Know Your HIV-Prevention Response: Southern Province, Zambia

Chart Book on Implementation of HIV-prevention Interventions by Nongovernmental Organizations

Anastasia J. Gage

NAC ZAMBIA

This research has been supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development (USAID) under the terms of MEASURE Evaluation cooperative agreement GHA-A-00-08-00003-00, which is implemented by the Carolina Population Center at the University of North Carolina at Chapel Hill, with Futures Group, ICF International, John Snow, Inc., Management Sciences for Health, and Tulane University. The views expressed in this publication do not necessarily reflect the views of PEPFAR, USAID, or the United States government. August 2014 MS-14-96

List of Figures

Figure 1 Percentage of organizations surveyed in Southern Province that were currently implementing standardized interventions, Zambia 2013 ...... 7 Figure 2 Percentage of organizations surveyed in Southern Province that were currently implementing harm reduction interventions, Zambia 2013 ...... 8 Figure 3 Percentage of organizations surveyed in Southern Province that were currently implementing standardized interventions, Zambia 2013 ...... 9 Figure 4 Percentage of organizations surveyed in Southern Province that were currently implementing biological or biomedical interventions, Zambia 2013 ...... 10 Figure 5 Percentage of organizations surveyed in Southern Province that were currently implementing interventions to mitigate barriers to prevention and negative social outcomes of HIV infection, Zambia 2013 ...... 11 Figure 6 Percentage of organizations surveyed in Southern Province that were currently implementing interventions to mitigate biological outcomes of HIV infection, Zambia 2013 ...... 12 Figure 7 Percent of organizations surveyed in Southern Province by level of sufficiency of the quantity of resources for HIV-prevention activities, Zambia 2013 ...... 13 Figure 8 Percent of organizations surveyed in Southern Province by level of sufficiency of the quality of resources for HIV-prevention activities, Zambia 2013 ...... 14 Figure 9 Percentage of organizations surveyed that implemented HIV-prevention activities in the past 12 months in districts of Southern Province, Zambia 2013 ...... 15 Figure 10 Percentage of organizations surveyed in Southern Province that implemented voluntary counseling and testing and condom social marketing programs in the past 12 months by district, Zambia 2013 ...... 16 Figure 11 Percentage of organizations surveyed in Southern Province that implemented comprehensive sex education and social mobilization interventions in the past 12 months, Zambia 2013 ...... 17 Figure 12 Percentage of organizations surveyed in Southern Province that implemented comprehensive sex education and social mobilization interventions in the past 12 months, Zambia 2013 ...... 18 Figure 13 Percentage of organization surveyed in Southern Province that implemented selected HIV-prevention interventions in the past 12 months by type and site of intervention, Zambia 2013 ...... 19 Figure 14 Percentage of organizations surveyed in Southern Province that implemented interpersonal education programs and mass media campaigns in the past 12 months by type of place of residence, Zambia 2013 ...... 20

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 1 Figure 15 Percentage of organizations surveyed in Southern Province that distributed condoms in the past 12 months by type of place of residence, Zambia 2013 ...... 21 Figure 16 Percentage of organizations surveyed in Southern Province that implemented harm reduction interventions in the past 12 months by district and intervention site, Zambia 2013 ...... 22 Figure 17 Availability of organizations surveyed in Southern Province that promoted or conducted voluntary medical male circumcision in the past 12 months by district, Zambia 2013 ...... 23 Figure 18 Percentage of organizations surveyed in Southern Province that implemented selected interventions to mitigate barriers to prevention and negative social outcomes of HIV infection in the past 12 months by district, Zambia 2013 ...... 24 Figure 19 Percentage of organizations surveyed in Southern Province that implemented selected interventions to mitigate barriers to prevention and negative social outcomes of HIV infection in the past 12 months by district, Zambia 2013 ...... 25 Figure 20 Percentage of organizations surveyed that implemented HIV-prevention interventions in Southern Province in the past 12 months by type and site of intervention, Zambia 2013 ...... 26 Figure 21 Percent distribution of organizations surveyed in Southern Province by level of integration of gender issues into their HIV-prevention activities/interventions, Zambia 2013 ...... 27 Figure 22 Percentage of organizations surveyed in Southern Province that addressed key gender issues in their HIV-prevention activities/interventions by type of issue, Zambia 2013 ...... 28 Figure 23 Percentage of organizations surveyed in Southern Province that addressed key gender issues in their HIV-prevention activities/interventions by type of issue, Zambia 2013 ...... 29 Figure 25 Percentage of organizations surveyed in Southern Province that received funding for HIV-prevention activities from specific sources, Zambia 2013 ...... 30 Figure 24 Percentage of organizations surveyed in Southern Province that targeted specific key populations in the past 12 months, Zambia 2013 ...... 31 Figure 26 Percentage of organizations surveyed in Southern Province that provided the 10 most common interventions targeted at female sex workers in the past 12 months, Zambia 2013 ...... 32 Figure 27 Availability of at least one organization providing WHO priority HIV-prevention interventions for female sex workers in the past 12 months by district, Southern Province, Zambia 2013 ...... 33 Figure 28 Percentage of organizations surveyed in Southern Province that provided the 10 most common interventions targeted at people living with HIV in the past 12 months, Zambia 2013 ...... 34 Figure 29 Availability of at least one organization surveyed in Southern Province that provided WHO priority interventions for illness prevention, treatment and care in people living with HIV, by district, Zambia 2013 ...... 35

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 2 Figure 30 Availability of at least one organization surveyed in Southern Province that provided positive prevention interventions to prevent HIV transmission to other people, by district, Zambia 2013 ...... 36 Figure 31 Percentage of organizations surveyed in Southern Province that provided the 15 most common interventions targeted at young people aged 10-24 years in the past 12 months, Zambia 2013 ...... 37 Figure 32 Availability of at least one organization surveyed in Southern Province that provided key interventions for HIV prevention in young people aged 10-24 years in the past 12 months, by district, Zambia 2013 ...... 38 Figure 33 Percentage of organizations surveyed in Southern Province that implemented the 15 most common HIV-prevention interventions targeted at pregnant women, infants and young children in the past 12 months, Zambia 2013 ...... 39 Figure 34 Availability of at least one organization surveyed in Southern Province that provided key interventions for HIV prevention in pregnant women, infants and young children, by district, Zambia 2013 ...... 40 Figure 35 Percentage of organizations surveyed in Southern Province that implemented the 10 most common HIV-prevention interventions targeted at migrants and mobile populations in the past 12 months, Zambia 2013 ...... 41 Figure 35 Availability of at least one organization surveyed in Southern Province that provided selected interventions for HIV prevention in migrant and mobile populations, by district, Zambia 2013 ...... 42

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 3 List of Acronyms

ARV antiretroviral

ART antiretroviral therapy

CSO Central Statistics Office

HIV human immunodeficiency virus

HPV human papilloma virus

INESOR Institute of Economic and Social Research

KYR Know Your Response

NAC National HIV/AIDS/STI/TB Council

MSM men who have sex with men

NGO nongovernmental organization

PEPFAR U.S. President's Emergency Plan For AIDS Relief

PLWH people living with HIV

PWID people who inject drugs

STI sexually-transmitted infection

TB tuberculosis

UNAIDS Joint United Nations Programme on HIV and AIDS

USAID U.S. Agency for International Development

VCT voluntary counseling and testing

WHO World Health Organization

YFS youth-friendly services

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 4 Introduction

In 2007, Southern Province of Zambia had an HIV prevalence rate of 14.5 percent among men and women aged 15-49 years (Central Statistical Office et al., 2009). Data provided by the National HIV/AIDS/STI/TB Council (NAC) showed that in 2010 HIV prevalence was highest in Livingstone (25.3 percent), followed by Mazabuka (18.4 percent). Overall, 15.7 percent of adults in the districts of Choma, Monze, and Siavonga and 15.2 percent of those in Kalomo and Kazungula were HIV positive. Gwembe and Namwala had the lowest prevalence of HIV in Southern Province (6.2 percent). The National HIV and AIDS Strategic Framework of 2011-2015 identified the acceleration and intensification of prevention in order to reduce the annual rate of new HIV infections as one of the four national priorities for the HIV and AIDS response (Zambia NAC, 2009).

In 2013, MEASURE Evaluation in collaboration with the NAC and the Institute of Economic and Social Statistics (INESOR) of the University of Zambia, implemented the Know Your HIV Response (KYR) study, a situation analysis of HIV-prevention interventions in Southern Province, Zambia. The study had three primary objectives:

• determine what specific HIV-prevention interventions were being implemented; • determine by which organizations and in which districts the interventions were being implemented; and • assess the extent to which the HIV-prevention response matched current HIV- transmission patterns, were focused on geographic areas where HIV was spreading most rapidly, and covered technical recommendations for populations at higher risk of HIV exposure.

The purpose of this chart book is to disseminate easily understandable information on gaps in HIV-prevention interventions in the nongovernmental sector in Southern Province. It is hoped that the information presented will guide program implementers as they select and prioritize prevention interventions that are needed to have an impact on HIV incidence and prevalence.

Data and Methods

The data come from a pilot test of the KYR tools. The study was funded by the U.S. Agency for International Development (USAID) and was implemented from September to October 2013 in Southern Province, in collaboration with the Institute of Economic and Social Research at the University of Zambia, and the NAC. One of the objectives of the pilot test was to determine whether data collected via the tool kit yielded information that was needed to assess the extent to which prevention interventions were focused on geographic areas where HIV was spreading most rapidly and covered technical recommendations for HIV-prevention among populations at higher risk of HIV exposure.

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 5 The Program Implementer Core Questionnaire and Program Implementer Modules for Key (and vulnerable) Populations at Higher Risk of HIV Exposure provided the information analyzed in this chart book. The core questionnaire and modules were administered to all HIV-implementing organizations operating in Southern Province, based on a list of registered implementers provided by the NAC. A total of 93 Program Implementers in the nongovernmental organization (NGO)-sector were successfully interviewed, representing a response rate of 84 percent.

The core questionnaire collected basic information about the implementing organization and for each of the organization’s projects that currently conducted HIV-prevention activities, data were collected on the type of HIV-prevention activities implemented in the past 12 months, financial resources expended for HIV prevention activities in the past 12 months, and sources of funding for HIV-prevention activities implemented in the past 12 months. The structure of the core questionnaire was guided by Michael Sweat’s (2008) framework for classifying HIV-prevention interventions, which was published by the Joint United Nations Programme on HIV/AIDS (UNAIDS).

The modules identified which of the following key/vulnerable populations were targeted by the organization in the past 12 months: female sex workers; men who have sex with men and transgender; people who inject drugs; young people aged 10-24 years in the general population; emergency settings and refugee/internally displaced populations; migrant and mobile populations; pregnant women, infants, and young children; uniformed personnel/services; and incarcerated populations. For each population subgroup, data were collected on a standard set of HIV-prevention interventions as well as on specific interventions for the group based on recommendations by the U.S. President's Emergency Plan For AIDS Relief (PEPFAR) and World Health Organization (WHO).

The study was approved by the Tulane University Human Research Protection Program Biomedical Institutional Review Board (IRB), New Orleans, Louisiana. Local IRB approval was obtained from ERES Converge, Lusaka; and authorization to conduct the study was from the Zambia NAC. Interviewers and supervisors received a one-day research ethics training, based on the FHI 360 Research Ethics Curriculum. The data collection instruments were pretested in Chongwe and Kafue Districts near Lusaka in July 2013.

The data were analyzed using Stata version 12.0. In order to estimate implementation rates for each intervention in a given district, percentages were calculated based on the total number of organizations that were completely interviewed (i.e., n=93 program implementing organizations for each calculation). Some charts also show the district availability (yes or no) of at least one surveyed organization that implemented a given priority intervention in the past 12 months for population subgroups at higher risk of HIV exposure.

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 6 FIGURE 1

Fewer organizations provided self-testing and door-to-door testing for HIV compared to provider- or client-initiated testing. Percentage of organizations surveyed in Southern Province that were currently implementing standardized interventions, Zambia 2013

None 32

Other intervention 21

Social mobilization 73

Comprehensive sex education 73

Condom social marketing 43

Door-to-door testing 25

Self-testing 13

Home-based testing 26

Client-initiated 35

Provider-initated testing 45

Voluntary counseling & testing 54

0 20 40 60 80 100 Percent

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 7 FIGURE 2

Mass media campaigns were implemented by fewer organizations surveyed than sex education programs or prevention counseling. Percentage of organizations surveyed in Southern Province that were currently implementing harm reduction interventions, Zambia 2013

None 20

Other intervention 15

Prevention counseling 84

Education to promote adherence to universal precautions 69

Sex education 84

Inerpersonal education and persuasion programs 73

Mass media campaigns 30

0 20 40 60 80 100 Percent

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 8 FIGURE 3

Livelihood alternatives to transactional sex were five times less commonly implemented than condom distribution. Percentage of organizations surveyed in Southern Province that were currently implementing standardized interventions, Zambia 2013

None 36

Other intervention 19

Livelihood alternatives to transactional sex 12

Providing safe spaces for vulnerale people 15

Provision of equipment required for universal 26 precaution

Needle and syring exchange 12

Distribution of condoms 63

0 20 40 60 80 100 Percent

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 9 FIGURE 4

Less than half of organizations surveyed implemented biological or biomedical interventions. Percentage of organizations surveyed in Southern Province that were currently implementing biological or biomedical interventions, Zambia 2013

None 57

Other intervention 1

Drug treatment including drug substitution therapy 4

Use of gloves and protective clothing 28

Disinfection of tattoo, body piercing & barber equipment 2

Disinfection of medical equipment 13

Screening blood products or donated organs for HIV 3

Breastfeeding for infants born to HIV+ MOTHERS 22

ARV prophylaxis for infants born to HIV+ mothers 14

Medical male circumcision 13

Family planning services 30

Post-exposure prophylaxis 11

Diagnosis & treatment of STIs 20

0 10 20 30 40 50 60 70 80 90 100 Percent

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 10 FIGURE 5

Three of every 10 organizations surveyed worked on reforms to protect the rights of HIV- positive people. Percentage of organizations surveyed in Southern Province that were currently implementing interventions to mitigate barriers to prevention and negative social outcomes of HIV infection, Zambia 2013

None of the above 30

Other intervention 3

Legal, policy and institutional reform 30

Counseling 82

Medical and legal assistance services 18

Finance and in-kind sustenance support 29

Self-help and solidairty groups 39

Separate accomodation for at-risk populations 2

Training of service providers and law enforcement 55

0 20 40 60 80 100 Percent

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 11 FIGURE 6

Two in every five organizations surveyed provided palliative care for people living with HIV. Percentage of organizations surveyed in Southern Province that were currently implementing interventions to mitigate biological outcomes of HIV infection, Zambia 2013

None 30

Other intervention 9

Palliative care for PLWH 40

Prevention, diagnosis, & treatment of viral hepatitis 7

HIV-related opportunistic infection prophylaxis and 13 treatment

HIV treatment with ARV drugs 11

TB prevention, diagnosis & treatment 10

0 20 40 60 80 100 Percent

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 12 FIGURE 7

More than half of organizations surveyed felt that the quantity of infrastructure was insufficient for current HIV-prevention activities. Percent of organizations surveyed in Southern Province by level of sufficiency of the quantity of resources for HIV- prevention activities, Zambia 2013

100 90 80 70

60 50

Percent 40 30 20 10 0

Insufficient Somewhat sufficient Mostly sufficient Completely sufficient

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 13 FIGURE 8

There was greater dissatisfaction with the quality of infrastructure than with the quality of human resources for HIV-prevention activities. Percent of organizations surveyed in Southern Province by level of sufficiency of the quality of resources for HIV- prevention activities, Zambia 2013

100 90 80 70

60 50

Percent 40 30 20 10 0

Insufficient Somewhat sufficient Mostly sufficient Completely sufficient

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 14 FIGURE 9

Most organizations surveyed worked in Choma, Kalomo, Livingstone, Mazabuka and Monze districts. Percentage of organizations surveyed that implemented HIV-prevention activities in the past 12 months in districts of Southern Province, Zambia 2013

18 17 17 16

14 13 12 12 11

Percent 8 8 7 6

4 3 3 2 2 1 1

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 15

FIGURE 10

No organizations surveyed implemented condom social marketing programs in Pemba and Sinazongwe districts. Percentage of organizations surveyed in Southern Province that implemented voluntary counseling and testing and condom social marketing programs in the past 12 months by district, Zambia 2013

14 13 12 12

10 10 10

Percent 8 8 8 7 7 6 6 6 4 4 3 3 3 2 2 1 1 1 1 1 1 1 0 0 0 Voluntary Counseling & Testing Condom Social Marketing

Choma Gwembe Kalomo Kazungula Livingstone Mazabuka Monze Namwala Pemba Siavonga Sinazongwe Zimba

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 16

FIGURE 11

No organizations surveyed implemented comprehensive sex education or social mobilization interventions in Pemba. Percentage of organizations surveyed in Southern Province that implemented comprehensive sex education and social mobilization interventions in the past 12 months, Zambia 2013

18 17 17 16 15 15 15 14 14

10 9

Percent 8 8 8 8 7 7 6

4 3 3 2 2 2 2 2 1 1 1 0 0 0 0 Comprehensive Sex Education Social Mobilization

Choma Gwembe Kalomo Kazungula Livingstone Mazabuka Monze Namwala Pemba Siavonga Sinazongwe Zimba

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 17

FIGURE 12

In Mazabuka, Livingstone and Choma, more organizations implemented compre-hensive sex education programs in urban than in rural areas. Percentage of organizations surveyed in Southern Province that implemented comprehensive sex education and social mobilization interventions in the past 12 months, Zambia 2013

Urban Zimba 1 1 Rural 1 Sinazongwe 2 1 Siavonga 1 0 Pemba 0 6 Namwala 7 7 Monze 6 13 Mazabuka 9 14 Livingstone 7 0 Kazungula 2 6 Kalomo 6 0 Gwembe 3 13 Choma 9

0 20 40 Percent 60 80 100

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 18

FIGURE 13

Schools, communities and worship places were less frequently sites for harm reduction interventions than for standard interventions. Percentage of organization surveyed in Southern Province that implemented selected HIV-prevention interventions in the past 12 months by type and site of intervention, Zambia 2013

17 Other 15 Harm reduction 28 23 Workplace 30 31 23 Affect knowledge, Health Facility 29 attitudes, behavior 31 13 Worship Place 20 31 Standard 36 Mobile Outreach 36 48 31 School 48 55 33 Home 36 39 58 Community 79 81

0 20 40 60 80 100 Percent

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 19

FIGURE 14

Livingstone had the highest percentage of organizations implementing interpersonal education programs. Percentage of organizations surveyed in Southern Province that implemented interpersonal education programs and mass media campaigns in the past 12 months by type of place of residence, Zambia 2013

10 Percent 8

Mass Media Campaigns Interpersonal Education

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 20

FIGURE 15

No condom distribution was implemented in Zimba and urban areas of Gwembe, Kagungula, and Pemba districts by organizations surveyed. Percentage of organizations surveyed in Southern Province that distributed condoms in the past 12 months by type of place of residence, Zambia 2013

0 Zimba 0 Urban 1 Sinazongwe 2 Rural 1 Siavonga 1 0 Pemba 1 6 Namwala 7 3 Monze 4 4 Mazabuka 4 11 Livingstone 6 0 Kazungula 1 6 Kalomo 4 0 Gwembe 2 12 Choma 9

0 10 20 30 40 50 60 70 80 90 100

Percent

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 21

FIGURE 16

The community was the most common implementation site for harm reduction interventions except in Kagungula and Mazabuka. Percentage of organizations surveyed in Southern Province that implemented harm reduction interventions in the past 12 months by district and intervention site, Zambia 2013

18 Community

16 Home

14 School

12 Mobile outreach

10 Percent 8

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 22 FIGURE 17

No organization surveyed was conducting or promoting voluntary medical male circumcision in eight out of 12 districts. Availability of organizations surveyed in Southern Province that promoted or conducted voluntary medical male circumcision in the past 12 months by district, Zambia 2013

STI Diagnosis & Post-exposure Voluntary Male Medical District Treatment Prophylaxis Family Planning Circumcision

Choma Yes Yes Yes Yes Gwembe Yes Yes Yes Yes Kalomo Yes Yes Yes Yes

Kazungula Yes Yes Yes No

Livingstone Yes Yes Yes No

Mazabuka Yes Yes Yes No Monze Yes Yes Yes Yes

Namwala Yes No No No

Pemba No No No No

Siavonga No No No No

Sinazongwe No No No No

Zimba No No No No

STI – Sexually Transmitted Infections

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 23 FIGURE 18

No organizations surveyed trained service providers and law enforcement, organized solidarity groups, or provided financial and in-kind sustenance support to people living with HIV in Pemba and Siavonga. Percentage of organizations surveyed in Southern Province that implemented selected interventions to mitigate barriers to prevention and negative social outcomes of HIV infection in the past 12 months by district, Zambia 2013

14 13

12 11 10 10 9 9

Percent 8 8 7 7 6 6 6 6 4 4 4 4 4 3 2 2 2 2 2 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0

Training service providers and law enforcement Self-help and solidarity groups Financial and in-kind sustenance support

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 24 FIGURE 19

In all but three districts, more organizations surveyed provided counseling than medical and legal assistance or legal, policy and institutional reform to protect the rights of PLWH. Percentage of organizations surveyed in Southern Province that implemented selected interventions to mitigate barriers to prevention and negative social outcomes of HIV infection in the past 12 months by district, Zambia 2013

18 17 16

14 13

12 11

Percent 8 8 7 7 6 6 6 6 4 4 4 3 3 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0

Medical and legal assistance Counseling Legal, policy, and institutional reform

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 25

FIGUREFIGURE 1620

At each implementation site, the least common interventions were those that mitigated biological outcomes of HIV infections. Percentage of organizations surveyed that implemented HIV-prevention interventions in Southern Province in the past 12 months by type and site of intervention, Zambia 2013

100

50 Percent 40

0 Community Home School Mobile outreach Worship place Health facility Workplace

Standard interventions Knowledge, attitudes, beliefs Harm reduction Mitigate barriers to prevention Mitigate biological outcomes

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 26

FIGURE 21

Nearly one out of five organizations surveyed did not integrate gender issues in their HIV- prevention activities. Percent distribution of organizations surveyed in Southern Province by level of integration of gender issues into their HIV- prevention activities/interventions, Zambia 2013

14% 19%

32%

35%

None Some key issues Most key issues All key issues

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 27 FIGURE 22

Half as many organizations addressed cross-generational sex as compared to violence against women. Percentage of organizations surveyed in Southern Province that addressed key gender issues in their HIV-prevention activities/interventions by type of issue, Zambia 2013

Other 6

Gender differentials in access to education/economic security 39

Gender differentials in care giving 49

Gender barriers in access to & utilization of HIV/AIDS services 68

Cross-generational sex 37

Violence against women 73

Gender norms 71

0 10 20 30 40 50 60 70 80 90 100 Percent

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 28 FIGURE 23

Unemployment, migration and poverty were the biggest constraints to the implementation of HIV prevention activities. Percentage of organizations surveyed in Southern Province that addressed key gender issues in their HIV-prevention activities/interventions by type of issue, Zambia 2013

Social Context Economic Context 100 100

80 80

60 60

48 42 42 Percent 40 37 40 31 32 24 19 19 20 15 20

0 0 Religion Gender Cultural Ethnic Social Unemploy Migration Poverty Donor Currency norms practices affiliation status ment priorities exchange rates

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 29 FIGURE 24

Only three percent of organizations surveyed received funding from the private sector for HIV-prevention activities. Percentage of organizations surveyed in Southern Province that received funding for HIV-prevention activities from specific sources, Zambia 2013

100

54 Percent 40

22 19 20

6 3 1 0 Government Donor Private sector Clients NGO/FBO/CBO Other

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 30

FIGURE 25

Young people aged 10-24 years were the population subgroup most targeted with HIV- prevention interventions by organizations surveyed.

Percentage of organizations surveyed in Southern Province that targeted specific key populations in the past 12 months, Zambia 2013

People living with HIV 71

Incarcerated populations 17

Uniformed personnel 15

Pregnant women, infants and young children 62

People who inject drugs 1

Migrants/mobile populations 23

Refugees/displaced populations 4

Young people aged 10-24 years 87

Men who have sex with men 2

Female sex workers 20

0 10 20 30 40 50 60 70 80 90 100 Percent

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 31

FIGURE 26

The three most common interventions targeted at female sex workers were HIV VCT, comprehensive sex/HIV education, and prevention counseling.

Percentage of organizations surveyed in Southern Province that provided the ten most common interventions targeted at female sex workers in the past 12 months, Zambia 2013

Community-based outreach to FSW 10

Linkages to other HIV prevention services 11

Condom distribution 11

Linkages to health care and ARV 12

Training of service providers/law enforcement 12

Education on adherence to universal precautions 12

Condom social marketing 13

Prevention counseling 14

HIV VCT 15

Comprehensive sex/HIV education 15

0 10 20 30 40 50 60 70 80 90 100 Percent

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 32

FIGURE 27

In five districts, no organizations targeted female sex workers with WHO priority HIV-prevention interventions for this key population group.

Availability of at least one organization providing WHO priority HIV-prevention interventions for female sex workers in the past 12 months by district, Southern Province, Zambia 2013

STI Detection Information, Voluntary Condom and Education, and Counseling District Distribution Management Communication and Testing

Choma Yes Yes Yes Yes

Gwembe No No No No

Kalomo Yes No Yes Yes

Kazungula Yes No Yes Yes

Livingstone Yes Yes Yes Yes

Mazabuka Yes No Yes Yes

Monze Yes No Yes Yes

Namwala No No No No

Pemba No No No No

Siavonga Yes No Yes Yes

Sinazongwe No No No No

Zimba No No No No

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 33

FIGURE 28

Two in every five organizations surveyed targeted people living with HIV with comprehensive sex/HIV education and community-based outreach. Percentage of organizations surveyed in Southern Province that provided the ten most common interventions targeted at people living with HIV in the past 12 months, Zambia 2013

Linkages/referrals to ARV 30

Spiritual care 30

Focused anti-discrimination/anti-stigma 32

Targeted interpersonal education/persuasion 33

Community-based HIV VCT for families/partners 34

Prevention, safe sex, risk reduction counseling 34

Community mobilization 36

Education on adherence to universal precautions 39

Comprehensive sex/HIV education 42

Community-based outreach to PLWH 43

0 10 20 30 40 50 60 70 80 90 100 Percent

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 34 FIGURE 29

No organization surveyed worked in Gwembe, Kazungula, Pemba and Sinazongwe in the past 12 months to provide interventions to prevent illness and infection in PLWH. Availability of at least one organization surveyed in Southern Province that provided WHO priority interventions for illness prevention, treatment and care in people living with HIV, by district, Zambia 2013 Opportun- Interventions to Prevention, istic Prevention, Improve Quality Food Security Diagnosis and Education to Infection Tuberculosis Diagnosis, of Drinking of HIV-affected Treatment of Promote Anti- Prophylaxis Prevention, Treatment Water and Malaria Households; Sexually- Adherence to retroviral and Palliative Diagnosis and of Viral Hygienic Prevention and Nutritional Care Transmitted Universal District Therapy Treatment Care Treatment Hepatitis Practices Treatment and Support Infections Precautions

Choma Yes Yes No Yes Yes Yes Yes Yes Yes Yes

Gwembe No No No No No No No No No No

Kalomo No Yes No Yes No Yes No Yes No Yes

Kazungula No No No No No No No No No No

Livingstone Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Mazabuka Yes Yes No Yes Yes Yes Yes Yes Yes Yes

Monze No No No Yes No Yes No Yes No Yes

Namwala No Yes No Yes No No Yes Yes Yes Yes

Pemba No No No No No No No No No No

Siavonga No No No No No No No No Yes Yes

Sinazongwe No No No No No No No No No No

Zimba No No No No No No Yes No Yes Yes

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 35 FIGURE 30

There were fewer geographic disparities in the availability of interventions for preventing HIV transmission to others as compared to interventions aimed at illness prevention, treatment and care for people living with HIV. Availability of at least one organization surveyed in Southern Province that provided positive prevention interventions to prevent HIV transmission to other people, by district, Zambia 2013

Prevention, Safer Sex, Risk Provider- Reduction Community- initiated Counseling, based HIV Counseling Family Distribution and Sero- VCT for and Testing Planning and Prevention of of Condoms discordant partners and for partners Repro- Mother-to- and Condom- Couple families of and families ductive Child Trans- Compatible Mass Media District Counseling PLWH of PLWH HealthCare mission Lubricants Programs

Choma Yes Yes Yes Yes Yes Yes Yes

Gwembe No No No No Yes No Yes

Kalomo Yes Yes Yes No Yes Yes Yes

Kazungula No No Yes No Yes No Yes

Livingstone Yes Yes Yes Yes Yes Yes Yes

Mazabuka Yes Yes Yes Yes Yes Yes Yes

Monze Yes Yes Yes Yes Yes Yes Yes

Namwala Yes Yes Yes Yes Yes Yes Yes

Pemba No No No No No No No

Siavonga No Yes No No Yes No No

Sinazongwe No Yes No No Yes No Yes

Zimba Yes Yes Yes No Yes Yes No

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 36 FIGURE 31 More than half of organizations surveyed targeted community-based outreach, comprehensive sex/HIV education and preventions/safer sex and risk reduction counseling interventions at youth aged 10-24 years. Percentage of organizations surveyed in Southern Province that provided the 15 most common interventions targeted at young people aged 10-24 years in the past 12 months, Zambia 2013

Training service providers/law enforcement 34 VCT 36 Prevention and response to sexual violence 39 Adherence education for universal precautions 40 Distribution of condoms & compatible lubricants 40 Assess risk, needs, vulnerability of youth 40 Linkages/referrals to health care & ARV 41 Focused anti-discrimination/stigma activities 42 Linkages/referrals to psychosocial support 44 Linkages/referrals to other HIV-prevention services 45 Advocacy 45 Targeted interpersonal education/persuasion programs 45 Comprehensive sex/HIV education 52 Prevention, safer sex, & risk reduction counseling 54 Community-based outreach to youth 58

0 10 20 30 40 50 60 70 80 90 100 Percent

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 37 FIGURE 32

Mazabuka was the only district in which there was at least one implementing organization for each of the key HIV-prevention interventions targeted at young people aged 10-24 years. Availability of at least one organization surveyed in Southern Province that provided key interventions for HIV prevention in young people aged 10-24 years in the past 12 months, by district, Zambia 2013 Design/ Establish- ment of Fostering Providing Harm Prevention, Youth- Parent and Informa- Reduction Diagnosis Access to Training for friendly Commun- tion and for People and Voluntary HIV Voluntary HIV Service Facilities ity Support Counsel- Distribution of Who Inject Treatment of Medical Male Counseling Treatment HPV Providers/Law District and Services for YFS ing Condoms Drugs STIs Circumcision and Testing and Services Vaccination Enforcement

Choma Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes

Gwembe No No Yes Yes Yes Yes No Yes Yes No Yes

Kalomo Yes Yes Yes Yes No No Yes Yes Yes No Yes

Kazungula No No No No No No No No No No No

Livingstone No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Mazabuka Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Monze Yes Yes Yes Yes No No Yes Yes Yes No Yes

Namwala Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes

Pemba No No No No No No No No No No No

Siavonga No No No No No No No No Yes No Yes

Sinazongwe Yes Yes Yes Yes Yes No No Yes Yes No Yes

Zimba Yes Yes Yes Yes Yes No No Yes Yes No No

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 38 FIGURE 33

Only one WHO-recommended intervention for primary prevention of HIV transmission in pregnant women – safer sex and risk reduction counseling – was included among the 15 most common interventions targeted at pregnant women, infants and young children. Percentage of organizations surveyed in Southern Province that implemented the 15 most common HIV-prevention interventions targeted at pregnant women, infants and young children in the past 12 months, Zambia 2013

Sexual violence prevention & response 24 Family planning and reproductive health care 26 Palliative care for HIV+ pregnant women 26 Linkages/referrals to psychosocial support 28 Focused anti-discrimination/stigma activities 28 HIV voluntary counseling & testing 31 Assess risk, needs, vulnerability of PWIYC 32 Advocacty 32 Linkages/referrals to other HIV-prevention services 32 Linkages/referrals to ARV and health care 32 Adherence education for universal precautions 32 Targeted interpersonal education/persuasion programs 33 Prevention, safer sex and risk reduction counseling 34 Community-based outreach 42 Comprehensive sex/HIV education 43

0 10 20 30 40 50 60 70 80 90 100 Percent

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 39 FIGURE 34

Infant feeding counseling and support was not provided in 7 out of 12 districts by organization surveyed. Availability of at least one organization surveyed in Southern Province that provided key interventions for HIV prevention in pregnant women, infants and young children, by district, Zambia 2013 Survival Virilogical/ Infant Interventions Serological Financial/In- Linkages/ HIV STI Family Feeding for HIV- Tests for kind Referrals to Tuberculosis Voluntary Diagnosis Planning and Anti- Counseling Exposed/ HIV- Sustenance Psychosocial Prevention, Counseling and Reproductive retroviral and Infected exposed Support/Social Support Diagnosis, and District and Testing Treatment Health Care Drugs Support Infants Infants Welfare Services Treatment

Choma Yes No Yes Yes Yes Yes No Yes Yes Yes

Gwembe No No No No No No No No No No

Kalomo Yes No Yes Yes Yes Yes No Yes Yes No

Kazungula No No No No No No No No No No

Livingstone Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Mazabuka Yes Yes Yes No Yes Yes Yes Yes Yes Yes

Monze Yes No Yes No No No No No Yes No

Namwala Yes Yes Yes No No Yes Yes Yes Yes No

Pemba No No No No No No No No No No

Siavonga Yes No Yes No Yes No No No Yes No

Sinazongwe No No No No No No No No No No

Zimba Yes No No No No No No No Yes No

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 40 FIGURE 35

Behavior change communication programs were the most common HIV-prevention intervention targeted at migrant and mobile populations by organizations surveyed. Percentage of organizations surveyed in Southern Province that implemented the 10 most common HIV-prevention interventions targeted at migrants and mobile populations in the past 12 months, Zambia 2013

Focused anti-discrimination/stigma activities 11

Adherence education for universal precautions 12

Linkages/referrals to other HIV-prevention services 12

Linkages/referrals to ARV and health care 14

Advocacy 14

Community-based outreach to migrants & mobile pop. 14

HIV voluntary counseling & testing 14

Targeted interpersonal education/persuasion programs 15

Comprehensive sex/HIV education 16

Prevention, safer sex and risk reduction counseling 18

0 10 20 30 40 50 60 70 80 90 100 Percent

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 41 FIGURE 36

Only Choma and Namwala had at least one implementing organization targeting migrant and mobile populations for each of the HIV-prevention interventions shown. Availability of at least one organization surveyed in Southern Province that provided selected interventions for HIV prevention in migrant and mobile populations, by district, Zambia 2013

Focused Community- Harm Prevention, Anti- based HIV Compre- Reduction Diagnosis Discrimin- Voluntary Prevention Outreach to Voluntary hensive for People and ation and Medical Male and Response Migrants and Counseling Sex/HIV Distribution Who Inject Treatment Anti-Stigma Circum- to Sexual Mobile District and Testing Education of Condoms Drugs of STIs Activities cision Violence Populations

Choma Yes Yes Yes Yes Yes Yes Yes Yes Yes

Gwembe No No No No No No No No No

Kalomo Yes Yes Yes Yes No Yes No Yes Yes

Kazungula No No No No No No No No No

Livingstone Yes Yes Yes Yes Yes Yes No Yes Yes

Mazabuka Yes Yes Yes Yes Yes Yes No No Yes

Monze Yes Yes Yes No No Yes Yes No Yes

Namwala Yes Yes Yes Yes Yes Yes Yes Yes Yes

Pemba No No No No No No No No No

Siavonga No No No No No No No No No

Sinazongwe No No No No No No No No No

Zimba Yes Yes Yes Yes Yes Yes No No Yes

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 42 References

Central Statistical Office (CSO), Ministry of Health (MOH), Tropical Diseases Research Centre (TDRC), University of Zambia, Macro International Inc. 2009. Zambia Demographic and Health Survey 2007.Calverton, MD: CSO and Macro International Inc.

Sweat, Michael. 2008. A Framework for Classifying HIV Prevention Interventions. Geneva, Switzerland: Joint United Nations Programme on HIV/AIDS (UNAIDS).

World Health Organization. 2010. Priority Interventions: HIV/AIDS Prevention, Treatment and Care in the Health Sector. Geneva, Switzerland: World Health Organization.

Zambia National HIV/AIDS/STI/TB Council (NAC). 2009. Zambia HIV Prevention Response and Modes of Transmission Analysis. Lusaka, Zambia: Zambia National HIV/AIDS/STI/TB Council.

Know Your HIV-Prevention Response: Southern Province, Zambia Chart Book on Implementation of HIV-prevention Interventions by NGOs 43

MEASURE Evaluation Carolina Population Center 400 Meadowmont Village Circle, 3rd Floor Chapel Hill, NC 27517 http://www.cpc.unc.edu/measure/