The Herald (Harare)

10 August 2011

Zimbabwe: Cultural Barriers Bar Women From Health Services

"Masculinity is culturally constructed as essentially into a dominant person who discriminates against and subordinates women.

"Boys and men are socialised to believe that sex is their right and they are entitled to it whenever they want it.

"Men are placed at risk by masculine values, which discourage them from protecting themselves, their partners and their families.

"Men are the key decision makers in all aspects of the transmission and they have the powers to protect their partners.

"Engaging men in care brings them face to face with the realities of HIV and Aids and the need for change.

"Interventions should challenge the attitudes, values and behaviours' of men that compromise their own health and safety as well as the health and safety of women and children and having men actively involved in HIV and Aids related programmes."

A challenge to men by Kelvin Hazangwi, National Director of Padare/ Enkundleni/ Mens Forum at a recent discussion forum aimed at tackling the social and cultural barriers to HIV and Aids treatment in the country. The discussion forum was organised by Médecins Sans Frontières (MSF).

Many speakers at the forum agreed that many years after the introduction of ARVs as a way to manage HIV and Aids social and cultural practices and beliefs continue to prevent many people,

especially women and children, from accessing timely and adequate treatment.

The discussion forum at the just ended Book Fair in Harare also acted as a platform to highlight other challenges faced by society and people living with HIV and Aids.

Deputy Minister of Health and Child Welfare Dr Douglas Mombeshora said treatment is a reality whose time has come and to make it a success requires that people work together to address barriers such as social and cultural.

"In our patriarchal communities boys and men are socialised to believe that sex is their right and they are entitled to it whenever they want it.

"Again men are placed at risk by masculine values, which discourage them from protecting themselves, their partners and their families hence the say in Shona, "bhuru rinoonekwa nemavanga".

"They are the key decision makers in all aspects of the transmission and they have the powers to protect their partners but they lack health seeking behaviours' which allow them to go for testing early," he said.

Dr Mombeshora pointed out that on the other hand young married women face challenges in seeking treatment such as enrolling on Prevention of Mother to Child Transmission (PMTCT) programmes because their husband's relatives such as the mothers in law, aunties, husband's sisters forbid them.

"In fact they always want to have a say on the daughter in-law's reproductive health and rights.

"Cultural practices such as widow inheritance, early marriages, and polygamy play a bigger role in the spread of HIV in Zimbabwe.

Further gender roles in the homes, power dynamics in sexual relations, poverty and dependence on men for money, biological make up as well as religious beliefs play an important role on female's vulnerability towards HIV and Aids," he explained.

The deputy health minister added that stigma and discrimination remain a challenge that needs urgent address.

"Stigmatised people are often viewed as unworthy, unacceptable, and threats to communities, congregations or families.

"Stigma arises from negative communal norms, prejudices and taboos. Many taboos are related to gender, sexuality, ethnic identity, disease, and death.

"Sadly, these concepts are also often related to HIV and Aids," he explained.

Dr Mombeshora further pointed out that due to stigma, in churches people living with HIV and Aids may be seen as sinners leading immoral lives and as a result people fear to go for HIV testing.

"Yes, the quest for treatment remains a centerpiece to an effective response to HIV and AIDS in Zimbabwe.

"There is no doubt that without the challenges to treatment above access to affordable and low cost treatment will be provided to the majority of PLWHIV, thereby bringing hope and relief to those affected and infected by the disease within families, communities and the nation at large.

"We cannot talk of Universal access without addressing issues that hinder the provision of treatment.

"In many places, we see our friends; family and colleagues die not because there is no treatment but because certain factors such as religion and culture do not permit them to seek treatment. But why? My Ministry together with you should be able to address these challenges," he said.

Dr Mombeshora revealed that an estimated 70 percent of the country's hospital admissions are due to HIV-related conditions.

In the absence of massively expanded prevention, treatment and care the Aids death toll will continue rising, he warned.

"There is a great need in our country to make every effort to provide progressively and in a sustainable manner the highest attainable standard of treatment for HIV and Aids, including prevention and treatment of opportunistic infections, and effective use of anti-retroviral therapy.

"The challenges in ensuring universal access to treatment are many but we must not be cowed by social or cultural nor infrastructure and the limitations of human resources," he expounded.

He added that through organisations such as MSF, the necessary momentum can be generated to mobilise communities and prepare them for the roll-out of treatment.

"The point of the matter is that treatment prolongs life and treatment brings hope," he added.

Dr Mombeshora explained that the Ministry of Health and Child Welfare fully recognises the tremendous task ahead in strengthening health infrastructures, in having enough human resources, in developing laboratory technology, in training thousands upon thousands of health care professionals and community health workers.

"These challenges are too large for my Ministry to face alone.

"Through forums like these, greater impact can be achieved. There is need to create opportunities to share experiences, circulate information and provide mutual assistance to ensure that treatment roll out is indeed a success," he noted.

According to Dr Mombeshora, the community is an essential partner in terms of articulating these social and cultural barriers to treatment.

" We must strive to listen to our communities as we go about work. They need to be prepared for the roll-out of treatment. In this regard, civil society has a big role to play in mobilising communities in preparation for treatment.

The challenge is great but let's works together, SAfAIDS continue disseminating information on this, NAC, Padare, WASN, ZCC and the media; lets break the taboos and encourage communities to seek treatment," he said.

Jean François Saint-Sauveur, Medical Co-ordinator MSF-Spain said there is low knowledge of HIV status in general and in males in particular.

"We confront a gendered HIV epidemic with catastrophic consequences on children: HIV prevalence is three times higher in females in reproductive age versus males.

"There is also poor coverage and accessibility of HIV comprehensive services for women and children in need, particularly in the rural areas.

"According to MoH data from 2010, there is only 8 percent ART start-up sites in the country (mainly in urban/growth points) and only 31,5 percent of children in need of ART are on treatment," she said.

Mr Mambeu Shumba, Planning and Implementation Co-ordinator, National Aids Council (NAC) revealed that Zimbabwe has one of the highest rates of premature adult mortality in the world, largely due to Aids.

"HIV and Aids is also the leading cause of death among mothers and infants accounting for over 27 percent of all deaths.

"Coverage of PMTCT prophylaxis among HIV positive pregnant women at 59 percent remains sub-optimal. In general, there is lack of knowledge and literacy on HIV and health issues.

"Fear of disclosure and discrimination as result of shame associated with HIV is still huge.

"It is not helping that prominent figures prefer to die than seeking treatment even if symptoms of HIV are evident.

"The system also needs to clean up allegations of corruption across the board procurement, distribution, health facility and implementers, as well as of richer members of society using connections to access ART, jumping the queues," he said.

But Paida Magaya, Communications and Advocacy Officer, Zimbabwe National Network of People Living with HIV and Aids (ZNNP+) said that the main barriers encountered by people living with HIV and Aids in Zimbabwe to access quality treatment are related to poverty (user fees, travel costs, inadequate food), to a rigid healthcare system (services mainly in urban areas, slow registration/initiation, lack of stocks, unfair dismissals, the handling of patients by health workers), as well as social and cultural issues (stigma, discrimination, religion, witchcraft and the phenomenon of faith healing).

"At present, there are 116 188 adults and 12 420 children on waiting list to receive ART," she said.

Mary Sandasi, Director of Women & Aids Support Network (WASN) said: "HIV and Aids is an opportunity to analyse health issues through gender lenses.

"It is a fact that HIV and Aids in our communities wear a woman's face.

"But what is it which is putting women and girls more at risk of infection?

"Social and cultural practices and beliefs such as gender roles in the homes, power dynamics in sexual relations, poverty and dependence on men for money, biological make up and lack of knowledge on own body as well as religious beliefs play an important role on female's vulnerability towards HIV and Aids."

Mrs Rosemary Munaki, Programme Officer, Zimbabwe Council of Churches (ZCC) explained that the Zimbabwe Council of Churches believes that the church has a responsibility to address and combat HIV and Aids-related stigma.

"We are working together to create different spaces where persons living with HIV and Aids can experience a presence of love and inclusion.

"Stigmatising denies a person's human dignity and value. Zimbabwe Council of Churches is involved in training different levels of church leaders and facilitate on ways of removing stigma to enable our churches to become inclusive and homes of refugee.

"The Church has not always acted as it should have in relation to HIV and Aids pandemic. It's time for the Church to take responsibility, globally as well as locally. Healing and reconciliation is possible, and this requires love, compassion and an open, non-judgmental mind and heart."

Catherine Murombedzi, a sub-editor and columnist with The Herald noted that the media's role in overcoming cultural barriers is pivotal as they are a voice that people listen to.

"The media is a powerful voice, thus should not speculate but report factual. The way HIV was presented three decades ago, even a decade ago, left a lot to be desired and is responsible for the mindset today. HIV is everyone's business and the media's role as the link to current trends remains pivotal," she said.

With such challenges at hand, it is extremely important to make treatment available for all those who need it in order to avoid more unnecessary deaths and improve their quality of life.

Changing social and cultural practices which have been recognised as a complex issue demand a collective effort from many stakeholders, including the civil society as a whole and men as key decision makers in particular.

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