The HIV epidemic in Zambia: socio-demographic

prevalence patterns and indications of trends

among childbearing women
Knut Fylkesnes*†, Rosemary Mubanga Musonda‡, Kelvin Kasumba*†§,
Zacchaeus Ndhlovu*†§, Fred Mluanda‡, Lovemore Kaetano‡
and Chiluba C. Chipaila‡

Objective: To examine socio-demographic HIV prevalence patterns and trends

among childbearing women in Zambia.
Design: Repeated cross-sectional surveys.
Methods: Personal interviews and unlinked anonymous testing of blood samples of
women attending antenatal care in selected areas.
Results: The 1994 data includes information from 27 areas and a total of 11 517
women. The HIV prevalence among urban residents appeared with moderate
variation at a very high level (range 25–32%, comparing provinces). The
geographical variation was more prominent in rural populations (range 8–16%) and
was approximately half the prevalence level of the urban populations. With the
exception of the 15–19 years age-group, HIV infection was found to rise sharply
with increasing educational attainment (odds ratio, 3.1; confidence interval,
2.6–3.8) when contrasting extreme educational levels. Although the assessment of
trends is somewhat restricted, the available information indicates stable prevalence
levels in most populations over the last 2–4 years.
Conclusions: The data showed extremely high HIV prevalence levels among
childbearing women. Longer time-intervals between surveys are needed, however,
in order to verify the stability in prevalence identified by this study. The tendency to
changing differentials by social status is suggested as a possible sign of an ongoing
process of significant behavioural change.

AIDS 1997, 11:339–345

Keywords: Zambia, HIV, childbearing women, prevalence, trends,

educational attainment, socio-economic status

Introduction ed (15–44 years age-group) ranges from 15–30%, with

Globally, a number of countries found in a contiguous
belt stretching from Uganda southward to Zambia and
Botswana, have experienced HIV prevalence rates far
above any others. In this main HIV belt, the propor-
tion of the population in urban areas that is HIV infect-
striking urban/rural differentials [1]. Outside this belt
the HIV prevalence levels are still relatively low, except
from a few countries in West Africa. The available
information on trends in HIV infection from sub-
Saharan Africa indicate that prevalence rates may be
stabilising in several countries both within and outside

From the *Epidemiology and Research Unit, National AIDS, STD, TB & Leprosy Programme, Lusaka, Zambia, the †Institute of
Community Medicine, University of Tromsø, Norway, the ‡Immunology Unit, Tropical Disease Research Centre, Ndola and
the §University Teaching Hospital, Lusaka, Zambia.
Sponsorship: Supported financially by the Norwegian Agency for Development Cooperation (NORAD), the Ministry of
Health, Zambia, the Swedish International Development Authority (SIDA), and Irish AID.
Requests for reprints to: K. Fylkesnes, Institute of Community Medicine, University of Tromsø, 9037 Tromsø, Norway.
Date of receipt: 20 June 1996; revised: 7 November 1996; accepted 11 November 1996.

© Rapid Science Publishers ISSN 0269-9370 339

340 AIDS 1997, Vol 11 No 3
the main HIV belt [2–5]. Signs of declining prevalence
rates appear in the northernmost part of the main HIV
belt [6–7], contrasting with the recent and sharp oppo-
site trend in South Africa, Swaziland and Namibia
[8–9].
Childbearing women (CBW) have been identified as
the key sentinel population for monitoring the HIV
epidemic in the sexually active population [4,10], and
most data on the epidemic in sub-Saharan Africa stems
from surveillance systems among CBW. These systems
are primarily intended to monitor trends of infection
from sequential cross-sectional surveys of the same
population, however, and are rarely designed to pro-
vide national representative estimates. In Zambia, an
HIV sentinel surveillance system among CBW was
established in 1990 [5,11,12], and in 1994 it was con-
siderably expanded in order to improve the area of
geographical representation and to obtain more detailed
information on the socio-demographic characteristics.
In this study we examine the socio-demographic pat-
terns of HIV infection and describe prevalence trends
based on sequential cross-sectional surveys during the
period 1990–1994.
Material and methods
Study population and methods of data
collection
The HIV sentinel surveillance system in Zambia has
gradually been developed since 1990, and the criteria
for selecting the geographical areas (coverage of an
antenatal clinic) included in the system before 1994
have been described elsewhere [5,11,12]. In order to
further improve the geographical coverage of the sys-
tem, 15 new areas were included in 1994 (total 27),
and each of the nine provinces was represented by at
least one area with primarily rural residents and one
representing the provincial headquarters, with mostly
urban/peri-urban residents. The exception was the
capital, Lusaka, where four sites were selected, each
representing the coverage of an urban health clinic.
The choice of the new rural areas which were added to
the system in 1994 was a random selection from a list
of health clinics at province level.
All first attendees for antenatal care during a maximum
period of 4 months were enrolled. The required and
maximum sample size was 500, but the limit of 4
months on the data collection period resulted in sample
sizes below the required level from clinics with low
population coverage. For most sites the data collection
took place from August to November 1994.
Procedures were instituted to fulfil the requirement
of unlinked anonymous HIV testing of blood samples
collected for syphilis screening as part of the routine
standards of care. Personal interviews were carried out
by specially trained nurses using a pre-tested, structured
questionnaire. The main information collected was
socio-demographic characteristics, and in this study,
age, marital status (married versus unmarried), residence
and educational attainment were employed in the
analyses. Residence (urban versus rural) was measured
at individual level, and urban was defined according to
the definition employed by the Zambia Central
Statistical Office, namely, a locality with at least 5000
inhabitants, having half the population in non-agricul-
tural activities, and with attributes such as piped water
and electricity. Educational attainment was measured
by the number of years in school. Complete informa-
tion on HIV status and residence was obtained from a
total of 11 517 women. A total of 208 did not provide
information on age, and in addition 1069 did not
respond to the question about the number of years in
school.
HIV serology 1994
A venous blood sample was taken from each person
and serum separated in the laboratory at the local hos-
pital. All sera were tested for antibodies to HIV
(Capillus Rapid Test, HIV-1/HIV-2, Cambridge
Biotechnology, Galway, Ireland) by the local laboratory
technician, who had been specially trained and super-
vised by laboratory personnel from the two national
reference laboratories. The sera were frozen and trans-
ported to one of the two national reference laborato-
ries. Those from the sites in the four northern
provinces were sent to the laboratory in Ndola, and
samples from the other sites were sent to the laboratory
in Lusaka.
The accuracy of tests performed in the local laborato-
ries was assessed as follows: 50% of all HIV antibody
reactive sera and 5% of non-reactive sera (randomly
selected) were re-tested using RTD (recombigen HIV-
1/HIV-2 Rapid Test Device, Cambridge Biotech-
nology). Discordant results were tested again using
Western blot or an enzyme-linked immunosorbent
assay (HIV-1, ELISA), (both supplied by Cambridge
Biotechnology). No further testing of sera was per-
formed in geographical sites showing no discrepancies
between the first and second test (among 50% of the
sites). False positives were the most common form of
discrepancy detected. In all sites where false positive
tests appeared the remaining 50% reactive samples were
also tested again, and in sites where false negatives were
detected, the remaining 95 non-reactive samples were
retested.
Data analysis
Data were entered in EpiInfo (Centers for Disease
Control and Prevention, Atlanta, Georgia, USA) and
later converted to SPSS–Windows (Statistical Package
 The HIV epidemic in Zambia Fylkesnes et al. 341

for the Social Sciences, Chicago, Illinois, USA) for Table 1. Prevalence of HIV infection among childbearing women
analysis. Confidence intervals (CI) were calculated by province and area, Zambia 1994.
(using one–way ANOVA) assuming a random sample Province/Area No. HIV-positive 95% CI for
tested (%) % HIV-positive
of individuals. Missing data due to non-response to the
question on education were not found to represent any Western
Mongu 479 28.4 24.3–32.4
selection bias when it comes to HIV status. A logistic Kalabo 293 10.2 6.7–13.7
regression model was used to estimate the probability Southern
of HIV infection with the inclusion of age-groups as Livingstone 595 31.9 28.2–35.7
dummy variables (15–19 years as reference), residential Macha 497 9.1 6.5–11.6
Lusaka urban
status, marital status and educational attainment as inde- Chelstone 462 24.7 20.7–28.6
pendent variables (full model). Supplementary analyses Chilenje 456 35.3 30.9–39.7
were performed in order to test the assumption that the Kalingalinga 512 21.7 18.1–25.3
Matero 394 28.4 24.0–32.9
impact of educational attainment on infection is less Central
prominent in young versus older age-groups. When Kabwe 492 29.5 25.4–33.5
performing separate analyses of the 15–19 years age- Kapiri Mopshi 500 13.0 10.0–16.0
Eastern
group, the years in school were re-grouped (from 0–4, Chipata 498 30.3 26.3–34.4
5–6, 7, 8–9, 10+ as used in the full model) to 0–4, 5–6, Minga 489 9.6 7.0–12.2
7 and 8+, and the age-adjustment was done in terms of Northern
Kasama 470 23.8 20.0–27.7
age in years in the logistic regression. Chilonga 311 16.7 12.6–20.9
Isoka 498 10.6 7.9–13.4
Mporokosso 379 12.9 9.5–16.3
Luapula
Mansa 462 23.6 19.7–25.7
Results Kashikishi 508 14.6 11.5–17.6
Kasaba 499 12.0 9.2–14.9
The 1994 findings Samfya 404 20.0 16.1–24.0
Copper belt
Table 1 shows the HIV prevalence estimates for all Ndola 501 27.5 23.6–31.5
areas by province, with the provincial headquarters list- Ibenga 361 11.4 8.1–14.6
ed first. The proportion of HIV-seropositive individu- Kamuchanga 402 23.1 19.0–27.3
als in the Lusaka areas or provincial headquarters North-western
Solwezi 231 23.8 18.3–29.3
ranged from 22–35%. The areas which were mainly Mukinge 380 9.5 6.5–12.4
rural were shown in general to have about half the Kabompo 318 5.0 2.6–7.4
level of provincial headquarters (approximately 13%), Chitokoloki 126 7.1 2.6–11.7
Total 11517 19.8 19.1–20.6
although with some striking variation from area to area
CI, Confidence interval.
(range 5–23%). Provincial estimates by urban versus
rural residence, i.e., residence measured at the individ-
ual level, showed the urban residents to be at generally Table 2 shows the overall distribution of HIV infection
uniform prevalence levels in all provinces (range by educational attainment and Table 3 the same distrib-
25–32%) with some more distinct differences between ution for the different age-groups. Among both urban
the provinces among rural residents (range 8–16%). and rural residents the seroprevalence was found to be
The results of a logistic regression model after adjust- rising significantly with increasing educational attain-
ment for age only, revealed an estimated odds ratio ment. However, among adolescents (15–19 years) HIV
(OR) of 2.60 (95% CI, 2.36–2.87) when comparing infection was not found to differ by educational level
urban with rural residence. (Table 3). As shown from the results of the logistic
regression model (Table 4), the estimated OR was 3.13
The pattern of HIV infection by age was found to be (95% CI, 2.59–3.79) when comparing the two most
closely similar in the selected areas, and is given in extreme levels of educational attainment. Separate
Table 2 for the total material according to residential
analysis for urban and rural residents yielded estimated
status. In both urban and rural areas the highest sero-
OR of 2.46 and 4.23 for urban and rural respectively
prevalence was in the 25–29 years age-group (34% ver-
sus 17%), although not significantly higher than the (Table 4). Separate logistic regression analyses per-
prevalence of the 20–24 years age-group. In all age- formed for particular age-groups supported the assump-
groups the urban : rural ratio was approximately 2 : 1. tion of less prominent impact of education attainment
The age distribution of infection from the 15–19 years on infection in young individuals. No statistically sig-
age-group appeared closely linear in shape and with a nificant impact of education was revealed within the
clearly steeper slope in urban compared to rural popu- 15–19 years age-group; i.e., separate analysis for urban
lations; i.e., from 11% to 28% versus 4% to 11% in and rural strata revealed an OR of 1.11 (CI, 0.63–1.98)
urban and rural areas respectively. in urban and 1.58 (CI, 0.88–2.84) in rural strata.
342 AIDS 1997, Vol 11 No 3

Table 2. Distribution of HIV seroprevalence by residence, age and years in school of childbearing women in Zambia, 1994.
Urban Rural
N HIV-positive N HIV-positive
(% in category) (%) 95% CI (% in category) (%) 95% CI
Total* 5251 28.2 27.0–29.4 6058 12.9 12.1–13.8
Age-group (years)
15–19 1147 (22) 20.4 18.1–22.7 1446 (24) 9.0 7.5–10.5
20–24 1867 (36) 32.2 30.1–34.4 2012 (33) 15.2 13.6–16.7
25–29 1097 (21) 33.9 31.1–36.7 1147 (19) 16.5 14.3–18.6
30–34 718 (14) 27.6 24.2–30.9 861 (14) 12.5 10.3–14.8
35–39 355 (7) 18.9 14.8–23.0 442 (7) 9.3 6.5–12.0
40–44 67 (1) 10.4 2.9–18.0 150 (3) 6.7 2.6–10.7
Years in school
0–4 516 (11) 20.2 16.7–23.6 1682 (32) 8.0 6.7–9.3
5–6 695 (14) 23.5 20.3–26.6 1138 (21) 11.4 9.6–13.3
7 1511 (31) 26.0 23.8–28.2 1446 (27) 14.2 12.4–16.0
8–9 1255 (25) 30.3 27.7–32.8 753 (14) 20.8 17.9–23.8
10–11 442 (9) 40.6 35.5–44.6 178 (3) 20.2 14.3–26.2
12+ 508 (10) 39.4 35.1–43.6 121 (2) 39.7 30.8–48.5
*The total number is less when comparing different educational groups due to non-response to the question on years in school. CI,
Confidence interval.

Table 3. HIV infection and educational attainment by residence according to age-group.

Age group (years)
15–19 20–24 25–29 30–44
Years in Urban Rural Urban Rural Urban Rural Urban Rural
school N (%) N (%) N (%) N (%) N (%) N (%) N (%) N (%)
0–4
18.4 6.8 21.7 9.5 20.7 9.2 20.0 7.2
(98) (385) (161) (483) (82) (282) (120) (362)
5–6
20.9 10.1 27.1 11.3 27.3 15.6 19.3 11.4
(182) (298) (247) (379) (121) (192) (114) (193)
7
19.8 11.0 30.6 16.2 29.9 17.4 19.8 11.7
(339) (318) (517) (463) (311) (293) (273) (281)
8+
22.1 10.4 38.4 28.2 40.9 31.7 29.1 17.7
(457) (250) (812) (390) (509) (221) (309) (136)

Table 4 shows an estimated OR of 2.03 of HIV infec-
tion when comparing urban and rural residents and
after adjustment for age, marital status and educational
attainment. Further, it also shows the likelihood of
being infected is slightly higher among unmarried
women than married. In the 15–24 years age-group no
difference was revealed between currently married and
not married, while the age-specific analysis in the
25–44 years age-group revealed that those unmarried
were twice as likely to be infected as those married
(OR, 2.18; CI, 1.62–2.94).
Indications of trends of HIV infection
1990–1994
Table 5 shows the HIV prevalence among antenatal
women from areas where at least two results from
repeated measurements are available since 1990. The
results from Lusaka, as the only urban area with avail-
able repeated measurements, indicate a stable preva-
lence during the period 1990–1994 when considering
all areas together. The only peri-urban area, Solwezi in
north-western province, shows a rather unlikely single
result from 1990, and the two latest results indicate an
increasing trend. The remaining five areas shown in
Table 5 represent rural population. Four of them reveal
a stable prevalence during the last 2–3 years. Only one
area appears to have a tendency to increasing HIV
prevalence (Kalabo).
Unfortunately, age-specific trend analyses are seriously
hampered since only the 1993 and 1994 sentinel sur-
veillance system provided information on the age of
individuals. Change in prevalence within the 15–19
years age-group might be indicative of trends in inci-
dence, however, and the finding within this age-group
of a decline in the HIV prevalence in all four Lusaka
areas is worth mentioning (down from 27.6% to 22.5%
when proportions of each area are weighted equally).
Parallel age-specific comparisons from the four rural
areas with age-specific data showed the prevalence to
be stable in two of them (Macha and Minga), a decline
in one (Minga) and an increase in Kalabo (1993: no
information on age from Mukinge and Solwezi).
 The HIV epidemic in Zambia Fylkesnes et al. 343

Table 4. Results of logistic regression analysis of HIV infection among childbearing women in Zambia in 1994*.
Total Urban Rural
odds odds odds
Variable ratio 95% CI ratio 95% CI ratio 95% CI
Age-group:
15–19 (ref.) 1 1 1
20–24 1.85 1.60–2.14 1.89 1.57–2.27 1.79 1.41–2.26
25–29 1.95 1.66–2.29 1.91 1.55–2.35 2.03 1.57–2.62
30–34 1.42 1.18–1.71 1.49 1.18–1.88 1.32 0.97–1.78
35–39 0.98 0.76–1.26 0.93 0.67–1.29 1.05 0.70–1.56
40–44 0.73 0.42–1.27 0.55 0.23–1.31 0.92 0.45–1.89
Residence
Rural (ref.) 1 – –
Urban 2.03 1.83–2.26 – –
Marital status
Not married (ref.) 1 1 1
Married 0.85 0.72–1.00 0.81 0.67–0.99 0.95 0.71–1.27
Years in school
0–4 (ref.) 1 1 1
5–6 1.42 1.17–1.72 1.26 0.95–1.69 1.48 1.14–1.91
7 1.66 1.40–1.96 1.39 1.08–1.79 1.80 1.42–2.28
8–9 2.18 1.82–2.26 1.67 1.29–2.16 2.87 2.22–3.71
10+ 3.13 1.59–3.79 2.46 1.89–3.20 4.23 3.08–5.80
CI, Confidence interval. *Urban: n = 4846; rural: n = 5191.

Discussion An assumption relevant to the first 5–10 years of the

Due to the comprehensive geographical coverage, the
findings from 1994 are expected to show the main
geographical patterns of HIV infection among child-
bearing women in Zambia reasonably well. The selec-
tion of areas at province level was arbitrary, however,
and prevalence estimates presented at provincial and
national levels should be interpreted with caution.
CBW seem to provide overall prevalence estimates
very close to those of the population within the 15–44
years age-group [13], but somewhat underestimate the
population prevalence of women within the age group
15–34 [2]. The results from a recent population-based
survey in an urban Zambian population revealed the
same relationship: an overall HIV prevalence for both
sexes within the 15–39 years age-group of 26%
(n = 2170) compared to 25% among pregnant women
(n = 462) recruited from the same population (unpub-
lished data).
Our new data-set from Zambia provides some impor-
tant information leading towards a better understanding
of the dynamics of the epidemic. One of the major
uncertainties has been the degree to which HIV infec-
tion will spread from urban to rural populations [12]. It
is noteworthy in our present findings that the HIV
prevalence levels appeared surprisingly homogeneous
among urban residents in all provinces. Furthermore,
the surveillance data available provides some indications
that the urban : rural ratio in HIV prevalence might
have stabilized at a level of approximately 2–2.5 : 1.
However, several more years of surveillance is needed
for verification, and the data presented here are the first
which is seen as an acceptable baseline for future
repeated measurements, putting the urban/rural differ-
ences under continuous scrutiny.
epidemic in sub-Saharan Africa has been that of a
social-status bias in transmission towards the higher
social-status groups. When employing educational
attainment as a proxy variable for social status, studies
conducted in the early 1990s, within the main HIV
belt did not conclusively suggest an increased risk
among the higher educational groups [14–16]. The
present results indicate strong social-status differentials
in HIV seroprevalence in Zambia. Prominently higher
rates of infection were found in groups with higher
educational achievement compared to those less well-
educated. A previous report based on Zambian blood
donors revealed the same distribution pattern of HIV
infection at that very early stage of the epidemic [17].
Given the relevance of a theoretical assumption that
the process of behavioural change takes place through
diffusion of innovation from higher social-status groups
and downwards, the well educated are expected to be
the first to receive and to employ information on HIV
protection. Accordingly, it is likely that the socio-eco-
nomic pattern in transmission rates will gradually
change. In most age-groups it might be too early for
disclosing this type of change by prevalence rates, since
the majority of adults contracted the virus during the
first 5–10 years of the epidemic. A second factor is that
the progression time from HIV infection to
AIDS/death is presumably longer among the higher
educational groups. In this regard the 15–19 years age-
group represents an exception regarding our data, in
particular when considering that this group became
sexually active at a time when the information available
about protection had significantly improved in compar-
ison with the 1980s. Accordingly, if a significant
behavioural change has started, we should expect to
find a less prominent difference in HIV infection by
education in the youngest age-group. Findings from
344 AIDS 1997, Vol 11 No 3

Table 5. Prevalence of HIV among childbearing women by area, contrast between the same countries and communities
Zambia 1990–1994 (areas with two or more measurements). with regard to when the prevalence levels stabilize
Province/site Year N HIV-positive 95% Cl [2–4,18]. Within the main HIV belt, however, the
%
level at which stabilization occurs seems the same. In
Lusaka: Zambia, the available data for most areas are still ham-
Chelstone 1994 462 24.7 20.7–28.6
1993 299 26.8 21.7–31.8 pered by short time-intervals between surveys.
1992 208 22.6 16.9–39.7 Accordingly, the revealed overall tendency of stable
Chilenje 1994 456 35.3 30.9–28.3 prevalence levels based on data from ten areas with
1993 287 22.0 17.1–26.8
1992 445 27.0 22.9–31.1 repeated measurements will have to be verified. With
Matero 1994 394 28.4 24.0–32.9 the extremely high prevalence levels revealed in our
1993 288 27.1 21.9–32.2
1992 323 29.7 24.7–34.7
study in mind, however, it should be emphasized that
Kalingalinga 1994 512 21.7 18.1–25.3 even a situation with stable HIV prevalence is likely to
1993 442 23.5 19.6–27.5 mask high incidence.
Lusaka+ 1990 750 24.5

Southern:
Macha 1994 497 9.1 6.5–11.6
1993 500 10.0 7.4–12.6
1992 418 7.9 5.3–10.5 Acknowledgements
Eastern:
Minga 1994 489 9.6 7.0–12.2
1993 497 17.7 14.3–21.1 We acknowledge the support received from the staff at
1992 497 12.9 10.0–15.8 the two reference centre laboratories, the University
Luapula: Teaching Hospital, Lusaka and the Immunology Unit,
Kashikishi 1994 508 14.6 11.5–17.6
1993 490 15.1 11.9–18.3 Tropical Disease Research Centre, Ndola, and all the
1992 202 11.4 9.2–13.6 staff at the various sentinel areas.
Western:
Kalabo 1994 293 10.2 6.7–13.7
1993 306 4.9 2.5–7.3
1992 220 5.9 2.8–9.0
North-western:
Solwezi 1994 231 23.8 18.3–29.3 References
1993 380 15.0 11.4–18.6
1990 100 30.0 21.0–40.0
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