Since the start of 2000 the global response to HIV/AIDS pandemic has seen much-needed improvement. In 2000 the G8 countries acknowledged the need for resources to combat HIV/AIDS, and African leaders confirmed this need for resources in Abuja in 2001. The United Nations General Assembly Special Session (UNGASS) on HIV/AIDS in 2001 concluded with a firm commitment to create a global fund to fight HIV/AIDS. World leaders made commitments in the Millennium Development Goals (MDGs) to promote gender equality and empower women (MDG 3) and to combat HIV/AIDS, malaria, and other diseases (MDG 6) by halting and beginning to reverse the spread of HIV by the year 2015. Significant initiatives have been launched and significant resources mobilized to fight the pandemic and rollout treatment.
In September 2003 the World Health Organization (WHO) and UNAIDS launched the 3 by 5 initiative, aiming to have three million people in need of HIV treatment on ARVs by the end of 2005. This included two million people in the African continent, and 1,297 million people in East and Southern Africa.240 In 2003 the US government created the Presidents Emergency Plan for AIDS Relief (PEPFAR). All these initiatives and political commitments enabled countries in the global South with sufficient political will to roll-out HIV treatment.
In 2005 leaders of the G8 pledged to work with WHO, UNAIDS, and other international bodies to develop and implement a package for HIV prevention, treatment, and care for all those who need it by 2010. Member States of the UN endorsed this goal at the High-Level Plenary Meeting of the UNGASS in September 2005. At the UNGASS High-Level Meeting on AIDS in 2006, the states agreed to work toward the goal of universal access to comprehensive prevention programs, treatment, care, and support by the year 2010.241
The gender dimensions of HIV/AIDS in Southern Africa, the sub-region most affected by the pandemic, received relatively better attention, thanks, among other factors, to advocacy by womens NGOs and concerned UN personnel: the former UN special envoy for HIV/AIDS in Africa, Stephen Lewis, and the executive director of the World Food Program, James Morris,242 recommended urgent action in addressing the gender dimensions of HIV/AIDS in Southern Africa.243 In response the former UN Secretary-General established a task force on women, girls and AIDS in Southern Africa to focus on improving the response to HIV/AIDS in nine countries of the sub-region, including Zambia. The task force focused on six areas, including property and inheritance rights, and violence against women and girls.244
The global political commitments to address HIV/AIDS translated into increasedalthough not sufficientfinancial resources. In turn, the number of people receiving ART in Africa grew from just 100,000 in 2003, to over one million by December 2006.245 Resources from the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria (Global Fund), PEPFAR, and other bilateral, multilateral, and private donor resources, played a major role in this increase in the number of people receiving treatment.
The rest of this chapter outlines the role of the two largest contributors to Zambias HIV treatment programs, namely the United States (US) government and the Global Fund in responding to some of the abuses described in this report.
The United States
The US government is one of the major donors in Zambia, particularly in the area of HIV/AIDS, including support for HIV treatment programs through PEPFAR.246 Under PEPFAR Zambia received more than US$81.6 million in 2004, about $130.1 million in 2005, and approximately $149 million in 2006 to support HIV/AIDS prevention, treatment and care programs. 247 PEPFAR is providing $216 million in fiscal year 2007.248 Funds are disbursed to partner organizations and sub-partners and are used to cover a wide range of HIV services and activities.
In its various documents, the Office of the US Global AIDS Coordinator (OGAC), which coordinates PEPFAR, recognizes the importance of adopting service delivery models that potentially reduce client risk of gender-based violence, and also of supporting interventions that enhance womens decision-making power in the private and public spheres. 249 However, a number of international AIDS advocacy organizations have criticized PEPFARs response to gender-based violence.250
In terms of addressing gender-based violence and other abuses in Zambia, officials in the major US agencies tend to link their program interventions to the White House Womens Justice and Empowerment Initiative (WJEI). Announced by the US president in June 2005, WJEI is a $55 million initiative that aims to support ongoing activities to promote womens empowerment and their access to justice in four African countries, including Zambia.251 The initiative is supposed to strengthen the capacity of the legal system so it can protect women through training of the police, prosecutors, and judges in areas of gender-based abuses, including sexual violence. The initiative also aims to strengthen laws that protect women, such as the Sexual Offences and Gender Violence Bill in Zambia, improve the capacity of shelters, and address womens health needs.252 According to the US State Department, WJEI funds will help raise awareness about gender-based violence, protect and assist victims of rape and domestic violence, and bring justice to perpetrators of violence.253
The implementation of WJEI has unfortunately been substantially delayed. As of November 2007that is, over two years since the start of the programno WJEI funds had actually been disbursed for projects in Zambia. According to the officer in charge of WJEI at the US Department of State, the process of disbursing the funds involved planning, identification of needs on the ground, and ways to complement existing programs.254
In terms of specific programs addressing gender-based violence and unequal property rights, the second secretary at the US Embassy in Lusaka told Human Rights Watch, We tend to integrate gender into all of our programs [including in the areas] of justice and legal reform.255 Potential future areas of support indicated by diplomats at the US Embassy in Lusaka include the establishment of shelters (mainly for victims of trafficking), and establishing additional one-stop centers.256 The US Embassy in Lusaka also has a small grants program.
PEPFAR Reauthorization and Debates on Prevention and Treatment Approaches
The law that created PEPFAR is up for reauthorization in 2008. One of the main areas of contention around reauthorization is the allocation of resources in the area of HIV/AIDS prevention. In 2003 Congress required that 55 percent of PEPFAR money be allocated toward HIV treatment, 15 percent toward palliative care for individuals with HIV/AIDS, 10 percent toward helping orphans and vulnerable children, and 20 percent toward HIV prevention.257 However, at least 33 percent of the prevention funds were earmarked to be spent on abstinence-until-marriage programs, which attracted tremendous criticism from local, regional, and international organizations, including Human Rights Watch.258 PEPFARs policies on prevention have been described as ill informed and ideologically driven.259
The frustration of Zambian AIDS activists with the US prevention strategies was evident during the visit of US First Lady Laura Bush to Zambia and a number of other African countries in June 2007. The founder of Health Triangle Trust, which addresses HIV/AIDS, tuberculosis, and malaria, stated that the good work that the US is doing in providing treatment and care [in Zambia] will come to nothing as long as new infections are not prevented. We are therefore, demanding that the US reconsider its policy on HIV prevention and other reproductive rights issues in order to stop new infections.260 Abstinence-until-marriage and fidelity programs, stated the Health Triangle Trust, do not take into consideration the social, cultural and economic contexts that people live in. To simply promote faithfulness without taking into consideration the power play that exist between women and men in [Zambia] is not only ineffective but also puts the women at risk of contracting HIV from their spouses.261
Similarly, the Treatment Advocacy Literacy Campaign (TALC) issued a press statement on the visit of First Lady Laura Bush to Zambia, stating that the conditionalities attached to US government funding for HIV prevention programs were likely to undo the impressive gains made in the area of HIV treatment in Zambia.
The Protection against Transmission of HIV for Women and Youth Act (PATHWAY) bill proposed by Congresswoman Barbara Lee would abolish the requirement to allocate 33 percent of prevention money to abstinence-until-marriage HIV prevention programs. It also requires the president and OGAC to establish a comprehensive HIV prevention strategy that addresses the vulnerabilities of women and girls to HIV infection in all countries that receive US HIV assistance.262
Another proposed law, the African Health Capacity Investment Act of 2007, is particularly important in addressing the disastrous lack of capacity in the healthcare system in Zambia and other countries affected by HIV/AIDS in sub-Saharan Africa. The bill aims to enhance the efforts to achieve internationally recognized goals in the treatment and prevention of HIV/AIDS and other major diseases and the reduction of maternal and child mortality by improving human health care capacity and improving retention of medical health professionals in sub-Saharan Africa.263 The bill would amend the Foreign Assistance Act of 1961 and authorize the US president to provide assistance for programs to improve health infrastructure and retain healthcare workers in sub-Saharan Africa. The Act would also direct the US president to develop a strategy to coordinate, implement, and evaluate assistance programs to build the healthcare capacity in Africa. The Act proposes appropriations of $150 million, $200 million, and $250 million for the fiscal years 2008, 2009, and 2010, respectively.264
The Global Fund is one of the main resource providers in Zambias HIV sector, including in the area of HIV treatment rollout. In funding rounds one (2003) and four (2005), the Global Fund approved a total of $322.22 million toward HIV programs in Zambia. By January 2007 the Global Fund had disbursed $93.10 million of these funds. However, little of this money covers gender-based violence or gender-specific projects.265
The Global Fund has four main recipients in Zambia: the Ministry of Finance and National Planning, the Ministry of Health, Church Health Organizations in Zambia, and Zambia National AIDS Network. The Global Fund works through a country coordinating mechanism (CCM) in Zambia. The CCM is responsible for developing national priorities and for overseeing the development and implementation of proposals. There is no representation of womens organizations in Zambias CCM.
240 UNAIDS, UNAIDS Regional Support Team for East and Southern Africa: Annual Report 2004 (Johannesburg: UNAIDS, 2005), p. 9.
241 WHO, Towards Universal Access by 2010: How WHO is Working with Countries to Scale-Up HIV Prevention, Treatment, Care and Support , p. 5.
242 The former UN Secretary General appointed James Morris as his Special Envoy for Humanitarian Needs in Southern Africa in July, 2002.
243 UN Secretary-Generals Taskforce on Women, Girls and AIDS in Southern Africa, National Report: Zambia, September, 2003. The final version of the report is entitled Facing the Future Together: Zambia Country Report of the United Nations Secretary-Generals Taskforce on Women, Girls, and HIV/AIDS in Southern Africa, 2004. For an elaborate account of the work of the task-force and lack of follow up see Stephen Lewis, Race Against Time: Searching for Hope in AIDS-Ravaged Africa (Toronto: Anansi, 2005), pp. 133-142.
244 UN Secretary-Generals Taskforce on Women, Girls and AIDS in Southern Africa, National Report: Zambia, p. 3.
245 WHO, Towards Universal Access by 2010, p. 12.
246 On May 30, 2007, President Bush announced his intention to work with Congress towards PEPFAR reauthorization. He presented a five-year, $30 billion proposal, which would be in addition to the United States initial $15 billion commitment made in 2003. The United States Presidents Emergency Plan for AIDS Relief (PEPFAR), Reauthorizing PEPFAR, July 2007, http://www.pepfar.gov/press/88590.htm (accessed August 1, 2007).
247 Human Rights Watch interview with Greg Marcus, second secretary, Embassy of the United States in Zambia, Lusaka, February 14, 2007 and PEPFAR, 2007 Country Profile: Zambia, http://www.pepfar.gov/press/81694.htm (accessed September 15, 2007).
248 PEPFAR, 2007 Country Profile: Zambia.
249In 2005 the Office of the US Global AIDS Coordinator formed a Gender Technical Working Group to provide technical support to focus countries on gender and HIV. During the financial year 2006 PEPFAR allocated $104 million to support activities on gender-based violence in focus countries.
250For example, the Global AIDS Alliance wrote the following about PEPFARs response to gender-based violence in countries such as Zambia: [p]rograms designed to prevent and respond to gender-based violence, a major risk factor for HIV, are not well funded as discrete programs, and a lack of transparency makes it nearly impossible to determine their efficacy and impact. The Global AIDS Alliance, First Ladys Trip to Africa Highlights Problems with US Policies on Health and Education, http://www.globalaidsalliance.org/index.php/673/ (accessed August 3, 2007).
251 In July 2007 USAID issued an Annual Program Statement on WJEI, where it called for grants applications from US and Zambian private voluntary organizations, toward programs that aim at reducing gender-based violence, for up to US$5.369 million in four provinces in Zambia, including Lusaka and the Copperbelt. This includes $ 1.7 million for raising awareness and $3.7M for victim support, rehabilitation, and reintegration. A separate program, administered by the Department of Justice, will complement these activities. It will focus on the justice sector response to gender-based violence. USAID, USAIDs Annual Program Statement on The Presidential Womens Justice & Empowerment Initiative (WJEI), APS Number: M-OAA-EGAT-WID-07-250, July, 2007, http://www07.grants.gov/search/announce.do;jsessionid=HqrFQ7K1r51Gnxkx1plsMQCp5LJCr1s34JZPf3tJpX5J21JJrY28!1320028050 (accessed November 1, 2007), p. 12.
252 Human Rights Watch interview with Greg Marcus, second secretary, Embassy of the United States, Lusaka, February 14, 2007. See also United States Department of State, Presidential Initiatives, http://www.usaid.gov/about_usaid/presidential_initiative/init_othermech.html#wje (accessed September 18, 2007).
253 United States Department of State, Womens Justice and Empowerment Initiative, http://www.state.gov/p/af/rt/wjei/ (accessed September 18, 2007).
254 Phone communication with Camille E. Jackson, Office of Economic Policy Staff, US Department of State, Washington DC, November 1, 2007. Jackson told Human Rights Watch that USAID and the Department of Justice were negotiating an agreement with the Zambian government.
255 United States Department of State, Womens Justice and Empowerment Initiative.
257 United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003, Pub.L. No. 108-25, sect. 403(a). See also Presidents Emergency Plan for AIDS Relief, http://www.avert.org/pepfar.htm (accessed September 2, 2007).
258 In 2006 the United States Government Accountability Office (GAO) reported that the Office of the US Global AIDS Coordinator advised Congress in 2004 that it defined abstinence-until-marriage activities to include those that promote both abstinence and fidelity. OGAC stated that abstinence-until-marriage programs would focus on achieving two goals: (1) encouraging individuals to be abstinent from sexual activity outside of marriage to protect themselves from exposure to HIV and other sexually transmitted infections and (2) encouraging individuals to practice fidelity in sexual relationships, including marriage, to reduce their risk of exposure to HIV. GAO, Global Health: Spending Requirement Presents Challenges for Allocating Prevention Funding under the Presidents Emergency Plan for AIDS Relief, GAO-06-395, April 2006, http://www.gao.gov/new.items/d06395.pdf (accessed November 17, 2007), p. 14
259 HIV Prevention Policy Needs an Urgent Cure," The Lancet, 367(9518), April 15-21, 2006.
260 Health Triangle Trust Kabwe, Press Statement by Health Triangle Trust on the Occasion of the Visit of the US First Lady, June 28, 2007, http://www.globalaidsalliance.org/index.php/646 (accessed August 19, 2007)
262 Protection against Transmission of HIV for Women and Youth Act of 2006 (The PATHWAY Act), 109th US Congress, 2nd Session, 2006, http://www.pepfarwatch.org/pubs/WomenandAIDSLeeBill.pdf (accessed October 17, 2007)
263 African Capacity Investment Act of 2007 (introduced in US Senate and House, 2007).
264 Ibid., sec.5.
265 Human Rights Watch interview with Elizabeth Mataka, executive director of Zambia National AIDS Network and member of Zambias Country Coordinating Mechanism, Lusaka, February 14, 2007.