VI. Human Rights and HIV/AIDS in Zimbabwe
Human Rights Watch documented a number of human rights violations against PLWHA and those who are vulnerable to infection that threatened their rights to health, information, work, equal protection before the law, and nondiscrimination.
Operation Murambatsvina and the economically harmful policies associated with informal traders have disrupted lives and increased the risk of HIV infection for thousands, while further endangering those already infected. More insidiously, the failure of the government to protect women by preventing or prosecuting domestic violence and violations of property and inheritance rights perpetuates the greater vulnerability of women and the inability of those infected to seek and receive effective care.
In previous reports, Human Rights Watch has documented how Operation Murambatsvina, the government of Zimbabwes program of forced evictions left up to 700,000 people homeless, without a source of livelihood or both.75 The evictions also interrupted access to health care for thousands of people including PLWHA.
In November 2005, a national survey of 5,407 households of PLWHA or families living with PLWHA on the effects of Operation Murambatsvina by ActionAid found that 61 percent of PLWHA lost their access to home based care; 46 percent lost access to antiretroviral therapy; 45 percent lost treatment for opportunistic infections; 48 percent of PLWHA relocated to areas where treatment and support is limited and 22 percent lost their access to reproductive health support.76 Human Rights Watch interviewed 19 people living with HIV/AIDS who had lost their homes during Operation Murambatsvina and they reported similar problems.
The situation of PLWHA displaced to the rural areas remains unclear as many international and local humanitarian organizations have been unable to trace people who were displaced to the rural areas. Human Rights Watch has found that in the urban areas there was severe short-term disruption of treatment and care for many PLWHA. There were relatively few cases of long-term disruption of ART among the PLWHA interviewed by Human Rights Watch. Many reported that they were eventually able to resume home based care and ART. Nevertheless it should be noted that even short term disruption of ART can lead to the patient developing resistance to ARV drugs. Among the PLWHA interviewed by Human Rights Watch on ARV drugs, a number reported that they were unable to access drugs for periods ranging between a week and three months.
Human Rights Watch spoke to PLWHA in three areas affected by the evictions; Hatcliffe Extension, Mabvuku, and Highfield in Harare. In these areas, several PLWHA informed Human Rights Watch that their access to treatment and care was disrupted when they were sent to holding camps where they received little or no care for a period of up to three months. For example Teresa N., whose daughter was diagnosed HIV positive just before the evictions began and was put on ARV drugs, told Human Rights Watch, My house was destroyed and I had to go with my sick daughter to Caledonia camp and we were sleeping out in the open. She continued, We were sleeping out in the open and then she fell very sick and there was no treatment for her for the three months we were there. Teresa N., informed Human Rights Watch her daughter was eventually diagnosed with tuberculosis when they left the camp in October.77
Many of the PLWHA affected by Operation Murambatsvina interviewed by Human Rights Watch continue to live in appalling conditions that sometimes exacerbate their condition and make them more prone to opportunistic infections. One HIV positive man took Human Rights Watch to the temporary shelter where he lived with his HIV positive wife and their children. Despite the oncoming winter, their shelter had no windows and they were sleeping on the bare ground.78 Others told Human Rights Watch researchers that they were living in overcrowded conditions, sleeping in houses without roofs while a couple reported that they were still living out in the open almost a year after the evictions took place.
Priscilla K., a 59- year-old HIV positive widow suffering from pneumonia told Human Rights Watch:
Im living outside because of the tsunami [Operationa Murambatsvina]79. Before the evictions I was living in a little shack behind a house but they destroyed it. Now I have a bed outside. I have a little bit of plastic to cover it. Before the evictions I was growing tomatoes, vegetables; I would go find mushrooms to sell. Now I have nothing. I lived in that house for 26 years and they tore it down. Its like Im a wild animalliving outsideand with many others all around me.80
The fact that few of the people interviewed by Human Rights Watch suffered long term disruption to the evictions was not due to any government effort but was mainly due to the efforts of PLWHA to continue their treatment from wherever they had been displaced to, as well as the work of NGOs and clinical trials to track down patients to ensure continuity of care. As one woman in Hatcliffe Extension explained, My house was destroyed during the tsunami and I went to Caledonia. I used to get my ARVs every two weeks and at Caledonia I had to travel to Newlands Clinic to get the ARVs. Sometimes if I didnt have the transport, I would walk there even though it was far. I knew that I couldnt stay without my medication. At Caledonia, they gave us nothing.81
Testimony from victims of the evictions interviewed by Human Rights Watch, and analysis of NGO reports by organizations such as ActionAid on the evictions show that Operation Murambatsvina has increased vulnerability to HIV infection in an already vulnerable population. Although there is no quantitative analysis currently available on the effects of the evictions on vulnerable groups, the conclusion of international NGOs and those working with evicted populations is that the evictions have made vulnerable groups even more prone to HIV infection and sexually transmitted infections (STIs). For example, representatives of one international organization working with evicted people in some areas of Harare informed Human Rights Watch that they had noted an increase in the number of sexually transmitted infections among the evicted population.82 According to medical experts, STIs can increase a persons risk of becoming infected with HIV/AIDS.83
Displacement resulting from the evictions has been shown to increase the risk of new infections.84 Vulnerability to HIV increases in these situations because men and women are more likely to engage in casual (and unsafe) sex due to the breakdown of families, and for women who have lost their livelihood to exchange sex for shelter, food and protection. In many cases families were separated in the holding camps. In other cases men sent their wives and families to the rural areas while they remained in the urban areas to work.85
As a result of the displacements, international and local NGO contacts informed Human Rights Watch that they had observed an increase in numbers of displaced women engaging in transactional sex in the aftermath of the evictions in order to survive.86 This information is reinforced by ActionAids study on the effects of Operation Murambatsvia, which found that 45% of respondents in its survey of 5407 households reported that they had either engaged or witnessed an increase in casual sex relationships, while 50% reported that they had either witnessed or engaged in commercial sex work as a result of the evictions.87
Operation Murambatsvina also disrupted access to information on HIV prevention and treatment to many people including PLWHA. In turn, this affected peoples right to health including for vulnerable or marginalized groups who needed it most, such as PLWHA or groups at risk of HIV infection. For example, during the operation, the national condom social marketing program was severely disrupted. The destruction of tuck shops (small shops found in the high density residential areas of cities around the country) and hair salons affected close to 2000 condom outlets representing more than 40% of outlets for distribution. Mobile sales of condoms were further affected by instability resulting from the evictions, increases in transport costs and restrictions on informal trading.88
In Hatcliffe Extension, a clinic running a free ART and opportunistic infection treatment program under the St. Dominican Sisters was destroyed during the evictions and the program disrupted.89 As a result, a number of PLWHA on the treatment program reported to Human Rights Watch that initially they could not access treatment as the Dominican Sisters were forced to move out of the area. Others reported that they were unable to join the program because the Dominican Sisters scaled down their operations in the aftermath of the evictions. To continue treatment, others were forced to travel a longer distance to Harare where the sisters now run their program.
Netsai A., a 45-year-old woman living with HIV/AIDS told Human Rights Watch:
I have a problem with medication. The Dominican sisters were providing me with medication for opportunistic infections. When the tsunami came the Dominican sisters left. My house was demolished on May 26. I was sent to Caledonia Farm and was there for three months. I had no medication. I had pneumonia and it was winter and we were living in the open because there wasnt shelter. I didnt receive any treatment. I just recovered by myself. These days we dont get opportunistic infection treatment. We have to go to Hatcliffe poly clinic but we have to pay Z$500000 (US$5) [for consultation]. Then they give you a prescription to buy for yourself. When I get sick I cant afford to go to the clinic, I just buy panadol. The Dominican sisters program was disturbed by the government. Their clinic was destroyed.90
The evictions have also revealed the stigma and discrimination that PLWHA often face. Human Rights Watch found that the evictions left some PLWHA vulnerable to discrimination from potential landlords and relatives. Although Human Rights Watch could not determine the extent of the practice, a number of PLWHA and their families reported that since they lost their homes to the evictions, they were unable to rent new accommodation because landlords refused to let out houses if they discovered that someone in the family looking to rent the house had HIV, or the potential tenant was HIV positive. According to one woman living with HIV/AIDS, I have seen some of the evicted people being turned away or chased away from their new lodgings because of their (HIV/AIDS) status. The landlords are scared they will fall sick. They chase you politely. They try to find a reason to chase you or raise the rent exorbitantly.91 Others told Human Rights Watch that they faced discrimination from relatives whom they moved in with when their homes were destroyed.
Nelly S., a 36-year-old mother of four and her husband tested positive for HIV/AIDS in early 2005. In June 2005, police came and destroyed their house and the family was forced to move in with Nellys aunt. Nelly S. told Human Rights Watch about the discrimination her family faced:
My auntie wants us to find our own accommodation because my husband and I are sick. Some people think that if you stay with someone with HIV you get the virus. The landlords discriminate against people with HIV. I have tried to rent a house but the minute theyve known my status they have said no. If you are HIV positive and disabled they say no. You cant say your status; you have to keep it a secret because if the landlord finds out they kick you out.92
A number of PLWHA interviewed by Human Rights Watch researchers said that as a result of discrimination they felt unable to openly declare their status because they risked being thrown out of a relatives house or being chased away by their landlords.
Government promises to provide housing to all those affected by the evictions and prioritize the needs of vulnerable groups, seem to have amounted to little.93 Human Rights Watch researchers found that most of the PLWHA affected by the evictions with the exception of those interviewed at Hatcliffe Extension were not provided with any shelter or accommodation by the government. The situation was only slightly better for those interviewed at Hatcliffe Extension, many of whom were living in unfinished government housing. As highlighted earlier, most of the houses had no windows and roofs. The plastic sheeting used by the evictees to provide some protection from the elements was provided by international NGOs.
Operation Murambatsvina also badly damaged the informal sector which the majority of poor Zimbabweans rely upon to earn a livelihood. The governments program of forced evictions and demolitions has resulted in restrictions on informal economic activities around the country. Despite the countrys high unemployment rate (approximately 80%), informal traders who go into the streets to sell their wares are regularly arrested and fined by members of the Zimbabwe Republic Police and their goods confiscated. For many PLWHA, informal trading is the only means to earn money for food and medication including ART. Economic restrictions on trading have also increased the risk of infection for thousands of people working in the informal sector who have been left without any source of livelihood. The link between poverty and HIV/AIDS has been well documented by international bodies such as UNAIDS. According to UNAIDS, The [HIV/AIDS] epidemic flourishes especially among people and communities that are deprived of the elementary benefits of successful development (public social services such as education and health care, secure employment, shelter and social safety nets for sustaining livelihoods).94
The government claims that informal trading has led to criminality within the high density areas of Zimbabwe and needs to be curbed and regulated.95 As a result all those wishing to engage in informal trade are required to apply for a license to operate in a government designated area. Yet in the late 1990s, the governments own policies effectively encouraged informal activities in residential areas. As a result of measures designed to lessen hardships faced by households, the government designated new sites for informal trade and micro enterprises including, peoples markets, and flea markets. In addition the government relaxed enforcement of regulations, especially on the operation of businesses run from peoples homes.96 The government then destroyed tens of thousands of these businesses during the 2005 evictions.
Activities such as hair dressing, tailoring and stone carving were also deregulated when the government brought into law Statutory Instrument 216 in 1994.97 According to the report of the UN Special Envoy on the effects of the evictions, the change in the law sent a clear signal to local council authorities that the government was eager to promote the informal economy. This resulted in local council authorities turning a blind eye to the explosion of the informal economy.98 Thus as the formal economy has declined and unemployment risen, more and more people have turned to informal trading.
The rapid increase in the number of people engaging in informal trading activities may indeed require regulation but the government needs to recognize the rights of Zimbabweans to earn a living in an environment of high unemployment. Procedures for acquiring a license should be made more affordable and clear to applicants. Currently, the cost of acquiring a trading license to sell goods in government-designated market places is prohibitive. For example the monthly cost of a trading stall in Harare is about $Z1.7 million ($US17) and is expected to increase to about $Z4 million ($US40) by September 2006, 99 which many women in particular cannot afford. The criteria for getting a license for those who pursue it are not always made clear to applicants.100 Many women and men interviewed by Human Rights Watch reported that they were unable to secure a license and did not know the reasons for their rejection. As one woman told Human Rights Watch, I tried to get a license to be able to sell vegetables, but the city council turned down the request. They only approved a few people to get a license.101
A significant proportion of those who work in the informal sector are women.102 International organizations have highlighted the importance of economic autonomy for women in the global fight against HIV/AIDS.103 Yet the government of Zimbabwe has made women more economically insecure by barring many of them from selling wares in the street. Human Rights Watch researchers documented many cases of police harassment, intimidation and arrest of PLWHA and other vulnerable groups such as widows who were trying to make a living as informal traders.
The harassment, intimidation and arrest of informal traders narrows the range of livelihood strategies available and in the case of women, increases their economic dependence and may drive them to undertake risky livelihood measures such as engaging in unsafe transactional sex or outright sex work, which increases their exposure to HIV infection. For example, a number of women informed Human Rights Watch that they had sought male sexual partners or considered engaging in sex work because they were unable to make money from informal trading due to police harassment. One informal trader said, I sometimes think of doing the sex work when I have problems of money but I am scared of getting sexually transmitted infections and HIV/AIDS.104
Fadzai B. a widow with four children told Human Rights Watch:
I sell tomatoes to earn a living. I have been selling tomatoes for 11 years. I sometimes get arrested by the police and have to pay a fine. I have been arrested about five times now. It has been worse since Operation Murambatsvina. I have registered for the hawkers license but havent received it yet. Things are tough. I get tired of playing hide and seek with the police. When things are really bad and the police have taken away my goods, I sometimes think of going to the bars to find men even though I have a boyfriend. I dont know if I will do it but thats what I think.105
Nyandzo C., a divorced 46-year-old informal trader worked as a sex worker for eight years. Five years ago she decided to stop and become an informal trader and started growing and selling her own vegetables. During Operation Murambatsvina police started harassing informal traders, arrested them and then took away their goods and continued to do so in the aftermath of the evictions. She told Human Rights Watch researchers, I stopped working as a sex worker because I was scared of getting the virus (HIV) after I was found with herpes. But now I need to survive so I have returned to sex work. When the police take away my goods, I go to the bars to find men so that I can recoup the money I lost. I try to insist on condoms, but not all of the men listen.106
The long and drawn out process for procuring a trading license leaves many desperate women with no choice but to operate without a license and leaves them subject to police harassment and intimidation. One organization that works with sex workers and vulnerable women informed Human Rights Watch that up to 70 of its 700 clients had not heard from the city council even though they had applied for licenses several months earlier.107
A number of social factors put women at greater risk of HIV infection including poverty, and gender inequality. The U.N. Special Envoy for HIV/AIDS in Africa has stated that, where AIDS is concerned, gender inequality is lethal.108
Zimbabwe has taken some vital steps to improve the status of women and children by putting in place certain laws and policies. In addition, Zimbabwes National Policy on HIV/AIDS recognizes that the government should change these underlying social cultural structures that perpetuate the vulnerability of women to HIV infection and transmission.109 In October 2000, the National Gender Policy of the Republic of Zimbabwe was issued with the aim of providing guidelines, institutional framework, and parameters to ensure the availability of resources for the successful and sustainable implementation of the Zimbabwe Constitution and legislative requirements, regional and international conventions, protocols, declarations and agreements on gender equality, equity and nondiscrimination110 The Gender Policy recommends the following with regard to HIV/AIDS:
Yet, as a number of womens organizations point out, a lot more needs to be done, and some of the laws so far have had little impact on the lives of most women and children.112 In many cases customary laws with discriminatory elements113 continue to take precedence over formal laws with regard to womens property rights, while according to local womens organizations, the attitudes of relatives, government officials, and the judiciary still reinforce traditional belief systems. Additionally, amendments to the law on inheritance have made little impact because there is little enforcement. The discrimination against women exemplified in section 23 (3)(b) of the constitution of Zimbabweas highlighted in the next paragraph of this section, the practice of discriminatory customary law and the inability of many women to pursue their cases in the court deprives women of their rights to property, and increases the vulnerable position of women in society. This section highlights how gender inequality, poverty and domestic violence in Zimbabwe puts women at greater risk of HIV infection and prevents women living with HIV/AIDS from mitigating the economic consequences of their condition.
The Constitution of Zimbabwe prohibits discrimination on the basis of gender. However this key provision is circumvented by, Section 23 (3) (b) of the constitution of Zimbabwe which allows discrimination on issues of personal law. This covers family laws such as adoption, marriage and inheritance, and effectively allows customary law to override other inheritance laws.114 Specifically this section of the constitution provides that a man's claim to family inheritance takes precedence over a woman's, regardless of the woman's age or seniority in the family.115 For example, in the event of a man's death, his brothers claim to the inheritance takes precedence over that of the deceased's wife. The Administration of Estates Amendment Act was introduced by the government of Zimbabwe in 1997, to make inheritance laws more favorable to widows and is supposed to address the problems women faced in inheriting property under Zimbabwes customary laws.116 However there has been little enforcement of the Act in the courts.
The poor economic status of women often makes it difficult for them to pursue their cases in the courts. With few exceptions, most of the women Human Rights Watch interviewed for this report worked in the informal sector. As a result very few could afford to take their cases to the courts. Women whose partners fall sick and die, particularly of AIDS, frequently suffer discrimination and lose their homes, inheritance, possessions or livelihoods. This was confirmed in several cases which Human Rights Watch documented, where women suffered abuses after the death of their husbands from HIV/AIDS.
Mary S., a 53- year-old widow with three children whose husband died from HIV/AIDS told Human Rights Watch:
When my husband died in 2000, his relatives came and took everything. They took the house and sold it. I had to find a place to live, for myself, my children, and my 3 grandchildren. I asked my brothers for help and they said that theyve got their own family, how can they help me? I went to the police but they didnt help, they told me to go to social welfare. I went there and there was no help either. They wrote my name down. I went back and then they said they would come for a house visit. They came but they gave me no help. I dont know why. I am a dressmaker, but I have no work right now I have no capital to get things going. I am trying to sell tomatoes to make money. It is difficult. The police arrest us; they take all of our things. We pay a fine Z$250000 (US$ 2.50) all the time.117
The husband of Patrcia E., a 45- year-old widow, died in 2000. Patricia was diagnosed with HIV in the same year. She told Human Rights Watch:
After my husband died, his relatives came to take the house. They wanted to take it and send me away to the rural areas. I was able to stand up to them and stop them but they took all his tools (he was a mechanic). They said that because I am a woman I didnt have the power to use the tools. I wrote a will for my children so that they will not have so many problems from the relatives. I used to sell clothes in Botswana. I used to go often, but now the situation in Zimbabwe is too difficult. Now I work for other people doing washing (clothes), in their farms. I have a small garden. My children arent working. My youngest is still in school, but I cant afford the school fees118
Property-grabbing119 sometimes forces women to compensate for their loss of economic security by engaging in unsafe sexual behavior. In a couple of the cases Human Rights Watch documented, women had turned to sex work in order to survive. Sibonikhile F., a 28-year-old widow told Human Rights Watch:
My husband died in 2002 when I was pregnant. His relatives took everything away and left me with nothing. At the time we were living in the rural areas and I had nowhere to go. I couldnt go back to my parents because they are dead. The chief refused to do anything so I came here (to the city). Life became very difficult and so I decided to go the beer halls to work as a commercial sex worker. I had no one to help me. I needed money to buy nappies for the baby and so I had no option. I now have a boyfriend and decided to leave sex work because he has agreed to look after me and my child.120
There is limited data available about violence against women in Zimbabwe but press reports and reports from womens organizations indicate an increase in incidents of gender based violence in the past few years. Many womens organizations report that domestic violence is pervasive in Zimbabwe.121 On March 1 2005 UNICEF issued a press release condemning the increasing tide of violence against women in Zimbabwe and called for the enactment of the Domestic Violence bill. According to UNICEF, a combination of an inflexible approach to cultural and traditional practices; an economic downturn that has seen women become the chief bread winners as men are made unemployed; together with odious beliefs on HIV and virgins has meant gender based violence is frighteningly common in Zimbabwe.122 Although the governments Sexual Offences Act legislates against rape in general and marital rape,123 domestic violence in Zimbabwe is often viewed by the police and the judicial authorities as a family matter and not for the courts. The Prevention of Domestic Violence Bill of 2005 which was drafted 10 years ago will be brought before parliament in late July 2006. The bill among other things makes domestic violence a crime in its own right and also covers economic, verbal and psychological abuse. 124
Gender based violence contributes to the risk of infection or spread of HIV/AIDS. Human Rights Watch interviewed several women who in an attempt to escape violent relationships entered into sexual relations with men in exchange for the provision of food, shelter and other goods. In the five cases that Human Rights Watch documented, the police failed to provide protection to the women. In two cases, the women were told that the violence was a family issue and not a matter for the police.
Pauline G., a 22- year-old mother of one recounted her story to Human Rights Watch:
My father died in 1996 and my mother in 1997. I lived with my aunt for a couple of years after my mother died but I had a lot of problems. She refused to pay my school fees, and refused to even give me food to eat sometimes. I moved in with my brother until I got married. I didnt want to get married really; I just got married because I needed someone to support me.
My husband was violent. He would hit me for no reason. He was a drunkard. I went to the police and they didnt do anything. I went to my brothers too. My husband took everything when we divorced. At first my brothers took care of me, but I knew I had to find my own support. I went to the bars to look for a boyfriend. I met someone, hes a truck driver. I think he has other girlfriends but he pays for the rent, for food, for clothes. He takes care of the baby.125
Josephine H., a 21-year-old orphan was diagnosed HIV positive in November 2005. She told Human Rights Watch:
When my parents died in April last year, I went to stay with my grandmother and my uncles beat me and chased me and my sister away and so we used to go and live with boys and sleep with them for shelter and security. The father of my child is in South Africa. He left me when I fell sick with tuberculosis and doesnt help with anything. I am worried because every time I go to stay with my grandmother, my uncles beat me and chase me away. My six siblings and I have been chased away on several occasions. I go and stay with men because I have no choice. I know I have to use protection with them now because I am positive. My aunt went to social welfare for help to look after us but they didnt do anything. She has also reported my uncles to the police but they dont do anything.126
Domestic violence, or even the threat of violence, also decreases a womans ability to negotiate her sexual autonomy, making her more vulnerable to HIV infection. Womens economic dependence made worse by discriminatory laws in the case of divorce also increases their vulnerability to violence and HIV-infection and leaves them unable to escape from potentially deadly marriages or partnerships. One woman told Human Rights Watch, I know that my boyfriend is HIV positive because I saw his medical papers. Every three months he goes to get tested but I just keep quiet. I dont ask him about his status because I am scared of him. He would not take it well if I asked him. I am also scared that I may have the disease now. But if I asked him he would say I didnt trust him.127
Womens vulnerability is often compounded by the stigma and discrimination that faces them once their HIV status is revealed. Women who admit to having HIV risk social exclusion or abandonment. The governments divorce laws which fail to recognize womens property rights in the case of unregistered customary marriagessome 80% of all marriagesleaves women particularly vulnerable when it comes to divorce or abandonment.128
Numerous women reported to Human Rights Watch that once their HIV status was revealed, their male partners had abandoned them and their children, thrown them out of the house, or taken property without leaving provisions to support them and their children. The women were often left destitute and unable to deal with the economic consequences of living with HIV/AIDS.
A number of the women told Human Rights Watch that they could not afford to take their husbands to court, while others were not aware of their right to do so. In other cases the women felt they had no recourse to the courts because they were involved in polygamous marriages or unregistered customary unions. In most of the cases the men reportedly blamed their female partner for bringing AIDS into the relationship.
Cecilia M., 40, tested positive for HIV/AIDS after her daughter died of AIDS at the age of ten. When Cecilia M. eventually fell seriously ill her husband left her:
My husband left when I fell sick. He now stays with another wife. Before my husband left I was on medical aid and then he left and I had nothing. My husband doesnt pay any maintenance and he took my property away. I hear people saying that he is showing signs of sickness now. We were together for 13 years and its obvious that he is also positive. My relative who I stay with doesnt know that I am HV positive. There are three other families in the same household and the others suspect that I am HIV positive and they arent comfortable with me. If they knew they would chase me. I dont work. I do some embroidery but business isnt going well. I have had to sell some of my clothes to meet expenses. I just manage to pay the rent. We only have one meal a day in the evening. Its tough. Sometimes you just think that maybe if you die, things will get better. I have to find transport to get my ARVs and when I dont have the money I walk to get the ARVs. I am so stressed. I nearly committed suicide because things are so tough. Theres no bright future because when you dont know what you are going to eat tomorrow, theres no future.129
Several women interviewed by Human Rights Watch were particularly distraught that their relationships with their partners had deteriorated or ended since they had revealed their HIV status. Priscilla P. an HIV positive woman in Gweru told Human Rights Watch, Since I told my boyfriend about my status he has been cold with me. He is also sick all the time but he keeps saying he has been bewitched. He wont say who (has bewitched him) but I think he blames me. He spends more time away from the house now.130 Another woman living with HIV/AIDS told Human Rights Watch, My boyfriend knows I am HIV positive but refuses to get tested. Now he doesnt look healthy. He keeps getting flu and fevers. I dont talk because he is rough and sometimes beats me.131
Tafadzwa K., a 36-year-old divorced woman with four children told Human Rights Watch:
Ive been living with a man for 6 months now. He hasnt been tested. His 2nd wife died, so maybe he is infected. I have been too afraid to talk to him about HIV. He might leave me. He might hurt me. He loves me so much but I cant tell him that Im positive. I want someone to share my life with. We use condoms sometimes. Sometimes he refuses and I cant convince him.132
The government of Zimbabwes policies and actions undermining the fight against HIV/AIDS have been both sudden and catastrophic (Operation Murambatsvina), and subtle and insidious. Progress in the fight against AIDS has also been undermined by the government of Zimbabwes social welfare policies. High user fees for health services, the collapse of the system of social welfare exemptions of health fees, and the failure to ensure that national policies on eligibility for ART are followed have resulted in thousands of individuals living with HIV/AIDS being turned away from the health care that they are entitled to, and that the government of Zimbabwe has committed itself to provide.
Many Zimbabweans face significant obstacles in accessing health services even where these are widely available. In the midst of high unemployment rates and a declining economy, the high cost of user fees for health services means that the majority of Zimbabweans who can no longer afford user fees are therefore unable to access treatment. Those living with HIV/AIDS find it even more difficult to cope with the extremely high costs of AIDS treatments, tests and hospitalizations.
Zimbabwe has long had user fees as a part of its health system. User fees are often promoted by governments as a means for rationalizing health care use and for increasing resources to the health sector. Zimbabweans pay a user fee ranging from 250,000 (US$2.50) for children to 500,000 (US$5) for adults to 7,500,000 (US$75) for pregnant women (per visit) to get a consultation at a government run hospital or clinic.133 In addition, they are required to pay for any treatment they receive as well as any tests that are undertaken at clinics or hospitals. Patients seeking to go onto the government ART programs are required to pay a monthly fee of Z$500,000 (US$5).
Organizations such as Save the Children Fund have pointed out that user fees are not necessarily an effective cost recovery policy.134 Other critics have argued that the uncertainty of user fees (regarding the cost of procedures and the uncertainty of getting exemptions to fees) has prevented access to treatment. Research into the impact of users fees135 found that while the availability of resources did increase, the quality and quantity of care provided to the poor had changed little, resulting in a kind of sustainable inequality, with fees enabling service provision to continue while concurrently preventing part of the population from using these services.136
However, the central problem is that for fees to become a substantial source of revenues, they must be set at a level far beyond the reach of the poorest households. In sum, experience shows that user fees not only exclude the poor from health care and education but are an ineffective tool for raising revenues.137 A 2004 survey by the civic monitoring program on the socio economic situation in all ten provinces of Zimbabwe showed that the cost of treatment was the main reason for peoples inability to use health services.138
The inability to use health services due to high user fees has had a particularly detrimental effect on PLWHA who require treatment. Although the government has pledged to make the cost of health care for HIV/AIDS treatment and care more affordable and available,139 Human Rights Watchs findings in the urban areas of Zimbabwe, show that high user fees present a significant barrier to the ability of PLWHA to access health services.
Charles L., a 48-year-old man diagnosed with HIV told Human Rights Watch:
They told me to come back for nutritional counseling, but they didnt say anything about medicine. The clinic was very, very busy. I didnt have any money for the CD4 test. I was surprised to find out I had HIV. I dont know if Im going to die. My wife is still crying.
The clinic is 1.5 km away but the [medical] card costs 250,000 (US$2.50) then there are prescription costs, injection costs. I cant afford it. Before the clearance the Dominican sisters ran a clinic here they didnt require fees. But it was destroyed when they destroyed the houses.140
High user fees pose even more significant problems for those on free NGO-managed ART programs and undermine the medical benefits of the treatment. For example, one man in Mabvuku told Human Rights Watch that despite being on free ARVs he was required to take regular liver function tests to assess his adherence to the ARVs. Unfortunately, he could not always afford them, I have to buy other medicine and pay for tests. The liver function test costs Z$3 million ($US30). You cant take ARVs without these tests.141
Other PLWHA told Human Rights Watch that they were forced to resort to herbs and other unknown medications in an attempt to alleviate the symptoms of HIV/AIDS. One man explained, I take a few herbs when I feel bad or have diarrhea. Right now I have pneumonia. I dont have any money so theres nothing I could afford.142
Peter K., a 57- year-old man in Mabvuku, told Human Rights Watch:
I got some medicine in March 2005 from a friend who works in a chemist shop. He brought the medicine to me and I would give him a little money. I took the medicine until August and stopped because there was no change. I havent been to the doctor in a long time. I dont know where to go. I have no money.143
The government of Zimbabwe has put in place a number of programs that allow poor and destitute Zimbabweans to access free services including medical care and education for their children. The Department of Social Services under the Ministry of Public Service, Labor and Social Welfare is responsible for running these programs. Human Rights Watch researchers documented many examples of the arbitrary assessment of applications for user fee exemptions by social welfare officers which although designed to protect poor Zimbabweans, in practice fails to protect vulnerable people such as those living with HIV/AIDS.
The public assistance scheme under the governments Social Welfare Assistance Act is specifically designed to provide assistance to:
In determining whether a person qualifies for public assistance, the Director of Social Welfare, or social welfare officers consider the degree of financial hardship of the applicant, the availability to the applicant and his dependents of any assistance financial or otherwise from any source and the state of health, educational level and the level of skills for purposes of the employment prospects of the person applying for financial assistance.144 Those receiving assistance may be given a letter from the department of social welfare that exempts them from paying for health care and treatment.
To establish eligibility, potential beneficiaries have to go to social welfare officers with extensive documentation including pay slips, income tax returns and letters from social welfare offices. This information is used to determine the income of the beneficiary. Critics have noted that the requirement of such extensive documentation poses a significant obstacle to accessing the exemptions.145 For example, in 1995, to qualify for exemptions for user fees patients had to prove that monthly household income was less than Z$400. At the time it was noted that the policy ignored the situation of women who do not live with their husbands, and have no access or ability to compel them to identify their earnings.146 In addition, the majority of the poor work in the informal sector and are unlikely to have wage slips as proof of earnings.
Government schemes to provide assistance to poor and destitute people have in recent years been plagued by a lack of funding. These programs were originally meant for the chronically poor in the 1990s147 (i.e. destitute and poor people unable to help themselves and with no families). However the government of Zimbabwe has failed to take into account the increasing numbers of chronically poor, and the specific characteristics of those who are ill and impoverished as a result of the HIV/AIDS epidemic. Instead it has issued more health fee exemptions than it can pay for causing hospitals and clinics to refuse to accept them and turn away those possessing them. Another result has been the arbitrary provision of exemptions by welfare officers and the refusal to provide them to those who qualify under stated eligibility criteria.
The government does not provide sufficient information to the public on the criteria for exemptions which also leads to many individuals failing to avail of them. In addition, the availability of and the process for receiving the exemptions vary from one township to the next. As a result, some PLWHA interviewed by Human Rights Watch who appeared to meet eligibility criteria under the exemption program had not even pursued the option.148 Many people interviewed by Human Rights Watch reported that in some towns there were no social welfare officers to visit their homes to assess whether they could get exemptions. Several others reported that because there were no welfare officers available in their area, they had to travel long distances to get assistance. In many cases, they could not afford the transport to get to the office.
People still encountered problems even if the welfare officers were available. For example, a 65-year-old woman nursing her seriously ill HIV positive daughter told Human Rights Watch that she had made several calls to the social welfare officers in her area to request a home visit but had received no response.149
An aggravating factor is that social welfare officers within the department of social welfare tend to apply and assess candidates for exemptions in an inconsistent and arbitrary manner.
For example, as stipulated in the Social Welfare and Assistance Act, an individual is required to prove that they suffer from continuous ill health which prevents them from working to receive assistance. Yet, a significant proportion of PLWHA interviewed by Human Rights Watch reported that they were unable to secure social welfare assistance even though they met such criteria. Several PLWHA presented their medical cards to Human Rights Watch that showed their continuous ill health as well as letters from health officials recommending that the patient should be given welfare assistance as a priority.150
The criteria for exemptions follow the principle of necessity i.e. they are designed in accordance with who needs the exemptions most. With funds for social services in short supply it is essential that those most in need of the exemptions are properly identified to receive assistance.
Susan W., a 46- year-old unemployed widow living with HIV/AIDS has suffered from continuous ill health in the past year which has prevented her from working or earning a living. The medical card she showed Human Rights Watch indicated that she had visited the hospital nine times in the past twelve months with various opportunistic infections related to her HIV/AIDS status. She told Human Rights Watch:
I am now on cotrimoxazole which I am supposed to buy from the chemist for Z$ 340000 [US$3.40] a month. Its very expensive and sometimes I have to beg for the money to buy it. I have been sick on and off. I went to Harare Hospital in March 2006 and they said they were closed and not taking on any new patients for ART and that I would have to join a waiting list after my CD4 test. But I cant afford it. I went last time to the department of social welfare but I didnt get any help. They told me to come back another time. But I dont have the transport to go back. I dont work because I have constant chest pains and always feel weak. I am always sick on and off. Last month I had no money for cotrimoxazole, I just stayed without it. Sometimes I take herbs instead of medication.151
The criteria for exemption differed across townships depending on the welfare officer in that area. Different officers considered peoples plights differently and the process for whether a person deserved free treatment or not was quite randomly applied by social welfare officers. This situation was confirmed by numerous PLWHA interviewed by Human Rights Watch in Harare who tried to access social welfare services. For example, one of the stipulations of the Social Welfare and Assistance Act is that a recipient must be destitute or over the age of sixty to qualify for exemption. However, Human Rights Watch interviewed a number of PLWHA under the age of sixty who qualified and received the exemption because they were destitute. At the same time young PLWHA of similar backgrounds who were destitute in other areas of Harare were told that they were too young to qualify for exemption and that they should go and find work.152
Public information is not always widely available on which hospitals accept exemptions letters and which hospitals do not. In a number of cases people who had a letter of exemption from the department of welfare told Human Rights Watch that they had not received exemptions from hospital staff at Harares main hospitals such as Parirenyatwa hospital after being told that the department of social welfare had failed to pay its bills to the hospital. Although government health workers often tell those who are destitute to apply to the welfare department for assistance to access health care, international and local NGO contacts informed Human Rights Watch that two of Harares major hospitals, Harare and Parirenyatwa, were no longer accepting exemption letters from the department of social welfare. Instead, people who go to Parirenyatwa hospital for instance are required to pay cash up front.153
The director of one international organization working with PLWHA told Human Rights Watch, Sending people to the Ministry of Social Welfare is no help at all. It sometimes takes 6 to7 months for them to receive treatment. The letter [for user fee exemption] from the department of social welfare doesnt necessarily mean they will get free ARVs.154
The lack of clarity about how people get exemptions leaves the process open to manipulation. PLWHA and NGOs informed Human Rights Watch that even with a social welfare letter some people were still being charged for treatment at hospitals. For example, one international organization told Human Rights Watch researchers that in Gweru, one of its NGO voluntary counseling and testing staff members presented a local hospital with bills and evidence that the hospital was charging people with a social welfare letter and was thrown out of the hospital by officials.155 Although unable to confirm the allegations, Human Rights Watch researchers also received reports from NGO activists and a number of PLWHA that the process of being granted a social welfare letter was sometimes politicized or manipulated by local government officials as it required political party membership or a reference from village elders, chiefs, or ward counselors depending on location.
Mavis E., 54 and her husband were both diagnosed as HIV positive in 2005. Mavis E., has just recovered from tuberculosis. Maviss 57- year-old husband, Paul J., also has tuberculosis which has affected his joints and left him unable to walk. They have a 21- year-old daughter with severe disabilities who is wheel chair bound and needs full time care. Both Mavis and her husband no longer work and rely on charity. They have made efforts to get an exemption letter from the department of social welfare. In their tiny one-bedroom home they told a Human Rights Watch researcher about the obstacles they faced in trying to get assistance from the department:
I was diagnosed with tuberculosis and then HIV last year together with my husband. We were both put on the waiting list to receive ART. I havent recovered from the tuberculosis but I am on drugs. I have to go to the hospital next week for a CD4 count and I have to pay. I will have to borrow the money for that. I also have to go to the department of social welfare to collect a letter so that we can get free tests and free opportunistic infection drugs. Last year the house we owned was destroyed by Operation Murambatsvina and we stayed out in the open for three months. UNICEF gave us some support to pay for the rent [for the house] for three months. Now we cant pay the rent. Members of the church have paid for the rent for two more months but we need assistance from social welfare. If we dont get the assistance we will be homeless. Before Operation Murambatsvina I used to do selling but now its not allowed and I have to look after my husband and daughter. My husband used to be a driver but he fell sick. As you can see his joints are swollen and he cant walk. His wheel chair is broken and he needs one. He shares one wheel chair with my daughter. The tuberculosis has affected his joints. To acquire a social welfare letter for free treatment, I need to take my husband to the Highfield welfare department to prove that he is sick and that we need help. Last time I took him there but there was a long queue so we had to come back. Then I need to take him to the Parirenyatwa hospital for treatment and with transport costs its difficult. I also have to use my daughters wheel chair to transport him in. Here in this area, the department of social welfare doesnt do home visits so I have to go all the way to Highfield which is difficult. I am weak from the tuberculosis and pushing the wheelchair is hard but we need help so we will have to find transport to go back.156
As exemplified above, the lack of information on exemptions for user fees and the arbitrary application of exemptions for user fees within the social welfare system effectively deny people their right to health. With a significant proportion of Zimbabweans living below the poverty line and the governments continued policy of restricting economic activities in a climate of high unemployment, desperately poor individuals who are unable to obtain assistance from the department of social welfare, find living with HIV/AIDS onerous. Transportation fees, consultation fees, medicines and tests are well beyond the means of most Zimbabweans. Without assistance from the department of social welfare, many are unable to access healthcare.
The government of Zimbabwes failure to provide information to public sector physicians, AIDS service organizations and networks of people living with HIV/AIDS, as well as patients testing HIV positive, on the national standards for antiretroviral therapy eligibility and the misapplication of these standards has restricted access to treatment for thousands of people in desperate need of the life-saving drugs.157
Human Rights Watch found significant misconceptions about ART and CD4 test requirements (CD4 tests are a marker of immune system function) among PLWHA, AIDS service organizations, government AIDS officials, and medical providers. All these individuals and organizations believe that all HIV positive individuals are required to have a CD4 test to be eligible for ART. The cost of a CD4 test is between $Z7-15 million (US$ 70-150).
However, under the governments national guidelines for treatment of HIV/AIDS (which are based upon World Health Organization guidelines)158 ART should be commenced in all individuals with a positive HIV test and: (1) a CD4 count of less than 200 mm3 (regardless of clinical symptoms) or (2) clinical symptoms consistent with WHO HIV clinical stages III or IV (with or without a CD4 test).159 These guidelines therefore do not require a CD4 test for a patient in the latter clinical stages of AIDS to receive ART if for some reason the test has not been taken or is not available.
The unnecessary requirement by government health care providers that all PLWHA with WHO HIV clinical stage III or IV undergo a CD4 count before commencing treatment poses a significant barrier to access ART for seriously ill individuals particularly for those who cannot afford the test. Human Rights Watch interviewed over 30 PLWHA in Harare who were turned away from life-saving ART because medical providers had told them they required a CD4 test which they did not in fact need and could not afford.162
Patricia M., a 46-year-old widow with two children, tested positive for HIV in February 2006. She was diagnosed with tuberculosis in 1998 and in 2003 and told a Human Rights Watch researcher that she had a severe rash all over her body. She told Human Rights Watch that after she was diagnosed with HIV she went to Parirenyatwa hospital to get onto the government ARV program. They told me that I had to go for a special test first (CD4) before I could get on the ARV program, she said, but when I asked for it they required money. I cant afford it so I wont go.160
James L. told Human Rights Watch that he tested positive for HIV shortly after he was diagnosed with TB. He was told that he should start taking anti-retroviral drugs, but that he first needed to get a CD4 test. When he went for the test, he was told that the CD4 machine wasnt working and that he had to go to a private clinic. The government hospital gave him a letter of referral to a private clinic, but it cost 10 million Zimbabwe dollars (US$100) for the test and he didnt have the money. As a result James was unable to get onto the program.161
Margaret, C., a 25-year-old mother of two in Mabvuku, Harare was diagnosed with tuberculosis and then tested positive for HIV. After her tuberculosis treatment she was told to go for a CD4 test to get access to the government ARV program. I tried to go and get a CD4 test at Parirenyatwa, she said, But they wanted money and I had none. I then went to an NGO giving out free ARVs but they told me they had enough people and that I should go back in six months. Right now I have chest problems and severe rashes. I also have problems eating. I have tried to get help from the church but they dont have the money to help. She concluded, I think I am going to die.162
Human Rights Watch researchers also documented cases where private doctors and even health personnel in some government hospitals deliberately withheld the results of CD4 tests if patients did not pay for the test.
Chipo D., in Mabvuku, told Human Rights Watch:
My husband was cleared of tuberculosis in February but is very sick and is bed ridden. I went to see a private doctor who said he had pneumonia. He went for a CD4 count at the private doctor which cost me Z$15 million (US$150) and it was 78 and so they said he should be put on ARVs but I couldnt afford the treatment for ARVs so he just went on treatment for pneumonia. He had ten injections and all in all it cost me about Z$ 12 million (US$120) and then the tablets cost about Z$3 million (US$30). I am not working but got some money from relatives but now they have stopped giving me money so my husband is just at home and we need help. I havent tried going to the department of social welfare because those guys are a problem. Some people who have gone there say that its just a waste of time.
I am thinking of getting my husband on free government ARVs but to get his CD 4 results from the private doctor is a problem because he thinks that I am going to run away. When I asked him for my husbands results he asked me why I wanted them. I told him it was to go for free ARVs and he refused to give me the tests. When we were first diagnosed we were counseled at a government centre and told about the government program but they said there was a waiting list and that to get on it we needed the CD4 test results but they are with the private doctor.163
Abigail J., a 42- year-old widow told Human Rights Watch:
I went for an HIV test in 2005 because I was very sick. I have sores on my back and feel very sick. I went to Parirenyatwa hospital in Harare for a CD4 test but was not given the results because I had no money. Then I went there with a letter from the department of social welfare but they are refusing because they say that the Ministry of Social Welfare doesnt pay the bills and the CD4 count has to be paid for even with a letter. I am not on ARVs because I have no CD4 test. I cant afford the medicine for the sores on my back. I go to the clinic [in her area] and they give me prescriptions for antibiotics but I cant afford to buy them.164
Human Rights Watch was unable to determine precisely why medical care providers required all HIV positive patients to get the CD4 test, and it is likely that there are multiple reasons. Universal CD4 tests are generally preferred by physicians to best manage patient care, and a simple lack of knowledge of the hardship CD4 test costs pose, the lack of exemptions for diagnostic tests, or official ART policy is one possible reason for the situation of requiring CD4 tests for all patients. Some NGOs and advocates for PLWHA suggested, but not confirmed, that other reasons may be behind the requirement for CD4 tests. These include: an intention by health care providers to recoup costs or make money (as other costs are minimally covered, e.g., consultancy costs) or an intention to minimize waiting lists of patients for ARV drugs (as those who fail to undergo a CD4 test cannot get on to the waiting list to receive ARV drugs). The ability to pay for the CD4 test as a proxy measure of ability of the patient to adhere to the ARV drug regimen was also suggested as a possible reason by some NGOs.165 One private medical provider told Human Rights Watch that the ability of patients to afford transportation to the clinic was a requirement for eligibility for ARVs.166
Regardless of the reasons for this requirement, the failure of the government to inform individuals who test HIV positive about ART eligibility criteria and governments failure to ensure that medical providers follow national ART guidelines, has resulted in thousands of people turned away from care that they need and are eligible for. In addition, other individuals, who do not fulfill the WHO stage III or IV clinical guidelines, but cannot afford the cost of a CD4 test are potentially excluded from necessary care, if their CD4 count is below 200 mm3. These individuals, despite the lack of clinical symptoms, face as dire an outcome as individuals with advanced AIDS symptoms when they are turned away from CD4 testing because of an inability to pay and the failure of the social welfare system to provide for exemptions for payment of these diagnostic tests.
The political and human rights environment in which HIV/AIDS organizations and PLWHA operate has hampered their effectiveness in addressing the crisis.
Articles 19, 21 and 22 of the International Covenant on Civil and Political Rights (ICCPR) to which Zimbabwe is party protect the rights to freedom of expression, assembly and association respectively. In addition, PLWHA should have the right to receive information regarding HIV/AIDS as well as to participate in representative mechanisms to advocate for provisions that improve their access to health.167
The governments inclusion of HIV/AIDS organizations and PLWHA in national HIV/AIDS strategies has done little to increase debate and activism on HIV/AIDS or to improve the rights of PLWHA. Human Rights Watch is concerned that a climate of fear exists in Zimbabwe that curtails peoples ability to exercise their right to freedom of expression, association and assembly. PLWHA and HIV/AIDS activists to whom Human Rights Watch researchers spoke reported problems expressing their concerns within the context of advocating for HIV/AIDS and human rights. The government was particularly hostile when they commented on the human rights ramifications of government policies on PLHWA, financial management or equitable distribution of resources to HIV/AIDS associations and NGOs.
In interviews with Human Rights Watch several HIV/AIDS organizations questioned the disbursement of the national AIDS levy and the governments utilization of resources meant for HIV/AIDS. They also expressed concerns about the lack of transparency within the National AIDS Council (NAC) when it came to disbursing funds for HIV/AIDS programs to different organizations. When voiced publicly within Zimbabwe, these concerns were often met with hostility by the government. For instance, on December 1 2005 World AIDS Day demonstrations to focus attention on the need for greater budget transparency and accountability for the HIV/AIDS levy were disrupted by police and five HIV/AIDS activists arrested under the Public Order and Security Act (POSA) for incitement despite a judicial ruling allowing the protests. The activists were detained for two days and then released without charge.168Commenting on the arrests one activist said, Because of the arrests, it will be difficult to get the people to attend future marches or protests to advocate for their rights.169
The government has also used the state run media to criticize and intimidate activists and NGO organizations who speak out about some of its policies and their effects on HIV/AIDS. For example, the representative of one international organization which highlighted the effects of Operation Murambatsvina on PLWHA told Human Rights Watch that it got repeated tongue lashings from the state-run newspapers.170
The government of Zimbabwe has promulgated a raft of restrictive legislation that violates the rights of people to freedom of expression, association and assembly. This has affected the work of NGOs including those working on HIV/AIDS. Advocating for the human rights of PLWHA under such laws has not always been easy. As one NGO representative in Harare pointed out to Human Rights Watch:
Unfortunately the laws we have make it criminal for NGOs to act on human rights and we have been gagged in raising the issue of human rights even in connection with HIV/AIDS. The proposed NGO bill makes it difficult for us to make noise because if we do we want be registered as an NGO. NGOs are now towing the line. Theres no one to make noise about human rights issues. We know that civil servants and ministers are benefiting from the public roll out system for ARVs but we cant say that.172
The representative of an NGO in Harare informed Human Rights Researchers, Once we started making noise about Operation Murambatsvina and its effects on PLWHA and the general health of the population, we got a call from the Office of the President reminding us that we had submitted papers for registration as a PVO and that we were putting this in jeopardy.173 Another HIV/AIDS activist in Harare confirmed, The political environment seems to play at the back of the minds of civil society organizations. They feel they have to restrain themselves in terms of advocating for the hard issues. You concentrate on what you can do without ruffling feathers.174
Restrictive legislation such as POSA requires all NGOs to request permission to hold public meetings or workshops. Although local HIV/AIDS organizations are supposed to be exempt from such requirements this is not the case in practice.175
In one incident, the representative of an organization working with HIV positive women informed Human Rights Watch that when she visited an area in Mashonaland province- a stronghold of the ruling ZANU PF party to hold a workshop on HIV/AIDS, she was denied permission to do so by the local ZANU PF officer who accused her of being a member of the opposition.176
NGO representatives and human rights activists are routinely harassed and interrogated by members of the central intelligence organization, while peaceful protests are regularly disrupted by the police and the demonstrators arrested. As has already been highlighted earlier such clampdowns are not restricted to human rights activism but extend to activism by HIV/AIDS organizations.
International and local NGOs are also required to go through a vetting process and seek permission from the governors office, and district administration officers to be able to operate. Such requirements prevent NGOs from freely airing their views on various political issues. As one HIV/AIDS NGO representative in Harare said, The people we seek permission from are the same groups that we have to criticize if things go wrong. He continued, If we do then these same people can chase us away and refuse to give us authority to work in their areas. It makes it difficult. The space for activism is very narrow now.177
The politicized environment has led to an extreme level of paranoia within government structures and amongst government officials. Increased tension between the government and civil society as well as the government and western donors means that many local and cabinet level government officials view local and international NGOs with great suspicion. Local NGOs are accused of being supporters of the opposition and of receiving funds from western donors who are enemies of the government. Similarly international NGOs are also seen as backing the opposition and out to destabilize the country.178 Although the government has been less obstructive with NGOs working on HIV/AIDS compared to other NGOs, they nevertheless have to tread carefully when they interact with western donors and governments. They are often closely watched and routinely interrogated by government operatives.
The director of one NGO working on HIV/AIDS prevention programs described to Human Rights Watch how he was routinely harassed by CIO:
I am under the spotlight from the government. Sometimes I get CIO visiting me and asking, Where do get your funding? Do the funders tell you what to do? If a foreign official visits me, I get questions. Each time we distribute mealie meal to our orphans, vulnerable children and PLWHA we have to inform the CIO. They want to know who is giving us the mealie meal because they think we are opposition. They dont like to see NGOs competing with the government. For example when one foreign official came to visit we had three CIO coming to ask us what we were discussing. It was an intimidating tactic.179
A representative of one NGO in Harare informed Human Rights Watch that during elections, it was difficult to distribute condoms in the high density urban areas of Harare because employees distributing the condoms were sometimes harassed and attacked by police, ZANU-PF officials and youth militia who accused them of working for the opposition.180
 Human Rights Watch, Evicted and Forsaken; Human Rights Watch, Clear the Filth: Mass Evictions and Demolitions in Zimbabwe, A Human Rights Watch background briefing, September 11, 2005, http://hrw.org/backgrounder/africa/zimbabwe0905/.
 ActionAid International in collaboration with the Counseling Services Unit (CSU), Combined Harare Residents Association, and the Zimbabwe Peace Project, An in-depth study on the effects of Operation Murambatsvina, (Harare: ActionAid International, 2005), p. 21.
 Human Rights Watch interview with Teresa N., (not her real name), Hatcliffe Extension, April 20, 2006.
 Human Rights Watch interview with HIV positive man, Hatcliffe Extension, April 20, 2006.
 Most Zimbabweans described the evictions as a tsunami, as the police who evicted them from their homes came without warning and destroyed everything in their path.
 Human Rights Watch interview with Priscilla K., (not her real name), Highfield, April 20, 2006.
 Human Rights Watch interview with HIV positive woman, Hatcliffe Extension, April 20, 2006.
 Human Rights Watch interview with representative of international NGO, Harare, April 21, 2006.
 UNAIDS, 2006 Report on the Global AIDS Epidemic, Comprehensive HIV prevention, http://data.unaids.org/pub/GlobalReport/2006/2006_GR_CH06_en.pdf?preview=true (accessed June 24, 2006), p. 130.
 For example see Belinda Dodson and Jonathan Crush, Deadly links between mobility and HIV/AIDS, Crossings, vol. 7 no. 1. March 2006, p. 2.
 Human Rights Watch report, Evicted and Forsaken. p. 32.
 Human Rights Watch interviews with local and international NGOs, Harare, April 18 May 2, 2006.
 ActionAid International, An in-depth study on the effects of Operation Murambatsvina, p. 22.
 Human Rights Watch interview with local and international NGOs, Harare, April 18 -May 2, 2006.
 Human Rights Watch, Clear the filth,p. 28.
 Human Rights Watch interview with Netsai A., (not her real name), Hatcliffe Extension, April 20, 2006.
 Human Rights Watch interview, woman living with HIV/AIDS, Highfield, April 20, 2006.
 Human Rights Watch interview with Nelly S., (not her real name), Mabvuku, April 22, 2006.
 According to reports the government of Zimbabwe admitted that it has rebuilt only 3000 housing units despite pledging to build over a million houses in the next four years. See Zimbabwe houses not for officials, News24online, March 14 2006, http://www.news24.com/News24/Africa/News/0,,2-11-1447_1897729,00.html (accessed March 14, 2006).
 See UNAIDS, HIV/AIDS, Human Resources and Sustainable Development, World Summit on Development, Johannesburg, 2002, http://data.unaids.org/Publications/IRC-pub02/JC865-WSSD_en.pdf (accessed July 10, 2006), p.5.
 See Government of Zimbabwe, Response by the Government of Zimbabwe to the Report by the UN Special Envoy on Operation Murambatsvina/ Restore Order, August 2005, http://www.un.org/dpi/ngosection/fall05/briefings/27oct-resp-zimb.pdf (accessed June 12, 2006), pp. 15 16.
 Before the 1990s micro entrepreneurs who wanted to operate outside designated areas had to submit an application, advertise, advise neighbors, and acquire special consent. However all this changed when as part of structural adjustment programs, the government was encouraged to lessen restrictions on micro and small enterprises. For more on this subject see: Carolyn Barnes and Eric Keogha, An assessment of the impact of Zambukos microenterprise program in Zimbabwe: Baseline findings, USAID, AIMS Project Brief 23, 1999, pp. 11-12.
 Regional Town and Country Planning Act, Chapter 29:12, 1976. Statutory instrument 216 specifically provides for non-residential uses in residential areas.
 U.N. Special Envoy on Human Settlement Issues in Zimbabwe, Report of the Fact-Finding Mission. In its critical response to the UN Envoy, the Government of Zimbabwe acknowledged that it indeed attempted to promote the informal sector in residential areas. See Response by the Government of Zimbabwe to the Report by the UN Special Envoy on Operation Murambatsvina/ Restore Order.
 Combined Harare Residents Association, 2006 City of Harare Budget Analysis, March 2, 2006, http://www.kubatana.net/docs/locgov/chra_harare_budget_analysis_060302.doc (accessed July 13, 2006). p. 6.
 Carolyn Barnes and Erica Keogh, An assessment of the impact of Zambukos microenterprise program in Zimbabwe: Baseline findings, USAID, AIMS Project Brief 23, 1999, p. 12. The government does not have an existing piece of legislation governing the operation of micro enterprises. But according to local authority regulations, anyone operating a business (including home based income generating ventures) is required to obtain a license which is renewable annually. The license depends on the type of business for example shop trading, vending or hawking. However as has already been indicated local authorities have turned a blind eye to these requirements. In addition surveys on the informal sector in the late 1990S found that most micro-entrepreneurs did not have a license which supported the conclusion that existing regulations had been relaxed until Operation Murambatsvina.
 Human Rights Watch interview with informal trader, Gweru, April 26, 2006.
 Womens Resource Centre Network and Southern African Research and Documentation Centre, Beyond Inequalities, Women in Zimbabwe 2005, http://databases.sardc.net (accessed June 24, 2006); ActionAid International, Sectoral Impact of Operation Murambatsvina/ Restore Order.
 See Global Coalition on Women and AIDS, a UNAIDS initiative, Economic Security for Women Fights AIDS, (2006), http://data.unaids.org/pub/BriefingNote/2006/20060308_BN_GCWA_en.pdf (accessed June 13, 2006); International Community of Women Living with HIV/AIDS, Action needed to reduce gender inequality and poverty in the lives of HIV positive women, (2004), http://www.icw.org/tiki-download_file.php?fileId=62 (accessed, June 26, 2006).
 Human Rights Watch interview with informal trader, Gweru, April 26, 2006.
 Human Rights Watch interview with Fadzai B., (not her real name), Mabvuku, Harare, April 22, 2006.
 Human Rights Watch interview with Nyandzo C., (not her real name), Gweru, April 26, 2006.
 Human Rights Watch interview with director of organization (name and location withheld), April 26, 2006.
 Speech by Stephen Lewis at the Centre for Strategic and International Studies, Washington DC, October 4, 2002.
 Zimbabwe, National Policy on HIV/AIDS for Zimbabwe, (1999), Section 7.
 National Gender Policy of the Republic of Zimbabwe, October, 2000, p.1.
 Ibid., p. 12. In section 6.2.3, the Gender Policy recommends the following strategies in an effort to guarantee human rights and democracy: 1) Lobbying for the promotion of equal and equitable participation of women and men in decision making. 2) Legislate and enforce against discriminatory practices, beliefs and traditions that hinder the advancement of women and men especially the girl child. 3) Incorporate provisions of international human rights instruments into domestic law.
 Human Rights Watch interviews with womens organizations and women in Harare, Gweru and Masvingo, June 2005, September 2005 and April 2006.
 Zimbabwe has a dual legal system. As a result womens property rights in Zimbabwe are subjected to two sources of law: general law i.e. The Roman Dutch system of law and the customary law of the two main groups of Zimbabwes indigenous peoples, the Ndebele and the Shona. The right to property in Zimbabwe is protected by section 16 of the Constitution of Zimbabwe, 1979.
 Constitution of Zimbabwe, section 23 (3) (b), 1979. The section outlines that the Application of African customary Law shall not be held to be discriminatory in other issues of personal law such as inheritance, access to communal land which then prejudice womens rights to access property. For more on womens property rights in Zimbabwe see Thandekile Ngwenya, Zimbabwe Women Lawyers Association, Strategic Litigation Womens Property Rights in Zimbabwe, Bulawayo presentation at a Strategic Litigation Workshop, Johannesburg, August 15-18, 2005.
 An unfortunate precedent was set by this section of the Constitution in the case of Magaya v. Magaya when the Supreme Court ruled that under family law, a mans claim to family inheritance takes precedence over a womans. Although the Administration of Estates Act was eventually amended in 1997 to address the problems highlighted in Magaya v. Magaya, the Act only applies to deaths occurring after 1 November 1997. Thus deceased estates of persons, who passed away before 1 November 1997, are bound by the Magaya decision.
 Administration of Estates Amendment Act 6:07, 1997.
 Human Rights Watch interview with Mary S., (not her real name), Gweru, April 26, 2006.
 Human Rights Watch interview with Patricia E., (not her real name), Gweru, April 26, 2006.
 Property grabbing can be defined as when a mans relatives descend upon his widow to claim the households material possessions.
 Human Rights Watch interview with Sibonikhile F., (not her real name), Gweru, April 26, 2006
 See Womens Resource Centre Network, Beyond inequalities, Women in Zimbabwe 2005; Activists demand GBV law, IRINnews, March 7, 2006, http://www.irinnews.org/report.asp (accessed March 7, 2006); Zimbabwe rape cases on rise countrywide, AllAfrica.com, April 12, 2006, http://www.allafrica.com/stories/200604110253.html (accessed April 12, 2006).
 Sexual Offences Act, Chapter 9:21, 2001, section 8.
 Email communication from Veritus Trust (Zimbabwe) to Human Rights Watch, July 1, 2006; see also Activists demand GBV law, IRINnews, March 7, 2006, http://www.irinnews.org/report.asp (accessed March 7, 2006)
 Human Rights Watch interview with Pauline G., (not her real name), Gweru, April 26, 2006.
 Human Rights Watch interview with Josephine H., (not her real name), Mabvuku, April 22, 2006.
 Human Rights Watch interview, Gweru, April 26, 2006.
 In Zimbabwe it is reported that almost 80% of all marriages are customary marriages. See Woman Kind, Zimbabwe country profile, http://www.womankind.org.uk/why-zimbabwe.html (accessed June 20, 2006).
 Human Rights interview with Cecilia M., (not her real name), Highfield, April 20, 2006.
 Human Rights Watch interview, with Priscilla P., (not her real name), Gweru, April 26, 2006.
 Human Rights Watch interview, Gweru, April 26, 2006.
 Human Rights Watch interview with Tafadzwa K., (not her real name), Gweru, April 26, 2006.
 Human Rights Watch interviews with medical personnel and PLWHA, Harare, Gweru and Bulawayo, April 17 May 2 2006.
 The introduction of fees has rarely freed up additional resources for targeted assistance to the poor, or for intra-budget reallocations to basic services. This is because governments dont usually allocate a fixed share of the budget to one subsector, and because the sums raised are small compared with the needs especially after collection costs are taken into account. For example, data from 1991-92, found that user fees contributed only 3.5% of Ministry of Health recurrent expenditures in Zimbabwe. Cited in Creese, A and Kutzin J, Lessons from cost recovery in health, Division of Strengthening Health Services, Discussion Paper No. 2; World Health Organization, 1995; Save the Children, An Unnecessary Evil, User fees for healthcare in low-income countries, (London: Save the Children, 2005).
 F. Nyantor. and J. Kutzin,. Health for Some?: The Effects of User Fees in Volta Region of Ghana, Health Policy and Planning, 1999, 14(4) pp. 329-341.
 Ibid., p. 329.
 ActionAid, User fees: the right to education and health denied. A policy brief for the U.N. Special Session on Children, New York, May 2002.
 Civic Monitoring Programme, Quarterly Community Assessment of the Socio-Economic Situation in Zimbabwe: Health and Education, March 2004.
 Government of Zimbabwe, National Policy on HIV/AIDS for Zimbabwe, (1999) Guiding Principle 12.
 Human Rights Watch interview with Charles L., (not his real name), Hatcliffe Extension, April 20, 2006.
 Human Rights Watch interview, Mabvuku, April 22, 2006.
 Human Rights Watch interview with Peter K., (not his real name), Mabvuku, April 22, 2006.
 The Social Welfare and Assistance Act, Chapter 17:06, 1988, section 6 (1), (2) http://www.parlzim.gov.zw/Resources/Acts/acts.html (accessed June 6, 2006).
 F. Dlodlo, Implementation Impact of User-Fee Policy: Case Studies in Zimbabwe, Research Paper, 1995, Institute of Social Studies, The Hague.
 L.T.Munro, A social safety net for the chronically poor?: Zimbabwe's Public Assistance Programme in the 1990s, The European Journal of Development Research, 17 no. 1 (2005) pp. 111-131.
 Human Rights Watch interviews, Harare, April 20 and 22, 2006.
 Human Rights Watch interview, Hatcliffe Extension, April 20, 2006.
 Human Rights Watch interviews Hatcliffe Extension and Highfield, April 20, 2006.
 Human Rights Watch interview with Susan W., (not her real name), Hatcliffe Extension, April 20, 2006.
 Human Rights Watch interviews, Harare and Gweru, April 20, 22 and 26, 2006.
 Human Rights Watch interviews, Harare, April 17 May 2, 2006.
 Human Rights Watch interview, Harare, April 21, 2006.
 Human Rights Watch interview, Harare, April 21, 2006.
 Human Rights Watch interview with Mavis E., and Paul J., Mufakose, (not their real names), April 30, 2006.
 According to: J.T. Boerma et al., Monitoring the scale-up of antiretroviral therapy programmes: methods to estimate coverage, Bull World Health Organ, February 23, 2006, 84(2), Epub 2006, individuals with advanced symptoms of AIDS who meet eligibility criteria for ART but who do not receive it would be expected to die within 2 years. pp. 145-50.
 WHO, Scaling up ART in resource-limited settings: guidelines for a public health approach. WHO, 2003, http://www.who.int/docstore/hiv/scaling/anex1.html (accessed July 11, 2006). WHO stage III or IV symptoms include: unexplained chronic diarrhea for longer than one month, unexplained persistent fever (intermittent or constant for longer than one month), severe weight loss (>10% of presumed or measured body weight), oral candidiasis, oral hairy leukoplakia, pulmonary tuberculosis diagnosed in the last year, severe presumed bacterial infections (e.g., pneumonia, empyema, meningitis, bacteraemia, pyomyositis, bone or joint infection) or acute necrotizing ulcerative stomatitis, gingivitis or periodontitis (stage III); and HIV wasting syndrome, Pneumocystis pneumonia, recurrent severe or radiological bacterial pneumonia, chronic herpes simplex infection (orolabial, genital or anorectal of more than one months duration), oesophageal candidiasis, extrapulmonary tuberculosis, Kaposis sarcoma, central nervous system toxoplasmosis, and HIV encephalopathy (stage IV).
 Ministry of Health and Child Welfare, Zimbabwe HIV/AIDS Standard Treatment Guidelines, 1st edition, 2004. (Harare: Ministry of Health and Child Welfare, 2004), p. 40.
162 Human Rights Watch interviews with PLWHA in Hatcliffe Extension, Highfield, Mabvuku , and Gweru, April 20, 22 and 26.
 Human Rights Watch interview with Patricia M., (not her real name), Mabvuku, April 22, 2006.
 Human Rights Watch interview with James L., (not his real name), Mabvuku, April 22 2006.
 Human Rights Watch interview with Margaret C., (not her real name), Mabvuku, April 22, 2006.
 Human Rights Watch interview with Chipo D., (not her real name), Mabvuku, April 22, 2006.
 Human Rights Watch interview with Abigail J., (not her real name), Highfield, April 20, 2006.
 Human Rights interviews with NGO representatives and HIV/AIDS activists, Harare and Bulawayo, April 17 May 2, 2006.
 Human Rights Watch interview with medical provider, Bulawayo, April 24, 2006.
 Committee on Economic, Social and Cultural Rights (CESCR), The Right to the Highest Attainable Standard of Health, (Art 12), E/C.12/2000/4, (August. 11, 2000) General Comment no. 14, on the normative content of article 12 of the ICESCR, para 11. The Committee interprets the right to health, as defined in article 12.1, as an inclusive rightextending not only to timely and appropriate health care but also to the underlying determinants of health, such as access to safe and potable water and adequate sanitation, an adequate supply of safe food, nutrition and housing, healthy occupational and environmental conditions, and access to health-related education and information.
 Human Rights Watch interviews, Harare, April 19 and 20, 2006.
 Human Rights Watch interview with HIV/AIDS activist, (name withheld), Harare, April 20, 2006.
 Human Rights Watch interview with international NGO representative, (name withheld), Harare, April 19, 2006.
 Human Rights Watch telephone interview with local NGO Director, (name withheld), Harare, June 19, 2006.
 Human Rights Watch interview with HIV/AIDS NGO representative, (name withheld), Harare, April 21, 2006
 Human Rights Watch interview with director of local NGO, (name withheld), Harare, April 21, 2006.
 Human Rights Watch interview with HIV/AIDS activist, (name withheld), Harare, April 20, 2006.
 Under POSA Chapter 11:17, AIDS service organizations are exempt from procedures relating to political organization.
 Human Rights Watch interview with HIV/AIDS NGO representative. (name withheld), Harare, April 21, 2006.
 Human Rights Watch interview with local NGO representative, (name withheld), Harare, April 21, 2006.
 Government representatives have routinely accused local NGOs and international NGOs of supporting the opposition. For example in a speech at the inaugural session of the human rights council on June 21 2006, the Minister of Justice, Legal and Parliamentary Affairs, Patrick Chinamasa accused local NGOs working on human rights and governance as being financed by developed countries as instruments of their foreign policy, and called for the security council to produce a framework which prohibits direct funding of local NGOs. According to the Minister, the objectives of these foreign governments were to undermine sovereignty and promote disaffection and hostility among the local population. The full text of the speech can be found online: http://www.ohchr.org/english/bodies/hrcouncil/docs/statements/zimbabwe.pdf (accessed June 22, 2006).
 Human Rights Watch interview with director of HIV/AIDS NGO, (name and location withheld), April 26, 2006.
 Human Rights Wach interview with representative of NGO, (name withheld), Harare, April 21, 2006.