V. The Impact of Gender-Based Abuses on Women’s HIV Treatment

We have seen domestic violence interfere with ARVs [antiretroviral drugs] many times.  There are several examples of such cases among women in [YWCA’s] shelter.  One [of the women in the shelter] had a partner who threw away her pills.  [He] said to her, “If you have to drink medicine you’re out of this house.”     

—Yeta Mekazu, shelter manager, Young Women’s Christian Association, Lusaka, February 1, 2007

Human Rights Watch identified gender-specific barriers that impede Zambian women’s ability to seek HIV information or start and continue using ART.  These include violence and the fear of violence by intimate partners, the fear of abandonment and divorce in an environment where women suffer insecure property rights, and property grabbing upon the death of a spouse.  These abuses occur in the context of poverty and of a culture that condones male authority and control over women.  The final result can be severe.  Some of the women in need of ART either do not access ART in the first place, with dreadful impact on their health and their lives, or they hide their HIV status and their ART, which sometimes results in missing vital ART doses or appointments to collect their medication.

Gender-Based Violence

Women reported to Human Rights Watch that domestic violence at the hands of their husbands and intimate partners, and the fear of such violence, had a direct, harmful impact on their ability to start and continue using ART.  Women said that they were beaten, slapped, shouted at, verbally abused, and raped upon discussing HIV testing and treatment with their husbands, after disclosing their HIV status to their husbands, and as a result of visiting health facilities to collect their ART. 

Some of the women interviewed for this report said that they could not be tested for HIV infection or get access to ART because of the kinds of abuses described in this chapter, or fear of such abuses.  Some women only accessed HIV services and started ART after their husbands died.  Others said that they received HIV tests through antenatal services while pregnant, but because of violence and the fear of violence they did not go back to the health facility to collect their test results.  Other women started taking ART without informing their husbands. 

HIV Testing and Disclosure

To access treatment women need to receive an HIV test, and if the test results are positive, they usually take further tests before they can start ART.  Married women interviewed for this report stated that their husbands and other intimate partners beat, kicked, or emotionally abused them when discussing HIV testing and treatment, and when they disclosed their positive HIV status.  This caused critical delay in their ability to start ART.  Mercy Z., 29, told Human Rights Watch,

I got married in 2004 and my husband started giving me STDs [sexually transmitted diseases]…. He goes out with women.  When I ask for a condom, or go to the clinic to get treatment, he starts beating me. In January 2006 I went for VCT [voluntary counseling and testing].  He was refusing [to receive an HIV test].  The results came positive. From the time I got the results, he started beating me up.  After two months he chased me away. He beat me everywhere.  When I was four months pregnant he beat me until the placenta came out.  I had to go to the Victim Support Unit [a special unit of the Zambian police that addresses abuses against women and children].58

Some of the women interviewed for this report described the psychological abuse they experienced as a result of discussing HIV testing with their husbands and when their husbands found out about their HIV status.  Unique Z., who lived with her Zambian husband in a neighboring country where he worked, told Human Rights Watch that when she discussed HIV testing and counseling, “[My husband] just ignores me, he does not even eat in the house.  He just comes home and takes a bath and goes out again.”59  Unique Z. said that this delayed her decision to receive an HIV test until she became very sick:

When I became very sick, I said that I needed to be near my mother and came … back to Zambia. [That was when] my brother took me to take an HIV test.  [At the time], my CD4 countwas 21.60  When I tested positive, I went into depression for three weeks … I am on ARVs [antiretroviral therapy] and on Monday my CD4 count was 725.  When I [first] met [my former husband] he was very good.  Two months after we met he said to me “I want you as a parent [mother for his children].” I said to him okay, let us have [an HIV] test.  I [later] discovered that he was just a womanizer.  We fought when I asked him about women.  He hit me on the mouth.  He tore half of my hair.  I spoke to his brother but he told me that this was a domestic affair and there is no need to involve the police.  I just went to his elders and discussed it.  “He is not a criminal.” That is what they said.61

Numerous other women said that their husbands described them as “prostitutes,” suggesting that the women had extramarital affairs and as a result they suspected that they had sexually transmitted infections.  As such, several women interviewed for this report told Human Rights Watch that they decided not to discuss the matter with their husbands or take HIV tests.   

Women who access routine HIV testing as part of antenatal services sometimes fear domestic violence should they raise the issue with their partner or husband and as a result some may never return to the clinic to receive their HIV diagnosis or to be assessed for readiness for ART. Others simply decide not to start ART.  Monica Mwachande, a senior nurse at the government’s Kalingalinga Clinic, said that when she asks women why they did not return to the clinic for further tests, “At times they say, ‘Suppose I find my results positive, this may cause problems at home.’”62

The impact of the delay in HIV testing and in commencing ART as a result of violence is reflected in the testimony of Precious C., 43, who was only able to receive an HIV test and later enroll on ART after her husband abandoned and then divorced her.  She told Human Rights Watch, “My CD4 count was only 4 …. I went down to 27 kilograms from 68 kilograms.  [I looked like] a skeleton.  There were buds [bumps/blisters associated with AIDS related skin conditions] coming from my body and I was impaired whenever I came into contact with sunlight … I realized that I was killing myself.”63  Precious said that had she still been with her husband, she never would have been able to start ART, and that she could have died as a result:  “If I was still with him I am sure I would have died [by now] because he’d never have allowed me to test or go on medication…He used to beat me a lot.”64 

Another factor that delays women’s access to HIV testing and ART is that women sometimes feel that they must obtain their husbands’ or partners’ permission to receive an HIV test.  Many of the women interviewed for this report said they were counseled upon reaching puberty to be submissive and obey their future husbands.  Women also repeatedly told Human Rights Watch that they received pre-marital counseling from elderly female relatives who emphasized women’s subordinate role within the household and their obligation to obey their husbands.  Violence against women within the household, they were told, was normal and acceptable, and a woman should remain in her marriage regardless of her husband’s behavior.  In some traditions, according to Women in Law and Development in Africa (WiLDAF), “domestic violence is misconstrued as a sign of love, ‘rather than divorce her, he is willing to mould her into the kind of woman that he wants.’”65  Like gender-based violence, these gender norms and socialization often shape women’s attitudes toward seeking healthcare, including HIV testing and counseling, with devastating results. 

A number of women said that until their husbands died, they felt unable to take an HIV test or access treatment.  When Ruth M., a 52-year-old farmer from Chongwe, and her husband started getting sick, she tried in vain to convince her husband to allow her to receive an HIV test, and for him to test as well:

I used to tell my husband, we should both [receive] HIV test[s].  He refused.  He didn’t want me to go for a test.  He said, “This is not AIDS but people just [be]witched us.”  We used to go to witch doctors, but there was no help.  We just wasted a lot of money… I went for [an HIV] test and the results were positive.  I am on ARVs now… If it was not for my husband, I would have gone for VCT long ago.  I didn’t know what was wrong [with me] and sold a lot of things at the farm to pay the [witch] doctors….  Now there is hunger at home and a lot of poverty.66

A growing body of research addressing women in sub-Saharan Africa shows that despite incidents of gender-based violence and abandonment upon disclosure,67 where there is acceptance of a woman’s HIV-positive serostatus by her partner, being able to disclose HIV test results to sexual partners resulted in less anxiety, increased social support, and improved access to care and support programs.68  Still, the difficulties that women in sub-Saharan Africa face in disclosing their HIV-positive status are reflected in the fact that the lowest rates of disclosure in the studies conducted among women receiving antenatal services were in sub-Saharan Africa.69 Many of the women interviewed for this research said they felt unable to disclose their HIV status to their husbands, and as a result had to take HIV medicine secretly (see below).

The Impact of Violence and Abuse on Access and Use of ART

Women interviewed for this report who were enrolled in ART programs told Human Rights Watch that, as a result of physical and psychological abuse and the fear of such abuse, they sometimes missed ART doses and clinic appointments, including appointments to collect their medicine.  Some women felt compelled to hide their HIV status and medicine because of fear of violence, or because they feared that their husbands might dispose of the medicine.  Berta K., whose husband beat her routinely, told Human Rights Watch, “I started medication in 2006. [My husband] does not know.”70  Beatrice S. told Human Rights Watch that she was not planning to inform her husband about her HIV status: “My husband is not good to me.  Once I asked him to go for VCT but he refused.  He does not want me to drink any medicine or go anywhere.  Even these scratches on my face are because I was in the market to buy vegetables.  He said, ‘You are late, why?’ and he started beating me.  He beats me up about every two weeks.”71

Commencing ART without informing their husbands, many women told Human Rights Watch that they had to grapple even with where to keep their medication. Some of the women testified that they dug holes in the ground or in flower pots to hide ARVs.  These women then retrieved the medicine—which they must take for the rest of their lives—twice every day and then hid it again.  Others told Human Rights Watch that they hid the medication in the dish or bag for the family’s mealie meal (maize-based traditional staple).  Others said they hid the medicine in suitcases under their beds, or in aspirin and panadol containers.  Some pretended they were taking family planning pills.  Some of the women said they missed ART doses as a result of all this subterfuge.  One woman told Human Rights Watch that because she fears domestic violence, “I take the medicine out of the bottle and put it in a plastic [bag] or in a paracetamolbox [container] …. Sometimes I would miss a dose.”72 Marrietta M., who said that her husband often beat and insulted her, hides ART in her clothes: “I hide my treatment in my clothes.  My husband will not look for it in my clothes.  My husband and I fight a lot.  He insults me and he says very bad things to me. He is a very difficult person and I do not want … to upset him.”73   

Having started ART secretly, some of the women interviewed by Human Rights Watch said that when they experienced side effects of treatment, they had to make up explanations so as to avoid violence and other abuses.  Marietta M. told Human Rights Watch, “When I started the medication, I had bad side effects.  I had to tell my husband that it was malaria.”74   

Regardless of whether husbands knew about their HIV status or treatment, women whose husbands continually beat them or otherwise abused them sometimes missed ART doses.  Berta K., stated,

[Sometimes, my husband] comes back at 18:00 hrs, drunk, closes the door and says, “Today you are going to freak out.”  He locks [me] in, he beats me up and then he locks me out.  [On another day I would say], “Here is Nshima” (traditional Zambian food), and he would say, “You think I am not wise enough to know this is Nshima?”  He beats me up and locks me out of the house.  I go to the neighbors.  If they have mercy they will let [me] in, if not, [I] sleep under a tree until tomorrow.  As a result of that I miss doses sometimes.  I feel very bad.  I don’t even feel like taking the medicine.  I say, “Ha, let me die.”75 

Other women told Human Rights Watch that their husbands beat them or threatened to beat them if they saw them taking ART.  Charity T. said, “I do not take my medicine in front of my husband.  He told me that he would beat me if he saw me taking the pills.  He did slap me when he saw me take them.  I did miss taking some of the pills because I was scared of my husband.  It was very difficult for me to take the medication in the beginning because of him.”76 

Most of the women interviewed for this report testified to the impact of verbal abuse on their health in general and on their adherence to ART.  Rooted in dominant beliefs about women, verbal abuse described by women interviewed also reveals how stigma is entrenched in society.  Verbal abuse often takes place alongside other forms of abuse. Efforts to avoid such abuse have caused over 30 of the women we interviewed to miss ART doses.  The testimony of Maria T., 45, whose husband only knows that she has tuberculosis, is telling:

I did not tell anybody about my [HIV] status apart from [members of] the support group.  I fear to tell my husband because I fear that he can shout [at me] and divorce me.  He uses bad language with me every time, especially when he is drunk.  [He says], “The vagina of your mother,” “the anus of your mother, move away from me you are a patient of TB, you could die in my hands.” I hide the medicine, I put it on a plate, add mealie meal, so when he takes the lid off he [does not find the ART medicine].  I take the medicine at 8:00 hrs [when he is] at home and at 20:00 hrs when he is still at work.  I have to make sure that he is outside.  That is why I forgot to take medicine four times since I started treatment [in June 2006].  Last year he hit me around the back with his fist. I got the cooking stick and hit him back.77

In addition to the direct, dire impact of physical and verbal abuse on women’s ability to access and continue using ART, at least five women told Human Rights Watch that their husbands threw away their antiretroviral medicine.  Charity T., whose husband abused her physically, stated,

Once [my husband] threw away my medication … into the pit latrine.  He said that he did not want to see these medicines in his house.  I used to hide the medicines with my neighbor; I left them there for six months.  After he threw the medicines away, I had to go back to the clinic the next day to get more medicine.  I did explain to the nurse what had happened.  She got me more medicines.78

Several support group leaders, activists in women’s groups, and HIV treatment- adherence counselors told Human Rights Watch similar stories.  Ida Mukuka, an AIDS activist and former support groups coordinator, said that in some of the groups she ran “Women would come and say, ‘My husband rapes me every night. He would throw the ARVs in the toilet.’  It is a very sad situation.”79  An adherence counselor in Lusaka also relayed the experience of a former patient who passed away: “She took her drugs at the same time as her husband.  Every time they quarreled her husband would beat her up and take her drugs and throw them away.”80  The manager of the shelter that the Young Women’s Christian Association (YWCA) established in Lusaka also recounted the stories of two women survivors of domestic violence who used the services of the YWCA shelter, “The partners of two women who are … on ARVs refused [to let] the women drink [HIV] medicine.  One woman [said that] her husband threw away her medicine and told her, ‘If you drink that medicine, you are out of this house.’”81

The experiences of women interviewed for this research show that gender-based violence thwarts the ability of many of them to continue HIV treatment.  The majority of the women interviewed told Human Rights Watch that they attended adherence counseling sessions at ART clinics.  When asked whether they discussed their experiences of verbal, psychological, and physical abuse, they said that counselors did not usually ask about these issues, unless they notice visible marks of assault (see Chapter VI).82

Some of the women interviewed by Human Rights Watch stated that despite continuous beating and verbal abuse, they made sure to take their ART on time.  This could be because the majority of the informants started treatment when they were already extremely ill with full-blown AIDS and so have seen the difference ART made in improving their health over time.  Or another reason, as noted in Chapter III, could be that Human Rights Watch researchers mainly interviewed women who were connected to support groups, attended adherence counseling, or both.  Support group leaders and adherence counselors often emphasize that patients should take ART on time as prescribed by clinic staff.  Women who have missed appointments to renew their prescriptions for ART reported that they were “told off” by clinic staff.  Consequently, some of the women interviewed might have decided not to admit missing ART doses as they associated Human Rights Watch researchers with clinic staff. 

The testimonies in this chapter show that women are very resilient and often use creative means to ensure that they take ART on time and attend clinic appointments, while at the same time undertaking key care responsibilities. Some even use gender-based violence as an excuse to attend clinic appointments.  The story of Lucia G. is indicative:

I tested [for HIV] in 2005.  I was ill … [and] a nurse asked me to go for VCT.  I asked my husband who refused and said “if you go for VCT and test positive I will divorce you.”  I went secretly [to the clinic] and tested positive.  This way I knew what was wrong with me.  After three months my CD4 [count] went down so I was put on ARVs.  I am still on ARVs but my husband does not know.  I am only managing because I hide medicine.  I dig in the ground, put medicine in a tin, and put it in a hole then put the water bucket over it, so no one would know that there is medicine buried underneath.  I am always thinking about my life.  I do not want to lose my marriage and I do not want to lose my life, so I have to do this to keep my marriage and my life.  If I am divorced I cannot look after the children.  My husband is very arrogant.  This scar on my face is because he hit me.  He beats me because he suspects I am ill and because I go to the clinic a lot when I am ill or [to collect] ARVs.  He beats me, insults me, and asks me why I go to the clinic every time.  I tell him I need to go to the clinic because of the beating.  If I do not get beaten for a whole week that is too long.  He hits me almost everyday, which is good for me because I can [find an excuse to] go to the clinic.  I never reported him [to the police].  I once told the headman [village chief].83   

Lucia G., and other women interviewed for this research described how they raise funds specifically to cover transportation costs to attend clinic appointments.  “When my appointment [at the HIV clinic] gets nearer, I sell pumpkin leaves to raise money [for transportation].  Sometimes I manage [and] sometimes I don’t, so I borrow money from friends.”84  Similarly, Angela R., a market vendor who sells fruits, who said she hid ARVs between two flower pots, told Human Rights Watch: “I go [to the clinic] by bus and have to pay [Kw10,000 (about US$2.50) for a round trip].  I do not [usually] get profit from my business, so when there are a few days left for my appointment at the clinic, I do some piece work, like washing other people’s clothes.  Once I missed a clinic appointment last December because I had no transport money.  At the clinic they shouted at me and warned me not to miss [appointments or ART doses] because this is very dangerous.”85

Insecure Property Rights

Women interviewed for this report identified unequal property rights, and their inability to protect their property rights, as a major factor impeding their access to ART and their ability to adhere to treatment.  For women who married under discriminatory customary laws, their lack of property rights often mean having to remain in abusive marriages, which in turn can impede treatment.  Fear of divorce in a context where women are economically dependent on men forces some women to hide ART. Women who seek divorce and lose property they accumulated during their marriage suffer constraints that restrict their ability to afford transportation costs to attend clinic appointments, collect ARVs, or attend treatment-adherence counseling.  Similarly, widows told Human Rights Watch about property grabbing by in-laws when their husbands died, which made it harder for them to start and continue taking ART, due to economic constraints.  Property grabbing also led some women to enter new, abusive marriages just to sustain themselves and their children.

Unequal Property Rights upon Divorce

Right now, [we have about] seventy clients for [each] legal officer.  The most common issue is divorce in local courts.  If married under customary law, nothing is given to the woman.  [Not] even her clothes!

—Rumbidzai Mutasa, legal officer at the Women’s Legal Aid Clinic, Lusaka, February 23, 2007 

As noted above, among some ethnic groups in Zambia, to which over 50 percent of the women interviewed for this report belong, women who marry under customary law often lose the property accumulated during their marriages upon divorce.86  The resulting economic hardship often affects their HIV treatment.  Women who divorced under customary law told Human Rights Watch that they suffered abject poverty and were not able to afford transportation to health facilities to collect ARVs or even to afford food.  As a result, they had to take medicine on an empty stomach.  This is problematic as some ARVs must be taken with food and good diet can help with recovery.  Moreover, the appetite of people recovering from AIDS related illnesses may increase.87   

Human Rights Watch documented the experiences of women abandoned by their husbands and other intimate partners, chased from their homes, and divorced by their husbands as a direct result of disclosing their HIV status.  Women told Human Rights Watch that fear of abandonment and divorce, and the consequent loss of property, sometimes forced them to hide their HIV status and their ARVs.  Caroline M., 31, whose first husband divorced her upon finding out that she had HIV, eventually married another man to whom she did not disclose her HIV status, so she hid ARVs.  “If I disclose my status to my husband,” said Caroline M.

I fear two things: [being] divorced again or that my husband would just say, “Stop taking ARVs, you are okay”….  So when I get the ARVs from the clinic, I throw away the box [container] and keep the plastic [bag].  I place the medicine underneath clothes in the wardrobe.  My husband does not even touch clothes.  He asks me to bring clothes to him from the wardrobe. I take the medicine at 8:00 hrs and 20:00 hrs.  We only have two rooms so when my husband brings friends home I prepare themedicine and put it in the kitchen in advance.  My new husband is bossy.  He always says “You can’t be positive, and these ARVs you hear about are not good.”  He thinks he cannot be HIV-positive.  When he’s drunk he is a problem.  He hits me and shouts at me.88

Ann K., 27, whose husband divorced her, received her HIV-positive test result one day prior to her interview with Human Rights Watch.  Married according to customary law, she told Human Rights Watch that upon divorcing her, her husband appropriated all her belongings, including plates, cupboards, mattresses and sheets.  Ann K. said she complained to the “headman” of the farm where she lived with her husband, but her husband ran away to Lusaka to avoid confrontation with the headman, and her former husband’s new wife claimed that these items were presents from her parents.  Ann K. said that she gave up trying to reclaim her badly needed belongings due to ill-health“I am sick but I have no sheets or mattresses.  I have to sleep on a mat on the floor.  I have one blanket that my niece gave to me.  I share it with the children.”89  She was due to return to the HIV clinic on the next day for further tests.  Ann K. said that although the doctors might enroll her on ART, she might not be able to tolerate the medication with no food to eat.

Property Grabbing

Widows living with HIV/AIDS interviewed by Human Rights Watch described the daunting impact of property grabbing—the unlawful appropriation of property by relatives of the deceased (usually a man)—on their HIV treatment.  Property grabbed by in-laws, said these widows, could have helped them start small businesses, feed themselves and their children, and pay for transport to attend clinic appointments.  Some of the widows who needed HIV treatment before it was available for free also said that property grabbed by in-laws could have helped them generate income to cover ART costs.

When Mina P.’s husband died in 1999, she had already told him that she was living with HIV/AIDS.  Along with his relatives, he accused her of “bringing HIV to the house.”  Upon her husband’s death, his relatives took the couple’s property:

I was not working when my husband died.  His relatives blamed me … They said that I had brought illness into his house.  His relatives took all the property and they sold our land.  I didn’t get any money from the land.  I did not [report this to the Victim Support Unit].  My relatives said that I must not fight over the land ...  You do not fight over land as we all come from the soil.  When I had the land, [my family] always had something to eat.  After they took the land, I really struggled and we often did not have food.  This was not good for my health and I got sick. I could not afford [HIV] treatment at this time.  If I had had the land, I could have sold it to pay for [HIV] treatment or I could have sold some of the things that we grew.90

Even after the Zambian government made ARVs available for free, property grabbing by in-laws has at times forced widows receiving ART to miss vital clinic appointments because they were unable to afford transportation costs.  The experience of Hilda M. is illustrative:

All the property was taken by [my late husband’s] relatives. They took a motor vehicle, TV, radio, DVD player, dining room suite and sitting room chairs.  They told me that I was going to die so I would not need these things. I did not try to get this property back—it is the way things are—I have no power.  My problem is that I do not have enough food now.  These drugs are very strong.  I need to have food to take them.  If I had the minibus I would use it for business and I would get money for food and transport. I have to catch a bus to the hospital to get my medication every month.  My sister has to give me money for this, and when she can’t, I have to walk. It is too far when I am feeling weak.   I have missed some appointments when I do not have money for transport.  Once I did not collect my medication for three days.91

Not only does property grabbing intensify poverty among women, it also prompts them to enter into new relationships for economic security, in some cases with abusive partners.  When June S.’s husband passed away in 1991, his relatives “grabbed everything.”92  June S. never got her property back.  Having received an HIV-positive diagnosis the same year, she went to live with her father and stepmother, where she was mistreated.  After four years June S. remarried.  She told Human Rights Watch that her current husband beats her up, rapes her, and refuses to use protection during sexual intercourse, even though she disclosed her HIV status to him.  Whenever she refused to have unprotected sex with her husband, said June S., her husband would just grab her.93  June S. reported her husband to the government’s Victim Support Unit (VSU) when he beat her badly, and VSU officers offered to refer her to the YWCA shelter.  June S. told Human Rights Watch that she wanted to know her CD4 count to see if she needed HIV treatment, but that her husband “does not want to hear about HIV treatment.”94  She explained to Human Rights Watch that had her property not been grabbed when her first husband died, she could have sold the property to keep going, and that she could have left her current abusive husband.

When the husband of Beatrice S., 35, died, his relatives grabbed all their belongings.  “The family got these things because [my] husband worked: TV, fridge, stove, sofa, and iron.  I got nothing, just my clothes.”95 Beatrice, who has been receiving ART since 2004, had to find accommodation with a friend who later married her.  Beatrice S. said that she will not inform her current (similarly abusive) husband about her HIV status or about the fact that she is on ART. 

Lack of Access to Food

Many of the women interviewed for this report, especially those who lost their property upon divorce or upon the death of their partners, spoke of hunger as a major problem marking their experiences of taking ART.96  Lack of adequate food is a general problem in Zambia, where, in 2004, 68 percent of the population was classified as poor, and 53 percent of the population could not afford the cost of a basic food basket of Kw78,223 (about US$18.50) per month.97  Poverty in Zambia affects women disproportionately, given their already low economic status and dependency on male partners.  For example, in 2002/2003 poverty stood at 58 percent in female-headed households, compared to male-headed households where poverty stood at 43 percent.98 

For adults and children living with HIV/AIDS, adequate food and nutrition are essential for the health of their immune systems and for the success of ART.  According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), “Adequate nutrition is essential to maintain a person’s immune system, to sustain healthy levels of physical activity, and for quality of life. Adequate nutrition is also necessary for optimal benefits from antiretroviral therapy.”99 Similarly, Pathfinder International explains that,

Many people who are diagnosed with AIDS have lost weight through chronic ill health. They may have decreased appetite, be unable to eat much because of candidiasis in the mouth or esophagus, have poor absorption, or have chronic diarrhea. Co-infection with TB is common in HIV infection, and widespread TB infection may also cause weight loss. Weight gain may be rapid for persons commencing ART and after treatment of …TB. Some ARVs must be taken with food and recovery may be assisted by a good diet. Many people recovering from AIDS-related infections have increased appetite, and this can be a problem in poor households that are not food secure.100

Payment of Related Costs

Women who do not enjoy secure property rights may also lack the resources needed for tests related to ART where these are not consistently available for free, as is the case in the Copperbelt province.  As discussed earlier, in June 2005 the Ministry of Health announced that it would provide a full package of HIV/AIDS care, including ART, free of charge to Zambians. It appears, however, that this policy is not being uniformly applied in the two provinces studied for this report.  Interviewees in Ndola, in the Copperbelt province, indicated that they only receive antiretroviral medicine free of charge, and must pay for CD4 countsand other diagnostic tests. 

For all the reasons explained above, the cost of these tests also severely impacts women in abusive relationships.  For example, Dorothy M., who said that healthcare workers advised her to have a CD4 count every six months, said that she was four months late on taking the test because she could not afford the cost.  Her husband—who assaulted and abandoned her along with her two children when he found out that she had HIV—refused to pay for it.101  Another woman told Human Rights Watch that she was unable to commence treatment because she could not afford the cost of the CD4 count. Her doctor recommended that she take the test as soon as possible since she had suffered from a number of opportunistic infections, but her husband refused to pay.102 

58 Human Rights Watch interview with Mercy Z., Lusaka, February 21, 2007.

59 Human Rights Watch interview with Unique Z., Lusaka, February 20, 2007.

60 CD4 count is the measure of the number of helper T cells (cells in the immune system) per cubic millimeter of blood, used to analyze the prognosis of patients infected with HIV.

61 Human Rights Watch interview with Unique Z., Lusaka, February 20, 2007.

62 Human Rights Watch interview with Monica Mwachande, nurse-sister, Kalingalinga Clinic, Lusaka, February 8, 2007.

63 Human Rights Watch interview with Precious C., Lusaka, February 8, 2007.

64 Ibid.

65 WiLDAF, “Elimination of Discrimination Against Women in Zambia,” undated, p.10. 

66 Human Rights Watch interview with Ruth M., Chongwe, February 9, 2007.

67 In the case of Zambia recent research in five districts including Lusaka, Kitwe, and Ndola found that many women receiving ART experienced daunting barriers to adherence, including fear of disclosure, gender-based violence, and having to share ART with an untested husband.   Out of 560 women who took part in the study, 66 percent did not disclose their HIV status to their intimate partners because of “fear of blame, abandonment and losing the economic support of their partner.” See K.P. Zulu “Fear of HIV Serodisclosure and ART Success: the Agony of HIV-Positive Married Women in Zambia,”3rd IAS Conference on HIV Pathogenesis and Treatment 2005, Rio de Janeiro, Brazil, 24–27 July 2005. (Abstract no. TuPe11.9CO3); (accessed October 10, 2007).

68 P.Gaillard et al., “Consequences of Announcing HIV Seropositivity to Women in an African Setting: Lessons for the Implementation of HIV Testing and Interventions to Reduce Mother-to-Child HIV Transmission,” abstract no. TuPpB1157, International AIDS Conference, South Africa, July 9-14, 2000.  In this study researchers interviewed 331 HIV-positive women participating in a study on the prevention of mother-to-child transmission of HIV in Mombasa, Kenya, two months after they received their HIV test results.  Thirty-two percent of those in stable relationships had informed their partners of their test results after receiving counseling.  Seventy-three percent of those who informed their partners said that the latter were understanding.  See also P. Keogh et al. “The Social Impact of HIV Infection on Women in Kigali, Rwanda: A Prospective Study,” Social Science and Medicine, 38(8), 1994, pp. 1047-53; O.A. Grinstead et al., “Positive and Negative Life Events after Counseling and Testing: the Voluntary HIV-1 Counseling and Testing Efficacy Study,” Aids , 15(8),  2001, pp. 1045-52; S. Issiaka et al., “Living With HIV: Women's Experience in Burkina Faso, West Africa,” AIDS Care, 13(1), 2001, pp. 123-8; W.L. Heyward et al., “Impact of HIV Counseling and Testing among Child-Bearing Women in Kinshasa, Zaire”, Aids  7(12), 1993, pp. 1633-7; Suzanne Maman et al., “High Rates and Positive Outcomes of HIV Serodisclosure to Sexual Partners: Reasons for Cautious Optimism from a Voluntary Counseling and Testing Clinic in Dar es Salaam, Tanzania,” AIDS and Behavior, 7(4), 2003, pp. 373-382.

69 Suzanne Maman, “To Disclose or Not to Disclose: An Overview of Women’s HIV Serostatus Disclosure Experiences Globally,” in USAID/Synergy, Women’s Experiences with HIV Serodisclosure in Africa: Implications for VCT and MTCT, Meeting Report (Washington, DC: USAID, March 2004), p. 3.

70 Human Rights Watch interview with Berta K., Lusaka, February 3, 2007.

71 Human Rights Watch interview with Beatrice S., Lusaka, February 3, 2007.

72 Human Rights Watch interview with Berta K., Lusaka, February 3, 2007.

73 Human Rights Watch interview with Marrietta M., Ndola, February 20, 2007.

74 Ibid.

75 Human Rights Watch interview with Berta K., Lusaka, February 3, 2007.

76 Human Rights Watch interview with Charity T., Lusaka, February 3, 2007.

77 Human Rights Watch interview with Maria T., Lusaka, February 3, 2007.

78 Human Rights Watch interview with Charity T., Lusaka, February 3, 2007.

79 Human Rights Watch Interview with Ida Mukuka, AIDS activist and former support groups coordinator, Lusaka, January 31, 2007.

80 Human Rights Watch interview with Eric Nachibanga, member of the Network of Zambian People Living with HIV/AIDS (NZP+) and counselor at the University of Zambia HIV Clinic, January 31, 2007.

81 Human Rights Watch interview with Yeta Mekazu, YWCA’s shelter manager, Lusaka, February 1, 2007 (group interview with the director, programs manager, and shelter manager of YWCA).

82 Human Rights Watch group meeting with ten women living with HIV/AIDS, Lusaka, February 3, 2007.  One woman who uses the services of the Matero main clinic in Lusaka told Human Rights Watch that counselors at the clinic asked about domestic violence, talked to her late husband, and advised her to use YWCA services, which lead to a decrease in the violence but not an end to it.  Human Rights Watch interview, Lusaka, February 3, 2007.

83 Human Rights Watch interview with Lucia G., Lusaka, February 10, 2007.

84 Ibid.

85 Human Rights Watch interview with Angela R., Lusaka, February 10, 2007.

86 WLSA, The Changing Family in Zambia, pp.172-180.  According to WLSA, “a number of advantages of contracting marriage under Statutory law have been cited … a woman married under statutory law can (at least on paper) claim a share of matrimonial property whereas, under customary law, whether the woman gets a share or not depends on the customary law applicable.  Divorce cases observed in Local Courts (which apply customary law) … showed that, in most cases going before Local Courts, the court justices [made] no mention [to] what was to happen to the matrimonial property.” See WLSA, The Changing Family in Zambia, p. 164.  WLSA contends that in reality, a woman married under statutory law in Zambia “is in the same precarious position as one married under customary law.” Ibid.  On December 9, 2005, however, there was an encouraging development in the divorce case of Martha Kembo Mwanamwalye and Collins Mwanamwalye, where the magistrate ruled that “notwithstanding that the parties in this matter were married under customary law, justice demands that when a marriage has broken down, the parties should be put on equal position to avoid any one of them falling into destitution.”  “Landmark Judgment for Women in Customary Marriages.” IRIN News, December 21, 2005, (accessed December 26, 2006).

87 Pathfinder International, “Technical Series Number 5: The Essentials of Antiretroviral Therapy for Health Care and Program Managers,” April 2007, (accessed May 1, 2007), p. 13.

88 Human Rights Watch interview with Caroline M., Mandevu, Lusaka, February 10, 2007.

89 Human Rights Watch interview with Ann K., Kafue, February 7, 2007.

90 Human Rights Watch interview with Mina P., Ndola, February 20, 2007.

91 Human Rights Watch interview with Hilda M., Ndola, February 20, 2007.

92 Human Rights Watch interview with June S., Lusaka, January 31, 2007.

93 Ibid.

94 Ibid.

95 Human Rights Watch interview with Beatrice S., Lusaka, February 3, 2007.

96 Research by Physicians for Human Rights documented similar experiences of food insufficiency among people accessing ART, particularly women in Botswana and Swaziland. Physicians for Human Rights, Epidemic of Inequality: Women’s Rights and HIV/AIDS in Botswana and Swaziland (Cambridge, Massachusetts:  PHR, 2007).

97 Central Statistics Office (CSO), Zambia 2000 Census of Population and Housing (Lusaka: CSO, 2003), p.  xxi.

98 Ministry of Finance and National Planning, Fifth National Development Plan, p. 313.

99 UNAIDS, “Nutrition and Food Security,” (accessed on 3 December, 2007).

100 Pathfinder International, “Technical Series Number 5: The Essentials of Antiretroviral Therapy,” p. 13.

101 Human Rights Watch interview with Dorothy M., Kitwe, February 21, 2007

102 Human Rights Watch interview with Sarah D., Ndola, February 20, 2007