safaids regional office: country office - zimbabwe: on

SAfAIDS Regional Office: 479 Sappers Contour, Lynnwood, Pretoria 0081, South Africa. Tel: +27-12-361-0889 Fax: +27-12-361-0899 E-mail: [email protected]

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Country Office - Mozambique: Av. Paulo Samuel Kankomba n.2051, R/C Maputo, Mozambique, Telefax +258-213-02623, Email: [email protected]

www.safaids.net

Turning the Tide on Gender Based Violence

Best Practices of Organisations Applying the ‘Changing the River’s Flow’ Model in Southern Africa

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Acknowledgements

Southern Africa HIV and AIDS Information Dissemination Service (SAfAIDS) would like to express its sincere gratitude to the directors, programme staff, stakeholders and

beneficiaries of the nine organisations documented in this book for their support and input during the documentation process.

We are grateful for the input of the Regional Selection Committee members who were instrumental in selecting the Best sPractices documented in this book, as well as the Peer Reviewers whose insights were key to the improvement and finalisation of the reports.

This report has been summarised from longer country reports Mozambique, Namibia, South Africa, Swaziland and Zimbabwe which were authored by a number of contributors. Tendayi Kureya and Sisa Sibanda of Development Data, with support from Sibongile Ndlela, compiled the Swaziland report. Victoria James and Ishmael Mafundikwa of New Dimension Consulting wrote the Namibia report with assistance from Rejoice Chakare of SAfAIDS; and Victoria James and Nathan Mhungu (also of New Dimension Consulting) wrote the Mozambique report. Luciano Macumbe of SAfAIDS formed part of the data collection team in Mozambique. Petronella Mugoni wrote the South Africa report, with support in data collection provided by Maserame Mojapele. Tendayi Kureya (Development Data) with assistance from Juliet Mkaronda of SAfAIDS, authored the Zimbabwe report. The authors also provided the pictures for their respective chapters.

This book was summarised for SAfAIDS by Carrie Brooke-Sumner with guidance and contributions from Rouzeh Eghtessadi, Sara Page and Lois Chingandu, and edited by Petronella Mugoni, all of SAfAIDS. Design and layout was done by Anthony Dalton.

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Executive Summary

Three decades into addressing the HIV epidemic the southern Africa region continues to bear the brunt of the HIV burden, and to experience more HIV-related deaths than any

other region in the world. Although governments, non-governmental organisations and AIDS service organisations continue to intensify their response to the epidemic; southern Africa in particular continues to be ravaged by HIV. HIV and AIDS continue to cause immense human suffering on the continent; UNAIDS 2010 estimates indicate that 34% of all people living with HIV in the world are in the fifteen countries of the Southern Africa Development Community (SADC).

The most obvious effect of the HIV crisis has been illness and death, but the negative impact of the epidemic is certainly not confined to the health sector. Households, schools, workplaces and economies have also been badly affected. HIV mainly affects the economically active population (15 to 49 years) meaning that the negative impacts on national economies, and as a consequence on regional development, cannot be underestimated.

Clearly there is a missing piece to the puzzle that creates a situation where although there are 38 other countries on the African continent, the epidemic remains mostly concentrated in the southern region. This is in spite of multiple programmes and interventions which have been implemented at community and national level since the early 1990s. Could that missing piece be the various cultural practices and beliefs which are practised in communities in southern Africa? Could some of these harmful practices which encourage sexual contact with low condom use and low HIV testing; which take away women’s right to make decisions on sexual matters and which predispose women and girls to experiencing violence be contributing to high rates of new HIV infections, even as countries scale-up prevention and mitigation programmes?

This book draws its content from the work done by SAfAIDS between 2009 and 2011 in supporting partners to implement the ‘Changing the River’s Flow’ programme in five countries (Mozambique, Namibia, South Africa, Swaziland and Zimbabwe) in southern Africa. The programme is implemented according to a model designed by Lois Chingandu, Executive

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ary Director of SAfAIDS in 2006. The model was piloted in the peri-urban Zimbabwean community

of Seke in the same year. It has since been scaled-up and replicated in 36 communities in nine southern African countries. Addessing HIV and gender related challenges through a cultural lens, is core to the model.

The ‘Changing the River’s Flow’ model is based on the understanding that the answer to effective and sustainable HIV and gender based violence (GBV) prevention in Africa lies in building the capacity of community members to address cultural practices that fuel the two epidemics. Implementation is further supported by the understanding that harmful cultural beliefs and practices uphold gender inequalities and lead to higher incidences of GBV, which fuel the spread of HIV. The model, which is easily adaptable, thus helps communities to act on some context-specific cultural practices, and overarching traditional beliefs that increase individuals’ risks of experiencing violence, and becoming infected with HIV.

The name ‘Changing the River’s Flow’ mirrors the idea that culture is not fixed, like a rock or stone but that, it is a ‘river’, constantly moving and changing, even if we do not notice changes as they happen. Culture is something beautiful, rich and vital for our lives, just as a river is an essential part of the lives of those who live on its banks. Therefore, in working to change the aspects of culture that are harmful, the model acknowledges the need for communities to respect, hold close, and strengthen the aspects that protect families and individuals, and which enrich lives (Price, 2006).

Like a surging river, culture is a powerful force whose course is seemingly unchangeable; but the ‘Changing the River’s Flow’ model is based solidly on the knowledge that culture can change, and that it is changing, and that there are organisations which are working to ensure that changes occur.

This book presents information on nine organisations working in five countries in the region. It highlights the work of these organisations in the hope that the information on processes, strategies and counter-strategies provided will encourage and support other organisations as they implement similar initiatives in other communities, with the ultimate aim of turning the tide of the HIV epidemic, achieving reductions in incidences of gender based violence, and consequently reductions in new HIV infections.

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ary It must be noted that although the ‘Changing the River’s Flow’ model has not yet been put

through a rigorous scientific study in order to evaluate its effectiveness in preventing new HIV infections, there is anecdotal evidence from communities indicating that it is contributing to changes in attitudes and perceptions, changes in the ways in which certain traditions are practiced, and increasing community members’ understanding of the ways in which gender based violence, women’s rights, HIV and culture inter-link.

This book is based on information collected in the field. Following a call for expressions of interest in being documented, nine programmes were selected for documentation based on their fulfilment of Best Practice criteria. An initial literature review of programme documentation was carried out before visits to each country for data collection. Data collection was done through key informant interviews, focus group discussions and observation. Information obtained was then reviewed and incorporated into a Best Practice report for each programme. The reports were subjected to peer review and validation before being used as the basis for this book.

This book is aimed at programmers working around women’s rights and HIV issues, representatives of community based organisations, government officials and leaders, including traditional leaders, and researchers. It is an important read for anyone interested in understanding the inter-linkages between gender based violence, HIV, women’s rights and culture in southern African communities and in contributing to efforts to achieve reductions in new HIV infections.

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ContentAcknowledgements_______________________________________________________________1

Executive Summary__________________________________________________________________2

List of Acronyms_____________________________________________________________________6

HIV, Gender Based Violence and Culture In Southern Africa_______________________________7

Links Between GBV and HIV_________________________________________________________10

The ‘Changing the Rivers Flow’ Model_________________________________________________15

How Does This Model Fulfil Best Practice Criteria?_______________________________________16

Implementing the CTRF Model_______________________________________________________18

Promoting Cultural Change__________________________________________________________22

Mozambique ______________________________________________________________________23

The Cultural Environment in Mozambique______________________________________________24

MULEIDI Addressing Pitakufa In Manhica________________________________________________25

OMES Addressing Pitakufa in Mungari__________________________________________________29

Namibia________________________________________________________________________35

The Cultural Environment in Namibia__________________________________________________36

ACT Addressing GBV To Improve ART Adherence__________________________________________36

NWHN Addressing GBV and Sexual and Reproductive Rights________________________________42

South Africa_______________________________________________________________________47

The Cultural Environment in Khayelitsha________________________________________________48

GAPA Challenging the Sexual Cleansing of Ifutha_________________________________________49

Swaziland______________________________________________________________________55

The Cultural Environment in Swaziland_________________________________________________56

SWANNEPHA Working with Traditional Leaders to Address Sithembu and Kungena____________56

NATICC, Working with Men and Youth To Address Ukwendzisa and Kungena_______________61

Zimbabwe_______________________________________________________________________67

The Cultural Environment in Zimbabwe_________________________________________________68

Padare/Enkundleni - Men Working with Men to Address GBV_________________________________68

WAG Working Through Traditional Courts to Address GBV__________________________________73

The CTRF Model - Working Approaches for Success_______________________________________76

Conclusion______________________________________________________________________83

Recommendations for Scale-Up and Replication________________________________________85

References________________________________________________________________________88

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List of AcronymsACT AIDS Care TrustAIDS Acquired Immune Deficiency SyndromeARV Antiretroviral TreatmentCBV Community-Based VolunteerCTRF ‘Changing the River’s Flow’FGD Focus Group DiscussionGAPA Grandmothers Against Poverty and AIDS GBV Gender-Based ViolenceGFTM Global Fund To Fight HIV, Tuberculosis And MalariaHEC Health Ethics CommitteeHIV Human Immunodeficiency VirusIEC Information, Education and CommunicationMCP Multiple Concurrent PartnershipsMOH Ministry of HealthMOHSS Ministry Of Health and Social ServicesMULEIDE Association Women Law and DevelopmentNATICC Nhlangano AIDS Training Information and Counselling CentreNGO Non-Governmental OrganisationNWHN Namibia Women’s Health NetworkOMES Organisation for the Women Educator on AIDSOVC Orphans and Vulnerable Children PEP Post-Exposure ProphylaxisPLHIV People Living With HIVPMTCT Prevention of Mother-to-Child TransmissionSADC Southern African Development CommunitySAfAIDS Southern Africa HIV and AIDS Information Dissemination ServiceSTI Sexually-Transmitted InfectionSWANNEPHA Swaziland National Network of People Living with HIV and AIDSUNAIDS Joint United Nations Programme on HIV and AIDSUNDP United Nations Development ProgrammeVCT Voluntary Counselling and TestingWAG Women’s Action GroupWHO World Health OrganizationYAC Youth Against Crime

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HIV, Gender Based Violence and Culture In Southern Africa

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Background

Nearly 30 years after the world first started talking about the HIV epidemic, where are we in southern Africa? The region remains the epicentre of the HIV epidemic and although

new infections are decreasing in some areas, the region as a whole is still at crisis point. Figure 1 highlights just how much of the burden of this disease is borne by the sub-Saharan African region. Southern Africa has only 2% of the world’s population but has a staggering 34% of new HIV infections, and the majority of these new infections are in women.

Figure 1 - Latest UNAIDS data on new infections globally show the great burden of disease in sub-Saharan Africa

As of 2009, over 11.3 million people were living with HIV in sub-Saharan Africa (nearly a third more than in 1999) and despite work on prevention of parent-to-child transmission (PMTCT) of HIV, the latest UNAIDS data show that 232,200 infants were infected with HIV in the region in 20091. Concerted efforts have been ongoing to prevent new infections, and an ever-growing number of people can access treatment, but for every two people starting treatment, another three are newly infected2. We need to turn things around to change the way this epidemic is devastating the region.

1 UNAIDS Report on The Global AIDS Epidemic, UNAIDS 20102 UNAIDS Regional Support Team for Eastern And Southern Africa http://www.unaidsrstesa.org/regional-country-profiles-home/regional-profiles

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Caught in the Current: Women and HIV Why the concern about women and HIV? Women are more vulnerable to the disease due to a combination of physiological, social, cultural and economic factors. It is much easier for women to contract HIV during sex as they are exposed to more fluids (semen) and because the motions during sex can lead to small cuts on the inside of the vagina that the virus can pass through easily. These cuts happen even more when sex is violent or forced.

Besides these physiological factors, poverty and lack of education may force women to use sex (often unprotected) as a way of supporting themselves and their families. But we need to look deeper than this, at the issue of gender-based violence (GBV). Gender-based violence happens across the world and affects us all in some way. While men too can suffer violence at the hands of their partners, it is mainly women who bear the brunt of gender-related violence, where they can be forced or intimidated into having sex against their will. In this book, we focus on the extent to which the violence experienced by women links with HIV.

GBV is a problem worldwide (Figure 2) but if we look at two countries that have national level data (Namibia and Zimbabwe), 20-30% of women who have been married report having experienced violence from their partner. Other countries may not have data on GBV at national level, but does this mean that it is not happening? Certainly not. Often women are afraid of reporting violence to their families or the police because they are all too aware that the justice system has failed many women before them. They feel there is no benefit for them in reporting violence – and in many cases they are right. But we can change this. Women and men in southern Africa are standing up and saying that things have to change, we cannot continue to be swept along by this river of violence. If we want to see progress on the important goals we have set for ourselves (like Millennium Development Goals 3, 4, 5 and 63) then we need to make sure GBV is high on our list of priorities.

3 Millennium Development Goals 3 (promote gender equality and empower women), 4 (reduce child mortality rate), 5 (improve maternal health) and 6 (combat HIV, malaria, and other diseases).

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“Gender-based violence is violence involving men and women, in which the female is usually the victim. It’s caused by unequal power relationships between men and women and includes physical, sexual and psychological harm.” - (UNFPA Gender Theme Group, 1998)


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Figure 2 - Reported gender based violence worldwide

Links Between GBV and HIVAlthough GBV exists in all communities, few people openly talk about it and most see it as something to be dealt with ‘behind closed doors’. This is especially true when violence happens in our homes, and this also means we are in a ‘cycle of violence’ where those who see or experience violence are more likely to commit acts of violence themselves. Women victims of gender based violence

(GBV) (rape and sexual assault) have a high risk of HIV infection because of the small cuts that are caused by forced sex and the lack of lubrication, and also because it is very unlikely that condoms are used. The psychological trauma can also make survivors of violence more likely to have ‘risky’ behaviours, like having multiple partners and not using condoms in the future. That is not the end of the story. It is not only violence but the threat of violence that can stop women from doing things that are crucial for protecting their health, like asking their partners to use a condom, going for voluntary counselling and testing (VCT) and starting on

antiretroviral therapy (ART). In addition, men who perpetrate violence are also at high risk of infection, especially if they are repeat offenders.4,5

4 UNAIDS Technical Meeting on Young Women in HIV Hyper-endemic Countries of Southern Africa5 Gender-based violence, young women and girls, and HIV in southern Africa, Policy and Programme Action Brief Neil Andersson and Anne Cockcroft

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If we consider all the GBV perpetrators and victims, it is estimated that about one third of people in southern African are currently in a cycle of GBV and HIV.5


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Cultures reflect our values, behaviours and ways of thinking. These are constantly changing in positive and negative ways, but cultures are a positive and enriching part of our lives – they tell us who we are and how we belong in the world around us. It is sometimes difficult to pin down exactly what we mean by culture when we are talking about how it can have an impact on HIV – but it is not only ‘African traditional culture’ that we are talking about here, there are also Christian and other religious systems that form part of many cultural identities.

As much as culture is a positive force in our lives, there are also aspects of our cultures that lead to a ‘patriarchal’ or male-dominated society where men hold the political and economic power and make most of the decisions, and often all of the decisions related to sex. Women are seen as being inferior and dependent, and often cannot own property, work for their own money, make decisions relating to their children, and express their sexuality, among a host of other things.6

It is condoned (or even expected) for men to have many different sexual partners, and women cannot confront them about this, or leave them if they feel their health is being put at risk. The power men hold makes it possible (and often accepted) for them to coerce or force women to have sex, and when this happens, women may not feel they can report the violence, or even talk about it with their families and people in their communities. Looking even deeper into ‘culture’, people can also use ‘culture’ as a reason not to change – for example to justify having sex with many different partners, or not using condoms. We need to look past these arguments and say; does our culture really support us doing something that can be harmful? And if not, what needs to change?

6 SAfAIDS, Inter-linkages between Culture, Gender Based Violence , HIV and AIDS and Women’s Rights, 2008

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Experiencing GBV is an intense violation of a woman’s rights - especially The Right to Freedom and Safety and The Right to Decide Whether and When to Have Children.7 Although GBV is often perpetrated by individuals, it is not just something done by men and boys who are ‘bad’ or ‘angry’. GBV is subtly and sometimes openly condoned in cultures where the unequal power relations between men and women continue. This is not unique to southern Africa, but it is without a doubt one of the critical factors driving HIV in our communities.

Southern Africa is home to a host of diverse cultures that contribute to the rich heritage of the region. People often describe their culture as incorporating their language, the area where they live, and particular social structures and practices that have special meaning to them. In African traditional groups these practices especially relate to a person’s stages of life, from birth to adulthood and marriage, to being a parent and grandparent, and finally death. In this context, we cannot understand people’s behaviour just by looking at their own personal reasons for engaging in that behaviour - culture plays an integral part in shaping behaviours.

Although every culture is constantly changing, in many parts of the world it is not changing fast enough to keep up with the demands placed on community members. Nowhere is this more evident than in southern Africa where the challenge of HIV is pushing us to our limits. The slowness of some aspects of culture to change has led to their being identified as ‘harmful’ because of the role they play in the spread of HIV infection. Besides building intolerance for GBV, and providing support for survivors, communities that really want to change the way HIV is affecting them need to look at some ‘harmful cultural practices’ that put women (and men) at risk of HIV infection. Changing the negative aspects of culture is easier said than done, but it IS possible, and this book describes community-led programmes that are working to do just this.

7 IPPF Charter on Sexual and Reproductive Rights, IPPF 2003

What Are Harmful Cultural Practices?Besides culturally condoned GBV, there are some cultural practices in southern Africa that put women at risk of HIV infection because they mean these women end up having unprotected sex against their will. In many of these situations men also have an increased risk of infection, but women are often not able to make their own decision on whether to be part of the practice or not. A deep understanding of what can be done to support communities to make these practices safer is urgently needed. Several harmful cultural practices explained below are found in different communities throughout the region. Other practices specific to certain countries and regions will be covered later in the book.

Polygamy is common in much of southern Africa, and is often characterised by low condom use as cultural beliefs are that “one cannot use a condom with one’s wives”. It is often accepted that men will have not only several wives, but also other partners outside of the marriage. Men who have relationships outside the polygamous marriage are at risk of infection, and if infected they may pass the infection on to ALL of their wives. Wives in polygamous relationships may also look for support and fulfilment from other men and this (as well as the husband’s ‘side’ relationships) leads to a sexual network where all partners are at much greater risk of infection. This risk is made even higher because testing for HIV is not common in polygamous marriages. The acceptance of polygamy is related to the wide practice of having multiple concurrent partnerships (MCP), known to be one of the key factors in the spread of HIV in southern Africa.

Forced or arranged marriages are when women (and especially younger women or adolescent girls) find themselves in marriages often to older men who may already be married. Often they did not want or choose the marriage and both partners may be exposed to the virus as it is unlikely that either would be tested before the marriage. In these types of marriages both partners may look for fulfilment or support in other romantic relationships, increasing the chance that they bring HIV back to the marriage partner. The woman or girl’s risk of infection is also increased if the man she marries is polygamous.

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Besides culturally condoned GBV, there are some cultural practices in southern Africa that put women at risk of HIV infection because they mean these women end up having unprotected sex against their will. In many of these situations men also have an increased risk of infection, but women are often not able to make their own decision on whether to be part of the practice or not. A deep understanding of what can be done to support communities to make these practices safer is urgently needed. Several harmful cultural practices explained below are found in different communities throughout the region. Other practices specific to certain countries and regions will be covered later in the book.

Polygamy is common in much of southern Africa, and is often characterised by low condom use as cultural beliefs are that “one cannot use a condom with one’s wives”. It is often accepted that men will have not only several wives, but also other partners outside of the marriage. Men who have relationships outside the polygamous marriage are at risk of infection, and if infected they may pass the infection on to ALL of their wives. Wives in polygamous relationships may also look for support and fulfilment from other men and this (as well as the husband’s ‘side’ relationships) leads to a sexual network where all partners are at much greater risk of infection. This risk is made even higher because testing for HIV is not common in polygamous marriages. The acceptance of polygamy is related to the wide practice of having multiple concurrent partnerships (MCP), known to be one of the key factors in the spread of HIV in southern Africa.

Forced or arranged marriages are when women (and especially younger women or adolescent girls) find themselves in marriages often to older men who may already be married. Often they did not want or choose the marriage and both partners may be exposed to the virus as it is unlikely that either would be tested before the marriage. In these types of marriages both partners may look for fulfilment or support in other romantic relationships, increasing the chance that they bring HIV back to the marriage partner. The woman or girl’s risk of infection is also increased if the man she marries is polygamous.

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husband’s brother (or another male relative). Although this has its roots in a desire of the community to make sure that the widow and her children are ‘taken care of’, it still means

that she may be exposed to HIV in this new relationship, and often widows are not given the choice of whether to enter into the relationship or not. Again testing may not happen before the marriage, exposing all marriage partners to the risk of infection. A widow whose husband died from an AIDS-related illness may be infected herself, and may also pass the virus to her new husband, as well as any other wives.

Traditional courts often have the potential to support women as they may be the only place where women feel they can go to settle ‘domestic’ issues like GBV and widow

inheritance. However these same courts may also have a bias in favour of men since most of those sitting in the courts are men. And while many countries have laws to uphold the rights of women (e.g. to protect them from GBV) these laws often do not protect women on the ground in their day-to-day lives because cultural norms still make it acceptable to violate women’s rights. Because culture is so strong and entrenched, these issues are not simple to address – in fact it is quite daunting. Change takes time and this is a marathon, not a sprint - so it is vital that we start looking at which programmes are achieving successes in changing the way cultural norms put people at risk.

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“My husband ‘inherited’ his late best friend’s wife who also happens to be a close friend of mine. She is HIV positive and taking ARVs. I still love him, he is my husband, we have seven children together - the problem l am facing is that he does not want to go for HIV testing.” – Woman in rural Zimbabwe


The ‘Changing the River’s Flow’ Model

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By Lois Chingandu


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In the challenging environment of working to address women’s rights, culture, GBV and HIV, programmes in countries and communities that face similar challenges need to take

every opportunity to document and share what they are learning from Best Practices to improve their own programmes, and to help build up other similar programmes. The ‘Changing the Rivers Flow’ (CTRF) Model is emerging as a Best Practice in the southern African region. The name of this model mirrors the idea that culture is not fixed, like a rock or stone, it is a ‘river’, constantly moving and changing, even if we do not notice the changes that happen over a long time. Culture is also something beautiful, rich and vital for our lives, just as a river is an essential part of the lives of those who live on its banks. Therefore while working to change the aspects of culture that are harmful, we need to respect and strengthen the aspects that protect us and enrich our lives. Like a surging river, culture can be a powerful force, but the CTRF model is solidly based on the knowledge that culture CAN change, and it IS changing, and there are organisations that are already spearheading this process.

How Does This Model Fulfil Best Practice Criteria?According to SADC guidance, for a programme to be classified as a Best Practice (and to be selected for documentation for this book) it needs to show that it fulfils the Best Practice criteria outlined overleaf:

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A Best Practice is a practical instrument that facilitates sharing within and between (SADC) Member States in order to assist local authorities to scale up interventions based on what is known to work, through documenting, understanding, and appreciating best experiences, facilitating learning of what works and what does not, sharing experiences, and assisting replication of small successful interventions on a larger scale. (SADC Framework of HIV and AIDS, 2006)


Best Practice Criteria for HIV Programmes

Does the programme have objectives based on needs in the community, and is it fulfilling these needs?

Does the programme respect human rights, confidentiality, informed consent?

Does the programme achieve results using time and resources wisely and effectively?

Does the programme take into consideration the cultural, social and economic situation of the community and risk behaviours of community members?

Can the programme be set up or adapted easily elsewhere?

Does the programme bring to the table ways of working that are unique or new?

Can the programme continue into the medium to long term? Do those involved in the programme have a sense of ownership to continue?

The CTRF model is effective because it is grounded in the understanding that harmful cultural practices uphold gender inequalities, leading to GBV, which fuels the continued spread of HIV. Addressing these harmful practices is a crucial first step to preventing new HIV infections in communities in southern Africa. The model is highly relevant as it encourages communities to talk about sensitive issues and taboos in their community, to understand the interlinkages between HIV, GBV and specific cultural practices, and to begin to think and talk openly about how things can be done differently. The CTRF Model’s innovative approach guides a process of change driven from within communities themselves. ‘Change from within’ is more likely to lead to sustainable changes in the behaviour of individuals that will have a positive impact

on women’s rights and reduce new HIV infections. The approach also recognises the powerful role that traditional, religious and other leaders have as opinion leaders who can influence communities to change, and to sustain the change in the long term.

Effective

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The CTRF model is designed to be replicable as it allows flexibility in implementation. Every country, area and community will be different and have different challenges, and organisations using the model have the freedom to adapt the model to be responsive to their particular situations. The model’s approach is ethically sound as it harnesses the potential of communities to address their own challenges without too much external influence. It also encourages participation, support for human rights and confidentiality, and it works within the community’s existing structures (e.g. the local municipality, local government departments, health services, police and traditional courts) which is key to making the implementation of the model cost effective and sustainable.

Implementing the CTRF ModelSAfAIDS launched the ‘Changing the River’s Flow’ programme by piloting it in Seke, a peri-urban Zimbabwean community in 2006. Since then, SAfAIDS has scaled-up the model to nine countries (Botswana, Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Zambia and Zimbabwe) supporting 36 organisations to implement CTRF programmes between 2006 and 2011. Here we outline the core aspects that most of the organisations used to implement the model, but these organisations are also responding to their cultural and socio-economic environments in unique and innovative ways. The essence of the approach is always to be respectful of cultural dynamics, and hold the position that overall culture is a positive influence in our lives. This helps to avoid resistance that might arise from older generations and those in positions of traditional power. Due to the sensitivity of issues around GBV, everyone involved in CTRF programmes is trained on the importance of confidentiality, non-discrimination and respect for human rights so that beneficiaries of the programmes are treated as equals, autonomous and intrinsically valuable, irrespective of their situation, age or gender.

Engaging LeadershipOrganisations implementing the CTRF model invest significantly in working with leadership, starting by explaining the programme, its goals and the urgent need to examine harmful cultural practices. Working with political, administrative and traditional leaders and

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training them on the inter-linkages between women’s rights, culture, GBV and HIV is the crucial first step to get them thinking about GBV as a health issue for their communities, and not just something to be dealt with by husbands and wives behind closed doors. Traditional leaders in particular are gatekeepers for change because they are opinion leaders and people with the power to change things for the better in their communities, and they are often the ones involved in cultural practices like widow cleansing and wife inheritance. They also pass judgements in traditional courts, especially on cases of GBV and can influence the decisions in these courts in favour of women. Once they are committed to the programme, traditional leaders play a pivotal role in mobilising the rest of their community and encouraging them to participate in activities. In many cases, traditional leaders also provide the venues for activities, freeing up funds for other programme activities to reach more community members.

Training of TrainersOrganisations work with a cascade model of training in which several trainers are trained on the links between women’s rights, culture, GBV and HIV and how the CTRF model aims to support communities to start processes of change. These trainers in turn train community-based volunteers (CBVs) using the standard training manual developed by SAfAIDS.

Community-Based VolunteersOnce CBVs have been trained they carry out several roles, including (i) door-to-door visits in their community where they share the information they gained in their training; (ii) mobilising people to participate in activities; (iii) coordinating and mobilising around cultural dialogues as well as facilitating these dialogues; and (iv) referring survivors of GBV to sources of support at health centres and social services offices. CBVs are the essential ‘agents of change’, the core of the programme, and the people who support processes of change in their communities. They are chosen because of their strong leadership qualities and their commitment and track record in tackling HIV and GBV in their communities.

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Cultural DialoguesCultural dialogues are a space for leaders and ordinary community members to talk about issues that face their community. Separate cultural dialogue sessions are held with men, women and traditional leaders (Figure 3) to help people to come out of their shells and talk about these difficult issues. Although cultural dialogues are run by CBVs, the aim is for community members to identify the issues that they feel are important and to be able to look for solutions themselves. The dialogues focus on the concepts of culture, GBV and HIV, and specific harmful cultural practices identified in the community. Through active discussion in the dialogues community members (especially women and youth who often struggle to find a voice) start talking frankly about cultural factors that impact on their lives.

Figure 3 – The Cultural Dialogue Model by Lois Chingandu and Chrispin Chomba

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Four seperate dialogues convened exclusive for each category

Category: Facilitator:Women’s WomanMen ManCustodians Manof culture

Each group identifies practices fuelling the HIV epidemic

Ballot boxes used

Groups are combined

Common issues discussed from first dialogue identification and linked to HIV, gender, women’s rights and GBV

The facilitator has deep understanding of critical issues of HIV, gender, women rights and GBV

Discussions re-enforced by use of performing arts

Groups are separated into three

Women onlyFacilitator facilitates for women to talk about HIV, gender, women rights and GBV as it affects them

MenMen discuss gender, culture, women’s rights as it affects them

Custodians of culture link cultural laws, practises and how they impact on women and HIV

Groups are combined to discuss more on issues identified from each specific dialogue

More provocative discussion through performing arts

Community capacity gaps in gender, GBV, women rights and HIV identified

Leadership Sensitisationfor leadership buy-in

Baseline

Dialogue Dialogue DialogueDialogue

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Many organisations use community media to increase the reach of the programme. Phone-in shows on community radio and in local languages give people a chance to discuss difficult issues like GBV anonymously and bring those who cannot read into the discussion.

Community GalasOrganisations implementing the CTRF model have used community galas at the beginning of the programme (or at other points during implementation) to encourage interest and community participation in the activities that follow. Creative approaches, including edutainment in the form of music, dance, drama or sport have been used to create the ‘pull factor’. Some organisations have also linked the galas to national or international events (for instance a Cape Town-based organisation, Grandmothers Against Poverty and AIDS, launched its programme at the start of the 16 Days of Activism Against Gender Violence in 2009.

Figure 4 - Youth attend a community gala in Swaziland

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Promoting Cultural Change

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Promoting Cultural Change

Mozambique

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Moz

ambi

que The Cultural Environment in Mozambique

Social, cultural and religious norms in Mozambique lead to beliefs and attitudes that put men on top of the pile – and women very far towards the bottom. This has an impact

on what is accepted behaviour for men and women (for instance, it is accepted that men will have sex with many different women). In this strong patriarchy, traditionally women have been economically and socially dependent on men – especially since their rights to own, sell, and inherit land are often not legally protected. The new Family Law (2003) gives women the right to work outside the home and own property without their husbands’ consent – but for Mozambican women, especially those in rural areas, putting this law into practice is far from easy. GBV is a key driver of HIV infection in Mozambique - in 2008 alone over 14,000 survivors, including more than 2,700 children, sought help from police support centres after experiencing violence.

Mozambique has several tribal groups - including Shangaan, Chokwe, Manyika, Sena, and Makua. These tribal groups have distinct cultures, languages and traditions, but they also share some cultural practices, which people in communities believe are fuelling the spread of HIV:• Kutchinga or pitakufa (widow cleansing). After her husband dies, a widow has to be

‘cleansed’ of the death spirit by having sex with a male in-law (condom use is discouraged to make sure the cleansing is effective). In the event that the cleansing is not done, it is believed that more members from the same family will also die.

• Polygamy is common, even though it is not sanctioned by law. Wives are seen as a labour force for farming so having many wives (and children) is an attractive option for men, especially in rural areas.

• Passing on of traditional beliefs, in the form of ‘initiation rites’ for girls teaches them to see their position as inferior and to obey and be at the service of their husbands.

• ‘Commoditisation’ of girls. The value of girls in terms of the bride wealth they attract can lead to early marriages, and also to young girls being used by their parents to pay off debts. Often this means they are married into polygamous marriages or to men who are much older, which can put the young girls at risk of HIV infection, and stop their progression in school.

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MULEIDI Addressing Pitakufa in Manhica Association of Women, Law and Development (MULEIDE) was the first women’s human rights organisation in Mozambique – set up in 1994 to provide legal support to survivors of GBV who could not afford it. Through their work, MULEIDE recognised that women continued to be vulnerable to GBV and HIV infection because they remained uneducated and unable to support themselves and their children. The communities in which MULEIDE works have identified several harmful practices, including polygamy and kutchinga/pitakufa (widow cleansing), as well as multiple concurrent partnerships rooted in the belief that women cannot have sex after menopause which leads to their partners seeking out younger women. This belief has also been identified as being responsible for the high incidence of polygamy, as men marry more and more women as the last wife becomes pregnant. MULIEDE conducted a baseline study which uncovered positive practices that help protect people from HIV infection – among them kuleya (life counselling for young men and women done just before a wedding). MULEIDI implemented the CTRF programme in the Manhica Administrative Post of Manhica District.

Unique Aspects of the MULEIDI CTRF ProgrammeMULEIDI worked closely with the Traditional Healers Association and five traditional healers were actually trained as CBVs (120 CBVs were trained in total). The knowledge and skills they gained have helped them to question and speak out about practices that they might have supported in the past. The traditional leaders took a lead role and were at the forefront of introducing and ensuring the implementation of non-sexual ways of kutchinga/pitakufa (widow cleansing). MULEIDI has also worked with traditional healers to help them counsel couples about the new Mozambique Family Law and what it means for women’s rights.

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One way of non-sexual widow cleansing endorsed by the community involves the widow sleeping with a pestle overnight, resembling spending a night with the late husband. In the morning she uses the pestle to grind mealie meal mixed with herbs and prepares a meal which is eaten by the whole family.


Figure 5 and 6 - Community elders in Mungari explain how kutchinga can be done with a pestle

What Change Has Been Achieved?

The community is driving changes in widow cleansing - Traditional leaders and community members have suggested non-sexual forms of widow cleansing, and although these changes were not accepted immediately by everyone, more and more people are using traditional herbs or spending the night with a pestle and mortar as a cleansing ritual.

“We did not ask people to leave their culture but made them realise the dangers associated with it and supported them to come up with possible alternatives.” – Executive Director of MULEIDE

Cultural dialogues helped to get to the root of the cleansing beliefs, for example women themselves questioned what would happen if they were not cleansed. This highlighted just how severe the disempowerment of women is that they feel that this process is needed for them to have security. The acceptance of this powerful cultural belief supports the CTRF approach of finding alternative practices, even when

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those involved in the practices resist change as community-identified and endorsed solutions are more sustainable than those imposed from external sources.

“Women did not have a choice before, the family just passed on the decision. Now women can choose not to do the practice or use alternative ways of cleansing without any harassment from the family members who are equally aware of the dangers of HIV.” – Programme Implementer, MULEIDI

Traditional leaders are in the forefront of the fight against harmful practices - Through their position as opinion leaders, traditional leaders are influencing the community to change practices that lead to the spread of HIV. These leaders are also being very clear with people that they cannot cure HIV and that they need to go to health facilities.

“Males from the same family continued to die one after the other when they went in to do kutchinga. At first we thought the ceremony was not being done in the proper manner so we continued to repeat it. Our eyes were opened when MULEIDE came in with the community dialogues and explained the possibilities of HIV transmission through the practice.” - Community Leader, Manhica

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“As a Community Leader who is supportive of the programme, I offered MULEIDE land to establish an office after seeing changes that the community was experiencing. We love this programme and would like it to continue running.”- Traditional leader Manhica


“Traditional healers were a group of people in society who were deemed ‘unreachable’ but the programme managed to involve them and put them in the forefront of introducing alternative ways of pitakufa.” – Female Beneficiary, Manhica

CBVs are trained and empowered to play a vital role as agents of change in their communities – Seeing positive changes in their community is motivating CBVs to keep up their work even without financial incentives. Trained and motivated CBVs are committed to seeing change in their community.

“We do it because we have seen results coming and people acknowledging our help.” - MULEIDI Manhica Focal Point Person

“We are MULEIDE and we will go on, our relationship with MULEIDE goes beyond financial resources. With or without resources, we will carry on with our work.” - CBV speaking at a Focus Group Discussion

“They [CBVs] even use money from their own pockets to make calls to arrange for meetings and communicate key issues among themselves or with us.” - MULEIDE Executive Director

Women and widows are moving towards accessing their rights - The programme has encouraged widows to be self reliant rather than ‘going with the flow’ and being inherited and perhaps abused. Evidence from the fieldwork indicates that women, especially widows, now understand their rights and have found a place in the community cultural dialogues to express their concerns without worrying about what might happen to them.

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“As a woman, the society would always blame you for the death of your husband as if you would have asked for his death. This would violate your rights of freedom and interaction as a woman with other family members and community until kutchinga was performed on you.” – Female Programme Beneficiary, Manhica

The church is taking a stand on cultural practices - The church is now used as a platform for challenging cultural practices like wife inheritance and early marriage that can increase women’s risk of contracting HIV.

Reduced stigma and discrimination - Before the CTRF programme men used to stop their wives from going for VCT due to fear of stigma and discrimination from the community, and women would also fear this from their own husbands. More men and women reported going for testing due to reduced levels of stigma and discrimination in the whole community. This also greatly contributed to a reduction in the incidence of HIV in infants.

Through their use of the CTRF approach, MULIEDI has shown its potential for increasing women’s knowledge on their right to live free from violence and for creating awareness about the HIV risks in GBV and widow cleansing. MULIEDI’s work also reinforces the essential role that traditional and religious leaders have to play in the process of adjusting cultural norms to prevent the spread of HIV.

OMES Addressing Pitakufa in Mungari

Organisation for the Women Educator on AIDS (OMES) works through female CBVs to share information and knowledge on how HIV is spread, and the effects it has on individuals and communities. Through its networks and experience, and a baseline study undertaken in 2009, OMES realised that there were two key harmful cultural

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practices that were contributing to high incidence of HIV in the communities where it worked. These were pitakufa (widow cleansing), done in the belief that it removes the death spirit of the man who has died from the family and allows ndaca pita (the inheritance of the widow) and polygamy; supported by the belief that a breastfeeding woman should not have sex with her husband for at least two years. Due to this, men often looked for other women during this time. OMES has implemented the CTRF model in three communities of Mungari Administrative Post (Julius Nyerere, 25 Septembro and Aluta Continua) of Guro District.

Unique Aspects of the OMES CTRF Programme

OMES encouraged the Chief of Mungari Administrative Post to become a CBV, which helped the community to take the programme seriously, to take ownership and to commit to finding their own solutions. In response to the challenge of limited financial resources which the organisation was experiencing, OMES encouraged the community to mobilise resources to support programme activities like dialogues and meetings. OMES CBVs also went beyond their mandate of giving just information on GBV, culture and HIV. They also distributed condoms during their activities, and in their interactions with people they encouraged them to go for VCT, offering counselling before the test.

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Figures 7 and 8 - Focus Group Discussion with CBVs in Mungari (left), and a CBV packs condoms for distribution


Traditional leaders are taking a stand on pitakufa (widow cleansing) – The beliefs surrounding pitakufa are so ingrained that even after the community dialogues and community agreement to abandon the practice, some families still turned around and expected women to go through the sex ritual. Women have approached traditional leaders for support, and these traditional leaders have stepped up and asked the families not to force women into having sex, but rather to use other ways of cleansing.

“We could see that our relatives were dying though we were doing pitakufa but we did not know what was happening. We were blaming the women involved until we were made to see the problem.” - Traditional Healer, Mungari Administrative Post

Traditional healers and medicine harnessed to offer safe alternatives to cleansing – Traditional healers (curandeiros) occupy a prominent social space and are trusted and respected in Mozambican communities. They play an important and influential role in advising local elites and families, thus making them key stakeholders in the creation of a long-term shift towards cultural interpretations and practices that uphold women’s

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rights is an effective strategy. Some traditional healers have been successfully brought on board in interventions, and have played an important role in promoting behaviour change for safer sex. These positive aspects should be harnessed for the promotion of gender-sensitive cultural practices.

Alternatives to sexual cleansing are emerging – Cultural dialogues gave community members a chance to talk about their experiences of using alternative methods of cleansing. This was supported by traditional leaders, who highlighted other ways of cleansing that were used in the past, for example fusula na banda where a woman could sleep with a mortar and pestle for a night, or bath with a mixture of herbs provided by a traditional healer. Some women were concerned that they would not ‘feel’ like they were cleansed, but overall support is growing for the different cleansing methods. A key challenge remains in that widows who cannot support themselves may think that having sex with someone could lead to them being inherited. For real change to happen and to be sustained, cultural change needs to be complimented by the empowerment of women to be financially independent.

“We were taught that doing pitakufa through sexual intercourse is very dangerous in relation to HIV. We were urged to use alternative methods of pitakufa. We still do pitakufa as our culture but not through sex.” - Community Leader, Mungari

Groundwork for community action has been laid – The separate dialogues with men, women, youth and traditional leaders set the stage for community members to feel comfortable talking about taboo issues and to agree on some of the challenges they faced – and from there to jointly seek solutions.

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“In this programme we only prepared the ground and the community did everything that followed.” - OMES Programme Officer

CBVs are committed to their role of igniting change in their community – with the training they have received, and as they have started to see the changes their community is making, CBVs realise the importance of what they are doing and are determined to continue their work.

“Yes we will continue doing the work even on our own because we have seen that if we stop, we will die.” - CBV at a FGD

Women and youth are finding a voice – Through the separate and joint dialogues, women and youth who were traditionally expected not to have opinions on issues like culture, GBV and HIV have found the strength to speak out on these issues, and have been empowered by the fact that people have listened to them.

“Before OMES came to work with us, it was taboo in our culture to hear women and young people speak about sexual issues in public.” - Young Person, Mungari

“We are now stranded as young men, we no longer have anyone to marry because all the young girls are being taken as wives by the older men.” - Youth at a Focus Group Discussion

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“We as young people did not understand some of these cultural practices before, we did not know what was happening even at funerals, and why some of these things were being done. Now we know and can even refuse to be part of these activities as they have an impact on our health.” – Young Person in Mungari


OMES’s work using the CTRF model demonstrates that the model has significant potential to help address specific harmful cultural practices identified by communities. Solutions such as non-sexual widow cleansing gain traction when they are identified

and introduced by traditional leaders, and supported by influential players like traditional healers, and not from an external organisation. Although the process of changing cultural norms may be slow, it has begun, and people in these communities are beginning to see the benefits of these changes - reducing the spread of HIV.

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“They should not take long to expand the programme. In some villages no-one has been trained and people still drink too much, resulting in violence.” - Community Based-Volunteer, Mungari


Namibia

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The Cultural Environment in Namibia

Namibia is a diverse country with many racial, religious and cultural groups, each with their own traditions, values and practices. Namibian society is developing

and modernising but it is still strongly patriarchal, men are in control of almost all aspects of life. Traditionally a ‘good woman’ needs to be sexually passive and not talk about sex, whereas men dominate in sexual relationships and are encouraged to experiment with many different partners. Within this male dominated set-up, there are social norms that mean people accept or tolerate GBV; physical violence, verbal abuse and emotional manipulation. In fact, GBV is very common in Namibia - one study found that a third of all respondents said they had experienced physical violence (MOGECW, 2008). The cycle of GBV is cemented by widespread poverty, which keeps women economically dependent on men.

ACT Addressing GBV To Improve ART Adherence

AIDS Care Trust (ACT) is a non-governmental organisation that has been providing psychosocial support, daily living essentials, and other support to disadvantaged youth and orphans and vulnerable children (OVC) since 1991. The trust also offers home-based care (HBC), counselling and treatment adherence support. Over the years, staff of ACT recognised how culture and GBV (or even the fear of violence) were having an impact on people (especially women) living with HIV adhering to their treatment. With this in mind, when ACT began a plan to scale-up its HBC it aimed to link HBC activities with implementation of the CTRF model. The model has been implemented in Khomas and Omusati regions in Tobias Hainyeko, Moses Garoeb, Windhoek Rural and Okahao constituencies.

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Unique Aspects of the ACT CTRF Programme

ACT incorporated the CTRF model with the unique approach of using HBC as an entry point. This meant that CBVs who were already providing an essential service to members of their community could use their time in homes to raise awareness of how harmful cultural practices and GBV are linked to the spread of HIV. ACT also responded to the situation by adding some unique aspects to their programme, so as well as looking at culture, GBV and HIV, ACT also focused on alcohol abuse, MCPs and poor communication between couples, and how these are related to GBV.

ACT worked with different levels of leadership, including parliamentarians, church leaders and other local community and national level leaders. Working with parliamentarians in particular was important because it opened up the way for the programme to have a bigger impact through providing parliamentarians with information so they could speak out about and advocate for laws and policies dealing with the inter-linkages between culture, GBV and HIV.


Communities have come together and understand the links between culture, GBV and HIV - before the programme, culture, GBV and HIV seemed like separate challenges, but cultural dialogues have given people the chance to come to a shared understanding that they are linked. It also empowered them to take action.

“We were not united and there was no proper coordination of community issues, but through dialogues we are now closer to each other and can easily tackle issues.” – Male FGD Respondent

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“They came and provided us with information which taught us how to do things for ourselves.” - Mayor of Okahao

The community cultural dialogues also brought up new challenges, in that older men and women felt they should go back to traditional social norms of male control, giving traditional leaders more power to get involved in people’s personal issues as a way of impacting on high HIV incidence. Young people on the other hand felt that women needed a stronger and more protected role in society. The challenge is how to find the best mix between these two avenues. The dialogues also revealed the highly patriarchal opinions of men in the communities, indicating how far the organisation needs to go to work for women’s rights, but at least the topics are being discussed openly by members of these communities.

“All this talk of equality makes women think they can challenge their husbands, which is wrong. They start asking too many questions and denying us food when we come from drinking beer. This causes us to get angry and we end up beating them up.” - Male Participant during a Focus Group Discussion

Reporting of GBV has increased - Women are increasingly aware of their right to live free from violence, and this is encouraging them to report GBV. Knowing about the support system available to them and that acts of violence will be followed up by the police and courts also encouraged women to report.

“People are now reporting violations. Before, they would suffer in silence because they did not know their rights and the culture of silence made people, especially women, think that violence is the norm.” – Programme Implementer

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Alcohol abuse and MCPs are decreasing – the programme has helped people understand the links between GBV, alcohol abuse and MCPs, and how avoiding GBV and MCPs can reduce their risk of HIV infection.

“People were tired of only hearing about HIV, but they are now listening to new things which are still part of HIV.” - ACT Staff Member

Leadership is speaking out on GBV – through working closely with community leaders in a way that does not threaten their position in society or in their community, ACT has helped community leaders to speak out on how culture and GBV impact on HIV. Community leaders are taking responsibility for making sure that people in their communities know about the links between GBV and HIV, and that people know their rights. At the same time, community leaders also recognise that the issue of GBV is one that has to be addressed with the support of everyone in the community.

“We did not adequately address GBV before because when people reported, we did not have the information and the people did not know their rights. Because of the programme they now know their rights and this is no longer an issue of leaders alone but it is a community issue.” - Community Leader, Okahao

“As a leader I am happy we are addressing these issues together. Leading people is easier if they are happier and healthier. It is also best that some of the burden has been taken away from us.”- Traditional Leader, Okahao

Community members are gaining confidence that change can happen – community members are seeing those around them, particularly men, change their mindsets and this is creating an environment for social and cultural change.

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“If you give information to perpetrators of violence they will stop. People do not have basic facts and once they get some facts it becomes easier to try and change their mindsets.”- Woman working with ACT “I have seven children who I don’t know where they are, but if I knew the information I know now about the relationship between violence and HIV as well as the negative impact of alcohol on the wellbeing of families, I would have done things differently.” - Male Beneficiary, Okahao

Stigma and discrimination are decreasing - dialogues, trainings and other activities have become places where PLHIV, especially women, can discuss HIV-related issues without fear of discrimination. These open discussions have paved the way for reductions in levels of stigma and discrimination, especially between married couples who blamed each other for their positive status.

“The situation regarding stigma and discrimination is getting better, people are disclosing their status.” – Focus Group Discussant

“Communication within couples is still difficult but when they are brought together, they open up.” - Community Leader in Okahao.

Community leaders are linking with police and justice systems – Focusing on GBV and helping community leaders to realise that they are not the only ones tasked with addressing GBV has opened up a space for improved relationships between community leaders, police and other service providers. ACT has played an integral part in improving coordination between these partners and strengthening their relationships.

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“The issue of violence between men and women was a big problem for us as leaders. In the past if people reported violence we would just talk to them and ask them to forgive each other but now we know that it should not end there.” - Traditional Leader in Omukondo Village

“We work well with ACT and it would be good if many organisations would do the same as there are a lot of entities that seem to be working in isolation.” - Chief Inspector at the Women and Child Friendly Unit

These partnerships will be a vital factor supporting the sustainability of the programme in the future, and there is commitment from partners to ensure this sustainability.

“The programme is sustainable and will continue - key ministries will continue implementing according to the Namibia Development Plan (NDP) 3.” - Mayor of Okahao

HIV testing is being encouraged - the programme has helped people (especially men) understand the importance of knowing their status, and more couples are going to be tested together. Male partners who go for testing together with their female partners may be less likely to perpetrate violence than if the female partner goes alone for testing.

“People used to laugh when they heard that a person is HIV positive but now they understand and are even supportive.” - Traditional Leader in Okahao

“After talking to couples within their homes some have gone for couple testing.” - Community-Based Volunteer

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The evidence of change from ACT’s programme highlights the variety of positive changes that can be started and achieved through the CTRF model. Changing norms that support GBV is not a simple task, and solutions for how to deal with this may still need to come out, but these communities have taken the first step by beginning to challenge the norms that support GBV. Changing norms and the opinions of men can be difficult, highlighting the need to keep these types of activities going in the longer term to see real change.

NWHN Addressing GBV and Sexual and Reproductive Rights The establishment of the Namibian Women’s Health Network (NWHN) came about in response to the forced sterilisation of women living with HIV – NWHN has documented the stories of many of these women. Since 2005 NWHN has been providing women living with HIV with information on sexual and reproductive health (SRH), prevention of mother-to-child transmission (PMTCT) of HIV, the unlawful nature of forced sterilisation, as well as information on where to access services if they have experienced GBV. NWHN’s work is rooted in the understanding that many women live in situations where GBV and rape are common. In their communities poor education and few opportunities mean chronic levels of unemployment and poverty that go hand in hand with high rates of alcohol abuse, (especially by men) and high rates of GBV. NWHN implemented the CTRF model in Katutura (rural Windhoek) as well as the rural town of Dordabis.

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Unique Aspects of the NWHN CTRF Programme

From the outset, although NWHN was clear they wanted to support women through using the CTRF model, they also knew it was crucial to involve men, youth and community leaders as each of these groups has a role to play. NWHN made it clear that men were welcome and included, especially in income- generating activities (because poverty doesn’t affect women alone) and because of this, men were more likely to actively participate in GBV and HIV prevention activities. NWHN also tailored the programme for these communities by adding elements on crime prevention and addressing alcohol abuse in training and other activities. To respond to unemployment and food insecurity in Dordabis, NWHN started the Youth Against Crime project which was aimed at helping young people

to earn an income through rearing chickens and gardening.

In an early community meeting, NWHN and community members realised that some people were being turned away from health services because of their HIV status, and young people were also being denied sexual and reproductive health services (like family planning). In response to this, and in an effort to encourage

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Figure 9 - Women participating in a NWHN meeting

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“The most common crimes in this time are rape and in terms of domestic violence it usually happens to married women with children and reporting is low.” - Police Officer, Dordabis


improvements in health service delivery, Health Ethics Committees (HEC) which monitored suggestion boxes in health facilities were set up at two clinics. The aim of these committees was to create an environment where clinic staff and clients treated each other with respect and dignity. The members of the HEC were chosen by the communities themselves and after seeing the benefits of the two pilot clinics with HECs, the Ministry of Health and Social Services (MOHSS) is considering using the approach throughout the country.

What Change Been Achieved?

Reporting of GBV has increased – Women are more aware of their rights and are increasingly reporting violence to the authorities, who are following up on cases. Through the HECs, communities have developed stronger relationships with health services and the police, making it easier to report and follow up on GBV cases.

“The programme opened my eyes, in my culture I would never have reported that my husband was beating me up.” - HIV Positive Woman in Dordabis

Violent crime levels have gone down – Aspects of the CTRF model may be contributing to reductions in GBV in areas where the programme is being implemented.

“Formerly common crimes like rape have declined and so far this year only 13 cases have been reported, which is 50% of the total number of cases at the same time between 2008 and 2010.” - Police Officer, Dordabis

Improved health services for GBV survivors are available - Not only have service providers improved their treatment of PLHIV and youth, but through showing the

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need for post-exposure prophylaxis (PEP), NWHN successfully lobbied the Ministry of Health and Social Services to provide PEP to women who have experienced violence.

“As a result of the human rights outreach programme, people can go to a clinic and ask to be served appropriately. Now PEP is also available in the clinic because people spoke up.” - Woman Beneficiary, Dordabis

“Matters considered urgent are attended to promptly, for example in cases where patients spent a long time waiting to be attended to, the Ministry increased the number of nurses. Service has improved as nurses compete to be the best nurse.” - HEC Facilitator

“The HEC is very important as it provided a platform for people’s issues to be raised and addressed. Even in the middle of the night people are phoning us with concerns related to access to health services.” - HEC Member, Dordabis

Community members are empowered by having their voices heard – Community members feel they have a voice and can make changes in their communities. They have seen how HECs have made changes based on their feedback.

“We used to be treated without respect at the clinic but the suggestion boxes have improved things and we are now treated with the respect accorded to all community members.” – Woman Living with HIV, FGD Participant, Katutura

Stigma and discrimination are decreasing - Cultural dialogues and training have given women a safe space to talk about HIV. Also, an improved understanding of the experiences of women living with HIV in the community as a whole has decreased stigma and discrimination.

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“When we started there was not even one young woman living with HIV but that has changed and young women are disclosing their status.” - NWHN Founding Member

Vulnerable youth are empowered through being productive - Youth are now involved in productive activities and less likely to have unsafe sex or resort to violence.

“There is a lot of poverty here. There is no radio or television reception here so we end up drinking, fighting, stealing and having sex. This results in young girls having babies. The poultry project has given us hope, we see new possibilities.” - Dordabis Youth

“The chicken project for youths is doing well and we hope that it can be extended towards adults because we are also poor and unemployed.” - Elder, Dordabis

NWHN’s work using the CTRF model shows the potential of the approach to bring communities together and empower them in the knowledge that their voices are being heard. These are crucial first steps in changing the cultural acceptance of GBV, but progress is hampered by the continuing challenge of the economic hardships faced by women. Working for cultural change alone is likely to meet obstacles; it needs to be done in tandem with work on poverty alleviation and economic empowerment of women.

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The Cultural Environment in Khayelitsha

South Africa is a large and diverse country and this Best Practice focuses on an informal township called Khayelistsha in Cape Town, Western Cape Province.

Khayelitsha reportedly has a very young population; fewer than 7% of its residents are over 50 years old, and over 40% of its inhabitants are under 19 years of age. The township also reportedly has the highest rape prevalence rate in Cape Town; this rate is also one of the highest in the country.

Although community and Government services recognise the problem of GBV and are trying to make Khayelitsha safer for women, there were still 259 reported cases of GBV between April 2009 and March 2010. People in Khayelitsha also believe several specific practices are leading to the spread of HIV:

• Traditional male circumcision: Circumcision is an important rite of passage for young Xhosa men, but often the traditional leaders use the same blade for many young men, which can lead to infections. Although the young men are advised not to have sex for at least six weeks while they heal, often they do not do this so they and their sexual partners are at increased risk of infection.

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• Sexual cleansing of ifutha: Ifutha is a white clay paste that is put on amankwenkwe (the initiates’, or young men who are to be circumcised) bodies when they are away from home at traditional initiation ‘schools’. When they come home, the ifutha is washed off symbolising that the young men can now start their lives as men in their community. Besides ‘washing’ of the ifutha, young men also believe that they need to sexually cleanse themselves. They believe they must have sex with someone ‘who doesn’t

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“When they come back from the mountain and have smeared the ifutha, they must remove it and change their clothes and then they can have sex again. The problem is that when the boy comes back from the mountain he doesn’t go far to find a girl.”-GAPA Beneficiary, Focus Group Discussant


matter’ to them, who they do not love. Sadly this means some young men force young women and girls to have sex with them. Very young girls are especially vulnerable because of the common belief that having sex with a virgin can cure HIV. During the December holidays when traditional circumcision happens, there are many more cases of rape reported.

Figure 10 - A Khayelitsha initiate with his face smeared with ifutha (the white clay paste)*

GAPA Challenging the Sexual Cleansing of Ifutha

As the name says, Grandmothers Against Poverty and AIDS (GAPA) is an organisation working with grandmothers to help them cope with the strains HIV puts on them and their families. GAPA is a membership organisation – its members are grandmothers, many of whom have lost their children to HIV, or whose children are sick and they are nursing them. Each month GAPA has workshops for grandmothers to acquire skills and gain knowledge

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page 49* Picture courtesy of New Nation New Reporters Newsroom

“Violence is a big problem here. We experience physical and verbal abuse from the children daily. The children are taking advantage of us. Neighbours and husbands are raping our children. Poverty and unemployment and drug and alcohol abuse make the whole situation worse.” - GAPA Member, Beneficiary


on HIV and AIDS, as well as how to care for people living with HIV in their homes. There are also weekly support groups and GAPA promotes income generating activities where grandmothers make and sell beadwork, bags, cushions and other items.

Unique Aspects of the GAPA CTRF Programme

Like other NGOs, GAPA faces resource challenges and they incorporated an important cost saving measure into their CTRF programme. Programme implementers knew that they needed to do a baseline study on GBV, and they also knew that there was already data on GBV in Khayelitsha from the City of Cape Town Health Department which they used to save time, effort and costs. GAPA also forged a Memorandum of Understanding with the City of Cape Town whereby CBVs who were already working for and paid by the City (and paid stipends by the City) could incorporate CTRF activities into their work.

To increase participation and relevance, GAPA planned key activities to happen in December, around the time when initiation schools get going, and when the issue is a ‘hot topic’ in the community. They also aimed to bring an extra flair and flavour to

activities, using them as a chance to honour the positive aspects of Xhosa culture. GAPA gave activities like dialogues and galas a festive feel by encouraging people to wear their traditional dress, and by serving traditional food.

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As a female dominated organisation, GAPA found it challenging working with traditional leaders, but they identified more forward thinking, open minded leaders in the community to work with. GAPA trained an especially open minded traditional healer (Dr Albert Kandekande) about how harmful cultural practices like sexual cleansing are linked to GBV and HIV. Through the knowledge and skills he has gained he has become a ‘champion’ for GAPA. GAPA also realised it was not enough to work with leadership alone, they needed to reach the initiates who are the ones who may go on to perpetrate violence. In December 2010, before the initiates set off for the initiation schools, Dr Kandekande facilitated training on the cleansing of ifutha for 50 boys going to the initiation schools and their male relatives.


The community is getting to the root of the issue of cleansing of ifutha - through bringing this issue to the fore, a process of change has been ignited. Women were worried about what young men were being told at the initiation schools, they felt they were encouraged to see all women as inferior. Women were also worried that they did not know what actually went on at the initiation schools. Women were asking questions, they feel they had the right to know.

“When our boys go to the mountain we the women and mothers are not involved...The information must be shared with the mothers whose role it will be to take care of the boy when he comes back from the mountain sick.” - GAPA Project Implementer, Beneficiary

Women also expressed their concern about the sticks that the young men bring back from the schools that they thought symbolised an acceptance of men abusing women. Through the dialogue process women and men were able to come to a shared understanding of the positive symbolism of these sticks:

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“While growing up we knew that men beat women. But now no-one wants to own up to the fact that it may be culturally sanctioned as tradition. During the CTRF cultural dialogues we challenged the practice of giving the new initiate a stick. We asked if the stick was meant to be used to beat us. They explained that it is for the man to protect his family from the enemy. And we told them that this is how it should be.” - GAPA Director

The dialogues also got to the root of the violence against women that is part of sexual cleansing of ifutha by giving women a chance to question what gives young men the right to abuse women.

“We the women asked them (men - during the community cultural dialogues), we wanted to know who is this woman who must be used in this way to cleanse a man – sometimes by force and sometimes through rape.” – Female, GAPA Beneficiary

The community is taking steps to make traditional circumcision and the cleansing of ifutha safer – GAPA and Dr Kandekande have managed to get people talking about a safer method of cleansing that does not involve sex.

Figure 12 - GAPA works with Dr Albert Kandekande, a traditional healer

“Initiation has been discussed with GAPA. When we are sending boys to the mountain, there are tools that are used and we have discussed this and we are changing this practice.” – Paramount Chief Mdumiseni Gawulana

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“I advise that when the boys come from the mountain, they must use our traditional medicine (ntololwane) to cleanse their blood. The medicine is easily available and it also offers immunisation against lightning that also affects the boys when they are on the mountain. They should wait about two months before they have sex, but then they will be clean and can go back to their steady girlfriends. We also advise that they access HIV testing, and ensure that the men who circumcise them use multiple assegais to circumcise.” - Dr Albert Kandekande, Traditional Healer

The community is harnessing African problem solving strategies – the dialogues are successful because they fit in with the way the Xhosa have dealt with challenges and change in the past. The dialogues are not threatening to men and to leadership as they respect the structures that are already in place and emphasise positive cultural practices. Community members report that men are taking on board the information they hear about GBV, culture and HIV during the dialogues and are willing to make changes in their lives.

“The Changing the River’s Flow’ project shows us that there is nothing wrong with our culture. We wanted to do western things and in the process we lost our culture.” - Co-Founder Member of GAPA and Project Beneficiary

“I always felt that culture is what we do every day. But I learnt that culture can be changed in a positive way to address the negative things around us.” – Project Beneficiary

“GAPA’s focus on traditional issues is very important for this community. They focus on children, encouraging positive practices and behaviours among girls like marriage before sex, and in providing opportunities for children to engage in traditional dance in order to keep them busy and not to get caught up in wrong/harmful practices.” – Paramount Chief Mdumiseni Goodman Gawulana

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GAPA is sharing practical information that supports women – Through dialogues and CBVs activities, GAPA has shared information on policies, laws and services that protect survivors of GBV.

“We have seen that women are more confident in getting protection orders agaist someone who is abusing them, and in taking legal action.” – Programme Implementer

People are more aware of their rights – In the dialogues, men and women have a ‘safe space’ where they can talk about taboo issues around women’s rights and place in society, GBV, HIV and other issues that they may have no other outlet for.

“Dialogues are empowering people to know their rights and to seek services. The protection orders are useful for getting people to seek services. People are being encouraged.” – GAPA Member, Project Beneficiary

“Our husbands are the old fashioned ones who must switch off the light before they take off their clothes. Now we have more power to tell them not to so that we can see if their private parts are healthy.” – GAPA CBV, Project Beneficiary

GAPA’s work with the CTRF model and with a traditional healer who is a ‘champion’ for change has shown that it IS possible for communities to begin to consider and take action to come up with acceptable alternatives to sexual cleansing. This change in a relatively short space of time illustrates that besides working for the long-term process of changing a male dominated culture that condones violence against women, we also need to focus on short-term gains in the practical changes to harmful cultural practices.

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Swaziland

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The Cultural Environment in Swaziland

Swazis share a common language and traditions which means traditional culture is strongly entrenched. Swazi culture emphasises men’s power and dominance

over women. Boys are brought up to be strong, productive and in control; girls are brought up to rely on a men (their husbands, fathers, brothers, uncles) and to focus on their role as mothers. Several harmful aspects of Swazi culture are still widespread and HIV testing is not common in these situations:• Sithembu (polygamy) is common and condom use is low in polygamous

marriages. Because men pay lobola (bride wealth) for their wives there is now a trend for men not to formalise polygamous marriages, and instead they are keeping side relationships with girlfriends outside marriage to avoid paying lobola.

• Kungena (widow inheritance): Widows are inherited by a brother-in-law, who takes on the responsibility of looking after the widow and her children. Most often HIV testing is not considered before the marriage begins.

• Umhlanga (Annual reed dance): This is a custom where young virgin girls come to pay homage to the Queen Mother and present her with reeds to build windscreens around the royal village. Although the practice itself is positive, encouraging young women to wait for sex, it also makes them vulnerable to HIV infection as men come to the events specifically to find virgins.

SWANNEPHA Working with Traditional Leaders to Address Sithembu and Kungena

Swaziland National Network for People Living with HIV and AIDS (SWANNEPHA) was formed in November 2004 to provide coordination for the many organisations offering support to PLHIV in Swaziland. Under this umbrella, SWANNEPHA has implemented the CTRF model in the three peri-urban chiefdoms of Mbabane East (Fonteyn, Sidwashini and Msunduza).

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Unique Aspects of the SWANNEPHA CTRF Programme

In working with leadership SWANNEPHA collaborated with traditional leaders who are also key players in the political set up in Swaziland (for example, a well known Member of Parliament), so the messages of cultural change were strongly endorsed from the very top. The network also set out to identify specific protective cultural practices and to support traditional leaders in communicating the benefits of these practices. These protective practices included: endlini kagogo where a family forum of elders comes together to discuss issues affecting married men and women; liguma where older men pass on their wisdom on being a ‘good Swazi man’; and lisangu, where older women encourage young women to wait for sex, among other positive behaviour.

Figure 13 - Women participating in a cultural dialogue in Mbabane East

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People are increasingly recognising the importance of understanding the risk of HIV infection and the need for HIV counselling and testing for all parties

in polygamous marriages - This increased awareness has encouraged people to look critically at the ways in which polygamous marriages have changed from their ‘pure’ form over time, as well as the importance of HIV testing if they were planning to enter into such a relationship. Clinic staff indicated that they were seeing more people requesting HIV counselling and testing.

“During our days polygamy meant that a man would officially and legally marry as many wives as he would see fit. The man would then take the responsibility of taking care of his family financially and emotionally. But in this day and age, polygamy is now likened to having multiple sexual partners. Bride price is only paid for the first wife. The young generation should be conscientised on the importance of VCT before engaging in sexual intercourse. It is difficult to eradicate polygamy as it is our tradition and encouraged in our country but there is a need to educate people on the negative health effects of such negative cultural practices.” - Local Councillor

People are appreciating the importance of HIV testing when a widow is inherited - People who have been involved in the CTRF programme are more aware of the risks involved in kungena (widow inheritance) and the need for both partners to know their status before entering into the marriage.

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“We aim to build awareness on the interlinkages between culture, gender based violence, HIV and women’s rights among support groups and their communities.” - SWANNEPHA Executive Director


“It is in our culture to inherit the wife and we continue to respect it, but prior to the wife inheritance ceremony it is important for both parties to go for VCT to ensure that they are aware of their status.” - Male Focus Group Discussant

There has been a reduction in GBV – Increased awareness of women’s rights, and of the links between GBV and the spread of HIV may be contributing to the lower numbers of GBV cases. This also highlights the benefits of SWANNEPHA’s partnership with the local police force.

“Awareness campaigns against GBV by the victim friendly unit, in partnership with SWANNEPHA, have played a pivotal role in the reduction of GBV incidences. Our department provides information on legal action taken by the police in cases of GBV.” – Police Representative

Women are aware of their rights - Women who have been involved in the programme are more aware of their rights and are empowered to be more assertive in exercising them.

“Women are now able to participate during mixed sex dialogue sessions; they voice their opinions on issues that affect them. Most women indicate that if they suspect that their husband is having an extra marital affair, they negotiate for condom use.” - Female participant during a FGD

“...the various trainings have greatly improved community members’ understanding of the relationship between gender, women’s rights, HIV and culture. Community members report being able to differentiate between harmful cultural practices and good cultural practices that need to be preserved.” - Programme Implementer

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Through implementing the CTRF model, SWANNEPHA has improved coordination between police, health services and community members - This has helped ensure that GBV cases are dealt with in a holistic way, through improving support for survivors and increasing awareness of the consequences for perpetrators of violence.

“Community members agreed that all incidences of GBV would be reported to the nearest police station where cases would be handled by the Victim Friendly Unit. Prior to the community dialogues, many community members reported that they failed to report cases of GBV because they were not aware of the institutions that could address their problems.” - Community Based Volunteer, Mbabane East

Health services are noticing ‘spin-off’ benefits of CTRF programme activities - Clinic staff have noticed that there has been an increase in condom uptake and a decrease in STIs, suggesting that community members are having less unprotected sex.

“We distribute condoms in the clinic and some of the condoms are put in toilets. We have noticed an improved uptake and some people come to the clinic to ask for condoms.” - Local Clinic Staff

“The increased use of condoms by people has led to a reduction in STI cases. SWANNEPHA has played a critical role in conscientising the community on the effects of unprotected sex.” - Local Clinic Staff

Figure 14 : Swazi men participating in a focus group discussion

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SWANNEPHA’s work with the CTRF model emphasises that changing aspects of culture like polygamy and wife inheritance is not a simple process as they are still widely supported, but change IS possible – although it may be difficult to completely change practices that are deeply entrenched, it is possible to make them safer by encouraging VCT before people enter into new sexual relationships.

NATICC, Working with Men and Youth To Address Ukwendzisa and Kungena

Nhlangano AIDS Training Information and Counselling Centre (NATICC) is a Swazi church-based, non-profit organisation that has been providing training, information and counselling on HIV since 2004. It is active in three chiefdoms in the rural part of Nhlango – in Mbilaneni, Dlovunga and Magwaneni.

Unique Aspects of the NATICC CTRF Programme

With an eye to the future and long-term change in communities, NATICC has incorporated working intensively with youth into their CTRF programme. Youth as future leaders have an important role to play in changing harmful cultural norms and practices that support the dominance of men, which is the root cause of many harmful practices. NATICC has also worked intensively with traditional leaders, identifying and building the capacity of ‘champions’ for the programme. The organisation also supports traditional leaders by bringing them together for regular meetings where they give feedback on the number of GBV cases they would have addressed and talk about positive changes observed, as well as the difficulties they are facing. These meetings also give leaders the chance to learn from those in other areas and to share experiences and effective strategies for addressing GBV.

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NATICC also realised that through encouraging people to talk about GBV and to know their HIV status, they were creating a demand for VCT and psychosocial support which they had a responsibility to provide, so they set up a mobile clinic in partnership with the local clinic. Here, medical staff from the clinic offer HIV testing whilst NATICC staff offer psychosocial support and counselling.

Figure 15 - Traditional leaders taking part in NATICC community activities


Traditional leaders are committed to working with NATICC and are role modelling effective prevention strategies - Chief Malambule Mdhulo of Mbilane is young, energetic and unmarried, and has been in the forefront of encouraging members of his community to go for testing and for medical male circumcision (he underwent the procedure himself ).

“We are glad to be the first ones to be notified about the project. Therefore we are willing to work together with NATICC in this project.” - Traditional Leader

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Awareness of the need for VCT before entering into new relationships is increasing – While sithembu (polygamy) is still common and accepted, the need to go for VCT before the marriage is also increasingly being recognised. Ukwendzisa (forced marriage) and kungena (widow inheritance) are also reportedly becoming less common and awareness of the need for testing in these situations is also increasing.

“Chief Malambule Mdhluli is outspoken about encouraging women to report cases of abuse or forced inheritance to the traditional courts.” - NATICC Programme Staff

”Before l marry I will go with my partners for HIV testing and will occasionally conduct group HIV testing with my wives. In my community l encourage men to use condoms in all their sexual encounters and to go for HIV testing with their partners. I am also part of the council that addresses cases of GBV in the community. We ensure that all cases are reported and handled accordingly because we are trying as much as possible to reduce the incidences of GBV.” - Chief Malambule Mdhluli

“You would realise that in most instances in practices such as widow inheritance, people would not bother about knowing each others’ status before they sleep together. However due to the training received from the CTRF programe and the follow-up dialogue sessions, people are becoming more cautious about their sexual behaviours. I have noticed that after the trainings we attend to increased numbers of people seeking HIV testing and counselling and condoms. It is because during the CTRF trainings they are referred to the clinic for condoms and HIV testing and as a result many of them visit the clinic.” – Local Clinic Staff

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The systems in place for dealing with GBV cases are improving - Strong partnerships have been built between NATICC, the police, traditional courts and local clinic staff so GBV cases are handled in a holistic way. Women say that it is now easier for them to go to the traditional courts when they have experienced violence.

“As far as GBV was concerned, we would take it as normal that the husband has physically abused his wife or children and when it came to sexual abuse it was an in-house matter that could not be shared with outsiders. However, the programme has changed our thinking regarding harmful cultural practices and GBV. People are enlightened and cases of GBV are reported to the police. The training that we have acquired from the CTRF programme contributed immensely to people condemning these harmful practices.” - Community Leader

“The project, through the information and training shared, has also cemented collaborations between NATICC, the local police and clinic staff, making the handling of GBV cases in an integrated and timely manner much easier.” - Community Leader

Community members have more information about the ways in which culture, gender and HIV are linked and on where to find HIV and GBV information and services. Fewer cases of GBV are being seen. One Chief noted that the number of GBV cases addressed per week had been reduced due to awareness campaigns.

Women are more empowered to speak up about their rights - Women say they are more able to open up and share information on personal experiences around cultural beliefs that have affected them

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because this is the only platform that we can be listened to as women. Men should know that as women we also have rights and need to be treated with respect.” - Woman Focus Group Discussant

“When the project was introduced to us, I learnt on the inter-linkages between gender, culture and HIV, and I also trained as a CBV...I do not want women in my community to go through my experience...The CTRF Programme transformed my life and my husband’s, we live positively and healthily and we share knowledge with community members.” - Interview Participant (Mbilaleni)

Figure 16 - Men participate in a focus group discussion

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NATICC’s work shows that an integral factor for the success of the CTRF approach is finding the right traditional leaders to work with, and giving them considerable support to be champions for cultural change and to deal effectively with GBV. Providing opportunities for traditional leaders from various communities to meet, share experiences and learn from each other also helps to build a critical mass of community leaders who understand the ways in which women’s rights, culture, GBV and HIV are inter-linked. This work underscores the benefits of stepping up communication and forming strong working relationships between police, health services and traditional courts to ensure that women who report GBV get the level of care and justice they deserve.

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The Cultural Environment in Zimbabwe

Zimbabwe faces the same struggles as other countries with regards to gender inequality, high levels of GBV and harmful cultural practices, but these are

aggravated by the economic crisis that the country has been experiencing. While traditional leaders and heads of families have a vital positive role to play in instilling a sense of responsibility and respect, the cultural environment in Zimbabwe robustly supports customary law, which protects and allows for practices that can violate women’s rights:• Commercialisation of bridal wealth (lobola) – When very high prices are paid for

a woman’s hand in marriage, it may be hard for her to have a say when it comes to sex, and can increase risk of experiencing domestic violence.

• Early marriages – Especially in some religious groups older men (often in polygamous marriages) may say that God has asked them to take a young girl as a wife, which can expose her to infection with HIV.

• Widow inheritance (kugara nhaka) – This practice has changed from its original form in that now it is more informal – a man can just approach the widow without her family knowing and start a relationship with her.

• Kubatidza moto – This is a secretive practice where if a husband is infertile his younger brother is asked to sleep with his wife so that she can become pregnant.

Padare/Enkundleni - Men Working with Men to Address GBV

Padare/Enkundleni Men’s Forum on Gender believes that the negative roles of men in communities can be changed. Since 1995 Padare has been working with men, getting them to reflect on how they can reduce their risk of HIV infection and the risk for their partners. Padare has been implementing the CTRF model in four communities; Mutoko, Chirau, Mhondoro (Chief Murambwa Ward) and Kushinga Phikelela Agricultural College in Zimbabwe.

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Unique Aspects of the Padare CTRF Programme

Padare aimed to focus on those who hold the power in communities (men, boys and traditional leaders) and they also worked with influential men in other positions – like pastors from the apostolic sects, village heads and school headmasters. Once trained, these opinion leaders were tasked with increasing the understanding of the linkages between GBV, culture and HIV among various audiences in schools, colleges and churches. Padare made their activities more attractive to men by holding discussions in pubs, sports clubs, and churches, as well as organising soccer matches between local amateur teams to drive home the need for men to be involved in addressing and reducing GBV in their communities. Padare has also been working to increase the role of men in caring and support activities for those living with HIV in these communities. Often most CBVs are women, but Padare has trained almost equal numbers of men and women to raise awareness on the linkages between GBV, culture and HIV and to provide support to their fellow community members.

Figure 17 - A discussion forum where drama was used to show the inter-linkages between GBV, HIV, culture and women’s rights

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“We challenge men to take a lead in challenging cultural practices. Men have always been privileged in getting whatever they want at the expense of women.” - Padare Project Officer



People are more equipped to face the challenges of HIV - they now see HIV as a community issue, and its prevention and mitigation as the responsibility of everyone in the community. Through CTRF programme activities community members are thinking about how cultural practices can fuel HIV, and they are also getting these messages out to others – especially through drama performances. These performances are so popular that Mutoko and Mhondoro have already established seven drama groups which put on performances dealing with the inter-linkages.

Traditional leaders have an improved understanding of how some cultural practices contribute to increased new HIV infections – along with this awareness has come willingness from leaders to address harmful cultural practices, and an understanding of their role as opinion leaders in getting their communities and others to start the process of change.

“I committed myself to ensuring that my community is enlightened on the inter-linkages between culture, gender, women’s rights and HIV. I sponsored the awareness campaigns on HIV and AIDS using my own funds, I encouraged people to go and get tested and know their HIV status. As a way to lead by example I went for VCT myself. You will notice therefore that the number of deaths related to HIV and AIDS in my community have been reduced.” - Paramount Chief Murambwa, Mhondoro-Ngezi

“I personally went to Rwizi, Mashayamombe, Chivero and Nyamweda communities to inform the chiefs in those areas that they should encourage their people to go for VCT. I also encouraged the chiefs to lead by example by going for VCT. I am the first chief in the whole of

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Zimbabwe to be part of the campaign against cultural practices and gender inequalities in order to prevent HIV in our communities. I am therefore willing to lead the national campaign through educating other chiefs on how they can replicate the project in their communities.” - Paramount Chief Murambwa, Mhondoro Ngezi

A strong partnership has been formed with a network of PLHIV based in, and deeply rooted in the community - Padare, as an ‘outsider’ organisation forged a relationship with Simbarashe Network of People Living with HIV (a community-based organisation that has strong roots in the community) to encourage support and participation in the CTRF programme.

“People living with HIV are very active in supporting the CTRF project; most of them also work as Community-Based Volunteers. The project has ensured that PLHIV take the lead in awareness campaigns. Their sharing of testimonies is very important in encouraging other people to go for HIV testing so as to know their HIV status.” - Padare CTRF Project Officer

Men are at the forefront of changing awareness and beliefs in their communities - Involving men (especially as CBVs) in the process of looking at and trying to change harmful cultural practices has given the process legitimacy and given community members confidence to believe they can change.

“Traditionally it was taboo to pinpoint negative aspects of our cultural practices but today the men and the community leaders are taking the lead in identifying and plucking out negative practices.” - Executive Director, Simbarashe Network of PLHIV

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“I have been trained to assist others and I am willing to walk long distances in order to provide my services...We can now go for six months in our community without attending a funeral from an AIDS related death.” - Male Community Based Volunteer

Cases of GBV are on the decline - people feel that because men took the lead in programme activities, they are making it less acceptable to perpetrate GBV.

“During the dialogues, the men are able to note that there is nothing special about being men, we are all equal; as a result the number of reported GBV cases has been significantly reduced.” – Male Community Based Volunteer

The communities are seeing fewer HIV related deaths and more people are living positively - Before the programme, there were about two AIDS-related deaths per week, and men especially did not seek help, even when they were very ill. People reported that adhering to their medication was easier, and there was more uptake of sporting activities and gardening.

“The community never believed in HIV before the enlightenment from Padare. The belief that came into mind when one was sick was ‘akaroyiwa’ (he or she was bewitched).” – Community Member, Beneficiary

Women are more assertive in claiming their rights - Through dialogues and providing information, Padare has helped encourage women to be more assertive about claiming their rights, and in communicating with men, and with other women on their rights and protecting their bodies.

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Padare’s work focusing on men as agents of change in their communities highlights the need to recognise men as those who hold the power in relationships and communities and therefore those who have the power to start and sustain processes of change to support the women in their lives to claim and enjoy their rights. Working on the other side of the equation increases women’s awareness and assertion of their rights, creating a fertile environment for the long- term process of changing and eradicating harmful cultural norms and practices.

Figure 18 - A religious leader emphasising a point during a Padare focus group discussion

WAG Works Through Traditional Courts to Address GBV

Women’s Action Group (WAG) was founded in 1983 and advocates for women’s rights in Zimbabwe. This Best Practice is from WAG’s experiences and successes in implementing the CTRF programme in Guruve, a rural area in Zimbabwe’s Mashonaland Central Province where polygamy, early marriage of young girls, widow inheritance and other negative religious practices are at the heart of women’s vulnerability to HIV infection.

Unique Aspects of the WAG CTRF Programme

WAG’s unique contribution on the CTRF programme involved working hand-in-hand with the traditional courts to influence their rulings where cases of GBV or harmful cultural practices were involved. For example, when a woman went to the traditional

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court because her husband had slept with her younger sister and then taken her as his second wife. WAG also introduced an ‘individual risk assessment’ exercise to trainings on the inter-linkages between women’s rights, culture, GBV and HIV. In this exercise, programme implementers encouraged people to examine/revaluate their own lives and what placed them at risk of infection with HIV, as well as to look at contributing factors tied to their culture and environment.

In a further innovative approach, because married women in the community in particular were at a very high risk of both domestic violence and HIV, WAG trained married couples together on the links between culture, GBV and HIV in order to reach couples together and counter possible resistance to change by husbands. The trained couples also offer peer counselling and share knowledge gained with others in the community to support the work of CBVs. WAG opened up the community cultural dialogues to both young and old (anyone from 16-65 years was welcome). These dialogues provided a much needed opportunity for different generations to come together and talk openly about taboo topics they would not otherwise discuss.


Incidences of harmful practices like wife inheritance and early marriages have decreased. Since the CTRF programme was launched, WAG reported that there had been a reduction in the cases of people engaging in harmful cultural practices.

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“Community gatherings are an opportunity for CBVs to share information on the inter-linkages between culture, gender based violence, HIV and AIDS. The CBVs engage community members in these gatherings to dialogue on solutions to the challenges of harmful cultural practices.” – Programme Implementer

There are fewer cases of GBV - This is seen as being due to the village courts quickly and effectively dealing with cases, and also due to WAG working closely with the police on reporting cases. Other successes observed by local clinic staff are fewer sexually transmitted infections (STIs), more people going for HIV testing and taking condoms from the clinics, and fewer unwanted pregnancies.

“We used to have at least 10 cases of GBV per month in our courts and as a result of the programme the cases have declined to about four cases a month.” – Traditional Leader

Women and men are more aware of how gender inequalities link with HIV transmission - Women are also more aware of their rights to protect their lives and bodies. Young people are thinking more carefully before having sex and thinking about who they are having sex with.

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The CTRF Model - Working Approaches for Success

The key to using Best Practices is to look at success factors – common threads that run through these programmes which have been key to achieving their goals.

Although a core strength of the CTRF model is the way it lends itself to being adapted for different communities, cultural practices and additional issues, there are common ‘success factors’ and ‘working approaches’ that all programmes can work towards. Using these working approaches will increase participation and buy-in and build confidence in the power of the model to help communities to change from within, and to sustain that change.

1. Accept That Change Takes Time And Persist In The Face Of Resistance - The aims of the CTRF model are challenging to achieve. Changing cultural practices is not something that can happen overnight, or even over a couple of years. Sufficient time, training and resources are needed to enable CBVs, traditional leaders and community members to have an impact on ‘changing culture’. This way of working to support communities to change from within means that the change is more likely to be real and long lasting. CTRF activities need to carry on into the longer term to have an impact on changing beliefs and attitudes, especially when working with elderly community members who may be the ones holding on strongly to the preservation of negative cultural practices. Organisations may even expect some kind of resistance at some point, perhaps from traditional leaders who are the ‘custodians’ of culture. GAPA’s work showed that respectfully explaining the effects of harmful cultural practices on high HIV infection rates can enable traditional leaders to become more willing to accept the programme over time. Working with a ‘champion’ who is a traditional leader can get the organisation access, credibility and support from traditional leaders where resistance might have been an issue. Also, showing respect for culture and emphasising the positive and protective

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aspects of culture can help ‘win over’ traditional leaders who might be resistant to the process. There needs to be a delicate balance between challenging harmful practices and promoting positive practices.

2. Motivate, Support And Monitor CBVs – CBVs are the heart of the CTRF model. They live in the communities they serve and have a vested interest in seeing change. Carefully selected and well-trained and supported CBVs are trusted and respected in their communities and their skills and knowledge can be a vital resource for sustainability of future programmes. Increasing male involvement is a key factor for success. CBVs tend to be women, but Padare’s work has shown that men also have an important role to play as CBVs. They have the advantage that household heads are more likely to talk to them about issues of culture and there is also a great opportunity for male CBVs to gain personal satisfaction from doing something important for their community.

In a perfect world we would not be worried about a lack of funding, but in reality limited funding means it can be difficult to support CBVs. Even so, relatively small amounts of funding, which could be used creatively and simply to motivate CBVs, may go a long way to improving the way they do their work. CBVs are motivated to serve their community, but incentives are still needed to keep up morale and ensure activities are conducted effectively and as planned. WAG’s experience showed that CBVs were more active when they knew that the WAG Field Officer from Harare would be visiting, but CBVs needed to be motivated to be active, even when there were no monitoring visits. A simple motivation used by several programmes is t-shirts that identify CBVs as being part of the programme (giving them credibility). Other incentives could be sling bags, hats, bicycles, or refresher training courses. Exchange visits for CBVs to other CTRF programme sites could also be a successful motivator. MULEIDI and OMES faced challenges in that literacy levels in their CBVs were quite low, and this limited their use of valuable training materials. This is likely to be a common issue, and programmes could be greatly strengthened by

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encouraging or providing opportunities for CBVs to improve their literacy, which would also be an important motivator.

Apart from incentives, CBVs need moral and where possible, financial support to avoid burn out. They face difficult situations every day, and providing counselling may be an option to support CBVs’ mental health. Organisations need to mobilise and use community resources to support CBVs wherever possible. This not only fosters community ownership but also reduces financial costs. Strategies need to be in place to avoid losing CBVs due to burn out for other reasons, for example having to walk long distances (especially problematic for those who are sick or disabled). Creative solutions to transport challenges need to be sought at every possible opportunity – including requesting traditional leaders to provide transport or arranging activities in more central locations.

3. Leverage Traditional And Political Leadership To Advocate For Change - Strong and early involvement of community leaders builds ownership and participation in programmes activities. As NATICC has clearly shown, investing time and effort in working with young or more open-minded community leaders means they can become ‘champions’ or ‘ambassadors’ for the messages of cultural change and have great potential for impact as role models. They can also spark interest and commitment to activities. Committed and mobilised traditional leaders can offer support (transport, financial, refreshments and venues) in their personal capacities. Further, intensive training (beyond one training session) on the linkages between gender, culture and HIV can help traditional leaders to make more of their roles as agents of change.

Working closely with Ministries of Health (and other relevant ministries) has great potential for making change happen on a larger scale, as evidenced in the work of MULEIDI and OMES in Mozambique. When ministries see the benefits and change that can happen, it provides a drive and direction for government to take the

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initiative forward. In all southern African countries there are different organisations working on GBV, and also probably indirectly addressing harmful cultural norms and practices. These organisations need to coordinate their activities and working through a ministry which can coordinate these activities can help.

4. Form Strong Partnerships With Existing Community Structures – Formalised partnerships with the police, clinics and religious groups (or others providing psychosocial support) are essential for the smooth running of CTRF programmes, and to ensure community members get the best care and support. Members of the police need to be motivated to deal with GBV cases quickly and effectively by seeing how their failure to do so can have an impact on the safety of women in their homes and communities. Amongst the partners there also need to be systems in place to monitor how GBV cases that are reported are dealt with, and if there are other ways that survivors of GBV need to be supported. Each partner needs a clear role (e.g. in Swaziland, the police handle GBV cases, and the church and NATICC offer counselling services). There should be good referral links between the partners and clear articulation of roles so that cases of GBV can be handled quickly and effectively, to discourage violence and improve support for survivors. For example SWANNEPHA improved coordination between the police and health services - it referred survivors of GBV to the Police Victim Friendly Unit. Personnel there investigated cases and apprehended perpetrators. The clinic also provides VCT services and medical attention for survivors of GBV who have been referred to them by SWANNEPHA.

For organisations which are not based in the areas where they want to work

(like Padare) working with a reputable community-based organisation (like the Simbarashe Network of People Living with HIV) means that activities are received with respect and the organisation based in the community also has the power and influence to encourage positive changes to cultural practices in a more sustained manner.

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In many southern African countries, some religious groups are secretive about their church practices, often because they can be harmful to women (e.g. child marriages). In Zimbabwe for instance, religious practices are also often intricately linked with cultural practices in a community. Therefore bringing in church leaders (who are often also village headmen) in a constructive way is vital so they can understand how these practices are linked to HIV and share their knowledge with members of their religious group.

5. Promote Cultural Dialogues As Safe Spaces For Communities To Work Towards Change – Almost every organisation covered in this book demonstrated that the community members they had worked with benefited greatly from being able to talk about difficult and taboo issues that they had no other forum for. Participation in dialogues is also improved because community members themselves drive the process and the direction of the dialogue. Separate dialogues with community leaders, women and men give each group a chance to share their views in a space they are comfortable with before bringing their issues to the larger group. Part of this ‘safe space’ also means a safe space for individuals to tell their own stories, or testimonies – about how they have been affected by harmful cultural practices, GBV and HIV. Separating participants by age can ease the process of speaking about sex and sexuality issues. Bringing the groups together then enables them to focus together on agreeing on solutions to the issues raised. On a practical note, CTRF programme staff consistently explain that to get good participation in dialogues and other activities, they need to provide food or refreshments for participants. This can be worked out effectively and at relatively low cost. For example, in several of the Best Practices documented here the organisation buys the food and community members prepare it for the events.

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6. Make Activities Exciting And Attractive For Community Members - In some rural areas there is hardly any entertainment and edutainment activities can fill this gap. Using interactive approaches makes activities more engaging, and helps people to depersonalise issues and engage better in dialogue. Edutainment can be in the form of drama, song, dance, sport, or almost any other innovative format that still enables the message on harmful cultural practices and HIV to be brought across. Using different venues like pubs, sports clubs and other places where people congregate, as is being done by OMES and Padare, can also make activities more attractive. Similarly, radio is a great tool because it brings in people from all income groups, social and educational levels to be able to participate in discussions about how GBV affects them and what can be done to change this. It also has a wide reach, and can be cost-effective if approached creatively and with buy-in from radio stations. NWHN and others have successfully used different radio formats such as talk shows and phone-in shows to mobilise around their programmes and increase awareness of the issues of culture and GBV.

7. Find Innovative Ways Of Disseminating Information - Many people in more rural communities in southern Africa cannot read, or more specifically cannot read materials in English. Materials with information on the linkages between gender, culture and HIV in local languages are useful so that many more people can be reached. In addition, further ways of ‘getting the information out there’ need to be used, for example community meetings where CBVs can speak. CBVs need to be empowered and encouraged to take advantage of any gathering of men, women or young people in a community as an opportunity to share their knowledge. Organisations implementing the CTRF programme also need to market the programme to its stakeholders and other partners, for example using newsletters, news alerts and print and electronic media to share experiences and lessons learned. This can also open up funding streams to continue and broaden the reach of the current programmes.

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8. Promote Livelihoods Programmes For Women – Poverty is consistently linked to the economic dependence of women on men and consequently to women’s inability to report and escape GBV. A variety of income-generating activities and approaches are needed to give women the greatest chance for economic independence. On a practical level, this means linking work on culture, GBV and HIV with income-generating activities and making CTRF programmes sustainable in the long term.

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Conclusion

The Best Practices discussed in this book have brought to the fore the fact that harmful cultural practices are deeply entrenched, and changing them needs to

be approached sensitively but with boldness to see results. Although many people in southern Africa have moved into cities and urbanised settings, they retain and hold sacred many aspects of their traditional culture - these are adapted to urban lifestyles but are still hugely important. In rural communities harmful cultural practices may have an even stronger hold because of the influence of traditional leaders and elders. An added challenge is that because of the subtleness of cultural change, it can be hard for organisations working in this area to know, or to show, whether they are actually having an impact.

This book demonstrates that progress has been made - training and working with traditional leaders and CBVs, and giving communities space to dialogue IS showing benefits that are sustainable. There ARE emerging achievements in changing beliefs and norms that lead to harmful cultural practices. Many of these achievements have been attained with very little external funding – implying that communities have within them the power to change, and that what is needed is information and platforms like community cultural dialogues to bring about and drive this change.

However, there is still a long way to go. Male power and dominance are so entrenched in southern African cultures that it remains a key challenge to get men involved and committed to changing harmful practices. At the same time, the involvement of these men is absolutely critical to make these changes happen. We need to make clear what the benefit is for men in going against the grain and redefining what it means to be a man in their generation and community. It is not only women who stand to gain by accessing their rights – men also stand to gain through reducing their own risk of contracting HIV, and in improving their relationships with the women around them.

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These challenges should not take away from the changes that we are seeing - we should be encouraged by seeing that change CAN happen. Increased knowledge and open discussion on the impacts of harmful practices is the first step on the road to lasting change. More and more women are feeling empowered and safe enough to speak about sex, their relationships, and how cultural practices affect them without fear of violence or of discrimination. This in itself is important progress as communities come together in dialogue and talk about things that were taboo.

The Best Practices in this book are from widely varying contexts, which reinforces the flexibility and adaptability of the CTRF model. This hinges on the fact that communities themselves have the knowledge and experience to make change happen once the CTRF model ignites this change.

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Recommendations for Organisations Implementing the CTRF Model

Along with the working approaches we have gained from these Best Practices, recommendations for improvements and how to increase the ‘footprint’ of reach

of the model are also becoming clear.

1. Conduct A Situation Analysis To Identify Needs• Organisations need to undertake a baseline survey, or mapping exercise to find

out what cultural practices are considered harmful by community members before implementing the CTRF model. It is essential to get community members themselves to discuss and articulate the practices which they consider harmful – this should not be imposed by the ‘outsider’ organisation.

• Programmes can be improved by identifying positive aspects of culture that help communities prevent the spread of HIV. The model is rooted in the appreciation that cultures are beautiful and that positive aspects (like the passing on of wisdom and values between generations) are important in the fight against HIV. Identifying these positive aspects and specific positive practices before implementing the CTRF programme is as important as identifying harmful practices. Organisations using the CTRF model should also work to support traditional leaders to promote these positive practices within their communities.

2. Form Partnerships With Organisations In The Area• Before using the CTRF model, or before taking it to more communities in

different areas, organisations need to take time to understand the different organisations working in the area and how their activities link with or mirror what the CTRF model is trying to achieve. With this knowledge organisations can form partnerships, making the most of each other’s strengths and coordinating their activities so that resources are not wasted on doubling up and so that communities do not become ‘fatigued’ with multiple HIV prevention programmes.

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ion • Information and referral systems must work hand in hand for programme

effectiveness, especially between traditional courts, law enforcement and law courts and also with health services.

3. Work Closely With Government And Traditional Leadership• Organisations using this model also need to make sure that local government

and traditional leadership know the aims of the programme and can offer support and not obstacles to activities. They also need to make sure that the CTRF programme does not just target communities close to capital cities, or within convenient travelling distance, but that it also begins to reach deep rural communities. Working with local government also has advantages as the project can be included in the work plans, budgets and long term plans of local government. Activities can also be coordinated in line with government priorities for the area.

4. Ensure The Effectiveness Of CBVs• Because CBVs are not ‘employed’ a Memorandum of Understanding between

the organisation and the volunteer can be useful to make the expectations on both sides clear.

• The time and energy that CBVs commit to their community and to the programme needs to be gratefully acknowledged. Organisations need to find ways to ensure that CBVs know their work and dedication is highly valued, even though it is not always feasible to pay them a salary. This acknowledgement is vital if the CBVs are to continue as the core of the programme without becoming burnt out and having low morale. Setting up income-generating activities for CBVs may also go a long way towards offering some financial support for them and their families, which will free them up to do their work in their communities better.

• Organisations need to recognise that CBVs have other roles, and are not just providing information on links between culture, GBV and HIV. For example they may encourage people to go for VCT, and so organisations implementing the CTRF model need to make sure that testing is accessible to the communities it serves. CBVs also need to be trained in these other areas of work so they can work ethically with members of their community.page 86


• Implementing organisations need to make sure CBVs have ‘supportive supervision’ so that CBVs have regular support visits where they can ask questions, see if they are doing things right, and keep up their motivation levels.

• Funding sources need to be found to give CBVs a travel allowance. Some walk exceptionally long distances when they do door-to-door outreach services. Alternatively, organisations could arrange transport from a central location.

5. Work On Sustainability For The Long Term Vision Of Cultural Transformation To make sure the programme continues to have a sustained impact, funding needs to be continuous. Organisations can explore linkages with other funding sources like the Global Fund to Fight Tuberculosis and Malaria (GFTM) to support CBVs. Everything possible should be done to make sure that activities do not stop and start with funding challenges or donor systems for releasing money. Organisations also need to have in place the ability (and resources) to take on and implement spin-off activities. For example sex and sexuality training for couples, couples communication training or income-generating activities, if these are identified as being important to the success of interventions and in ensuring their sustainability.• Organisations should have a strategy in place for when their funding ends, or

when they plan to leave the community. This should focus on how to keep the process of change going – how CBVs can keep sharing information on culture and harmful practices, and use community meetings and other events as opportunities to dialogue.

Change takes time, but it can happen, and every community deserves the

chance to ignite this process from within. The Changing The River Flow model and these nine Best Practices from southern Africa point the way for continued work to develop cultures that protect women from violence and halt the spread of HIV in our communities into the future.

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SAfAIDS Regional Office: 479 Sappers Contour, Lynnwood, Pretoria 0081, South Africa. Tel: +27-12-361-0889 Fax: +27-12-361-0899 E-mail: [email protected]

Country Office - Zimbabwe: 17 Beveridge Road, Avondale, Harare, Zimbabwe. Tel: +263-4-336193/4 Fax: +263-4-336195 E-mail: [email protected]

Country Office - Zambia: Plot No. 4, Lukasu Road, Rhodes Park, Lusaka, Zambia. Tel: +260-125-7609 Fax: +260-125-7652 E-mail: [email protected]

Country Office - Mozambique: Av. Paulo Samuel Kankomba n.2051, R/C Maputo, Mozambique, Telefax +258-213-02623, Email: [email protected]

www.safaids.net

Turning the Tide on Gender Based Violence

Best Practices of Organisations Applying the ‘Changing the River’s Flow’ Model in Southern Africa

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