THE HISTORICAL CONTEXT OF HIV AND AIDS IN ZIMBABWE
2.3. The AIDS Epidemics in sub-Saharan Africa
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churches in Manicaland carried out HIV interventions, there were always a number of limitations. Hence, according to Rosenberg this trend is historical:
AIDS has, in particular, forcefully reminded us of the difficulty of providing adequate care for the chronically ill in a system oriented disproportionately towards acute intervention—and of the complex linkages between disease categories, hospital policies, and reimbursement formulas.229
Consequently, the present study is a historical analysis of church responses to HIV within the socio-economic context of Zimbabwe. In the section that follows attention will now be drawn to the AIDS epidemic in sub-Saharan Africa
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countries in southern Africa where the estimated percentage of adults (15-49) living with HIV rapidly escalated from 5-10% in 1984, reaching 20-36% between 1989 and 1999.233
In an overview of the HIV epidemics in sub-Saharan Africa, in 2002 UNAIDS reported that in 2001 approximately 3.5 million new infections occurred, 28.5 million people were living with HIV in sub-Saharan Africa, fewer than 30, 000 people having benefited from antiretroviral drugs, and the number of children orphaned by AIDS in the region was at 11 million.234 The Arab North has been spared of high level of severity of the African HIV epidemics. At the end of 2001, the estimated number of PLHIV in North Africa together with the Middle East was only 500,000.235 Comparatively, southern Africa remained the hardest hit area in Africa and topped the world list of HIV prevalence. Buvé noted: ―In seven countries of Africa, including Botswana, Lesotho, Namibia, South Africa, Swaziland, Zambia and Zimbabwe, at least one in five adults is infected with HIV and all of these countries are in southern Africa.‖236
This has been further confirmed by statistics of HIV prevalence among pregnant women from southern Africa who attended antenatal clinics during the period 1997- 2007. The statistics cited here are not current but serve to give a picture of the situation in different countries as recorded then. Swaziland and Botswana had a HIV prevalence rate of 30%, followed by Lesotho and South Africa at slightly below 30%, Namibia on 20% and Mozambique and Zimbabwe at 15%. On the contrary, in Ethiopia, the rate dropped from 14% in 1997 and to 9% in 2005, whereas in Kenya the rate dropped from 14% to 5% in the same period.237 This was in further contrast to the situation in West Africa. HIV prevalence in Côte d‘Ivoire dropped from 10% in 2001 to 5% in 2005, Burkina Faso experienced a HIV prevalence decline from 6% in 1997 to 2.5% in 2006. In the same period, Ghana had been fluctuating between 2.5%
Africa in a historical perspective, Online edition, (October 2006), 41. See www.sorat.ukzn.ac.za/sinomlando/publications.
233 S. Craddock, ―Beyond epidemiology: Locating AIDS in Africa,‖ in E. Kalipeni et al. (eds), HIV and AIDS in Africa: Beyond epidemiology, (Oxford: Blackwell Publishing, 2004), 2.
234 UNAIDS, Report on the global HIV/AIDS epidemic, (July 2002), 22-23.
235 UNAIDS, Report on the global HIV/AIDS epidemic, 8.
236 Buvé, ―The HIV epidemics in sub-Saharan Africa,‖ 41.
237 UNAIDS, The 2008 report on the global AIDS epidemic, 41.
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and 4%, and in Senegal it has been stable at an average of 1.5% in 1997 to 1% in 2004.238 It should be noted that these figures only serve to illustrate certain trends and thus have not been given detailed scrutiny.
Iliffe is one of a few authors who provide crucial insights on the African AIDS epidemic. While the origin of HIV is beyond the scope of the present research study, Iliffe used the work of scholars including Luc Montagnier, Elizabeth Bailes et al., Nathan D. Wolfe, William M. Switzer et al., Daniel Candotti and Claire Tareau et al.
to trace the origins of AIDS to the African soil. This is linked to the collapse of European rule in Africa especially Leopoldville, present day Kinshasa in Belgian Congo, as far back as 1959.239 For example, Montagnier, whose laboratory first identified HIV, connected it to the death of an American men in 1952, a Japanese Canadian who died in 1958, an African woman who died in 1958, a Haitian American who died in 1959, a sexually active American youth who died in 1969.240 Therefore, AIDS could have existed invisibly on the African continent since 1959. In line with this observation, Caraël also stated:
Tests, which were later carried out on stored blood, confirmed the presence of the virus in central Africa from the end of the 1950s, both in rural and urban areas. But it is likely that the epidemic of the infectious AIDS virus, the human immuno-deficient virus HIV, began towards the idle or ends of the 1970s and then slowly spread through several continents amongst the most vulnerable populations.241
Within sub-Saharan Africa, the AIDS epidemic could have existed without being noticed and has therefore been described as a silent killer. It is for that reason that Iliffe stated that the African AIDS epidemic is ―especially dangerous to human life, makes it difficult to check, ensures that it does not burn itself out…has given the AIDS epidemic its unique character.‖242
An overview of the African AIDS epidemic by Iliffe indicates that ―HIV-1 first became an epidemic during the 1970s in western equatorial Africa, its place of
238 UNAIDS, The 2008 report on the global AIDS epidemic, 41.
239 Iliffe, The African AIDS epidemic, 3.
240 Iliffe, The African AIDS epidemic, 3, 4.
241 Caraël, ―Twenty years of intervention and controversy,‖ 30.
242 Ibid., 8
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origin.‖243 Countries in that region include the Democratic Republic of Congo, Central African Republic, Congo, Gabon, Equatorial Guinea and Cameroun. The epidemic spread eastwards to Uganda, Rwanda, Burundi, Tanzania and Kenya,244 before taking a southward move towards Zambia, Malawi, Zimbabwe, Mozambique, South Africa, Botswana and Namibia.245 Later HIV and AIDS penetrated the western part of Africa.246 Epstein has concurred with Iliffe and Caraël‘s observations but further argues that AIDS reached the Bukoba-Kagera region of Tanzania from West Africa in the late 1970s and quickly spread to Rwanda, Kenya, Burundi, Uganda, Zambia, Tanzania, Malawi and Zimbabwe.247 In Africa, AIDS was first identified in Zaire (present day Democratic Republic of the Congo) in the early 1980s as Brooke Schoepf noted: ―AIDS was diagnosed among Zairians in Europe in 1983.‖248 In 1984 the epidemic had spread to other African countries including Uganda, Rwanda, Burundi, Tanzania, Ivory Coast, Burkina Faso, Togo, Zambia, Cameroon, Congo Brazzaville and Zimbabwe.249 Kocheleff, writing on personal day-to-day experience with the epidemic states that in 1983 clinicians in Burundi discovered strange occurrences of what appeared to be AIDS as had been recently described in the United States.250 Malawi appears to be a unique case because AIDS-related sickness was discovered in the Karonga region of the country in 1982.251
In Zimbabwe‘s southern neighbour, South Africa, HIV was detected in 1982 reportedly ―in a white homosexual air steward who had probably contracted the disease in New York. …Blood specimens from 200 homosexual men in Johannesburg in 1983 later showed that 32 were already infected.‖252 Though first identified in a male foreigner from the Democratic Republic of Congo, HIV could have been in existence within South Africa among heterosexuals in 1985. Consistent with this assertion, Iliffe observed: ―The first African in South Africa definitely known to have suffered from HIV was a man from DR Congo who apparently sought treatment early
243 Iliffe, The African AIDS epidemic, 10.
244 Iliffe, The African AIDS epidemic, 19-22.
245 Iliffe, The African AIDS epidemic, 33-47.
246 Iliffe, The African AIDS epidemic, 48-57.
247 Epstein, The invisible cure, 155-156.
248 B. G. Schoepf, ―AIDS, history, and struggles over meaning,‖ in Kalipeni, HIV and AIDS in Africa, 20. See also Caraël, ―Twenty years of intervention and controversy,‖ 30.
249 Buvé, ―The HIV epidemics in sub-Saharan Africa,‖ 44.
250 Kocheleff, ―AIDS in Burundi and South Africa,‖ 143.
251 Iliffe, The African AIDS epidemic, 33.
252 Iliffe, The African AIDS epidemic, 43.
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in 1985.‖253 Within the Southern African Development Community (SADC), social- political and economic interdependence has a long history. Economic factors account for high levels of migration in which adult males from Lesotho, Malawi, Mozambique, Namibia (as well as Swaziland and Zimbabwe) migrate to South Africa and Botswana in search of work opportunities. While this has the unintended effect of fuelling the spread of HIV, ―This risk is not new and it was recognised before the emergence of HIV.‖254 Other than regional factors, a unique set of conditions within a given space seems to fuel the spread of HIV in a particular country or locality. Denis further elucidated upon this by stating:
AIDS develops in a territory which, for generations, has been marked by gender questions, political relations, class conflicts and racial tensions which determine or, or at the very least, explain the particular paths which the epidemic follows.255
The transition from an agrarian and rural based economy to a modern urbanised economic system could have led to increased HIV prevalence in sub-Saharan Africa.
In many of the cases, married males live separately from their spouses. Some husbands who move to urban areas in search of jobs usually leave wives in rural areas and this gives way to concurrent sexual relationships especially among male spouses.
Epstein has observed that the AIDS epidemic in Africa has been triggered by rapid social and economic transmission ―from an agrarian past to a semi-urbanised present.
…The resulting upheavals in social life have generated an earthquake in gender relations that has opened wide channels for the spread of HIV.‖256 Similarly, Iliffe focused on Zimbabwe as a specific case and observed: ―In Zimbabwe a similar oscillating pattern had grown up in the colonial period as men maintained land rights and families in the communal reserves while working in mines and cities.‖257
African HIV epidemics could also have been fanned by transactional sex. In support of this assertion, Epstein has argued that transactional sexual relationships were encouraged by income inequalities among males and females and ―the exchange of
253 Iliffe, The African AIDS epidemic, 44.
254 Zungu-Dirwayi, An audit of HIV/AIDS policies, 12.
255 Denis, ―Towards a social history of HIV/AIDS in sub-Saharan Africa,‖ 16.
256 Epstein, The invisible cure, 67.
257 Iliffe, The African AIDS epidemic, 41.
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money and gifts gives men a sense of ownership over a girlfriend‘s sexuality.‖258 Therefore, generally in Africa the low status of women in society exposed them to risks of contracting HIV and this had negative influence on HIV prevention.
According to The 2008 Report on the Global AIDS Epidemic, in Burkina Faso, Cameroon, Ghana, Kenya and the United Republic of Tanzania, ―two thirds HIV- infected couples were serodiscordant, that is only one partner was infected. Condom use was found to be rare.‖259 While sex work has also been identified as one of the modes of HIV transmission in the epidemics of sub-Saharan Africa, this has less influence on HIV prevalence in southern Africa. The HIV and AIDS pandemic in Zimbabwe has not mainly been driven by sex work but by other forms of sexual intercourse that include marriage. The same report indicates that Zimbabwe experienced ―substantial HIV transmission during sexual intercourse unrelated to sex work.‖260 Within African epidemics, generally the HIV prevalence among females is higher than in males. A survey of HIV prevalence in 15-24 year olds for the period 2005-2007 revealed that Zimbabwe was in third position for both, with females at 11% and males at 4%. Swaziland was at the top of the list with 23% for females and 6% for males, followed by South Africa with 17% for females and 4% for males. The least was Senegal, where the figures were below 1% for females and less than 0.5%
for males.261 Globally, the HIV epidemics in Zimbabwe, South Africa, Botswana, Lesotho, Namibia, Zambia and Kenya, all from Africa, indicate a bleak future as Denis stated:
In the seven countries where the average rate of HIV prevalence in adults who are sexually active exceeds 20%, the projections for the 2010-2015 period are terrifying: the number of deaths multiplied by three, life expectancy reduced to the age of thirty, and level of infant mortality almost doubled.262
The trend in Zimbabwe indicated that in February 1986 patients suspected to be suffering from AIDS-related illness were already dying of the pandemic in Livingstone, a town south of Zambia just across the Victoria Falls town in Zimbabwe.
258 See Epstein, The invisible cure, 79.
259 UNAIDS, The 2008 report on the global AIDS epidemic, 43.
260 UNAIDS, The 2008 report on the global AIDS epidemic, 43.
261 For this see figure 2.10, UNAIDS, The 2008 report on the global AIDS epidemic, 42.
262 Denis, ―Towards a social history of HIV/AIDS in sub-Saharan Africa,‖ 18.
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It is therefore possible that the ―silent epidemic had penetrated Zimbabwe some time before, although perhaps three or four years later than Zambia and Malawi as the virus was carried southwards.‖263 Surveys carried out to establish the earliest possible data on HIV and AIDS in Zimbabwe show that ―the first cases of AIDS and aggressive Kaposi‘s sarcoma were diagnosed in 1983.‖264 It appears that not much was said and done by the State until two years later in 1985 when blood was screened for the first time.Meanwhile, a young HIV epidemic in Zimbabwe indicated a general north to south pattern of movement. Consistent with this assertion, Bassett and Mhloyi observed: ―Within Zimbabwe, data support a north-to-south spread. In 1985, for example, 3% of blood donors in the northern city of Harare were seropositive, compared with 0.05% in the city of Bulawayo, to the south.‖265 Iliffe also supports the same view and used HIV tests done at the district hospital at Hurungwe in Mashonaland West province which showed that the number of those who tested HIV positive between 1986 and 1988 increased from 16 to 292 people. The HIV prevalence for Harare escalated from 10% in 1989 to 18% in 1991 and reached 32%
in 1995. Manicaland, in particular the city of Mutare, located on the border with Mozambique and along the Harare-Beira corridor, experienced a similar phenomenal increase in HIV prevalence reaching 37% by 1997.266
Zimbabwe is one of the countries in southern Africa whereby the AIDS epidemic rapidly escalated from an estimated 5-10% in 1984 to 20-36% in 1994 the number of adults in the 15-49 years range living with HIV.267 Another source indicates estimates of HIV prevalence of ages 15-49 to be 0% in 1983, 12% in 1991 reaching 25% in 1995.268 The figures illustrate that at least a quarter of the economically active citizens aged 15-49 years were living with HIV. Meanwhile, in Zimbabwe, unemployment rate increased phenomenally from 18% in 1982 to 60% in 1999 nationally.269 A report
263 Iliffe, The African AIDS epidemic, 37.
264 Iliffe, The African AIDS epidemic, 38.
265 Basset and Mhloyi, ―Women and AIDS in Zimbabwe,‖ 148.
266 Iliffe, The African AIDS epidemic, 39. For this also see Gregson, ―Recent upturn in mortality in rural Zimbabwe,‖ 1269-1280.
267 Craddock, ―Beyond epidemiology,‖ 2.
268 NAC and MOHCW, The HIV and AIDS epidemic in Zimbabwe: Where are we now? Where are we going? Harare, (May 2004), 10.
269 M. van Donk, ―Development planning and HIV/AIDS in sub-Saharan Africa,‖ A report prepared for the United Nations Development Programme regional project on HIV and development in sub-Saharan Africa (July 2004), 133, <http://web.undp.org/hiv/docs/dev_plan_report_fnl.pdf/> [Accessed 2 May 2009].
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by the USAID, Zimbabwe HIV and AIDS Health Profile published in September 2008 stated that Zimbabwe experienced an increase in the adult population of PLHIV from 10% in the early 1990s to 36% by 1997.270 The cumulative AIDS cases for the period between 1988 and 1997 indicated that Manicaland had 7,050 PLHIV; Harare had 11,776 cases, Bulawayo, 7,751 cases, Mashonaland West, 7,447 cases and in Masvingo, 7,335 cases. The breakdown according to gender for Manicaland showed that 3,890 PLHIV were male, 3,125 were female and 35 were unspecified.271 Nationally, the overall picture of HIV prevalence rate was about 29% by 1997.272 HIV prevalence in pregnant women indicated that Manicaland had the highest rate of 53%
of women infected in 1997.273 The HIV prevalence rate stabilised and gradually took a downturn from 1999 and made Zimbabwe one of the first African nations to witness such a trend.274
The USAIDS statistics are higher than those of WHO and Mirjam van Donk. These discrepancies could be due to underreporting and over-reporting of incidence of HIV by both the State and private laboratories in Zimbabwe. According to the NACP, under-reporting was caused by laboratories which carried out HIV tests and did not report the figures to the MOHCW. Furthermore, ―some doctors feel that it is no longer necessary to send patients for HIV tests as the symptoms themselves are enough to indicate that a patient is HIV positive.‖275 The statistics from antenatal surveillance in Manicaland could be a reliable indicator of HIV prevalence bearing in mind the fact that generally; in Zimbabwe antenatal visits facilitate regular contact between pregnant women and healthcare centres. However, because testing for HIV was voluntary, there could have been cases of under-reporting. The 1997 estimates of HIV prevalence in Zimbabwe by the WHO, UNAIDS and UNICEF, having been shared with the national AIDS programmes for review and comments, indicate a low limit of 28%, a high estimate of 31% and an adult HIV prevalence of 29%.276
270 USAID, Zimbabwe: HIV and AIDS health profile (September 2008).
271 Edward Rogers‘ private archives, Harare (ER), NACP and MOHCW, ―HIV, STI and AIDS Surveillance Zimbabwe,‖ Quarterly report, (January to March 1997), 2.
272 WHO, UNAIDS and UNICEF, Epidemiological fact sheet on HIV and AIDS: Zimbabwe 2008 update, (October 2008).
273 International programmes centre, ―HIV/AIDS profile, Zimbabwe,‖ Population Division, U. S Census Bureau, (June 2000). This article was accessed as a pdf.
274 USAID, Zimbabwe: HIV and AIDS health profile.
275 ER, NACP and MOHCW, ―HIV, STI and AIDS Surveillance Zimbabwe,‖ 1.
276 WHO, Epidemological fact sheet on HIV and AIDS: Zimbabwe, 4.
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In 2001 Zimbabwe had one of the worst HIV pandemics in the world. With a total population numbering 11,500,000, the number of PLHIV was estimated at 1,500,000 people nationally in 2001. The adult HIV prevalence was at 25.06%, the number of AIDS-related orphans was at 900, 000 and that of AIDS-related deaths was at 160,000. Zimbabwe ranked third position in the sub-region after Botswana and Swaziland with an adult HIV prevalence of 35.8% and 25.25% respectively.277 However, the decline of new HIV cases nationally from 29.3% in 1997 to 15.6% in 2007 occurred.278 Gregson et al. observed that in rural Manicaland, HIV prevalence in attendees at antenatal clinics dropped from 21% in the period 1998-2000 to 15% in 2003-2005, and in men, HIV prevalence fell from 19.5% to 16.5% in the same period.279 A number of factors accounted for the decline in HIV prevalence that included:
…substantial reductions in the proportion of individuals particularly men reporting non-regular partners…low proportion of men having sex without condoms with regular partners…earlier increase in condom use contributed to a fall in the HIV incidence.280
Economic meltdown led to a reduction in opportunities of travel and entertainment in a context whereby ―HIV incidence was associated with poverty in men—especially young men—from 1998 to 2003 in Manicaland, Zimbabwe.‖281 However, the findings from the study by Gregson et al. were quite unclear on how churches contributed towards the subsequent reduction in the spread of HIV.
The Government of Zimbabwe embraced the ―Millennium Development Goals,‖ an initiative of the United Nations launched in 2001. Goal six is critical for the present study as it spells out the commitment by the global family of nations to halt the spread of AIDS, malaria and tuberculosis by 2015.282 Furthermore, in 2001 member states of the United Nations signed the ―Declaration of Commitment on HIV and AIDS,‖ and
277 D. Mullins, ―Land reform, poverty reduction and HIV/AIDS,‖ Unpublished paper presented at the Southern Africa regional poverty network (SARPN), Pretoria, (4-5 June 2001).
278S. Gregson et al., ―HIV decline in Zimbabwe due to reductions in risky sex? Evidence from a comprehensive epidemiological review,‖ International Journal of Epidemiology 39 (2010), 1311. See also Halperin, ―A Surprising prevention success,‖ 2.
279 Gregson, ―HIV decline in Zimbabwe,‖ 1317.
280 Gregson, ―HIV decline in Zimbabwe,‖ 1321.
281 Lopman, ―HIV incidence and poverty in Manicaland.‖
282 UNAIDS, The 2008 report on the global AIDS epidemic, 13.