An_Audit_of_HIV_AIDS_Policies_(includes_Lesotho).pdf

AN AUDIT OF HIV/AIDS POLICIES

IN BOTSWANA, LESOTHO, MOZAMBIQUE, SOUTH AFRICA,

SWAZILAND AND ZIMBABWE

FUNDED BY THE WK KELLOGG FOUNDATION

EDITED BY NOMPUMELELO ZUNGU-DIRWAYI, M.A., OLIVE SHISANA, SC.D,

ERIC UDJO, PH.D, THABANG MOSALA, PH.D & JOHN SEAGER, PH.D

RESEARCH

MONOGRAPH

SOCIAL ASPECTS OF HIV/AIDS AND

HEALTH RESEARCH PROGRAMME

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Compiled by the Social Aspects of HIV/AIDS and Health Research Programme of the

Human Sciences Research Council (HSRC)

Funded by the WK Kellogg Foundation

Published by HSRC Publishers

Private Bag X9182, Cape Town, 8000, South Africa www.hsrcpublishers.ac.za

© 2004 Human Sciences Research Council

First published 2004

All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers.

ISBN 0 7969 2066 4

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Contents List of tables vi Abbreviations vii Contributors x

Executive summary 1

Research context 5

The research 7 Rationale for this study 7 Objectives of the study 7 The problem of HIV/AIDS in selected SADC countries 7

Botswana 7 Lesotho 8 Mozambique 9 South Africa 9 Zimbabwe 10 Swaziland 11

Factors fuelling the epidemic in the SADC region 12

Methodology 15 Generic research instruments 15 Policy review 15 Review of implementation of HIV/AIDS programmes 15 Legislation review 15 Ethics of conducting the study 16 Approval for the study from government 16 Methodology: country specific 16

Botswana 16 Lesotho 17 Mozambique 17 South Africa 18 Swaziland 18 Zimbabwe 19

HIV/AIDS national policies and legislation 21 Rationale for policies 21 HIV/AIDS policy and strategic plans 21

Botswana 21 Lesotho 23 Mozambique 25 South Africa 26 Swaziland 30 Zimbabwe 31

Summary 34 General conclusions on the policy aspects 34 Recommendations 35 iii

©HSRC 2004

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Implementation: Guidelines, barriers and proposed solutions 37 Guidelines: voluntary counselling and testing (VCT) 37 Guidelines: prevention of mother-to-child transmission of HIV (PMTCT) 37 Guidelines: treatment of opportunistic infections 37 Guidelines: infant feeding of HIV positive mothers 38 Guidelines: nutrition for people living with HIV/AIDS 38 Existence of guiding documents 38 Existence of policies on orphans and rape 39 Existence of ministerial policies 40 Barriers to implementation of HIV/AIDS policies and strategic plans 40

Botswana 40 Lesotho 40 Mozambique and Swaziland 40 South Africa 40 Zimbabwe 41

Recommendations for addressing barriers to implementation of HIV/AIDS policy and plans 41

HIV/AIDS drug policy 43 Background 43 Level of development of national drug policies for six SADC countries 45 Patent laws and their effect on drug policies for HIV/AIDS and availability of drugs 46 Methods that can be used to circumvent the patent protection obstacles 47

Parallel importation 47 Voluntary license 47 Compulsory license 47 Civil disobedience 47

Conclusion 48

Services and programmes 49 Botswana 49 Lesotho 51 Mozambique 52 Swaziland 53 South Africa 56

Summary 58

Findings of the legislation review 59 Botswana 59 Lesotho 60 Mozambique 60 South Africa 60 Swaziland 62 Zimbabwe 62

Conclusion 62

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Recommendations 63 Gender and HIV/AIDS 64 General conclusions on the legislative aspects 65 Recommendations on legislative aspects 66

Summary, conclusions and recommendations 67 Legislative aspect 69 Overall recommendations 69 General barriers to implementation of policy 70

Appendices 73

References and documents reviewed 85 v

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Table 1: Prevalence rates of HIV/AIDS in 2002 5 Table 2: HIV/AIDS policies and process of development 35 Table 3: HIV/AIDS strategic plans and process of development 36 Table 4: Summary of findings on the existence of guiding documents 39 Table 5: Antiretroviral drugs on the WHO Essential Drugs List 44 Table 6: Summary of the level of development of drug policies in the four main areas 45 Table 7: Drug availability in the country 47 Table 8: International conventions on HIV/AIDS 63 vi

©HSRC 2004

List of tables

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ACHAP African Comprehensive HIV/AIDS Programme

AIDS Acquired Immune Deficiency Syndrome

AMICAALL Alliance Of Mayors Initiative for Community Action on AIDS at the Local Level

ANC Ante-Natal Care

ART Antiretroviral Therapy

ARV Antiretroviral

AZT Zidovudine

BCC Behaviour Change Communication

BHRIMS Botswana HIV/AIDS Response Information Management System

BONASO Botswana Network of AIDS Service Organisations

BONEPWA Botswana Network of People Living With AIDS

BOTUSA Botswana and USA Partnership

CASS Centre for Applied Social Studies

CBO Community Based Organisation

CHBC Community Home-Based Care

CSO Central Statistic Office

DENOSA Democratic Nurses of South Africa

DSMCA District Multisectoral AIDS Committee

EDM Essential Drugs and Medicines (WHO)

ELISA Enzyme Linked Immunial Sorbent Test

FAMSA Family and Marriage Services Association of South Africa

FP Family Planning

GSK GlaxoSmithKline

HAART Highly Active Antiretroviral Therapy

HBC Home-Based Care

HIV Human Immunodeficiency Virus

HSRC Human Sciences Research Council

IEC Information, Education and Communication

IRDP Integrated Rural Development Program

LAPCA Lesotho AIDS Programme Co-ordinating Authority

MCC Medicines Control Council

MOH Ministry of Health

MOHCW Ministry of Health and Child Welfare

MOHSW Ministry of Health and Social Welfare

MONASO Mozambican Network of Organisations against AIDS

MRC Medical Research Council vii

©HSRC 2004

Abbreviations

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MTCT Mother-to-Child Transmission

MTP Medium-Term Plan

NAC National AIDS Council

NACA National AIDS Co-ordinating Agency

NACP National AIDS Control Programme

NDP National Drug Policy

NERCHA National Emergency Response Committee on HIV/AIDS

NGOs Non-Governmental Organisations

NIP National Integrated Plan

NITF National Interdisciplinary and Inter-sectoral Task Force

NNRTI Non-Nucleoside Reverse Transcriptase Inhibitors

NP National Policy

NPC AIDS National Programming for Combating AIDS

NRTI Nucleoside Reverse Transcriptase Inhibitors

NSP National Strategic Plan

PBC Planning and Budgeting Committee

PEP Post-occupational Exposure Prophylaxis

PLWHA People Living With HIV/AIDS

PMB Prescribed Minimum Benefits

PMTCT Prevention of Mother-to-Child Transmission of HIV

RDP Reconstruction and Development Programme

RH Reproductive Health

RHM Rural Health Motivators

RSA Republic of South Africa

SADC Southern African Development Community

SAHA Social Aspects of HIV/AIDS and Health

SAHARA Social Aspects of HIV/AIDS and Research Alliance

SALC South African Law Commission

SAMA South African Medical Association

SANC South African Nursing Council

SAPS South African Police Services

SASO Swaziland AIDS Support Organisation

STD Sexually Transmitted Diseases

STI Sexually Transmitted Infections

STP Short-Term Plan

SWAGAA Swaziland Action Group Against Abuse

TAC Treatment Action Campaign viii

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TB Tuberculosis

TBA Traditional Birth Attendants

UNAIDS United Nations Programme of HIV/AIDS

UNDP United Nations Development Programme

UNGASS United Nations General Assembly Special Session

UNHCR United Nations High Commission for Refugees

UNICEF United Nations Children’s Fund

USAID The United States Agency for International Development

VAWnet Violence Against Women Network

VCT Voluntary Counselling and Testing

WHO World Health Organisations

WKKF WK Kellogg Foundation ix

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Sponsor of the multi-country study: Olive Shisana

Editors: Nompumelelo Zungu-Dirwayi, M.A.

Olive Shisana, Sc.D Eric Udjo, Ph.D Thabang Mosala, Ph.D John Seager, Ph.D

Country research teams

Botswana

Dr Sheila Tlou, of the University of Botswana, was the project director for the Botswana study and worked with senior research fellows.

Lesotho

The Lesotho study was conducted by Ron Cadribo, Department of Political and Administrative Studies (Team Leader) and Mokhantso Makoae, Department of Sociology, both at the National University of Lesotho.

Mozambique

Dr Joel Gudo, of Maputo Central Hospital, was the project leader in Mozambique and worked along with Amilcar Tivane, Maria Ester, Moisés Ernesto, Avertino Barreto and Francisco Mbofana.

South Africa

The South Africa team was led by Efua Dorkenoo, OBE., then Director of the Social Aspects of Health division of the SAHA programme of the HSRC. It included the following people: Mthobeli Guma, Prudence Ditlopo, Shandir Ramlagan, Nelson Kamoga, Evodia Mokoko, George Petros, and Ayanda Nqeketo.

Consultants: Jobi Makinwa (legislation policies), Henry Fomundam (Drug Policy)

Swaziland

The project leader for Swaziland was Rudolph Maziya of Alliance Of Mayors Initiative for Community Action on AIDS at the Local Level (AMICAALL) and his team included the following: S Dlamini, Z Hlanze and I Ziyane.

Zimbwabwe

The Zimbabwean team was led by Brian Chandiwana and included S Mtero-Munyati, Alfred Ching’ono, George Chitiyo and Farai Chieza, all from the Biomedical Research and Training Institute’s Centre for International Health and Policy (BRTI-CIHP), in collaboration with the Blair Research Institute.

x

©HSRC 2004

Contributors

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Executive summary This report is the result of a three-month study, commissioned by the Centre for Applied Social Studies (CASS), through the WK Kellogg Foundation. The aim was to review and analyse HIV/AIDS policy, legislation, financing and the implementation of programmes in six selected Southern African Development Community (SADC) countries, namely Botswana, Lesotho, Mozambique, South Africa, Swaziland and Zimbabwe. African leaders were party to the Declaration on the Commitment on HIV/AIDS at the United Nations General Assembly, Special Session (UNGASS) on HIV/AIDS, held on June 25–27 2001, which stated that, by 2003, countries should have developed multisectoral, national strategic plans which directly address the HIV/AIDS epidemic. Hence, an underlying theme of this study was to assess to what extent each of the heavily affected Southern African countries has met this goal.

The Social Aspects of HIV/AIDS and Health Programme of the Human Sciences Research Council (SAHA) was selected to supervise and direct the project. Accordingly, research teams were identified in the six countries, whose role it was to direct and supervise the preparation of country reports and case studies, to illuminate salient aspects of the research topic. These included the University of Botswana, the National University of Lesotho, the National Blood Transfusion Service in Mozambique, the University of Witswatersrand, and the Centre for International Health and Policy of the Biomedical Research and Training Institute in Zimbabwe and AMICAALL in Swaziland.

Staff of SAHA, and specifically of the recently established Social Aspects of HIV/AIDS Research Alliance (SAHARA) provided generic research tools, designed to guide the research in the selected countries and to encourage standardisation, so that study results could be effectively compared and conclusions drawn. Research instruments were also customised to meet the specific needs of each country in the study, through consultation with the research teams, and were outlined and explained in an operational handbook, prepared for use in the field. For Mozambique, the research guidelines were translated into Portuguese. SAHARA staff also supported a literature search on thematic areas, organised a review workshop, at which in-country research teams presented their findings, and elaborated this final report.

This report is based on:

1. National reviews of current policies, strategic plans and actual programmes, on

HIV/AIDS.

2. Key informant interviews (conducted with staff of governmental departments and Ministries, Non-Governmental Organisations (NGOs), Civil Society Based Organisations (CBOs), Voluntary Counselling and Testing centres (VCTs), Prevention of Maternal to Child Transmission (PMTCT) and other health facilities, People Living With HIV/AIDS (PLWHA), as well as with patients at various levels of health care delivery) were administered to assess to what extent the above policies were actually impacting at the district level in the countries targeted and to determine the general state of prevention and care services.

3. Detailed analysis of in-country drug policies in relation to prevention and treatment of the disease, and gauging the extent to which these comply with the latest WHO recommendations on essential drugs for resource-poor settings. Analysing the level of existing infrastructure for the provision of antiretroviral drugs and options for increasing access to essential drugs were also explored.

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An audit of HIV/AIDS policies

©HSRC 2004

4. A review of documentation from state financial institutions in the selected countries, combined with strategically selected interviews with relevant policy makers, to assess the state of financing for programmes designed to combat the disease, and to present recommendations for expanding these programmes appropriately.

5. A review of national legislation affecting those living with HIV/AIDS in the selected countries.

6. Information elicited at workshops that were organised with relevant key informants on the implementation of programmes at Kellogg sites.

The results of this research demonstrated that, in all of the six countries surveyed, there is some level of commitment to the management of the HIV/AIDS epidemic. HIV/AIDS policies and strategic plans have been developed in most of the countries, through participatory and consultative processes. In all countries, multi-sectorial structures have been established, to co-ordinate and direct prevention and care activities. With the exception of Lesotho, and to some degree, Swaziland, most countries have developed protocols and guiding documents on these activities. Various mechanisms also exist in all countries to finance HIV/AIDS related activities.

However, serious constraints have been identified in the implementation of HIV/AIDS policies, strategies and programmes. In most countries, with the possible exception of Botswana, services such as VCT and PMTCT are inadequate in rural areas. Antiretroviral drugs are primarily available in private hospitals and are accessible only to the relative few who can afford them. In all countries, the fear of stigmatisation and discrimination, as well as traditional cultural norms, continue to impede more effective provision of support to those affected by the disease.

With the exception of South Africa, there is a chronic lack of financial resources to implement necessary programmes. Adequately trained staff, including medical, counselling and support personnel are also in short supply in all countries. People Living With HIV/AIDS and caregivers are not, in general, receiving the level of support that they require. Poor service infrastructure, especially in rural areas, severely limits access to care.

There is a desperate need for increased community involvement in programmes to enhance the effectiveness of such access. Data also indicated that the level of monitoring and evaluation of existing intervention programmes is inadequate. There was also general agreement that the rate of spread of the epidemic is unlikely to diminish unless ways are rapidly developed to decrease the high level of violence against women in all of the countries studied, as rape is a primary exacerbating factor in the levels of infection.

The following is a summary of the specific recommendations, which are expanded upon in the report:

1. Training in and development of strategic planning skills and capacity of implementing agencies so that they are better organised to channel resources for effective implementation of HIV/AIDS programmes.

2. Involvement of communities as well as traditional and religious leaders can improve community participation in all HIV/AIDS initiatives and increase the awareness of the HIV/AIDS epidemic at community level.

3. Programmes of mass public education on the rate of HIV infection, as well as on lifestyles that promote the spread of HIV should be strengthened. This will increase openness about HIV/AIDS among partners, in work places, among children and in

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Executive summary communities. Such programmes will contribute to the removal of negative stigma associated with infected and affected persons.

4. Existing community-based programmes should be strengthened, including income-generating projects. There should also be improved life skills, such as training youths in home-based care, and support to orphans.

5. Donors also need to play a more supportive role by working within the framework of the national strategic plan and channelling resources to meet national priorities, rather than focusing on their own projects, as is the general perception.

6. Monitoring and evaluation systems should be strengthened.

7. There should be greater leadership commitment from the government. This would help uproot stigma and silence and promote open disclosure of HIV/AIDS status.

8. Best practices should be improved to increase accountability of official authorities in management of HIV/AIDS funds and programmes.

9. Greater decentralisation is recommended, as well as the involvement of district and regional structures in implementation of HIV/AIDS programmes.

10. There is need for a rigorous resource mobilisation strategy from both the internal and external sources. A clear strategy is needed to partner with the private sector on HIV/AIDS financing.

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Countries in the Southern African Development Community (SADC) are the hardest hit by the HIV/AIDS epidemic. At the end of 2002, it was estimated that 29.4 million, out of 42 million people living with HIV/AIDS, lived in sub-Saharan Africa. In 2002 alone, about one million people in sub-Saharan Africa were infected. This constitutes a rise of two million people from the end of 2001 (UNAIDS, 2002). The figures rose by another million by the end of 2002, from 28.5 million in 2001, suggesting that, despite all the prevention campaigns in the region, the epidemic is not yet under control (UNAIDS, 2002).

New infection rates are still very high. In 2002, five million new infections were recorded globally, of which 3.5 million were in sub-Saharan Africa. Similarly, the number of deaths due to AIDS is high. Of the three million deaths reported worldwide in 2002, 2.4 million were recorded in the sub-Saharan region (UNAIDS, 2002).

Within the SADC region, the countries that have the highest HIV/AIDS prevalence rates among the adult population are Zimbabwe, Zambia, South Africa, Botswana, Lesotho and Swaziland (UNAIDS, 2002). The prevalence rates among adults in these countries range from 15 per cent to 38 per cent (UNAIDS, 2002). Table 1 illustrates the severity of the epidemic in each country. Botswana has the highest prevalence rate, while South Africa is home to the highest number of people living with HIV/AIDS in the world.

The major mode of HIV transmission in sub-Saharan Africa is heterosexual (UNAIDS, 2001). A high prevalence of sexually transmitted infections, unsafe sex and multiple partners remain the most common causes of new HIV infection rate in the region

(UNAIDS, 2002).

©HSRC 2004

Research context

Table 1: Prevalence rates of HIV/AIDS in 2002 (Source: UNAIDS, 2002)

Country Total population Population of Adults No of Estimated Sero- Year

2001 (thousands) PLWHA (adults (15–49) children AIDS prevalence and children) prevalence orphaned deaths

Botswana 1 554 000 330 000 38.8% 69 000 26 000 44.9% 2001

Lesotho 2 057 000 360 000 31.0% 73 000 25 000 42.2% 2000

Mozambique 18 644 000 1 100 000 13.0% 420 000 60 000 14.4% 2000

South Africa 43 792 000 *4 500 000 15.6% 660 000 360 000 24.3% 2000

Swaziland 938 000 170 000 33.4% 35 000 12 000 32.3% 2000

Zimbabwe 12 852 000 2 300 000 33.7% 780 000 200 000 31.1% 2000

*Nelson Mandela/HSRC HIV/AIDS study

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Rationale for this study

Currently, there is no scientific documentation on SADC countries’ HIV/AIDS policies, legislation, financing and the implementation of programmes, even though this information may be crucial for several reasons. Firstly, in terms of assisting countries to design effective and efficient interventions for curbing the epidemic; and secondly, the progression of the HIV/AIDS epidemic in each country is different. This provides us with a unique opportunity for learning from those countries that have dealt with the epidemic for a longer period. It also provides an opportunity to share experiences and expertise from each country in the fight against HIV/AIDS. Thus, there is clearly a need to scientifically document this crucial data within the region.

In view of this gap in knowledge and as part of its commitment to assist economic and social development in Southern Africa, the WK Kellogg Foundation has established an Integrated Rural Development Programme (IRDP), managed by the Universities of Zimbabwe and Pretoria. An important component of this programme is designed specifically to contain the spread and mitigate the impact of HIV/AIDS in rural communities. With this goal in mind, WK Kellogg, acting through the Centre for Applied Social Sciences, at the University of Zimbabwe, commissioned the Social Aspects of HIV/AIDS and Health Research programme of the Human Sciences Research Council (HSRC) to undertake a review of the HIV/AIDS epidemic in six Southern African countries (Botswana, Lesotho, Mozambique, South Africa, Swaziland, and Zimbabwe).

The primary goal was to put forward recommendations to Kellogg on how best to strengthen their policy in this area, and also to guide future policies on HIV/AIDS and Rural Development.

Objectives of the study

1. To conduct key informant interviews, to elicit additional primary data.

2. To undertake a detailed case study on financing of HIV/AIDS programmes in

Botswana, Lesotho, Mozambique, South Africa, Swaziland and Zimbabwe, with a view towards identifying commendable practices.

3. To conduct a review of legislation affecting people living with HIV/AIDS in the six countries.

4. To review national HIV/AIDS policies and strategic plans in the six countries and document case studies.

5. To investigate access to HIV/AIDS prevention and care services in all six countries, based on surveys of the population.

6. To review pharmaceutical policies and infrastructure for the provision of antiretroviral drugs in the six Southern African countries.

The problem of HIV/AIDS in selected SADC countries

Botswana

It is estimated that 330 000, of a total population of 1.554 million (i.e., 14 per cent of the population), are living with HIV/AIDS (UNAIDS, 2002). The country is currently experiencing one of the fastest growing rates of HIV infection in the world. About one in four of its sexually active and economically productive adults are living with HIV/AIDS.

©HSRC 2004

The research

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According to estimates and projections made by the U.S. Bureau of Census, life expectancy in Botswana has declined to 45 years, from a projected 61 years in 1996, as a result of the HIV/AIDS epidemic. By 2010, it is estimated that life expectancy will decline further, to 33 years. In 1996, as a result of lowered fertility and the premature death of children and adults from AIDS, the population growth rate dropped from an estimated 2.6/1000 to 1.6/1000 per annum. The HIV epidemic is expected to have serious macro-economic repercussions. Households will face large financial burdens, due to loss of income from family members who die from the disease, as well as because of increasing costs of treatment for HIV/AIDS and associated opportunistic infections.

In Botswana, as in other countries, the HIV epidemic disproportionately affects people and communities who are economically and socially disadvantaged. Heterosexual intercourse has been the predominant mode of HIV transmission. In addition, vertical transmission, from mother-to-child, has contributed to the rapidly growing epidemic.

Women have been hardest hit by HIV infection. Recent data indicate that 58 per cent of infections in the age group 15–49 years occur in women. In addition, women face the physical and emotional burden of bearing HIV-infected infants and are also expected to assume much of the care-giving burden for people living with AIDS. Poverty, unemployment, legal and socio-cultural disadvantages, dependence on partners for financial support, and lack of empowerment in negotiating sexual and reproductive matters, all contribute to an increased vulnerability to HIV infection among women. If women refuse to have unprotected sex with their partners, they may be at risk of physical and sexual violence.

Lesotho

UNAIDS (2002) estimates that 360 000, out of 2.057 million people (i.e., 17.5 per cent of the population), are living with HIV/AIDS. The overall prevalence rate is estimated to be 31 per cent with 24 per cent of adults infected. Rates among females in the 15–49 age group are higher than those for males in the same age group. In women aged 15–19, the prevalence rate is estimated to be between 25 per cent and 51 per cent. The rate of progression from HIV infection to AIDS is also reported to be faster among women than men (UNAIDS, 2002).

Since the first case of AIDS was reported in 1986, the disease has spread rapidly throughout the country. In 1997, there were 2 203 reported cases. There was an increase of 30 per cent (to 3 242) in the number of AIDS cases reported in 1998. By December 2000, the Ministry of Health reported 14 880 cases of AIDS. Reported cases are estimated to be less than one quarter of all AIDS cases in Lesotho. A joint estimate by WHO and UNAIDS placed the number of Basotho aged 15–49 years living with HIVAIDS at 40 000 in 1994, increasing to 79 000 by 1997, 92 000 by 1998 and 240 000 by 2000, (representing a sero-prevalence of 23.5 per cent of all adults aged 15–49). Sentinel surveillance in several sites in the country showed that, over the years, there has been a steady upward trend in the proportion of individuals testing HIV positive among pregnant women aged 20–24 years, with sero prevalence rising from 3.9 per cent in 1992 to 26 per cent in 1996.

HIV prevalence among persons attending antenatal care clinics (ANC), as well as clinics for sexually transmitted infections (STI) also increased over time. For STI patients, the increase ranged from 4.8 per cent to 7.1 per cent in 1991, and from 34.9 per cent to 63.5 per cent in 2000. For women attending ANCs, increases were dramatic, ranging from 0.7 per cent to 5.5 per cent in 1991, and from 15.8 per cent to 42.2 per cent in 2000. Of all

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.h sr cp re ss .a the AIDS cases in Lesotho reported to date, 45.1 per cent were male and being 54 per cent female. In 1998, 69.5 per cent of persons with AIDS were married, 16.6 per cent were single, 75 per cent were separated, 5.4 per cent were widowed and 1.1 per cent were divorcees. It is observed that the rate of HIV infection in sexually active adults continues to double every two years, and is concentrated in people between the ages of 15 and 49.

One of the tragic consequences of AIDS is the death of parents, leading to a high number of orphans. UNAIDS estimates for 2001 indicate that the country experienced 25 000 AIDS deaths. In 2001, it was estimated that 73 000 Basotho children were orphaned, mainly due to AIDS. However, the figures provided by UNICEF are higher. The latter estimates that Lesotho has as many as 117 000 AIDS orphans.

Forces driving the spread of HIV/AIDS in Lesotho are associated with cultural, traditional, behavioural, economic, technical and biological factors. Among these are: unprotected sex, wife inheritance, polygamy, traditional medicine practices, (such as scarification and ritual shavings at funerals), biological factors, such as the physiology/anatomy of women, blood transfusions and mother-to-child transmissions.

Mozambique

UNAIDS estimated that there are 1.1 million people (about 6 per cent of the total population) living with HIV/AIDS in Mozambique. The prevalence of HIV in Mozambique has increased dramatically from 4 per cent in 1992 to 12.2 per cent in 2000 for the adult population. In the central corridor provinces (Manica, Sofala and Tete), the prevalence is even higher (21 per cent in the Manica Province, the capital of which, Chimoio, is a Kellogg site).

In 1992, only 662 cases of AIDS had been recorded. However, by the end of 1998, the number of recorded cases was 10 863 and by 2001 the figure had risen to 1 100 000. It is projected that, without an effective response and if the rate of infections remains at 500 infections per day, there will be 100 000 new HIV infections by the end of 2003.

The epidemic is resulting in a high number of orphans, straining households’ coping capacity, changing the dependency ratio, and increasing poverty. Estimates in 1998 showed an average of 1 770 cases of AIDS per hospital and an occupation rate of seven cases per hospital bed.

The number of opportunistic diseases, including pulmonary tuberculosis, is increasing, thereby raising the morbidity rates even further. Studies have revealed an increase in the prevalence of HIV among patients with TB. For example, in 1994, the prevalence of HIV ranged from 2.9 per cent to 30.3 per cent in different parts of the country. By 1997 the range was from 10.5 per cent to 37.8 per cent.

South Africa

The first reported cases of HIV in South Africa occurred in the early 1980s. Today, South Africa is reported to have the largest number of people living with HIV/AIDS in the world (UNAIDS, 2002). It was estimated at the end of 2002 that there were 4.5 million people aged two years and older and about 11.4 per cent of the population, living with HIV/AIDS. Of these, 15.6 per cent were adults. (Shisana et al, 2002).

©HSRC 2004

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The reasons for the rapid spread of the epidemic in South Africa are complex and often imbedded in historical, socio-cultural and psychosocial factors. These include: the policies of separate development, which encouraged discrimination and the abuse of Human Rights in the country; high levels of untreated STIs; a low level of condom usage; and social norms that permit and encourage high numbers of sexual partners (Nelson Mandela/HSRC HIV/AIDS Study, 2002). Widespread unemployment, poverty and low levels of income among certain demographic groups are driving forces behind the commercial sex industry. Lack of adequate education, which leads to disempowerment, further entrenches gender and race inequality. The system of migrant labour, which also encouraged men (and later women) to leave their communities, countries and families in search of employment, leading to the breakdown of families, was another compounding factor.

The national antenatal studies, conducted by the Department of Health, suggest a HIV sero-prevalence of 24.8 per cent among pregnant women at the end of 2001 (Department of Health, 2001). Kwa-Zulu Natal has the highest antenatal-based HIV prevalence figure (33,5 per cent), followed by the Free State, with a prevalence of 30.1 per cent .

There were 660 000 orphans and 360 000 deaths in 2001 alone (UNAIDS, 2002).

According to a report from the Medical Research Council (MRC), there has been a shift in the pattern of mortality from natural causes in previous decades such that more young people, particularly women, are dying now than older people (Dorrington, et al, 2001).

Zimbabwe

The first officially reported case of AIDS in Zimbabwe was in 1985. Since then, HIV infection has spread rapidly throughout both urban and rural areas. By the end of 1999 an estimated 1 500 000 were living with HIV/AIDS and 200 000 persons had died from AIDS. Ninety-three per cent of PLWHA were adults, of whom 800 000 were women in the reproductive age group and 56 000 were children, aged 0–15. Today, an estimated 2 300 000 Zimbabweans, i.e., about 18 per cent of the population, are living with HIV/AIDS.

The Ministry of Health and Child Welfare records show that the prevalence of infection for women aged 15–19 is 27.8 per cent and that five times more women are infected as men in this age group, with about 1.5 times more in the 20–29 age group. Based on the 2000 sentinel survey of pregnant mothers, the current sero-prevalence rate in women of child bearing age is 35 per cent, while women aged 15–19 years have a prevalence rate of 27.8 per cent. This represents a substantial and rapid increase from the 29 per cent recorded in the 1997 survey. Reports to the Ministry of Health (MOH) show that 70 per cent of all reported cases of HIV related disease are in the 20–49 age group. The peak age of HIV infection in adults is reported to be 20–29 years for females and 30–39 years for males. About 32 per cent of people aged 15–24 years, in both urban and rural areas, are HIV positive. These are the actively reproductive population as well as adults with young families. High HIV prevalence in these age groups results not only in high prevalence of HIV infected young children, but also in the tragedy of young orphans, some of whom are also HIV infected. This group also constitutes the majority of the country’s workforce. High mortality in this group has adverse effects on the economy.

Viewed together with the 20 per cent increase in the sero-prevalence rate between 1997 and 2000, the epidemic is undoubtedly on the increase. It is projected that the number of PLWHA will rise to 2 million by 2005. Those who have progressed to AIDS will rise to 1.3

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.h sr cp re ss .a million and cumulative deaths are estimated to reach 1.2 million by 2005. Studies reveal that the leading mode of HIV transmission in the country is heterosexual, which accounts for 92 per cent of all infections. This is followed by mother-to-child transmission (MTCT), which is responsible for approximately 7 per cent of all infections. All other modes of transmission account for about 1 per cent of HIV infections.

The number of known AIDS orphans has increased rapidly, from a small number in 1990 to about 200 000 in 1995. UNAIDS/WHO have estimated that, by 1999, some 900 000 children under 15 years of age had lost either their mother or both of their parents to AIDS and there were 623 883 surviving orphans under 15 years of age.

The epidemic in Zimbabwe is fuelled by historical, political, psychosocial, economic, cultural and other factors. These have been discussed in detail in a previous report and thus will not be extensively covered here. However, it is worth reiterating cultural factors, as they still play a key role in the current state of the epidemic in Africa as a whole.

Swaziland

Swaziland is a landlocked Southern African country. It shares borders with the Republic of Mozambique on the east and with the Republic of South Africa on the south, north and west. Swaziland is a comparatively small country that extends over an area of 17 364 square kilometres and has a total population of 980 722 (CSO, 1997). Of this population, 44 per cent are children under the age of 15 years, while 48 per cent are adults who are aged 15–49 years. Up to 78 per cent of the population resides in rural Swaziland. The population of Swaziland grows at a rate of 2.9 per cent per annum (CSO, 1997).

According to the Swaziland census, fertility was estimated to be 4.8 births per woman, while contraceptive use was reported to be 34 per cent in 1998 (MOH&SW, 1998).

Teenage pregnancy is believed to account for approximately 28 per cent of all annual births.

Available data suggest that the quality of life of the people of Swaziland has been increasing steadily over the years. Between 1966 and 1977, life expectancy at birth increased from 44 years 58.8 years in 1977. The crude death rate decreased from 20.5 per 1 000 population in 1966 to 8.4 in 1991, while infant mortality declined from 156 per 1 000 live births in 1976, to 72 in 1991. Similarly, under-five mortality declined from 218 in 1976, to 89 in 1991. Maternal mortality is estimated to be 229 per 100 000 live births using the sisterhood method. In discussing these indicators, it is important to note that even though the quality of life has improved over the years, many current indicators are still unacceptably high and are poorer than those of countries with a commensurate economic standing. Morbidity and mortality continue to be driven by preventable environmental factors, even though non-communicable diseases are also becoming a challenge, suggesting that the country is experiencing an epidemiological transition.

Leading reasons for outpatient clinic visits include respiratory conditions, diarrhoeal diseases, skin disorders, STIs, and digestive disorders.

Swaziland is a lower middle-income country with an income per capita of US$1 170 (1995). Economic growth has declined from an average of 8 per cent in the 1980s. The decline has been especially pronounced in the period that corresponds to the independence of the Republic of South Africa. Job creation has been consequently slow.

According to official statistics, unemployment is 22 per cent and is unofficially believed to

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©HSRC 2004

be much higher. It would appear that employment in the informal sector has increased even though data are not available. A significant number of Swazis work in the Republic of South Africa as migrant labour. Poverty is common in the country, with almost half of all Swazis (48 per cent) living below the food poverty line.

The country generally lacks data on progress indicators. Available data is limited to HIV prevalence among antenatal clinic attendees, aged 15–19 and 20–24 years. HIV sentinel surveys are carried out every two years. HIV prevalence among antenatal attendees aged 15–19 increased from 25.6 per cent in 1998 to 26.3 per cent in the year 2000. Among people aged 20–24 it increased from 38.4 per cent in 1998 to 42.5 per cent, in the year 2000.

Factors fuelling the epidemic in the SADC region

The SADC region is made up of 14 countries, which are in close proximity to one another. The region is economically and socially intertwined. There is also a political interlink between countries. The interdependence can be traced to historical ethnic conflicts, with certain ethnic groups and clans from the South migrating to settle in the areas over the Limpopo, today known as Mozambique and Zimbabwe. Later the interdependence was caused by economic migration, with many men from Lesotho, Malawi, Mozambique and Namibia migrating to South Africa and Botswana in search of work in the gold and platinum mines.

Today economic- and civil war-induced migration remains the major reason for movement of people within the SADC region and in Africa as a whole. The migration of labourers, while boosting the economies of the region, has also had the unintended consequence of transporting diseases. This risk is not new and it was recognised before the emergence of HIV/AIDS. In the past, conditions such as TB were rampant within the mining communities. The high prevalence of TB among miners could be explained by poor housing and the overcrowded conditions that existed in the single-sex mine hostels.

In Africa, the major mode of transmission of HIV is heterosexual, followed by mother-to-child transmission and, to a lesser extent, blood transfusion. Unsafe sex and multiple partners remain the most common cause of new infections in this region. The ongoing movement of people, whether due to economic reasons or because of war, continues to destabilise the region. The influx of refugees into local communities exposes both the refugees and the locals to the risks of contracting HIV. Within the contexts of conflict, HIV/AIDS prevention programmes are often suspended, as finances are redirected towards survival and coping mechanisms. Access to health care is also affected, as the priority is shifted towards attending to the casualties of war. Quality reproductive health care services may not be available, thus fuelling the spread of STIs, which, in turn, increase the risk of contracting the HIV infection.

However, there has been a debate on the role of heterosexual transmission involving multiple partners and unsafe sex in propelling the epidemic. Recently, researchers have questioned this theory and provided evidence of cases in which children had become infected and the mode of transmission had not been sexual. Also, research suggests that in many developing countries, health systems are inadequate. In many sub-Saharan countries, for example, there are alarming signs of deterioration of health systems, evidenced in the rise in maternal and child mortality rates, one of the principal measures of national development.

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Research has indicated that dirty needles and poor health delivery systems may be partly responsible for fuelling the HIV/AIDS epidemic in sub-Saharan Africa, especially in the SADC region. Therefore, more research on the role of poor health delivery systems and dirty needles in fuelling the HIV epidemic, particularly in developing countries, is urgently needed.

Previously, economic migration was driven by the economic boom, with many men leaving their homes and countries to work in diamond, gold, coal and platinum mines.

Today, however, migration is primarily a consequence of famine, which has led to acute poverty in the sub-Saharan region. The drought in Africa has had a negative impact on regional food security. Rural communities are most affected, because of their dependence on subsistence farming. The United States Agency for International Development (USAID) estimates that Lesotho, Malawi, Mozambique, Swaziland, Zambia and Zimbabwe will be in need of humanitarian food aid in 2003. Food insecurity causes migration to other areas.

This type of migration can be within or outside of the country. Both types of migration expose people to vulnerable situations. Being separated from family increases the risk of HIV infection, as those left behind, as well as those who have migrated, are more likely to seek other sexual partners, who may be infected with HIV.

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Methodology Generic research instruments

The study had four components, namely a policy review, a review of implementation of HIV/AIDS programmes, a review of financing policies and a review of legislation. The instruments were designed to illicit data on all aspects of the study. Workshops were also organised with relevant key informants on the implementation of programmes at Kellogg sites and on legislation in the six countries.

Research instruments in policy, financing and programming were developed by SAHA and refined in consultation with the other six countries’ research teams. An operational handbook was developed for all the instruments and the research teams from the six countries used this. Each instrument was accompanied by detailed guidelines on how to implement it, as well as the rationale for each question. In Mozambique, all questionnaires were translated into Portuguese, revised and adjusted to the local needs.

Policy review

SAHA developed a semi-structured questionnaire and adapted it for use in the six countries. The questionnaire examined to what extent different HIV/AIDS policy documents existed at the national level and to what extent the government had responded to the epidemic. This questionnaire had to be directed to the managers responsible for HIV/AIDS policy in different governmental departments at the national level. These included the Health-HIV/AIDS Directorate, the Medicines Control Council, the Chief Financial Officer, Trade and Industry, Education, National Treasury, Agriculture, Labour, Land Affairs, Justice, Social Development and Transport. Content analysis was used to analyse data.

Review of implementation of HIV/AIDS programmes

A qualitative interview schedule was employed to elicit to what extent HIV/AIDS policies, strategic plans and programmes were being implemented at district level. It should be noted that key informants were selected according to the key areas of service provision on HIV/AIDS. These included VCT, PMTCT, STIs, Care and Support of HIV/AIDS infected and affected people and Violence against Women. The key informants’ interviews also attempted to determine the extent to which service providers were involved in policy and strategic plan formulation. The interview schedule was directed to district facilitators, religious leaders, district training managers, professional nurses and midwives, traditional healers, counsellors, social workers, provincial administrators, national administrators, PLWHA and police officers.

Legislation review

A semi-structured questionnaire, designed to assess whether the country has legislation protecting the rights of people living with HIV/AIDS, was directed to Justice departments, NGOs working on Law, Human Rights, Women’s groups and organisations for PLWHA. In South Africa, the Legal Resources project at the University of the Witwatersrand was commissioned to review legislative aspects. The review attempted to assess to what extent legislation protected rights of PLWHA from discrimination and other negative manifestations.

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Ethics of conducting the study

Prior to commencing data collection, clearance to conduct the study was sought from relevant national authorities in each country, such as research ethics authorities and HIV/AIDS co-ordinating bodies. Consent was obtained from the respondents for the key informant interviews.

Approval for the study from government

Prior to commencing data collection, clearance to conduct the study was sought from the heads of different national government departments. With regards to Policy, Finance and Legislation reviews, letters were written to the relevant officials. Regarding the key informants’ interviews, access to the Kellogg sites was made possible through the assistance of the University of Pretoria, WKKF Integrated Rural Development Programmes and District Facilitators, located in the respective provinces.

Methodology: country specific

The present investigation was co-ordinated by the HSRC through the SAHA programme, which mandated its recently established Social Aspects of HIV/AIDS Research Alliance (SAHARA) to both identify partners in the countries, as well as to facilitate sharing of expertise in conducting the multi-country, operational social sciences research. SAHARA identified the following partnerships: the University of Botswana, the National University of Lesotho, the National Blood Transfusion Service in Mozambique, the Social Aspects of HIV/AIDS and Health programme of the HSRC, the University of Witwatersrand, the Alliance of Mayors Initiative for Community Action on AIDS at the Local Level (AMICAALL) in Swaziland and the Centre for International Health and Policy of the Biomedical Research and Training Institute in Zimbabwe.

To ensure that the review was of a high quality, and that comparable standards were applied in all six countries, the HSRC was responsible for the following:

• Supporting country teams with literature searches on the thematic areas identified.

• Providing generic research instruments for adaptation to countries’ specific needs.

• Organising two tele-conferences for in-country research team leaders to review the methodology and finalise the review tools.

The study was conducted between September 2002 and March 2003.

Botswana

The national policies, strategic plans and programmes on HIV/AIDS were reviewed, as well as Botswana’s drug policies in relation to prevention and care, taking into account the latest WHO recommendations on essential drugs for HIV/AIDS in resource-poor settings and options for increasing access to HIV/AIDS drugs.