Women in Southern Africa Struggle Against HIV

* Young women now make up more than 60 percent of those 15-24 years old who are HIV/AIDS positive. Globally, young women are 1.6 times more likely to be living with HIV/AIDS than young men.

* Sub-Saharan Africa is the region most disastrously affected by the HIV/AIDS epidemic with 23 million adults now infected, 57 percent of them women. Young women aged 15-24 are three times more likely to be infected than young men.

Some African countries are fighting back. UNAIDS reports that in Uganda, the first African country to have subdued a major HIV/AIDS epidemic, prevalence has fallen from 13 percent in the early 1990s to a level of 5-6 percent, and there has been a sustained and significant decline of HIV prevalence among pregnant women attending antenatal clinics.2

Twenty five years ago, early in the HIV/AIDS epidemic, women rarely figured among the infected. As the pandemic exploded, it has become clear that women are being infected and are dying because they are women.

As in other countries, many of Africa's leaders at first preferred avoidance to recognition and action. But the pattern has begun to change. In June 2001, Mozambique's Prime Minister, Dr. Pascoal Mocumbispeaking out strongly in New York at the UN General Assembly Special Session on AIDS (UNGASS)warned that the primary means by which AIDS is spread in sub-Saharan Africa is through risky heterosexual sex. This goes beyond a health issue, he stressed, for "unlike the communicable killer diseases we have encountered most often in the past, HIV/AIDS is transmitted through the most intimate and private human relationships, through sexual violence and commercial sex; it proliferates because of women's poverty and inequality."

Mocumbi reported that in Mozambique the rate of infection among girls and young women is twice that of boys their age, "not because the girls are promiscuous, but because nearly three out of five are married by age 18, more than 40 percent of them to much older, sexually experienced men, who may expose their wives to HIV/AIDS. Abstinence is not an option for these child brides. Those who try to negotiate condom use commonly face violence or rejection."

Continuing gender discrimination creates life-threatening dangers for Africa's women. "There has rarely been a disease so rooted in the inequality between the sexes," noted Stephen Lewis, U.N. Secretary-General Annan's Special Envoy for HIV/AIDS in Africa. The entire continent needs to understand that "women are truly the most vulnerable in this pandemic, that until there is a much greater degree of gender equality women will always constitute the greatest number of new infections." Lewis underscored "the degree of cultural oppression that has to be overcome before we really manage to deal with the pandemic," as he outlined the situation of millions of women who are effectively sexually subjugated and forced into risky sex without condoms, "without the capacity to say no, without the right to negotiate sexual relationships."

Biology works against women, as the virus spreads more rapidly from male to female than from female to male. For physiological reasons, women who have intercourse with men are more vulnerable to HIV infection than their partners and are twice as likely to be infected by their male partner as the reverse.

Nevertheless, the physiological reasons which place women in a more vulnerable situation through heterosexual sex are not sufficient to account for the explosion of HIV/AIDS in their ranks. It is gender inequalitywhich is based on the unequal relations between men and women in societythat is the major driving force in the pandemic.

Gender inequality fuels the HIV/AIDS epidemic because it deprives women of the ability to say no to risky practices, leads to coerced sex and sexual violence, keeps women uninformed about prevention, puts them last in line for care and life-saving treatment and imposes an overwhelming burden on them to care for the sick and dying. When combined with poverty this means that women often have little option other than to engage in unsafe sexual practices in order to feed their children or because they are economically unable to leave their husbands.

* Saying no is not an option in many societies, where a culture of silence surrounds sex and dictates that 'good' women are expected to be ignorant about sex and passive in sexual interactions. This makes it difficult for women to be informed about risk reduction, and more difficult, even if they are informed, for women to pro-actively negotiate safer sex or the use of condoms. A study in Zambia revealed that only 11 percent of the women interviewed believed that a married woman could ask her husband to use a condom, even if she knew him to have been unfaithful and infected.3

* The widespread traditional expectation of virginity for unmarried girls increases young women's risks of infection because it restricts their ability to ask for information about sex, out of fear that they will be branded as sexually active.

*The strong norms of virginity and the culture of silence that surrounds sex also make seeking information and accessing treatment for sexually transmitted diseases dangerously stigmatizing for both adolescent and adult women. Women can face a tragic set of circumstances when the male head of their household dies: the husband's family often blames the widow as the source of the disease and may refuse to accept her or her children into the family support system. That stigma, coupled with fear, has even produced lynch mobs in communities, when women are discovered to have the disease, or, as in the case of young South African activist Gugu Dhlamini, courageously reveal their HIV status.

* Women's economic dependency increases their vulnerability to HIV. Although women are the primary producers of food across much of Africa, they rarely own the land, have rights of inheritance or earn an income from their labor. Their poverty and this economic dependence often make it impossible for women to negotiate the terms of their relationships or remove themselves from relationships that put them at risk. Women are frequently forced to endure high levels of domestic violence within relationships, which both increases their chance of contracting HIV/AIDS and deters them from seeking testing and treatment. With few opportunities to earn paid livelihoods independent of men, women may turn to exchanging sex for favors or are even forced into commercial sex, an occupation which places them at enormous risk.

* Violence against women is both a cause and a consequence of HIV/AIDS. The World Health Organization research suggests that one in four women may experience sexual violence by an intimate partner in her lifetime; the fear of partner violence deters women from visiting clinics, joining treatment programs and adhering to treatment regimens, because women are trying to hide their pills.

* Periods of war or conflict exacerbate gender-based violence in horrifying ways. In Rwanda, women who were raped in the 1994 genocide are now dying of AIDS, so for them the genocide continues. Currently, in the Darfur region of Sudan, human rights activists are convinced that rape is being used deliberately, as a weapon of war.4

* Women's access to and use of services and treatments is also affected by the power imbalance that defines gender relations. Throughout southern Africa only one eligible person in 25,000 is receiving drug treatment. Most of those are educated men living in urban areas.5

Women are the first to take care of their sick partners, children and families and to comfort the dying. They are the last to get lifesaving treatment. Yet their critical role as the family caregiver is even greater when HIV/AIDS strikes. Caring for an AIDS patient can increase their workload by one-third. A rural woman interviewed in southern Africa estimated that it took 24 buckets of water a day, fetched on foot (often from a significant distance) to care for a family member dying of AIDS.6

* In Africa most women only discover that they are HIV infected when they are pregnant and visit prenatal clinics. The risk of mother to child transmission is high, but women are often offered little to help them reduce the risks; which might include anti-retroviral therapy, the more recently developed drug nevirapine, advice to make informed decisions about the alternative dangers of breast-feeding and of breast-milk substitutes and ongoing care, counseling and support. High costs of drugs and medical services have meant that even if treatment is offered it has, until now, been for only a brief period, to prevent infant infection, thus leaving the mother to face the cruel prospect of her own death, and the abandonment of her orphan children.

Leadership failures, cowardice, denial and avoidance have all contributed to the exploding pandemic. Stephen Lewis, U.N. HIV/AIDS envoy, says: "For 20 years African leadership was largely silent, in denial... traumatized, paralyzed... the Western world, which had the resources and knew how to deal with the pandemic... contributed a negligible quantity of money to Africa. In the process 17 million lives were lost and 25 million people were already infected. It is one of the most astonishing moral lapses in post-war history."

Lewis makes a powerful argument against helplessness and hopelessness: "We know how to turn the disease around and we have the capacity at this moment to prolong and improve the lives of millions and to prevent the infection from spreading to other millions, and at the heart of it is largely the question of resources which still isn't resolved. It can be done ... it is just a matter of fashioning the will and the commitment to do it."

In April 2001 U.N. Secretary General Annan called for the establishment of a Global Fund on AIDS and Health, estimating that a global campaign against the epidemic needed $7-10 billion annually, over and above current spending, for an effective response.

One reaction came in December 2001, when 18 of the world's leading economists, sitting in the specially established "Commission on Macroeconomics and Health; Investing in Health for Economic Development," chaired by Harvard Professor Jeffrey D. Sachs, reported that massive investment in global health ($15.5 billion annually), could save eight million lives a year and generate at least $360 billion annually within 15 years. The report argued that there are very powerful links between health, poverty reduction and economic growth.

Policies that aim to erase the gender gap in education, improve women's access to economic resources, increase women's political participation, protect women from violence and enable them to achieve their rights to sexual and reproductive health and self-determination are key to empowering women. And empowering women is the key to challenging the pandemic. Women have developed a serious set of blueprints for addressing inequality. Now governments need to implement the recommendations laid out in such key documents as the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) and the Beijing Platform for Action. These need to become the guiding frameworks in the development of all HIV/AIDS prevention, treatment and care strategies.

2. Advocate U.S. policies for Africa that place women at the center of planning and decision making about poverty eradication, debt cancellation, expansion of education and health care.

3. Urge U.S. policy makers to adopt and implement a rights-based approach to combating the epidemic, rather than only urging abstinence, and avoiding a holistic approach to human rights and the provision of comprehensive reproductive health services.

4. Maintain the pressure on U.S. corporations to avoid placing patents and profits ahead of both women and men's need for truly affordable drugs. Encourage research targeted to giving women the ability to protect themselves via women initiated technology, such as female condoms and microbiocides.

5. Build direct connections and partnerships with African NGO's, women's organizations and other sectors of civil society you will find amazing dedication, knowledge and courage. Such links can help strengthen the grass roots pressures which have already made some cautious governments move beyond their paralysis and failures of commitment to battle the pandemic.



	Women in Southern Africa Struggle Against HIV Quick Facts * Worldwide, there are now 17 million women and 18.7 million men between the ages of 15 and 49 living with HIV/AIDS, mostly in developing countries. * Young women now make up more than 60 percent of those 15-24 years old who are HIV/AIDS positive. Globally, young women are 1.6 times more likely to be living with HIV/AIDS than young men. * Sub-Saharan Africa is the region most disastrously affected by the HIV/AIDS epidemic with 23 million adults now infected, 57 percent of them women. Young women aged 15-24 are three times more likely to be infected than young men. * 77 percent of all HIV positive women live in sub-Saharan Africa.1 Some African countries are fighting back. UNAIDS reports that in Uganda, the first African country to have subdued a major HIV/AIDS epidemic, prevalence has fallen from 13 percent in the early 1990s to a level of 5-6 percent, and there has been a sustained and significant decline of HIV prevalence among pregnant women attending antenatal clinics.2 Three Allies Deliver Death: HIV, Poverty and Inequality Twenty five years ago, early in the HIV/AIDS epidemic, women rarely figured among the infected. As the pandemic exploded, it has become clear that women are being infected and are dying because they are women. As in other countries, many of Africa's leaders at first preferred avoidance to recognition and action. But the pattern has begun to change. In June 2001, Mozambique's Prime Minister, Dr. Pascoal Mocumbispeaking out strongly in New York at the UN General Assembly Special Session on AIDS (UNGASS)warned that the primary means by which AIDS is spread in sub-Saharan Africa is through risky heterosexual sex. This goes beyond a health issue, he stressed, for "unlike the communicable killer diseases we have encountered most often in the past, HIV/AIDS is transmitted through the most intimate and private human relationships, through sexual violence and commercial sex; it proliferates because of women's poverty and inequality." Mocumbi reported that in Mozambique the rate of infection among girls and young women is twice that of boys their age, "not because the girls are promiscuous, but because nearly three out of five are married by age 18, more than 40 percent of them to much older, sexually experienced men, who may expose their wives to HIV/AIDS. Abstinence is not an option for these child brides. Those who try to negotiate condom use commonly face violence or rejection." Prevention and Lack of Power Continuing gender discrimination creates life-threatening dangers for Africa's women. "There has rarely been a disease so rooted in the inequality between the sexes," noted Stephen Lewis, U.N. Secretary-General Annan's Special Envoy for HIV/AIDS in Africa. The entire continent needs to understand that "women are truly the most vulnerable in this pandemic, that until there is a much greater degree of gender equality women will always constitute the greatest number of new infections." Lewis underscored "the degree of cultural oppression that has to be overcome before we really manage to deal with the pandemic," as he outlined the situation of millions of women who are effectively sexually subjugated and forced into risky sex without condoms, "without the capacity to say no, without the right to negotiate sexual relationships." Double Jeopardy Biology works against women, as the virus spreads more rapidly from male to female than from female to male. For physiological reasons, women who have intercourse with men are more vulnerable to HIV infection than their partners and are twice as likely to be infected by their male partner as the reverse. Nevertheless, the physiological reasons which place women in a more vulnerable situation through heterosexual sex are not sufficient to account for the explosion of HIV/AIDS in their ranks. It is gender inequalitywhich is based on the unequal relations between men and women in societythat is the major driving force in the pandemic. Gender Dimensions of HIV Gender inequality fuels the HIV/AIDS epidemic because it deprives women of the ability to say no to risky practices, leads to coerced sex and sexual violence, keeps women uninformed about prevention, puts them last in line for care and life-saving treatment and imposes an overwhelming burden on them to care for the sick and dying. When combined with poverty this means that women often have little option other than to engage in unsafe sexual practices in order to feed their children or because they are economically unable to leave their husbands. Ways in which this is manifest: * Saying no is not an option in many societies, where a culture of silence surrounds sex and dictates that 'good' women are expected to be ignorant about sex and passive in sexual interactions. This makes it difficult for women to be informed about risk reduction, and more difficult, even if they are informed, for women to pro-actively negotiate safer sex or the use of condoms. A study in Zambia revealed that only 11 percent of the women interviewed believed that a married woman could ask her husband to use a condom, even if she knew him to have been unfaithful and infected.3 * The widespread traditional expectation of virginity for unmarried girls increases young women's risks of infection because it restricts their ability to ask for information about sex, out of fear that they will be branded as sexually active. The strong norms of virginity and the culture of silence that surrounds sex also make seeking information and accessing treatment for sexually transmitted diseases dangerously stigmatizing for both adolescent and adult women. Women can face a tragic set of circumstances when the male head of their household dies: the husband's family often blames the widow as the source of the disease and may refuse to accept her or her children into the family support system. That stigma, coupled with fear, has even produced lynch mobs in communities, when women are discovered to have the disease, or, as in the case of young South African activist Gugu Dhlamini, courageously reveal their HIV status. Women's economic dependency increases their vulnerability to HIV. Although women are the primary producers of food across much of Africa, they rarely own the land, have rights of inheritance or earn an income from their labor. Their poverty and this economic dependence often make it impossible for women to negotiate the terms of their relationships or remove themselves from relationships that put them at risk. Women are frequently forced to endure high levels of domestic violence within relationships, which both increases their chance of contracting HIV/AIDS and deters them from seeking testing and treatment. With few opportunities to earn paid livelihoods independent of men, women may turn to exchanging sex for favors or are even forced into commercial sex, an occupation which places them at enormous risk. * Violence against women is both a cause and a consequence of HIV/AIDS. The World Health Organization research suggests that one in four women may experience sexual violence by an intimate partner in her lifetime; the fear of partner violence deters women from visiting clinics, joining treatment programs and adhering to treatment regimens, because women are trying to hide their pills. * Periods of war or conflict exacerbate gender-based violence in horrifying ways. In Rwanda, women who were raped in the 1994 genocide are now dying of AIDS, so for them the genocide continues. Currently, in the Darfur region of Sudan, human rights activists are convinced that rape is being used deliberately, as a weapon of war.4 * Women's access to and use of services and treatments is also affected by the power imbalance that defines gender relations. Throughout southern Africa only one eligible person in 25,000 is receiving drug treatment. Most of those are educated men living in urban areas.5 Women are the first to take care of their sick partners, children and families and to comfort the dying. They are the last to get lifesaving treatment. Yet their critical role as the family caregiver is even greater when HIV/AIDS strikes. Caring for an AIDS patient can increase their workload by one-third. A rural woman interviewed in southern Africa estimated that it took 24 buckets of water a day, fetched on foot (often from a significant distance) to care for a family member dying of AIDS.6 * In Africa most women only discover that they are HIV infected when they are pregnant and visit prenatal clinics. The risk of mother to child transmission is high, but women are often offered little to help them reduce the risks; which might include anti-retroviral therapy, the more recently developed drug nevirapine, advice to make informed decisions about the alternative dangers of breast-feeding and of breast-milk substitutes and ongoing care, counseling and support. High costs of drugs and medical services have meant that even if treatment is offered it has, until now, been for only a brief period, to prevent infant infection, thus leaving the mother to face the cruel prospect of her own death, and the abandonment of her orphan children. Action for Survival: Empowering Women Leadership failures, cowardice, denial and avoidance have all contributed to the exploding pandemic. Stephen Lewis, U.N. HIV/AIDS envoy, says: "For 20 years African leadership was largely silent, in denial... traumatized, paralyzed... the Western world, which had the resources and knew how to deal with the pandemic... contributed a negligible quantity of money to Africa. In the process 17 million lives were lost and 25 million people were already infected. It is one of the most astonishing moral lapses in post-war history." Taking Action and Providing Resources Lewis makes a powerful argument against helplessness and hopelessness: "We know how to turn the disease around and we have the capacity at this moment to prolong and improve the lives of millions and to prevent the infection from spreading to other millions, and at the heart of it is largely the question of resources which still isn't resolved. It can be done ... it is just a matter of fashioning the will and the commitment to do it." In April 2001 U.N. Secretary General Annan called for the establishment of a Global Fund on AIDS and Health, estimating that a global campaign against the epidemic needed $7-10 billion annually, over and above current spending, for an effective response. One reaction came in December 2001, when 18 of the world's leading economists, sitting in the specially established "Commission on Macroeconomics and Health; Investing in Health for Economic Development," chaired by Harvard Professor Jeffrey D. Sachs, reported that massive investment in global health ($15.5 billion annually), could save eight million lives a year and generate at least $360 billion annually within 15 years. The report argued that there are very powerful links between health, poverty reduction and economic growth. Taking Action and Empowering Women Policies that aim to erase the gender gap in education, improve women's access to economic resources, increase women's political participation, protect women from violence and enable them to achieve their rights to sexual and reproductive health and self-determination are key to empowering women. And empowering women is the key to challenging the pandemic. Women have developed a serious set of blueprints for addressing inequality. Now governments need to implement the recommendations laid out in such key documents as the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) and the Beijing Platform for Action. These need to become the guiding frameworks in the development of all HIV/AIDS prevention, treatment and care strategies. What you can do: 1. Challenge your Congressional Representatives, Senators and the President to adopt new standards for generous funding appropriations to the Global Fund. 2. Advocate U.S. policies for Africa that place women at the center of planning and decision making about poverty eradication, debt cancellation, expansion of education and health care. 3. Urge U.S. policy makers to adopt and implement a rights-based approach to combating the epidemic, rather than only urging abstinence, and avoiding a holistic approach to human rights and the provision of comprehensive reproductive health services. 4. Maintain the pressure on U.S. corporations to avoid placing patents and profits ahead of both women and men's need for truly affordable drugs. Encourage research targeted to giving women the ability to protect themselves via women initiated technology, such as female condoms and microbiocides. 5. Build direct connections and partnerships with African NGO's, women's organizations and other sectors of civil society you will find amazing dedication, knowledge and courage. Such links can help strengthen the grass roots pressures which have already made some cautious governments move beyond their paralysis and failures of commitment to battle the pandemic. Footnotes 1. Women and HIV/AIDS: Confronting the Crisis, A Joint Report by UNAIDS/UNFPA/UNIFEM, 2004. pp. 1-3 2. AIDS Epidemic Update 2004. UNAIDS 3. Women and HIV/AIDS: Confronting the Crisis, A Joint Report by UNAIDS/UNFPA/UNIFEM, 2004. p. 16 4. Ibid, pp. 45, 46 5. Ibid, pp. 23-25 6. Ibid, P. 32 Written by Jennifer Davis First Published 1st Quarter, 2005, Vol. 14, No. 1 in Stewardship of Public Life, RESBYTERIAN CHURCH (USA). Africa/Women and Families