V. HIV/AIDS Epidemic in Zimbabwe
Zimbabwe has one of the highest HIV prevalence rates in the world,36 with 20% of these aged 15-49 living with HIV or AIDS. An estimated 1.6 million Zimbabweans37 out of a total population of 12.9 million38 are living with HIV and AIDS. According to 2005 National Estimates from the Ministry of Health and Child Welfare, one hundred and fifteen thousand (115,000) of the people living with HIV/AIDS are children under the age of 15.39 In 2005, 162,000 Zimbabweans were newly infected with HIV and 169,000 Zimbabweans died of AIDSmore than 3,000 each week.40
More than half of all new infections are estimated to occur among young people aged 15-24. In this age group it is estimated that the ratio of young women living with HIV to young men living with HIV is three to one.41 According to UNAIDS, HIV infections among young people were concentrated among orphans with female double and maternal orphans most vulnerable.42
HIV/AIDS experts have suggested that a number of specific populations and locations within Zimbabwe have increased rates of HIV prevalence. HIV prevalence surveys have shown higher levels of infections in border areas, growth points (rural development towns or centers), mining towns, and commercial farms.43 There is also evidence that HIV prevalence is elevated in roadside trading centers along major highways44 suggesting mobility and spousal separation as major vulnerability factors. The military is believed to have a high prevalence of HIV and a 1998 UNAIDS45 report states that prevalence among military personnel was three to four times higher than the civilian population.
Tuberculosis is the leading cause of death for those living with HIV/AIDS in Zimbabwe. Of the 74, 000 cases of all forms of tuberculosis in 2000, about 30,000 (41%) were attributable to HIV.46
Women have been recognized as a high risk population for HIV worldwide. According to the World Health Organization, women in Zimbabwe are disproportionately affected by AIDS, constituting 51 percent of the population and 53 percent of people living with HIV/AIDS in 2003.47 National AIDS estimates show that the majority of new cases (57%) and deaths (58%) in 2005 were also women.48
In Zimbabwe like many other countries in the region, women are vulnerable to HIV/AIDS for a number of reasons including: the greater statistical probability of male to female transmission; a lack of protection against prejudicial cultural and traditional practices in sexual and reproductive health matters and relationships that restrict their decision-making; low incomes that make them more vulnerable to unsafe sexual practices such as forced and unprotected sex and prostitution; and laws that do not give them equal rights.49
A key driver of the HIV/AIDS epidemic in Zimbabwe is the combined effect of poverty and inequality among women. According to a 1995 Poverty Assessment Study Survey (PASS) by the government of Zimbabwe, female-headed households constituted the majority of households living in poverty.50 Their level of poverty is likely to make them more vulnerable to HIV infection and less able to respond effectively to its consequences. Because female-headed households are more vulnerable to poverty, they are susceptible to particular livelihood strategies that open them to the risk of HIV infection.
In rural areas women generally have lower education levels than men and as a result they have limited capacity to access new technology and knowledge to enhance their productivity. Women are very often the main caregivers for those with AIDS and their dependants. They have limited means of negotiating the fidelity or condom use of their partners, or of accessing and negotiating their own female condom use. Women who are infected die at an earlier average age.51
The government of Zimbabwe has had some success in preventing the spread of HIV/AIDS. According to UNAIDS, the 2004 Ante Natal Care (ANC) surveillance report by the Ministry of Health and Child Welfare52 suggests that HIV prevalence has declined over recent years, with substantial declines in HIV prevalence in the 15-44 year-old (from 32% to 24%) and 15-24 year-old (29% to 20%) age-groups over the period 2000 to 2004. Results from a comprehensive epidemiological data review done by UNAIDS which drew upon diverse studies (including studies of postnatal women in Harare, and general population data from Manicaland) suggested that HIV prevalence has declined over the period 2000-2004, but cautioned that it was possible that the decline is less pronounced than is indicated by the national antenatal surveillance data.53
While rising adult mortality occurring from the early-and mid-1990s contributed to the declining HIV prevalence, the authors of the UNAIDS review suggest that in Harare and rural Manicalandthe parts of the country for which the most comprehensive and detailed data are availableadult mortality appears to have stabilized, albeit at extremely high levels. The report states that a substantial increase in condom use with non-regular partners and an increase in faithfulness have contributed to the decline, and that in research from Manicaland recent delays in onset of sexual activity, reductions in rates of sexual partner change and, for women with high rates of partner change, further increases in consistent condom use.54 Despite the decline it is important to note that underlying vulnerabilities such as gender inequality, population mobility, poverty and human rights abuses, which contribute to unsafe sexual behavior, adversely affect treatment and services and fuel the pandemic, remain of serious concern.
A recent study by the Zimbabwe Economic Policy Analysis and Research Unit found that the HIV/AIDS epidemic has significantly weakened Zimbabwe's economy, hindering economic growth from 1994 to 2003 by 13.3%.55 In addition, HIV/AIDS is eroding the country's workforcecomposed of people ages 15 to 49as well as national savings and investments, which now have to be spent on controlling the disease. The epidemic is also fueling food insecurity by decreasing production and productivity.56
The loss of many small-scale and subsistence farmers to AIDS and the high level of AIDS-related morbidity have contributed to reduced food security at household level and to lower productivity overall.57
The epidemic has resulted in a sharp increase in the burden of disease. About three hundred and fifty thousand of the 1.6 million carrying the virus need ARVs and six hundred thousand may need some care and support.58 In 2003, UNICEF estimated that the number of orphans were 1.3 million59 (about 19% of the child population) about 1 million of them AIDS orphans. Recent national and sub-national surveys suggest that the number of orphans may even be higher. In 2004, a Ministry of Public, Labour and Social Welfare/ UNICEF Orphans and Vulnerable Children (OVC) Survey 2004 found that 30% of the child population in the rural and urban high density regions of Zimbabwe was orphans.60
In terms of the health sector, HIV/AIDS has also increased health expenditures. Over 70% of admissions to medical wards in Zimbabwes major hospitals are patients with HIV and AIDS related opportunistic infections such as tuberculosis and other pneumonias.61
The availability of medical care provided by government and NGOs for PLWHA has increased in the past few years due to efforts to scale up access to treatment, but does not begin to meet the needs of the population. Voluntary Counseling and Testing (VCT) programs are expanding and administered free of charge or for a small nominal fee. One month of ART without additional tests costs approximately Z$500,000 (US$ 5) per month in the public sector and between Z$ 2-6 million (US$ 20-60) per month in the private sector.62
In 2006, Zimbabwe announced a rapid scale-up of ARV delivery (with a goal of more than 300,000 people on ARV drugs by 2010),63 but only about 23,000 out of the 350,000 Zimbabweans in need of ART are currently being treated with ARV drugs. 64 On June 16, 2006 the Minister of Health and Child Welfare David Parirenyatwa, speaking at a workshop on HIV/AIDS indicated that the government aims to have 40,000 more people on ARV drugs by the end of 2006 if the country receives more money from the Global Fund to Fight AIDS, Tuberculosis and Malaria.65 More recent reports indicate that the government is actually aiming for 70,000 people on ARV drugs by the end of the year.66
In August 2005, more than 200 facilities in the country were providing Preventing Mother-To-Child Transmission (PMTCT) services.67 Many more patients are benefiting from active and prophylactic treatment against opportunistic infections. In most cases patients are required to pay for prescription drugs or antibiotics although treatment for tuberculosis is free. Shortages of prescription drugs often mean that patients are forced to buy them from pharmacies at increased cost.68
Some doctors and health experts expressed the concern to Human Rights Watch that HIV/AIDS treatment programs within the NGO sector are now operating at full capacity.69 They cite the limited capacity within the health sector for adequate medical follow-up of large numbers of HIV/AIDS patients due to massive emigration of trained healthcare staff.
Additionally, the hike in private hospital fees has put an extra burden on the public health sector. Doctors in the public sector and the NGO sector told Human Rights Watch that due to increasing costs many Zimbabweans accessing ARV drugs in the private sector were moving to the public sector to access subsidized government treatment programs because they could no longer afford treatment in the private sector.70 To ensure their adherence to the ARV drugs, health workers had no option but to put them to the front of waiting lists so that they could continue their treatment without disruption.
A lack of foreign currency has led to interruptions in the importation of raw materials for the local production of ARV drugs and resulted in shortages of ARV drugs in the countrys major hospitals. For example one generic ARV drug, Stalanev had limited supplies available through the government sector for a period of several months in 2005.71 In May 2006, the director of the para-statal national pharmacy board reported that there was a one-month supply of ARV drugs available in the country, and that the Reserve Bank was refusing to release previously agreed-upon supplies of foreign currency needed to import anti-retroviral medicines or raw materials.72 Shortages of ARV drugs contributed to Zimbabwes failure to reach the goal it set (as part of the WHO 3x5 initiative)73 of 120,000 people on treatment by December 2005, by nearly 100,000 people reporting just 23,000 on therapy.74 Interruptions in ART by PLWHA can lead to both deteriorating health conditions and can contribute to the spread of drug resistant strains of the virus.
 UNICEF, Background country report, Zimbabwe, http://unicef.org/infobycountry/zimbabwe_1403.html (accessed June 13 2006).
 UNAIDS, Zimbabwe National HIV/AIDS Estimates 2005, Preliminary Report, http://www.unaids.org.zw/unaids_documents/2004Estimatesprelim.pdf (accessed June 12, 2006).
 World Bank, 2006 development indicators, http://devdata.worldbank.org/wdi2006/contents/Section2.htm (accessed June 13, 2006). Officially Zimbabwes population is reported to be almost 13 million although actual population figures are considered to be quite low with reports of almost 3 million Zimbabweans having left the country because of the political and economic environment.
 UNAIDS, Zimbabwe National HIV/AIDS Estimates 2005, Preliminary Report.
 Advancing the human rights approach to HIV and AIDS in Zimbabwe, Presentation, by Hege Waagan, UNAIDS Social Mobilization Adviser, for the launch of the Zimbabwean HIV/AIDS Human Rights Charter, Harare, May 27, 2006, http://www.unaids.org.zw/unaids_documents/27may06.pdf (accessed June 26, 2006). Double orphans are children who have lost both their parents while maternal orphans are children who have lost their mothers. See UNICEF, Children on the brink 2004, factsheet, http://www.unicef.org/aids/files/COB_2004_fact_sheet.doc (accessed July 14, 2006).
 J. Decosas and N. Padian, The profile and context of the epidemics of sexually transmitted infections including HIV in Zimbabwe, Sex Transm Infect., 2002, (Suppl 1):i40-6.
 Poverty Reduction Forum, Zimbabwe Human Development Report 2003, Redirecting our responses to HIV and AIDS Towards reducing vulnerability the Ultimate War for Survival, (Harare: Poverty Reduction Forum, Institute of Development Studies University of Zimbabwe, 2004); UNAIDS, AIDS and the Military, UNAIDS Best Practice Series. May 1998.
 Global Fund to Fight AIDS, Tuberculosis and Malaria, Government of Zimbabwe proposal to the Global Fund To Fight AIDS, Tuberculosis and Malaria, January 31, 2002, GFATM/B1/6A.
 World Health Organization, Summary country profile for HIV/AIDS Treatment Scale Up, June 2005.
 UNAIDS, Follow-up to the Declaration of Commitment on HIV/AIDS (UNGASS),Zimbabwe Country Report, Reporting period: January 2003 December 2005, http://data.unaids.org/pub/Report/2006/2006_country_progress_report_zimbabwe_en.pdf (accessed June 12, 2006).
 Poverty Reduction Forum, Zimbabwe Human Development Report 2003, pp. 6 9.
 Ministry of Public Services, Labour and Social Welfare, Poverty Assessment Study Survey (1995), Government of Zimbabwe,1995.
 UNDP, Development Planning and HIV/AIDS in sub-Saharan Africa, Zimbabwe, 2004, http://www.sarpn.org.za/documents/d0001371/AIDS_Dev_July2004-Zimbabwe.pdf (accessed June 24, 2006), p. 135.
 UNAIDS, Evidence for HIV decline in Zimbabwe: a comprehensive review of the epidemiological data, November 2005, http://data.unaids.org/publications/irc-pub06/zimbabwe_epi_report_nov05_en.pdf (accessed June 13, 2006) p. 11.
 Ibid. p. 43.
 Ibid., p. 39.
 Global Challenges, HIV/AIDS Has Significantly Weakened Zimbabwe's Economy, Study Finds, June 19, 2006, http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=37969 (accessed June 19, 2006).
 FAO, Special Report Zimbabwe, July 2005, http://www.sarpn.org.za/documents/d0000854/P971-FAO_Zimbabwe_5July2004.pdf (accessed July 6, 2006) p. 5.
 Follow-up to the Declaration of Commitment on HIV/AIDS (UNGASS), p. 8.
 UNICEF, Zimbabwe statistics, http://www.unicef.org/infobycountry/zimbabwe_statistics.html#18 (accessed June 12, 2006).
 Follow-up to the Declaration of Commitment on HIV/AIDS (UNGASS).
Ibid. p. 7.
 Human Rights Watch interviews with medical personnel, Harare and Bulawayo, April 17 May 2 2006.
 Ministry of Health and Child Welfare, Zimbabwe National HIV/AIDS and Strategic Plan pre-final draft, 2006-2010, April 2006.
 UNAIDS, Zimbabwe National HIV/AIDS Estimates, 2005.
 Global Fund to bankroll ARV scale-up, IRIN PlusNews, July 10, 2006, http://www.plusnews.org/AIDSreport.asp?ReportID=6140 (accessed July 12, 2006).
 USAID, Zimbabwe HIV & AIDS Logistic Systems Assessment, January 2006, http://www.synergyaids.com/documents/ZIMBABWE-HIV-AIDS-LIAT1.pdf (accessed June 26, 2006) p. 5.
 See Zimbabwe faces AIDS drug shortage, BBC news online, May 3, 2006, http://news.bbc.co.uk/2/hi/africa/4969228.stm (accessed May 3, 2006); Human Rights Watch interviews with PLWHA, Harare and Gweru, April 17 May 2 2006.
 Human Rights Watch interviews with doctors and health experts, Harare and Bulawayo, April 17 May 2 2006.
 Zimbabwe faces AIDS drug shortage, BBC news online.
 The World Health Organization 3 by 5 initiative was launched by WHO and UNAIDS in 2003 as a global target to provide three million people living with HIV/AIDS in low and mid-income countries with life-prolonging antiretroviral treatment by the end of 2005.