Gender Perspectives on Preventing and Coping with HIV/AIDS in post conflict African Societies:

 Dr. Daraus Bukenya[1]

  Conflict and HIV/AIDS:

 The magnitude and momentum of HIV/AIDS in Africa particularly in sub Saharan Africa has by far exceeded the worst projections. The impact on communities, families and individuals has been devastating.

 Conflict in Africa has played a significant role in the rapid spread of HIV on the continent. The risk to HIV infection is higher among women not only because of the biological nature of their vulnerability as child bearers but also because of the social injustice they suffer and which in turn is exacerbated by conflict. Because of the violence, instability and insecurity that follow, intra country and cross border conflict as commonly happening in Africa also translates into increased conflict and violence at the household level. In such situations, women, children and adolescents suffer the worst and prolonged consequences. 

 Conflict, Population Movement and HIV/AIDS – an Example in Tanzania

 In the aftermath of the Rwandan genocide of 1994, North and NorthWest Tanzania was flooded with hundreds of thousands of refugees. The influx was immediately followed by a second influx of relief workers mostly from local and international relief agencies coming in to provide services to perhaps the largest refugee concentration the world has seen in recent years. Some of the relief agencies very rapidly established huge bases in district towns and regional capitals to support their operations in the refugee camps.

 The impact of the influx of refugees and relief workers extended beyond the refugee hosting districts, affecting the entire Lake Victoria zone of Tanzania. The impact was felt at various levels including the socio-economic level. The increased financial inflows into the region and employment opportunities that never existed before attracted large numbers of Tanzanian men, women and adolescents away from their homes to where the job market was - among the relief agencies and the refugee camps. Families were disrupted as a result, but most important, many women and children were left abandoned by, in most instances the bread earners who are the spouses and fathers as they went searching for new opportunities, thereby creating an environment where temptation for sexual mischief could thrive. Indeed many of the men found new sex partners in their new areas of employment and never returned to their families. Young boys and girls were also affected as some took to prostitution and other quick money making ventures especially in trading centres around the refugee camps and in larger towns in the Lake zone.  Today, the Lake zone of Tanzania probably has one of the largest concentrations of commercial sex workers in the country.

 

At the time of the refugee influx, the HIV epidemic had already attained peak levels in the Great Lakes region such that HIV prevalence among both refugees and the Tanzanian communities was high. Risk to HIV infection was enhanced as a result of the socio economic disruptions brought about by the refugee crisis.

 

Traditional culture and the family in Tanzania could provide substantial protection, in some ways, to the weaker members of society, as is the case in most African cultures where the concept of the extended family is still valued. In this culture, abandonment and loss of a bread earner greatly increases the risk to HIV infection as women and children have to make desperate choices to cope. The sudden loss of cultural norms and values and protection from society resulting from conflict exacerbates the situation. The risk to HIV infection increases many times as a result, with the more vulnerable women and children affected most. Devastation of families in the Lake zone of Tanzania is now evident as a result of the changing gender roles in a disrupted socio-economic environment. Although these shocks of conflict are felt by much of the society in general, women and children have suffered most of the consequences.

 Conflict has only exacerbated the violence that women in many parts of Tanzania already suffer and therefore the risk to HIV infection. Such violence includes female genital mutilation or cutting (FGM) among many others. Domestic violence including sexual and physical abuse is rampant, as is child abuse in several forms including defilement, rape and coerced marriage. Therefore, even in normal times, the woman (and child) in the Lake Victoria zone has been denied her rights; the rights to the universally accepted human rights, access to productive resources, ownership to property, access to information and freedom to take charge of her own livelihood. Consequently, dignity and self esteem is low, options and opportunities are limited while societal protection dies particularly with the death of peace and stability, thus further predisposing the woman to HIV infection. In such circumstances, abuse such as rape and domestic violence may not receive the attention of society, as traditional coping mechanisms no longer exist to protect the weaker members of the society.

 Mwanza is one of the regions in the Lake Victoria zone of Tanzania. Although just bordering Kagera and Kigoma where the refugee camps are situated, Mwanza has also shared in the disruption brought about by civil life in the Great Lakes region. The effects of the Rwandan conflict were felt in the region as well. With a major port on the shores of Lake Victoria, Mwanza is a gateway to many of the countries in the Great Lakes region and is therefore not spared from conflicts in the region. In addition, a highly mobile population, including those seeking safety, employment and cross border transporters in the Great Lakes region are found in Mwanza thus creating an environment where gender related violence and abuse thrives thereby increasing the risk to HIV infection.

Response to mitigate impact of conflict on gender based HIV vulnerability

 In the aftermath of the Rwandan crisis and following the Cairo International Conference on Population and Development (ICPD) of 1995, the African Medical and Research Foundation (AMREF) in collaboration with several other civil society organisations such as Kuleana, a Child Rights advocacy agency, made an assessment of the reproductive health status of women under the circumstances that prevailed in the region. A program was designed that would demonstrate the delivery of a woman centred reproductive health care within the framework on a woman’s rights. The collaborative program drew expertise in advocacy, training, HIV/AIDS and reproductive health services from several institutions including the public sector specialist hospitals in the region. Out of the collaborative partnership, a steering committee was established to guide the implementation and further development of the program with a view of eventually expanding any success stories to other parts of the Lake zone of Tanzania where women lived in similar circumstances. 

 With funding from several donors including the Comic Relief of the UK, the British Department for International Development (DfID), the Netherlands-based Hivos and the Royal Netherlands Embassy in Tanzania, a program was initiated by AMREF later in 1996. 

 The goal of the program was to create an environment where a woman would enjoy an improved reproductive health status through respect for her rights at the family, community and service delivery levels and by accessing quality reproductive health information and services.

 The primary target were therefore women in Mwanza, most of whom poor with an experience of a form of violence and abuse. Standing out among these were the young women involved in commercial sex as a coping mechanism for their livelihoods. Many other women also suffered repeated violence in their ad hoc or more permanent relationships, exposing them to HIV and other sexually transmitted infections.

 Although the primary target of the program were the women, many of the activities in fact focused on those who caused trouble for them. They included the sex partners, community leaders and service providers. Also to a lesser extent were the planners and managers of services as well as the policy makers.

 Among the strategies was the empowerment of women to regain their lost self-esteem and dignity in the family and the community in general. Hence, plenty of supportive counselling was provided. The program also trained women in lifeskills to enable them handle various situations and particularly to stick to their guns when negotiating with men in a sex relationship. The new knowledge was supported with the appropriate reproductive health services for the women, which also included the right information on sexuality and reproductive health. Networks were created through which additional opportunities such as peer support and income generation could be provided to women.  Therefore, referrals were often done within the networks. Advocacy aimed at gaining the support of the service planners.

 Several activities were carried out according to the target.

 1.     Demonstration medical centre for woman centred reproductive health services

 The idea behind the medical centre was to demonstrate that it is indeed possible to provide an integrated quality reproductive health service within the context of a woman’s rights. The scope of services was wide and not always medical. It included HIV voluntary counselling and testing, gynaecological examinations, family planning, sexuality and reproductive health information, support counselling, fertility checks, advice on income generation, advice on relationships, lifekills education and others, all provided in an integrated manner such that a woman could access a variety of services under one roof and in a single visit. It was also important that maximum privacy and confidentiality was observed. This was necessary because many of the women in Mwanza had to seek explicit permission from their sex partners to attend a health facility and that did not happen very easily. Indeed some of the women only sneaked out of their homes to come to the centre while the spouse is away. They therefore had limited time to spend at the health centre. With the encouragement of the centre workers, several women would come in with their sex partners particularly for educational sessions and counselling.

 Where a male partner agreed to attend the centre, it almost always resulted in dramatic improvement in the relationship at home and marked reduction or even a halt of domestic violence. Unfortunately, only a few women would bring themselves to telling the partner to accompany them to the centre. Even when that happened, it was only after a drawn out period of convincing. It was even more difficult for the young women who used sex to earn a living. With time, a few more men started coming with their partners, initially out of curiosity but later to actually obtain services, mostly counselling on fertility and treatment of sexually transmitted infections. But most women preferred to keep the centre to women alone and never wanted any man around. This caused a few constraints in involving men and getting couples to the centre.

 This program was overwhelmingly successful in drawing the interest of women and many families to the issues that increase their vulnerability to reproductive ill health including HIV/AIDS. The demonstration medical centre was soon overwhelmed with the demand for services from women coming as far as close to the borders of neighbouring countries (Rwanda, Uganda, Kenya). Many women believed there was a magical message at the centre that enabled sexual harmony to prosper. Infertility is one of the concerns of many families in Tanzania and indeed a common reason for domestic conflict. It often leads men and women to sexual mischief as they look for solutions. At the demonstration centre, simple advice and sometimes, appropriate treatment of an existing sexually transmitted infection did the trick resulting in some of the woman conceiving. In several of Mwanza communities are couples telling stories of how they were helped. 

One man described to a group of visitors to the project how he continuously battered his wife so she could leave because she had failed to conceive three years after marriage. The wife sought the help of the project staff who gave her some information and materials to take home to the husband. She could not bring herself to talking to the husband so she placed the materials at a place where his attention could be attracted and indeed it was. He questioned what the materials were all about thus giving her a chance to discuss. The man after some convincing by the wife attended a session at the health centre. The couple attended several follow up sessions together. A few medical check ups and additional counselling was done and a pre-existing STIs treated. In just over a year, the wife had her first child saving the marriage and ending the abuse. This couple like many others has become one of the advocates for women’s rights and HIV prevention in the Mwanza community.

 2.     Community involvement

 AMREF believed that without targeting the family and the community, there was no hope of resolving the impact of conflict as it affects women. Hence, in several communities, the program was introduced as a pilot attempt to learn lessons. Through intense sensitisation and mobilisation, the rights of women were promoted and eventually responsibility passed on to the community to protect them. Involvement of the community leadership and later the general population resulted in the creation of several community structures that monitored and solved problems of violence and abuse in the homes and in the community. Among the structures created were the domestic violence watch groups mostly composed of the community leadership, most of whom men. Despite the gender bias, they did a wonderful job, as they finally believed in the cause of the program to end conflict. In one community, there was such a dramatic drop in the number of cases of violence reported to the local community court. What is interesting is that although the community court always existed, violence and conflict nevertheless continued. But with the involvement of the leadership in its prevention, the preventive efforts gave results.

 In addition, involvement of the community leadership enabled sensitive topics such as the representation of women on community leadership structures and their participation in decision-making processes. Indeed the project scope expanded far beyond women empowerment and protection against sexually transmitted infections and HIV. Discussions on the gender roles were important as they created a better understanding of the vulnerability of women to HIV and other medico-social problems when the gender roles are misunderstood or ignored. 

 Again at the community level, paraprofessional counsellors were trained to support women and even entire families that suffered from violence and abuse. In the past, traditional counsellors existed in traditional African societies within the extended family frameworks. The program therefore provided an option that was not too unfamiliar but that was more informed in tackling contemporary problems including HIV/AIDS. Cases that could not be handled at the community level would be referred to the demonstration health centre. To date, one family after another is telling stories of a sexual relationship that has been salvaged and peace attained at the family level as a result of the work of the community paraprofessional counsellors. 

 3.     Health service provider training:

 The breakdown of the social service infrastructure and the changed attitudes among service providers in post conflict situations affects the most vulnerable population who have lost a voice and protection of their rights. This is compounded by poverty associated with conflict. In such a situation, services become inaccessible to women and children being among the most vulnerable.

 The program took steps to restore the quality of health services provided to women in several specialist public health facilities. This included improvements on the physical infrastructures to provide the privacy and confidentiality much needed by women to utilise the services. Health workers were also retrained in their approach to service provision. The demonstration centre was used by several medical interns to practice a holistic and woman centred reproductive health care.

 The improved quality of service delivery was observable as women clients now left the health facilities with a smile. They also talked of the improved practice at the public facilities. Interestingly, the health providers themselves demonstrated renewed interest in their work as the client-provider relationship improved. Subsequently, the new approach was adopted by the health authorities and is now under replication elsewhere in the region.

 4.     Awareness to the general population

 Awareness creation in the general public aimed at restoring the respect for the female sex in the general public. Public debates were held with groups including men, organised community and professional groups and the media. Women’s rights promotional materials were distributed and murals located in public places to convey messages. The messages were followed with the creation of a network among organised groups that further conveyed messages beyond the program zone.

 As a result of the awareness campaigns, there was reportedly a reduction in the occurrence of sexual gestures and insults directed at women by men on the streets of Mwanza. The public awareness campaigns also reportedly helped to further build the confidence of those community leaders that had taken steps to protect the rights of women. They were reassured that what they did had the support of the community. This has in the long term enabled the expansion of the community component to additional communities.

 5.     Advocacy among service planners and policy makers

 As a demonstration program, advocacy was not a main focus for the program. Lessons were still being learnt and evidence generated. However, a few advocacy activities directed at the service planners resulted in the acceptance of the approach in health facilities to be adopted in the entire region.

 Lessons learned and recommendations:

 Three years into the project, an evaluation was carried out which discovered a great deal of positive change in male female relationship in the communities where the project concentrated but also difficulties in rapidly expanding such an intensive program to the wider Tanzanian community.  The evaluation discovered several success stories. Among the most important was throwing responsibility for conflict resolution back to the community itself. Most conflict resolution efforts have often ended at the political level, failing to involve those who suffer most the consequences. While those efforts are commendable, sustained peace and harmony ought to become a value at the community and family level. In this way, the peace agenda becomes the responsibility of everyone.  Non involvement of the community, their leaderships and the family in the process leads to individuals replaying their experiences of conflict when an opportunity arises thus threatening peace efforts.

 Much of the success of the program was attributable to the very high level of commitment of staff who truly believed in the cause. To them, the program was more than just a job but a service.

 Among the lessons learned was the difficulty in convincing policy makers and even some donors that indeed a new approach like this one really works. Small initiatives therefore need to be supported, as eventually they are the ones that could come up with solutions to big problems.

 Culture has a very strong influence on conflict resolution. An understanding of what cultural values and beliefs are could help identify what could work. For example, paraprofessional counsellor training in this program was based on the fact that such an institution could become accepted as it easily related to a traditional institution that existed and was valued.

 

[1] African Medical and Research Foundation, Tanzania

 

 

CERTI HomeAbout CERTI USAID's Role CERTI Publications CERTI StrategiesCERTI Links CERTI Resources Collaborating Institutions News, Events, & Activities

The CERTI web site was developed with support from USAID and Tulane University. Questions or for more information, please email Dr. Nancy Mock of Tulane University; Web Site Administrator, BJ Cameron.  This web site is best viewed with Microsoft Internet Explorer.