How long journeys and drought endanger HIV care in Zambia

Over two decades of progress in Zambia’s fight against HIV are at risk of being undone as access to antiretroviral therapy (ART) becomes increasingly challenging. Many patients in some remote areas face long, arduous journeys to health centres for their vital medication, a situation worsened by the country’s severe drought.

The difficulty of reaching clinics has led to rising rates of non-adherence to ART, threatening the health gains achieved by initiatives like the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight HIV, tuberculosis, and malaria.

Zambia continues to have one of the world’s highest rates of HIV infection. According to the World Health Organisation, about 1.4 million Zambians are infected with HIV, and the infection rate is about 11 per cent for those between the ages of 15 to 49.

Twenty years ago, HIV was an undeniable presence in everyday life across Zambia. Streets and clinics bore stark reminders of the epidemic, from the sunken faces of the infected to families mourning lost loved ones. Thanks to sustained global efforts, those scenes have largely vanished, rendering HIV a less visible but still dangerous pandemic.

Without immediate action to address these access challenges, Zambia risks reversing the progress made in combating HIV. In remote areas like Ngabwe district, 150 km northwest of Kabwe in Central province, long distances to health centres have forced some patients to miss treatments or share antiretroviral drugs—actions that could undermine the nation’s fight against AIDS.

The district reports an HIV prevalence rate of 11% among its 47,000 residents, closely matching the Central Province’s rate and slightly below the national average of 11.1%, according to the 2018 Zambian Demographic and Health Survey (ZDHS). However, certain hotspots, such as Mumbachala near the Kafue River—where fish trading and associated high-risk behaviors are common—pose heightened transmission risks. Fishing camps have also been identified as key areas for increased HIV transmission.

“We are concerned that the ongoing drought and resulting food insecurity may force more women into transactional sex for survival, further increasing the risk of HIV transmission,” said Mphande Chishala Ngabwe district senior clinical care.

Ngabwe currently has eight health facilities—five health centres and three mini hospitals—serving a population of about 47,000. Until the systemic challenges, such as inadequate health infrastructure, are addressed, long distances to health centres will continue to hinder ART distribution and adherence.

Testimonies from HIV positive individuals

A distraught and exhausted Mathews Muyambango, formerly of Kasu Village in Chief Mukubwe’s area, shares his struggle with accessing ART. The journey to the nearest Mumbachala rural health centre takes him over three hours each way.

His situation is further worsened by the drought affecting over nine million Zambians across 84 of the country’s 117 districts. As water levels have dropped, Muyambango, a fisherman, has been forced to relocate further downstream along the Kafue river due to dwindling fish stocks at his previous location.

With no public transport available, 56-year-old Mr. Muyambango,who has been on ART since 2021, faces a gruelling five-hour trek to access his medication. The journey is so long that he often has to spend a night midway before reaching the health centre.

“I used to take three hours from Kasu, but since I moved further in search of fish, it now takes me over five hours to reach the clinic,” Mr. Muyambango shared.

This challenging situation has forced him to make difficult decisions. “Because of the long distances, I sometimes borrow ARVs from friends before I can get my own. Right now, I’m managing with some I got from a friend,” he said.

“This will last me until I can get my own drugs,” added Mr. Muyambango, who had spent a night in the neighbouring Myashi village on his way to Mumbachala rural health centre.

A plight shared by many

Mr. Muyambango’s struggle reflects a broader problem across the country.

Samuel Penyengwe, a 48-year-old fisherman from Mwapwa village in Chief Mukubwe’s area, shares a similar story of hardship. Mr. Penyengwe, who has been on ART for three years, admits that the distance to Mumbachala health centre—over 16 kilometres away—sometimes forces him to skip treatment.

“ARVs have helped me stay healthy and alive, but the biggest challenge is the distance to the clinic. Sometimes, I’m forced to miss treatment,” Mr. Penyengwe said. “It’s even worse during the rainy season when the area gets flooded.”

For 42-year-old Reuben Mapulanga, a farmer and fisherman from Mupuka village, the three-hour journey to the nearest health centre has been a significant barrier to adhering to his ART treatment. Diagnosed with HIV in 2017, Mr. Mapulanga started ART but stopped after a year due to severe side effects, including hallucinations.

“I started ART in 2017 when I was near death, but the medication caused me to almost lose my mind. People advised me to stop and just eat plenty of nshima. Since then, I’ve been okay,” he said.

“Friends have urged me to return to the hospital for a check-up to address the side effects, but the long distance is a major challenge.”

Volunteer highlights struggle of HIV patients in accessing treatment

Awanu Chimwala, a dedicated community volunteer at a local health centre for the past eight years, has seen firsthand the challenges HIV patients face in accessing ART.

“Distance is a major hurdle. We often find patients who are two months behind in their treatment, even though they should not go more than 28 days without their medication,” says the 36-year-old Ms Chimwala, from Chipalo village in Chief Ngabwe’s area. Every day, she crosses the Kafue river to reach the health centre.

Desperate situations often lead to desperate actions. “Patients sometimes admit to borrowing drugs from friends, but we strongly discourage this because they may be on different treatment regimens,” she explains.

For those who miss doses, Ms Chimwala warns of the dangers: “Interruptions in treatment (IIT) can result in an unsuppressed viral load, putting patients at greater risk.”

Health official Mpande Chishala echoes Ms Chimwala’s concerns, emphasising that distance remains the greatest barrier to managing ART, with some patients travelling over 70 kilometres to reach the nearest health centre.

Mr. Chishala, who is a medical officer at Mukubwe mini-hospital, highlights that the problem worsens during the rainy season, when flooding cuts off access to many areas. In response, patients with a suppressed viral load are given a six-month supply of medication since many communities become unreachable.

“We’ve encountered cases where patients exhaust a four-month supply in just two months. Upon investigation, we often find they are sharing their medication, usually with their partners,” Mr. Chishala notes.

“The risk is that couples may be on different treatment regimens, and missing appointments due to fear of being questioned leads to treatment interruptions, which can result in drug resistance,” he warns.

No response from NAC

Ngabwe district director of health, Dr. Kelvin Mwila, points out the significant challenge posed by the long distances to health centres, which affects access to ART and adherence.

“Many people live far from health facilities, making it difficult for them to access ARVs. Some resort to borrowing drugs from friends without realizing they may be on different treatment regimens,” said Dr. Mwila.

He acknowledged a previous programme that used volunteers to deliver ARVs, but noted that it was not sustainable.

This lack of access also contributes to harmful practices like sharing medication. Awareness about ART treatment remains low, as evidenced by one resident, Muyambango, who admitted, “I didn’t know there was a difference in the drugs we take or that we shouldn’t share them.”

In Zambia, the national HIV response is overseen by the National HIV and AIDS Council (NAC), established in 2002. However, the NAC has not responded to MakanDay’s questions, including concerns about how the shift in focus from HIV and AIDS to other diseases may affect the country’s HIV response.