HIV/AIDS in Africa
We are facing a silent and invisible enemy that is threatening the very fabric of our society.
-Nelson Mandela, World AIDS Day Message, December 1, 2000
The magnitude of the HIV/AIDS crisis in Africa is staggering and numbing: sub-Saharan Africa, the epicenter of the AIDS epidemic, accounts for over 75 percent of those infected worldwide. Over 28 million Africans are living with HIV/AIDS, and in several countries, more than 25 percent of the adult population is infected.3 Yet, at the end of 2001, the U.N. estimated that fewer than 30,000 people were benefiting from antiretroviral drug therapy.4 AIDS has become the most important cause of death in Africa, having killed more than 18 million people since the mid-1980s. The epidemic has been concentrated particularly in East, Central and Southern Africa, though prevalence rates are now rising in West Africa. Given these grim realities, it is no wonder that former South African President Nelson Mandela described AIDS as a "war against humanity."5
Since so many of those dying from AIDS are between the ages of twenty and forty, AIDS is orphaning millions of children. Although it is impossible to get exact statistics on the numbers of children orphaned by AIDS, due in part to the stigma associated with the disease, the United Nations estimates that 13 to 15 million children under age fifteen in sub-Saharan Africa have lost one or both parents to AIDS; that number is expected to rise to 25 million by 2010.6 In addition to children orphaned by AIDS, there are many more who are caring for sick relatives, acting as breadwinners for the family, and unable to continue in school.
The secretary-general's report to the U.N. General Assembly Special Session (UNGASS) on HIV/AIDS in June 2001 put the AIDS crisis in Africa in stark terms:
Africa faces a triple challenge of daunting proportions: it must reduce new infections by enabling individuals to protect themselves and others; it must bring health care, support and solidarity to an increasingly infected population; and it must cope with the cumulative impact of millions of AIDS deaths on survivors, communities and national development.7
The U.N. Joint Programme on HIV/AIDS (UNAIDS) released data for the Group of Eight (G8) meeting in June 2002 indicating that sub-Saharan Africa's rate of economic growth has fallen up to 4 percent because of the pandemic and that labor productivity has been cut by up to 50 percent in the hardest-hit countries. "The devastating impact of HIV/AIDS is rolling back decades of development progress in Africa," said Peter Piot, executive director of UNAIDS.8
HIV/AIDS and Women and Girls
[T]o this catalogue of horrors, there must be added, in the case of Africa, that the pandemic is now, conclusively and irreversibly, a ferocious assault on women and girls. . . . The toll on women and girls is beyond human imagining; it presents Africa and the world with a practical and moral challenge which places gender at the center of the human condition. The practice of ignoring a gender analysis has turned out to be lethal.
-Stephen Lewis, U.N. Secretary-General's Special Envoy for HIV/AIDS in Africa, July 3, 2002.
Africa is the only region where women and girls outnumber men and boys among persons living with AIDS. A study released in July 2002 by the United Nations Children's Fund (UNICEF) found that in Ethiopia, Malawi, Tanzania, Zambia and Zimbabwe, "for every 15-19-year-old boy who is infected, there are five to six girls infected in the same age group."9 This disparity is present in a number of other heavily affected countries in Eastern and Southern Africa.10
There is ample evidence that gender inequality, and the resulting economic deprivation and dependency, are fueling Africa's HIV/AIDS epidemic. Stephen Lewis, the U.N. secretary-general's special envoy for HIV/AIDS in Africa, has tried to draw attention to the gender dimension of the crisis in Africa:
In a pretty fundamental way the biggest challenge is gender. It is to get the entire continent to understand that women are truly the most vulnerable in this pandemic, that until there is a much greater degree of gender equality women will always constitute the greatest number of new infections and there is such a degree of cultural oppression that has to be overcome before we really manage to deal with the pandemic. You simply cannot have millions of women effectively sexually subjugated, forced into sex which is risky without condoms, without the capacity to say no, without the right to negotiate sexual relationships. It's just an impossible situation for women and there has rarely been a disease which is so rooted in the inequality between the sexes. Therefore, gender is at the heart of the pandemic and until governments and the world understand that it will be very difficult to overcome it. . . .11
A recent study published in the medical journal The Lancet confirmed that HIV is far more prevalent in young women than young men in sub-Saharan Africa, and that having an older sexual partner is associated with increased risk of HIV infection.
It has long been suspected that younger women having relationships with older men contributes to the spread of HIV infection in young women. . . . This aspect of sexual partner networks has a pivotal role in the persistence of major HIV epidemics because not only do large segments of successive cohorts of young women become infected through this route, but many further infections result when these women marry and have children. Breaking this link in the pattern of transmission must become a central focus of HIV prevention strategies.12
In addition, the study notes that "[p]ractices such as dry sex and forced sex may magnify underlying female biological susceptibility."13 ("Dry sex" is explained below in the section "Traditional Practices.")
Young women are at a higher risk of HIV transmission than are older women because the vagina and cervix are less mature and less resistant to HIV and other STDs such as chlamydia and gonorrhea. This is linked to changes in the reproductive tract during puberty that make the tissue more susceptible to HIV transmission, and to the fact that young women produce less of the vaginal secretions that provide a barrier to HIV in older women.14 In addition, the presence of other STDs, which are highly prevalent among young people in some parts of Africa, greatly increases the risk of transmission of HIV.
The consequences of the AIDS pandemic for women and girls themselves become causal factors in further transmission. Girls are more likely than boys to be pulled out of school when a parent becomes ill, thus depriving them of the preventive impacts of a general basic education (see below). Girls frequently have to become the breadwinners of the family,15 and AIDS-affected children, including large numbers of girls, continue to swell the numbers of street children. Girls in these situations increasingly have to engage in trading sex to survive, putting them at high risk of HIV transmission.16
HIV/AIDS in Zambia
Generally, women lack complete control over their lives and are taught from early childhood to be obedient and submissive to males, particularly males who command power such as a father, uncle, elder brother or guardian. In sexual relations, a woman is expected to please her male partner, even at the expense of her own pleasure or well-being. Dominance of male interests and lack of self-assertiveness on the part of women puts them at risk. Women are taught never to refuse having sex with their husbands, regardless of the number of partners he may have or his non-willingness to use condoms, even if he is suspected of having HIV or another STD.
-Ministry of Health/Central Board of Health, "HIV/AIDS in Zambia: Background, Projections, Impacts, Interventions," September 1999
Zambia is confronting a devastating HIV/AIDS crisis. There has been an explosion in prevalence of the epidemic in the twenty years since AIDS first appeared there. With HIV/AIDS and AIDS-related infections as a leading cause of mortality in Zambia,17 adult life expectancy dropped from fifty-four years in the mid-1980s to thirty-seven years by 1998. The government has declared HIV/AIDS a national emergency.
The rate of new infection is judged by some experts to have peaked in the mid-1990s but prevalence remains high.18 HIV prevalence is now estimated at 19.95 percent in the adult population.19 The Zambian Ministry of Health reports that prevalence of HIV in urban areas is about twice as high as in rural areas, with urban prevalence among adults as high as 27.9 percent. Of Zambia's population of approximately 10 million, half are under twenty. Persons aged fifteen to twenty are thought to be the most vulnerable to HIV, albeit some recent studies (see below) attribute the decline in the rate of new infection in part to a slight decline in prevalence among young people.
These figures are estimates, rather than an accurate count, because the stigma associated with HIV/AIDS remains pervasive and is a factor inhibiting people from being tested to learn their status, while for those who go through with the test, the stigma influences whether that person decides to disclose HIV/AIDS infected status.20
The two main modes of HIV transmission in Zambia are sexual transmission and mother-to-child transmission (MTCT), with the large majority of new infections from sexual transmission. According to the National AIDS Council: "Heterosexual transmission of HIV in Zambia is dramatically increased by the presence of a sexually transmitted infection by one partner during unprotected sex, the practice of dry sex that is likely to cause ulcerations in the genital area, and unprotected sex with multiple partners."21
In its official strategy paper, the government's National AIDS Council emphasized the seriousness of the threat against young girls:
Approximately 1.75 million girls in Zambia are vulnerable to HIV and this is due to a host of socio-cultural and economic factors as well as those that are socio-biological in nature. Initiation ceremonies and practices that prepare the girl-child for marriage are common and widespread in both rural and urban Zambia. Some of these practices may increase risks associated with STD and HIV transmission. For example, among the Tonga and Bemba people of Southern and Northern Provinces respectively, instructions include lessons on how to use corrosive herbs and ingredients to dry out the vagina in order to increase male sexual pleasure. This form of sex has been earlier referred to as dry sex. . . . The practice of incest and coerced sex wherein young girls are victims are not uncommon and yet they have little or no legal recourse to addressing these matters.22
STDs are reportedly widespread among adolescents in Zambia. An obstacle to treatment of STDs that is frequently cited, especially for girls, is the attitude of health workers who have reportedly often scolded adolescents presenting with STDs and accused them of promiscuity.
As is the case elsewhere on the continent, there is a strong link between poverty and HIV/AIDS in Zambia. AIDS-affected families suffer severe financial strains related to illness and death among breadwinners and the requirements of dealing with orphans, which propel girls into risky situations to generate income. Meanwhile, circumstances of poverty in general generate high-risk behavior and make girls more vulnerable to HIV transmission, since girls are compelled to seek alternative sources of income for their families, which all too often means having to trade sex for survival. The economic downturn in Zambia, symbolized by the closing of factories and mines for copper, the country's main export, clearly increases economic pressures on all families. Dr. Gordon Bolla, the director general of Zambia's National AIDS Council, stressed the link between HIV/AIDS and poverty: "Poverty is a big issue. People say, do I live now, or do I go into the street and earn a living? A person who is so poor, who will die if he doesn't eat, will do bad things to survive."23
Regarding MTCT, infants can be infected either during pregnancy, in childbirth, or after birth through breastmilk, with the biggest percentage being infected during childbirth. The National AIDS Council estimates that the risk of MTCT was 39.5 percent in Zambia in 2000, which meant that some 30,000 infants were believed to have been born with HIV or to have become infected during breastfeeding that year.24
Social welfare indicators in Zambia paint a bleak picture of the deteriorating social and economic situation: life expectancy is down, infant mortality is up, primary school enrollment rates are down, immunization rates are down, adult literacy rates are down.25 Zambia is struggling under an enormous debt burden, aggravated by the fall in copper prices. A report by Oxfam released for the Barcelona AIDS conference in July 2002 noted that the Zambian government now spends 30 percent more on debt repayment than on health.26
Emerging positive trends and interventions
In the midst of such grim statistics, Zambia may be beginning to experience a more positive trend. A July 2002 report by UNAIDS signaled that Zambia may be one of very few countries to begin to see a decline in HIV prevalence rates, especially among young people. The report found that prevalence among young adults in urban areas had fallen from 28 percent in 1996 to 24 percent in 1999, and that prevalence among young adults in rural areas had fallen from 16 to 12 percent.27 A study released by the U.S. Agency for International Development (USAID) for the July 2002 international AIDS conference in Barcelona, documented this trend:
Recent analyses of age-specific prevalence levels show encouraging trends among 15- to 19-year olds and 20- to 25-year olds. Between 1993 and 1998, there was a 42 percent decline in HIV seroprevalance among Zambian youth 15 to 19 year old. Seropositivity rates dropped from 28 percent in 1993 to 15 percent in 1998 for the 15- to 19-year old group in Lusaka. National behavioral surveillance data indicate a reduction in reported casual sexual behavior from 17 percent in 1996 to 11 percent in 1999. The decline was validated by an external UNAIDS analysis.28
This report attributes the decline to mobilization of community and faith-based groups in awareness campaigns with a focus on young people.
The emergence of youth-friendly health services is meant to counter the failure to address STDs among young people appropriately. Designed for young people, including counseling and health education by specially trained staff, often including young people serving as "peer counselors," and featuring designated time slots during which youth get special attention, these services are thought by experts to increase the likelihood that young people with STDs will seek treatment and be present for follow-up examinations. "Youth-friendly health corners have been helpful because girls have had serious problems in going to clinics because they are seen as prostitutes. There has been a sharp rise in young people seeking treatment . . . due to these clinics," noted Elizabeth Mataka of Family Health Trust in Lusaka.29
Orphans and Vulnerable Children
Father died when I was two. I lived with my mother, but she died when I was six. Mother's sister kept me, but not very well. She didn't support me in school, so I left school in 2001. There was no one to care for me. When I was sick, she didn't care for me. I was twelve when I ran away. . . . When people wanted water, I'd fetch twenty liters. That's how I got money for food. I also sold vegetables . . . . Boys liked to chase us, sometimes they'd beat us.
-Elsie R., fourteen, interview at FLAME Orphanage, Lusaka, May 24, 2002
Zambia is facing a dramatic challenge of coping with orphans and vulnerable children (OVC). Estimates of the number of orphans vary. The U.N. has put the figure for AIDS orphans (having lost their mother or both parents) under age fifteen in Zambia at 570,000;30 others estimate that the total number of orphans and vulnerable children is one million. The 1996 Living Conditions Monitoring Survey for Zambia defined an orphan as a person eighteen or under with at least one parent dead and estimated that 13 percent of children in the country are orphans.31 Other sources estimate that the figure could rise to nearly 19 percent by 2010.32 In his address to the U.N. General Assembly Special Session on Children in May 2002, Zambia's President Levy Mwanawasa stated that 44 percent of Zambian households have taken in orphans.33
The enormous numbers of children from AIDS-affected families are in very difficult circumstances, even before they lose a parent. As Brenda Yamba, project manager for SCOPE-OVC (Strengthening Community Partnerships for the Empowerment of Orphans and Vulnerable Children) in Zambia, put it: "They suffer the trauma of neglect, the trauma of watching their parents get sick, the trauma of knowing they will die."34 Stigma remains pervasive, and-as it affects the family of the infected person as well as the individual-children are often stigmatized because of their parent's status, even before the parent dies.
Given the dimensions of the AIDS crisis in Zambia, it is clear that many children from AIDS-affected families are at risk of contracting HIV. An analysis of the situation of orphans and vulnerable children in Zambia undertaken by the Zambian government in cooperation with USAID, UNICEF and the Swedish International Development Agency (SIDA) painted a grim picture of the problems confronting orphans and vulnerable children. It reported that some 4.1 million children below the age of eighteen live in Zambia, with almost three quarters living below the poverty line. The report estimated that 86 percent of orphans were single orphans, 64 percent of them had a deceased father, 22 percent had a deceased mother, and 14 percent were double orphans.35 The report described the crisis:
Currently, Zambia faces a silent crisis. The suffering of orphans and vulnerable children is contained within the confines of the family and the community. Daily, children suffer from malnutrition and childhood illnesses. Their suffering is seldom seen outside their immediate surroundings, while those not affected continue without knowledge of the growing crisis and the pending impact the crisis will have on the country as a whole. . . . Increasingly, growing numbers of street kids are seen in the hubs of Zambia's urban centers. Young boys fight to carry parcels to earn a few hundred kwacha,36 they guard cars day and night to earn extra money. Increasingly, young girls and boys sell their bodies in exchange for food. The daily pains of life are worn on the faces and seen in the eyes of many children in Zambia.37
Girls, particularly orphans, are often used to perform domestic service. For that reason, girl orphans are more likely than boys to be taken in by relatives or other families, a setting in which they are vulnerable to sexual abuse (as detailed below). There are also potential incentives, since the families hope to marry off the girl and receive the lobola or bride price.38
Girls are very disadvantaged in our environment. It's not an accident; the reasons are known. Zambia is a culture of men.
-John Zulu, director, Child Affairs Department, Ministry of Sport, Youth, and Child Development, Lusaka, May 30, 2002
Within Zambia, many traditions and practices impede efforts to tackle HIV-related issues. Deep-rooted cultural taboos inhibit parents from discussing sex with their children, and create obstacles to effective sex education.39 "Culture has an incredible influence," said Caroline Chanda of Kara Counseling. "That's why we barely talk about HIV."40 Moreover, some of the diverse range of traditional practices among Zambia's seventy-three ethnic groups put girls at heightened risk of HIV infection. Formulating appropriate prevention strategies depends on an understanding of these practices. As Elizabeth Mataka of Family Health Trust put it: "Any prevention strategy has to be culturally sensitive. We have to begin to break down barriers."41
The government of Zambia acknowledges that the key underlying cultural factor that makes girls vulnerable to HIV is the subordinate status of women and girls, which deepens their social and economic dependency on men.42 Just as described by UN Special Envoy Stephen Lewis in his Africa-wide analysis, Zambian girls are raised to be obedient and submissive to males and not to assert themselves. These ingrained tendencies make it extremely difficult to negotiate safe sex and to control their sexual lives and therefore place them at high risk of HIV transmission. In a commentary on the government's report on the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), a group of women's NGOs noted:
HIV/AIDS has a special gender dimension. First, women who are married are at the greatest risk of infection because of male promiscuity which is tolerated by social and cultural norms. There are no criminal or civil sanctions for HIV transmission. It is not covered by the Public Health Act, which seeks to contain and regulate infectious diseases. Traditionally, men cannot commit adultery except with another man's wife. Safe sex is rarely practiced within marriage. Traditional practices which contribute directly to high levels of HIV transmission are not prohibited.43
Beyond women's subordination, there are a number of traditional practices that take on added risks in the era of HIV/AIDS.
Sexual cleansing is a practice whereby a widow has sex with another man following the death of her husband. This may affect adolescent girls as well as women since there is no minimum marriage age for women or girls under customary practices. This "cleansing" is meant to purge the husband's spirit from his wife. The National AIDS Council described it as "very common and prevalent," and explained that:
To be purged of the "evil forces" assumed to have caused the death of a spouse, the widow or widower is "cleansed" through the act of sexual intercourse with a relative of the deceased. Closely related to the issue of ritual cleansing is the notion of wife inheritance whereby close relatives take over the widow or widower. Both practices are insisted on irrespective of the HIV status of the person appointed to perform these rituals.44
Given the AIDS epidemic, the dangers of this practice are apparent since a woman whose husband died from AIDS would in many cases be infected herself. Human Rights Watch was told about one man who was always the one in his community who volunteered to cleanse the widow after the funeral. Not surprisingly, he is dead now, apparently due to HIV/AIDS.45
Some observers say the practice of sexual cleansing has been misunderstood. Mulenga Kapwepwe, a consultant on adolescent health, explained it this way: "Sex is seen as a potent force, traditionally. It creates a bond that can't be broken easily. In our tradition, there were so many rules we followed, especially about sex. . . . When the other party died, that bond had to be broken by someone else, to free you of that bond. It had to be a relative . . . . [But] you can wreck communities if these practices are used or abused."46
Despite information both in government documentation of the AIDS crisis and in materials disseminated by counselors and AIDS outreach workers about the risks associated with sexual cleansing, it is not easy for a woman to refuse to participate in such practices, especially in rural areas. A group of HIV-positive women told Human Rights Watch that more women are at least attempting to refuse to comply with the practice. However, by doing so, they make enemies with the family, who then might refuse to support them.47 The consequences of being rejected by the family are severe, given a woman's economic and social dependency.
In certain parts of southern Africa, including Zambia, so-called "dry sex" is frequently practiced whereby girls and women attempt to dry out their vaginas in an effort to provide more pleasurable sex to men.48 As alluded to above, the dryness is achieved by using certain herbs and ingredients that reportedly reduce vaginal fluids and increase friction during intercourse. Given the likelihood that dry sex will cause tears and lacerations in the vaginal wall, especially among adolescent girls, the practice clearly increases the risk of HIV transmission.49 A 1999 report by the Zambian Ministry of Health and the Central Board of Health stated: "to enhance male pleasure, a number of women continue to practice dry sex, which can increase vulnerability to infection through exposing genital organs to bruising and laceration."50
While the practice is being discouraged by counselors working with young people and in official government documents, it is hard to know whether it is on the decline. "Like condoms, it is difficult to say if people follow what they know," noted Brenda Yamba of SCOPE-OVC.51 AIDS educators discuss the dangers of dry sex in outreach programs, explaining that it is an easy way to transmit HIV. But, as one counselor told Human Rights Watch, "Men love dry sex. If you're wet, they think it's not normal. So we talk about it in outreach; we say `stop eating those herbs.'"52
Counselors at the YWCA drop-in center, one of the main NGOs providing counseling for abused girls, explained that girls are made to believe that they are supposed to be dry. There is even a name given to girls who are too wet-Chambeshi River, referring to a river in Zambia.53 Some men tell girls that being wet means that they have been with too many men. Service providers working with sex workers noted that they do not generally practice dry sex; rather, it occurs more in "stable" unions where the girl or woman is seeking to maintain the relationship.54
Some observers also noted that the preeminence of men's sexual pleasure is a feature of the initiation ceremonies undergone by Zambian girls in some ethnic groups.55 In these rituals, which are meant to prepare girls for marriage and teach them about sex and child-bearing, a girl may be taught to focus on the man's sexual pleasure and not to refuse her husband's demands for sex. Still, some traditional leaders are becoming sensitized to the need to integrate HIV/AIDS education into these ceremonies.56
3 UNAIDS, "Report on the Global HIV/AIDS Epidemic 2002," (Geneva: July 2002), pp. 8, 14.
4 Ibid., pp. 22-23.
5 British Broadcasting Corporation (BBC) News, "Mandela calls for end to Aids stigma," July 12, 2002.
6 USAID/UNICEF/UNAIDS, "Children on the Brink 2002," p. 3. Available at www.unaids.org/barcelona/presskit/childrenonthebrink/introduction.pdf (retrieved July 15, 2002).
7 United Nations General Assembly, "Special Session of the General Assembly on HIV/AIDS: Report of the Secretary-General," February 16, 2001, p. 5.
8 UNAIDS, "UNAIDS releases new data highlighting the devastating impact of AIDS in Africa," Geneva, June 25, 2002.
9 UNICEF, UNAIDS, World Health Organization (WHO) press release, "Major UN study finds alarming lack of knowledge about HIV/AIDS among young people," July 2, 2002. Available at www.unicef.org/newsline/02pr42opportunity.htm (retrieved July 15, 2002).
10 "Special Session of the General Assembly on HIV/AIDS," p. 7.
11 U.N. Integrated Regional Information Network (IRIN), "Interview with Stephen Lewis, U.N. Special Envoy for HIV/AIDS," December 3, 2001.
12 Simon Gregson, Constance A. Nyamukapa, Geoffrey P. Garnett, Peter R. Mason, Tom Zhuwau, Michel Caraël, Stephen K. Chandiwana, Roy M. Anderson, "Sexual mixing patterns and sex-differentials in teenage exposure to HIV infection in rural Zimbabwe," The Lancet, Vol. 359, June 1, 2002, p. 1901.
13 Ibid., p. 1902. "Dry sex" refers to a traditional practice by women to use herbs to dry their vaginas to enhance the sexual pleasure of a male partner.
14 The Population Information Program, Center for Communications Programs, The Johns Hopkins University Bloomberg School of Public Health, "Population Reports: Youth and HIV/AIDS," Volume XXIX, Number 3, (Baltimore, MD, Fall 2001), p. 7.
15 Ministry of Health/Central Board of Health, "HIV/AIDS in Zambia: Background, Projections, Impact, Interventions," (Lusaka: September 1999), p. 51.
16 National HIV/AIDS/STD/TB Council, "Strategic Framework 2001-2003," (Lusaka: October 2000), p. 10.
17 National AIDS Council, p. 1.
18 Ministry of Health/Central Board of Health, p. 13.
19 UNAIDS and the World Health Organization, "Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections - Zambia, 2000 Update (Revised)," p. 3.
20 National AIDS Council, p. 4.
21 National AIDS Council, p. 2.
22 National AIDS Council, p. 9.
23 Human Rights Watch interview with Dr. Gordon Bolla, director general, National HIV/AIDS/STD/TB Council, Lusaka, May 30, 2002.
24 National AIDS Council, p. 2.
25 Sources: World Bank Development Indicators, Living Conditions Monitoring Survey Report 1996 and Living Conditions Monitoring Survey 1998.
26 Oxfam-UK, "Debt relief and the HIV/AIDS crisis in Africa," Briefing Paper no. 25, July 9, 2002.
27 U.N. IRIN, "Africa: Report on Global HIV/AIDS Epidemic - UNAIDS," Johannesburg, July 2, 2002.
28 USAID, "HIV/AIDS in Zambia: A USAID Brief," July 2002.
29 Human Rights Watch interview with Elizabeth Mataka, executive director, Family Health Trust, Lusaka, May 20, 2002.
30 UNAIDS, "Report on the global HIV/AIDS epidemic 2002," (Geneva: July 2002), p. 190. The USAID/UNICEF/UNAIDS report released for the Barcelona AIDS conference, Children on the Brink 2002, defines orphans as children under fifteen who have lost one or both parents.
31 Government of the Republic of Zambia, "Orphans and Vulnerable Children: A Situation Analysis, Zambia 1999," Joint USAID/UNICEF/SIDA Study Fund Project, November 1999, p. 151.
32 The World Bank ACTafrica, "Exploring the Implications of the HIV/AIDS Epidemic for Educational Planning in Selected African Countries: The Demographic Question," March 2000, p. 7.
33 Brian Saluseki, "HIV/AIDS has continued to rob Lusaka of its People - Levy," The Post, May 10, 2002.
34 Human Rights Watch interview with Brenda Yamba, project manager for SCOPE - OVC, Lusaka, May 18, 2002.
35 "Orphans and Vulnerable Children," p. 9.
36 The kwacha is Zambia's currency, currently exchanged at about 4300 to the U.S. dollar.
37 Government of the Republic of Zambia, "Orphans and Vulnerable Children: A Situation Analysis, Zambia 1999," Joint USAID/UNICEF/SIDA Study Fund Project, November 1999, p. 8.
38 Human Rights Watch interview with James Gutinyu, director, Messiah Ministries Orphanage, Lusaka, May 19, 2002; Human Rights Watch interview with Grace Muzyamba, Director Social Welfare, Ministry of Community Development, Department of Social Welfare, Lusaka, May 30, 2002.
39 Human Rights Watch interview, May 20, 2002; Human Rights Watch interview, May 18, 2002; Human Rights Watch interview with Judge Lombe Chibesakunda, chair of the National Human Rights Commission, Lusaka, May 30, 2002.
40 Human Rights Watch interview with Caroline Chanda, training manager, Kara Counseling, Lusaka, May 17, 2002.
41 Human Rights Watch interview with Elizabeth Mataka, Lusaka, May 20, 2002.
42 Republic of Zambia, Gender in Development Division, Office of the President, "National Gender Policy," (Lusaka: March 2000), p. 2, 9-11; Ministry of Health/Central Board of Health, "HIV/AIDS in Zambia: Background, Projections, Impacts, Interventions," (Lusaka: September 1999), p. 49.
43 Women in Law and Development in Africa (WILDAF)-Zambia, "NGO Commentary on the Government of Zambia Combined Third and Fourth Report on the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW)," (Lusaka: May 2002), p. 15.
44 National AIDS Council, p. 10.
45 Human Rights Watch interview at Umoya, May 22, 2002.
46 Human Rights Watch interview with Mulenge Kapwepwe, Lusaka, May 24, 2002.
47 Human Rights Watch interview with members of Positive and Living Squad (PALS), Lusaka, May 23, 2002.
48 National AIDS Council, p. 9.
49 National AIDS Council, p. 9.
50 Ministry of Health/Central Board of Health, p. 49.
51 Human Rights Watch interview, May 19, 2002.
52 Human Rights Watch interview with women from PALS, Lusaka, May 23, 2002.
53 Human Rights Watch interviews with counselors at YWCA, May 20, 2002.
54 Human Rights Watch interview with Professor Nkandu Luo, Lusaka, May 21, 2002.
55 Kamuwanga Chaze, "A study to determine how cultural practices and beliefs influence the spread of HIV/AIDS in Lusaka," a research study submitted to the University of Zambia, School of Medicine, Department of Post Basic Nursing, December 2000, p. 18.
56 Human Rights Watch interview, May 18, 2002.