Zimbabwe's Second Wave?

This is a time of cautious optimism in Zimbabwe; the last thing its citizens need right now is a newly invigorated HIV epidemic.
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As the economic and political turmoil in Zimbabwe begins to ebb, a resurgent HIV epidemic looms as the next crisis to threaten the beleaguered nation. An alarming report published last month by Zimbabwe's National AIDS Council showed a 75 percent jump in treatment for syphilis, gonorrhea and chlamydia between 2008 and 2009. An uptick in new HIV infections is likely not far behind.

Like all southern African countries, Zimbabwe is not unfamiliar with the scourge of HIV/AIDS. In fact, buried in the social, economic and political bedlam that has plagued Zimbabwe over the past several years is the most pervasive HIV epidemic on record: 29 percent of Zimbabwean adults between the ages of 15 and 49 were HIV infected in the late 1990's. Since then, however, the epidemic has been in sharp decline - HIV prevalence today hovers around 15 percent of adults - due to a combination of factors including high mortality rates, some success with condom use, and, ironically, years of economic and social upheaval that ruptured the social networks vital to HIV transmission.

Though it may seem counterintuitive, the post-conflict environment is often more conducive to HIV spread than the conflict period itself, and today's more stable and peaceful Zimbabwe is at risk for a torrent of new infections. Zimbabweans are returning home from HIV-afflicted neighbors like South Africa, Mozambique and Botswana in search of work in urban areas where unemployment remains spectacularly high. Disenfranchised young adults turning to sex work for survival and victims of sexual violence in the post-election chaos are potential new sources of infection.

The new data on sexually transmitted diseases corroborate concerns expressed by local experts who lament the recent shift in focus from prevention to treatment, which has undermined earlier gains in condom use and left newly sexually active young adults ill-prepared to protect themselves and their partners. Further complicating the picture is Zimbabwe's woefully under resourced and under staffed public health system that is struggling to deal with 1.5 million existing infections. And thanks to an irregular supply chain, fluctuating prices, and an active black market for HIV drugs, drug resistant strains of HIV (caused by inconsistent adherence to the drugs) may be circulating in the population. An escalating HIV epidemic in Zimbabwe threatens to undo a hard-won and fragile peace, as well as HIV prevention and treatment gains in neighboring countries.

To avoid this nefarious post-conflict infection trap, treatment programs must be paired with commensurate prevention efforts that address epidemic drivers, including concurrent multiple sexual partnerships, long-term discordant couples (where one partner is infected and the other uninfected), and early sexual debut.

This requires regaining lost momentum on condom use, suspending health clinic user fees which prevent people from accessing health care, and linking sexually transmitted disease treatment to routine HIV testing and prevention education services. Prevention campaigns that target adolescents and young adults are also essential, and ensuring universal access to HIV counseling, testing and treatment for pregnant women in will prevent HIV transmission from mother to newborn and reduce maternal deaths.

A crushing national debt means that most of this prevention effort, along with any health system strengthening initiatives, will have to be largely externally financed. Donors are understandably cool to the idea of giving money to the government in light of its kleptomaniacal tendencies, but there are ways to avoid the central bank. The Global Fund for AIDS, Tuberculosis and Malaria has established a special health spending account managed by the United Nations Development Programme (UNDP) on behalf of the ministry of health. Other donors, including the U.S. President's Emergency Plan for AIDS Relief (PEFPAR), should similarly engage contractors to manage HIV prevention and treatment grants that bypass the government and flow directly to implementing organizations, thereby ensuring fiscal probity.

The news is not all bad: the Ministry of Health launched a 100-day emergency plan to attract back Zimbabwean health care workers, including some of the 20,000 nurses it lost between 1999 and 2008. It is also trying to re-engage with civil society partners to provide essential health services, and re-evaluate the national policy on user fees that prevents people from accessing health care. It has done remarkably well at putting people on HIV treatment: approximately 50 percent of the treatment need has been met, which is comparable to its more stable and better resourced neighbor South Africa.

This is a time of cautious optimism in Zimbabwe; the last thing its citizens need right now is a newly invigorated HIV epidemic. Donors must take this opportunity to re-engage with the Zimbabwean people, to build on domestic health system strengthening initiatives, and to support aggressive prevention programming in order to mitigate a renewed HIV threat and bolster Zimbabwe's recovery.Peter Navario is a Fellow in Global Health at the Council on Foreign Relations.

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