Puppets help Zambian children deal with HIV stigma

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The Center’s David Bryden describes a visit to the Bwafwano Community Home Based Care organization in Zambia during a recent Congressional delegate trip to Africa.

Children clap and sing as the congressional delegates arrive at the Bwafwano Program.

“Hello, hello! We welcome you to our school!” about 100 clapping children sang as our congressional study tour arrived at the Bwafwano Community Home Based Care organization, run by Executive Director Beatrice Chola. The Bwafwano program provides health and related services to children, including those living with HIV/AIDS.

There followed a presentation of dancing and singing by a group of about 15 women who were part of the voluntary caregivers group that helps support the local children, a short speech by an HIV positive teenage girl about how she is persevering despite health challenges, and a presentation by Mrs. Chola about current successes and challenges.

This was perhaps the most moving of all the site visits on our congressional study tour to Zambia, where children less than 15 years of age make up 50 percent of the population of 12.2 million, according to a 2007 survey (ZDHS 2007).

We were also thrilled to see a demonstration of the puppet show the program uses to educate the children to take their medication on time and to not be ashamed of being HIV positive.

“I wish to thank the staff from the US Congress for visiting Bwafwano this afternoon,” Mrs. Chola said.   The program receives essential support from PEPFAR, through the Center  for Infectious Disease Research in Zambia (CIDRZ) and the Elizabeth Glaser Pediatric AIDS Foundation. “I wish to further thank the U.S. Government for its continued support toward HIV and AIDS programs in Zambia and I can only pray that this support continues for a long time to come.”

Bwafwano Community Home Based Care was established in 1996 as a community response to the increasing number of HIV/AIDS,  and TB cases, and orphaned and vulnerable children (OVC) in the Chipata catchments area.  This part of Lusaka has a population of more than 80,000 people, but has few health services.

Since then, Bwafwano has expanded into a comprehensive, multi-sector service organization providing quality care and support services to people living with HIV/AIDS and OVC. It is currently operating in four districts of Zambia; Lusaka and Chongwe Districts in Lusaka Province and Chibombo and Mkushi Districts in Central Province of Zambia.

Care and support is provided to OVC while building capacities of families and communities.  HIV prevention for young people is addressed, including thorough reproductive health education.  The program also trains clients and caregivers in income generating skills.

Children line up at the entrance of the Bwafwano Program to welcome the U.S. congressional delegates.


In 2008, Bwafwano began its Community Pediatric ART Program with support from CIDRZ. To date the program has enrolled 300 children into the program and initiated 197 on ART, while the remainder are not yet clinically eligible for treatment.

Services include counseling, medical care, adherence and nutrition support, and home-based care.  Our delegation also visited Bwafwano’s delightful play house where children can receive play therapy in a safe, comforting environment.

In an effort to actively address TB, Bwafwano trains community volunteers in TB and HIV management including early diagnosis, treatment and prevention. They are also actively involved in the implementation of Directly Observed Therapy Short-course (the WHO-recommended treatment strategy for detection and cure of TB) and provide community-based laboratory services for TB.

Mrs. Chola told us about several challenges currently faced by the program:

  • Staff retention problems due to low salaries
  • Inadequate nutrition supplements
  • Inadequate feeding options for breastfeeding children, leading to HIV positive mothers breastfeeding their babies for up to 1 year and 2 months, or more
  • Issues of disclosure
  • Lack of PCR testing equipment, which would provide an accurate HIV diagnosis for infants.

Judging from PEPFAR’s plan for Zambia for 2010 (the 2010 County Operation Plan or “COP”), some of these challenges might be addressed this year.  The COP states that the launch of a bilateral nutrition support project is expected in 2010 (page 13).  This program will target prevention of mother to child transmission (PMTCT) clients and their HIV exposed infants for nutrition support.

PEPFAR is the largest source of external support for OVC services, and this support from the U.S. government is crucial, including for capacity building.  The COP states that the Zambian government’s agencies charged with addressing the needs of children “have not been very effective in implementing OVC services as they are inadequately funded and have insufficient manpower.” (page 40)

PCR testing for infants is crucial, since antibody tests for infants may yield false positive results for up to 18 months. In the absence of early infant diagnosis, most HIV exposed infants are lost to follow up and 50 percent of untreated HIV-positive infants die before their second birthday.

HIV testing for infants using PCR equipment can currently be performed in only three locations in the country, though the COP documentation states that the percentage of children receiving this test has gone from 9 percent in 2007 to 23 percent in 2008 (page 45).

At Bwafwano, the staff showed us how they collect a sample of an infant’s blood on filter paper, providing a Dried Blood Spot (DBS), which is then sent to the laboratory for testing for the presence of HIV or viral RNA.

PEPFAR support goes beyond medical care to providing support for school fees, which supports HIV prevention.  The COP states that by mid fiscal year 2009 it had provided scholarships to more than 24,000 students, of which 6,000 have gone on to university. PEPFAR language states that this support helps protect students from dangerous situations where they could be exposed to HIV. (COP, page 41)

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