? Filling the gap in Community HIV/AIDS Education and Service - Joseph Zulu - Imponderabilia

Filling the gap in Community HIV/AIDS Education and Service

In reaction to the high HIV infection rates in Zambia, the government declared in June 2005 that the HIV medicine / antiretroviral therapy (ART) would be "free of charge in the public health sector" (Human Rights Watch 2007: 13). Before 2004, only about 20,000 people were accessing ART (UNAIDS 2008:12).
                              
Despite making access to the drugs free, most of the people living with HIV/AIDS in Zambia are still not able to access these drugs.  Human Rights Watch (2007) observes that women face more challenges than men in getting treatment. The study reported that husbands prevent their wives from accessing the treatment (Human Rights Watch 2007: 4).
Generally, the majority of studies on HIV/AIDS and treatment (for example, Baylies and Bujra 2003; Dowsett 2003; Castro and Farmer 2005) attribute low access to ART to either stigmatization, poverty or domestic violence. This may explain why a number of HIV/AIDS programmes in Zambia focus on these three aspects.
I would however argue that the reasons for non-use of the HIV/AIDS testing facilities and treatment are complex and reach beyond the three areas.

If we were to take domestic violence as the main reason for women not being able to access treatment how should we include those who are young (0-14 years old) and not married who may not be on treatment? Also, this approach does not explain why some widows and men do not go for treatment. Similarly, it seems as though poverty is an insufficient explanation, as some members of higher socio-economic classes are not accessing treatment either. In addition, I believe that citing poverty as a major reason for non-accessibility to HIV treatment may also be limited by the fact 'the treatment is provided for free in Zambia' (Human Rights Watch 2007: 13). 
What about the stigmatization approach? I should mention that a great deal of discrimation exists in Zambia against those diagnosed HIV positive. Stigmatization, on its own, is also a limited approach to understanding the complex reasons why people do not access drugs unless the "factors that are responsible for constructing it are explored" (Castro and Farmer 2005: 35). The factors may include cultural or religious values that associate being HIV positive to marital unfaithfulness. For instance, Frederiks observes that "the current programmes on HIV/AIDS promoted by the churches stress on marital faithfulness and abstinence as the best ways of reducing the pandemic. This seems to suggest that HIV/AIDS is an illness for those who do not adhere to the moral code, and thus, by implication, seems to insinuate that the epidemic is a punishment for 'irregular' sexual behaviour" (2008: 1).       

Over 15% of the people in Zambia aged between 15-49 years are living with HIV/AIDS, the majority of these being women (UNAIDS 2008).
About 1,100,000 people were living with AIDS in Zambia in 2007 (UNAIDS 2008). Out of this number, only 330,000 were on treatment. Proportionally few children were treated (UNAIDS 2008).
Therefore, if we are aiming to understand the complex reasons why ART is not accessed using only one of the approaches cited above is limited.
My interest in finding possible solutions to this problem is shaping my ongoing postgraduate fieldwork in the Copperbelt province in Zambia. My preliminary findings indicate diversity in the reasons for use and non-use of the HIV services. This is illustrated in one of my interviews.

Case Study. 
Mr. Phiri (not his real name) resides in Kitwe District of Zambia. He is 51 years old and has been living with HIV since 2005. He narrated his story as follows:

In 2005, I had a serious cough and I decided to go to the hospital and was found with TB. The doctors requested me to take an HIV test. At first, I refused, but after noticing that my situation was deteriorating I agreed to take the test. I was found HIV positive, but could not immediately commence ART because I was supposed to pay 60,000 Kwacha (12 dollars) to start treatment and did not have the money. I was only able to access ART in 2006 when ART was being provided completely for free. Because of lack of access to the treatment, my legs got paralyzed and I also became blind. Currently, I cannot do any work. Due to this condition and the fact that I am HIV positive, my wife and relatives do not like me. My wife openly complained that she was tired of looking after me. She said that I am a finished person. At night  my wife normally comes late and drunk. She normally refuses to have sex with me. I have difficulties going for medical reviews because I do not have money to pay for transport since I cannot walk to the clinic. I also fail to procure other drugs that am supposed to take in addition to ARVs.  At one point, I went to the witch doctor that told me that the condition that I am in now is because of witchcraft and not because of HIV. To be honest, my perception of life has changed from the time I discovered that I am HIV positive. I no longer make long-term plans. I live life by each day. (Mr. Phiri, 1st January 2009).

From the interview, a number of reasons for non-access to HIV testing and medicine can be deduced. Firstly, there is fear of rejection by the family and community when one is HIV positive, stemming from social stigma or social insecurity. This is especially the case in communities where being HIV positive brings 'shame' to the family (Osei-Hwedie 1994: 35). Poverty is also a real issue even in cases where ARVs are provided for free. In the case of Mr. Phiri, the effects of poverty are visible in his failure to pay for transport to the hospital and in his limited ability to purchase supplementary drugs. Physical incapability such as paralysis may mean failure to access health care especially when coupled with poverty. Fear of being rejected by love partner or denied sex can also be important. In this case there is a role reversal where it is the woman who responds negatively towards a man. From the interview, another important issue is the belief in the diagnosis or treatment. Mr. Phiri did not fully believe the diagnosis as well as the ART, hence decided to consult a traditional healer.

From this case study and other literature, (for example, Human Rights Watch, 2007; Baylies and Bujra 2003; Dowsett 2003; Castro and Farmer 2005 and some NGOs in Zambia); I argue that limiting the problems to access to ART to stigmatization, poverty or gender-based violence is not enough. There is need to consider all possibilities when analysing a case and go into deeper into these possibilities.  These may include stigmatization (constructed by either religious or cultural values), poverty (failure to meet supplementary drugs or transport costs), gender-based violence (not just male violence against women but also female violence against men). Others include physical insecurity, existential insecurity or loss of hope for life and lack of belief in the treatment or medical diagnosis.  
I think that a broader approach to understanding the problems regarding access to the HIV drugs would facilitate the designing of strategies that would capture several major obstacles to accessing ART, some of which may not be very visible in the community, thereby making access to HIV drugs easier.

References

Baylies, C. and Bujra J. (2003) 'AIDS, Sexuality and Gender, Collective Strategies and Struggles in Tanzania and Zambia'  in Journal Social Science and Medicine, 56

Castro, A. and Farmer, P (2005) 'Understanding and Addressing AIDS -Related stigmatization: From Anthropological Theory to Clinical Practice in Haiti' in Journal of Public Health, 95(1)

Dowsett, G. W. (2003) 'Some considerations on sexuality and gender in the context of AIDS'  in Reproductive Health Matters, 11(22)

Human Rights Watch (2007) 'Hidden in the Mealie Meal' in Gender -Based Abuses and Women's HIV Treatment in Zambia, 19: (18) (A)

Osei-Hwedie,K. (1994) 'AIDS, the Individual, Family and Community: Psychosocial Issues' in  Journal of  Social Development in Africa, 9 (2)

Rangeley,W.H. (2001) 'Notes on the Chewa Tribal Law. The Society of Malawi' in Journal 53(122): Millenium Edition

UNAIDS (2008) 'Epidemiological Fact Sheet: On HIV and AIDS Zambia.  Core data on epidemiology and response Zambia' www.unaids.org [accessed 12 November 2008]

Zambia Poverty Reduction Paper (2002) www.planipolis.iiep.unesco.org/upload/Zambia/PRSP/Zambia%20PRSP%202002.PDF [accessed 11 November 2008]

Joseph Mumbu Zulu is a Zambian citizen. He did his Bachelor degree training in Social Work at the University of Zambia from 2000 to 2004 and is currently studying a Master Programme in Social and Cultural Anthropology at Vrije University in the Netherlands. Joseph has worked with a number of programmes that aim at improving the welfare of orphans and vulnerable children, vulnerable women and people living with HIV/AIDS. He has also done general social welfare administration. Joseph's fields of interest are poverty alleviation (community development), environmental (natural resources) management and HIV/AIDS.