Gender and HIV/AIDS in Africa
More than twenty-five years after the first HIV cases were detected, Africa remains in the grip of a terrible epidemic. Millions of children have been orphaned and are at risk of abuse and exploitation, thousands of adults in their most productive years are dying every day, millions of others are sick, and countless others fear abandonment and even violence if they disclose their HIV status to family and friends.
Globally, 33.2 million people are living with HIV/AIDS. Of these approximately 15.4 million are women.1 Sub-Saharan Africa remains the epicenter of the pandemic, with 22.5 million of all those with HIV living in this region, representing 68 percent of all infections.2
In Africa women with HIV outnumber men, constituting between 59 and 61 percent of all adults with HIV above age 15.3 There is now a well established body of international and regional research that illustrates how gender inequalities fuel the epidemic and hamper efforts to prevent new infections among women.4 Womens subordinate status within intimate relationships and their economic dependence on male partners make it difficult for them to negotiate safer sex and to use condoms consistently, for fear of being abandoned or assaulted. Concurrent relationships (or suspicion of concurrent relationships) in the age of HIV/AIDS often give rise to tensions that can result in domestic violence.5
The World Health Organization (WHO) has identified violence, including violence against women, as a major public health problem in Africa.6 Gender-based violence creates conditions conducive to the transmission of HIV to women, since women in violent relationships often experience coercive, violent sex and are unable to negotiate HIV prevention. Furthermore, some women may be unable to leave violent relationships because of their economic and psychological dependence on their abusers. Womens unequal property rights also contribute to the HIV/AIDS epidemic in the region. Under the laws and customs of many sub-Saharan African countries, women neither inherit nor keep property upon divorce on an equal basis with men. This reinforces their dependence on men, sometimes locking them in abusive relationships. This may also render women and their children destitute upon divorce or the death of their husbands.
In 2003 2.1 million adults and children died of AIDS-related causes worldwide, the vast majority unable to pay for life-saving medication. At that time only 400,000 people in low- and middle-income countries were receiving antiretroviral therapy.7 By December 2006 the reach of treatment had increased five-fold, to over two million, but even this figure represents only 28 percent of those who needed treatment.8 Many adults and children still cannot access life-saving ART. Leaders of the Group of Eight (G8) and the United Nations General Assembly made commitments in 2005 and 2006 to work with the WHO, Joint United Nations Program on AIDS (UNAIDS), and other international institutions to move as close as possible to universal access to treatment by the year 2010.9 This political commitment led to increased resources for HIV treatment programs, and in sub-Saharan Africa the scale-up of treatment has been dramatic.10
Despite these advances, governments and international health agencies point to several constraints in the delivery of and adherence to ART. These include the procurement and supply of drugs and equipment for diagnostic testing, limited human resources, limited capacity of healthcare systems, and lack of proper program management and monitoring systems.11 These and other factors, such as food insecurity, poverty, lack of money for transport, stigma and discrimination, and direct and indirect user fees, are all factors that hold back the expansion of treatment programs. As Chapter V below shows, gender-based abuses substantially curtail womens ability to benefit fully from ART. In some cases womens enrollment in ART programs exposed them to domestic violence, and to abandonment and divorce, which coupled with insecure property rights, often exposed women to further impoverishment and even homelessness. If ART programs are not strengthened so that they take into account and help to address the impact of gender-based violence, lack of protection for women in family and property rights issues, and unequal relations between men and women in general, women will continue to miss out on life-saving treatment.
A high level of adherence is critical for the success of ART. According to the WHO, adherence to ART is well recognized as an essential component of individual and programmatic treatment success.12 Research on drug adherence has shown that higher levels of drug adherence are associated with improved virological, immunological and clinical outcomes and that adherence rates exceeding 95 percent are necessary in order to maximize the benefits of ART.13 Lack of adherence can lead to the development of drug resistance, which can lead to treatment failure among individuals and drug resistant strains of HIV can be transmitted to others during unprotected sex and other high-risk activity.14
In 2006 the prevalence of HIV in Zambia was about 17 percent (approximately 1.1 million people) among the 15 to 49 age group.15 Women account for 57 percent of Zambians infected with HIV.16 Girls and young women between ages 15 and 24 are four times more likely to be infected with HIV than their male counterparts.17
Despite increased knowledge of the importance of HIV counseling and testing, few Zambian women and men know their HIV status.18 According to the most recent Zambia Sexual Behavior Survey (2005), although 80 percent of Zambian women and 83 percent of Zambian men stated that they knew a place where they could have an HIV test,19 the percentage of Zambians who had ever been tested remained low. In 2005 the percentage of Zambian women and men who had ever been tested was 15.3 percent and 11.4 percent respectively.20 Fear of learning the result, fear of stigma and discrimination, and lack of adequate health facilities are all factors contributing to the low percentage of people aware of their HIV status in Zambia.21 Gender-based abuses and the fear of such abuses also determine womens decisions to access HIV testing.
In 2004 the Zambian government introduced free access to ART in the public health sector for those who need it, and in June 2005 the government declared that the whole ART service package would be available free of charge in the public health sector.22 It appears, however, that this policy is not being uniformly applied in the two provinces studied for this report. Interviewees in Ndola, in the Copperbelt province, indicated that they only receive antiretroviral medicine free of charge, and must pay for CD4 countsand other diagnostic tests.23 As the testimonies in Chapter V indicate, the cost of these tests is prohibitive for women with insecure property rights and also severely impacts women in abusive relationships.
In January 2004 only 1,483 people were accessing HIV treatment in Zambia. By November 2005 an estimated 43,964 people living with HIV were accessing antiretroviral drugs through 53 public health facilities throughout the country.24 At the end of 2006 the number had increased to 75,000 and the number of sites to 110.25 According to PEPFAR, by September 2007 the number of people receiving HIV treatment in Zambia had increased to 122,700.26
In 2006 61 percent of those accessing treatment were women.27 Women are more likely to know their HIV status through antenatal healthcare services, Prevention of Mother to Child Transmission of HIV (PMTCT) programs, and through seeking pediatric medical assistance when a child is ill. However, the slightly higher percentage of women accessing HIV treatment raises the risk of complacency where healthcare providers and other stakeholders may overlook the serious hindrances to womens access and adherence to HIV treatment such as those discussed in this report.
The US Presidents Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) are the largest funders of HIV treatment in the country. Zambia is one of PEPFARs 15 focus countries, and received support from the Global Fund in rounds one and four (see Chapter VIII).
HIV has placed enormous pressure on a public health system that was already struggling to serve Zambians while only committing approximately US$51 per capita per year for health services.28 The Zambian government has identified a number of barriers to improving the healthcare system. These include a human resource crisis, the poor state of health facilities, inadequate drugs and medical supplies, long distances to and between health facilities, poor transportation infrastructure, and high-levels of poverty.29 Similarly, PEPFAR has identified several limitations within the health system that are hindering ART scale-up, such as inadequate staff and gaps in supply of drugs in the public sector.30 Other barriers, such as stigma and food insecurity, compound the effects of these obstacles in the health system.
Staff shortages hinder the governments efforts to expand access to ART and ensure that access is equitable via addressing the specific needs of women who experience gender-based abuses. A 2006 Ministry of Health evaluation of the ART program in Zambia identified severe shortage and high turnover of trained staff as the most significant constraint in ART service delivery.31 The report identified inadequate recruitment, insufficient re-training of the few staff in position, inadequate monetary and non-monetary retention incentives, long working hours in ART sites, and increased workload due to rapid increase in numbers of enrollments due to the free ARV policy32 as major causes of staff shortages. The latest available data on the number of healthcare workers in Zambia indicates that in 2004 there were only 1,264 physicians0.12 physicians per 1,000 peopleand 16,990 nursesthat is 1.56 nurses per 1,000 people.33
Dr. James Banda, director of the District Health Management Team for Kitwe, a large town in the Copperbelt, stated that staff shortage was the most fundamental challenge that we face every day.34 According to Banda, Kitwes population of 460,000 is serviced by just 483 health care workers.35 Staff shortages in Zambia are discussed further in Chapter VI.
Women in Zambia
Zambian women face multiple forms of discrimination and abuses, including gender-based violence and insecure property rights. Womens relatively low socioeconomic and political status is reflected in a number of indicators that are discussed below.
In 2001-2002 more than half of ever-married women surveyed reported being beaten or abused by their husbands.36 In November 2006 the Zambia chapter of Young Womens Christian Association (YWCA) reported that their shelter recorded ten cases of rape of adult women in Lusaka every week.37 There is no specific law against domestic violence, so cases must be prosecuted under the general assault statutes, which typically do not provide effective protection for women because of the need to provide evidence of gross bodily harm, or of the fact that the perpetrator was carrying a weapon. Moreover, the penal code does not specifically prohibit marital rape, and the provisions on rape in the code do not in practice apply to spousal rape.
Zambian statutory law partially protects womens inheritance and property rights, but failure to prevent discriminatory customary law taking precedence over statutory law undermines such protection. Moreover, the laws are poorly enforced. The Intestate Succession Act (1996 amendment) provides that a widow should receive 20 percent of her deceased husbands estate, and that it is illegal to evict a surviving spouse from a matrimonial home.38 However, under the customs of some ethnic groups, which are more widely used by Zambians than statutory law, the right to inherit property often rests with the deceased man's family. The inability to enforce their property rights in the area of inheritance is compounded for HIV-positive widows since in-laws sometimes threaten to punish them if they insist on keeping their property by not caring for their children were they to fall sick or die. A lawyer at the International Justice Initiative, an organization that focuses on cases of property grabbing, told Human Rights Watch, We had one case when a woman was [HIV] positive, [her in-laws] said, It is just a matter of time, you are sick [and will die soon] and then see what we are going to do to the children.39
In-laws may also insist that a widow undergoes sexual cleansing (through sexual intercourse with a hired male of lower social status), and as a result, widows sometimes give up their property to avoid this practice. As Yoram Siame, HIV/AIDS program officer at the Church Health Association of Zambia, a PEPFAR partner, put it, If a widow is not willing to share property with in-laws, they will say, Take everything, but we want cleansing.40
The Matrimonial Causes Act, which address division of marital property upon divorce, was passed by the National Assembly passed in 2007 and is awaiting presidential signature.41 When it comes into force, the Matrimonial Causes Act will be applicable to civil marriages under the Marriage Act.42 It enables courts to determine settlement of property upon divorce, but is silent in terms of equal distribution of property upon divorce. However, most people in Zambia marry according to customary law rather than the civil marriage statute, and thus the protections of the Matrimonial Causes Act will not apply to them.43 Although customary law is continuously evolving and heterogeneous, reflecting the norms of Zambias 73 ethnic groups, it generally continues to discriminate against women in marriage and divorce. Customary practices tend to grant men all rights to marital property.
Zambias constitution prohibits the enactment of any law that is discriminatory on the basis of sex or has such discriminatory effect. But it also recognizes a dual legal system, which allows local courts to administer customary laws, some of which discriminate against women.
One promising property rights development is Zambias land policy, which requires that 30 percent of all land advertised for lease be allocated to women. However, to qualify for the land acquisition it is necessary to prove the capacity to develop the land, as evidenced by bank statements, and this is often an impossible hurdle for women.44
A range of indicators show that women are at a distinct social and economic disadvantage in Zambia. Statistics on literacy show that only 59.7 percent of women are literate compared to 76.1 percent of men.45 Poverty affects women disproportionately. Many women are in low-paid and low-skilled jobs with little job security. Seventy-six percent of women in Zambia are engaged in agriculture, fisheries, and forestry.46 Sixty-three percent of women engaged in agricultural work receive no payment for their work, compared to 56 percent of males working in the same sector who do not get paid for their work.47
In Zambia womens representation in government falls below the 30 percent target set by the Southern African Development Community and the 50 percent target set by the African Union.48 In 2006 only 100 women stood for election to the National Assembly, compared to 605 men. Of these 100 female candidates, only 21 were elected to the National Assembly, representing 14.19 percent of the Assembly.49 There are currently only 22 women MPs out of a total of 150 elected and nominated members of the National Assembly. Only six out of 23 cabinet members are women, although after the 2006 elections the President of Zambia appointed a Minister of Gender and Development.50
In Zambia womens ability to make informed decisions about their health and lives, including their ability to obtain information on HIV/AIDS, counseling, and testing, and their ability to negotiate safer sex, is seriously impaired by the perceived and real control of men (particularly intimate partners) over their lives. At the household level, statistics from the Zambia Demographic Health Survey (ZDHS) indicate that the majority of husbands have the final say in making decisions on wives healthcare.51 As the interviews for this report indicate, this meant that women felt unable to receive HIV testing or treatment without their husbands permission. The ZDHS also indicates a strong correlation between a womans financial position and her decision-making power: of wives who indicated that they had no say in household decision-making, 36 percent were unemployed, 30 percent were employed but not for cash, and only 18 percent were in formal, paid employment.52
Women in some of Zambias ethnic communities are socialized to be submissive, not to challenge male authority, and to respect and please men.53 As one activist told Human Rights Watch, Women cant speak in public. They shouldnt discuss their domestic affairs. They must keep quiet as a wife.54 Over half of the women interviewed for this research indicated that married women in many Zambian communities are taught to submit to demands for sex from their husbands and have little power to negotiate safer sex. They said it was considered inappropriate for women to initiate discussions about sex with their intimate partners.
Many of the women interviewed for this report described the difficulties they experienced in attempting to negotiate condom use. Isabel H. told Human Rights Watch that healthcare workers told her that she must refrain from having unprotected sex with her husband as both were living with HIV. Isabel H.s husband refused to use condoms: Every time we had sex, there was a quarrel. He didnt want to use condoms.55
Cultural beliefs about the roles of women and men also inform how women themselves think about, and respond to, gender-based violence. The ZDHS found that a large majority of women (85 percent) and men (69 percent) believed that a husband is justified in beating his wife for at least one reason.56 As one activist put it, our culture means that women must accept certain extremes, for example, violence. They are constrained by culture when [a woman] gets married, she is told, take things as they come. She must accept a certain level of abuse, its a way of life.57
1 Joint United Nations Programme on AIDS (UNAIDS), AIDS Epidemic Update: December 2007 (Geneva: UNAIDS, December 2007), http://data.unaids.org/pub/EPISlides/2007/2007_epiupdate_en.pdf, (accessed November 20, 2007), p.1.
2 Ibid., p. 15.
3 World Health Organization (WHO), UNAIDS, and United Nations Childrens Fund (UNICEF), Towards Universal Access: Scaling Up Priority HIV/AIDS Interventions in the Health Sector: Progress Report (Geneva: WHO, April 2007), p. 19; UNAIDS, AIDS Epidemic Update, p. 15.
4 See for example Julia Kim and Charlotte Watts, Gaining A Foothold: Tackling Poverty, Gender Inequality and HIV in Africa, British Medical Journal , no. 331, October 1, 2005, pp. 769-772; K. L. Dunkle et al., Gender-Based Violence, Relationships, Power, and the Risk of HIV Infection in Women Attending Antenatal Clinics in South Africa, The Lancet , vol. 363 (2005), pp. 14151421.
5 Helen Epstein, The Invisible Cure: Africa, the West, and the Fight Against AIDS (New York: Farrar, Straus and Giroux, 2007) p. 179.
6 Alpha O. Konare, Foreword, in WHO Regional Office for Africa, The African Regional Health Report: The Health of the People (Geneva: WHO, 2006), http://www.afro.who.int/regionaldirector/african_regional_health_report2006.pdf (accessed October 1, 2007), p. xi.
7 WHO and UNAIDS, Progress on Global Access to HIV Antiretroviral Therapy: A Report on 3 by 5 and Beyond (Geneva: WHO, 2006), http://www.who.int/hiv/progreport2006_en.pdf (accessed May 14, 2007), pp. 71-75.
8 WHO, UNAIDS and UNICEF, Towards Universal Access: Scaling Up Priority HIV/AIDS Interventions in the Health Sector, p. 15.
9 WHO, Towards Universal Access by 2010: How WHO is Working With Countries to Scale-Up HIV Prevention, Treatment, Care and Support (Geneva: WHO, 2006), p. 5.
10 WHO and UNAIDS, Progress on Global Access to HIV Antiretroviral Therapy, p. 19. By the end of 2006 1.3 million people in sub-Saharan Africa were on ART, compared to 100,000 in 2003. Sub-Saharan Africa is home to 67 percent of all those on treatment in low-and middle-income countries, up from 42 percent in 2003. WHO and UNAIDS, Progress on Global Access to HIV Antiretroviral Therapy, p. 14.
11 WHO and UNAIDS, Progress on Global Access to HIV Antiretroviral Therapy, p. 9.
12 WHO, Antiretroviral Therapy for HIV Infection in Adults and Adolescents, p. 70.
14 WHO, Adherence to Long-Term Therapies: Evidence for Action (Geneva: WHO, 2003), http://www.who.int/chp/knowledge/publications/adherence_full_report.pdf (accessed October 1, 2007), p. 96.
15 UNAIDS, Zambia, Country Profile, http://www.unaids.org/en/Regions_Countries/Countries/zambia.asp (accessed October 9, 2007).
16 UNAIDS in Zambia, Joint United Nations Programme of Support on AIDS (2007-2010) (Lusaka: UNAIDS, 2006).
17 Ministry of Finance and National Planning, Fifth National Development Plan (2006-2010) (Lusaka: Ministry of Finance and National Planning, 2006), p. 296.
19 In 1999 only 21 HIV testing sites were available in Zambia. By the end of 2005 HIV testing facilities were available in 226 centers around the country. By January 2006 the number of testing sites increased to 485 country-wide. Ministry of Health, Zambia National Guidelines for HIV Counseling and Testing (Lusaka: Ministry of Health, 2006), p. 1.
20 Republic of Zambia Central Statistics Office (CSO), Ministry of Health, and MEASURE Evaluation, Zambia Sexual Behavior Survey (2005), March 2006, table A.1.6., p.111. The survey is country-wide and was designed to produce sex disaggregated estimates in rural and urban areas of Zambia. A total number of 2,330 households were covered, where interviews were completed with 2,174 women and 2,046 men in the age range of 15-49 years old.
21 Ibid., p. 12.
22 WHO, Zambia: Summary Country Profile for HIV/AIDS Treatment Scale Up, 2005, http://www.who.int/hiv/HIVCP_ZMB.pdf (accessed October 5, 2007), p. 2.
23 It appears from our interviews that prior to commencing ARV treatment patients are required to undergo a CD4 count, a full blood count, a chest X-ray, and a liver function test.
24 WHO, Zambia: Summary Country Profile, p.2.
25WHO, UNAIDS, and UNICEF, Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections - Zambia, http://www.who.int/globalatlas/predefinedReports/EFS2006/EFS_PDFs/EFS2006_ZM.pdf (accessed October 4, 2007), p.12.
27 WHO, UNAIDS and UNICEF, Towards Universal Access: Scaling Up Priority HIV/AIDS Interventions in the Health Sector, Progress Report, April 2007, p. 19.
28 WHO, UNAIDS, and UNICEF, Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections, p.5.
29 Ministry of Finance and National Planning, Fifth National Development Plan, pp. 160-161.
30 The United States Presidents Emergency Plan for AIDS Relief (PEPFAR), 2007 Country Report: Zambia, http://www.pepfar.gov/documents/organization/81673.pdf (accessed September 29, 2007).
31 Ministry of Health, Scale-Up Plan for HIV Care and Antiretroviral Therapy Services (2006-2008), 2006, p. 11.
33 WHO, World Health Statistics 2007, 2007, http://www.who.int/whosis/whostat2007_5healthsystems_hrh.pdf (accessed October 10, 2007), p. 62.
34 Human Rights Watch interview with Dr James Banda, Director, DHMT, Kitwe, February 21, 2007.
36 Mary Kazunga and Patrick Mumba Chewe, Violence Against Women in Central Statistical Office-Zambia, Zambia Demographic and Health Survey 2001 -2002 (Lusaka: Central Statistics Office, 2003), p. 187. The sample for the 2001-2002 survey covered the population residing in private households ages 15 to 49. The survey was country-wide and was designed to produce sex disaggregated estimates in rural and urban areas of Zambia. The number of female respondents to the survey was 7,658 and the number of male respondents was 2,145.
37 Young Womens Christian Association, 2006 Statistics, on file with Human Rights Watch. Also see Zambia: More than 10 Girls Raped Every Week, IRIN PlusNews , November 28, 2007, http://www.worldywca.info/index.php/ywca/layout/set/print/world_ywca/ywca_news/association_news/zambia_more_than_10_girls_raped_every_week (accessed October 3, 2007).
38 Intestate Succession Act, No. 5 of 1989.
39 Human Rights Watch interview with Pamela Mumbi, lawyer, International Justice Initiative, Lusaka, February 21, 2007.
40 Human Rights Watch interview with Yoram Siame, HIV/AIDS program officer at the Church Health Association of Zambia, Lusaka, February 20, 2007.
41 The Matrimonial Causes Act 2007 (draft). Section 57(1) of the draft Matrimonial Causes Act provides for settlement of property upon the dissolution or annulment of a marriage. Christine Zulu, assistant to the Clerk, Zambia National Assembly, informed Human Rights Watch that the Bill went through with a lot of amendments. As soon as these amendments have been effected and the Bill assented by His Excellency the President and published into an Act, it will be made available on our website (email correspondence, August 20, 2007).
42 The Marriage Act, Chapter 50 of the Laws of Zambia.
43 Women and Law in Southern Africa (WLSA), The Changing Family in Zambia (Lusaka: WLSA, 1997). Informed by earlier research, WLSAs position on the traditional customary law system is that it is more accessible to most people, mainly because it is directly relevant [to their daily lives], but also to a large extent because it requires less resources to reach it. WLSA, Justice in Zambia: Myth or Reality? p. 1.
44 Human Rights Watch interview with Matrine Chuulu, WLSA regional coordinator, Lusaka, January 28, 2007 and Engwase Mwale, executive director of NGOCC, Lusaka, February 13, 2007.
45 WHO, UNAIDS and UNICEF, Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections, p .5.
46 Republic of Zambia Gender and Development Division, Zambias Country Report on the Implementation of the Southern African Declaration on Gender and Development and its Addendum on the Prevention of Violence Against Women and Children, August 2006, p. 33.
47 Zambia Association for Research and Development and Southern African Research and Documentation Center, Beyond Inequalities 2005: Women in Zambia (Lusaka and Harare: ZARD and SARDC, 2005), p. 20.
48 Gender in Development Division (GIDD), Zambias Country Report on the Implementation of the Southern African Declaration on Gender and Development, pp. 15-21. In 1997 the SADC Heads of State committed to Ensuring the equal representation of women and men in the decision making of Member States and SADC structures at all levels, and the achievement of at least thirty percent target of women in political and decision making structures by 2005. Declaration on Gender and Development, Southern African Development Community, 1997, http://www.sadc.int/key_documents/declarations/gender.php, article H.
49 Electoral Institute of Southern Africa, Zambia: 2006 National Assembly Elections Gender Breakdown, October 2006, http://www.eisa.org.za/WEP/zam2006resultsg.htm (accessed October 1, 2007).
50 Ibid., p. 15.
51 The 2001-2002 ZDHS preliminary report (CSO 2002) indicates that husbands often make the final decision in areas of a wifes healthcare (58 percent), and large household purchases (63 percent). World Bank, Zambia Strategic Country Gender Assessment, June 2004, http://siteresources.worldbank.org/EXTAFRREGTOPGENDER/Resources/ZambiaSCGA.pdf (accessed September 20, 2007), p. 43.
52 Ibid., p. 43.
53 ZARD and SARDC, Beyond Inequalities 2005, p. 12.
54 Human Rights Watch interview with Lumba Siyanga, information and advocacy manager, Women for Change, Lusaka, May 25, 2006.
55 Human Rights Watch interview with Isabel H., Lusaka, February 3, 2007
56 CSO - Zambia, Zambia Demographic and Health Survey 2001 -2002, p. 46. Reasons for wife beating covered in the survey included infidelity, arguing with a husband, neglecting the children, refusing to have sex with a husband, and cooking bad or late food.
57 Human Rights Watch interview with Sinya Mbale, head of programs, Agricultural Recovery, Lusaka, May 25, 2006.