Commentary by Prof. Nkandu Luo

What is particularly sad about the impact of HIV and AIDS on women in Zambia is that when you stratify by age, it is younger women that are more infected. In fact if you look at the statistics for women, they are 1.4 more times more likely to be infected than men, and young women could be as much as four times more likely to be infected than men. A UNICEF study found that, up to the age of 15, you see an equal infection rate for young women but somewhere between 15 and 19 something happens in the lives of these young women and the infection rates sky-rocket, especially around 17, 18 and 19. The infection rates again are quite high for married couples and it is true to argue that to be married is to be at risk.

I think a lot of us have been trying to understand why this is the case. Now we know that one of the main reasons for high infection rates among women is the whole gender inequality issue. We need to unpack what gender inequality means, and that's where the issue of the socio-cultural aspects come in with, for example, the whole issue of gender based violence. We have evidence on the way women are socialised (as against men), women are socialised to be subordinate. They are socialised to be tools, not human beings. They are socialised not to enjoy their rights. Therefore as a woman grows, their primary goal is to be married. If you look at the opportunities available – if you go into a home with few resources, the choice of who attends school is very obvious; the boy will attend school and the girl will get married. You will find situations where older and younger women stay in abusive marriages, simply because that is what they are expected to do by society; do what you are told, do not question your husband even if he has multiple concurrent partners. But what about the rights of the woman, what about the rights of children in the home?

Traditional practices happen in urban areas as well as rural areas although because it is not so pronounced people don't discuss it. Sexual cleansing, for example, happens in both urban and rural settings. What is interesting is that sexual cleansing traditionally is not just about sex; some people jump over a goat, wear some white beads or have mealie meal thrown over them to say ‘you are cleansed, you have moved from that husband, you are free to remarry.' That is its primary meaning but now the sexual cleansing has become predominant. While it is decreasing in prevalence, it is still an issue upon which we must continue to campaign.

Another practice involves the use of herbs to dry the women's vagina as it is believed that men enjoy sex more if the woman's vagina is dry, so women put herbs in their porridge, in tea or even insert it into their vagina. However, as a result of awareness campaigns and increased knowledge, the practice is also decreasing.

...for many years, traditional healers have filled the gap in health services, they are the closest health providers at household level. Because people do get well so they believe in traditional medicine because there is no other alternative.

The other practice that is hidden and that people don't talk about a lot is the situation where a man fails to make a woman pregnant – the ‘blame' is passed to her. Often, the family gets together and talks about it quietly and arranges to find a brother or a cousin to father the child, there is a secret arrangement where the ‘arranged' man makes the woman pregnant and the husband knows that this is not the child. That's why, in our tradition it is never a child from the male side who becomes chief; it is always from the female side. This is because the woman then knows for sure that this is her child.

People in the rural areas have not been adequately reached in terms of information messages, awareness etc., especially as regards how they translate that knowledge to risk reduction.

In a lot of African countries there is very poor access to health services and people have to walk up to 50kms to get to a rural health centre and even further for access to a hospital. What is even worse is that having walked that far to a centre, there may be nothing, not even drugs. You might find unqualified people delivering health services and so, for many years, traditional healers have filled the gap in health services since they are the closest health providers at household level. Because people do eventually get well, so they believe in traditional medicine because there is no other alternative. Personally, I think we have not used traditional healers adequately in the fight against HIV. On a daily basis in a village, the homes of healers are full of people seeking help and this is a good opportunity to increase awareness and knowledge. For example, campaigns on the use of condoms and so on could have worked through these traditional healers.

A witch doctor is very different from a traditional healer. A witch doctor is someone who is believed to have magic, and can do things through magic whereas a traditional healer is someone who delivers traditional medicines to the people and this usually comes from the roots of trees, barks of trees and leaves - it is organic. If you look at how some medicines are made, they are made with the same ingredients; it is just that a traditional healer does not have a defined dosage, so they may ‘overdose' the person or they may not know fully what medication for what disease.

People in the rural areas have not been adequately reached in terms of information messages, awareness etc., especially as regards how they translate that knowledge to risk reduction. They have to risk. They have often not had adequate access even to condoms (or to non-defective condoms). So we need to do a lot more. The whole crisis of orphan children has shown how the whole extended family system has broken down; given the poverty of rural areas it is increasingly difficult for people to look after these children.

We need to rethink our strategy for HIV. Despite the fact that we have known for a long time that women are more infected than men, we still undertake ‘general' interventions; it is now time for interventions that target women directly. And not women generally, but women at different levels, because the epidemic does not affect an older woman in the same way it affects a younger woman.

Despite the fact that we have known for a long time that women are more infected than men, we still undertake ‘general' interventions; it is now time for interventions that target women directly.

The other thing we need to appreciate better is that because women have been socialised to think they are subordinate or second class citizens, they lack assertiveness and self esteem – they look on themselves with pity. We need a lot of education and exposure for women at a very young age so that they begin to appreciate who and what they are in society. We continue to think that the people who develop our countries are men but, in my opinion, the male form of leadership in Africa has failed. In addition to that, we must mobilise women to become an increasing part of the decision making process. We can use HIV as an opportunity to deliver these messages. When you look at the National AIDS Councils all over the world, they are run by men and they don't create enough programmes that address women's issues per se.

The economic empowerment of women is vital; with respect to HIV, education is not enough. I work with one of the most vulnerable groups in the world – sex workers - and they are one of the most organised groups of women. They will tell you they know in detail about HIV because they have nursed their friends through it. Yet, they will go on the streets the next day because they have to. We need to empower them with skills so that they will start earning money and will not be on the street and exposed to HIV. At the centre of any HIV programme must be income generation and entrepreneurship. Educational campaigns alone are a waste of money because women know about HIV, but they will still expose themselves because they have no alternative.

The role of the government in relation to HIV and AIDS is crucially in the areas of policy and law, in addition to funding. What is sad about Africa is that too many of our governments have decided they have no money. But if there was an election tomorrow, they would find money for the election. So they need to rethink their priorities; we need to mobilise our governments to put money on the table. The government needs to wake up to the reality and know what the priorities are. One of these priorities is to reduce HIV infections in our nation and to reduce the burden of disease among the people, and also to reduce the impact HIV is having on people, households and families. It is time to move from rhetoric to action.

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A former Zambian Minister of Health, Professor Luo is President of the Society for Women and AIDS in Zambia. She is well known for her project - TASINTHA which was designed to support and protect sex workers in a variety of ways.