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GlobalPost's John Donnelly and a team of reporters investigate what experts are calling a 'turning point' in the global fight to reduce HIV infection rates. Successes in southern African countries have produced valuable lessons on effective approaches to fight AIDS, lessons that need to be learned in US cities where infection rates remain persistently high — particularly among African-Americans. Meanwhile a political confrontation looms in Washington over critical funding which could threaten gains already made.
Despite being largely left behind by PEPFAR, Zimbabwe has still managed to reduce its HIV prevalence rate.
DUFUYA, Zimbabwe — Tendekai Sibanda, a single mother of two, starts her day at 4:30 am. After preparing a meal on firewood in a dimly lit thatched hut, she trudges village to village, covering up to 12 miles a a day on foot to attend to bed-ridden AIDS patients.
In this poor village roughly 200 miles southwest of Harare, the capital, the fight against AIDS is distinctly Zimbabwe’s own. The country was largely left behind in the AIDS fight by the US government when Washington started the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003 under President George W. Bush.
Instead, Zimbabwe relies on its own well-mapped network of community health workers such as Sibanda, who fan out daily across the country to make sure the country’s AIDS patients receive care. Evidence is emerging that the model works. Zimbabwe’s HIV prevalence among adults aged 15 to 49 stood at 15 percent in 2011, down from 18 percent in 2006, according to national Demographic and Health Surveys.
With funding from the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and planning organized by Zimbabwe’s Health Ministry, health workers were trained and given a small salary. They became the country’s front-line health soldiers.
Sibanda couldn’t believe her good fortune, saying, “I had always yearned for an opportunity to learn more health care and actually caring for the people.”
Still, what makes the case of Zimbabwe so curious – and even confounding to many outside observers – is that this country found success even though it was largely cut out of the big spending by PEPFAR’s list of 15 so-called “focus countries.”
This graphic shows PEPFAR funding of its 15 focus countries and one not on list, Zimbabwe, which received far less than all but one focus country. It also shows HIV prevalence in several countries. In Zimbabwe, HIV prevalence dropped by 3 percent since 2006, while in Uganda, Tanzania, Kenya, and Ethiopia, prevalence has changed very little.HIV prevalence is a snapshot of the number of people HIV positive at a specific moment. As treatment expands, a steady prevalence rate may indicate that fewer people are getting infected and more HIV-positive people are living longer.
A simple decision made nine years ago – countries either made a favored list, or were left off – meant hitting the aid jackpot or being left at the loser’s table. Zimbabwe wasn’t the only loser. Others were Malawi, the Democratic Republic of the Congo, Burundi, Cameroon, Lesotho, and Swaziland. Each of them, based on a decision made by a handful of people in Washington, lost out on hundreds of millions of dollars by not being a PEPFAR focus country.
The reason for excluding Zimbabwe from the bulk of funds was no mystery. Its government, led by long-time President Robert Mugabe, was mostly punished by Western donors because of its election fraud; human rights abuses; and its policy to seize white-owned farms and give them to black Zimbabweans, many of whom were cronies of Mugabe.
The result: Zimbabwe, with an HIV prevalence rate of 15 percent, has received $200 million in direct US funding for AIDS since 2003, while ‘focus’ country Ethiopia, with an HIV prevalence rate of 1.5 percent, has received $1.6 billion under PEPFAR.
Zimbabwe had roughly a 10 times higher prevalence rate than Ethiopia, yet Ethiopia received $1.4 billion more.
Are countries better off with less funding?
So how did Zimbabwe reduce its HIV prevalence rate with dramatically less assistance than other countries? Are countries forced to depend on themselves in some instances better off without huge amounts of donor funding? And is Zimbabwe’s experience a model for a future when PEPFAR begins to dwindle and countries fend more for themselves?
Experts disagree on the answers to those questions, and several point out that other outside funders – notably the Global Fund, a multi-lateral effort, which includes roughly one-third US funding – played a major role in supporting almost all of Zimbabwe’s efforts.
Since 2003, the Global Fund has earmarked $538 million to Zimbabwe for health programs, including nearly $193 million for HIV/AIDS. In comparison, Zimbabwe’s contribution, while steadily increasing from a national AIDS levy from $5 million collected in 2006 to $19 million in 2010, has covered a small fraction of the cost. Overall, the country’s AIDS fight has had more than a $1 billion less to spend than Ethiopia’s in the last decade.
But no one denies that Zimbabwe was forced to do more with less. And its results are better than many PEPFAR-favored countries.
Geoff Foster, a Zimbabwe-based pediatrician and a global HIV expert, said that the local response strategy – the one deploying thousands of workers like Tendekai Sibanda – is largely responsible for the decline in HIV prevalence. He said Zimbabwe not only learned from its own experts but also from other African countries, such as Uganda, to focus its response on educating people to stop having multiple sex partners.
“Zimbabwe’s home-grown HIV prevention response ... has been enormously beneficial,” Foster said. “Zimbabwe’s response has focused on behavioral change rather than simple condom promotion. Having multiple sex partners is what drives HIV epidemics.”
Foster, who founded the Family AIDS Caring Trust in 1987 to promote sexual abstinence outside marriage and faithfulness within marriage, said that the strategy had its problems at the start.
“We were involved in HIV prevention work, yet national HIV rates were increasing rapidly in the 1990s,” he said, citing UNAIDS statistics that at one point said Zimbabwe’s HIV prevalence rate was 30 percent – a figure that now is acknowledged as exaggerated due to faulty statistical modelling.
Local effort yields results
Zimbabwean President Robert Mugabe is pictured 16 June 2004 during the official opening of the first national AIDS conference in Harare. Mugabe voiced confidence that Zimbabwe can win the fight against AIDS, which he described as 'one of the greatest challenges' facing the southern African nation.
Foster said that his organization joined with the Mutare City Council in 1993 to start a peer education program aimed at stopping multiple sexual partnerships. A later study showed a 50 percent decrease in sexually transmitted infections in city clinics in one year.
He said PEPFAR failed to more explicitly promote monogamy or even partner reduction, although one-third of the US prevention funding in PEPFAR was the so-called “ABC” strategy: abstinence, being faithful, and condoms. This strategy was widely criticized in many donor and AIDS expert circles, but Foster said he believes that it worked in Zimbabwe and Uganda. Uganda used the approach of treating HIV primarily as risk avoidance, treating HIV as a behavioural rather than a technical and medical challenge.
“Imagine if $15 billion was made available to address lung cancer on a global scale. Surely we would have to address smoking behaviour, not smoking in the first place, stop smoking or at least take fewer cigarettes per day,” he said.
Dr. Henry Madzorera, Zimbabwe’s health minister, said in an interview it was easy to successfully implement the Uganda strategy in Zimbabwe because HIV evokes a personal touch to many Zimbabweans.
A commitment rooted in personal loss
“Almost every Zimbabwean has a relative or close friend who died from the disease,” he said. “That has also emerged as a strength, because even when we are low on money we can always count on our people. Communities always rally together when it comes to organizing against HIV,” he said, adding that despite the fall in prevalence rate, Zimbabwe still is in dire need of funding.
The National AIDS Council, a quasi-government organ set up to coordinate the fight against HIV, launched a community response programme emphasizing prevention in 2001. By 2004, the Council claimed that the prevalence rate had dropped from 30 percent to 24.6 percent among those aged 15 to 49.
Still, doubts remain about the statistics. Some of those doubts are rooted in the reality in the country’s hospitals and health clinics.
A file picture shows Zimbabwean women's pressure groups as they march in Harare on December 1, 2005 to mark World AIDS Day.
The public health infrastructure has suffered from years of neglect and of tens of thousands of trained health workers fleeing the country for better-paying jobs elsewhere. In the hospitals, record keeping often is suspect and buildings are dilapidated.
At Harare Central Hospital’s opportunistic infections unit, patients form long lines for prescription drugs and doctors say they are running out of space for patients in the wards.
Dr. Tapiwanashe Bwakura, who joined the hospital straight from medical school in 1988 and now heads the opportunistic infections unit, said finding enough health workers is a huge challenge. Only a handful of doctors and nurses are around to serve a daily stream of between 200 and 300 people, he said.
One patient, who declined to give her name, interviewed in the line said receiving AIDS treatment went smoothly when she started in 2006, but the last few years has been more difficult because of the growing numbers of patients.