FEATURE: Zim’s goal to end Aids is so close — Why are health experts worried?

By Gamuchirayi Masiyiwa

PRECIOUS rarely takes her medication in public. If she must, she keeps the pills in an unmarked case and discreetly opens it inside her handbag before taking the medication. Even at home in Mabvuku, a suburb east of Harare, Precious makes sure the pills remain in her secret place — the unmarked case. The 31-year-old has her reasons.

In 2004, Precious, who asked to use her middle name for fear of stigma, was diagnosed with HIV. She was put on antiretroviral therapy. Soon after, she moved in with her cousin and divulged her status.

“She then broke the news to her friends. News spread that I was on antiretroviral treatment,” Precious said.

The mother of two was devastated. She felt betrayed. “I thought that she was going to keep the issue a secret when I confided in her,” she said.

Enraged, Precious went home and poured the case of pills into the toilet. For 12 years, she stopped taking medication and resolved to keep her status a secret. Even now, Precious — who is a sex worker — has not shared her HIV status with the men she has been intimate with.

Precious is one of many Zimbabweans living with HIV in a country which was among the worst affected by the epidemic. The first national estimate, produced in 2003, showed that 24,6% of the country’s adult population (ages 15-49) was infected.

But in the last few years, Zimbabwe has managed to reduce its HIV prevalence. By 2022, the HIV prevalence figure dropped to 11%, according to data from the Joint United Nations Programme on HIV/Aids, known as UNAids.

Zimbabwe is also one of the few countries in the world that, according to a July report by UNAids, has achieved the 95-95-95 targets at national level. This means that 95% of people living with HIV are aware of their status, 95% of them are on medication and 95% of those on medication have a suppressed viral load.

Despite these significant strides, there is little cause for celebration in stigma and discrimination, which are on the rise. In a 2022 stigma index survey, a tool that measures stigma and discrimination experienced by people living with HIV/Aids, 69,7% of people living with HIV reported experiencing stigma or discrimination, up from 65,5% in 2014, according to the non-profit Zimbabwe National Network of People Living with HIV, known as ZNNP+. And according to a UNAids update this year, about 30% of people aged 15 to 49 in Zimbabwe had discriminatory attitudes towards people living with HIV.

Experts caution that the battle against stigma (negative attitudes and beliefs) and discrimination (actions based on those beliefs) remains vital in Zimbabwe.

Bernard Madzima, CEO at National Aids Council, is worried that the rise in stigma and discrimination could affect Zimbabwe’s chances of attaining the UNAids goal to end the HIV/Aids epidemic by 2030, as well as increase the burden on health services.

“If people are afraid of being stigmatised, they will not present themselves for HIV testing and/or will not access treatment services. This means that these people will not have their viral load suppressed and remain capable of infecting anyone that they engage in sex with,” Madzima said.

When they skip medicine, they end up with full-blown Aids, agrees Tonderai Mwareka, stigma index co-ordinator at ZNNP+. They are also more vulnerable to opportunistic infections, infections that occur more frequently and are more severe in people with weakened immune systems.

Sex workers, transgender people and people in prison are among those most affected, said Mwareka, as they face double stigma based on both their HIV status and their occupation, sexual orientation or incarceration respectively.

In Precious’ case, when her cousin noticed that she was no longer taking medication, she lied. She told her cousin that she had gone for another checkup and told to stop taking medication because she was negative.

“I said maybe the machine had made an error,” Precious said.

She did not disclose her status to her clients either, as she worried how that might affect her sex work. Although she said she advocated use of protection, some clients preferred not to.

For the 12 years Precious did not take any HIV medication, she struggled with headaches and dizziness and self-medicated with painkillers. In 2015, Precious relocated to another town and temporarily stopped sex work to start a new life with her newfound boyfriend. Because of the dizziness and headaches, a niece who stayed in the same town and was on HIV treatment encouraged her to get tested.

“I went to a local clinic, got tested and was put on treatment,” she said. She did not tell her niece that she had found out about her status 12 years earlier.

Precious was put on medication again. Since she had not told her boyfriend about her status, she kept the medication at her niece’s place and went there each day for her dose. Whenever she ran out of medication, her niece would collect it on her behalf. But this arrangement only lasted for a year. She said she found out that her niece had been revealing her status and so she quit taking her medication again, this time for six years.

It was when she moved to Harare to resume sex work in 2022 that things changed. Precious attended an outreach programme conducted by New Start Centre, an organisation that offers HIV testing and counselling services, where she learned about the importance of staying on medication and the risks of reinfection. She then resumed her medication.

Precious believes that her health could have worsened had she not resumed treatment. But she still opts to keep her status a secret because of stigma. If people found out, the news would spread fast, she said.

“I make sure that I take my medication in the morning to ensure that even if I bring a client home, they will not know about my status,” she said. “Even if they sleep over, I always find tricks to take my treatment without them noticing.”

The main cause of increased stigma and discrimination, Mwareka said, was lack of knowledge. He says in the 1990s and early 2000s, there was a lot of investment in HIV messaging in both print and broadcast media.

“Every corner you passed had a poster about HIV/Aids. But this is not the case anymore,” he said. “We relaxed a bit thinking that we had won the war, but the effects are now coming out.”

Owen Mugurungi, who directs the Health and Child Care Ministry’s Aids and tuberculosis unit, finds the rise in stigma and discrimination worrying. He blames misconceptions and false information around HIV spreading through social media. The government will ramp up its efforts to address the issue by ensuring proper information is available on all media channels, including social media platforms, he said.

“We want it to be at zero stigma or less than 5% and the key driver for us to do it is through community education,” he added.

Mwareka would like to see a return to robust HIV awareness campaigns. But while ZNNP+ leads awareness campaigns and HIV disease management programmes, he says, they have limited resources and cannot cover the whole country.

ZNNP+ is not the only one affected by lack of resources. A weak economy has caused the Zimbabwe government to invest less in HIV prevention as well, according to 2022 planning documents for the United States President’s Emergency Plan for Aids Relief programme in Zimbabwe, which notes that “declining economic conditions and fiscal space have exacerbated the difficulties in mobilising domestic resources for health, a plight that has been exaggerated further by the COVID-19 pandemic.”

Caroline, who also asked to use her first name for fear of stigma, believes that although stigma and discrimination are still rife in Zimbabwe, things have slightly improved. The soft-spoken mother of one said when she was diagnosed with HIV in 2008, even her family members were too embarrassed to escort her to hospital. As a result, she missed some appointments. But she was lucky because, at the time, hospital staff followed up if she missed check-ups.

At home, the 39-year-old said she had a designated plate, cup and spoon and that no one wanted to use the same plate as her.

“I had a niece that I took care of since she was 3 months. She got used to being around me. We could eat from the same plate. But when I was sick, her mother beat her for eating from my plate, assuming she would get infected,” Caroline said. “It affected me deeply.”

Even when she got better and did not appear visibly sick, the stigma did not stop. “The times I went to fetch water at a well in my neighbourhood, people would say if I fetched the water, I may cough and the virus will contaminate the water,” she said.

At least people are now accepting that a person with HIV can live longer, she said, while before, they viewed it as a death sentence.

Despite the prevalence of stigma, Caroline still holds out hope. “We will get to a point where we will be able to eliminate HIV — if people adhere to medication, and maybe an injection that one may get once a year will help ensure that people adhere to treatment,” she said.

-AMH