Geographical context and HIV/AIDS: multiple health perspectives on Mozambican women¹

Abstract

The aim of this article is to understand the gender vulnerability experienced by women living with HIV/Acquired Immunodeficiency Syndrome (AIDS) in the city of Maputo, Mozambique, according to the reports of representatives and leaders of the health services who work directly on the issues of these conditions for the female public. To this end, the research was based on qualitative methodologies, since the production of the data was supported by a semi-structured script that considers the following themes: HIV/AIDS; gender; culture; and health services. The interpretations are mediated by Discourse Analysis (DA), which enables immersion in linguistic resources through meanings and connections. This allows us to interpret the complexity of the geographical context of women living with HIV/AIDS in the region, highlighting the need to promote actions toward the issues surrounding the disease, since it is urgent to establish a geographical interpretation of health, especially considering the reality lived by women who experience difficulties, oppression, stigma, and discrimination on a daily basis.

Keywords:
Geographical Context; HIV/AIDS; Vulnerability; Gender; Women

Resumo

O objetivo deste texto é compreender a vulnerabilidade de gênero experienciada pelas mulheres que vivem com HIV/Síndrome de Imunodeficiência Adquirida (SIDA) na Cidade de Maputo, Moçambique, através dos relatos de representantes e lideranças dos serviços de saúde que atuam diretamente sobre as questões dessas condições para o público feminino. Para isso, a pesquisa se embasou em metodologias qualitativas, visto que a produção dos dados foi respaldada por um roteiro semiestruturado que considera os seguintes temas: HIV/SIDA; gênero; cultura; e serviços de saúde. As interpretações são mediadas pela Análise do Discurso (AD), que possibilita a imersão nos recursos linguísticos por meio dos sentidos e conexões. Isso permite a interpretação da complexidade do contexto geográfico das mulheres que vivem com HIV/SIDA na região, evidenciando a necessidade de se empenhar mais ações voltadas às questões das doenças, uma vez que se faz premente estabelecer uma interpretação geográfica da saúde, sobretudo, no que diz respeito à realidade vivida pelas que experienciam dificuldades, opressões, estigmas e discriminações no cotidiano.

Palavras-chave:
Contexto Geográfico; HIV/SIDA; Vulnerabilidade; Gênero; Mulheres

Introduction

Currently, HIV/AIDS is one of the diseases that has most affected the world’s population, with approximately 37.9 million people living with it worldwide, a fact that highlights this situation as a problem that crosses different scales and affects various segments ranging from the local to the global (UNAIDS, 2019).

In some places, the HIV/AIDS situation is very serious, due to the rapid spread of the disease and the lack of subsidies for containment, prevention, and treatment, which makes the different realities more complex. Thus, it is important to understand that its spread is related to the space-time conditions in which it occurs as a phenomenon, given that social, economic, political, and cultural elements shape the production of the geographical space that characterizes the multiplicity of the epidemic (Bastos; Barcellos, 1995).

In this sense, it should be emphasized that the magnitude and development of the HIV problem means that its pathogenic manifestations acquire the character of a pandemic. This is the case for a large part of the African continent, specifically sub-Saharan Africa, which continues to have the highest levels of HIV/AIDS in the world (UNAIDS, 2019). This is due to the set of factors involving complexities found in the many faces of the epidemic, considering that the manifestation of the disease conforms to the geographical context (Pedroso, 2017).

Considering the aforementioned elements, we made an effort to get closer to the reality of HIV/AIDS in Mozambique, given that this is one of the countries most in need of interpretation due to its global conditions (Allison; Harpham, 2002). In view of this, the seriousness of the HIV/AIDS situation in Mozambique is one of the most acute, as the country has a very delicate reality-with the eighth highest national prevalence in the world-to the extent that social and economic development is threatened because more than a quarter of adults are infected with the HIV virus or affected by AIDS in some regions (Cau, 2014).

Many of these complexities present in the Mozambican reality concern women. It is necessary to present the different relationships that are configured within this context from a gender perspective, as the relationship of the subjects and their experiences have strict links with the space in which they live and produce (Alves; Pedroso; Guimarães, 2019).

Having highlighted the main aspects of this study, we have focused our efforts on interpreting the reality experienced by women living with HIV/AIDS in the city of Maputo, Mozambique, with the aim of gaining a qualified understanding of the gender vulnerability they experience through the reports of representatives and leaders of the health services who work directly on HIV/AIDS issues for women. This proposal enters a complex field, which involves numerous, distinct, and important elements relating to the realities of Maputo-Mozambican women due to the interlocution between social, economic, political, educational, gender, and cultural aspects that place these women in mostly unfavorable positions (Estavela; Seidl, 2015). An example of this are some Mozambican traditions that organize family lineages into patrilineal (southern Mozambique) and matrilineal (central and northern Mozambique). According to Maúngue (2015, p. 56) these systems

dictate the ways in which women and men are socialized and, consequently, the positions each occupies in society. Lobolo, polygamy, early marriages, initiation rites and purification rituals for widows throughout the country are also relevant cultural aspects and part of the tradition. (2015, p. 56, free translation)

When we consider the reality of Maputo, the capital located in the far south of the country, we understand that the patrilineal organization is preponderant, as well as the systematizations and reflections resulting from this structure (Manuel, 2011). Together, these relationships create asymmetries, such as women’s submission to men, the instability of security in the community to which they belong and situations of poverty and prostitution (Estavela; Seidl, 2015), which exacerbates women’s lives and make them vulnerable to HIV/AIDS infection.

Thus, this issue configures a dynamic geographical process “that constructs and is constructed by everyday spatial experiences based on representations, [and that these] are founded on a specific socio-spatial order” (Silva, 2003, p. 42, free translation, our addition) of space-time, content, and agency, which for us constitutes the geographical context as an interpretative reasoning based on reality (Pedroso, 2022).

In view of this, it is important to highlight that the concept of geographical context makes a significant contribution, since it deals with the configuration of “[…] a set of dialogical, relational and dynamic relationships, which take subjects as the principle of action and meaning and, therefore, are subject to transformations that configure them while connecting them to the particular and the universal” (Pedroso, 2022, p. 118, free translation). This conceptual apparatus enables us to elucidate the complexity of real phenomena, highlighting the contours that underpin the conformation of specific realities of space-time, content, and agency which, for the most part, present flexible movements of impacts, (dis)continuities and intersectional complementarities, especially regarding issues of gender, health, and illness (Guimarães et. al., 2023).

For these reasons, we prioritized investigating the reality of Mozambique according to the geographical context of women living in Maputo, allowing us to ascertain the conditions, culture, policies, and actions in the face of the HIV/AIDS epidemic.

From these assumptions, we start to interpret gender issues in a relational and temporally and spatially situated way, as a social construction that is based on specific cultural, political, educational, and economic elements which, in turn, create countless possibilities in the different ways in which subjects experience their lives, in terms of their respective geographical contexts. It is along these lines that we seek to interpret the reality of Maputo-Mozambican women, to the extent that other conjunctures that are associated, that start from their reality and that consider their spatial modes of existence in relation to the process of health and illness are taken into account (Guimarães, 2019).

Materials and methods

The reality of HIV/AIDS in Mozambique is becoming more and more expressive for women (Estavela; Seidl, 2015), which has made us feel the need to delve deeper into theory in order to understand it, which is highly complex. This has led us to understand the geographical context of HIV/AIDS according to methodological steps. In this sense, it was necessary to move beyond statistical issues, understanding the subjects who conjure up these elements and, more than that, seeking to understand the structuring configurations of the geographical contexts that are relationally produced by these people (Guimarães, 2015; Pedroso, 2022; Guimarães et. al., 2023).

Starting from these premises, we reinforce the idea that it is important to enter the geographical context, so that there is interaction (above all) with people and health services, taking into account the structures that form the basis for the reality under investigation. It was necessary to establish a reasoning based on the agency of these elements and, from this assumption, we looked at the inequities present in the interaction between HIV/AIDS and gender, focusing on the struggle of Maputo-Mozambican women against the conditioning structures (Maúngue, 2020).

This study is based on a qualitative research approach, using methodological triangulation (Tuzzo; Braga, 2016), aiming to interpret reality based on the experiences of representatives and leaders of the health services that deal with HIV/AIDS in women in the city of Maputo. To do this, it was necessary to make efforts to implement investigation strategies prior to the approach, with reconnaissance, testing, and the establishment of contacts being important actions for a qualified construction of the empirical processes (Minayo, 1994).

How? Who? and Why?: methodological steps and interaction with the context

The empirical actions were materialized through numerous field works, so that this process continuously allowed for the establishment of active reflections between the theoretical and the practical (Zusman, 2011). Regarding the methodological steps, it is important to highlight the initial difficulties in approaching and establishing links with the representatives and leaders of the health services. These difficulties stemmed from excessive bureaucratization of documents, scheduling mismatches, and a certain strangeness due to the fact that we were researchers in the field of human sciences interested in issues related to HIV/AIDS, which a priori was interpreted as something unusual.

In this regard, it should be noted that the actions required were formal and gradual, taking into account that some institutions required the submission of the research project, letters of introduction and institutional letters in order to be analyzed and approved for the activities to begin. From these methodological prerogatives, we carried out field activities over a period of four and a half months, permeated by reading, technical visits, meetings to get to know each other, participation in events and meetings, as well as interviews.

The first actions in the field were based on rapprochement/interaction, with initial contacts being made through researchers who already had direct knowledge of the reality we were investigating. This relationship created strategies and guidelines that ensured dialogue with key people directly connected to the central proposal. In this way, we were able to tap into a network of sociability that ensured referrals and introductions to people, including specialists, public health workers and activists who deal with HIV/AIDS issues in women on a daily basis.

During these stages, we were promptly welcomed by all the participants who immediately agreed to take part in the research and did not hesitate to provide rich and in-depth dialogues about the reality of women living with HIV/AIDS in Maputo. Initially, the aforementioned actions allowed us to build important continuous bonds, allowing us to conduct interviews with representatives of the health services and activists who were concerned with establishing reflections on the geographical contexts of women living with HIV/AIDS in Maputo, Mozambique. In this context, it is worth noting that we held three meetings with each research participant, namely: (1) the first dedicated to introducing/approaching them; (2) the second focused on conducting the interviews; and (3) the third involved providing feedback on the analysis carried out as results.

A script was constructed containing questions structured by thematic fields that served as guiding axes for the narratives, since they were dedicated to structural themes such as: HIV/AIDS; gender; culture; and health services. This process was designed by the researchers aiming towards constructing the interviews using questions that made up a semi-structured script (Manzini, 1991). Under these propositions, we made use of technological recording resources (audio) to record the reports produced in the field, and these were transcribed in an attempt to faithfully capture the details present in the interview. We also used a field diary to record non-recordable data (expressions, feelings, movements, etc.).

Through this approach, it should be noted that we did not propose a probabilistic and/or statistical sample analysis beforehand, as we understood that the research universe investigated, as well as the strategies used, required other methodological approaches. In view of this, we prioritized interviews due to the accessibility and convenience of those involved, as it is through this method that “the researcher selects the elements to which he has access and admits that they may represent the universe” (Pessôa; Ramires, 2013, p. 122) under investigation, both in terms of the potential and the limitations of the research.

Based on these theoretical and methodological foundations, we ensured the participation of six interviewees who deal directly with HIV/AIDS issues in their work, activities, research, and activism, highlighting the point that the participants have direct contact with issues concerning women living with HIV/AIDS living in Maputo, Mozambique, as can be seen in Table 1, which shows the profile of the interviewees.

Table 1
Profile of the interviewees

Identification	Sex	Training	Place of work
Interviewee “X”	Female	Geographer	Eduardo Mondlane University (UEM); Women and Law in Southern Africa Research and Education Trust (WLSA)
Interviewee “O”	Female	Nurse	Association of Midwives of the City of Mozambique (APARMO); 1° de Maio Health Center
Interviewee “J”	Female	Activist	Hixikanwe Association
Interviewee “A”	Female	Public Health	STI-HIV-AIDS Control Program, Ministry of Health (MISAU)
Interviewee “E”	Female	Social Worker	Maputo City Health Services, Maternal and Child Health Department
Interviewee “S”	Female	Physician	Maputo City Health Services, HIV/AIDS Department

• Source: Prepared by the authors.

As mentioned above, the interviews were conducted using semi-structured scripts as the operational-methodological tool (Manzini, 1991), which ensured that numerous facets of the lives of women living with HIV/AIDS in the region could be articulated. These elements enabled a rich and plural dialogue with different fronts of action related to combating this epidemic and their respective gender relations, which led to profound exchanges through the narratives constructed.

It is worth mentioning that the interviews were carried out through constant meetings with each participant between September and December 2019. It should also be pointed out that the individual interviews lasted approximately one hour on average, which meant a lot of effort was put into transcribing them, since we consider this methodological process to be a pre-analysis of the data produced.

Finally, the processes mentioned above allowed us to focus on methodological issues related to the systematization and organization of qualitative data. In order to carry out this task, it was necessary to delve into Discourse Analysis (DA), which allowed us to immerse ourselves in linguistic resources and the different possibilities for investigating the materials (Maingueneau, 1997). This methodological strategy was aimed at the organicity of the speeches-statements and evocations-and the interpretation of the meanings and connections that are established in the subjects’ discourses.

In this study, DA was used to create a discursive corpus which we understood as an archive that brings together information that is dialogically articulated with other elements, other discourses, and different enunciating subjects at different times. This required us, as researchers, to take the lead in assuming the interpretations constructed from the texts, since this exercise “can only be achieved through spiral hermeneutic movements, which in each new return to the phenomenon enable a more radical and in-depth understanding” (Moraes, 2003, p. 201, free translation).

Thus, our central aim was to elucidate the consequences that the female population of Mozambique living in Maputo has been suffering as a result of this disease, which is becoming increasingly aggressive (Maúngue, 2020). It is therefore necessary to take women’s experiences into account from the perspective of the health services, since this dimension is of paramount importance in the composition of the geographical context of Mozambican women living with HIV/AIDS, as it makes up the political sphere of tackling the pandemic.

Perspectives and discourses on women living with HIV/AIDS in Maputo, Mozambique

To begin this reflection, it is necessary to understand that, for the most part, the profile of reported AIDS cases in women is directly linked to factors that corroborate the situation of vulnerability, understanding that “HIV infection and illness is the result of a set of characteristics of the political, economic, and sociocultural contexts that amplify or dilute individual risk” (Buchalla; Paiva, 2002, p. 118, free translation).

This takes into consideration a series of elements that cross the lives of the subjects in different ways. One example is the reality experienced by a large proportion of Mozambican women, analyzing that those reported as having HIV/AIDS have a lower level of schooling than men under the same conditions, relationships of economic dependence, compulsory responsibility for offspring and their care, etc. These elements condition women into less privileged situations, making them more vulnerable to infection (Andrade; Iriart, 2015).

In this sense, it is worth noting that the dialogue that was built-when the analytical focus was on the city of Maputo-was based on the geographical scales that underpin the respective analyses, with the discourses sometimes focusing on the general reality of Mozambique, sometimes delving into the specific context of the capital, as we can see when we first asked about the HIV/AIDS situation in the country.

When we think of these movements as relational processes, Interviewee E’s comments are pertinent, since she presents not only the context of Mozambique in relation to other African countries, but also shows the reality experienced in Maputo, which allows for a geographical interpretation between the local and the global (Massey, 2008) in relation to the HIV/AIDS phenomenon.

Overall, in Mozambique, the HIV situation has been increasing, although some provinces have high prevalence rates, others have low prevalence rates, but specifically for us in Maputo […] our prevalence is high, because it’s the big city, where everyone comes here. And there’s also our neighborhood with another country, with South Africa, and that makes our province have high HIV/AIDS rates. (Interviewee E, 2019)

Interviewee E’s arguments characterize the relationships, flows, and scales that permeate the complexity of HIV/AIDS in Mozambique, especially in Maputo, since she does not disregard the reality experienced by the Mozambican population. Thus, this complexity is intrinsic to the Mozambican geographical context, which ends up giving it characteristics that move between the general and the specific, given that the reality of Mozambique, as well as that of Maputo, are significant in terms of the records and notifications of cases over the years.

In this sense, it is also necessary to consider other issues that are part of this situation, such as social and cultural values and those of gender and sexuality, as well as issues of vulnerability and the various stigmas and prejudices related to HIV/AIDS. The trend towards the feminization of HIV/AIDS “[…] is found throughout sub-Saharan Africa, where women represent 58% of all people living with HIV, and also in all regions of Mozambique, with heterosexual relations being the predominant route of transmission” (Andrade; Iriart, 2015, p. 566, free translation).

Gender relations and their geographical contexts

It is extremely important to reflect from a spatial point of view on the vulnerability and gender issues experienced by Mozambican women in relation to HIV/AIDS (Estavela; Seidl, 2015). It is therefore necessary to focus on the relationships between the conceptualization of vulnerability, gender, and HIV/AIDS, since they cross and meet in the phenomenon of the feminization of the disease (Silva et. al, 2007; Passador, 2010), as interviewees X and J explained:

I’ll tell you that it’s no different from other southern African countries, except that here the situation in terms of the position of women in society, and in the construction of social relations between men and women, gender relations, is a little more accentuated […] Accentuated in terms of the discrimination and oppression that takes place around women. That’s why you have a feminization of AIDS, which in other parts of the world is not the case […] (Interviewee X, 2019)

The situation […] in the context of women is a situation that still needs a lot of fighting, especially for us women who work in the community. So, it’s still a big challenge because […] HIV […] we’ve been living with this epidemic for many years, we’ve had this epidemic here in Mozambique for over twenty years, but it’s like something new. So, there are still a lot of challenges so as to stop it, to keep people on treatment, so that they themselves accept this condition of being HIV-positive. (Interviewee J, 2019)

The contributions of interviewees X and J bring the issue of gender-with a focus on women-into the debate on the epidemic in the region under analysis, as the feminization of HIV/AIDS is a serious problem (Maúngue, 2020). From their speeches, it is possible to see that the reverberations about the epidemic are closely linked to the ways in which Mozambican society is structured, which, in general, reproduces the social-patriarchal conception and historically considers the female population to be subordinate and inferior to men, reinforcing the idea of dominant and dominated.

This construction is based on the prerogatives of power, or even the exercise of power between subjects (Foucault, 1979). This creates an asymmetrical structure in which those involved live under inequality, as Andrade and Iriart (2015) explain when they say that

Gender and power inequalities between the sexes mean that women, who are subjected to moral judgment, are blamed for HIV infection. Ignorance of their rights means that many find themselves dispossessed of their property after the death of their husbands or abandoned by them when their diagnosis is revealed (Andrade; Iriart, 2015, p. 572, free translation).

As such, the relationship of domination has inherent ties to the social construction of gender, which is a conception that starts from the differences between the sexes and makes some more vulnerable to situations than others. An example of this is HIV/AIDS infection among Mozambican women. These structuring logics condition the process of feminization of HIV/AIDS, which is linked to gender vulnerability, as Interviewee A tells us:

It has a kind of relationship because we are seeing the levels of infection that have affected women. It’s about the vulnerability linked to women, and not just because of their structure, their physiology, but because of their vulnerability in terms of the fact that most of them haven’t been to school, because their literacy level is much lower and some of them aren’t literate […]. You also see marriages that are premature, in other words, they have to be equipped with knowledge, and this is a gap that we have found, despite the fact that in general Mozambicans don’t have much information about HIV/AIDS, and this is even more the case for women because we are very fragile. (Interviewee A, 2019)

Interviewee A’s contributions go beyond the sphere of the social-collective and into the sphere of the specificity of women, in such a way that she lists structural points that elucidate their vulnerability in relation to HIV/AIDS, such as educational inequality (Maúngue, 2020) and economic and marital dependence. These arrangements are the result of the organizational and cultural form of Mozambican society which, in general, reinforces women’s submission (Estavela; Seidl, 2015), making it more complex and difficult for them to respond in situations of vulnerability, as highlighted by interviewees J and O:

Well, some women are still able to talk, but others, most of whom are in rural areas, end up being dependent, even here in Maputo […] it’s financial dependence, isn’t it? This is what makes women end up accepting the blame, suffering humiliation because they don’t want to lose their husband, and also because of child support. (Interviewee J, 2019)

As far as women are concerned, it’s what I said, it’s a challenge for women to be able to bring their partners or to negotiate condom use, so much so that even being able to negotiate sexual life at home is very difficult because of the education, what is offered as education at family level when women get married […]. If we can achieve this exercise in which women are able to decide for themselves, it would be a huge step forward, because they will be able to negotiate condoms. If you can’t negotiate what is your right, are you going to be able to negotiate condoms? Few women are able to negotiate condoms with their husbands at home. (Interviewee O, 2019)

The statements made by interviewees J and O provide pertinent elements for discussing the reality experienced by Mozambican women. It is from these aspects that the geographical context becomes preponderant in the analysis, since the way one looks at the different interfaces that make up the reality experienced by the social subjects allows for a situated and embodied interpretation of the phenomenon experienced (Pedroso, 2022).

This situation becomes material when we think about the concept of gender and its repercussions on Mozambican society, especially with regard to HIV/AIDS and its cultural aspects. Thinking about these configurations helps us not only to understand the geographical context experienced by women, but also to reflect on actions that combat the process of making them vulnerable, once we understand that these factors are perpetuated by social and gender inequality that maintains connections with the political, economic, and cultural dimensions, corroborating the growing feminization of HIV/AIDS (Cruz e Silva et. al, 2007). In this way, Passador and Thomaz (2006) make us reflect on the accuracy of this reality evoked in the speeches, as they ask

the rapid association made between “gender relations” or “masculinities” (within a normative Western model) and the spread of the epidemic [which] is, more than ever, the result of an ethnocentric, prejudiced and essentialist view of these spheres of Mozambican social life and, to a lesser extent, a way of associating with the tiny urban elite that exists in the country and which, to a large extent, is also unaware of the “rural” universe or that which populates the outskirts of Mozambican cities. (Passador; Thomaz, 2006, p. 272-273)

We therefore believe that it is essential to understand the socially produced geographical context in order to understand the spatial phenomena that occur as a result of the subjects. This is justified because these relationships stem from an oppressive system that sometimes conditions women’s ability to respond and act. This prerogative is highlighted in the speeches of interviewees A and E, who point to issues that do not necessarily come from women, but are directly linked to the conditions experienced in the specificity of space-time, content and agency of the Mozambican geographical context, especially when addressing the health-disease process related to gender issues and their respective impacts, as we see below:

For a man, spending some time in a health facility means he’s losing something, which is the livelihood he has to bring in, since he is the one responsible for his family. The workplace, whether formal or informal, has to be able to inform men about HIV/AIDS services. (Interviewee A, 2019)

That part does, because the man is the breadwinner, especially in a family where the man works, even if he has HIV, the woman is there to take care of her husband, but if it’s the woman in a serodiscordant couple […] when it’s the woman who has been tested positive and the man at that moment is negative […] it does create a lot of impact. (Interviewee E, 2019)

The accounts of interviewees A and E present specificities that contribute to the characterization of the geographical context through the lived plane, in which relationships take place on a daily basis. In addition to these elements, it is possible to observe in their speeches the weight and importance of the “role of men” in Mozambican society, especially from a patrilineal perspective, and how this becomes a structuring element in the construction of masculinities that end up having an impact on the health-disease process of men and women when it comes to HIV/AIDS issues.

All of this ends up being the result of the social structure of the Mozambican context, since men are seen as the economic providers of all needs. These relationships distance men from health services and care, especially those related to HIV/AIDS, making it the responsibility of women to take care, especially of themselves and their children (Cruz e Silva et. al, 2007).

HIV/AIDS: social and cultural aspects in geographical contexts

The present situation brings some social and cultural elements that belong to the reality of Mozambique in general, since there are nuances and particularities that can be accentuated or softened according to the characteristics of the geographical context produced.

The above speeches express the strong role that culture plays in gender relations in Mozambique, something that it ends up being a structuring pillar for understanding the geographical context of women living with HIV/AIDS in Maputo. When we consider these elements in this reality, we incorporate the interpretation of culture and the resulting influences from the point of view of women’s health, since culture is added to other elements that favor the HIV/AIDS epidemic (Passador; Thomaz, 2006).

In this sense, it should be emphasized that the contributions about culture, gender, and HIV/AIDS are interconnected, because they permeated the reflections made by the interviewees and allow us to establish different connections and interpretations about these issues in the Mozambican reality, especially in Maputo, so that we can observe these points when we ask the question about the social and cultural construction of Mozambique in relation to HIV/AIDS.

Absolutely, absolutely, absolutely, because the control of women’s bodies here in cultural terms is 500% […] it’s awful because the initiation rite itself has the fundamental objective of establishing this control over sexuality, over reproduction and over women’s labor power by men […] that’s the fundamental objective, that is, these initiation rites are somehow normative for male and female identity, in which this female identity must be culturally, because it is so and needs to be kept, oppressed by the male identity. (Interviewee X, 2019)

In this excerpt, Interviewee X reports on the reality experienced by Mozambican women, in a way that emphasizes the interrelationship of subjects through the different powers that drive the construction of gender (Foucault, 1979) and stresses that they occur from a very early age, in the sexual initiation rites that “indoctrinate” women through the control established by the valuation of what it means to be a man and a woman in Mozambican society.

In addition to this baseline construction, other elements and practices that are present in the geographical context of Mozambique (Lobolo, Pitakufa, Kudjinga) are highlighted, as we can see in the speeches of interviewees E and O, who portray, above all, purification rituals.

In some cultural aspects, yes, because there are early marriages, early initiation of sexual relations, some traditions we have like purification ceremonies, these all provide and facilitate HIV. It’s common to see a widow who has lost her husband to HIV, but she has to do the purification ceremony […] and at the purification ceremony it’s not accepted to use a condom, so the person who is going to do the purification ceremony is more exposed to contracting HIV. (Interviewee E, 2019)

At some point it does, I say this in relation to some rituals, when someone loses their husband and then they have to have a successor to perform the widow’s purification ritual, in which they have to have sexual contact with the deceased’s closest relative. Sometimes the person doesn’t even know, and the one who is going to get infected could even be the one who comes to purify, because sometimes the man died of HIV and the woman is already infected. And you can’t use condoms for this purification […]. And what does that mean? Does the one who is going to do the purification know what disease killed the other person?!” (Interview O, 2019)

The inputs of interviewees E and O focus on some practices that are present in Mozambican culture in the center and south of the country, in which, according to tradition, a widowed woman must agree to have unprotected sex with a relative of her deceased husband (Pitakufa/Kudjinga). “This is a traditional Mozambican practice: when the husband dies, the widow must have unprotected sex with her brother-in-law in order to purify her. If the widow refuses, she may lose the family’s property, taken by the deceased’s relatives” (Estavela; Seidl, 2015, p. 571).

Although some of these practices (such as purification rituals) may not be taking place in Maputo, their influence can somehow be felt in this geographical context, given that it is part of Mozambican society. In fact, some actions within the initiation and purification rites end up exposing women to a greater risk of HIV/AIDS infection, which ends up raising a necessary debate connected to the geographical context, considering the space-time, culture and the health of the subjects who produce and experience this reality.

In this context, it is important to draw attention to the fact that culture cannot be strictly blamed or even criminalized in relation to HIV/AIDS. It is necessary to maintain respect for traditions and customs, and further research is needed, as one of the reverberating consequences are interventions that “[…] tend to create distrust and discontent in the target population, as they feel that their beliefs, values and the logics that define their being and a harmonious social context are being disrespected” (Manuel, 2011, p. 347, free translation).

It is, therefore, necessary to create guiding actions that reduce and minimize damage to health without directly interfering in the social and cultural construction of the subjects. This debate takes shape in the words of Interviewees A and S, who advocate this construction:

Yes, it’s what I always say […] there is the relationship, but we can’t see certain things as negative in our culture. We have to accept what comes from our ancestors, but we have to know how we approach these aspects. For example, we have a habit of saying that initiation rites are harmful because of HIV/AIDS […]. What is harmful within initiation rites?! (rhetorical question). That’s what we have to discuss […]. Now, there are some practices within the initiation rites. These are the ones that have to be looked at and analyzed, it’s not a medical aspect, it’s a cultural aspect, it’s an aspect of society, it’s anthropological, which we have to study, which we have to analyze […]. Because we have to understand, we are Africans and we have our aspects, but we have to see what is negative within these aspects. (Interviewee A, 2019)

We have very personal cultural aspects, we have society built up in a certain way and then the disease comes along. So, the health service has to shape all these things. Of course, the health service isn’t going to come along and say that this is how we are now, but we still need to be able to provide care through everything that already exists. That’s the role of health (services), to give a package of care to everyone regardless of their beliefs […] and respecting.” (Interviewee S, 2019)

Both interviewees emphasize in their contributions that cultural aspects must be carefully analyzed when mediated by health issues, because all of these elements are important for developing an effective response to the HIV/AIDS epidemic. What’s more, they draw attention to what “type” of health should be built and offered to the population, since the reports point to the need for a service that is geographically contextualized with the reality in which it is located, showing that the health proposal itself should not be hermetic and crystallized (Guimarães, 2019).

Therefore, the links highlighted in all the reports are extremely important for the creation of a health service that is contextualized to the reality in question, since it starts to consider gender issues alongside Mozambican cultural values, as part of the essential response to the HIV/AIDS epidemic. This is because it takes the action of analyzing the practices experienced by Mozambican women, as well as by the population in general, which ponders the need to keep a geographical eye on the production of health for different population groups, thus allowing an adequate reading of the geographical context of HIV/AIDS in Maputo, as well as throughout Mozambique.

Final considerations

The accumulated debate has created possibilities for us to take another perspective on the reality of women living with HIV/AIDS in Maputo, since the reasoning established has been underpinned by the existing relationships between gender, culture, and health issues from a geographical perspective of analysis. Taking up this position is of great importance, but it also brings with it major challenges, because it deals with real aspects of people’s lives, highlighting the need for in-depth studies based on tensions between theory and practice.

The undertaking of this proposal was connected to different actions which, in turn, were situated in other segments of understanding, namely space-time, content, and agency. Through this movement, it was possible to interpret the reality of women living in Maputo in the light of the understanding of health services, and we based ourselves on the perception of professionals and/or representatives of institutions who are directly involved with the issue of HIV/AIDS, since they are the ones who deal on a daily basis with the demands that cross their lives.

With these articulations, we have constructed interpretations about the gender vulnerability experienced by these women in relation to HIV/AIDS, with the interviews conducted enabling us to discuss the different vulnerabilities that are present in the lives of Maputo-Mozambican women. This interpretation is based on our belief that these relationships are intrinsic to the dynamic nature of health and illness, which helps us to understand the complexities present in the geographical contexts covered.

This collection shows the progress and difficulties faced in relation to the HIV/AIDS epidemic, both in Maputo and in Mozambique, reinforcing the importance of the HIV/AIDS issue when it comes to gender vulnerabilities, since these women experience difficulties and forms of oppression that are different from other subjects. In this way, we believe that the efforts made here point to paths that have not yet been opened up and that need further research into elements such as the historical-geographical process in Mozambique, migratory flows, the health of young women, maternal, and child health, access and adherence to treatment, among others, to ensure that women’s universal health is taken into account in the most diverse geographical contexts.

Still in this relational context, it is possible to highlight the need to interpret the reality experienced by men, given that they maintain sociocultural relations that are mostly hierarchical with women, especially as protagonists of oppressive and dominating actions that make them vulnerable to HIV/AIDS. For this reason, we stress the importance of creating opportunities for studies aimed at understanding the geographical context of the process of formation and construction of masculinities and heteronormative spaces, which end up having significant repercussions on the HIV/AIDS health-disease process in Mozambique.

Therefore, we believe that these perspectives should be incorporated into health policies and practices as intervention strategies (health policy), so that they are able to return to the population effectively by being aligned with the specific demands of space-time, content, and agency of the geographical context in which the phenomenon takes place. We therefore stress the need to strengthen the dialogue between the different health services and the social activist movements dedicated to HIV/AIDS issues, so that the “different voices” can be heard, in other words, what Mozambicans have to say, promote, and build about policies to combat the epidemic. With this, we reiterate that the organization of health services must be equipped with a unified movement that considers political, economic, social, and cultural aspects, so that there is the possibility of effective transformations in their geographical contexts.

Acknowledgments

First of all, we would like to thank all the participants who shared their experiences with us. We would also like to thank the institutional support of the Universidade Eduardo Mondlane (UEM), the Universidade Estadual Paulista (FCT/UNESP), the Ministry of Health of Mozambique (MISAU), the Maputo City Health Directorate, the Women and Law in Southern Africa Research and Education Trust (WLSA), the Association of Midwives of Mozambique (APARMO) and the Hixikanwe Association, which provided coordination to the research. We would also like to thank the Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) for funding the national and international research (2018/05706-2; 2019/05071-0).

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• 1
  Financing: Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) for national and international research funding (2018/05706-2; 2019/05071-0).

Publication Dates

• Publication in this collection
  06 Sept 2024
• Date of issue
  2024

History

• Received
  05 May 2023
• Reviewed
  01 Sept 2023
• Accepted
  13 May 2024