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Human Rights Watch (HRW)

Hidden in the mealie meal:
Gender-based abuses and women's HIV treatment in Zambia

December 2007 Volume 19, No. 18(A)

Human Rights Watch (HRW)

December 2007

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    I started [HIV] medication in 2006. [My husband] does not know. I take the medicine out of a bottle and put it in a plastic [bag] or in a paracetamol box …. Sometimes I would miss a dose; he comes back at 18:00 hrs, drunk, closes the door and says, “Today you are going to freak out.” He locks [me] in, he beats me up and locks me out of the house …. I go to the neighbors, if they have mercy they will let [me] in, if not, [I] sleep under a tree until tomorrow. As a result of that I miss doses sometimes. I feel very bad. I don’t even feel like taking the medicine.
    — Berta K., Lusaka, February 3, 2007
Zambia is one of many countries setting ambitious targets for rapidly scaling up antiretroviral treatment for HIV/AIDS and is making impressive progress. It is addressing a range of obstacles to treatment and receiving substantial donor support to overcome them. However, women’s unequal status in Zambian society gravely undermines their ability to access and adhere to antiretroviral treatment (ART), and the government is paying little if any attention to the gender dimension of treatment, especially the impact of entrenched discrimination and gender-based violence and abuse.

Women in Zambia report that gender-based human rights abuses are, in fact, very real barriers to accessing and adhering to treatment. HIV programs, activists, and policy makers are increasingly recognizing that discrimination and violence against women must be addressed if the world is to combat the AIDS pandemic. But treatment policies and programs still tend to ignore the connection between domestic violence or women’s insecure property rights and their ability to seek, access, and adhere to HIV treatment. Although the Zambian government has taken some steps to address violence and discrimination against women generally, major gaps remain in legislation, HIV treatment programs, and support services to address poverty among women living with HIV/AIDS. This must change if HIV treatment is to be provided equitably and to succeed in saving women’s lives.

Human Rights Watch investigated the negative impact of gender-based human rights abuses on women’s access and adherence to HIV treatment in two provinces in Zambia, Lusaka and the Copperbelt, in 2006 and 2007. Women there told Human Rights Watch how beatings and rapes by their intimate partners, emotional and verbal abuse, loss of property upon divorce or death of a spouse, and fear of such abuses affected their access and adherence to HIV treatment. The abuses thwarted their ability to seek HIV information and testing, discouraged them from disclosing their HIV status to partners, delayed their pursuit of treatment, and hampered their ability to adhere to HIV treatment regimens. Many women, fearing abuse or abandonment, fabricated excuses for their absence from home during clinic visits or support group sessions and hid their medication in flower pots, holes in the ground, food containers, and elsewhere. Many struggled to find money for food, transport to clinics, and diagnostic tests, especially those whose property was taken when divorced, abandoned, or widowed. Some missed doses as a result. The strain took a toll on many, like Berta K., who told us that due to repeated abuse by her partner, “I miss doses sometimes. I feel very bad. I don’t even feel like taking the medicine. I say, ‘Ha, let me die.’”

Though gender-based abuses have seriously undermined their ability to get HIV treatment, most of the women Human Rights Watch interviewed said their difficulties are simply not discussed in the clinics where they go for HIV counseling or medicine. With few exceptions, health care providers did not raise the issue. Some of the institutions that train HIV counselors in Zambia told us “gender is integrated” into their training. Yet most of the dozens of HIV counselors Human Rights Watch interviewed said they do not screen for gender-based abuses, offer referrals for services, discuss safety strategies with patients, assess how this impacts treatment, or otherwise address the abuses. Treatment adherence counselors said they count women’s remaining pills and discuss certain other obstacles to adherence, but not gender-based abuses. Almost all, however, expressed willingness to start dealing with these abuses with proper training and support.

There is perhaps no better place than Zambia to create a model approach to responding to gender-based human rights abuses within HIV treatment programs as part of an overall strategy to prevent and address these abuses. Situated in Southern Africa, the region most affected by the pandemic, 17 percent of Zambia’s adult population is living with HIV/AIDS, and of these, 57 percent are women. Zambia also has high rates of gender-based violence. Recent surveys have found that more than half of women surveyed reported beatings or physical mistreatment since age 15, and one in six women reported having been raped.

On the positive side the government has enacted laws to protect women’s property rights, has established specialized police units to address gender-based abuses, and in 2006 appointed a cabinet minister for gender and development. Civil society organizations provide services for women survivors of abuse and adults and children living with HIV/AIDS. The country has high-level governmental and multi-sectoral bodies working on HIV/AIDS, and is commended globally for its fight against the epidemic. It has pledged to make HIV treatment and related tests free in the public health system and has increased the number of people on treatment over 30-fold in five years. However, almost half of all individuals in need of treatment are still not getting it. Increasing donor support for its HIV/AIDS response puts Zambia in the spotlight, including as one of 15 focus countries for the United States President's Emergency Plan for AIDS Relief.

Zambia has also ratified major regional and international treaties that require the government to eliminate violence and discrimination against women and to guarantee their rights to health, physical security, non-discrimination, and life. It has also committed to fulfill the United Nations (UN) Millennium Development Goals, which include promoting gender equality, empowering women, and combating HIV/AIDS. To safeguard women’s rights and dignity, and to ensure the success of HIV treatment programs, Zambia must turn these commitments into concrete action.

Human Rights Watch calls on the Zambian government to strengthen its response to HIV/AIDS by safeguarding women’s human rights, ensuring equitable access to antiretroviral therapy (ART), and providing women on ART access to healthcare services designed to help them deal with gender-based abuses as part of their treatment. In this effort the Zambian government should act urgently to enact and enforce legislation on sexual and gender-based violence. The government should ensure that the new constitution currently under debate guarantees women’s equality in all respects, including matters relating to personal and customary laws. And the government should ensure that health care providers working in the areas of HIV/AIDS and ART receive adequate training, clear guidelines, and support to detect and address gender-based abuses. It should improve health care infrastructure, including by ensuring that HIV counseling occurs in a private setting, where women and their healthcare providers can discuss the existence or risk of gender-based abuses.

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

This is a dynamic moment of opportunity and risk in the global fight against HIV/AIDS. Governments and international agencies are pressing to achieve universal access to HIV prevention, treatment, care, and support by 2010. Donors are spending tens of billions of dollars to support HIV treatment. The number of individuals on HIV treatment worldwide jumped from 400,000 in 2003 to more than two million in 2006, and millions more will seek testing for HIV infection and start treatment in the next few years. Without urgent attention to gender-based abuses, Zambia will not realize the potential for these efforts, and the lives of many women will be at risk.

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