Received: 24 March 2021 | Accepted: 27 May 2021

DOI: 10.1002/ijgo.13771

CLINICAL ARTICLE
Gynecology

Exploring the challenges of women taking antiretroviral

treatment during the COVID-­19 pandemic lockdown in peri-­
urban Harare, Zimbabwe

Mathew Nyashanu1 | Rumbidzai Chireshe2 | Fungisai Mushawa1 |

Mandu S. Ekpenyong3

1
Nottingham Trent University,
Nottingham, UK Abstract
Objective: To explore the challenges of women taking antiretroviral treatment (ART)
2
Department of Nursing and Public
Health, Kwazulu Natal University, Durban,
South Africa
during the COVID-­19 pandemic lockdown in a peri-­urban area.
3
Manchester Metropolitan University Methods: An exploratory qualitative study approach was used. Semi-­structured ques-
Faculty of Health, Manchester, UK tions were devised and used to elicit data on the impact of the COVID-­19 lockdown
Correspondence on women accessing treatment for HIV. Twenty women were interviewed through
Mathew Nyashanu, Nottingham Trent contacts from community and faith organizations in peri-­urban Harare. All interviews
University, 50 Shakespeare Street,
Nottingham NG1 4FQ, UK. were audio-­recorded, transcribed verbatim and entered into NVivo to make analysis
Email: mathew.nyashanu@ntu.ac.uk easy. The data were thematically analyzed, underpinned by the four phases of data
analysis in the Silences Framework.
Results: The study discovered that transport problems, confusing COVID-­
19 re-
strictions, abuse by police and soldiers at roadblocks, a shortage of medication,
lack of health check-­up routines, involuntary default of ART, and a shortage of per-
sonal protective equipment affected HIV-­positive women accessing ART during the
COVID-­19 lockdown.
Conclusion: People living with HIV need a robust supporting environment and a func-
tioning health system. In response to COVID-­19 all services were halted to prevent
the spread of COVID-­19. Pandemic preparedness is important in keeping an adequate
supply of ART and responding to the needs of individuals on HIV treatment.

KEYWORDS
antiretroviral treatment, COVID-­19, HIV, pandemic, women

1 | I NTRO D U C TI O N populations need functioning healthcare systems, sanitation and

hygiene, safe water, and a healthy food supply. Due to the epidemic,
The COVID-­19 epidemic has caused a disastrous situation for all af- people cannot maintain their jobs, resulting in the deterioration of
fected populations, particularly vulnerable groups within communi- the economy and public health services. Furthermore, important in-
ties, such as people with chronic diseases, i.e. HIV and AIDS.1 These stitutions, such as the health sector, were constantly under pressure

This is an open access article under the terms of the Creat​ive Commo​ns Attri​bution-NonCo​mmercial License, which permits use, distribution and reproduction
in any medium, provided the original work is properly cited and is not used for commercial purposes.
© 2021 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology
and Obstetrics

220 | 
wileyonlinelibrary.com/journal/ijgo Int J Gynecol Obstet. 2021;154:220–226.
NYASHANU et al. | 221

and were unable to respond adequately to the health demands of 2 | M ATE R I A L S A N D M E TH O DS

2
the population. Communities and social networks have fallen apart,
and individuals have had difficulties in sustaining their livelihoods The present study employed an exploratory qualitative study
and living healthily. In response to the challenges of the COVID-­19 (EQS) approach. As the name suggests, an EQS is designed to ex-
outbreak, all countries underwent a lockdown period as a strategy to plore the topic under consideration to better understand it rather
3
stop the spread of the infection. Under lockdown, all services were than offer a final and conclusive solution to existing problems
halted, and people were restricted indoors. Nutrition and access to under investigation.13 In doing so, an EQS may also identify possi-
health services for the wider population became a challenge in many ble areas for further investigation. As such, EQS is useful in under-
low-­and middle-­income countries (LMICs) during the COVID-­19 standing the overview of an existing issue from a new perspective
pandemic. and can provide key information for future interventions.14 Semi-­
HIV is one of the leading causes of preventable mortal infectious structured questions were devised and used to elicit experiences
diseases globally. In total, 37.9 million people have tested positive on the impact of the COVID-­19 lockdown on women accessing
with the virus and two-­thirds of them live in sub-­Sahara Africa.4 treatment for HIV. The interview protocol was informed by the
Since the rollout of antiretroviral therapy (HAART) in sub-­Saharan literature on access to sexually transmitted infections and HIV
Africa in the early 2000s, the life expectancy of people living with treatment among vulnerable groups from previous primary and
HIV (PLWH) has increased.5 However, the gains made in reducing secondary research studies. To test the appropriateness of the
mortality from HIV-­
related complications are being threatened interview schedule, four women accessing HIV treatment were
by COVID-­19 restrictions, implemented to curb the spread of the interviewed. After the completion of the pilot interviews, the
pandemic. women were asked whether they felt that the interview schedule
HIV/AIDS is still a persistent global health problem, particu- was suitable for the topic in question. None of the four women
larly in LMICs. 6 Enormous steps have been undertaken to treat suggested any substantial changes to the interview schedule and
and prevent HIV, such as the “90-­9 0-­9 0 targets” by the Joint it was therefore adopted for use in the research study. However,
United Nations Program on HIV/AIDS, which means that 90% of where appropriate, their comments were included to shape the
PLWH know their status, 90% of PLWH who know their status final research interview schedule.
are on treatment, and 90% of PLWH on treatment are virally sup- The Joint Research Ethics Committee (JREC) from the University
7
pressed by 2020. However, there is still much to be done to stop of Zimbabwe granted the ethical approval for this study. A total of
the spread of HIV and keep a supply of antiretroviral drugs (ARVs), 20 women were interviewed through contacts from the community
especially during the current COVID-­19 pandemic. Patients with and faith organizations in peri-­urban Harare. Letters and informa-
HIV risk running out of life-­s aving drugs because of quarantines tion sheets were sent to organizations and faith groups for women,
and lockdowns aimed at containing the COVID-­19 pandemic. The inviting their members to take part in the research study. Only those
lockdown makes it difficult to replenish vital medicine stocks for women who agreed to take part in the research study had their
chronic conditions such as HIV. 8 Most of the patients do not know names forwarded to the researchers to organize interview dates.
where to collect their next ARV refill. Lockdowns and restrictions The interviews were held at community and faith group centers
imposed by the government do not clearly explain how patients where the women normally meet for community and faith activi-
with HIV are to collect their medication, which means many pa- ties. This was to make sure that the research participants were com-
tients are going to run out of their HIV treatment with a possibility fortable and free to answer questions in an environment they were
of relapse.9 accustomed to. All the research participants signed a consent form
Some patients with HIV fear letting other people know why that accorded them the right to withdraw from the study without
they are desperate to get out of the cities, because they are afraid stating any reason. Each interview lasted 1 h.
to be stigmatized by others.10 It is believed that lockdowns in vari- The inclusion criteria included women who were HIV positive
ous cities have also meant that people with HIV who had travelled and taking ART. The women were supposed to stay in peri-­urban
away from their hometowns have not been able to return home Harare before the lockdown. It was important to recruit a heteroge-
and access HIV services, including treatment, from their usual pro- neous sample with regard to the cut off time they started staying in
viders. Adherence to antiretroviral treatment (ART) is a key factor peri-­urban Harare to make sure that their experiences during lock-
in ensuring optimal positive clinical health outcomes and is associ- down were explored under a uniform situation. The interviews were
ated with an improved survival rate among patients with HIV and conducted by two researchers who were both women. This was
AIDS.11 Sustained high levels of adherence (taking 95% or more of important to enhance openness and the sharing of silence among
medication as prescribed) are essential for treatment success.12 women as opposed to when a male researcher is involved. All inter-
Suboptimal adherence to treatment has been associated with vi- views were audio-­recorded, transcribed verbatim, and entered into
rologic, immunologic, and clinical failure, and may increase the risk NVivo to make analysis easy.15 For the verification of accuracy, all
of resistance to first-­line ARVs. In light of the above discussion, the transcriptions were taken back to the research participants for con-
aim of the present study was to explore the experiences of women firmation. This is deemed important as it validates the data collected
taking ART during lockdown. before analysis.16
222 | NYASHANU et al.

After the organization of the data by NVivo, the analysis of the public transport was not allowed to move or take people from one
data started with the coding of the data into broad categories by the place to another.
two researchers using the four phases of data analysis in the Silences
Framework.17 During phase 2 of data analysis, the researchers took the I live 60 kilometers from the health facility I get my
categorized broad themes to the research participants for verification ARVs supply and right now I do not know how I am
and confirmation as a true reflection of what they had said during the going to go for my next appointment because of
interviews. The research participants at this point had the opportunity this pandemic… no transport is servicing our area. (a
to refute or confirm the constructed broad themes in line with their 46-­year-­old woman)
contribution at interview. At phase 3 of data analysis, the data from
phase 2 were taken to a collective voice group for validation and veri- Even though I live 20 km away from the clinic, I am not
fication. The collective voice group is a group of people who mirrored sure I am still fit to walk that long to get to the clinic…
the research participants but did not participate in the research study. especially with this chronic condition that I have had
For example, this group was made up of HIV-­positive women receiving for the past 10 years. (a 50-­year-­old woman)
treatment and living in peri-­urban Harare but who did not take part in
the research study. At this point, the user voice group validated and
verified the data coined in phase 2. This was meant to critique the data
using an associative eye. Finally, in phase 4 the researchers analyzed 3.2 | Confusing COVID-­19 information
the data in line with the contributions made in each phase to form the
final output of the research study. Figure 1 shows the four phases of Research participants expressed that they all had a general idea of
the analysis described above. what COVID-­19 was, although there was a lot of wrong information
The research participants were given an information sheet to that was going around with no-­one to rectify it. They felt that there
read and ask question before participating in the research study. was no clear or strategic policy dealing with the dissemination of
information about the pandemic to the people.

3 | R E S U LT S Most of the information we heard was through so-

cial media and some of the information is not as clear
After analysis of the data on the impact of the COVID-­19 lockdown as one would want it to be, I have a lot of questions
on HIV-­positive women, the seven themes identified included trans- which are unanswered. (a 29-­year-­old woman)
port problems, confusing COVID-­19 restrictions, abuse by police
and soldiers at roadblocks, shortage of medication, lack of health This is the most difficult time to survive. We are afraid
check-­up routines, involuntary default of ARVs, and a shortage of of so much information, scary information… We need
personal protective equipment (PPE). clear communication from those in authority in future
to avoid this unnecessary fear. (a 36-­year-­old woman)

3.1 | Transport problems

All the research participants agreed that the travelling restrictions 3.3 | Abuse by police and soldiers at roadblocks
made them miss appointments and/or sometimes made it difficult
to travel to healthy facilities to collect their supply of ARVs because Encounters with the authorities, in most cases, in Zimbabwe is not a
pleasant experience, especially the police and soldiers at roadblocks.
With the introduction of these travelling restrictions, roadblocks
were established to help enforce these restrictions.

Police are the most unreasonable people I have ever

met; they act like they will never fall sick, or they do
not have relatives who are on this ARV program…
imagine I had to spend more than 2 h pleading with
them to pass. (a 48-­year-­old man)

Everyone knows that the police are very unreason-

able. They asked to see my hospital cards, violating
F I G U R E 1 The four phases of data analysis in The Silences my confidentiality in the process. I was not happy at
Framework17 [Colour figure can be viewed at wileyonlinelibrary. all. (a 36-­year-­old woman)
com]
NYASHANU et al. | 223

3.4 | Shortage of medication I spend 2 weeks without taking medication as I was

locked down in Bubi, where I had visited my sister.
Some of the research participants acknowledged that some of the The local clinic told me that they had supplies for their
clinics ran short of ARVs due to people being given supplies for registered patients only and advised me to go to my
3–­6 months. They reported that those who had got to the clinics registered clinic which was impossible due to lock-
first got enough supplies for 3–­6 months. down. (a 49-­year-­old woman)

By the time that I made it to my local clinic where I I had visited my brother in Bocha when the lockdown
normally collect my ARVs, the nurse told me that I happened. I could not make my way back to Gweru
was late, and I could only get supply for 1 month and I until after 3 weeks… The local clinic could not give
am now wondering where I will get my next supply. (a me any supplies, so I had to default for 1 week until I
42-­year-­old woman) returned to my Gweru. (a 37-­year-­old woman)

I could only get a supply for 2 months because the

clinic had been giving out 3–­6 months’ supply on the
first come first serve basis… I am thinking of going 3.7 | Shortage of PPE
to big hospitals to get more supply. (a 28-­year-­old
woman) The research participants reported difficulties in acquiring PPE for
themselves as it was very expensive and sometimes out of stock.
They reported the improvisation of PPE to protect themselves but
sometimes the improvisation was not fit for purpose.
3.5 | Lack of health check-­up routines
With fear of infection, everyone wanted to get PPE,
The research participants reported that there were no regular but it was very expensive. I ended up covering my
checks, i.e. blood pressure, temperature, blood glucose, and general mouth using an old cloth and I don't know whether it
check-­ups. They also found it challenging to communicate with the works or not… Honestly, we needed help with PPE as
nurse through a window just to drop their medical cards and sit as vulnerable people. (a 49-­year-­old woman)
far as possible waiting to collect their medication. Although this was
part of enforcing social distancing for individuals, they found it dif- I went round all shops and I could not get any PPE to
ficult to understand and acknowledge. cover myself… I ended up moving around with noth-
ing on my mouth… You don't even know when you
It is exceedingly difficult to be treated like someone will be infected. (a 42-­year-­old woman)
with leprosy but anyways I do understand the fear
this disease has instilled in us. It is difficult to under-
stand still… more of a concern, I could not get any reg-
ular check-­ups which I normally get as a person living 4 | DISCUSSION
with a chronic condition. (a 33-­year-­old woman)
Transport problems affect many health systems in LMICs owing to
Remember we have HIV, and our health depends on poor infrastructure.18,19 During COVID-­19, the Zimbabwean govern-
regular checks and some of us have developed other ment effected restrictions on unnecessary travel including public
conditions like BP and with no checks we do not know transport. 20 Many research participants reported difficulties in trav-
how we are doing right now. (a 43-­year-­old woman) elling to local clinics to collect ARVs because of the COVID-­19 lock-
down. They also missed some clinical appointments pertinent for
their HIV treatment. In future pandemics, there is the need for the
government to make provision for people living with chronic diseases
3.6 | Involuntary default to be ferried to different health facilities to collect their ARVs and
attend pertinent clinical appointments during the lockdown periods.
Most of the research participants reported involuntary default of It is important that when there is a pandemic such as COVID-­19,
medication due to their medication running out while being locked the affected communities need to be educated about it. 21 In
down in a different location far from their homes. The research par- doing so, it enables effective control of the pandemic through
ticipants also reported difficulties in getting supplies at health facili- changes in behavior informed by the information provided. Most
ties where they were not registered. of the research participants reported ever-­changing information
224 | NYASHANU et al.

about COVID-­19, leaving them in fear. It is important that during empathetic way to maintain a therapeutic relationship with them
a pandemic the government establishes effective channels of and avoid despondence.
communication that are available to and understood by all the Default of medication, whether voluntary or involuntary, has a
population. 22 It is also important that information is managed and direct impact on the health and well-­being of the patient.30 Most of
disseminated by qualified health practitioners. More importantly, the research participants reported an involuntary default of medica-
information needs to be simplified to make sure that it is free of tion due to their medication running out while being locked down in
technical jargon and easily understood by the lay members of the a different location far from their homes. The research participants
communities. 23,24 This is more important when dealing with peo- reported difficulties in getting supplies at health facilities where
ple accessing ART to ensure that their uptake of medication is not they were not registered, and this led to an involuntary default of
interrupted. their ART. With the advent of the COVID-­19 pandemic, they were
Meanwhile, although it is important that a lockdown should be now at risk of interrupting their HIV treatment.31 There is a need for
enforced by law enforcement agents such as police and soldiers, it is the central government to make it easy for individuals accessing ART
essential that the enforcement does not infringe on the rights of cit- to access their medication from any health facility in the country
izens, especially those who are vulnerable and accessing medication rather than referring them to where they are registered. This will
for chronic conditions such as HIV.25 Most of the research participants circumvent the problem of defaulting on treatment and enhance
reported abuse by police and soldiers at roadblocks while on their way positive outcomes for individuals on HIV treatment.
to collect their ART. They also reported breaches of their right to confi- Personal protective equipment is one of the most important re-
dentiality when the police and soldiers demanded to see their hospital quirements when fighting an infectious pandemic such as COVID-­19.32
cards. It is important that during pandemic periods police and soldiers The shortage of PPE posed a threat of COVID-­19 infection to individ-
are educated about their role during the pandemic, clearly articulating uals receiving HIV care or on ART. Nearly all the research participants
their roles and boundaries to avoid misuses of power, which can impact in the present study reported a severe shortage of PPE. The research
negatively on vulnerable people accessing ART. There is the need for all participants reported difficulties in acquiring PPE for themselves as it
law enforcement agents to have a clear knowledge and understanding was expensive and sometimes out of stock. They reported improvis-
on the laws governing confidentiality and sharing of information to pro- ing PPE to protect themselves as they travelled to get their supply of
tect vulnerable individuals accessing ART from being abused.26 This is HIV medication. The shortage of PPE also affected the health work-
crucial in protecting the rights of patients while upholding their dignity ers in many healthcare settings, exposing them to possible infection
when accessing medication for chronic conditions. of COVID-­19. The shortage of PPE undoubtedly created fear and
Shortage of medication in LMICs is one of the long-­standing health anxiety among the participants. This was also compounded by the
problems affecting many countries in this economic group.27 This is fact that COVID-­19 is untreatable.33 There is a need for the central
normally caused by weak health systems and infrastructure. Most of government to have a clear policy on the procurement of PPE. This
the research participants reported a shortage of ART during the lock- will ensure an adequate stock of PPE and access by vulnerable groups
down period owing to some patients being given treatment supplies such as people on ART. More importantly, a subsidy on the price of
for 3–­6 months. There is a need for the government to have reserve PPE is needed to make it affordable, especially to women accessing
ART in case of any future pandemics. This will prevent individual pa- ART who are usually unemployed.34 This will ensure affordability of
tients from taking medication errands during the lockdown period and PPE in times of pandemics such as COVID-­19.
possibly exposing themselves to infections. There is a need to measure
an affordable amount of medication that each patient can get before
exhausting the supply in reserve.28 For example, instead of giving a 4.1 | Implication for professionals working
supply of medication for up to 5 months, all patients can be given med- with PLWH
ication equivalent to 3 months to avoid a shortage. This would ensure
that every patient receives medication for the first 3 months and gives There is a need for professionals working with PLWHs to raise
health facilities time to prepare the supply for the next 3 months. awareness among government departments to enlighten other pro-
Regular check-­ups for people taking HIV treatment are import- fessionals such as the police and soldiers to understand the impor-
ant to prevent co-­morbidities and other complications. 29 The par- tance of treating HIV-­positive individuals with dignity. Furthermore,
ticipants also reported that it was challenging to communicate with professionals working in sexual health and HIV need to carry out a
the nurse through a window just to drop off their medical cards and more robust situational analysis to improve pandemic preparedness
sit as far as possible waiting to collect their medication. There is a when delivering services.
need to maintain the regular care of individuals on HIV treatment.
Health professionals need to be provided with PPE to make sure
that they carry out regular checks for vulnerable patients such as 4.2 | Limitations of the study
those on HIV treatment. This would enable medication to be regu-
larly monitored and replenished. There is also a need for health facil- The present study was carried out in a peri-­urban area in Harare.
ities to explain the changes in patient care to the patients in a more Research encompassing more regions may be necessary to
NYASHANU et al. | 225

8. World Health Organisation. WHO: access to HIV medicines se-

understand the generic impact of the COVID-­19 lockdown on in- verely impacted by Covid-­ 19 as AIDS response stalls? 2020.
dividuals accessing ART. The study utilized a qualitative paradigm. https://www.who.int/news/item/06-­07-­2020-­who-­acces​s-­to-­hiv-­
Another study utilizing mixed methods may be necessary to enable medic​ines-­sever​ely-­impac​ted-­by-­covid​-­19-­as-­aids-­respo​nse-­s talls.
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