ZAMBIA

Moses Sichone and Doreen Mulenge

Background

Zambia has a population of about 8.5 million people and a GNP per capita of US$400 per year. The first case of AIDS was reported in 1984. The epidemic was initially located in the urban areas but rapidly spread to all parts of the country. The national HIV prevalence is estimated at 20%, with urban areas having two times higher prevalence than rural areas.

National response

The government established a national AIDS control programme in 1986 with assistance from WHO/GPA. After the initial short-term plan for blood safety, mid-term plans were developed for 1988-92 and 1993-98. A mix of interventions including promotion of safer sexual behaviour, blood screening, and STD control are implemented. A condom social marketing programme was launched in 1992. A network of 62 STD clinics in different districts has been established. The STD and tuberculosis and leprosy programmes ha ve been combined with the AIDS programme.

In the context of the recent health sector reforms in Zambia many responsibilities have been delegated to the districts. Monitoring and evaluation now lies with only one person at the national level.

Monitoring and evaluation

Local and external reviews are used to assess the extent to which the national programme has achieved its goals.

The national AIDS programme has developed a core epidemiological surveillance and research system. This includes national sentinel surveillance in antenatal clinics, population-based surveys (with saliva based HIV testing), hospital notification of AID S cases and small-scale research studies. In 1994, a large national survey of antenatal women was carried out. The repeat survey in 1996 was delayed because of government procedures for procurement of test kits and will now take place in 1998. Donors fund most surveillance activities. In 1991, a prevention indicator survey was completed in Lusaka. Zambia had a national DHS with extensive sexual behaviour data in 1996 and has just completed a national survey on sexual behaviour using an extended version of the WHO/GPA protocol.

The small scale published and unpublished research studies have been collated into an annotated bibliography. The impact of the research studies on policy is considered to be small despite the occurrence of several (ad hoc) dissemination workshops orga nized by the AIDS programme.

Input, output and context

There is a paucity of data on actual expenditure for STD control. Monitoring of condoms distributed is done by medical stores and since 1996 about 25 million condoms have been distributed.

Several studies have evaluated the effectiveness of condom promotion. There are data on numbers of health workers trained but because multiple organizations may carry out training no complete data are available. Studies have also evaluated the implemen tation of the syndromic approach in specific areas. A national evaluation using PI 6 and PI 7 has just been completed. All blood is supposedly screened for HIV and other pathogens, but there is no quality control system in place. Knowledge levels have bee n assessed in the 1992 and 1996 DHS survey and were found to be high.

Proximate determinants

Self-reported data on sexual behaviour and condom use are available from the national DHS survey in 1996 and a number of local surveys, some of which are large (e.g. 1994 survey in Lusaka and one district). A repeat survey in Lusaka in 1995 showed sign ificant changes in sexual behaviour, including increased condom use and reduction of the number of sexual partners.

HIV and STD

Twenty two antenatal clinics are involved in the HIV monitoring system, but multiple HIV prevalence estimates at different points in time are currently available for only 10 clinics. In 1998, all 22 clinics will provide HIV data and can be compared wi th 1994. A comparison of population based and antenatal clinic data on HIV prevalence showed that antenatal data underestimate HIV prevalence in women over age 20 and overestimate prevalence in younger women.

Most STD prevalence data are obtained from outpatient clinics and the 64 specialized centres. Since 1996 no national data are readily available. Some data are available on syphilis prevalence among pregnant women from HIV monitoring sites.

AIDS impact mitigation

There is considerable underreporting of AIDS case by hospitals. There are number of small scale studies documenting the socioeconomic and household impact of HIV/AIDS and evaluating the effects of home and community-based care. Studies before 1996 are annotated in the bibliography.

Conclusion

During the past decade a range of monitoring and evaluation activities have been undertaken by the AIDS programme. This has provided a fairly good database on HIV/AIDS, and to a lesser extent on other STDs, but continuity is still limited. Zambia has s ufficient data to assess trends in self-reported sexual behaviour and these trends suggest significant changes. It is not clear however to what extent these changes can be attributed to interventions or whether they changes have led to reduced HIV or STD incidence.

Zambia is one of the few countries in which the AIDS and TB programmes are combined, but has not been able to show apparent benefits of this merger. Decentralization in the context of health sector reform has adversely affected monitoring and evaluati on. There is a need for establishing systems to disseminate information, e.g. resource centres in provinces and districts, to improve data dissemination and use.