LUSAKA, ZAMBIA — Single mother of three Evelyn Chalo always postponed her prenatal visits to the doctor until she was in the third trimester of her pregnancy. The nearest health facility is about 20 kilometers (12 miles) away from her home in rural Rufunsa and there is no convenient mode of transport. So she would typically visit the clinic just once before then giving birth in her mud-brick house with its grass-thatched roof and a small hole for a window, a ray of light filtering in to illuminate the interior during the day. Women from the community would gather to assist with the delivery.
When the coronavirus brought life as usual to a halt across the world, Chalo was pregnant with her third child. By the time she would normally travel to visit the clinic, Zambia was under partial lockdown, so she did not go — she worried that exposure to the virus would kill her. “Why would I go to the clinic where there are people sick with COVID, when the government had stopped people from moving?” she says. With no radio at home or any other access to credible information, her knowledge of the pandemic was based on rumors flitting about in her sparsely populated community.
Chalo had no complications during her pregnancy but was wracked with a persistent cough, which she treated with herbs plucked from nearby bushes. She gave birth to a son in October 2020, a pale and feeble child who kept falling ill. “If it wasn’t diarrhea, then it was fever or skin rash,” she says. Chalo’s herbal concoctions failed to make him better, so she finally took him, then 1 year old, to the clinic. That’s when Chalo and her baby were diagnosed with HIV.
Roughly 11% of Zambians over the age of 15 are HIV-positive and about 0.7% of all children are infected, according to 2021 data. Transmission of the virus from mother to child at birth or through breastfeeding accounts for 90% of all infections in children, which is why HIV testing is recommended during prenatal visits. If detected early, spread can be curtailed by providing antiretroviral treatment to infected pregnant or postpartum women and prophylaxis treatment to exposed babies. But a decline in hospital visits during the pandemic has widened existing gaps in testing, scuttling Zambia’s progress in combatting new HIV infections, especially among infants.
Zambia’s health guidelines encourage all women to test for HIV during their first prenatal visit and when in labor, if more than six weeks have elapsed since their last screening. During the first year of the pandemic, government data indicates a modest decline in deliveries at health facilities — from 80.5% in 2019 to 73.9% in 2020 — and a larger decrease in prenatal HIV testing, from 87% to 71%.
Graphic By Matt Haney, GPJ
Mwaba, a nurse at Chalo’s rural clinic who requested to be identified only by his middle name because he wasn’t authorized to speak to the media, says he observed fewer mothers visiting during the first year of the pandemic.
For Chalo, news of her HIV status was devastating.
“It took a lot of counseling,” she says. “The counselor would cycle to my place just to counsel me. It took three months for me to recover from the shock.” She and her son are now both receiving antiretroviral drugs. Her elder children, ages 15 and 13, remain healthy.
Mainala Tembo lives in the capital, Lusaka, where health services are easier to access. But she too shunned prenatal care during the pandemic and opted to have a home delivery. “When I heard statistics of the pandemic on the radio and TV, I got scared,” she says. “I had a healthy pregnancy, but after giving birth I started feeling weak, which I thought was normal for a breastfeeding mother.” When she went to the doctor six months after giving birth, she and her baby were both diagnosed with HIV.
Tembo, a mother of two other children, ages 16 and 12, says she was not screened for HIV during her earlier pregnancies either. (Zambia’s comprehensive testing policy was introduced in 2006.) One reason she demurred from getting tested was fear.
“I was not ready to handle the news of being HIV-positive,” she says. Grappling with the diagnosis now, she regrets her hesitation. “I think it’s foolishness. I should have done the test and prevented my baby from getting infected.”
Dr. Suilanji Sivile, an HIV technician with the Ministry of Health, says the ministry is trying its best to improve access. “One pregnant woman not tested for HIV is too many,” he says. “We as a ministry have ensured that our staff goes around to communities to give correct information and test those who are willing, especially pregnant women.” The pandemic disrupted many health programs but “we have learned to live with it,” he says. “I am sure even women that feared clinics are now freely visiting.”
The World Health Organization recommends that expectant mothers see a doctor, nurse or midwife at least eight times during pregnancy — revising its earlier recommendation of a minimum of four contacts — in order to receive services and information crucial for their health and that of their future children. In Zambia, according to the latest data from the United Nations Children’s Fund, known as UNICEF, fewer than two-thirds of women age 15-49 access prenatal care four or more times — another impediment in the country’s efforts to meet the United Nations goal of ending the AIDS epidemic by 2030. Eastern and southern Africa, accounting for approximately 55% of all people living with HIV, had made great strides in containing the virus. New HIV infections declined by 43% between 2010 and 2020, with a 64% decline among children — the sharpest reduction in any region.
Sivile acknowledges that distance may be a barrier to access, but he points to the availability of “mothers’ shelters” in rural areas: lodging available for out-of-town pregnant women waiting to deliver their babies at clinics or access other forms of care. Chalo says her rural clinic does have a mothers’ shelter but it was difficult for her to stay there. “You need to have enough money for food,” she says, “and I could not leave the children at home alone. I needed to be available for my children.”