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Mozambique National Human Development Report 2007Box 3.1 continuedtioned above, where silence about a situation which endangersthe life of somebody else and which, in the event of pregnancy,may also endanger the health of the unborn child, the questioncannot be limited to the patient-doctor relation, or to the rigidcontext of confidentiality. To us it seems a matter that meritswider treatment, at least at the level of the family, and of the circlesthat have emotional and amorous relations with the personconcerned.The HIV and AIDS situation is generalised in Africa, where themain route of transmission is unprotected sexual relations inwhich one partner is HIV-positive and the other is not. Its prevalenceis spread across all age groups, but particularly amongthose aged 15 to 49, regarded as the group of sexually activepeople.On the other hand, as mentioned in some studies from otherparts of the world, the violation of secrecy runs the risk of discrimination,and may lead to abandoning the health system –because it is not respecting the principle of confidence andsecrecy (Rueff, 2004). It is general knowledge in the literature onsexual and reproductive health that marginalized and ostracizedgroups of citizens rarely seek health services or medicaladvice (United Nations, 2005).those who know them. This fact has reduced theimpact of their testimony.Fear of stigma and discrimination are otherimportant factors that have a negative influence onMozambican attitudes, preventing them from seeingHIV and AIDS as a disease, like many other chronicdiseases, and which should be treated as such. Theseattitudes show a lack of preparation in society toaccept that HIV and AIDS are a national problem thataffects everybody.Biological determinants of the pandemicThe biological determinants or factors that influencethe transmission of HIV in Mozambique are partlysimilar to those already identified in other countries.On this theme there exists internally a large and variedamount of documentation, amongst which wemay mention the First HIV and AIDS Strategic Plan for2000-2002, and the Second HIV and AIDS StrategicPlan 2005-2009, drawn up by the National AIDSCouncil (CNCS).This work describes, with recognised scientificrigour, sex between different generations, casualunprotected sexual activity, multiple sexual partners orfrequent change of sexual partners, sexually transmittedinfections, the start of sexual activity at an earlyage, particularly for girls, as some of the factorsinvolved. However, there are other factors not frequentlydiscussed and relate to certain practices whichcause lesions on the skin of the genitals. The use ofplants and various other substances to contract thevagina during sex, or the rituals to “purify” widows followingthe death of their husbands are some of the factorsidentified that facilitate HIV transmission.Heterosexual relations remain the most commonform of transmitting HIV in the country. More than90% of HIV infections occur through sexual relationsbetween an infected individual and one who is notinfected. It does not necessarily have to be sexualactivity with many partners. However, having severalconcurrent sexual partners increases the likelihoodof infection and re-infection by HIV and other sexuallytransmitted diseases. This pattern is most commonamong sex workers who have a very high rate ofchanging partners.Sexually transmitted infections,stigma and gender inequalitySeveral studies have shown that Sexually TransmittedInfections (STI) are an important factor in HIV transmission.The STIs inflame the genitals, which facilitateHIV infection, particularly among women. Theanatomical configuration of the female genitalia providesan extensive surface for contact with infectiousagents, which makes women more vulnerable to STIsand to the risk of HIV infection. The complexity oftheir anatomical structure means that many sexuallytransmitted infections are not visible, and occur withoutsymptoms, which makes it difficult to diagnosethem.The early start to sexual activity facilitates thesexual transmission of HIV, particularly amongyounger women. The fact that their genital organs arestill developing makes them more vulnerable to thetransmission of disease.A further factor to bear in mind is that the surrounding,social, economic and political environment,in which people interact, also has a determinantrole in the pace of spread of the infection.Involved in this are factors such as poverty, discrimination,oppression, illiteracy, mobility or migrationof people, the status of women, levels of urbanisation,levels of violence, access to health care, and thedistribution of wealth, among others.Among the factors mentioned above, poverty,with an index in Mozambique of around 54% (INE,18
Roots of the Pandemic and its Determining Factors in Mozambique2004), deserves special mention since it contributesto vulnerability among individuals, households andcommunities, and it heavily influences the spread ofHIV. In turn, the impacts of the epidemic severelyaffect the environments less endowed with economicand social resources, worsening poverty, weakeningthe economic and food security systems and increasingthe number of poor people at risk of contractingthe infection.Indeed, the determinant variables of poverty,such as acute hunger, malnutrition, low level ofschooling, poor access to information, and particularlyto health services, among others, are associatedwith the conditions that increase social vulnerabilityto the epidemic.Women, particularly in the countryside, are still ata strong disadvantage in the economic, legal, culturaland social spheres, which increases their vulnerabilityto HIV infection, and to the epidemic’s impact. Thereare still a large number of girls of school age withoutaccess to education and women have few, if any, propertyrights or security of land tenure, or even inheritancerights, given the rule of the patriarchal structurethat influences customary law, used in many communitiesto settle disputes locally.Meanwhile, many of these women have beenexposed to the risk of sexual assault or rape or otherforms of violence. Coercive sex, for instance,expressed through non-consensual sexual activity,has been mentioned as a common practice restingon unequal power relations between men andwomen. This is an act that happens both domesticallyand outside the home, and the victims are children,youths and adult women. All forms of coercivesex can significantly increase the likelihood of HIVtransmission.The groups at high risk of HIV infection are generallythose who suffer from stigma and discrimination.Stigma increases vulnerability in several ways.Afraid of being discriminated against, individuals athigh risk of contracting the infection decline to seekinformation concerned with their sexual and reproductivehealth or other forms of disease prevention.Migration, urbanisation, commercial sex,and the prison populationA further factor contributing to the rapid spread ofHIV in Mozambique is the high level of mobility. Thecontinual degradation of living conditions in thecountryside, where young people and adults alikehave no work, and the decline in agricultural yields(due to constant climatic changes) have been factorsencouraging migration from the countryside to thecities, particularly after the end of the war in 1992.Concentrated in disorganised urban areas,where the traditional degraded neighbourhoods arespreading, these migrants increase, and rapidly, therisks of spread of the HIV virus, Generally, peopleemigrate from a rural area of low HIV prevalence tourban centres, where the prevalence rates are highand risky behaviour more frequent.Furthermore, urbanisation can favour inter-personalcontacts and encourage the search for unconventionalalternatives for survival. The option of manywomen for commercial sex has been common in theurban fabric. The fact that right from the start thesexual transaction occurs in a negotiating frameworkthat favours the man means that it is he who determinesthe nature and the conditions under which theact should occur. The women are potentially morevulnerable to infection.Additionally, the rate of change of partners, thecompeting partners, the sexual practices, and the useor not of condoms during the sex act are factors totake into account in determining the levels of vulnerabilityor exposure to infection under these conditions.As for the prisons, they are generally placeswhere infectious diseases such as HIV and AIDS,tuberculosis and hepatitis are spread. In general, theprison population comes from the poorest populationsegments of society, who are at a high risk of HIVinfection. The rates of infection among the prisonpopulation are generally higher than among the populationat large.Vulnerability and vulnerablegroups to the pandemicIn dealing with the content of this part, two conceptsdeserve attention, namely that of susceptibility and thatof vulnerability. Susceptibility to the pandemic is characterisedby a series of factors that determines the rateat which the disease spreads. It is thus easy to explainin the Mozambican case the reasons why areas contiguousto the great transit systems – the developmentcorridors – have relatively high prevalence rates. Theyare in fact converted into “inter-cultural” poles wherepeople from various parts of the country and fromneighbouring states cross paths. Commercial sex iscommon in these social interactions.19
Page 3 and 4: Preface“Mozambican men and women:
Page 5 and 6: Forewordby the UN Resident Coordina
Page 7: ContentsPrefaceForewordContentsList
Page 10 and 11: Mozambique National Human Developme
Page 18 and 19: 6Mozambique National Human Developm
Page 42 and 43: 30Mozambique National Human Develop
Page 48: Mozambique National Human Developme
Page 51 and 52: The General Threat posed by HIV and
Page 53 and 54: The General Threat posed by HIV and
Page 55 and 56: Chapter 7National Strategies agains
Page 57 and 58: National Strategies against the Spr
Page 69 and 70: Chapter 8Planning for the Future: T
Page 71 and 72: Planning for the Future: The Window
Page 79 and 80: Technical NotesTechnical Note 1Calc
Page 81 and 82:
Technical NotesConclusionsIn this w
Page 83 and 84:
Technical Notesmaximum and minimum
Page 85 and 86:
References and BibliographyADEPESE
Page 87:
Statistical Annex75
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