Mozambique Struggles to Contain HIV Epidemic Among Young Women
By Andrew Green
MAPUTO, Mozambique – At their first meeting, the group of 30 young women just eyed Nousa Winica warily. When she asked a question, they hurriedly dropped their gaze. It would be, she quickly realized, a struggle to earn their trust.
Winica spent the first few of their weekly gatherings sticking to light subjects – what chores they did, their favorite classes, even the weather – just to make the girls, pooled from one of the poorest neighborhoods in Mozambique’s capital, Maputo, comfortable sharing with her and with each other. Eventually, she started peppering the conversation with questions about HIV. What did they know about the disease? Could they explain how it was spread? What steps could they take to avoid getting infected?
After weeks of dragging answers out of them to the most banal questions, she was shocked at their interest in the topic. “They receive it with some kind of happiness,” she said. “Most of them have someone at home in the family who is sick. They have some questions about the disease.”
Winica, 22, is a volunteer with the campaign Acçao Para Rapariga – or Action for Girls. Each week for six months she meets with the 30 young women, who range in age from 10 to 19, gathering on a set of benches outside a local primary school. Associação Coalizão da Juventude Moçambicana, a Maputo-based organization, created the program to provide Mozambique’s girls with mentors who can talk to them about the issues no one else is – reproductive and sexual health, human rights and, most importantly, HIV.
“It’s to educate the girls,” Winica said. “The information is a basic thing. With no information, actually, we’re going to have problems.”
Mozambique already has more than a problem. It has a crisis among its young women. The country has one of the worst HIV infection rates in the world – an estimated 11.5 percent of people between 15 and 49 have the disease. But within that epidemic, women are disproportionately affected, registering 13.1 percent prevalence against 9.2 percent among men. In some areas of the country, HIV rates for young women are a staggering five to six times higher than among their male counterparts.
Mozambique’s numbers reflect the frightening reality: Young women have become the main drivers of the region’s pandemic. In sub-Saharan Africa, they now account for 71 percent of all new HIV infections. Officials in Mozambique blame a potent mixture of inadequate healthcare – especially in rural areas, lingering stigma and a social structure that leaves young women with little control of their own lives.
While the girls Winica works with have an interest in learning more about the disease, her next task – channeling that curiosity into actions that will give them some measure of control over their own health – is going to be much harder than gaining their trust. But it has to happen, and on a national scale, if Mozambique hopes to end its HIV epidemic.
One doctor for every 38,000 people
There’s no single reason behind the astronomical HIV rates among Mozambique’s young girls.
In part it is the fact that the country’s health system is one of the most overstretched in the world, with a ratio of one doctor for every 38,000 people. Neighboring South Africa, in comparison, has one physician per 1,250 people. Mozambique’s shortage limits not only access to HIV testing and treatment, but also to information that could help keep people from getting infected in the first place.
What particularly worries David Magaia is an increasing failure to meet that knowledge gap. Magaia, a preacher, first became involved with the country’s AIDS response in 1989 when he urged the Christian Council of Churches to be more vocal in explaining how to prevent the virus’ spread. He has been working in HIV programming ever since.
“All the organizations during ’98, 2000, 2005 almost to 2007, we were all busy talking about HIV,” he said, but donor priorities began to shift and programs moved with them. The transition was spurred in part, he said, by dramatic improvements to anti-retroviral therapy (ART), which transformed HIV from a death sentence into a chronic, manageable disease. Suddenly, prevention messaging didn’t seem so crucial. “Seeing how things are now, generally, it seems like the awareness of HIV for people has again gone down.”
What remains, though, is an obdurate stigma, which makes people hesitant to talk about the disease, to get tested and – if they are found to be HIV-positive – to adhere to the treatment that would save their lives.
A survey conducted among people living with HIV in Mozambique and released in 2013 found that more than half of all the participants had experienced some form of stigma or discrimination in the previous year because of their status. And nearly four in 10 said being HIV-positive had restricted their access to work, housing or social services – including healthcare.
Magaia warns that this stigma, combined with the drop in awareness about the virus, has left the country – and especially its emerging population of young people – prone to a surge of new HIV infections. And that is before considering the cultural norms – especially in rural areas – that strip women and girls of their autonomy and further heighten their risk of contracting the disease.
Ana Cristina Monteiro is a technical advisor on gender-based violence for the Elizabeth Glaser Pediatric AIDS Foundation. In Mozambique, the organization’s activities go well beyond what its name suggests, delivering a host of HIV services to broad swaths of the population. In her efforts to reduce gender-based violence, Monteiro said she repeatedly comes across scenarios where families and communities restrict women’s choices – whether it is to seek medical care or to adopt HIV prevention strategies.
“It’s like a prison,” she said. “You don’t go to the market alone. You don’t go to the hospital. It’s the husband or family to tell you if you can go. You can’t decide anything about your life, because your life belongs to your husband.”
Action for Girls’ programs
On a fundamental level, Action for Girls is about undermining those norms by equipping young women to advocate for themselves, whether it is to demand access to healthcare or the opportunity to finish school.
Volunteers regularly go door-to-door in neighborhoods across four of Mozambique’s 11 provinces, interviewing young women about their lives and recruiting them to the program. Once a group is formed, the mentors construct weekly discussions around a topic, beginning with basic information and building up to practical advice. For instance, when they talk about HIV, Winica tells the young women never to allow a partner to talk them into not using a condom, unless they have both been for an HIV test, preferably together.
Winica, who is in the third year of a journalism training program, got involved with Action for Girls because she noticed a slight loosening of cultural restrictions and wanted to help propel it. “I feel that society has changed the mentality,” she said. “My parents are investing in me to finish school, find a job.” She, in turn, wanted to invest in others – offering knowledge that might better equip them to assert what would be best for their lives. Although, she acknowledges, information alone is often not enough to change their situations.
Laura Winasse, the program’s coordinator, is aware of the limitations of their approach – girls often need more than knowledge to negotiate a situation. Action for Girls intentionally recruits from Mozambique’s poorer communities because the girls and women there tend to be the most vulnerable.
“The parents don’t have the money to support her in school, her uniform, whatever she needs,” Winasse said. “And she gets involved with people to get money. If she’s involved with that man, who can give her money to go to school, she doesn’t have the power to negotiate with that man, because she needs money. If she says, ‘Let’s use condoms,’ for example, he’ll just say, ‘I’ll find another girl who doesn’t want to use a condom.’”
So, in addition to information, Action for Girls tries to arm them with something tangible – whether its school fees or assistance in trying to find a job – so they have additional leverage. They also advocate for changes in government policies that restrict women’s rights, including a law that forces girls to temporarily drop out of school if they become pregnant.
More than seven thousand young women have now been through the program. Though it is not specifically aimed at HIV prevention or gaining women better access to healthcare, its organizers hope those will be some of the outcomes of their work. “The idea, actually, is to make them different in the society,” Winica said.
The Associação team are far from the only ones to recognize the importance of arresting transmission among Mozambique’s young women. And in a country of 25 million people, where nearly two-thirds of the population is 24 years old or younger, it will take more than one program to stem the spread of HIV.
Elizabeth Glaser partners with the ministry of health to offer school-based programs that shore up knowledge about women’s rights and access to healthcare. The organization has decided the need to prepare young people to protect themselves outweighs any societal hesitance.
“In our culture, it’s a little bit sensitive to talk about sexuality, because their parents see them as young,” said Nelma Massunda, a senior communications and advocacy officer with the NGO. “But they are teenagers. We can speak about it and learn about HIV and how to fight against it.” And in doing so, they have arrived at the same conclusion Winica did: Young women are eager to know more about the disease and what they can do to prevent it.
Mozambique is also set to become one of 10 inaugural countries to participate in a U.S.-led initiative: Determined, Resilient, Empowered, AIDS-free, Mentored and Safe women – or DREAMS. Each of the initial countries is in sub-Saharan Africa. Through the President’s Emergency Plan for AIDS Relief, the U.S. government’s primary channel for distributing bilateral HIV assistance, Mozambique received a two-year, $20 million DREAMS grant.
“What we know is that the young women are at higher risk of infection,” said Paula Simbine, the key population advisor for the Centers for Disease Control in Mozambique. “If we don’t target this higher risk now, it will be too late to prevent the new infections.”
Simbine, who will oversee the project, said they plan to roll DREAMS out in three provinces, reaching girls in schools, but also in their communities with a cornucopia of programs, including HIV counseling and testing, distribution of condoms and family planning services. There will also be an economic empowerment element, she said, though they are still working out the details.
Much like Action for Girls, Simbine said the bottom line for DREAMS is arming young women with everything possible – information, training, resources – so they are able to make their own choices and access the services they need to prevent contracting HIV. And reminding them that in taking control of their own lives, they can also save their country.
Andrew Green reported from Mozambique on a grant from the International Reporting Project, an independent journalism based in Washington, D.C.