about HIV/AIDS. In 2007, HEART held drama performances among school youth to focus on peer pressure and delayed onset of sexual activity, fidelity, and partner reduction.[54]
 
Within its OP activity Johns Hopkins provides in-depth education on “behavior change and the development of respectful, gender-equitable relationships between men and women” and encourages influential leaders to “serve as role models for men in order to affect change in the male norms and behaviors that undermine risk avoidance efforts.”[55] Its OP program sponsors local screenings and facilitates discussions of three videos: “Tikambe” (which addresses the stigmas surrounding HIV), “Mwana Wanga” (which focuses on prevention of mother-to-child transmission), and “The Road to Hope” (which provides information about ART).[56] More than 3,500 copies have been distributed and shown in 180 health center public waiting rooms. In addition, Johns Hopkins uses its OP funding to develop educational materials for both healthcare professionals and patients that focus on the acceptability of male circumcision, the importance of undergoing circumcision by a trained professional, and post-procedure care. In addition, Johns Hopkins uses research on the risks of alcohol abuse and HIV/AIDS to develop appropriate interventions and messaging around this topic, and has a new program focusing on gender with the goals of “reducing violence, empowering women to negotiate for healthier choices, and promoting partner communication and mutual decision-making and male responsibility.”[57]
 
Zambia received a total of $8,874,500 in funding for OP programs and was estimated to reach over half a million people through community outreach.[58] The organization that received the most funding for OP-only programs was Central Contraceptive Procurement at $600,000.[59] Through a partnership with PSI, Central Contraceptive Procurement provides accessible and affordable condoms to Zambians at high-risk of contracting HIV, such as HIV discordant couples (couples in which one is HIV-positive and the other is HIV-negative).  Central Contraceptive Procurement was set to receive 15 million condoms from the United States Agency for International Development (USAID) and distribute them to 5,191 outlets and 316 non-governmental organizations/community-based organizations. The organization hopes to contribute to “sustained and significant positive behavior change in Zambia and has increased Zambians’ acceptance and usage of condoms.”[60]  In addition, the organization trains health providers in the country to use the ABC method, including correct usage of both male and female condoms.[61]
 
Items of Note: Progress towards Universal Access
 
On June 15, 2006, the Republic of Zambia made a political declaration to the United Nations General Assembly: “(We) commit ourselves to pursuing all necessary efforts to scale up nationally driven sustainable and comprehensive responses…towards the goal of universal access to comprehensive prevention programmes, treatment, care and support by 2010.”[62] It has been two years since this declaration was made and there are just two years to go before reaching the target date. Zambia has made great progress toward obtaining universal access to prevention programs, treatment, and care services, yet much more work remains to be done.
 
According to the National Composite Policy Index (NCPI), Zambia has surpassed the global coverage of ART (31 percent), with an estimated 40–58 percent of those in need of ART receiving treatment in 2007. This is a huge increase from the 10 percent of coverage that Zambia had in 2004.[63] In addition, Zambia has surpassed the global coverage of PMTCT coverage (currently at 33 percent) with an estimated 42–50 percent of HIV-positive pregnant women receiving PMTCT services, a huge increase from the initial 18 percent of coverage in 2004.[64] 
 
Zambia’s efforts to obtain universal access have accelerated and strengthened its national HIV response and yielded some positive results. From 2004 to 2007, Zambia made great strides toward universal access by building up the infrastructure to support increased access to prevention, care and treatment services. This development has resulted in an increase in the number of ART sites from 8 to 322, the number of PMTCT sites from 2 to 678, and the number of voluntary counseling and testing sites from 450 to 1,023.[65] 
 
Despite this progress, Zambia is unlikely to reach most of the universal access targets it set out to reach by 2010. Although both ART and PMTCT coverage exceeds global coverage, both remain below Zambia’s 2010 targets of 60 percent coverage of ART and 65 percent coverage of PMTCT, goals that the country may not reach in two years.[66]  Zambia is however likely to attain its goal of reaching 25 percent of its population with HIV counseling and testing..[67] 
 
Zambia’s commitment to the Millennium Development Goals (MDGs) supports its larger goal of achieving universal access. The MDGs, created in 2000, establish social and economic targets to be achieved by 2015 as part of a global effort for worldwide country development. According to the United Nations Development Programme (UNDP), Zambia is likely to achieve four of the ten MDGs by 2015: halving the proportion of people who suffer from hunger, ensuring universal primary education of children, ensuring equal access to all levels of education to both men and women, and reversing the spread of HIV.[68]   Many of the MDGs are interrelated which support Zambia’s broader goals of addressing the HIV/AIDS epidemic. For example, while “halving the proportion of people who suffer from hunger” does not explicitly mention HIV/AIDS there is nonetheless a direct impact as those on ART are more likely to thrive when their nutritional needs are properly satisfied.   
 
It is imperative that Zambia and its foreign funders recognize the interconnection of the MDG goals, universal access, and the prevention of HIV/AIDS. For example, reducing child and maternal mortality depends on coverage of ART and PMTCT services, and yet less than half of pregnant women in Zambia who are need of ART are receiving it.[69] While ART coverage has increased with triple the number of people covered since it was first introduced in 2004, it only covers 8 percent of children in need.[70] ART is crucial to PMTCT services but it is also crucial to saving the lives of thousands of children who are already infected with the HIV. 
 
As the largest international donor responsible for HIV prevention, treatment, and care efforts in Zambia, PEPFAR has become integral to Zambia’s success of achieving universal access.  The Republic of Zambia has reported that currently there is “a need to accelerate progress on HIV-prevention efforts.”[71] The administrators of PEPFAR funding must recognize this need and support efforts in Zambia to provide access to prevention services, including comprehensive education about HIV/AIDS and condoms, as these remain key to reversing the HIV/AIDS epidemic and meeting the goal of obtaining universal access. 
 
Recommendations
 
In 2005, when SIECUS released the original PEPFAR Country Profiles publication, we made six recommendations: immediate actions necessary to remedy the problems in the PEPFAR legislation and its implementation. Sadly, although not surprisingly, three years and $19 billion in U.S. taxpayer funding later, little has been done. Lawmakers missed the opportunity to remedy the shortcomings of the original law in the reauthorization of PEPFAR in July 2008, despite ample evidence provided by researchers and advocates to guide them to create more sounds policy. Today, we reiterate each of these six recommendations as well as adding an additional one, and contribute evolving insight relevant to the current context:
 
1.  Abandon the Ideological Emphasis on Abstinence-Until-Marriage Programming
 
The newly reauthorized law brought about a technical change in the shape of the abstinence-until-marriage funding restrictions, although the impact is equally stifling. A hard earmark in the original legislation requiring that 1/3 of all prevention funding be spent on abstinence-until-marriage programming has been supplanted by an onerous reporting requirement. Despite the overwhelming evidence that abstinence-until-marriage programs are ineffective at preventing the transmission of HIV, they remain the cornerstone of the prevention policy. The new requirement states that if funding in this area falls below 50 percent of the total allocation for prevention of sexual transmission of HIV in any country, the Office of the Global AIDS Coordinator (OGAC) must issue a report to congress to explain the failure to prioritize abstinence and marriage promotion.  As long as there is a clear bias towards abstinence-until-marriage promotion programming in the law, countries will disproportionately seek to please the U.S. government and will funnel more monies into this failed approach. This wastes enormous resources on the ground and has created a situation that, if left unchecked much longer, will wholly destroy a comprehensive approach to HIV-prevention in many of the focus countries. Every attempt must be made to promote evidence-based strategies in prevention programming, not the ideological and hypermoralistic framework that characterizes the promotion of abstinence-until-marriage.
 
 
2. Increase Transparency of PEPFAR Prevention Funds
           
Since 2005, some progress has been made on the part of OGAC to provide more disaggregated prevention funding data in the 15 PEPFAR focus countries providing a somewhat clearer understanding of who is receiving the funds and what sort of programs are being carried out. For example, there is a greater delineation between prevention providers solely engaged in AB programming and those doing more comprehensive interventions. However, the substance of the actual initiatives being carried out remains elusive, particularly when it comes to entities receiving pass-through sub-grants from a primary agency. While there has been some improvement, OGAC must provide a fuller documentation of the content and delivery of prevention initiatives. This recommendation should not prove unduly onerous to OGAC given the extensive grantmaking and reporting requirements imposed on implementers that have generated a wealth of information already in OGAC’s possession. 
 
3. Enact Appropriate Oversight Mechanisms of PEPFAR Prevention Grantees
 
In 2005, this recommendation cited two key concerns. First, we cited a lack of oversight regarding the use of funds by faith-based organizations to ensure they are not proselytizing in their work funded by PEPFAR. Given the escalation in PEPFAR funding and the increasing proportion of funding going to religious organizations, we reiterate that OGAC must provide for a systematic review of the prevention programs by these groups both including closely looking at the materials programs are using and on-the-ground monitoring of program delivery.
 
Second, we recommended then and reiterate now that OGAC collect data and report on the organizations taking advantage of a clause in the law that allows them to opt out of any condom/contraception education under the claim that to do so would be a violation of their religious beliefs. This information seems even more critical as abstinence and partner reduction programs have eclipsed those that include condom and contraceptive instruction. Tracking this information more closely would allow better analysis about the extent to which the clause is invoked and the extent to which condom related services are not being provided.
 
We also now add a third concern in this area and call on Congress to conduct a systematic review of the process by which countries are involved in the development of their annual Country Operational Plans. A great deal of evidence has emerged from individual countries that suggests that the Country Operational Plans are written by OGAC and U.S. personnel in the USAID missions of the countries to meet ideological mandates. As a result, Country Operational Plans too often fail to conform to the actual needs of the countries to combat their epidemics.  
 
4.  Rescind the Anti-Prostitution Pledge
 
As the United States Congress began debate in 2008 on the reauthorization of PEPFAR, one message was sent loud and clear from social conservatives and the Bush White House: the anti-prostitution pledge was non-negotiable.  The anti-prostitution pledge requires all recipients of PEPFAR funds to denounce commercial sex work in order to receive U.S. government funding. SIECUS’ own research in Zambia has documented that the anti-prostitution pledge is more than just a piece of paper. It has manifested itself as the strongest of ideological weapons to shut down any outreach to women engaged in sex work, leaving them at an even greater risk for infection. The lack of political courage in Congress has meant the continuation of this dangerous policy as the reauthorization passed in July 2008 made no efforts to reverse this requirement. Congress must request an inquiry by the General Accounting Office (GAO) to undertake a survey in each of the 15 focus countries to determine the impact of the anti-prostitution pledge on HIV-prevention program delivery to women engaged in sex work. Further, a new administration in 2009 should provide leadership in directing OGAC to work with focus country governments to scale-up HIV-prevention programming to this population and actively engage in mobilizing non-U.S. government resources to fill this vital need. And of course, when the opportunity presents itself in the next reauthorization, this provision must be removed from the law itself.
 
5. Work with the International Community to Implement Programming and Policy that Connects HIV/AIDS to other Issues of Sexual and Reproductive Health
 
The current trend of separating public-health foreign aid into disease-specific silos, such as HIV/AIDS, malaria, and tuberculosis, purports to create a strong enough resource flow to significantly reduce the manifestations of each disease.  However, such segmentation has also led to too narrow a framework/conceptualization.  Sexual transmission is the most widespread driver of the epidemic globally, and women, particularly women in committed relationships, often including marriage, and the children they bear are increasingly becoming infected with HIV. Curbing the epidemic requires greater integration of sexual and reproductive health services to provide the education and commodities needed to prevent the spread of HIV, whether through sexual transmission between partners, or mother to child transmission. Sexual and reproductive health service delivery sites are often the only interface a woman has with healthcare, offering of the opportunity to engage with and gain access to someone who may not seek out information and services elsewhere. For reasons of stigma and discrimination, a woman may not be able to seek out services at healthcare delivery sites specifically oriented towards HIV/AIDS.
 
While OGAC has promoted “wraparound” with reproductive health services funded through funding streams outside of that authorized by PEPFAR, this has not proved sufficiently adequate. Such a narrow focus on HIV/AIDS specific health services has actually meant less money, not just a comparatively lower amount to the PEPFAR funding, on the ground for general sexual and reproductive health services. Due to this reality, the “wraparound,” while it may seem sound in theory, is not, in fact, a solution on the ground. 
 
From a public health perspective, integration of sexual and reproductive health with HIV/AIDS is simply good medicine, but on the policy end, the individual ideologies of policymakers have interfered with the creation of strong policy to support this end. OGAC needs to work with the international community to implement programming and policy that connects HIV/AIDS to other issues of sexual and reproductive health.
 
6.  On-the-Ground Monitoring of Funded Activities
 
Over the past four years of PEFAR funding, it has become disturbingly clear that PEPFAR has transformed the landscape of HIV-prevention programming in each of the 15 focus countries in worrisome ways.  Not the least of these is that the vast majority of PEFAR funding is going to international or U.S.-based NGOs and, in the process, indigenous NGOs in the focus countries are failing to benefit from this record investment. A quick look at the list of grantees in each country testifies to a lack of investment in building up the capacity for prevention programming among local NGOs, and distributing funds so that they may also carry out HIV-prevention programming.  PEPFAR’s largesse will not continue in perpetuity and therefore, investments in local capacity in this area seem among the wisest of investments in a long-term strategy to assist these countries. OGAC should be directed to begin an immediate scaling up of investment in indigenous prevention program providers and to set escalating targets over the next five years that will ensure than at least 50 percent of prevention program funding goes directly to indigenous NGOs.  We have a responsibility to these countries and to U.S. taxpayers to invest in system change in these countries, and that begins with building and investing in NGOs on the ground.
 
7. Eliminate the Clause Which Opens the Door for Implementers to Discriminate Against Certain Populations
 
 
The original law included a provision permitting implementers of prevention and treatment programs to opt out of delivery of services that they deemed to go against their religious beliefs. This provision offered a loophole which benefited the implementer more than those in need of prevention and treatment services, deferring to moral frameworks of the implementers instead of championing the evidence-based strategies. It granted the authority to the implementer to pick and choose which elements of a comprehensive approach to utilize, even when doing so undermines the integrity and effectiveness of the overall program. This troublesome provision raised the concerns of advocates early on whether ideology would trump evidence. In the time that has unfolded since the initial roll-out of PEPFAR programs, this provision has shown to be particularly problematic regarding the implementation of HIV-prevention interventions addressing sexual transmission. Many faith-based organizations have experienced a “moral panic” over the delivery of comprehensive prevention services, fearing a contradiction with the moral frameworks on sexuality derived from their faith traditions. The new law expanded this provision to apply to care services in addition to prevention and treatment services. This move is clearly a step in the wrong direction and must be remedied by fully repealing this clause in the next authorization of this law.
 
 
 
 


[1] Zambia Country Report: Multisectoral AIDS Response Monitoring and Evaluation Biennial Report 2006-2007, Ministry of Health and National AIDS Council, (Republic of Zambia), accessed 1 July 2008, http://data.unaids.org 8
[2] Ibid., 14
[3] Zambia HIV/AIDS Service Provision Assessment Survey 2005, (Republic of Zambia; UNAIDS; WHO; PEPFAR), Zambia, accessed 8 September 2008, http://www.measuredhs.com/pubs/pdf/SR122/SR122.pdf 3
[4] 2006 UNAIDS Report: Country profiles annex 1, UNAIDS, (New York, NY), accessed 19 August 2008,
[5] Epidemiological Country Profile on HIV and AIDS, 2008, UNAIDS/WHO, (New York, NY; Geneva, Switzerland) accessed 29 August 2008, http://www.who.int
[6] 2008 Report on the Global AIDS Epidemic Annex 1: HIV and AIDS estimates and data, 2007 and 2001, UNAIDS, (New York, NY) accessed 19 August 2008, http://data.unaids.org 214
[7] Epidemiological Country Profile on HIV and AIDS
[8] 2008 Report on the Global AIDS Epidemic Annex 1, 217-218
[9] Ibid., 214-215
[10] Epidemiological Fact Sheet on HIV and AIDS, Zambia 2008 Update, UNAIDS/WHO, (New York, NY; Geneva, Switzerland), accessed 29 August 2008, http://www.who.int 8
[11] 2008 Report on the Global AIDS Epidemic Annex 1, 217
[12] Zambia Country Report,18
[13] Ibid., 12-13
[14] Zambia HIV/AIDS Service Provision Assessment Survey 2005, 11
[15] Epidemiological Fact Sheet on HIV and AIDS, Zambia 2008 Update, 12, 16
[16] Zambia Country Report, 5
[17] 2006 UNAIDS Report: Country profiles annex 1, 13
[18] Ibid., 13
According to the World Bank, “GNI PPP is measured in current international dollars which, in principal, have the same purchasing power as a dollar spent on GNI in the US economy.”
[19] Ibid., 13
[20]  Monitoring ICPD Goals – Selected Indicators, UNFPA, (New York, NY) accessed 19 August 2008, http://www.unfpa.org 86
[21] 2008 Report on the Global AIDS Epidemic Annex 1,214
[22] Ibid., 215
[23] Ibid., 217
[24] 2008 Report on the Global AIDS Epidemic Annex 2: Country Progress Indicators, UNAIDS, (New York, NY), accessed 19 August 2008,http://data.unaids.org 302
[25] Ibid., 309
[26] Ibid., 315
[27] Monitoring ICPD Goals – Selected Indicators, 86
According to UNFPA, “Modern or clinic and supply ­methods include male and female sterilization, IUD, the pill, injectables, hormonal implants, condoms and female barrier methods.” 
[28] 2006 Update Condoms Count 6: Meeting the Need in the Era of HIV/AIDS, Population Action International, (New York, NY) accessed 19 August 2008,
[29] Monitoring ICPD Goals – Selected Indicators, 86
[30] The World’s Youth 2006 Data Sheet, Population Reference Bureau, (Washington, DC) accessed 5 August 2008, http://www.prb.org/pdf06/WorldsYouth2006DataSheet.pdf 14
[31] 2008 Report on the Global AIDS Epidemic Annex 2, 297
[32] Ibid., 292
[33] Zambia Country Report, 9
[34] National HIV and AIDS Strategic Framework 2006-2010, May 2006, Republic of Zambia/Nationals AIDS Council, (Lusaka, Zambia), accessed 3 September 2008, http://hivaidsclearinghouse.unesco.org 12
[35] Zambia Country Report, 34
[36] 2008 Report on the Global AIDS Epidemic Annex 2, 302
[37] Ibid., 297
[38] Ibid., 315
[39] Ibid., 317
[40] Zambia Country Report: Multisectoral AIDS Response Monitoring and Evaluation Biennial Report 2006-2007, 33
[41] Expenditures by Finance Source and Spending, UNAIDS, (New York, NY), accessed 3 September 2008, http://data.unaids.org/pub/report/2008/rt08_ZAM_en.pdf 
[42] Zambia FY 2004 Country Operational Plan (COP), Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 8 August 2008,
[43] Country Operational Plan 2005, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 19 August 2008, http://foia.state.gov/COP/zambia05Nov_Dec.pdf
[44] Approved Funding by Program Area: Zambia: FY 2006, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department. (Washington, DC) accessed 19 August 2008 http://www.pepfar.gov/about/77697.htm
[45] Approved Funding by Program Area: Zambia: FY 2007, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 19 August 2008, http://www.pepfar.gov/about/82454.htm
[46] Approved Funding by Program Area: Zambia: FY 2008, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 25 August 2008, http://www.pepfar.gov/about/opplan08/102022.htm
[47] Zambia FY 2007 Country Operational, 199, 205, 208, 212, 221, 228, 239
[48] Ibid
[49] Ibid., 99-100
[50] Ibid., 136-139
[51] Ibid., 137
[52] Ibid., 207, 120
[53] Ibid., 121
[54] Ibid., 121
[55] Ibid., 208
[56] Tikambe (Let's Talk About It) – Zambia, ZIHP-COMM (Zambia Integrated Health Programme: Lusaka, Zambia), accessed 3 September 2008, http://www.comminit.com/en/node/118910/36 ; U.S. Embassy Funds Production of "Mwana Wanga" Video and Radio Production, 4 October 2005, US Embassy, (Lusaka, Zambia), accessed 3 September 2008, http://zambia.usembassy.gov/zambia/pr092605.html ; Zambia HIV/AIDS Film ‘Road To Hope’ Wins Award At New York Festivals, 20 February 2007, US Embassy, (Lusaka, Zambia), accessed 3 September 2008, http://zambia.usembassy.gov/zambia/rth.html
[57] Zambia FY 2007 Country Operational Plan, 209
[58] Ibid., 196-197
[59] Ibid., 205
[60] Ibid., 205
[61] Ibid., 205
[62] Progress towards Universal Access Zambia, UNAIDS, (New York, NY), accessed 3 September 2008, http://data.unaids.org/pub/FactSheet/2008/ua08_zam_en.pdf
[63] Zambia: Progress towards Universal Access and The Declaration of Commitment on HIV/AIDS, UNAIDS, (New York, NY), accessed 4 September 2008, http://cfs.indicatorregistry.org
[64] Ibid
[65] Zambia Country Report: Multisectoral AIDS Response Monitoring and Evaluation Biennial Report 2006-2007, 88
[66] Progress towards Universal Access Zambia
[67] Ibid
[68] Zambia Millennium Development Goals Progress Report 2007, UNDP, (Lusaka, Zambia), accessed 3 September 2008, http://www.undp.org.zm/download/MDGs-2008-status.pdf
[69] Epidemiological Country Profile on HIV and AIDS 16; 2008 Report on the Global AIDS Epidemic Annex 1, 217
[70] Zambia Millennium Development Goals Progress Report 2007
[71] Ibid
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