Gender Violence Haunts HIV Positive Women

from All Africa

The East African (Nairobi)

By Zachary Ochieng

Violence against Zambian women is hindering them from accessing and adhering to HIV treatment, claims a new report by an international human rights group.

According to the report, Hidden in the Mealie Meal: Gender-Based Abuses and Women’s HIV Treatment in Zambia, by Human Rights Watch, HIV programmes, activists and policy makers recognise that discrimination and violence against women must be addressed if the world is to combat the Aids pandemic.

But treatment policies and programmes still tend to ignore the connection between domestic violence or women’s insecure property rights and their ability to seek, access, and adhere to HIV treatment. Although the Zambian government has taken some steps to address violence and discrimination against women generally, major gaps remain in legislation, HIV treatment programmes, and support services to address poverty among women living with HIV and Aids.

Human Rights Watch says this must change if HIV treatment is to be provided equitably and to succeed in saving women’s lives.

Zambia is one of many countries setting ambitious targets for rapidly scaling up antiretroviral treatment for HIV and Aids and is making impressive progress. It is addressing a range of obstacles to treatment and receiving substantial donor support to overcome them. “However, women’s unequal status in Zambian society gravely undermines their ability to access and adhere to antiretroviral treatment (ART), and the government is paying little if any attention to the gender dimension of treatment, especially the impact of entrenched discrimination and gender-based violence and abuse,” says the report.

Human Rights Watch investigated the negative impact of gender-based human rights abuses on women’s access and adherence to HIV treatment in two provinces in Zambia, Lusaka and the Copperbelt, in 2006 and 2007. Women there told the international NGO how beatings and rapes by their partners, emotional and verbal abuse, loss of property upon divorce or death of a spouse, and fear of such abuses affected their access and adherence to treatment.

The abuses thwarted their ability to seek HIV information and testing, discouraged them from disclosing their HIV status to partners, delayed their pursuit of treatment, and hampered their ability to adhere to HIV treatment regimens.

Many women, fearing abuse or abandonment, fabricated excuses for their absence from home

during clinic visits or support group sessions and hid their medication in flower pots, holes in the ground, food containers, and elsewhere. Many struggled to find money for food, transport to clinics, and diagnostic tests, especially those whose property was taken when divorced, abandoned, or widowed. Some missed doses as a result. The strain took a toll on many.

Though gender-based abuses have seriously undermined their ability to get HIV treatment, most of the women Human Rights Watch interviewed said their difficulties are simply not discussed in the clinics where they go for HIV counselling or medicine. With few exceptions, health care providers did not raise the issue. Some of the institutions that train HIV counsellors in Zambia told Human Rights Watch “gender is integrated” into their training. Yet most of the dozens of HIV counsellors the rights body interviewed said they do not screen for gender-based abuses, offer referrals for services, discuss safety strategies with patients, assess how this impacts treatment, or otherwise address the abuses.

Treatment adherence counsellors said they count women’s remaining pills and discuss certain other obstacles to adherence, but not gender-based abuses. Almost all, however, expressed willingness to start dealing with these abuses with proper training and support.

“There is perhaps no better place than Zambia to create a model approach to responding to gender-based human rights abuses within HIV treatment programmes as part of an overall strategy to prevent and address these abuses,” the report says.

Situated in Southern Africa, the region most affected by the pandemic, 17 per cent of Zambia’s adult population is living with HIV and Aids, and of these, 57 per cent are women. Zambia also has high rates of gender-based violence. Recent surveys have found that more than half of women surveyed reported beatings or physical mistreatment since age 15, and one in six women reported having been raped.

Before ARVs became freely available to all in Zambia, receiving a HIV-positive diagnosis was the equivalent of a death sentence. By introducing a policy of universal access to free ART, the Zambian government proved its seriousness in attempting to combat the HIV pandemic and save the lives of many Zambians living with HIV and Aids. But there are still life-threatening barriers to the success of ART programmes and some of these, such as domestic violence and insecure property rights, affect women disproportionately. The government of Zambia should urgently address and remove these barriers, recommends the report.

Zambian women living with the disease suffer persistent constraints to accessing HIV information, testing, and treatment, and to adhering to ART. The accounts of women interviewed for this report reveal the excruciating effects of gender-based violence and insecure property rights, not only as abuses in their own right, but as major factors that delay women’s access to life-saving ART, compel them to hide their HIV status and medicine, and eventually impede adherence to ART.

The consequences are potentially disastrous since adherence to ART must be close to perfect (95 per cent) to achieve proper suppression of HIV. Lack of adherence can also lead to the emergence of new, resistant strains of HIV that can both be transmitted to others and lead to drug failure.

Zambia’s health system and legal frameworks are ill-equipped to respond to gender-based abuses and their effects. In healthcare facilities HIV treatment adherence counsellors and other healthcare providers do not generally probe for, discuss, or respond to gender-based violence and other abuses, thus missing vital opportunities to support women’s treatment.

HIV treatment counsellors also do not receive specialised training to help them detect or respond to gender-based violence. There is no government protocol that instructs counsellors on the practical steps to detect or address gender-based violence.

Although Zambia has expanded its clinics substantially to accommodate the increasing need for and supply of ART, in most clinics there is inadequate private, confidential space for counselling.

Most of healthcare facilities also lack appropriate settings for women to be able to disclose their experiences of violence or other abuses.

With respect to legal protections, there is currently no specific law to address gender-based violence, and the Penal Code has limited application in cases of domestic violence. It also does not appear to cover psychological abuse or marital rape.

Widowed and divorced women who are living with HIV and Aids suffer impoverishment as a result of their inability to exercise and enforce their property rights, and this affects their ability to access and adhere to ART. The Intestate Succession Act is not properly enforced, and property grabbing still occurs.

Widows who experience property grabbing and many women divorced under discriminatory customary law often sink into deep poverty and fail to start or adhere to treatment as a result of their inability to afford food or the transportation necessary to attend clinic appointments to collect their ART.

According to the report, Zambia still has a long way to go to fulfill its international and regional obligations in relation to women’s human rights, including the right to the highest attainable standard of health. As a priority, the Zambian government should immediately take necessary steps to integrate detecting and responding to gender-based violence into the work of healthcare facilities providing ART. As a prerequisite, the government should build the capacity of healthcare facilities and providers so they can respond to the gender-based abuses described in this report, particularly violence against women. There are several useful guidelines developed by international and regional organisations that could help the healthcare sector in its response to gender-based violence.

The Zambian government should act immediately to introduce constitutional and legal reform as a critical measure to eliminate discrimination against women, including under customary law. The government should make sure that the new constitution affirms equal rights for all Zambians, including women. It should enact a law that addresses gender-based violence without delay, and as a necessary step towards the prevention of gender-based violence and effective prosecution of perpetrators. The Zambian government should also enforce the Intestate Succession Act. It should further ensure that the Matrimonial Causes Act provides for equal property rights for women upon divorce.

In the long run, it is essential that the Zambian government, UN agencies and donors work in collaboration with women’s rights organisations to transform the unequal power relations between women and men and the social, economic, political, and cultural factors that maintain gender-based abuses and inequality in Zambia.

In 2000, the Zambian government, along with other world leaders, made firm commitments, in the Millennium Development Goals, to promote gender equality and combat HIV/Aids.

This political commitment and the availability of resources — inadequate as they may be — could help Zambia set an example in the Southern Africa region by removing the overwhelming barriers to HIV treatment and support that some women face.

Otherwise, gender-based abuses will continue to shatter the lives of countless Zambian women in acute need of ART and contribute to avoidable losses of health and lives.

On the positive side, the government has enacted laws to protect women’s property rights, has established specialised police units to address gender-based abuses, and in 2006 appointed a cabinet minister for gender and development.

Civil society organisations provide services for women survivors of abuse and adults and children living with HIV and Aids. The country has high-level governmental and multi-sectoral bodies working on HIV and Aids, and is commended globally for its fight against the epidemic. It has pledged to make HIV treatment and related tests free in the public health system and has increased the number of people on treatment over 30-fold in five years. However, almost half of all individuals in need of treatment are still not getting it.

Increasing donor support for its HIV and Aids response puts Zambia in the spotlight, including as one of 15 focus countries for the United States President’s Emergency Plan for Aids Relief (Pepfar).

Zambia has also ratified major regional and international treaties that require the government to eliminate violence and discrimination against women and to guarantee their rights to health, physical security, non-discrimination and life. It has also committed to fulfil the United Nations Millennium Development Goals, which include promoting gender equality, empowering women and combating HIV and Aids.

To safeguard women’s rights and dignity and to ensure the success of HIV treatment programmes, Zambia must turn these commitments into concrete action.

Human Rights Watch calls on the Zambian government to strengthen its response to HIV and Aids by safeguarding women’s human rights, ensuring equitable access to antiretroviral therapy (ART), and providing women on ART access to healthcare services designed to help them deal with gender-based abuses as part of their treatment. In this effort the Zambian government should act urgently to enact and enforce legislation on sexual and gender-based violence.

The government should ensure that the new constitution currently under debate guarantees women’s equality in all respects, including matters relating to personal and customary laws.

And the government should ensure that health care providers working in the areas of HIV and Aids and ART receive adequate training, clear guidelines, and support to detect and address gender-based abuses, recommends the report.

It should improve health care infrastructure, including by ensuring that HIV counselling occurs in a private setting, where women and their healthcare providers can discuss the existence or risk of gender-based abuses.

Donor agencies should support these reforms as a priority, endorsing them as a necessary component of effective treatment for women with HIV and Aids.

This is a dynamic moment of opportunity and risk in the global fight against HIV and Aids. Governments and international agencies are pressing to achieve universal access to HIV prevention, treatment, care, and support by 2010. Donors are spending tens of billions of dollars to support HIV treatment.

The number of individuals on HIV treatment worldwide jumped from 400,000 in 2003 to more than two million in 2006 and millions more will seek testing for HIV infection and start treatment in the next few years.

Without urgent attention to gender-based abuses, Zambia will not realise the potential for these efforts, and the lives of many women will be at risk.