Safer Sex and Reproductive Choice: Findings from “Positive Women: Voices and Choices” in Zimbabwe

Abstract

Positive Women: Voices and Choices was an advocacy-research project developed by the International Community of Women Living with HIV/AIDS to explore the impact of HIV/AIDS on women's sexual and reproductive lives, challenge the violation of their rights and advocate improvements in policy and services. The project in Zimbabwe, the first one in three countries, was carried out from 1998 to 2001. This article presents selected findings from the Zimbabwe research report. It shows that HIV-positive women were unaware they were at risk before an HIV diagnosis, and that gender norms and economic dependence on husbands/partners restricted women's ability to control their sexual and reproductive lives. Prejudices that HIV-positive women should not be sexually active or have children meant women did not disclose their status to health workers, making it difficult for their needs to be acknowledged or addressed. Condom use was considered inappropriate in marriage. Younger childless women wanted to become pregnant, often in spite of previous miscarriage and stillbirths. Women with several children wanted to avoid further pregnancies, and contraceptive and condom use increased markedly after HIV diagnosis, especially among those attending support groups. Safe abortion was almost entirely inaccessible, though technically the law would have permitted it. Better economic opportunities for women, and integrated pregnancy and delivery care, family planning, STI and HIV-related services are needed which take account of HIV-positive women's needs.

Résumé

Positive Women: Voices and Choices était un projet de recherche et de plaidoyer lancé par l'International Community of Women Living with HIV/AIDS pour étudier l'impact du VIH/SIDA sur la vie génésique des femmes, lutter contre la violation de leurs droits et préconiser l'amélioration des politiques et des services. L'article présente les conclusions d'un rapport de recherche au Zimbabwe, premier des trois pays où le projet a été mené de 1998 à 2001. Il montre que les femmes ignoraient qu'elles étaient à risque avant d'être diagnostiquées séropositives, et que les normes sexuelles et leur dépendance économique à l'égard de leurs partenaires restreignaient leur capacité à maı̂triser leur vie sexuelle. Les préjugés interdisant aux femmes séropositives d'avoir des rapports sexuels ou de devenir mères les obligeaient à cacher leur statut aux agents de santé qui ne pouvaient répondre à leurs besoins. L'utilisation de préservatifs était jugée inconvenante dans le mariage. Les femmes jeunes et sans enfants voulaient devenir mères, souvent malgré de précédentes fausses couches et des enfants mort-nés. Les femmes ayant plusieurs enfants souhaitaient éviter de nouvelles grossesses, et l'utilisation de contraceptifs et de préservatifs s'est élevée nettement après le diagnostic de séropositivité, particulièrement parmi celles qui fréquentaient des groupes de soutien. Néanmoins, les avortements médicalisés étaient presque inaccessibles, même si la loi aurait dû les autoriser. Il faut offrir aux femmes de meilleures possibilités économiques, des soins obstétriques intégrés, une planification familiale et des services de lutte contre les MST et le VIH qui tiennent compte des besoins des femmes séropositives.

Resumen

Positive Women: Voices and Choices (Mujeres positivas: voces y opciones) fue un proyecto de investigación y defensa y promoción pública realizado por la Comunidad Internacional de Mujeres Viviendo con VIH/SIDA, orientado a explorar el impacto del VIH/SIDA en las vidas sexuales y reproductivas de las mujeres, desafiar la violación de sus derechos, y promover mejores polı́ticas y servicios. En este artı́culo se presentan los resultados del los resultados del proyecto en Zimbabwe, el primero de tres paı́ses donde se llevó a cabo el proyecto entre 1998 y 2001. Muestra que las mujeres viviendo con VIH no sabı́an que estaban en una situación de riesgo antes de conocer su diagnóstico y que tenı́an limitado control sobre sus vidas sexuales y reproductivas debido a las normas de género y su dependencia económica. Debido a prejuicios en contra de la actividad sexual o el embarazo para mujeres viviendo con VIH, ellas no revelaban su condición a los trabajadores de salud, ası́ dificultando la atención a sus necesidades. Se consideraba inapropiado el uso del condón en el matrimonio. Las mujeres más jóvenes sin hijos querı́an embarazarse, a pesar de haber sufrido abortos espontáneos o nacidos muertos anteriores. Las mujeres con hijos querı́an prevenir más embarazos, y el uso anticonceptivo y del condón aumentó después de su diagnóstico con VIH, especialmente entre las mujeres que asistı́an a grupos de apoyo. El acceso al aborto en condiciones adecuadas era prácticamente inexistente, aunque técnicamente permitido por ley. Las mujeres viviendo con VIH necesitan mejores oportunidades económicas y servicios integrados de atención al embarazo y parto, ITS y VIH, y planificación familiar que toman en cuenta sus necesidades.

Key Words:

• HIV/AIDS
• condoms
• contraception and unplanned pregnancy
• family size preference
• clandestine and unsafe abortion
• Zimbabwe

In Zimbabwe, sentinel surveillance of pregnant women attending antenatal clinics in 1997 found that 24–33% of women in urban areas and 7–53% in rural areas were HIV-positive.¹ Positive Women: Voices and Choices was developed by the International Community of Women Living with HIV/AIDS (ICW) to explore the impact of HIV/AIDS on HIV-positive women's sexual and reproductive decisions and choices, challenge the violation of their sexual and reproductive rights and advocate for improvements in policy and services in three countries—Zimbabwe, Thailand and Côte d'Ivoire. Zimbabwe was the first of the three countries in which the study was carried out, from 1998 to 2001.*

Methodology and participants

The project in Zimbabwe worked with established HIV support groups** in rural areas in the provinces of Manicaland, Midlands and Matabeleland South, and the city of Harare. The rural groups were in predominantly agricultural areas, though some women lived in or traded at rural growth points, designated centres for economic development. Study participants included women from the two major Zimbabwean ethnic groups, Shona and Ndebele.

Members of the participating support groups elected a total of nine team leaders from among their members, who were trained to collect data. They carried out fieldwork and helped to specify the issues for investigation. Data were collected by means of a survey of 209 women affected by HIV and AIDS and in-depth interviews with 59 women.* Roughly equal numbers of participants were recruited in each of the four areas. Almost all the women who participated in the survey and all but seven of the women who were interviewed were members of HIV support groups.

Further data were collected from discussions in residential Community Workshops in each of the four areas, whose aim was to present preliminary findings and enable positive women from local support groups to discuss their concerns with key members of their communities. Workshop size ranged from 23 to 45 participants each, of whom over half were HIV-positive women from local support groups and the rest included male and female representatives of community-based AIDS organisations, local community and health workers, and village and church leaders. The final stage of data collection was a review of the qualitative data by the national and international researchers with the team leaders, in which some gaps were filled in and questions clarified.

Of the 209 women in the survey, 174 (83.3%) had had an HIV antibody test and had known their HIV-positive status for at least a year. Eight of these had been diagnosed over 10 years before. The remaining 35 women (16.7%) suspected they were HIV-positive because of the illness or death of a spouse or a child from AIDS-related causes. All 59 women interviewed in-depth had tested HIV-positive except one, who learned she was HIV-positive when her child was diagnosed. Over 90% of the women in the survey and the interview whose ages were given were aged over 25. The study under-represented more recently diagnosed women and women under 25.

This paper presents selected findings from the study on how HIV-positive women viewed and looked after their sexual and reproductive health before and after their HIV diagnosis, and their experiences of pregnancy and childbirth.

Knowledge and awareness of risk before an HIV diagnosis

Sixty-one per cent of women in the survey said that they had been treated for sexually transmitted infections (STIs) in the previous three years, and many of them were by then already HIV-positive. Over 90% of the women interviewed said that before they knew their HIV status they had not used protection to prevent STIs or HIV. At first sight, this would appear to be a very high proportion, given the high prevalence of STIs and HIV in Zimbabwe and the extensive public education efforts made in recent years. Several women who were interviewed had also had STIs before they were diagnosed with HIV.

Why did the women not use protection? The explanation is to be found not just in their limited knowledge about HIV, but in an understanding of how they related their knowledge about HIV to themselves and to other aspects of their lives. This included their expectations of their sexual relationships and the degree of control they felt they had in them, as well as attitudes towards condoms and the control of disease more generally.

Over half the women interviewed said they had known nothing of HIV prevention before they found out they had HIV.

“We did not use any protection because we did not know and were ignorant of it.”

Nevertheless, many women acknowledged that they had heard of HIV, but either they knew nothing or very little about transmission or, more commonly, they did not see how this information applied to them. Their knowledge seemed very vague and incomplete.

“Before I was told about my HIV status, I only knew that there was AIDS but did not know all the facts about HIV or AIDS. So I did not try to protect myself from AIDS because I did not know about it.”

More commonly, women distanced themselves from HIV, so that it would not apply to them. This is very common in dealing with difficult or unacceptable information and has been much discussed in relation to HIV/AIDS.²³ Distancing oneself from HIV was easier for those who saw themselves as keeping to the strict rules of marital and sexual relations in Zimbabwe. Those perceived to be at risk were frequently seen as other types of women, who did not keep to the rules. HIV was viewed as an attribute of these types of people rather than as a virus. Thus, several of the women interviewed thought that HIV did not apply to married women. Others thought that HIV only applied to women they termed “loose women”, or sex workers. A married rural woman, described by the team as highly respected in her community, said:

“I did not protect myself because I had confidence in myself, and I knew I would not get HIV because I was faithful. HIV affects those who are not faithful so I never thought about getting it.”

This woman's strong feeling of self-worth contrasts with a common view that women put themselves at risk of HIV because they have low self-esteem.⁴

Some women had thought that AIDS could not affect a woman who had only had one partner.

“When I gave birth to my first child, I was always in and out of hospital. When the child was nine months old the doctors decided to do an HIV test. I was not afraid of the test, as I knew that my child would be negative. I was thinking AIDS was for people who have many sexual partners. At that time I had only one boyfriend. He is the one who took away my virginity.”

Since HIV had nothing to do with them, why would they bother to find out more about it? Many women had no idea that they were at risk, or did not perceive that their own or their husband's ill-health had anything to do with HIV. Thus, the majority of women discovered that they were HIV-positive only after their partner's sickness or death, or during or soon after pregnancy. Table 1

Table 1 Circumstances of HIV testing for Zimbabwean women (n=59)

Circumstances of HIV testing*	Number	(%)
Own illness	26	(44.1%)
Husband/boyfriend's illness or death	22	(37.3%)
Due to woman's illness during pregnancy or other pregnancy related problems	12	(20.3%)
Child's illness or death	4	(6.8%)
Other factors	4	(6.8%)
No circumstances given	2	(3.4%)

* These categories are not mutually exclusive. In many case where a partner or child was ill, women were also ill themselves.

shows the main circumstances in which the interviewed women were diagnosed as HIV-positive.

Risk of HIV and husbands' infidelity

Most of the married women in the study had had children with only one partner and believed that they had acquired the virus from husbands who were unfaithful. Some husbands spent little time with their wives as they worked in the towns, and some women were aware that the men were likely to have other sexual relationships there. However, they did not consider the health implications for themselves of the men's multiple relationships until they found out that they were HIV-positive.

Whilst many women acknowledged their husbands' unfaithfulness, others were surprised and shocked to discover it. In some cases, it was only after her husband was diagnosed with HIV that a woman would acknowledge his infidelity.

“My husband was very ill. They took him for counselling, and he called me so that we could be together in the lessons. After we were counselled, I then remembered his ways and guessed that the disease could be from his unfaithful acts.”

Women's perceptions of the HIV prevention strategies open to them in Zimbabwe have to be understood within the context of common expectations of marriage, which include having children and obeying your husband. Although women often express anger and resentment at the control exercised by their husbands, marriage is one of the few ways that women can ensure their social status and economic security.

Appropriateness of condom use in marriage

Whether as a means of contraception or as protection from STIs, condoms are strongly associated with extra-marital sex by both men and women in Zimbabwe.⁵⁶ Most commonly, women said that it was their husbands who refused to use condoms, and there is no doubt that men in Zimbabwe prefer not to use condoms.⁷ However, many women also felt that condoms were inappropriate within marriage.

“At that time (before HIV) my husband and I never used condoms. We thought they were only for use by prostitutes.”

Many women felt that because a man had sex with his wife without a condom, it meant that she was valued more than sex workers or other temporary partners.

“We cannot have it that when one sleeps out he uses condoms on the extra-marital mates, and when one is sleeping with his marital mate he uses condoms as well. It does not make sense.”

This may be why, in the rare cases where husbands proposed condom use, their wives were just as reluctant to use them as they claimed men were.

Control of sexual relations and condom use

Women felt that men generally controlled a couple's sexual encounters, both in terms of whether and when they had sex, and whether or not they used condoms. Over three-quarters of women in the survey said that men usually initiated sex and over two-thirds felt that the men also controlled how sex was carried out.

“Whenever my husband wanted to have sex we would do it just like that.”

Both the women's stories and the Community Workshop discussions showed that men and women shared an acceptance of men's sexual rights in marriage. Forced sex within marriage is very common in Zimbabwe and is widely regarded as “normal”, and even acceptable. Of the women in our survey 78% reported being forced to have sex by their regular partners, of whom half said this had occured while their partner had an STI.* Only 43% of the women surveyed regarded forced sex by their regular partner as rape.

During the Community Workshop discussions, groups of male community leaders were asked for their views on forced sex. Women's reasons for refusing sex were seen by the men mainly as signs of guilt or bad behaviour, such as having an extra-marital affair, possession by evil spirits, or having an STI. In such cases, sexual coercion by the male partner was viewed as a punishment. But even if men felt that a woman was refusing sex for “genuine” reasons, e.g. because she was angry or too tired, or had not been given money, these reasons were considered as insufficient to challenge what the men perceived as their conjugal rights. These conferred an obligation on women to have sex whenever their husbands wanted them to, on the grounds that lobola (brideprice) had been paid.⁶

Contraceptive use before HIV

In contrast to their limited knowledge of HIV prevention before they were affected by the virus, most women were familiar with modern contraception, which is widely available in Zimbabwe.⁸ All the women interviewed knew something about contraception, and 42% of them said they had used modern contraceptives before they knew they were HIV-positive. This is comparable with levels of contraceptive use by women reported in the Zimbabwe Demographic and Health Survey 1994.⁸

Mostly they had used oral contraceptives and injectables, but six women had used condoms before they were diagnosed HIV-positive. One woman had participated in a Norplant trial. Another had used an intra-uterine device (IUD) and continued to do so. Only one woman referred to traditional medicine as a means of contraception, but she had used it as well as oral contraceptives. One woman had used the “safe period” as a means of controlling her fertility, the method advised by staff at the local Catholic mission hospital.

Some women said that they had not used family planning because they or their husbands had wanted children. Very few women had discussed family planning with their husbands.

“We never talked about family planning. I just got pregnant.”

Information about contraception was much more readily available to women than information about safer sex. Many women mentioned that they had received no information about HIV at clinics where contraceptives were available. One woman was taught about family planning by health workers, who gave her free pills, but she “never took them because when my husband was strong he seldom came home”. It would seem that the health workers did not discuss the health implications of her husband's long absences with her. She only learned the difference between family planning and HIV prevention at the support group after she was already HIV-positive.

Contraceptive use and protection of sexual health since HIV diagnosis

After their HIV diagnosis, most of the women became much more aware of methods to prevent STIs and HIV re-infection and were generally also very anxious to prevent conception. Thirty-four of the 59 women interviewed (nearly 60%), used barrier methods alone or dual protection. Eighty-seven per cent of women in the survey said they used contraceptives and 75% used condoms to prevent STIs. Table 2

Table 2 Methods of contraception and secondary prevention since women knew they were HIV-positive (n=59)

Method	Number	(%)
Condoms alone	22	(37.3%)
Condoms plus a non-barrier contraceptive	12	(20.3%)
Abstention*	17	(28.8%)
No method	5	(8.5%)
No information	3	(5.1%)

* Of the women who abstained, one had been sterilised and the other kept her IUD, which had been fitted before she knew she was HIV-positive.

shows the methods of contraception and secondary prevention used by women interviewed since they had learned their HIV status. As very few of the women had ever used condoms before they were diagnosed, this represents a marked shift.

Women who wanted contraceptives found them easy to obtain, but some commented that the pill was expensive and only 12 women used a non-barrier method. Two-thirds of the women in the survey obtained condoms from the hospital or a community-based distributor, while 13% got them at beer halls. Many women who had tried them preferred using female condoms, but often found them difficult to obtain.⁹

There was no discussion in the interviews of whether the women used family planning clinics since they had learned they were HIV-positive, or whether those who did so disclosed their status. However, this would be very unlikely since 80% of women in the survey felt that society expected HIV-positive women not to be sexually active. This expectation may have contributed to the stigma and discrimination against HIV-positive women who gave birth.

The women's stories suggest that they changed their contraceptive and STI prevention methods based on information from support groups or from counselling, and that this information helped them to be more assertive with their partners.

“We discuss sexuality, how to plan it, and even the foreplay. We now have safer sex by using condoms. We got the advice from support groups and clinics.”

Major relationship changes, and shifts in knowledge and attitude of their partners, often took some time, however, and it was not always possible for women to use protection consistently and regularly.

Besides their concern with re-infection, many of the women were sure they did not want to have any more children. Some therefore used dual protection methods to prevent conception and re-infection.

“I was pregnant when I discovered that I was HIV-positive. I did not contemplate an abortion, but I do not want to be pregnant again. I have used the Depo injection, and we use condoms.”

“I use family planning tablets and condoms. I use these tablets so that if by any chance the condom tears, I will still not fall pregnant.”

However, despite an overall shift in awareness and use of contraceptives, where condoms were the only form of protection available, some women who did not want more children still remained at risk of unintended pregnancy. One woman, a widow at interview, who became pregnant with her sixth child three years after her HIV diagnosis, said:

“I had problems with my husband, who never wanted to use condoms. When I told him [my diagnosis] he just said: ‘Even if you are like that I cannot use your condoms.’ Many times he would force me to have sex. I no longer had much desire for it. I feared re-infection and worsening my health. When I was pregnant, I rarely thought about sex. He would often go mad about it.”

Women who were married with several children, particularly in rural areas, often had not been using contraceptives before they were diagnosed HIV-positive and started using protection only some time after they became aware of their HIV status. In some cases this resulted in unintended pregnancies. Of 11 women interviewed with unintended pregnancies since their HIV diagnosis, only two were using condoms regularly when they conceived. They described their pregnancies as accidents.

Practising safer sex since HIV diagnosis

Use of condoms varied greatly, according to age, relationship, number of surviving children and experiences of pregnancy. Five of the women interviewed, all in new relationships, used no protection because they wanted a child. Another woman, who had married her dead husband's brother to support herself and her children,* felt forced to accept his wish to have another child, and did not use condoms. Two other women interviewed who were sex workers used condoms with their clients but not with their non-paying partners, though both of them used oral contraceptives to prevent pregnancy. Two women interviewed described being forced to have unprotected sex with their husbands, who knew themselves to be HIV-positive.

For a woman to introduce condoms into a relationship successfully, the co-operation of her partner was crucial. Such co-operation often followed periods of great conflict and frequently involved the help of counsellors and the support groups.

Three interviewed women's husbands accepted the idea of using condoms after their wives began to talk about sexual health issues with them. All three accounts reflect mutual respect in the relationship and a practical perception of what needed to be done. The key issue for all of them was the recognition that they had to look after themselves, in order to survive to look after their families. Two couples were helped by being diagnosed together.

Two women managed to introduce condoms into their relationships without telling their partners their HIV status, by stressing the value of HIV prevention. Both of them found it difficult, however. One of them said that she did not tell her boyfriend because she was afraid he would reject her. She stressed the encouragement and support she received to introduce condoms from the support group she had joined.

Changes in sexual feelings since HIV diagnosis

HIV affected women's sexual relationships, including their sexual feelings and their sexual enjoyment. Of the 59 women interviewed, 11 felt that there had been no change to the sexual side of their relationships and that sex was still good, except that they now used condoms. One woman suggested that sex for her was now better because it was safer.

Many widows did not enter into another sexual relationship after they were diagnosed HIV-positive and their partners had died. Some women could not contemplate sex with another partner and one woman said that she had little desire because her “real lover” had died.

“Since my husband died I have never been sexually active. I am afraid of using a condom. I don't think I will have sex again.”

One woman described how the loss of a child, after she was abandoned by the child's father, affected her sexual feelings.

“I spent about four years without a boyfriend. I was thinking that my sexual feelings had died with my child's death.”

Abstinence within an ongoing relationship was not common. When it did occur, it had to do with loss of desire and protection of health. One woman felt her husband did not have sex with her because he no longer cared for her.

Two women discussed masturbation as a way of dealing with unsatisfied sexual desire. Several women said that sex was less frequent or irregular, or that it was painful because of STIs. Some commented specifically that their own or their partner's sexual health problems interfered with their sex lives.

“No man would like to have sex with someone who is always bleeding, even if I use condoms. I am still young and I want to have sex.”

HIV, pregnancy and having children

Public health services are widely used for antenatal and maternity care in Zimbabwe, although the quality and availability of facilities is variable between urban and rural areas, and between regions. Over two-thirds of women in Zimbabwe give birth in health facilities and 70% of women giving birth receive assistance from medically trained personnel.⁸

Most women who had been pregnant at the time of HIV diagnosis or since, felt that they had been well treated during antenatal and maternity care. However, only three reported being given advice about how to look after their general or sexual health during pregnancy. About a quarter felt that they were not given proper care because of their HIV status.

Four women did not disclose their HIV status to health workers in order to avoid exposure and discrimination. One woman said that she did not receive proper care when she gave birth because the health workers were all afraid of being infected with HIV. Another complained that she was criticised by health workers for having a child, despite the fact that her child was conceived deliberately and was much wanted by both her and her husband. Several other women reported being scolded by health workers for getting pregnant, but they also reported that nurses who had been through counselling training were more sympathetica and had referred them for family planning and to support groups.

Named, voluntary antenatal HIV counselling and testing was not routine or available free of charge and was normally only offered when recommended by a doctor. However, there were a few selected pilot antenatal care sites offering HIV testing and short-course zidovudine (AZT) or nevirapine treatment for pregnant women who tested HIV-positive and their infants to prevent mother-to-child transmission. Only women who wished to be counselled and tested took part.

Out of the 209 women who took part in the survey, 74 had had one or more children who had died. Of the 209, 89% thought that HIV-positive women should not have children, and 64% thought that their communities and relatives did not expect HIV-positive women to bear children either. Almost all the women who expressed these views were over age 25 and had already had at least one child. Similar feelings about pregnancy and childbearing were elaborated in the interviews and in the review workshop.

Women who already had some children wanted to give priority to them. They were worried about the economic impact of another child on their households, and the extra burden on their time and energy. They were also concerned that pregnancy and childbirth would affect their health and that their children would be left orphans.

The experience of the women was that the health of women living with HIV deteriorated in pregnancy and that HIV infection had a negative effect on pregnancy outcomes. Twenty-eight of the women interviewed were pregnant when diagnosed with HIV or gave birth after the diagnosis, totalling 41 pregnancies in all. Some women had been pregnant more than once since diagnosis. Of these 41 pregnancies, 27 resulted in live births, six ended in miscarriage and eight in stillbirths or neonatal deaths. Over half these women described severe health problems during pregnancy. Team leaders had also noticed members in support groups who had been well for some time becoming sick either during pregnancy or after delivery, and that babies often died within six months of birth.

There is other evidence of the negative effect of pregnancy on the health of women with HIV in developing countries.¹²¹³¹⁴ However, many women in Zimbabwe are not tested for HIV during or following pregnancy unless they or their baby show signs of HIV-related illness, and it may be these are women whose immune systems have already been considerably weakened by HIV and who are also more likely to transmit HIV to their babies.

Women were very aware of the risk of HIV transmission to their infants and did not want the new child to have HIV, but they had limited or no access to appropriate information, treatment or antenatal care that would protect their own and their babies' health. This included, in particular, limited access to short-course antiretroviral therapy to reduce the risk of HIV transmission during labour and childbirth, and advice and support for safer infant feeding.

Wanted pregnancies

Eighteen of the 59 women interviewed in-depth became pregnant after their diagnosis (Table 3)

Table 3 Wanted and unplanned pregnancies commenced after knowledge of HIV-positive status, by number of living children (n=18 women)

Number of living children	Wanted pregnancies	Unplanned pregnancies
0	5	0
1	1	0
2	1	2
3+	0	9

Some of them badly wanted to have a child, while others became pregnant reluctantly or by accident. Their feelings about these pregnancies and having children reflected their different personal circumstances, in particular whether or not they had other living children. Seven of these pregnancies were wanted while eleven were unplanned.*

Seven of the 18 women had wanted to have a child after they knew they were HIV-positive. Five of these seven women had no living children. Four of these five were in new relationships. The two women with children also had had none from their current relationship. These women recognised the risks involved, but these were outweighed by their desire for a child. The women's stories reveal the strength of their desire to have children. None of them wanted many children, but simply to give birth to and, if possible, raise one healthy child.

“This is my first pregnancy. I would really love to have a child. I have been well informed about the potential problems as an HIV patient but I am prepared to try my luck. I never tried any family planning methods because I wanted a child. I have deliberately not chosen to have an abortion because this could be my only child ever.”

Some wanted a child for themselves. Others wanted a child because their husband had paid lobola or just to please their partners. These feelings were not mutually exclusive. For example, one woman became pregnant while she was a teenager. She was very ill during the pregnancy and miscarried. After a slow recovery, she decided to go for an HIV test and was diagnosed HIV-positive. Later she married and became pregnant. During this pregnancy she became very ill again, and gave birth to a baby who died at nine months. At the time of the interview she still had no child and was pregnant for a third time:

“At the moment I am six months pregnant. I had to have a child to please my husband. It is not my choice, my husband paid lobola and he must have a child. I know that if I did not get pregnant he would look for another wife. I also want another child despite the fact that I lost a child to AIDS. I still want to be a mother.”

Some of the women were prepared to seriously risk their health to bring a pregnancy to term successfully and to have a child who survived. Five of the seven women with wanted pregnancies had already lost babies to AIDS, two after multiple stillbirths and neonatal death, yet all of them got pregnant again.

“At first I did not know that I was infected. I was a teenager when I met a man who infected me. He made me pregnant when I was still at school. I was very sick during that pregnancy. I had STIs. I got treated, but when I was about six months pregnant, I fell ill again and was admitted to the hospital for two days. I was at the maternity department and they were monitoring my disease. I gave birth to a dead baby. That was my first pregnancy. Then I met and married another man who made me pregnant again and I gave birth to a premature baby girl. She was underweight. She nearly died, but fortunately she is still alive. After that I had two stillborn babies and now I'm pregnant again hoping to give birth to a live baby. This time I am taking the AZT tablet.”

This woman had a healthy baby. The other six women also gave birth to live infants, though at the time of the study at least one child was sick and one woman lost her baby at six weeks. Two of the women described being very sick during their pregnancies; one contracted an STI during pregnancy but was successfully treated for it. Only two of these women (including the one on AZT) reported no further health problems during their pregnancies.

Unplanned pregnancies

Eleven women interviewed had become pregnant unintentionally since their HIV diagnosis. These women were in very different situations from those who wanted children. All of them already had at least two living children, some of whom were now grown up. Three women were in new relationships but were satisfied to have had children from previous partners.

The Zimbabwe Demographic and Health Survey 1994 showed (without reference to HIV status) that women's desire to stop having children increased sharply the more children they had.⁸ These 11 women had wanted to prevent further pregnancies or births but this was not always possible because of lack of access to appropriate contraceptives, lack of control over contraception and little or no access to safe abortion.

Like the women with wanted pregnancies, many of this group also experienced difficult pregnancies. Seven women said they became more ill during the pregnancy or afterwards. Four women gave birth to babies who were sick or died, four had healthy babies and one woman was still pregnant at the time of interview. Two women terminated their pregnancies.

Lack of access to safe, legal abortion

Nearly two-thirds of women in the survey said they would have an abortion for an unwanted pregnancy if it was available. However, abortion is only legal in Zimbabwe if there is a serious threat to the mother's life or physical health, if the child is likely to be born with a serious handicap, or the pregnancy is the result of rape or incest. While the law does not specifically provide for abortion on the grounds of HIV because it predates the advent of HIV, provision on grounds of HIV infection could fall within the terms of the Act. The Act states that abortion should take place within the first three months of pregnancy, but the complicated procedures involved in getting medical permission for a legal abortion make that almost impossible. As a result, women who wish to terminate their pregnancies often have illegal abortions, which may have serious health consequences.¹⁷¹⁸

Five of the women whose pregnancies were unplanned considered having an abortion, but did not do so because it was illegal or not available in their local Catholic-run hospitals. One woman preferred to continue the pregnancy rather than disclose her HIV status to get a legal abortion, and was determined to keep it secret.

The two women who had terminations, one of whom became pregnant after her husband had raped her, used traditional medicine, and both experienced serious complications.

“When I found that I was pregnant I tried to terminate it but it was not easy. The doctors refused to terminate my pregnancy even though I told them about my HIV status. Another doctor told me to give her Z$3,000 (c.US$80), which I did not have at the time. I tried to look for it to no avail. Seeing that I had failed to have an abortion from the specialist, I looked for traditional medicine. I used it and I had an incomplete abortion. I was very sick and was taken to the hospital.”

Discussion

In Zimbabwe, both the stigma of HIV and women's subordinate economic and social position restrict the sexual and reproductive rights of HIV-positive women. This study showed that women's desire to have children after an HIV diagnosis varied according to their personal situation. Young childless women wanted to have children regardless of their HIV status, while HIV provided an added incentive to women with several children to stop childbearing.

However, it was often difficult for HIV-positive women to get appropriate information and support to carry out their reproductive decisions safely or at all, especially given the prevailing view that HIV-positive women should not engage in sexual relationships or have children. Many women were unwilling or afraid to disclose their HIV status in family planning clinics or maternity units, or to obtain a safe abortion.

HIV-positive women who want children need advice on the impact of pregnancy and breastfeeding on their own health, on treatment for STIs, on safer conception for discordant couples, and on the risks of HIV transmission to infants during pregnancy, childbirth and infant feeding. Those who do not want children need services in which health workers accept that they are still sexually active. Integrated family planning, STI and HIV-related services are needed to provide advice and access to male and female condoms and other forms of contraception, including emergency contraception and free, safe legal abortions, and should be confidential.

Women's reported lack of knowledge about HIV before their diagnosis, and their perception that they were not at risk, with a consequent failure to protect themselves from the virus, is often interpreted as “denial”. However, it was widespread prejudice about at-risk groups that shaped women's perceptions and made them regard AIDS information as not relevant to them. Despite very high HIV prevalence rates in Zimbabwe, during the time that the women in this study became infected with HIV, the prevailing stigma created obstacles to the acceptance of prevention messages by encouraging people to believe that they were not at risk.

Once women knew they were HIV-positive and recognised the risks of HIV and STI transmission, it was still very difficult for them to initiate safer sex with their partners. Some women, with the help of counsellors and support groups, became more assertive and were able to negotiate safer sex and contraception, especially if their partners were also counselled. One of the more encouraging findings from this study was how support groups and counselling helped HIV-positive women take more control within their sexual relationships.

The research process itself, through local Community Workshops and individual conversations between team leaders and respondents, also showed the potential for peer education and discussion to open up and address difficult issues of sex and sexuality and women's rights and needs.* The week-long Review Workshop, during which team leaders analysed interview data and workshop reports with researchers, became a focus for sharing and questioning everyday behaviour both in terms of women's rights and of its implications for HIV. Such activities can lead to an increase in confidence and solidarity between HIV-positive women, enabling them to challenge discrimination and contribute to public education.**

Nevertheless, women's reproductive rights, including their susceptibility to HIV, are constrained by poverty and their economic dependence on their husbands/partners. This is discussed in the full report of the study, which suggests that such dependence not only makes their lives very hard after an HIV diagnosis, but also encourages women to accede to their partners' sexual demands, regardless of concerns for health or their childbearing preferences, in order to maintain the relationship. Poverty also increases the likelihood that women will engage in “transactional” sex in exchange for goods and services. Thus, improving women's economic opportunities and independence is also a crucial part of sexual empowerment. This suggests the need for partnerships between women's HIV advocates and other organisations already campaigning for better access for women to land, inheritance and property rights, to take note particularly of the impact of these issues on HIV-positive women.

Acknowledgements

This article presents findings from Feldman R, Manchester J, Maposphere C.Positive Women: Voices and Choices Zimbabwe Report, Harare: SafAIDS for ICW, 2002, and is published here with the agreement of ICW. The project was funded by Comic Relief, NORAD, UNAIDS and WHO. Thanks are due to all the HIV-positive women who participated in the study, and particularly to the team leaders Dominica Banire, Annatolia Chamuka, Etta Dendere, Nyaradzo Makambanga, Mavis Moyo, Mary Musesengwa, Joyce Mwedzi, Joyce Nyathi and Otilia Tasikani, who gave so much to the project. We are indebted to the members of both the Zimbabwe and international steering groups, and particularly the Women and AIDS Support Network, who helped establish the project in Zimbabwe. Special thanks to ICW members and supporters in Zimbabwe and elsewhere who helped to sustain the project, especially Lynde Francis and Joanne Manchester, and to Sunanda Ray and SAfAIDS, who published the report on behalf of ICW.

Notes

* The first author was international research consultant for the project and the second author was the national researcher in Zimbabwe.

** HIV support groups in Zimbabwe provide mutual emotional and practical support, information sharing and income-generating activities. Most are mixed sex, though women members predominate. Members are mainly people with low incomes.

* These are referred to in the text as “the survey” and “interviews” respectively. All direct quotes are from the interviews.

* At the time of the study, Zimbabwean law did not recognise marital rape. However, in 2001 the Zimbabwean government passed a new law, the Sexual Offences Act, that criminalises the deliberate transmission of HIV, recognises rape in marriage and imposes heavy penalties for a host of sexual offences.

* Traditionally, widows were “inherited” by their husband's brother to keep property and children within the patrilineage. This practice is now changing, though considerable pressure remains on women to be inherited to protect their rights to their homes and children.¹⁰¹¹

* Because of the complex conceptual difficulties involved in the notions of both ‘planned’ and ‘unwanted’ pregnancies, we categorised pregnancies as either ‘wanted’ or ‘unplanned’. Unplanned pregnancies are not necessarily unwanted.¹⁵¹⁶

* This is not a simple or unproblematic solution, however, see for example Epstein and Campbell.¹⁹²⁰

** The Voices and Choices team leaders have increased their public profile both locally and in national HIV organisations within Zimbabwe, and have been involved with peer education for HIV prevention.