By Lovemore Rambiyawo
Programs Manager – National Association of Societies for the Care of the Handicapped (NASCOH)
Zimbabwe has been conducting HIV and AIDS interventions for close to 3 decades, resulting in the HIV prevalence for adults (15-49 years) declining by 5.6% from 2011, to 15% in 2014 (UNAIDS 2014), accompanied by reduction in new infections, rise in access to anti-retro viral therapy, HIV testing and medical male circumcision in consonance with the majority of the world. However, as hope beckons for a gradual end to the AIDS epidemic, we have to ask ourselves a very pertinent question: As a country, are we closing the gap between the people moving forward and the people being left behind?
Specifically, are our interventions constantly responding to emerging global trends and changing circumstances with respect to HIV and AIDS? Are the interventions responsive to emerging perspectives, including target-specific human rights concerns? Are the interventions in sync with new research findings especially regarding new key populations that have hitherto, not been included in HIV and AIDS interventions? And, is anything being done to ensure that the health space that had been hitherto closed to these marginalised populations is not only demanded, occupied and defended, but also barriers are removed and access to public health life enhanced? For people with disabilities (PWDs), who, at 15% of every population (over 1 billion globally and 2.4million in Zimbabwe), constitute the world’s largest minority, and who suffer from a documented lack of access to fundamental freedoms and rights across the entire social, economic and political spectrum, the answer is a resounding NO! In the arena of sexual and reproductive health and rights (SRHR), where PWDs have been excluded from mainstream HIV and AIDS and SRH interventions on the erroneous assumption that they are not sexually active, social exclusion of PWDs reaches its lowest point.
While Zimbabwe is struggling to conceptualise PWDs as a key population at risk, the UNAIDS Gap report (2014) devotes a whole chapter on PWDs; the Global Fund’s Human Rights on HIV, TB, Malaria and Health System Strengthening information Note (2014) includes PWDs in the partial list of key populations; and a meta-analysis on HIV prevalence among adults with disabilities in Sub-Sahara Africa (De Beaudrap et al, 2014), shows that there is a gradient in the risk of HIV infection according to gender and disability status with a risk increasing from 1.48 for men with disabilities to 2.21 in women with disabilities when compared to non-disabled people. Critically, the Global Fund Information Note sets out three key steps for integrating human rights in Global Fund programmes: Identify who is at risk of HIV, TB or malaria, who has the disease, and what activities are needed to address human rights barriers and effectively reach those populations; Design all disease programs using a human rights-based approach; and Invest in a package of services to remove human rights barriers to access, including community system strengthening.
PWDs are manifestly at great risk of HIV, TB and malaria; they need a holistic and integrated range of prevention, treatment, support and care and physical accessibility services to address the multifaceted and interconnected human rights barriers they face in accessing health, designed using a rights based approach and also encompassing disability mainstreaming and community systems strengthening. The perception of PWDs as asexual beings by medical personnel, care givers and the generality of society and resultant stereotyping and ignoring of their sexuality, results in PWDs being subjected to attitudinal, physical, economic and informational barriers to accessing sexual healthcare. Incidences of women and men with disabilities being ridiculed and taunted by medical personnel when seeking SRH services, especially Anti-Retroviral Therapy (ART) at clinics and hospitals, are rampant. Physical barriers, including inaccessibility of medical facilities (lack of ramps, elevators etc.), distant medical facilities, lack of disability friendly infrastructure in clinics/hospitals; lack of suitable transportations; informational barriers (e.g. lack of information material in Braille, large print, simple language, and pictures; lack of sign language interpreters); providers’ lack of knowledge and skills about PWDs; and lack of coordination among health care providers combine to push SRH and HIV services out of the reach of PWDs. The 1.2 million women with disabilities (WWDs) in Zimbabwe, bear the brunt of this social exclusion in SRH interventions; 580 230 WWDs in the 15-49 age group are uniquely affected. WWDs experience major psycho-social problems that remain largely neglected including depression, stress, lowered self-esteem, and social isolation. Drugs taken to manage their conditions interact negatively with contraception. Girls and women with visual impairment are at high risk of being raped and abused with impunity due to their inability to identify the perpetrator; girls and women with hearing impairments due to their inability to communicate with medical personnel, law enforcers and the generality of society; and women with mental impairments due to their cognitive impairments often prevent them to perceive the gravity of the crime or that a crime had actually occurred. Schoolgirls with mental challenges are often put on Depo Provera without their consent to prevent unwanted pregnancies. These factors significantly increase the chances of these sections of the population to acquire HIV and resultantly be disproportionately exposed to stigma and discrimination.
The UNAIDS Gap report (2014), which devotes a whole chapter to disability, recognises that PWDs are multiply stigmatised and at increased risk of exposure to HIV due to lack of access to education in particular sexuality/sexual health education; increased risk to sexual violence and exploitation; potential of increased risk behaviours due to illiteracy; lack of access to inclusive health products and services; increased likelihood of living in poverty and sinking deeper into poverty as a result of generalised social exclusion ; stigma, prejudices, harmful practices, misconceptions and negative attitudes from family, community and society; and lack of application of national laws and policies supposed to protect and promote rights. At a strategic level, Article 25(a) of the United Nations Convention on the Rights of Persons with Disabilities (CRPD), of which Zimbabwe is a signatory, binds member states to provide PWDs with the same range, quality and standard of free or affordable health care and programs as provided to other persons, including in the area of sexual and reproductive health (SRH) and population-based public health programs. The CRPD recognises Disability Mainstreaming as an integral part of relevant sustainable development strategies and is consonant with Sustainable Development Goal 5: “Ensure universal access to SRH and reproductive rights “. Nothing is being done in this regard.
Paradoxically, the National Health Strategy (NHS) for Zimbabwe 2016-2020–Equity and Quality of Health: Leaving No One Behind, which sets out the strategic direction for the health sector in order to attain Zimbabwe’s vision to have the highest possible level of health quality of life for all its citizens, is fundamentally flawed and out of sync with the CRPD. The CRPD states that disability is not located in the individual, but results from the interaction between persons with impairments and attitudinal and environmental barriers that hinders their full and effective participation in society on an equal basis with others. The NHS, which has unbridled potential for including PWDs in Zimbabwe’s SRHR interventions, however, leaves PWDs behind. While it identifies quality, equity, gender and community participation as crosscutting issues integrated across all the strategy areas, disability is conceptualised erroneously as a non-communicable disease. It is not integrated into the priority programs of communicable diseases; non-communicable diseases; reproductive, maternal, newborn, child health and adolescents; public health surveillance and disaster preparedness. It is also not integrated into goal 2 of improving service delivery platforms and goal 3 of creation of an enabling environment for service delivery.
While the SRH,HIV, stigma and discrimination concerns of men who have sex with men, transgender people, people who use drugs and sex workers, have been, and continue to be addressed through multiple and intersecting interventions in Zimbabwe, the SRHR,HIV and AIDS needs of PWDs remain unmet, resulting in low SRH and ART uptake. HIV and AIDS standalone programming, coupled with broadly inclusive approaches, is necessary to expand access to HIV and Sexual and Reproductive Health services for people with disabilities. If PWDs are not factored in comprehensively in the 2018 to 2020 HIV and AIDS intervention in Zimbabwe, all the nascent momentum for disability inclusion in HIV and SRH might be irrevocably reversed.
National Association of Societies for the Care of the Handicapped is the umbrella body and official coordinating body for voluntary organisations working with and for people with disabilities in Zimbabwe. It can be reached at firstname.lastname@example.org, or +26348644102485/6.