For Malawi’s Pregnant Women Living with HIV, Intimate Partner Violence Is an Ever-Present Threat

LILONGWE — Alinafe, who is seven months pregnant with her second child. I meet her at the maternity wing at a hospital in Malawi’s capital, Lilongwe, soon after she arrives. She’s traveled by bicycle some 12 miles away from her village (the only means of transportation available there, locally known as “kabaza”). She’s tired, but she goes straight to the end of a queue of pregnant women waiting to be seen.

She’s waiting for her HIV screening, as are all of these women in the waiting room at the maternity wing; it’s mandatory in Malawi for pregnant women who have prenatal care at the hospital to be screened and she was told about her status after going through the screening process.

At first, she doesn’t disclose to me if she’s HIV positive, and she warns that none of these women here will, either. “We feel it is a private affair,” she tells me. But she does muse that pregnant women living with HIV are afraid of telling their husbands about their status for fear of abuse, abandonment, or discrimination. Or, all three.

Later, however, she shares with me that she is, in fact, positive on the condition that I protect her privacy (Alinafe is not her real name). She discovered her status at her first screening; now, she’s returned to measure her viral load. “When people know about your status,” she says, “they label you as hule (loosely translated as ‘prostitute’). Even your husband will start abusing you and [blaming] you for transmitting the virus to him, even though he knows I am not responsible.” Her husband once threatened to kill her if she didn’t tell him who had “infected” her, she says. Now, “we sleep in separate rooms.”

In Malawi, among people aged 15 to 49, 10.8 percent of women and 6.4 percent of men are living with HIV, according to the most recently-available data from 2015 to 2016, totaling 8.8 percent of the country’s population.

More women than men appear to be living with HIV here, but the gender disparity can be skewed. According to Brany Mithi, district laboratory manager at Rumphi District Hospital in the northern region of the country, women are often first informed of their status during these screenings. “Men tend to hide their HIV status from their spouses,” he said.

One recent study has revealed a concerning trend: the risk of intimate partner violence (IPV) is consistently higher among women living with HIV in sub-Saharan Africa than among those living without it. And for pregnant women living with HIV, IPV prevalence ranges from 20 to 60 percent—a significantly higher range than the national rate of around 40 percent.

And these could still be conservative estimates. Mithi said that pregnant women aren’t likely to report, either — neither their HIV serostatus nor violence or abuse by their partner — for a host of reasons.

“First of all, understand that our culture makes a man the head of the family, and women submit to their husband,” said Mithi. “So when a woman informs them about [their] HIV status, most often it doesn’t go well.”

He indicated that IPV often follows.

“Many men accuse their wives of bringing HIV into their marriages,” said Lawrence Khonyongwa, executive director of the Malawi Network of People Living with HIV and AIDS (MANET+). “In some cases, the relatives of the man accuse the woman, [but] they will not talk about the man having extramarital affairs with other women. Culturally, this is the norm.”

A study published in August shows that distant relatives, friends and church members are the main sources of stigma around people living with HIV, mostly because Malawians associate HIV with promiscuity, making disclosing one’s status all the more difficult.

Khonyongwa also said that hospital policy does little to protect patients’ privacy.

“Hospital visits are set up in a way that, during certain days or certain areas, you will have people living with HIV and AIDS,” he explained. “And people know that on this day, and at this health facility, there are people with HIV and AIDS getting treatment.”

One health worker, who asked to remain anonymous, told WMC Women Under Siege that this was the Ministry of Health policy, which is designed to keep separate records of people living with HIV and AIDS and provide specialized treatment. He said that combining them with the rest of the patient population would not help the ministry record those on anti-retroviral therapy (ART).

However, he admitted that some changes could be afforded: “The Ministry of Health can still collect data without using these big health pass books they give to people living with HIV,” he said. “Anyone who sees them (compared to the A5-sized booklets) will know that they are HIV positive.”

Mithi rebutted that there are other clinics for people with diabetes and sexually-transmitted infections (STIs). “We are looking at the greater good,” he said. “HIV clients undergo periodic counseling and screening for other opportunistic infections as well as viral load. Such things are well managed at their own clinic and it minimizes patient mobility and reduces waiting time.”

He said that the only thing that the ministry could do differently would be to introduce a computerized system to track patients discreetly and manage other care facets like counseling, non-adherence to drugs, and viral load test results.

Privacy is a critical consideration in disclosure, but pregnant women are more likely to disclose their status to their partners anyway to prevent their child from being born with HIV and to garner support from their partner. Still, they fear the consequences, like divorce and physical abuse.

Pauline Kaude, a spokesperson for the Ministry of Gender, Community Development and Social Welfare, said that her ministry receives reports of such cases of violence against women perpetrated by their partners, but the problem is that many of these cases are not reported to the police for immediate action.

“Women are afraid of reporting such violent acts for fear of reprisals from their partners or family members,” she admitted. “We urge women to report such issues to their nearest victim support unit at the police station or to our offices so that we can help them.” Kaude explained that her ministry refers such cases to law enforcement agencies and, where necessary, will provide legal representation through institutions like Malawi Legal Aid Bureau.

However, she said that the ministry is aware of the economic and cultural pressures that inhibit IPV victims and often influence them to plead with courts and law enforcement to release their partners when jailed.

As part of its cultural awareness programming, Kaude said that the government is approaching local chiefs to communicate messaging to community members, explaining that their role as custodians of culture is key to dismantling some of the dominant beliefs that put women at risk, including adultery, which, she says, perpetuates IPV.

Still, the conundrum of preventing reprisal—from the partner or his family—is one that the ministry has yet to address effectively. Kaude and Khonyongwa admit that the issue must be addressed systemically, from better confidentiality protections at the hospital to better access to proper health care and medico-legal services, including psychological support for those living with HIV. Mithi believes that the woman’s financial independence would take the pressure off of a relationship when disclosing.

But the cultural stigma against persons living with HIV remains deeply embedded. And for pregnant women with HIV experiencing IPV concurrently, the high likelihood of not delivering at a health facility further endangers their health. Given the country’s already high maternal mortality rate, which stands at 439 per 100,000 live births, the stakes could not be higher in responding to this structural ill. For women like Alinafe — who doesn’t know what will happen next for her, her baby, or her marriage — they are left shepherding their newborns into a world of unknowns. Without comprehensive support, they will do so entirely alone. But, Alinafe said, the only optimism she has is for her husband to have a change of heart and to love her again the way he used to.