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Women and HIV/AIDS

The Human Rights Council reviewed Zambia’s report under its Universal Periodic Review (UPR) mechanism in Geneva last Friday (9 May), and adoption of the report took place this week on Wednesday (14 May). Here in Lusaka, women, including those who describe themselves as “living positively,” are struggling to come out of the shadows that still obstruct the government’s efforts to fight HIV/AIDS.

The premises of a women's support group in Lusaka are so obscure that every time I visited, the group's coordinator has had to meet me at a Zambeef shop on the main road before leading me through a labyrinth of muddy pathways that reminded me of some of the streets of Khartoum in my country, Sudan, in the morning after a rainy night.  The voices and experiences of these women were strongly present when Human Rights Watch prepared its submission on Zambia for the UPR process.

Like dozens of other women that colleagues and I interviewed in Lusaka and the Copperbelt provinces, the support group members told me about their experiences with HIV and antiretroviral therapy (ART). A certain pattern started to unfold. Most of the women in the support group were either piece-workers or unemployed. They were all receiving HIV treatment, and nearly all of them were hiding their HIV status from their husbands or partners. The majority experienced excruciating physical, psychological or verbal abuse at the hands of their husbands, and this made it difficult for them to continue using the life-saving treatment.

“I fear to tell my husband,” said Maria (not her real name), a 45-year-old woman fearful of disclosing her HIV status at home. “He can shout and divorce me. He uses bad language with me.” She told me that she hides her antiretroviral medicine. When she takes her pills, she said “I have to make sure that he is outside. That is why I forgot to take medicine.”

Maria’s story is not unique. Nor are experiences of abuse limited to women who live in Lusaka. Women in Kafue, Chongwe, Ndola and Kitwe recounted similar ordeals that sometimes made them question their ability to start HIV treatment in the first place. When I interviewed Ann, a 27-year-old divorcee from Kafue, she had received an HIV-positive diagnosis on the previous day.

Ann was married according to customary law, and she said that upon divorcing her, her husband appropriated all her belongings, including plates, cupboards, mattresses and sheets. Ann said she complained to the headman of the farm where they lived, but her husband ran away to avoid confrontation with the headman. Ann said that she gave up trying to reclaim her badly needed belongings due to ill-health.

Ann was due to return to the HIV clinic on the next day for further tests. Ann said that although the doctors might enroll her on ART, she might not be able to tolerate the medication without food. Unfortunately, the discrimination that Ann faces under customary law is sanctioned by Zambia’s current constitution.

Although Zambia’s roll-out of free HIV treatment is commendable, and although more women than men are on HIV treatment in Zambia, the government has not done enough to ensure that women like Ann and Maria are able to start and, most importantly, continue using HIV treatment. Since drug resistance can occur and undermine treatment programs when patients are unable to adhere to their medications, there is very little scope for letting ART patients fail to take their drugs.

When asked whether healthcare workers and HIV treatment counselors discuss violence and other problems at home that might affect their treatment, the majority of the women told us that this only happened when they had visible bruises. Healthcare facilities providing ART have no systems in place to detect or address gender-based abuses such as domestic violence. The training that counselors receive does not cover violence against women in a systematic manner, nor does the understanding of gender-based abuses factor into official counselor certification.

Zambia still lacks government protocols on how to deal with violence against women and other abuses within ART programs. And monitoring systems do not track the effects of such abuse. With the exception of the Centre for Coordinated Response to Sexual and Gender-based Violence, our research found no partnerships in the healthcare system with institutions that could provide such services at healthcare facilities.

Similarly, the country’s legal framework fails to address these issues adequately. Zambia has no specific law that criminalizes gender-based violence. The penal code does not cover marital rape or psychological abuse. Prevalent customary laws discriminate against women in terms of allocating property upon divorce or the death of a husband. Women’s organizations told us that the 1989 Intestate Succession Act has led to a reduction in in-laws’ grabbing widows’ property, but it is ill-enforced. Addressing these legal shortcomings is important not only to protect women, but also essential for the success of Zambia’s HIV treatment programs.

It is true that Zambia has already made important steps toward introducing a gender-based violence bill, and has established the Victim Support Unit to address the needs of victims and survivors of gender-based violence. It is also true that Zambia’s health system is already overstretched and severely understaffed. This will make it challenging to sustain programs that detect and respond to violence against women and other factors that obstruct women’s HIV treatment. The majority of policymakers in the health sector and staff in healthcare facilities providing ART, however, told us that introducing initiatives that can respond to violence against women and other abuses would be feasible with sufficient guidelines, infrastructure, and staff training and support. Moreover, such initiatives should be carried out with support from the donor community and United Nations agencies.

Fortunately, there are already several guides produced by agencies such as the US Agency for International Development and the UN Population Fund that show how such programs could be integrated into healthcare facilities in countries with limited resources like Zambia. These initiatives range from providing information on violence against women and contact details for support groups, to having staff in clinics specifically trained to address violence against women.

As an African woman working to promote women’s rights in the continent, I was moved by the dignity and resilience of the Zambian women I interviewed. I was also impressed by these women’s perseverance in high levels of adherence despite the abuse they face, and by the creative means they use to cope with indescribable adversity.

Zambia’s ART program is an impressive effort to provide free and universal HIV treatment. For this program to succeed, however, the government needs to introduce reforms in the health and legal systems to end the abuses against women that are obstructing their ability to fully benefit from life-saving HIV treatment programs.

The outcomes of Zambia’s review, the final report of which will be adopted by the Human Rights Council in June 2008, can be seen as an expression of the consensus of the international community with regard to the human rights situation in Zambia. As such, Zambia’s media and non-governmental organizations should take full advantage of the outcomes of the UPR, to press for legal and health-system reform in Zambia toward the elimination of abuses against women, including abuses that impede their HIV treatment.

Dr. Nada Ali is the Africa researcher for the Women's Rights Division of Human Rights Watch.

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