The findings from this study reveal that, in marginalised settlements typical of Chivanhu Settlement, high levels of livelihood insecurity, gender inequality and inequity, social inequality, power inequality, intergenerational sexual relationships, multiple concurrent
181 sexual networks, inefficient health delivery systems and weak and ineffective governance systems create a complex web and vicious cycle that increase HIV susceptibility for adults and children residing there. This relates to the upstream phase in the HIV and AIDS time-line.
To begin with, the findings reveal that the average land holdings for most of the households are too small for a household to engage in meaningful agricultural production. Although the households revealed a variety of livelihood strategies for generation of income and accessing food, for the majority of households the opportunities for sustainable sources of income and food are limited. Hence the bulk of households residing in Chivanhu often experience chronic food insecurity as they do not have the capacity to produce adequate food for meeting the annual food consumption needs. There are also income inequalities between men and women, especially elderly men who settled earlier and hence have large pieces of land and more assets. There are also high numbers of female-headed households and widows in Chivanhu Settlement. Female-headed households do not have assets to fall back on in times of need, and hence the evidence shows that in times of need they had a higher likelihood of relying on transactional sexual relationships. On the other hand, young men and other adult men, who relied on highly migratory livelihood strategies, also have an increased risk of getting HIV through engaging in risky sexual behaviour.
Furthermore, the evidence shows high rates of multiple concurrent sexual networks. Multiple concurrent sexual networks increase the chances of getting HIV infection. The sexual networks in Chivanhu Settlement are intricately linked to household members’ livelihood survival strategies. Both male and female behaviour in this context is critical for understanding HIV susceptibility. As well, the existing health services are biased towards providing sexual and reproductive services for the 15-49 age groups. The services for HIV and AIDS and other reproductive health services are provided in a silo approach. This results in other risk-prone age groups (like older males and females, and young girls) not receiving critical prevention information. This is also worsened by other cultural belief systems that stigmatises post-menopausal women who want to continue having sexual relationships.
Intergenerational sexual relationships are also common in Chivanhu and there are high rates of older people above 50 years of age who are HIV positive. At the same time, ineffective governance for land and other critical resources create barriers for accessing information and create opportunities for sexual abuse and dispossession of survivors. Reports of direct and indirect sexual coercion were high in the settlement, and some of them involved the traditional leaders.
182 8.3 Understanding midstream AIDS vulnerability in marginalised communities
The study sought to find out what factors determine AIDS vulnerability in the midstream phase: that is, during chronic illness and when someone is living with HIV. The findings from this study show that, during HIV infection, several factors interplay to contribute to AIDS vulnerability. The following factors were identified in this study: age, household food and nutrition insecurity, access to treatment, treatment adherence, the existence of other infections, time and capacity of households to provide care and support, and ineffective governance systems. Some of these factors are also found to be critical for increasing the risk of HIV infection. Rates of death and the number of people who were found bedridden on several occasions were high considering that most people are accessing ART from Morgenster Mission Hospital.
Most HIV and AIDS-affected households were among those that experienced chronic food insecurity. The challenge of accessing food was found to be the big challenge contributing to poor adherence to taking ART drugs. Most of the HIV-infected showed that they were fast progressors25. Although there are exceptional cases of people who had survived with the HIV virus for periods longer than 10 years, most of the HIV-infected progressed from HIV infection to opportunistic infections at fast rates (in most cases they developed symptoms within two years of being infected with the virus). Access to food is critical for delaying progression to AIDS opportunistic infections. The other challenge was accessing treatment.
Due to highly migratory livelihood strategies, the findings are revealing that there are a high number of people with these migratory livelihood strategies reporting missing collecting doses on time. Some would come back when they are in advanced chronic illness stages and die due to having developed drug resistance. The availability of second-line treatment for individuals who developed resistance or were experiencing negative side effects was also a challenge. Findings reveal that some were initiated on ART in South Africa and Botswana;
they would fail to replenish their ART at the hospital, and would be forced to buy from the market.
In addition, records of men lost in follow up were frequent. Most HIV infected adults are supposed to use condoms to reduce re-infection, and the majority of men did not want to use
25 This means progressing fast from HIV to the onset of AIDS-defining opportunity infections. On average before ART, the period ranged from 2-10+ years. Fast progressors move from HIV infection to the AIDS stage faster (on average between 2 -5 years faster).
183 condoms resulting in re-infections and frequent STIs. Treatment for opportunistic infections required payment, and most of the HIV infected in Chivanhu reported that they were foregoing treatment due to lack of money for payment. The other factors that increased AIDS vulnerability in the midstream are the challenges of capacity for providing care and support to the chronically ill. Some households’ members did not have the capacity to provide care and support. This was also worsened by the fact that there were no community home-based care facilities due to other constraining factors, unlike in other communities in Zimbabwe where there are secondary community providers of home-based care services to complement the household. The plight of the HIV-infected in child-headed households especially was pathetic.
Treatment for children with HIV was available but the ART initiation took more time. The laboratory services for minor children are centralised and they took time to be processed. The members were supposed to pay for transporting the specimens and this resulted in some HIV infected children who needed ART drugs failing to access the drugs. Multiple HIV-infected individuals in specific households (some of whom were chronically ill) would fail to get the needed care and support where the household had challenges proving support, in large part because the people who are supposed to provide support are also chronically ill themselves.
The situation was worsened by ineffective governance systems and political interference that affected the effectiveness of support systems like ZNPP+ support groups.