Women make up the majority of people living with AIDS in Zambia, but they are the least likely to receive treatment. Husbands usually claim priority over their wives.
Zambia's Minister of Health Brian Chituwo recently boasted that 6,000 out of a targeted 10,000 people living with AIDS, have accessed the government's cheap anti-retroviral (ARV) drugs since a roll-out began last August. What he does not mention is that even though women make up the majority of people living with AIDS in this southern African country, they constitute less than 10 per cent of those accessing ARV drugs.
Last year, with much fanfare, the government made available more than $2 million for the purchase of ARV drugs for 10,000 people. The Central Board of Health says there are about two million people who have HIV/AIDS in Zambia, 70 percent of them women. The National AIDS Council (NAC), which monitors ARV provision says as of March 2004, there were only 800 women on these life-prolonging AIDS drugs.
NAC Acting National Director Dr Alan Simwaanza says the drugs are available to both men and woman – "I don't know why women are not accessing them," he says.
Nkandu Luo, former health minister knows why.
"Women are not being specially targeted. As usual all the activity is focused on men. Why don't medical people insist that a man brings his wife when he is being given the ARVs?"
She says wives of infected men must also be tested to see whether they too need to go on these drugs. "We demand to test the other partner when a person shows up with a sexually transmitted disease – why don't we do the same for ARVs?" she asks.
Luo, a medical scientist specialising in AIDS, says there has been no systematic attempt to inform women about HIV/AIDS or even encourage them to go for testing and take ARVs if they need to. Even those few women who are accessing ARVs are in the cities and towns – very few turn up at the rural health centres. In the rural town of Mazabuka, for instance, of the 160 people on treatment only seven are women.
"Even though they can see the statistics no one is doing anything about it. It's like as long as people (whether its men or women) are taking the drugs, than the job is done," Luo says.
She suggests that clinics should have special days or areas for women who have tested HIV-positive so they are not intimidated and can discuss their treatment freely.
Goliath Mumbuna, who is on ARVs says it is too expensive to have his wife on treatment. He was referring to the $8 a month that government clinics and hospitals charge for ARV treatment – expensive in a country where 80 per cent of the population live on a dollar day or less. Before the government's ARV roll-out last August, combination AIDS therapy would typically cost about $65 a month.
Unemployed Mumbuna says even buying his own supply of ARVs is a problem, so his son has to "scrape around".
Alines Ngoma, a nurse and traditional marriage counsellor, gets to the root of the problem. It's tradition and custom that are to blame, she says: "A woman is a being of sacrifice. To be considered a model wife and mother she must put the well-being of her husband and children first."
Ngoma says what Mumbuna is not saying: that when it came to the crunch, it was he who had first-call on the family's resources even though it is his wife, Agnes, a tomato seller who actually is the bread-winner. "It's culture and historically, culture has always disadvantaged the woman, so why should this be any different?"
Agnes agrees with her but for different reasons: "I was scared of being accused that I killed my husband or that I was a witch if I went on the ARVs and my husband did not. As it is, women are blamed for HIV in the home, so it is better he goes on the ARVs alone."
Agnes cannot even ask her relatives to buy the drugs for her because the fact that both she and her husband have HIV is still a secret. "My husband would kill me if it ever leaked." Nor can she use the profits from her small business to buy drugs because that is the money she uses to feed her family.
"The guilt if my family went without food would kill me faster than AIDS. I can never spend family income on myself."
Their son says he has left it up to his parents to decide which one would go on the drugs. He had hoped it would be his mother because she has a lower CD4 count and is often ill, but he "understands" her reasons.
Mary Bweupe says her husband got his relatives to buy him the drugs and told her to do the same with her own relatives. "He told me it was more important for him to survive and look after the children. In effect, he was saying I was dispensable."
"He knows I am an orphan and there is no one to buy the drugs for me. So while I would like to go on treatment, I can't. So I will just live like this by the grace of God."
There are exceptions. Bismart Mugala makes sure his wife eats with him and they both take their medicines on time. The days are hard for them, and sometimes there isn't enough money to buy the drugs. But there is never a question of one of them stopping.
"It never occurred to me that only I should go on treatment. I never thought like that. We both need the treatment. I know I gave my wife the virus, so it's up to me to make sure she gets treatment.
"I am amazed that men should allow that their wives to sacrifice themselves in such a manner."
Apart from the cost of ARVs, there is also the treatment regime, which is not without cost. Patients have to drink a lot of water and eat three balanced meals a day. Only 30 per cent of Zambians have access to clean and safe drinking water. Piped water is usually a two km-trek.
For Saraphina Muleba this simple fact meant she could not continue with her medication.
"I walk long distances to get water – if I have to make more trips it means I have no time for my work in the home and my family will complain." As far as food is concerned, like many Zambians her family eats one meal a day. She stopped treatment because she felt worse after taking her medication on an empty stomach.
When it comes to husband Nebat, however, every effort is made to ensure that he eats "something" with his tablets and gets clean water.
Nebat says it's up to his wife to take care of herself: "She is the mother of this home; she knows what to do. If she does not take care of herself and only cares for me.. well, what can I do? I cannot force her."
This angers nurse Brenda Manda, who says women should get rid of their beast-of- burden disposition. "We are human, flesh and blood, we get sick and need to maintain our health just like men. We should say 'no' to this unfair sacrifice."
She says women are reticent about demanding things for themselves, even though they will go through hell to ensure their families are fed and well.
She points to one of her patients, whose husband has refused to pay for her ARVs. "He says he can pay for treatment for a certain period, but if it is life-long, he would rather divorce her as she would be expensive to maintain. Because he is the bread earner, he does not see his treatment as an expense."
It's not just the cost of ARVs that is hindering women's access: a game of power has begun in some homes. Janet Illonga left her husband – and ARV treatment – when he beat her up once too often.
"From the time I went on ARVs he physically and emotionally abused me. I took it for a while but then the beatings got worse. He was killing me slowly anyway so there was not much point in staying in his home just because of the drugs."
Her relatives are poor and while they would have been able to buy her drugs for a couple of months, it was unlikely that they could have continued life-long treatment. So she has given up and prays for the best.
A mother of three daughters, Illonga says that rather than "look for money" for ARVs, she will fight for money to ensure her daughters are educated and financially secure. "I don't want them to end up like me – infected through no fault of my own and helpless to do anything about it."
Zarina Geloo is a Zambian freelance journalist.