Advocating for Sexual and Reproductive Health and Rights Across Africa
In Malawi, 2 in 5 sexually active unmarried women have an unmet need for contraception. In Zimbabwe, fewer than half of adolescents have comprehensive knowledge about HIV/AIDS. And each year, one million Tanzanian women have an unintended pregnancy. Thandie Msukuma from Malawi, Dr. Lilian Benjamin Mwakyosi from Tanzania, and Hilda Zenda from Zimbabwe, advocates from the Center for Health and Gender Equity (CHANGE), sit down with us to talk about what we can do to expand access to comprehensive sexual and reproductive health care for young people in these African countries.
Whether in Tanzania, Zimbabwe, or Malawi, comprehensive sexual and reproductive health services, particularly when it comes to HIV prevention, are paramount. There are many barriers that can prevent comprehensive access to sexual and reproductive health and HIV services, including shame and stigma from healthcare providers, parents, and teachers, a lack of inclusive and accurate sex education free of judgement, as well as the exclusion of young people in SRHR planning.
U.S. policy impacts the sexual and reproductive health care that women and girls throughout Tanzania, Malawi, and Zimbabwe can receive. DREAMS is a PEPFAR partnership that works to reduce rates of HIV/AIDS in women and girls in Kenya, Lesotho, Malawi, Mozambique, South Africa, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe. But in Malawi, for example, DREAMS is only available in two out of twenty-eight districts. It is vital that DREAMS continue, as 1,000 women and young girls are newly infected with HIV every day. Unfortunately, Since the transition into the Trump-Pence administration, there have been dramatic cuts to global health at large, and this includes HIV/AIDS.
It is difficult for young women to practice their empowerment when boys and men are not integrated into the fight for comprehensive and reproductive health and rights in Tanzania, Malawi, and Zimbabwe. Incorporating religious and community leaders to empower girls may also influence boys and men to support the SRHR growth of girls and women.
Jennie: Welcome to rePROs Fight Back a podcast on all things repro. I'm your host Jenny Wetter. In each episode, I'll be taking you to the front lines of the escalating fight over our sexual and reproductive health and rights at home and abroad. Each episode, I will be speaking with leaders who are fighting to protect our reproductive health and rights to ensure that no one's reproductive health depends on where they live. It's time for repros to fight back.
Jennie: Welcome to rePROs Fight Back. Today's episode should be a fun one. Being in Washington DC I'm lucky that I get to take advantage of a lot of amazing organizations that bring in advocates from around the world to talk about sexual reproductive health and rights issues, either on the hill or for special events. Today, I am extra lucky because the Center for Health and Gender Equity or CHANGE brought in several advocates from Africa, and I am so lucky to get to talk to three of them today. First, we have Thandie Msukuma from Malawi. Hi, Thandie. Thank you for being here.
Thandie: Hi. Thank you for having me.
Jennie: Next we have Dr. Lilian Benjamin Mwakyosi from Tanzania Lilian: Very pleased to be here.
Jennie: And then last but absolutely not least we have Hilda Zenda from Zimbabwe.
Hilda: Hi everyone Hilda Zenda here.
Jennie: So since we are lucky to have three different people, so that's three new voices for our listeners to get used to. Why don't each of you take a minute and introduce yourselves, tell us a little bit about yourselves and your work. Um, and that way listeners can not only learn about you but they can learn who's talking when.
Lilian: Hailing from the beautiful land of the United Republic of Tanzania. My beautiful name is Lilian Benjamin Mwakyosi. I am a medical doctor, a very proud young woman and a community advocate. I am an AVAC fellow 2018 hosted by Tanzania Youth Alliance. I've been doing a lot of advocacy around combination HIV prevention for adolescent girls and young women, specifically focusing on access to preexposure prophylaxis and HIV self test for this age group, 15 to 24.
Thandie: Hello, my name is Thandie Msukumar. I'm from Malawi. I work with a TB organization that works in the communities. I'm actually a human scientist. Um, apart from that, I'm also, I'm an advocate. I advocate for younger adults and women, um, concerning the issues concerning, um, reproductive health, HIV and AIDS or those cascading issues really. So I think, um, my recent advocacy work was coming up with, um, community guideline on what we actually want in the Country Operation Plan 2019. The one that PEPFAR for comes up with.
Hilda: Hi everyone. I'm Hilda Zenda, and I'm from Zimbabwe. Uh, I work for an organization that's known as Pangaea, Zimbabwe AIDS Trusts, and one of our key programs is working with key populations of which adolescent girls and young women are part of, uh, just creating safe spaces, uh, that are youth friendly to our young women to be able to access HIV prevention, treatment and care services. This includes HIV testing, this includes the, the rollout of PREP as well as, uh, just providing life skills to young women and girls in the community.
Jennie: So one of the things that I think you all seem to be very much experts in is the importance of comprehensive sexual and reproductive health services, particularly when it comes to HIV prevention. So you want to talk a little bit about the importance of that and what's going on in your country.
Hilda: I think one of the importance of, um, comprehensive HIV prevention methods, I think that we've seen from the experiences that we've seen, um, in our country, in our countries is that, uh, young when it comes to HIV prevention is not the, isn't only one solution or one way in which you can do things. Uh, we've seen that it's works better when it's coming as a package, uh, because then the package will be able to address the different barriers that hinder access to sexual reproductive health, health services as well as HIV prevention methods. So the idea of comprehensive and a comprehensive approach, uh, allows for all those barriers to be addressed. And, uh, at the end of the day allows for our goal, which is accessing, um, helping a young woman to be able to access the primary service to be able to actually access it. Jennie: For sure. Lillian, you talked about that you worked around youth. Do you want to maybe talk about the importance of youth in that?
Lilian: So it's necessary to include youth for instance. Um, okay. The situation is, uh, is similar to Zimbabwe in Tanzania and, um, for me as a young person myself, I look at this package, I mean it's not just about the package but what's included in the package. And one thing I'll, I have noticed that is missing at the moment. We have interventions, yes. But then I'm still the, the, the rest of new HIV infections among young people is still very high. And that kind of communicates that maybe the current, um, interventions do not fully speak to our needs. So I look at these as the ability to have more options, expanding options and choices young people can look into for prevention.
Thandie: I actually, I agree with, um, Tanzania and Zimbabwe because, um, we really can't talk about comprehensive sexual reproductive health rights without cutting into the HIV prevention issues. Um, so currently in Malawi you have very limited, um, HIV every prevention methods. Um, we have the condoms, which I think, you know, some people might actually be allergic to latex. And we have, um, the PMTCT, which is prevention mother to child transmission, which I feel like it's a little too late for that because you have, um, a mother who's already pregnant and then, um, she already has HIV and then you're just trying to prevent the child. But we didn't really, we have to to an extent for the mother, you know, and then we have things like voluntary male circumcision. And, um, currently we have PREP, a PREP policy, but we still haven't had that rollout and do have a lot of young girls in, um, adolescent girls and young women in the communities that actually ready to start using PREP. And they really want to, to have it up and running. But then for some reason, you know, it's dragging and then it's Kinda like minimizing the momentum or something like that.
Lilian: And maybe to add on, I think it really matters how young people are engaged in involved throughout the processes towards having all these services. Perhaps the reason to why the uptake of services by young people is not as good or I mean, yeah, it's not as good because maybe we were not involved in the planning processes and we have products that are introduced, HIV prevention products. Was there any concerns of young people prior to producing such products? We want to be consulted from the very beginning, not bringing up the product, And then that's when you start asking do you feel like you're going to use these, oh, are you going to, is this product going to help you also?
Thandie: But also the messaging around these products. For example, you have, um, family... contraceptives, contraceptives, yes. Which are viewed as a family planning method, right? And then, um, you have, you have the youth that think, okay fine, contraceptives are for people in marriages and you know, married women with let's say five kids. But you could be 19 and you could still be using contraceptives because you know, that's good sexual health. So it's, all these, all these issues that just, you know. Jennie: Yeah. And I think it's one of those things, particularly with the family planning, like we hear are use to saying that and you're right, like young people, that is not what they're thinking about. They're thinking about not getting pregnant. They're not necessarily thinking about planning their family. So making sure that we're using a language that's accessible to young people in the language that they would use themselves to make sure that the services are friendly, but that you're bringing them in to access the services to begin with.
Lilian: I totally agree with you.
Hilda: I think, um, well another thing that's very important is having our young women actually leading these programs because in many, many of the cases we do not have young women who are leading these programs. And I mean if it's for young women, then it should be led by young women.
Lilian: Nothing for us without us.
Jennie: Exactly. Well, I think another thing you often hear, and I'm sure you have seen this in your countries as well, is there's the talk of wanting to make sure that there's more access to services for young people, but they're not...when they go to see the provider, maybe the provider is not, it may be shamed them or they don't feel welcome to go see them to talk about their full needs and so the problem of, you know, once you bring them in they need to be also being in an environment that is friendly to youth.
Lilian: I agree and I think it all comes for from the roots that we were raised from. We come from very sort of conservative societies and we are progressing some . But you can't just change everybody all at once. It takes time. I'm thinking so remember if you go to school, the person who is teaching you, giving you the knowledge is an adult, but at the same time they are parents who can talk for instance to their kids back home about certain things, sexual issues. I would say the same applies to health care providers. If my mom, for instance, can talk to me openly about certain things, I like to believe they will wear the same sort of, you know, bias when they are attending to a younger person in the clinic as well. Yeah.
Hilda: And I think we're seeing more and more of that amongst young women. We, I mean, I think even just among us to think if you think of your first, uh, sexual encounter, uh, it's not that you were, it was something that you had been told about or you knew exactly what to expect, but you, it's information that you hear from outside of, you know, um, the, the walls of what you would call home. Um, and I think that's one of the key barriers that we're having, I think within our societies is that we do not have, I mean within the, within our homes, where our young women are growing up. They don't have that safe space and they're not learning these things from home. They learn everything else from home, going to school, focusing on school, doing well. But the one key thing that the know that's not being instilled in them is uh, about how real life is like out there and with regards particularly to um, to you know their sexuality. So yeah, I think that's also one of the barriers that we're having within our societies that are young women. We get to learn about all these things outside of our homes and yet everything else we're learning from home.
Jennie: What about access to comprehensive sex education in your countries? [laughter] I mean I can start. I mean I grew up in rural Wisconsin and I went to a Catholic school, so my version of sex education was the, if you've seen the movie Mean Girls, like you're going to have sex and you're going to die. Like yeah, it was not by any means comprehensive and helpful later in life.
Thandie: Um I think it's the same because we have what we call life skills...
Jennie: Ah yes I had "Valuing your Sexuality"
Thandie: So you know, the all these, um, little this, this, this and that, but never really the big things. You know, they never really dig deep into the, you know, the sexuality component. So you have, um, older men and older women teaching you about, okay, so this is what happens when people have sex, kids just don't pop up. Um, people have sex, but usually married people have sex and you can't really have, um, sex outside marriage because it's a taboo. So you know, you're all gonna burn and die. [laughter]
Jennie: That sounds familiar.
Thandie: Exactly. So it's, it doesn't really, um, give you opportunities to ask more questions or talk about what you're going through, cause it's more like I might die or they might tell my mom, cause you know, it's a very, these are very small communities and everybody knows everybody and people are talking. So you don't assume like that kid like oh so you're that terrible kid, Huh? So yeah, usually not comprehensive.
Lilian: The situation is similar in Tanzania, we do have an element of comprehensive sexual education in schools, certain levels of school actually. And like Thandie mentioned that you, you're given the knowledge in brackets, like you are not told everything and you can't really ask everything because of the age gap that is there. But then as a, um, at the same time, you can't really ask certain questions because of the shaming around sexual education from your colleagues in class as well. And remember this same teacher is a parent back home again. So if my parents back home cannot give me certain information because they are expecting my teacher to do that, it is the role of my teacher, then he, he's a parent. Oh, she is a parent as well. So there's that way of wearing that character and just go all parents aren't asked everywhere. Yeah.
Hilda: Yeah. I think it's very similar in Zimbabwe too. We do have a program that's being run in a tertiary institutions, but I think yeah, that you mean, like Lillian said from Tanzania, one of the challenges we have is the people who are presenting this information and knowledge to our young women. Um, the, uh, not necessarily youth friendly, um, people, and they're much older. So if a young person is actually listening to this much older person its more like you're listening to your mom and dad and already if it's so difficult, um, having your mom and dad, you know, communicate about such issues, the chances of you then listening and it's your lecturer who's um, giving you this information, very information is very slim, you know, which creates the, the barrier. And I think it also doesn't open up for our young women to be able to engage and questions they may specifically have, uh, regarding their sexual health.
Lilian: And considering we're in this digital era, do parents really want us to learn everything from the Internet? This is a good question to everyone.
Jennie: I mean you guys are going to get them...young people are going to get the information somewhere.
Lilian: Yes. Wrong information sometimes.
Hilda: Most of the time.
Jennie: Um, so you talked about the importance of having youth involved in services. Do you see some of the peer-to-peer education happening in an organized manner around sex education and services as well?
Lilian: There is. It's, it's been a thing of late using peers... Peers to reach out to peers. But then I don't think is something that is national wide yet. And yeah, I think we're getting there.
Thandie: Um, I think it's similar with Tanzania. In Malawi we have, we have some programs, we have some programs that um, peer to peer mentorship or you know, we have what they call the girl guides. So the girl and, and you know, convey messages on sex or protective health, HIV or those things. But then we don't really have much of it, you know, it's there, but like at a very minimal skills.
Hilda: Yeah, similar in Zimbabwe, we have what we call Katz. Uh, and basically, yes, it's also young women who engage with other young women, uh, on these particular issues. But I think what's also interesting, just touching on a, what my fellow country woman Lilian has mentioned from Tanzania is just the aspect of, um, trying to see how we can not completely do away with our culture as a country. Because when you look back, when I look at look back like in our culture and Zimbabwe in the, the, the specific people who used to tell us about this information would be our aunts. And I think in terms of, uh, in terms of programming, I think we shouldn't necessarily do away completely with that channel of messaging, but maybe try to see how we can start incorporating the cultural aspect. And training, maybe coming up with a program where we're actually calling upon, uh, we call them when I teach here and getting them, I'm actually training them on how to communicate this information and what's really changed because I mean to them, to them, I'm sure the information they got about, you know, about, uh, about sex is different from what it is like today. So I think maybe coming up with programs that can incorporate the cultural aspects of our country because like I guess if we do that, then it allows for a lot of people to be a bit more accepting of the idea of, you know, what sex means, you know, in our days. And as well as the idea of just having someone talk to our, our young women and girls about sex.
Thandie: Um, actually my friend here just reminded me of what we have in Malawi. It's what we call the mother groups. So these, uh, women that, um, talk to young mothers. You know, cause I think before we had the law of bring in girls back to school, you actually used to get expelled and you know, you'd be shunned from school and you'd get pregnant. But I'm after though, bring girls back to school campaign and everything. Literally have mother groups who go to young mothers, you know, they mentor them, talk to them. And that's just in other instances that you look after the babies whilst this women go back to school. So I think it's, we could, we could have that same approach but with um, sex education where we have older women talking to girls about what to... Comprehensive sexual education.
Lilian: I'm actually learning something from my colleagues right now. So currently in Tanzania, one's a secondary school girl gets pregnant, the ex, they are expelled from school and they cannot join public schools ever again. So I don't know, maybe maybe that model and the movement of bringing girls back to school would really work in my setting as well.
Jennie: So I know one of the things you were in DC for was to talk about how US policy is a affecting, um, the lives of women in your country. Do you want to talk a little bit about that right now?
Thandie: As a Malawian, I like to say the Malawians are actually very grateful with the funding we received from the American people. We have, um, the, the PEPFAR funding. And then within the PEPFAR funding, we have what we call the DREAMS program, which is determined resilient, empowered, aids, free, mentored and safe, you know, yeah. Dreams program where it's, um, it's like a comprehensive package that is given to young girls, young adolescent girls and young women. Yes. So, um, it's about economic empowerment, um, sexual reproductive health services. It has all these, um, they understand that to empower a girl, they a lot of cross cutting issues that, that surround her. So for you to be able to empower her and um, give her the rights materials and everything you have to like get into a little distant that some education, some maybe some business, you know, so, um, health information and all that. But currently we only have that in like two districts and I think the adding a third one, oh Malawi has like 28 districts. Those are like, so even half of what we actually have and I think could really be helpful and I think a lot of women would really like to utilize this, um, this program because it's really working...
Jennie: Oh, that's good.
Thandie: Yes. For these, for these districts it's really helping. You have a lot of um, women retained on ART, um, and you have all these ideas, you know, good things coming out of it. And I think the other adolescent girls and young women across Malawi would really utilize this service.
Lilian: Then the situation is similar in Tanzania but a little bit of a different context. So most of our HIV prevention care and treatment programs are run by the support of PEPFAR and the country has been making really incredible strides to end the epidemic. We see the progress and we appreciate it. And the most recent excitement for me was introduction of PREP in Tanzania preexposure prophylaxis. This is a pill that um, once taken daily can prevent a person from contracting HIV. It reduces the risk of getting HIV infection. And currently we are not there yet, but we do have these demonstrations study more of like an implementation science that is targeting key and vulnerable populations. And I'm very glad to say young women are reached out, um, adolescent girls and young women are inclusived in the KVP group. Okay. We are getting there but then there are still some challenges, um, around the use of these oral pills. Adherence remains an issue and we still have like high rates of dropout from like the rollout of using PREP. This speaks loud to me in it sends a message to me that perhaps we need more options. And this time around if the pill is not, um, as it doesn't cover the demands of young people, maybe we should look into investing more in the injectables or um, microbicides, things that people can use without maybe swallowing them but then use them topically. I mean, and they should be more of user controlled. So we need variety of options to cut out for the needs of young women and young people and the whole population generally, uh, for HIV infection and epidemic.
Jennie: Options are always better. So you can find what works best for you and the one you can adhere to.
Lilian: And you cannot always try different options to know what works best for you. One size clearly doesn't fit all.
Jennie: So do you guys have a message that you would like to send to the US government on behalf of the youth of your country?
Hilda: Uh, absolutely. Uh, I think first and foremost would just like to thank the US government for their continuous efforts towards trying to end this epidemic in our countries. Would also just like to give thanks to CHANGE for giving us this opportunity as well as yourself. Uh, rePROs thank you for that. Uh, but I think my message would be that, uh, we just want to let everybody know that, uh, we really do appreciate the funds that we're getting and we are utilizing them as best we can. Uh, specifically looking at HIV prevention programs for adolescent girls and young women looking at the DREAMs program. Um, we have seen that it's works and it's working very well for us. Our only cry is that it continues and um, we're able to then come get to a point where our countries are, uh, reaching a sustainable point with the actually able to run these programs on their own with or without a US funding.
Lilian: Okay. Well, for me as a young woman, and I believe everyone out there is somehow some way affected by the epidemic HIV. So I'm coming from a setting where a young women remain highly vulnerable to new HIV infections. And the, the, the rate is actually very high as compared to most other populations and age group, 15 to 24 the most highly affected. This could happen to anyone. It could be me, it could be someone else out there, they could be a sister or anybody else. And this is why I am deeply, really concerned, um, with the issue of expanding options. So my call to the US government is to look into expanding HIV prevention options and all sorts of options, both, both systemic and non systemic, and user controlled and that way. Um, look into options in the, in the, in the aspect of expanding research information and access to information for, uh, for young women, expanding interventions themselves. And last but most important importantly, the uptake of these services by young women. So they should be easy and accessible way to get to these services to end the epidemic.
Jennie: So we've talked a lot about girls and women, which obviously we are super important, but I think one thing we haven't really talked about is uh, boys and young men. Do you guys have projects or um, just want to talk a little bit about the importance of making sure that we're integrating boys and men into these programs as well.
Hilda: I think, um, we currently have a limited, a limited number of programs that are specifically for boys and men in all countries. And I think one of our cries right now is as much as DREAMs is working, would love to see the incorporation of programs similar to what DREAMSs is like, but specifically focused on young boys and men. Um, what we understand is that if we're empowering this young woman and she still has to go out into, into society and the same person that she's going to be dating is a young man or, or boy, and if this young man or boys is empowered, it makes it very difficult for this young woman to be able to practice empowerment or to be able to have control of her empowerment. And I think if we're really looking at a, if we're really going to be investing in lives and investing in, um, in these programs for daughters and girls and young women and empowering them, we need to be looking at a sustainable way of doing that. And the only sustainable way can do that is by ensuring that the environment around them is also growing with them. And that will need for young boys and men to be included in these programs and also be empowered.
Thandie: And I think on the, on the same note, it also be important to incorporate a religious leaders and our community leaders, you know, because this is a, what we consider our gatekeepers. You know, when the girls are empowered, wherever they are, they have to be helped. You have to go back to their communities and then they find the leaders there, the religious leaders there. So empowered, you go to church, but there's, there's all of this, you know, and then you start to kind of feel like your people are letting you down in a sense. So I think if we reached out to the leaders and the, yeah, the community leaders, the religious leaders and just in part the most, so for them to be able to actually prepare their congregations on, you know, this upcoming empowered girls that we're modeling I think would really be important for, um, sustainability of these many projects that we're actually embarking on.
Lilian: And I highly second everything my colleagues have stayed. One important factor that I would add in would be, um, I look at these current generation as the game changer. We are the ones that are going to change so many things and when we're thinking of how to involve boys and men into these movements to end the epidemic, it's really necessary to think about the next generation of young boys and girls.
Jennie: Well, great. Um, I think this is a great conversation. It was great to learn more about the work that's being done in your countries and um, the work that still needs to be done. So big thank you Thandie and Hilda and Lillian [laughter]. Great. Thanks for being here.
Jennie: For more information, including show notes from this episode and previous episodes, please visit our website reprosfightback.com. You can also find us on Facebook and Twitter at rePROs Fight Back.. If you like our show, please help others find it by sharing it with your friends and subscribing, rating and reviewing us on iTunes. Thanks for listening.