Over the past decade, Zambia has demonstrated notable progress in its response to the HIV epidemic. According to UNAIDS, annual HIV infections (for all ages) in Zambia have declined from 60,000 in 2010 to 51,000 in 2019. New infections among children aged 0-14 years have also decreased, from an estimated 10,000 in 2010 to 6,000 in 2019.
Despite this progress, the HIV burden remains high and disproportionately affects females. In 2019, it was estimated that there were 26,000 new HIV infections among women 15+ years, compared to 19,000 among their male counterparts. The Zambia Demographic and Health Survey (2018) reports that HIV prevalence among females aged 15-49 years is 14.2 per cent, compared to 7.5 per cent for males of the same age.
HIV/AIDS is considered the deadliest epidemic in the 21st century. Human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS) is a set of conditions caused by infection with the human immunodeficiency virus (HIV). HIV is transmitted by three main ways: sexual contact, significant exposure to infected body fluids or tissues, and from mother to child during pregnancy, delivery, or breastfeeding (known as vertical transmission).
Zambia is experiencing a generalized HIV/AIDS epidemic, with a national HIV prevalence rate of 11.3% among adults ages 15 to 49 as of 2018. As per the 2000 Zambian census, the people affected by HIV or AIDS constituted 15 per cent of the population, amounting to one million, of which 60% estimated were women. The pandemic results in increased number of orphans, with an estimated 600,000 orphans in the country.
The government of Zambia created an AIDS surveillance committee as early as 1986 and created an emergency plan to control the spread by 1987. As per the plan, all blood transfusion should be screened for HIV. By 2005, the government made antiretroviral therapy free for every individual.
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Zambia advances in fight against HIV-AIDS epidemic
Key Challenges and Disparities
Only 6 in 10 adolescent girls and 5 in 10 adolescent boys aged 15-19 years have ever been tested for HIV and know their HIV status, according to the Demographic and Health Survey. Despite an increasing trend of HIV testing and uptake of voluntary medical male circumcision (VMMC) among adolescents and young people, condom use by sexually active adolescents remains low.
Despite the recognition of the rights of young people to sexual reproductive health (SRH) information and services, adolescent and young people (AYP) still face challenges in accessing healthcare in public health institutions including access to comprehensive knowledge on HIV/AIDs, HIV testing and contraceptives. In Zambia, 3.8% of young women and men aged 15-24 are HIV positive. However, like in most developing nations, HIV prevalence is higher among young women than young men (5.6% versus 1.8%).
HIV prevalence rates vary considerably within the country. Infection rates are highest in cities and towns along major transportation routes and lower in rural areas with low population density. HIV prevalence among pregnant women can range from less than 10 percent in some areas to 30 percent in others.
In general, however, young women ages 25 to 34 are at much higher risk of being infected by HIV than young men in the same age group. The prevalence rates are 12.7 and 3.8 percent, respectively. Risk for the disease is higher for people with sensory, intellectual, physical and psychosocial disabilities, despite the 2012 Persons with Disabilities Act. Other at-risk populations include military personnel, people in prostitution, truck drivers, and people who work in fisheries.
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HIV-related stigma remains an issue in Zambia. In 2023, the People Living with HIV Stigma Index found that one third of people with HIV had experienced HIV-related stigma in the past year, and around half had experienced it at some point.
Zambia criminalises men who have sex with men (who face a prison sentence of up to 14 years), sex workers and people who use drugs. This stops many people from these groups from getting the HIV prevention, testing and treatment they need, despite being at high risk of infection.
Prevalence among adults in Zambia has changed little over the last decade despite decreasing infection rates. As a result, HIV prevention has been a key focus in recent years - PrEP has been rapidly scaled up and comprehensive sexuality education is now offered in primary and secondary schools. At the beginning of 2024, around 600,000 people in Zambia were using PrEP.
There is an encouraging trend in the number of potential HIV infections among children averted thanks to work on the prevention of mother-to-children transmission (PTMCT). HIV testing among pregnant women at antenatal clinics has increased significantly, with 9 out of 10 pregnant women getting tested and almost all (more than 95 per cent) of those diagnosed with HIV (at the antenatal clinic) being initiated on treatment (ARVs). However, there is a large gap around children - with about 71 per cent of HIV exposed children (born from a mother living with HIV) receiving early infant diagnosis, and 79 per cent of children 0-14 years living with HIV are on treatment.
The primary modes of HIV transmission are through sex, intravenous drug use and mother-to-child transmission.
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HIV Prevalence in Africa
Strategic Frameworks and Interventions
During the first half of 2017, the Government of Zambia completed the National AIDS Strategic Framework (NASF) 2017-2021 and the Adolescent Health Strategy 2017-2021. While the HIV Strategic Framework prioritises global treatment and prevention specifically for children, mothers and adolescents; the Adolescent Strategy emphasizes sexual reproductive health and HIV, with prevention of teenage pregnancy, scaling up HIV testing, and condom programming, among priorities. A mid-term review of the NASF was completed in first quarter of 2020.
The Zambian Ministry of Health acknowledges the importance of district-level estimates for more focused approaches in HIV programming and in facilitating the achievement of the Fast Track targets. These targets are a set of 10 global guidelines for countries to adopt and implement in order to end the HIV pandemic by 2030 through ensuring, among other things, zero new HIV infections, zero discrimination and zero AIDS-related deaths. The Zambian MoH also acknowledges the importance of district-level HIV estimates in the achievement of these targets in an equitable manner.
This will help to guide the HIV/AIDS response framework that will focus on strengthening integration, the five pillars of HIV prevention (i.e. combination prevention for adolescent girls and young women and key populations, condom programming, pre-exposure prophylaxis; and VMMC) while maintaining momentum in improving the quality and coverage of HIV treatment. The dual elimination of Mother To Child Transmission (eMTCT) of HIV and syphilis remains integral to HIV epidemic control for Zambia which is consistent with global goals.
The programme is centred on quality, accessible and proven HIV prevention, treatment, care and support interventions for children, adolescents and pregnant women. It also focuses on rights- and gender-sensitive quality services, enhanced awareness, demand for services, the use of data and evidence to strengthen accountability. The UNICEF HIV programme's primary focus is on responding to the HIV burden by supporting the Government of Zambia provide high quality interventions along the continuum of HIV care during the first and second decades of life.
UNICEF’s HIV/AIDS programme supports the Government of Zambia in implementing the:
- National Paediatric and Adolescent Prevention, Treatment and Care Implementation Plan 2017-2021
- AIDS Response Fast Track Strategy 2017-2021
- National AIDS Strategic Framework (NASF) 2017-2021
- Adolescent Health Strategy (ADH) 2017-2021
- Elimination of Mother-to-Child Transmission of HIV and Syphilis (eMTCT) Plan 2018-2022.
Centers for Disease Control and Prevention (CDC) office in Zambia has a long-standing partnership with the Ministry of Health (MOH) and its provincial health offices. For 25 years, CDC has supported the MOH to scale up HIV treatment and prevention programs to strengthen the HIV response. CDC focuses on increasing access to evidence-based prevention, expanding case identification and linkage for pediatrics, young people, and people at increased risk for HIV infection, and improving HIV services.
Supported the implementation of the SmartCare National Electronic Health Record system in over 1,600 high-volume health facilities nationwide with over 2 million people enrolled. Sustained laboratory diagnostic testing capacity for 24 viral load laboratories, more than 250 point-of-care testing platforms, and over 200 hub facilities. Supported Zambia in making progress to provide 98 percent (1,295,030) of PLHIV with antiretroviral therapy (ART) in FY2024. Supported Zambia in making progress to identify 88% of children living with HIV know their status and were on ART. Supported the implementation of evidence-based HIV programs to reduce new HIV infections and HIV-related deaths in Lusaka, Southern, Eastern, Western, and Northwestern Provinces.
With CDC support, 95 percent of all PLHIV have been screened for TB, 97 percent of the PLHIV have completed a course of TB preventive treatment, and 99 percent of all TB notifications had an HIV status as of April 2024. CDC's Division of Global HIV & TB activities are implemented as part of PEPFAR.
Zambia’s HIV response is reliant on international funding, which accounts for 95% of HIV-related spending. In 2019, the Zambian Government introduced a National Health Insurance Scheme to increase domestic resources for the health sector, including for HIV. But the fallout of the COVID-19 pandemic means the government is now cutting public spending, which is likely to affect health.
District-Level HIV Prevalence
The HIV/AIDS pandemic has had a very devastating impact at a global level, with the Eastern and Southern African region being the hardest hit. The considerable geographical variation in the pandemic means varying impact of the disease in different settings, requiring differentiated interventions. While information on the prevalence of HIV at regional and national levels is readily available, the burden of the disease at smaller area levels, where health services are organized and delivered, is not well documented. This affects the targeting of HIV resources. There is need, therefore, for studies to estimate HIV prevalence at appropriate levels to improve HIV-related planning and resource allocation.
HIV prevalence in Zambian is highest in districts located near international borders, along the main transit routes and adjacent to other districts with very high prevalence. The variations in the burden of HIV across districts in Zambia point to the need for a differentiated approach in HIV programming within the country.
The information on the geographical variation in HIV prevalence at provincial level is certainly important for guiding government policy, prioritization of interventions and resource allocation both across and within countries. It should, however, be noted that the burden of diseases within the provinces can be heterogeneous. This means that effective preventive and control strategies to combat HIV require knowledge of the burden of the disease at smaller and more similar areas such as districts.
District-level HIV statistics are of particular importance for Zambia because, a district is the lowest level of decentralization where health services are organized and delivered.
Map of Zambia
Methods for Estimating District-Level Prevalence
The district HIV prevalence was estimated using Small-Area Estimation (SAE) methods by utilizing multiple data sources. The SAE method is a statistical technique for obtaining reliable statistics for small areas that are mostly underrepresented in existing data sources due to small sample sizes. Using both direct and indirect methods, SAE models combine multiple data sources (censuses, surveys, etc.) containing other related information-auxiliary data-for these small areas.
Put simply, small-area estimates for HIV prevalence are a weighted average of the direct prevalence estimate from existing data which, due to sample size, may be too unreliable, and therefore requiring a statistical model that utilizes auxiliary data from outside the survey to improve the estimates. More weight is placed on the predicted prevalence if the variance of the direct prevalence is high, and vice versa.
This is achieved by increasing coverage of the following high impact interventions to high level targets as below:
- Pregnant women living with HIV receiving antiretroviral treatment, to 90 per cent.
- Children aged 0-14 years living with HIV receiving antiretroviral treatment, to 90 per cent.
- Sexually active adolescents aged 15-19 years who had an HIV test in the last 12 months, to 90 per cent.
- Eligible adolescents living with HIV on antiretroviral treatment, to 90 per cent.
- Consistent condom use among sexually active adolescents aged 15-19-years
- Children, adolescents and women living with HIV achieving viral suppression (significantly low numbers of viruses in the body) to 90 per cent
In order to achieve these results, UNICEF supports the Government of Zambia at policy level (policy, strategy development, review and monitoring), national and sub-national coordination of service implementation (governance structures like technical working groups), and service delivery for children, adolescents and women.
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