April 2005

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Letter from Zambia: HIV, TB, and Malaria
by Mary Furlong

Stephen Musonda, 14 years old, and his mother traveled 96 km. on an oxen cart to get to the Great North Road (a main road), and waited until they were offered a free ride to Kabwe General Hospital, only to be turned away as there were no services for new patients at the hospital from November 25th to December 16th as the one doctor was not available. He was referred to our Ranchod Hospice on a Friday afternoon, where our nurse and VCT (Voluntary counseling and testing) counselor diagnosed that Stephen had both TB and HIV (often connected here). Because we do not have anti-retroviral (ARV) drugs to give out and other limited medications, Stephen was dead by Monday.

The day I returned to Zambia, I heard of the death of a close friend, Samuel Mwenifumbo, a 36-year-old teacher in a community school in a rural area, and I wept that evening, both for him and his four surviving children. His wife had died in June 2002, probably of HIV, but there was so much silence about it. I will always remember Samuel inviting me to visit her grave–and I was a bit stunned (whites are not to go near graves here), but he assured me that he had obtained permission from the headman of the village for me to visit her grave. I always suspected Samuel had HIV (mainly because of his many illnesses), but never felt comfortable about asking if he knew his HIV status. With Kara Counselling, that is part of our “job,” whether formally or informally, to ask people if they know their HIV status and to encourage them to take the VCT test.

Having returned to Zambia in September 2004 as a volunteer recruited by the Catholic Medical Mission Board in New York to work with Kara Counselling, the first NGO to work with HIV/AIDS in Zambia, I am posted in the newest Kara office, which is in a more rural area (Kabwe). Kara Counselling has been designated as one of the four lead agencies in Zambia by the Global Fund to Fight HIV, TB and malaria (GFATM), and we are responsible for programs in Lusaka (the capital), Choma, Kafue, and Kabwe (about 30% of the population of the country). In an earlier article (January 2003), I had shared about the education system in Zambia, including the impact of World Bank decisions. In this reflection, I would like to share some perceptions of the GFATM, treatment options, and the impact of HIV/AIDS, especially as related to orphans and the farming industry (my Iowa and Adams County roots still spark my own interest in farming).

The GFATM’s potential is providing a substantial increase in financing to developing countries that could make a significant difference in turning the tide against the three diseases. The Global Fund has grown quite quickly in the first two years. In June 2004, the Fund had approved funding for 227 programs in 122 countries. One of the noticeable changes in this donor is that it takes an unusually hands‑off approach compared to most donors, leaving much of the responsibility for program design and implementation to country representatives and local groups (not government to government). It includes a much wider circle of organizations–NGOs, faith‑based institutions, civil society groups, people living with diseases, private companies, and foundations. For Zambia, the monies allocated were $40 million in 2004 and this figure will be doubled to $80 million in 2005. However, this has translated into only 13,000 people qualifying for ARVs (out of 2 million people who are infected). Next year, the projection is that 100,000 Zambians will qualify for the ARVS. So much to share about the lack of health care infrastructure, but I will wait until a further article.

When we turn to look at treatment, care and support for people living with HIV, TB and malaria in Zambia, there are many areas we could explore. As the theme for World AIDS day this year has been women and girls, let us first look at the role of gender. At our Kabwe office, I just finished an analysis of 2004 figures for VCT (voluntary counseling and testing), which is the first step, but only a difficult one. We provide the service free (based on donor contributions) but find that more men have come month after month. WHO figures suggest that 95% of Zambians know the causes of HIV. Our records show that 46% of the women who have taken the test with us are HIV positive, while 33% of the men are HIV positive. After this it will cost the average Zambian $26.00 to have three more tests, which will then qualify them for ARVS. Most of our clients can not afford to have these tests. Even after that initial test, Zambian women reported various reasons for not accessing treatment:

1) Discrimination: where money is limited, the family will pay for a man's treatment;

2) Property Rights: if a husband dies, his family would inherit his land, and the wife would have no way to support the children (six children is still the norm); if the wife dies, the husband would still have the land.

As to the issue of care of patients, there are only two hospices in Kabwe. Ours was started in October. 2003 and serves about 22 people. The beds are always full–from children age four to older men and women (the impact of opportunistic infections is overwhelming). We are fortunate to have four full time nurses (they work 12 hour shifts) and 8 volunteer caregivers (they get a small allowance of $30.00 a month). Thus, a home based care program which has trained volunteers to work with family members in caring for those infected with HIV and TB is what most families use when a family member becomes infected. The emphasis in the home based care program is on nutrition and positive living skills as well as preventing reinfection. But often the family is concerned about the stigma attached to the illness and will shun the family member (they may even provide less food).

Psychosocial support is very important to people living with HIV and TB. PLA (People Living with AIDS) support groups in each of the compounds (shantytowns) have been a priority for Kara Counselling. We are encouraging the groups to develop income-generating ideas so they can be self‑sustaining with their twice a month programs. They are also available to meet with family members who are not open to dealing with HIV. A professional friend of mine, Stephanie Stines, works in Washington, DC, with the National Association of People Living with AIDS and knows two people here in Kabwe (a small world!!) as a result of a visit in early 2004.

Finally, the impact of the three diseases is clear in Zambia. One out of five Zambian children will die of malaria before age five. One of my former Delone students, now in medical school, told me in mid-December that one of his questions on a final was, “Which country had the lowest life expectancy?” The answer, of course, was Zambia, with 32.4 years (the government refuses to accept this figure and sticks by its figure of 38 years). The impact of HIV/AIDS is so evident in the farming industry (seventy percent of the population are still farmers). In rural Zambia, households suffer when the head is chronically ill, and it has reduced the cultivation of land by 53%, which means reduced crop production and lower food availability. According to FAO (Food and Agriculture Organization), widows will end up working 2 to 4 hours more each day and the children will also put in the same hours to maintain the same level of production. Another impact that I see at least once or twice a week is the cost of funerals, which becomes a burden to the family. A coffin may easily cost K800.000 or $160.00 (remember that the annual income for the average Zambian is $365.00. Then the funeral house (at the home or at a brother/sister’s home) has to transport the mourners from the village of origin, provide meals for at least four days of mourning by family and friends and even must arrange transport to pick up the body at the mortuary and transfer it to the church and to the cemetery.

One other impact we see here in Zambia is the increased presence of prostitution. In a 2002 Zambian report, the average age of children engaged in prostitution was 15. About half of these children were double orphans and 24 % were single orphans. The need to earn money was the main reason given for entering into prostitution. There is still a myth here that if a man has sex with a virgin, he will be “cured” of HIV, so the term “sugar daddies”' has become a common reference here. The Zambian children’s daily earnings from prostitution ranged from $0.63 to $7.00; the majority, especially younger ones, rarely made as much as $2.10. On average, the children slept with three to four clients a day.

To end on a more positive note, from the time I left Zambia in August 2003 and returned in September 2004, there seems to be much more hope, especially with access to ARV drugs and the continued emphasis on the ABC program (adapted from Uganda):

A. Abstinence

B. Behavioural Change (only one partner)

C. Condom.

Local leaders, including traditional and religious leaders, administrators, prominent citizens, sports leaders, teachers, journalists seem to have a commitment to sensitizing Zambians to the impact of HIV/AIDS.

With the 40th celebration of Zambia’s Independence in October 2004, there was much pride in their gift of peace for their own people as well as being peacemakers to Central African and Southern African nations. May the gift of life and quality of life be the theme for their 45th celebration, as Zambians appreciate solutions to the HIV, TB and malaria pandemic.

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