Transcript of our interview with Dr. Moses Sichone

Brenda: How has Zambia been affected by HIV/AIDS?

Dr. Sichone: We face very high levels of HIV infection in the general population. We estimate that one in every five adults is infected with HIV in this country and that, basically, translates to more than a million people living with HIV/AIDS in Zambia. So we've got a very, very heavy AIDS burden in this country. And this is typical in Southern Africa, as you may be aware.

In addition to adult HIV infections, we also have quite a number of pediatric HIV infections. Children are infected with HIV, basically, from their parents and so we estimate in Zambia that, on an annual basis, we have something like 30,000 children being born every year with HIV infection.

Brenda: And how does this affect the country's economy?

Dr. Sichone: Certainly we have seen a very devastating impact on the Zambia economy. HIV/AIDS is a cross-sectional problem. It doesn't just affect the health sector but indeed we have seen the impact across many sectors. We have seen its severely serious impact on the education sector, for instance, both on the supply side and on the demand side. The teachers are dying; there's absenteeism; there's the issue of orphans. We've seen the impact on agriculture. Food security's being affected very severely because of the HIV epidemic. Because people are moving from more labour-intensive to less labour types of agriculture.

We have seen the impact on the health sector itself. We estimate that somewhere around 60 or 70% of hospital beds in medical wards are occupied by people suffering from HIV-related illnesses. We have seen the whole impact on the issue of orphans. Also the demographics in this country are changing because of the high mortality, particularly in the productive segment of the population.

Like many other countries in Southern Africa we estimate that the gross domestic product may be directly affected to the extent of 2% or more in terms of decline in GDP attributable to HIV infection. So we're seeing a tremendous impact on our economy in this country and, unless we are able to address it very vigorously, we'll see that the gains that we have made over the last four or five decades will be wiped away by the epidemic. So it is the key determinant to our socio-economic development.

Brenda: Can you explain to us how Zambia plans to deal with the effects of HIV/AIDS on children, on the welfare of children?

Dr. Sichone: The basic document that outlines our approach to both accelerate and expand the response is the National HIV/AIDS Strategic Framework. And this is a document that articulates very clearly, what we must begin to do in terms of priority strategies, to be able to scale up our interventions. I think through the experience that we've gathered over the past several years we know that there are interventions that do seem to work. But the problem has been that we don't have adequate resources to be able to scale up these interventions and, therefore, what we are seeking to do in this Strategic Framework is to be able to look at certain geographic priority areas so that we can have many more people covered in our interventions. And through this Strategic Framework we'll also be looking at the issue of orphans.

If you look at the particular sub-populations that we are targeting in this plan: we are targeting the youth who are our window of hope because we consider the youth to be largely uninfected and, therefore, if we can prevent them from getting infected we can have an impact on the course of the epidemic. And, as you know in Zambia now, we have witnessed a decline in HIV infection levels among the young people between 15 and 19 years of age and, therefore, youth, women, children, orphans, people living with HIV/AIDS, truck drivers, commercial sex workers and many other populations, fishing populations, migrant populations - they are all being deliberately targeted so that we can achieve a greater impact on the course of the epidemic.

Robert: Why do you think the numbers of HIV infections have declined among young people?

Dr. Sichone: It's been quite interesting and exciting for us to be able to witness this decline in HIV infection among young people. And I think that it's very difficult to isolate one specific intervention that you can attribute this decline to. However, because our interventions have been carried out for a number of years I think we're beginning to see their benefits. And I think we've seen that this decline is directly attributable to sexual behaviour change among young people. We have interviewed them and we are seeing young people having fewer non-regular sex partners. There's increase in condom use, there's access to peer education programs and information programs and all these interventions have led to what we are seeing now as a decline in terms of the HIV infection levels among the young population. And if we can begin to accelerate this kind of trend then I'm sure that, in the next several years, we will begin to have a greater impact and consequently reduce the scale and magnitude of the HIV epidemic in this country.

Brenda: What cultural practices have helped spread HIV/AIDS?

Dr. Sichone: Well, there are certain traditions and cultural practices in Zambia today that facilitate the transmission of HIV. That we do, in certain parts of this country, have traditions where a spouse has to be sexually cleansed once the husband or the wife dies and that obviously is a cultural practice that will facilitate the spread of HIV. There are other practices such as traditional healers, for instance in certain parts of the country, may use the same razor blade or the same cutting instrument to undertake circumcision and that clearly is a risk for those people that are being circumcised. But we have been able to work in productive ways with the traditional leaders in these parts and we're seeing a gradual change towards reduction of these types of behaviour that place people at risk. And so, I think, in many parts of the country now if you went there you'd see that there's been a reversal or, in fact, a ban on some of these cultural practices that put people at risk for HIV infection.

Brenda: How will Zambia be able to control the spread of HIV/AIDS in older generations?

Dr. Sichone: Well, I think, at the core of our Strategic Framework we are seeking to basically secure three objectives. One is to be able to prevent or reduce HIV transmission in the Zambian population, not only among the youth but also in the adult population. And we do this in several ways. We have our Information, Education, Communication campaigns. We've got our condom promotion social marketing - we distribute condoms both through the traditional and non-traditional outlets and we're working closely with a number of agencies that are engaged in condom social marketing. We're strengthening our STD control services, sexually transmitted disease control strategies, within our health facilities. We're able to continue with a number of other interventions that seek to basically change people's sexual behaviour. So, in other words, communication for behaviour change is a very key strategy.

Secondly, we need to deal with the impact, the socio-economic impact of the HIV/AIDS epidemic. And, as you know, we have more than a million people living with HIV and AIDS in this country and we need to be able to mitigate the impact of HIV/AIDS in this segment of our population. That means that people have to have access to medical care, they have to have the continuum of care from hospitals right down to the community. We are promoting home-based care and, as you know, Zambia played a pioneering role in the introduction of home-based care as a strategy for controlling or for handling HIV/AIDS. We're also working on the socio-economic impact with other sectors that have responsibility. The Ministry of Community Development and Social Services is playing an important role in terms of helping those people that are infected or affected by HIV/AIDS.

The third element that we are addressing is really to continue mobilizing resources on a massive scale. Because up to now I think that the magnitude and scope of the problem and the money that are spent on these programs are simply not matching. There's a mismatch between the size of the problem and the resources that we are allocating to it. So we will continue to work with our co-operating partners, both multilateral and bilateral partners, to ensure that the resources are commensurate with the scale and magnitude of the HIV/AIDS epidemic. And so we are, as you are aware now, discussing in the Consultative Group Meeting to make sure that resources are made available to respond to the challenge of HIV/AIDS epidemic.

Brenda: I know that there are regional zone workers that are talking to the Chiefs, you know people who are doing HIV/AIDS peer education are now speaking to the elders to try and get their support in adapting cultural practices so that the elements that could put people at risk are removed from the tradition without losing the tradition itself. Is that something that has been advocated by the Secretariat?

Dr. Sichone: I think that one of the strengths that we have in this country is that there's an extremely high level of knowledge on HIV/AIDS. You can go into any community in this country and you'll be amazed at the level of awareness on the issues of HIV/AIDS. And so, because of that awareness, communities are taking increasing ownership of the problem of HIV/AIDS. They are doing everything in their power to be able to address the issues of HIV/AIDS. They're talking with each other within the communities, they're talking with the traditional leaders, they're talking with political leaders to be able to ensure that all the services that are required for people living with HIV/AIDS are made available. It's a reflection, if you like, of the hard work that has been put into the HIV/AIDS programs in this country.

We are certainly hoping that this level of awareness can be translated into actual behaviour change. I think one of the challenges we face at the present moment is translating this high level of knowledge into sexual behaviour change. Because that's what puts people at risk. And, therefore, in our quest to ensure that this happens, this gap is narrowed between knowledge and behaviour we are working with all sectors of our communities to ensure that that does happen.

And this entails, for instance, the communities themselves sitting down and talking and looking at what they can do to address the epidemic. The communities themselves are talking to traditional leaders to change some of these risky behaviours that, as a result of traditions and customs, have been practiced for generations. Because HIV/AIDS has simply brought a whole new dimension to our existence in this country. And so it's challenging us in ways that are unprecedented.

Brenda: In taking on the challenge of HIV/AIDS what is your greatest worry?

Dr. Sichone: My greatest worry really is to be able to do fewer things but better. We should be able to identify those interventions that give us the greatest benefit. And sometimes we don't do that very well. So the greatest challenge that I face, as Director of the Secretariat, is to make sure that we are able to scale up the intensity of our interventions because that's really the challenge.

We know that there are certain things that work but we're not doing enough because the resources are not there, the human beings that are supposed to do that are not available, the skills and competencies are not there. So my greatest challenge really is to be able to ensure that we build the capacity and the competence of our communities to be able to respond to the challenge of HIV/AIDS. And, obviously, there are a number of political, technological, social and cultural impediments to achieving this but I certainly see that as a challenge and not as an obstruction to our capacity to be able to manage the HIV/AIDS epidemic.

Brenda: What are your hopes for the future?

Dr. Sichone: Well, my hope…my hope for the future er…certainly I would like to see the scale and magnitude of the epidemic reduced quite considerably and we can only achieve this if we work together in ways that promote collaboration, co-operation as well as working synergistically with the public sector, the NGOs, the private sector and CBOs and religious organizations. All of us must work together in a very cohesive manner so that then we can achieve that synergism to have a greater impact on the HIV epidemic and its course in this country. So I certainly hope that we will, in the next several years, be able to achieve a certain level of success in our interventions as evidenced by the already declining HIV sero-prevalence among the younger age groups.

Brenda: Those changes and synergies would create a different Zambia wouldn't they?

Dr. Sichone: Yes they would. Certainly we want to see a Zambia which is AIDS free, a Zambia that is going to allow ourselves, as Zambians, to live with dignity in peace and harmony. So our hope, certainly, is that we can bring this raging HIV/AIDS epidemic under control. And we can only do that with the collaboration and co-operation of our partners, our co-operating partners, our donors. Because we do need resources. Resources are scarce in this part of the world. We are facing serious macro-economic difficulties and it is my hope that we can continue to martial the necessary resources to be able to mount a concerted response to the HIV/AIDS epidemic.

Brenda: You have talked about the effect on the health system losing health professionals. You have also been losing educational professionals. Would you elaborate on that?

Dr. Sichone: HIV/AIDS has got a cross-sectoral impact and, certainly, within the educational sector now we've seen an unprecedented haemorrhage, if you like, of teaching staff. It is estimated by the Minister of Education that, on an annual basis, we lose more than 1000 teachers. And that is faster than we can replace them, faster than we can train new teachers. And that has an impact, a downstream impact, in terms of the people that are there to teach the young children. The teachers themselves are falling sick and dying off so that is one clear impact.

But also, within the educational sector, we have the problem of orphans. How do we support the orphans so that they can go in the education system, to become productive and reproductive adults in their future lives? Because if we don't invest in the young children then our efforts to control the HIV/AIDS epidemic are rendered useless. So we need to ensure that children, particularly the young girls, remain in the education system. And because of the impact of HIV/AIDS the mothers and the fathers are dying off and sometimes the children cannot be sent to school because they don't have money to go to school. So we need to ensure that we work out a comprehensive system for retaining the children within the education system.

Within the agricultural sector again we have seen the tremendous impact on food productivity in this country. The number of particularly the peasant farmers, because of mortality from HIV, because of morbidity from HIV/AIDS, there's been a decline in the production of food and that again impacts on the nutritional status of our people. And so there's a litany of all these impacts that are, in the time available I'll not be able to quite elaborate, but you can see that we're faced with a truly, truly devastating enemy in our country today.

Robert: What is the effect on small, rural communities like the fishing village that we went to see?

Dr. Sichone: In the fishing populations? We've carried out a number of studies in this country to look at the dynamics and the sexual networking that happens in rural communities as well as in fishing populations. What tends to happen is that the fishermen would, for instance, demand to have sex with the women who come to buy the fish, before they can sell them the fish. And, because of the nature of the trade, you'll find that women are disproportionately vulnerable to the risk of acquiring HIV infection from the trade. They not only have to deal with the fishermen, they have to deal with the truckers who transport their fish from the fishing camps right down into town. And so there are all these jeopardies that they have to deal with.

Now the problem there is that you have a high rate of sex, if you like, taking place within this closed community. And that just simply becomes explosive. Because you have a small group of people that are exchanging sex on a regular basis but not only are they exchanging sex within themselves they're also interacting with outsiders. When the women go back to town they have other sexual partners and therefore that tends to accelerate the spread of HIV/AIDS. And so, as I mentioned in our Strategic Framework, we are particularly targeting fishing populations as a sub-population that needs vigorous and robust interventions.

Robert: I'm sure Zambia has had its share of devastating illnesses in the past: cholera, yellow fever, or various diseases. Can you describe the difference between HIV/AIDS and previous disease epidemics?

Dr. Sichone: Clearly the HIV/AIDS epidemic is different from many diseases that we know and this is for the following reasons. First of all HIV/AIDS affects the most productive segment of the population between the ages of 15 and 49, and therefore you can see that it would have a disproportionate impact on the economic development of the country.

Secondly, in terms of prognosis, in terms of outcome, we know that HIV/AIDS remains incurable. And because we are in resource-constrained environments even drugs that are available in the developed countries of the North are not available here. So, in terms of prognosis you know it's going to be 100% fatal.

Thirdly, I think one peculiarity of HIV/AIDS is that it's a lifelong disease. You can get malaria - five or six days you are cured. You can get cholera - many get cured. But HIV/AIDS is really a lifelong disease and that has got its own implications: in terms of the development of the disease itself, the opportunistic infections that are associated with it, the medical costs that need to be borne by the patient.

And, I think, lastly HIV/AIDS takes away the productive time of other adults who must take time off to look after the patient. So, in other words, once you have a patient in a household other family members have to invest quite a lot of time in taking care of that patient because of the chronic nature of the illness. And therefore, it has got, if you like, a double impact. The person who's infected cannot produce, cannot be economically productive, but also other able-bodied people who are supposed to be engaged in economic activities, have to take time off to look after the patient. And for those reasons we find that HIV/AIDS, in fact, is quite different from many diseases that we know and certainly it's unique in that sense.

Brenda: If I can return to the issue of orphans for a moment, can you explain why you don't just build orphanages for the kids?

Dr. Sichone: We, in Zambia, are faced with a very serious orphan crisis. We estimate now that there are over 600,000 orphans in Zambia and the mechanisms to take care of these children have always been a challenge to the government and to the communities.

We basically discourage the setting up of orphanages for a number of reasons.

First of all, once children are put in orphanages they get dislocated from the communities where they should actually be socialized, where they can be given guidance. And secondly, orphanages are expensive to run and we've seen a number of orphanages set up in the past with all the good intentions but then a few years down the line the money runs out and so it becomes very difficult to be able to sustain the orphanages.

In Zambia we have traditionally encouraged community-based approaches towards the care of orphans and other vulnerable children. We normally, in Africa, rely on the extended families but, again, this is coming under severe threat because of the poverty that is so pervasive in our country. And so we must define mechanisms through which families, for instance, that accept to take an orphan can be given incentives - maybe through government, maybe through tax rebates or some form of support - so that they are able to continue taking care of the orphans.

And we also are working with a number of our partners to ensure that we develop comprehensive programs that will ensure support for orphans. Orphans need access to health care, they need access to education, they need access to many other social services. So we must develop social safety nets that ensure that orphans are not unduly disadvantaged as they grow up.

Brenda: While the families who are supporting them, are taking them in, many families have more than one orphan they have already taken in?

Dr. Sichone: Yes. In fact, we estimate that more than 70% of families in Zambia are taking care of either one or more orphans. And therefore these families need to be supported basically because we are in a very difficult economic situation and sometimes it's very difficult for families to continue, in addition to their own families, to take on additional orphans. So I think that's one challenge that we face to ensure that these families are given support by government or by other people that may render the support.

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