The ultimate sacrifice

The Zambian government's antiretroviral (ARV) drug programme has managed to provide cheap, life-prolonging AIDS treatment, but many HIV-positive Zambian women, denied access by a tradition of subservience and sacrifice, are not benefiting.

Last year the government made available over US $2 million for the purchase of 10,000 doses of ARV drugs. The Geneva-based Global Fund gave Zambia a further $42.5 million to boost government efforts in the fight against HIV/AIDS, tuberculosis and malaria.

Before the ARV rollout last August, combination AIDS therapy typically cost around Kwacha 300,000 (US $63) per month, a colossal amount in a country where 80 percent of people earn less than a dollar a day.

About 5,000 people - of a targeted 10,000 - have now qualified for the subsidised programme, with each paying around $8 for a four-week course of medication, delivered through the public health system.

A National AIDS Council report shows that of the 870,000 HIV-positive Zambians, 70 percent are women. But that gender ratio is not reflected in the statistics of those receiving ARVs. Instead, the majority enrolled in the programme appear to be men.

In Petauke, a small rural town in eastern Zambia, for example, of the 40 people who are receiving ARVs, only three are women. Dr Muchango Siwale, who works at the local hospital, is perplexed. Although fewer women than men come into his surgery, "a lot more than three should be on treatment."

While it is generally difficult for rural people to access decent and timely health care, it is doubly difficult for women, who are more often poor, voiceless and defer to customs that expect them to sacrifice for their families.

The problem, says Siwale, is that women traditionally try and ignore their health needs. "Women do not know their own value. They are real beasts of burden. They get sick but, as long as they are able to pick up a hoe and till the land, they carry on till they drop dead."

His assistant, nurse Alyce Banda, also blamed the expectations heaped on women if they are to be considered "good" wives. "When last did elders or even neighbours sit a man down and tell him to take his wife to the clinic because she does not look well? And yet women are chastised by society if they do not take their husbands to the clinic for the slightest ailment. They are accused of trying to kill him."

Banda, a midwife, said in her 10 years at the clinic she had seen women bringing their husbands on wheelbarrows, bicycles and even on their backs, like babies. But she has yet to see a man even offer the support of his arm and bring his wife for treatment.

A group of women attending antenatal classes in Petauke frankly explained that if they were HIV-positive, their husbands would be unwilling to spend money on lifelong ARV treatment for them. They would rather divorce a wife considered too "expensive".

"When I am pregnant, my husband gives me money for transport to the clinic and other things because he knows this will pass. He will not spend on indefinite treatment for me. Anyway, as a family we cannot afford it," said Mwanida Phiri.

Like many in the group, Phiri believes the situation would be, somehow, "different" if her children or husband were sick.

Traditionally women are taught that they should not be a burden to their family. "How would I feel if there is no food in the house to feed the children because the money has been spent on medication which is only for me?" asked Agnes Zulu.

But it appears that the men in Petauke have no such qualms.

Harriet Munjira and her husband, Benson, are both HIV-positive. But as they can only afford treatment for one person, naturally, Benson is receiving the ARVs. "I can look after the children - she will have problems. My family will take everything from her [due to inheritance customs] if I die, and she and the children will just remain suffering," he explained.

He feels bad that they cannot afford the additional US $8 for his wife, but is confident that "she will manage".

"She is the stronger of the two of us. Look at me," he said, displaying his thin, gangly legs, "I am the one on drugs, but I am in bed - Harriet is outside making a fire to cook food."

Though Harriet does not dispute she is physically the stronger of the two, she is not as healthy as her husband suggests. She also does not believe women should always be the ones who sacrifice. "I have no choice but to get up and do my chores, tend the needs of my husband, even though my body is telling me to rest."

Blinking back tears, Harriet says Benson has not changed in their 19 years of marriage. He is still selfish.

"Why couldn't I have gone on the treatment? I am the one who tends to the fields and looks after the children. Benson only came to me when he was sick - he has not supported this family in the last 12 years. As for the property that his family is likely to grab - two small huts and a few pots and pans - is that worth safeguarding?"

Still, she feels she cannot push the issue with the family elders. "People will accuse me of wanting my husband to die ... that I should defer to him, even though I am the one that has been holding this family together."

Holder Chama, a single mother of five, has a different set of concerns. She balked at taking her daily three-drug cocktail when she was told about the importance of eating a balanced diet. Displaying the medicines still tightly wrapped in her chitenge (traditional cloth) she said food was an issue in her home.

"On most occasions we go without food ... as women, we eat last and there usually is not enough to go around. So how can we go on the medication? We need food to go with it. I tried to take the medication on a stomach full of water and I vomited everything," she said. Another time, after taking the drugs she had such bad stomach cramps, she gave up.

Now she has left everything "in the hands of God".

For a series of Special Reports on Gender and HIV/AIDS by IRIN/PlusNews to mark International Women's Day visit:
http://www.plusnews.org/webspecials/womensday/default.asp