In-depth: The Treatment Era: ART in Africa
ZAMBIA: Second-class women left behind in access queue
Public health services are accessed more by women than men only when they are free
JOHANNESBURG, 6 December 2004 (IRIN In-Depth) - Zambia's rollout of antiretroviral therapy (ART) is one of the largest in Africa, but it is missing a vital chunk of the population - HIV-positive women.
According to Central Board of Health figures, of the 1,483 people who enrolled for ART in January 2004, only 537 were women. In spite of a higher HIV prevalence rate among women, men accessed more than 70 percent of ART, health minister Brian Chituwo told PlusNews.
Gender imbalance was even more pronounced in rural areas, he pointed out, where women were often not in formal employment or in control of household budgets, and therefore could not afford the government's antiretroviral (ARV) drugs, even at the subsidised price of US $8 a month.
"Public health services are accessed more by women than men only when they are free," said HIV-positive activist Winston Zulu. "Most Zambian women are disempowered [and] disadvantaged - it's part of the general societal picture."
At a recent meeting of Zambia's Network of People Living with AIDS on the problems of ART access, clinical officer Karana Mutibila commented that when household budgets are tight, men generally ensured they received treatment first.
"Many families cannot afford to have more than one person on ARVs because of the financial implications, so if there is one person that should go on the drugs, it is usually the man because, as the perceived head of household, he is less dispensable," Mutibila told PlusNews.
Saraphina Nakazwe said even though she was the family breadwinner, her husband controls household expenditure. He "literally grabs the day's takings and apportions how it is spent. There is money for food for the children, and what is left is for drink, but not for my medication". Her husband refuses to take an HIV test and claims her HIV-positive status was not a "family" problem but hers alone.
Apart from a lack of cash, both for the battery of tests that precedes treatment and the US $8 a month for ARVs, women are also disempowered by a culture that frowns on discussing sex-related issues. Sometimes they are simply too shy to seek treatment for what is likely to be a sexually contracted disease, said Chituwo.
On top of this, women are often daunted by the bureaucracy surrounding delivery, Mutibila explained. "There are official documents to sign and many women cannot read or write, so they feel intimidated. Some health workers speak the local languages so badly that they end up confusing the people about the process." While men demand explanations or clarifications, some women are reticent, he noted.
The lack of treatment literacy and preparedness has been a problem area in Zambia's rollout. Malita Himaanje, who until recently lived in Gwembe, a rural outpost in western Zambia, said in her villages women were given very little information about treatment. Mwila added that if her daughter had not told her about ARVs and brought her into town, she would probably have died last year.
"At one time the information we were receiving was that it was only available to men; then the information was that it was for prostitutes with STDs [sexually transmitted diseases]. Up until I left Gwembe early this year, there was very little information that ARVs were for all."
Himaanje suspects that the health officer in the area deliberately discouraged women from accessing ARVs because supplies were limited. "They do that for all drugs, whether its chloroquine or antibiotics, they try to give men first - I know the way these [guys] operate."
According to the Zambia Demographic Health Survey of 2002, the HIV prevalence rate among adults aged between 15 and 49 was about 16 percent. The level of HIV infection was higher among women (18 percent) than men (13 percent), and the urban population was more affected (25-35 percent) than the rural population (8-16 percent).
Under the World Health Organisation's '3 by 5' initiative, Zambia has set itself the target of having 100,000 people on treatment by the end of 2005. At present [December 2004] 13,555 people are receiving ART.
The Deputy Resident Representative of the UN Children's Fund, Tomoko Nishimoto, wants the ministry of health to make it policy that at least 50 percent of the allocation for treatment be spent on women, "and for people in absolute poverty, who cannot even afford transport to collect free ARVs".
Chituwo acknowledges the problem. "We need to have the women who are not pregnant or not lactating on the programme; we need to get rid of cultural or social taboos that discourage women from discussing their sexuality or reproductive health - this is the only way women are going to be empowered to seek treatment."