Project Description

This edition of the ALQ focuses on sexual and reproductive health and rights in the context of HIV and AIDS. the various articles in this issue examine a range of sexual and reproductive health rights and needs, as they relate to HIV and AIDS realities and challenges. The societal context in which especially women living with HIV and AIDS make choices about sexual and reproductive health and rights; the intersecting health and human rights crisis of HIV and AIDS and gender violence; the inseparable link between sexual and reproductive health and HIV and AIDS; as well as human rights instruments as a potential tool to claim sexual and reproductive rights are some of the issues explored in this edition.

A Publication of the AIDS Legal Network • March 2007
South African women living with HIV and AIDS’s ability to exercise their sexual and
reproductive rights and to achieve optimum sexual and reproductive health is one
of contradictions.
In this issue • 1 A long road to travel… Sexual and reproductive health and rights of women living with HIV • 2 Editorial
• 9 A tool for claiming sexual and reproductive rights… The AU Protocol on the Rights of Women: • 14 Rights are too
often overlooked… HIV and AIDS and gender-based violence – Intersecting health and human rights crises • 24 One thing
leads to another… Sexual and reproductive health rights in Nigeria • 29 In the absence of informed choice… Sexual
and reproductive health rights in the context of HIV and AIDS • 34 National View • 36 Regional View • 40 Comment
Sexual and reproductive health and rights of women living with HIV
A long road to travel…
QA
I D S L E G A L N e t w o r k
Susan Holland-Muter
Introduction
On the one hand, South Africa has an enabling
legislative and policy framework that promotes gender
equality, the right to health and enshrines women’s sexual
and reproductive health and rights. There are also numerous
laws and policies in place, which protect people who are HIV
positive and living with AIDS. However, at the same time,
traditional gender norms and practices, which underpin
and promote the unequal status of women, combined with
the levels of poverty experienced by the majority of women
in South Africa (particularly black women living in rural
areas or in urban informal settlements), contribute to a
situation whereby women bear the disproportionate burden
of reproductive health problems; are seen to be primarily
responsible for contraception and childcare; and have less
power to negotiate when, with whom and why to have sex.
Women bear the brunt of the HIV and AIDS pandemic,
both in terms of levels of infection, as well as shouldering
the burden of care of people living with AIDS. At the same
time, indices of violence against women in South Africa
are amongst the highest in the world, this combined with
HIV and AIDS and poverty, contributes to women’s poor
sexual and reproductive health status, especially women
living with HIV and AIDS.
Brief situational analysis of HIV and AIDS in
South Africa
South Africa currently faces one of the worst HIV and
AIDS pandemics in the world, whose mode of transmission
is fundamentally heterosexual. Estimates range from
5,300,000 adults and children living with HIV and AIDS1
to 6.29 million at the end of 20042. It is estimated that 11%
of the total population is HIV positive; of which 18.5% are
between the ages of 15 – 49.3
Due to the fact that vulnerability to HIV infection
and living with AIDS defining conditions is a result
Editorial…
Reproductive rights are central to human rights…
they derive from the recognition of the basic right
of all individuals and couples to make decisions
about reproduction free of discrimination,
coercion or violence. They include the right to
the highest standard of health and the right
to determine the number, timing and spacing
of children. They comprise the right to safe
childbearing, and the right of all individuals to
protect themselves from HIV and other sexually
transmitted infections. [UNDPF, 2005]
While sexual and reproductive health and rights
are recognised to be essential to the enjoyment
of other fundamental rights and freedoms, the
extent to which people are in the position to access,
claim and enjoy sexual and reproductive health
and rights is equally recognised to be indicative of
the gendered nature of HIV and AIDS realities and
challenges. Taking these recognised correlations
into account would also mean that any response to
HIV and AIDS has to have, at its core, not only the
access to, but also the enjoyment of, sexual and
reproductive health and rights.
In reality, however, the extent to which sexual
and reproductive health rights are accessible and
enjoyable remains to be largely defined by gendered
inequalities, imbalances and injustices, as well as
prevailing HIV related stigma and discrimination.
Moreover, reality is characterised by prevailing
beliefs and prejudices that people living with HIV
should not engage in sex and/or have children. As
a result, access to information and services is denied
and sexual and reproductive health and rights are
further limited.
It is within this framework that this edition of
the ALQ focuses on sexual and reproductive health
rights in the context of HIV and AIDS. The various
articles in this issue examine a range of sexual
and reproductive health rights and needs, as they
relate to HIV and AIDS realities and challenges. The
societal context in which especially women living
with HIV and AIDS make choices about sexual and
reproductive health and rights; the intersecting
health and human rights crises of HIV and AIDS
and gender violence; the inseparable link between
sexual and reproductive health and HIV and AIDS;
as well as human rights instruments as a potential
tool to claim sexual and reproductive rights are
some of the issues explored in this edition. This
issue is also introducing experiences and challenges
from Rwanda; ‘making a point’ about the ‘fear factor’
deterring men from accessing HIV testing services;
and providing women’s sector comments on the
National Strategic Plan for HIV and AIDS.
In this edition, Susan Holland-Muter discusses
sexual and reproductive health and rights concerns
of women living with HIV. Examining the societal
context in which women living with HIV and AIDS
‘make’ decisions regarding sexual and reproductive
health and rights, she argues that in order for sexual
and reproductive rights to become a reality, the
understanding of sexuality and the role it plays in
people’s lives has to be re-shaped and re-signified;
the social meaning attached to being a woman has
to be challenged; and sexuality has to be seen as an
integral dimension of being a human being.
Recognising the AU Protocol on the Rights of
Women as a tool to claim sexual and reproductive
rights, Caroline Murrithi raises the question as to
whether or not the Protocol adequately caters for
all women, including women living with HIV and
AIDS. Examining women’s realities and challenges
pertaining to their sexual and reproductive health,
and looking at the opportunities within the Protocol
to address these, she argues that the Protocol,
despite its progressiveness fails to adequately
address the needs and realities of women living with
HIV and AIDS and thus, calls for further advocacy
and lobbying so as to ensure that the sexual and
reproductive health rights of all women are equally
protected by the Protocol.
The intersecting and mutually reinforcing health
and human rights crises of HIV and AIDS and genderbased
violence are discussed by Susana Fried.
Analysing some of the critical issues surrounding
the intersection of gender-based violence and HIV
and AIDS, and introducing some promising practices
addressing these intersecting crises, she places gender
equality at the centre of the debate and argues that only
as and when responses are comprehensive, gendersensitive
and human rights-based, will they carry the
potential to effectively address the intersection of HIV
and AIDS and gender-based violence, and to create
conditions for safe, healthy, consensual and diverse
sexualities and life choices for all.
The extent to which the access to, and realisation
2 Editorial
ALQ March 2007
of inequalities in society, and at the same time deepens
existing inequalities, the pandemic features distinctive
racial, class, age and gender distributions.
…women have to take the decision about
whether or not they should take the
pregnancy to term in a context where
motherhood is revered and where there
is significant family and community
pressure on women to
have children…
Women make up 57% of the 5,100,000 adults
between the ages of 15 – 49 who are HIV positive.4
The prevalence rate is higher for women than men
aged 15 – 34 years. It increases dramatically among
young females and peaks at 33.3% for women aged
25 – 29 years. The increase is more progressive for
men on the other hand, and peaks at a lower level than
for women, 23.3% in age groups 30 – 34 and 35 – 39.5
The Department of Health’s 2005 National HIV and
Syphilis Sero-Prevalence Survey of women attending
public health antenatal clinics estimated that 30.2%
of pregnant women were HIV positive. Women
who were 20 – 34 years old were the worst affected,
with prevalence rates of up to 40% for women aged
25 – 29 years.
Young people aged 15 – 24 years are especially at
risk of HIV infection, accounting for 60% of all HIV
infections. However, young women make up 77%
of those living with HIV and AIDS in the 15 – 24
age group.6
Racial disparities are also revealed with 16% HIV
prevalence for Africans, 6.8% for Coloureds, 5.6% for
Whites and 2.7% for Indians between the ages of 15
– 49 years in 2004.7
It is estimated that about 525,000 people were
living with AIDS defining conditions, and 44% of
total deaths in South Africa can be attributed to AIDS
related causes in 2004.8 The 2nd Saving Mothers Report
revealed that AIDS is the leading course of maternal
deaths in South Africa, with estimates ranging from
17 – 27.6%.
What are the sexual and reproductive health
and rights concerns of women living with HIV
and AIDS?
South Africa is signatory to both international
agreements and programmes of action, which outline
the scope of issues, concerns and actions required to
promote women’s sexual and reproductive health and
rights.
The 1994 International Conference on Population
and Development Program of Action (ICPD POA)
defined reproductive rights as the rights of couples
and individuals to:
• Decide freely and responsibly on the number,
spacing and timing of their children, and to have
the information, education and means to do so;
• Attain the highest standard of sexual and
reproductive health, and make decisions about
reproduction free of discrimination, coercion
and violence.
The women’s rights perspective enshrined in the
ICPD POA was consolidated in Beijing during the
1995 Fourth World Conference on Women (FWCW)
Platform for Action. The Platform for Action defined
sexual rights as
…the human rights of women include their
right to have control over and decide freely and
responsibly on matters related to their sexuality,
including sexual and reproductive health, free of
coercion, discrimination and violence.9
However, the context in which women living with
HIV and AIDS ‘make’ decisions regarding their sexual
health and rights, and reproductive health and rights
is often characterised by a range of negative factors
related to their unequal status as women in relation to
men, lack of education and information, or in relation
to the gender specific stigma and discrimination faced
by women who are living with HIV and AIDS.
3
Sexual and reproductive health and rights of women living with HIV
March 2007 ALQ
of, sexual and reproductive health and rights impacts
on HIV and AIDS realities and challenges in Nigeria
are introduced by Busari Olusegun. Exploring
various realities of sexual and reproductive health
and rights, including practices of female genital
mutilation and child marriages, he argues that it is
not only vital to develop policies and programmes
addressing the inseparable link between sexual
and reproductive health and HIV and AIDS, but
also crucial to effectively implement these policies
and programmes, since the failure to adequately
implement policies and programmes is worse than
the absence of such policies and programmes.
Some of the specific sexual and reproductive
health rights issues of women living with HIV and
AIDS are introduced by Nomampondo Barnabas.
Exploring various challenges that contribute to
the violation of sexual and reproductive rights and
looking at the scope of sexual and reproductive
health services, she argues that the absence
of informed choices and adequate sexual and
reproductive health services not only denies
women living with HIV and AIDS their sexual and
reproductive health and rights, but also increases
their risk of morbidity and mortality.
HIV realties and challenges from Rwanda
are introduced by Emmanuel Habumuremyi.
Analysing various responses to HIV and AIDS
within the Rwandan context, including the use of
cell phones to enhance HIV and AIDS treatment,
support and care, he argues that, despite many
successes and utilisation of innovative measures
leading to the decline in HIV infection rates, there are
many remaining challenges, including ignorance,
continuously threatening the adequate response to
HIV and AIDS in Rwanda.
Kent Klindera, Dumisani Rebombo and
Andrew Levack are ‘making a point’ about the ‘fear
factor’ defining men’s preparedness and willingness
to be tested for HIV. Recognising the importance of
men accessing HIV testing services and analysing
the factors deterring men from utilising available
HIV testing services, the article argues that a new
form of masculinity is needed to maximise the
impact of HIV and AIDS strategies and programmes,
since gender roles not only limit men’s involvement
in HIV and AIDS efforts, but also limit the success of
these efforts.
While the particular examined reality may vary,
there seems to be a common underlying reality –
one of gendered inequalities, imbalances and
injustices, as well as stigma, discrimination and
violation of rights based on sex, gender, sexuality,
and/or HIV status – which ultimately defines the
extent to which sexual and reproductive health
rights are accessible and realisable. Thus, sexual
and reproductive health and rights are as much
limited, as choices are influenced, by the gendered
societal context and existing HIV related stigma and
discrimination.
If we are to agree that the right to make informed
choices ‘free of discrimination, coercion or violence’
is at the core of sexual and reproductive health
and rights, then we are to equally agree that the
prevailing societal context, not only perpetuating,
but also justifying, the occurrence of ‘discrimination,
coercion or violence’ based on sex, gender, sexuality
and/or HIV status, ‘threatens’ the very core of sexual
and reproductive health and rights. Similarly, if we
are to agree that rights are only as accessible as the
societal context in which choices are made ‘allows’,
then we are to agree that it is the very same societal
context, which ‘prescribes’ the continuous denial of
sexual and reproductive health and rights. Thus, at
the core of sexual and reproductive health and rights
is the societal context in which choices are made.
So, if we are to create an environment that
‘allows’ individuals to make informed choices and
decisions ‘free of discrimination, coercion or violence’,
then we are to challenge and transform the societal
context in which choices are made. Only as and when
the existing societal context ‘denying’ individuals to
make free and informed choices, is transformed, will
sexual and reproductive health and rights become
a reality. Until then, the extent to which people are
in the position to make sexual and reproductive
choices will continue to be defined by a person’s
sex, gender, sexuality and/or HIV status; and will
remain to be indicative of HIV and AIDS realities
and challenges. Thus, until the societal context is
transformed, there will be no ‘freedom of choice’, and
individuals who claim their right to make sexual and
reproductive choices will continue to be stigmatised,
discriminated against and/or violated…
Johanna Kehler
4 Editorial
ALQ March 2007
Women living with HIV and AIDS often face many
obstacles to prevent unwanted pregnancies. These
include lack of access to information concerning the
most appropriate methods, particularly about how
contraceptives may interact with ARVs and medications
to treat opportunistic infections; and an inability to
use condoms and contraception consistently, due to
unequal power relations with men, and pregnancies
which may result from rape.10
Women often only find out their HIV status once
they are pregnant, leaving them facing the decision
whether or not to disclose to their partners, often
fearing rejection, violence and of being accused of
having brought the disease into the home. In addition
to this, women have to take the decision about whether
or not they should take the pregnancy to term in a
context where motherhood is revered and where there is
significant family and community pressure on women
to have children, seeing it as fulfilling a woman’s role in
life and/or as a means to demonstrate adulthood status.
However, these decisions are taken in a context where
there is insufficient access to measures to prevent
mother to child transmission of HIV (PMTCT) and
where there is insufficient access to (and acceptance
of) termination of pregnancy services.11
On the other hand, women living with HIV and
AIDS face stigmatisation and social censure, if they
want to, and do, have children. Women are charged
with being irresponsible, because, as the argument
goes, they will die and leave their children orphans,
or they will infect their children. In addition, women
living with HIV and AIDS suffer discrimination, often
at the hands of healthcare workers, when women are
pressured to ‘abort’ or undergo forced sterilisation, for
example, by being threatened to only have access to
ARV treatment, if she agrees to undergo sterilisation
procedures.
At the same time, there are barriers at the level of
health programme design and in service provision,
which do not cater to the full range of health needs, and
specifically the sexual and reproductive health needs
of women living with HIV and AIDS. Women’s limited
and insufficient access to ARVs notwithstanding,
there is also the problem of ARVs being offered in a
programme and service that is separated from, and does
not address, their sexual and reproductive health (SHR)
needs. These SRH needs are also often offered with
a narrow focus on maternal health, especially issues
around the prevention of mother to child transmission
of HIV. Sexual needs and desires and information/
education needs around safe and protective methods of
engaging in pleasurable sex are not high on the agenda.
Instead it has been charged that women living with HIV
and AIDS are often faced with judgmental attitudes
from healthcare workers, which discourage them from
exercising a healthy and positive sexuality.12
What needs to be done in the future to promote
women living with HIV and AIDS’ sexual and
reproductive rights?
There are many socio-economic and cultural shifts
which need to take place in order to effectively promote
women living with HIV and AIDS’ sexual and reproductive
rights which have been adequately addressed elsewhere. I
would like to address two issues, notably that of reframing
how we think and talk about and exercise sexuality, and of
addressing the role of the state and community in taking
responsibility for childcare and children.
…sexual needs and desires and
information/education needs
around safe and protective
methods of engaging in pleasurable sex
are not high on the agenda…
A rights framework provides a basis to begin
addressing the context in which HIV infection
takes place, and the stigma and discrimination that
surrounds people living with HIV and AIDS. Within
this scenario, I will highlight sexual and reproductive
rights specifically, although the rights framework
goes beyond this (including economic, social, cultural
5
Sexual and reproductive health and rights of women living with HIV
March 2007 ALQ
and human rights more broadly). Within the context
of women and girls being the most vulnerable to HIV
infection, we often speak of promoting the rights of
women and girls to choose when, with whom, how and
why to have sex. I would agree with this. However, in
order for these rights to become a reality, and in order
to begin promoting women and girls’ sexual rights,
one would have to place sexuality itself under the
microscope, examine how it has been understood and
framed in a post colonial South Africa and re-signify
our understanding of sexuality and the role it plays in
our lives.
…there is the belief that people who
are living with HIV and AIDS should
not engage in sex, that they have been
irresponsible and should now reap
the rewards for their ‘wanton and
promiscuous behaviour’, by abstaining
from sex for the rest of their lives…
Although South Africa was colonised by both
the English and the Dutch, and there are a myriad of
understandings and experiences of sexuality in local
cultures, the hegemonic influence of an English Victorian
Christian world view of sexuality in South Africa is clear
for all to see. Within this worldview, sex is seen to be a dirty
and shameful act; a private, taboo subject, and only seen
to be good and Christian when it is exercised for purposes
of reproduction, and within the context of a monogamous
Christian marriage. In this case, it takes place between a
man and a woman, during their reproductive life cycles,
and in the ‘missionary position’. Over time, there has
been a growing acceptance of other kinds of sexual
acts between married partners, including oral sex and
maybe a range of different penetrative positions, but
apart from that, engaging in other sexual acts will
lead to ‘hell and damnation’.
It is for this reason that HIV and AIDS is being
signified as the result of ‘sinful behaviour’ and as ‘a
punishment from God’. It is within this context that
there is the belief that people who are living with HIV
and AIDS should not engage in sex, that they have been
irresponsible and should now reap the rewards for their
‘wanton and promiscuous behaviour’, by abstaining
from sex for the rest of their lives.
This also is the context in which promoting the
rights of people, specially women, to sexual pleasure
is regarded as vaguely shameful, and definitely not as
important and integral to somebody’s dignity, health
and well-being, as their right to housing, food, and
work. In the context of gendered norms, where men are
seen to be the active sexual subjects, sexual pleasure
and sexual needs are seen to be a male prerogative. A
woman’s relationship to sex is seen to be an expression
of love and affection for their (male) partner, preferably
married (if not, at least monogamous partner), and to
enable her to become what society has seen to be the
main signifier of womanhood, a mother. In addition, a
wife’s sexuality (and women more generally) is seen
to be in function of providing for their husband’s and
men’s sexual pleasure.
So a necessary part of promoting women and girls’
sexual rights, and particularly women who are living
with HIV and AIDS’s sexual rights, is to reshape and
re-signify society’s world view of sexuality, and the
role that it plays in our lives. In this case, it would
be to see sexuality as an integral dimension of being
a human being, and an integral part of achieving
emotional, spiritual and physical well-being. That is,
that sex is normal and part of everyday life. Sex is
something to be spoken about, taught openly to the
young, and exercised within the context of rights and
responsibilities.
Part of this would include reshaping the role that
sexuality plays in the lives of both women and men.
Sex needs to be seen as just as important and just as
necessary and part of a person’s identity for both women
and men. This would also mean changing the social
reactions to a woman who openly wants and desires
sex for her own pleasure, and not just her partner. This
would mean confronting and challenging the social
6 Sexual and reproductive health and rights of women living with HIV
ALQ March 2007
power that society ascribes to men in determining
when, where, how and why to have sex. It would also
mean men taking equal contraceptive responsibility,
and not seeing this as only a woman’s responsibility.
Related to this is the need to normalise and ‘sexify’
safer sex. As soon as one writes ‘safer sex’, then the
association of ‘good, hard and pleasurable sex’ might
go out of one’s head. However, part of ‘sexifying’ and
normalising safer sex is to reshape the meanings and
practices associated with barrier methods, namely
condoms (female and male), gloves, and dental dams.
Promoting the idea that condoms do not mean infidelity,
not loving somebody, and/or lack of pleasure would
go a long way towards promoting their acceptance
and use. If we could do this in a context where sex is
normal, and is seen as a means to communicate and
express oneself, then finding ways to put it on (and
in) as part of the sexual itself, might go some way to
addressing the resistance to condom use.
Motherhood, childcare and the role of the state
and community
Firstly, I think it is important that society needs to
be challenged to re-signify the social meaning attached
to being a woman. In this case, it is necessary to
promote the idea that women have value and meaning
in life, because they exist as human beings, and not
just because they bear children. In this sense, it is
necessary to change the association that being a woman
equals being a mother. In this context, choosing to
have a child or not, is the outcome of individual choice
and desire, and not as a precondition to have status,
acceptance and power in a community.
Secondly, it is important to recognise that it is not
just women who have children and who should bear the
responsibility for their care and upbringing. Here, it
is important to recognise that it is also the father who
plays a role, firstly in making the baby and secondly,
that it should also be his social responsibility to care
for the child, both in terms of upbringing, as well as
contributing to paying for their upkeep.
A related issue is what role should communities
and the state play, and what responsibility should
the state assume for childcare? Different cultures in
South Africa have different social norms around who
should be responsible for children, ranging from the
extended family and community’s responsibility to
being only that of the individual mother (and at times,
father). However, in the current context of breakdown
in social relationships, notions of there being an
extended family and community responsibility has
increasingly disappeared, leaving individual women to
carry the burden. This is not necessarily the biological
mother, as in the context of children, who survive
parents who have died from AIDS related diseases,
many grandmothers, aunts, cousins and other (female)
community members are taking on the responsibility
of caring for orphaned children.
…the state has a responsibility to ensure
that its citizens, in this case pregnant
women who are HIV positive, have
access to healthcare services that would
allow women to have safe and healthy
pregnancies, and healthy babies…
I would argue that women living with HIV and
AIDS have the right to choose whether or not to have
children. If women infected with HIV choose to have
children, the state has a responsibility to ensure that
its citizens, in this case pregnant women who are HIV
positive, have access to healthcare services that would
allow women to have safe and healthy pregnancies, and
healthy babies. This would include general healthcare,
antenatal care, and prevention of mother to child
transmission of HIV.
In a similar vein, it is interesting for me the
disparity of support provided by the state for childcare
depending on one’s relationship to the child. A foster
parent receives about eight times the amount of money,
than a biological parent, if one compares the Child
7
Sexual and reproductive health and rights of women living with HIV
March 2007 ALQ
Care Grant and Foster Care Grant13. Are the costs not
the same? This disparity reinforces the notion that
having a child is a private responsibility and the state
only steps in when the biological parents or family are
unable to do so.
…strategies to support … reproductive
choices need to go beyond merely
counteracting the discrimination and
stigma associated with choosing to
have a child…
I would argue that this should be revisited, and
that minimally the grants should be the same. This
is especially important considering that a person
living with HIV and AIDS will suffer the ill effects
of opportunistic infections and side effects from the
ARVs, which will limit their abilities to work and/or
create income. In this context then, strategies to support
women’s (and families’) reproductive choices need to
go beyond merely counteracting the discrimination and
stigma associated with choosing to have a child, while
living with an illness, but needs to consider the economic
support that would be required from the state.
FOOTNOTES:
1. UNAIDS. 2004. Report on the Global HIV/AIDS Epidemic.
2. Statistics South Africa cited in Health System Trust. 2005. South African
Health Review 2005.
3. ASSA 2002 model. Health System Trust. 2005. South African Health Review
2005.
4. UNAIDS. 2004. Report on the Global HIV/AIDS Epidemic.
5. Human Sciences Research Council. 2005. South African National HIV
Prevalence, HIV Incidence, Behaviour and Communication Survey 2005. Cape
Town.
6. UNAIDS. 2002. Report on the Global HIV/AIDS Epidemic.
7. Statistics South Africa cited in Health System Trust. 2005. South African
Health Review 2005.
8. ASSA 2002 model. Health System Trust. 2005. South African Health Review
2005.
9. FWCW Platform for Action, 96 as cited in Family Care International, 2000.
Sexual and Reproductive Health Briefing Cards. Family Care International, New
York.
10. de Bruyn, M. 2002. Reproductive Choice and Women Living with HIV/AIDS.
IPAS.
11. Ibid.
12. Odhiambo, D. 2006. ‘Do HIV and AIDS make us less human than others…?
Fertility desires and sexual and reproductive health needs of people living with
HIV’. In: ALQ, November 2006.
13. The Child Support Grant amount is R190 and the Foster Care Grant amount
is R590.
Susan Holland-Muter is an Independant
Researcher. For more information and/or
comments, please contact her at
hollandmuter@mweb.co.za.
8 Sexual and reproductive health and rights of women living with HIV
ALQ March 2007
The coming into force of the Protocol to the
African Charter on Human and Peoples Rights on
the Rights of Women (otherwise known as the
Women’s Protocol) on 25th November 2005 was
a victory for the women of Africa. At last, women
can celebrate the creation of a legal framework
that solely addresses women’s plight in Africa.
The Women’s Protocol was drafted to compliment the
already existing African Charter on Human and Peoples’
Rights (herein the ‘African Charter’). The African Charter
(1981) was the first human rights instrument to include
three generations of rights; namely, civil and political rights;
the social, economic and cultural rights; as well as group
rights. It was a breakthrough for Africa and marked for
the first time the willingness and commitment by African
States to adhere to international standards of human rights,
while addressing the specific needs of Africans.
The African Charter in Article 2 enshrines the principle
of non-discrimination on the grounds of race, ethnic group,
colour, sex, language, religion, political or any other
opinion, national and social origin, fortune, birth or other
status. Despite its progressive nature, the African Charter
was, however, criticised for failing to adequately provide
for women. The African Charter has only one provision,
Article 18(3), which calls on member states to
…eradicate all forms of discrimination against
women and ensure the protection of women
and children as stipulated in international
declarations and conventions.
The Women’s Protocol was, therefore, drafted to
supplement this provision and clearly lay out the rights for
women.
The Women’s Protocol was adopted in July 2003 and
came into force on 25th November 2005, becoming the
fastest human rights instrument to come into force in
Africa. It should be noted that this was due to concerted
efforts amongst activists, women rights organisations and
individuals, who had actively participated in the drafting
of the Women’s Protocol and did not want the gains, made
for women, to be lost.
The Women’s Protocol is a special document as it
specifically addresses the challenges that African women
face daily, such as lack of access to land and other resources,
harmful traditional practices, conflict, and exclusion from
political participation. The Women’s Protocol is the first
international human rights instrument to call for a legal
prohibition of female genital mutilation (FGM) and other
harmful traditional practices; it protects women’s rights
to own land and property; protects the rights of women
in marriage and upon dissolution of marriage; it provides
protection for widows, elderly women, women with
disabilities and women in distress, among other rights.
The Women’s Protocol is also the first international
human rights instrument to expressly frame women’s
reproductive rights as a human right’s issue and guarantee
a woman’s right to control her fertility. This is a big step
towards the recognition of women’s reproductive rights
and a cause for celebration. The Women’s Protocol gives
women in Africa a tool by which to claim their sexual and
reproductive rights. The question, however, is whether or
not the Protocol will cater for all women, including women
living with HIV and AIDS.
What challenges do women living with HIV and
AIDS face?
Women living with HIV and AIDS often face numerous
challenges regarding their sexual and reproductive
health. Generally, women’s access to healthcare is
often compounded with social, economic and political
inequalities.1 However, for women living with HIV and
9
The AU Protocol on the Rights of Women
March 2007 ALQ
A tool for claiming sexual and
reproductive rights…
The AU Protocol on the Rights of Women
Caroline Murrithi
AIDS this is more complicated, as they have to deal with the
stigma and discrimination, because of their HIV positive
status. Women in general tend to be marginalised in their
community and have no access to economic resources,
are uneducated and are economically dependant on their
male relative or spouses. This makes women vulnerable to
HIV and AIDS infection, as they have no decision-making
capacity within the society.
…rights and freedoms are intertwined,
and if women cannot enjoy their basic
rights and freedoms to bodily
integrity and dignity, they also cannot
enjoy good health…
Furthermore, women fear going for HIV testing,
because of the social implications and the blame that
is often put upon women as the ‘virus transmitters’.
A positive HIV test result can easily result in
violence from spouse or partner; loss of her children;
alienation from her family; as well as loss of property
and livelihood. In addition, women and girls are the
caregivers in the society, when a member of the family
is unwell, the onus is on the woman to provide the
care required. For women living with HIV and AIDS
this often means that they have neither the time nor
resources to seek the required medical attention, have
no time to rest and eat well. This is further complicated
by the fact that for most rural women hospitals and
clinics are inaccessible and expensive and, therefore, a
mere luxury they cannot afford. Women simply do not
have the time or resources to address their own health
issues and seek medical intervention.
Women, due to socio-economic realities, are often
not in the position to negotiate safer sex, even when they
are infected with HIV, and are at a constant risk of reinfection.
Women living with HIV and AIDS are often
discouraged by medical practitioners to have children
and, in some instances, have been sterilised to prevent
them from bearing children, due to the possibility of
transmitting the HI virus to their child. The right to
bodily integrity; right to family; the right to control
their fertility; and the right to decide whether or not
to have children are violated and women, who choose
to have children, are often viewed by the society as
irresponsible.
How then can these challenges be addressed to enable
women to achieve the highest attainable standard of health
and enjoy their rights and freedoms? Simply put, for women
to enjoy their health and reproductive rights, women must
first be empowered; be protected from discrimination and
violence; and be in the position to enjoy the most basic
rights and freedoms. According to HernÁndez-Truyo2 the
concept of women’s reproductive health must be redefined
beyond ‘sick’ and ‘medicalised’ to include matters of wellbeing,
such as education, economic self-determination,
political participation, environmental safety and personal
security. She further states that the issue of reproductive
freedoms highlights the critical importance of approaching
rights as indivisible and reveals the normative weakness of
the single-right approach. It is, therefore, important that, as
we look at women’s rights, we realise that these rights and
freedoms are intertwined, and if women cannot enjoy their
basic rights and freedoms to bodily integrity and dignity,
they also cannot enjoy good health.
Opportunities within the Protocol
Looked at holistically, the Protocol provides various
human rights protections that would ensure that all
women, and in particular women living with HIV and
AIDS, are protected. The Protocol, in its Preamble,
reiterates the principle of non discrimination enshrined in
Article 2 and 18(2) of the African Charter. This requires
states to take measures that eliminate discrimination
on the numerous grounds including gender and ‘other
status’. Women living with HIV and AIDS can utilise
these provisions to address discrimination, especially
regarding access to adequate health services.
The Protocol provides for the right to dignity3 and
obliges state parties to adopt and implement appropriate
measures to ensure the protection of this right and
protection from all forms of violence, particularly
10The AU Protocol on the Rights of Women
ALQ March 2007
sexual and verbal violence. The right to dignity is an
acknowledgment of the intrinsic worth of human beings,
a right to be treated as worthy of respect and concern.4
It further provides for the right to life, integrity and
security of the person5, and demands that state parties
enact and enforce laws that prohibit violence against
women, including unwanted or forced sex, whether in
private or public.
This is a key development in the international human
rights discourse. Traditional international human rights
law and the UN system did not consider so called ‘private
acts’ or acts ‘perpetrated by private actors’, and acts
that take place in a traditionally private sphere, such as
the home, to be human rights violations.6 This left the
issue of violence against women out of the legal system
and the human rights realm in general. The reality is
that most women suffer violence within the domestic
or private sphere; for example domestic violence and
violence occurring within the family and the community.
In addition, legal doctrines protecting the privacy of
the home and family have been widely used to justify
the failure of the State and society to intervene when
violence and abuse is committed against women in the
family and to take remedial actions.7 State parties under
the Protocol are, therefore, obligated to take action to
protect women within the private sphere.
…traditional international human
rights law and the UN system did not
consider so called ‘private acts’ or acts
‘perpetrated by private actors’, and
acts that take place in a traditionally
private sphere, such as the home, to be
human rights violations….
Another key development is that the Protocol
requires state parties to allocate budgetary and other
resources for the implementation and monitoring of
actions aimed at eradicating violence against women.8
Therefore, state parties are precluded from using
lack of resources as an excuse for not implementing
measures to protect all women from violence against
women.
…state parties are precluded from
using lack of resources as an excuse
for not implementing measures to
protect all women from violence
against women…
The Protocol in Article 14 explicitly provides for
sexual and reproductive health rights of women. It states
that women’s sexual and reproductive health is to be both
respected and promoted, which is predicated on women’s
right to control their fertility and by an obligation of states
to provide adequate, affordable and accessible health
services.9 Article 14 of the Protocol provides for a number
of health and reproductive rights for women, including the
right to control fertility; the right to decide whether or not
to have children and the number and spacing of children;
the right to choose a method of contraception; the right
to self protection and to be protected against sexually
transmitted infections, including HIV and AIDS; the right
to be informed of one’s health status and the health status
of one’s partner, if infected with sexually transmitted
infections, such as HIV and AIDS; and the right to have
family planning education.
The Protocol does not simply list the rights that
women are entitled to, but also lays out the follow-up
actions that states must take to ensure that the rights
provided are realised. A fundamental challenge to
women’s sexual and reproductive health is access to
health services and access to information pertaining
to their health. The Protocol in this regard places an
obligation on state members to ensure that women have
access to adequate, affordable and accessible healthcare
and that state parties must implement programmes
to disseminate information on women’s sexual and
reproductive health. To ensure that states do not use
11
The AU Protocol on the Rights of Women
March 2007 ALQ
any excuse for non-implementation, the drafters of the
Protocol incorporated Article 26 which requires that
state parties
…undertake all necessary measures and in
particular provide budgetary and other resources
for the full and effective implementation of the
rights herein.
This precludes state parties from neglecting to set
aside a budget for sexual and reproductive healthcare
and information to all women, amongst other obligations,
stated under the Protocol.
In this regard the Protocol provides a more detailed
list of sexual and reproductive rights than other global
human rights instruments. The Protocol drew inspiration
from the Convention on the Elimination of all Forms of
Discrimination Against Women (CEDAW), which calls
on state members to ‘eliminate discrimination against
women in the field of health care’10 and guarantees
women the ‘right to access to health care services’11,
and to ‘decide freely and responsibly on the number and
spacing of the children and have access to information,
education and means to enable [her] to exercise this
right’12. The Protocol is the only treaty to specifically
address women’s rights in relation to HIV and AIDS
and to identify protection from HIV and AIDS as a
key component of women’s sexual and reproductive
rights.13 The Protocol further requires States to
provide information, education and communication
programmes to women, especially to women in the
rural areas.14
Shortcomings within the Protocol
Despite these progressive provisions, the Protocol
has been criticised for failing to provide adequate
protection for women living with HIV and AIDS.
According to Delport15 the Protocol approaches HIV
and AIDS as a purely health issue, failing to link it
with other human rights issues, such as principles of
gender equality, right to dignity and bodily autonomy,
freedom from gender-based violence, and freedom from
discrimination. However, this omission is not fatal as
the Protocol has numerous provisions, which, if read
together with Article 14, would amount to sufficient
protection for women living with HIV and AIDS.
Another shortcoming of the Protocol is that the
same provision advocates for the right to be informed
of one’s health status and the health status of one’s
partners, if affected with a sexually transmittable
infection, such as HIV and AIDS. Taking note that
the intention of the Protocol is to protect individuals
from HIV and AIDS infection, it fails to recognise the
realities that women often face. Women, due to their
reproductive role, often visit hospitals and clinics
more often than men and are, therefore, more likely
to undergo HIV testing during pre-natal visits. This
provision takes away women’s right to privacy and
confidentiality and, thus, discourages women from
seeking medical attention for fear that once their HIV
status is discovered, their partners would be notified.
This fear is justified considering the social outcomes of
such a revelation. This provision would also discourage
women from going for voluntary HIV testing and in
effect prevent women from knowing their HIV status
and living positively. This in totality affects women’s
right to access health services.
…the Protocol approaches HIV and AIDS
as a purely health issue, failing to link
it with other human rights issues, such
as principles of gender equality, right to
dignity and bodily autonomy, freedom
from gender-based violence, and freedom
from discrimination…
These provisions, therefore, require the most
favourable interpretation in order that they serve all
women. It is a call to further advocacy and lobbying by
women and other non-state actors to ensure that women
living with HIV and AIDS are not discriminated against
within the healthcare system and that their right to
dignity and integrity are respected.
12The AU Protocol on the Rights of Women
ALQ March 2007
The beauty of the Protocol, despite the evident
challenges, is that it recognises that countries sometimes
have more advanced laws and policies that provide for
more rights other than those listed within the Protocol.
As a result, the Protocol in Article 31 states that none
of the provisions within the Protocol would affect more
favourable provisions in national legislation or any
other regional or international treaties. This, therefore,
calls on states to always apply the most favourable
human rights standards.
Summary
In conclusion, women in Africa have a very
progressive instrument with which to claim their
sexual and reproductive health. The Protocol is a new
instrument that will require progressive interpretation
to ensure that women’s rights are adequately protected.
To ensure that the gains made for women are not lost,
we must ensure to incorporate the already existing
guidelines and recommendations adopted by the
various UN agencies and others working in sexual and
reproductive health rights. Legal and policy framework
that support women’s sexual and reproductive rights
must be strengthened to enable women to claim their
rights, as well as to create national policies and laws
that address gender norms, violence, stigma and
discrimination as potential barriers to women’s access
to care and treatment. The Protocol gives women
living with HIV and AIDS a chance to claim their
sexual and reproductive rights and shape the thinking
and discourse relating to their sexual and reproductive
health rights.
…the Protocol is a new instrument that
will require progressive interpretation
to ensure that women’s rights are
adequately protected…
FOOTNOTES:
1. Centre for Reproductive Rights. 2006. Gaining ground: A tool for Advancing
Reproductive Rights Law Reform, p.67.
2. HernÁndez-Truyol, B.E. 1996. ‘Women’s Rights as Human Rights – Rules,
Realities, and the Role of Culture: A Formula for Reform’, In: J. Int’l L. 605.
3. Article 3 of the Protocol.
4. The South African Human Rights Commission Special Report findings in Layla
Cassim and Crawford Colleges [http://64.233.167.104/search?q=cache:
Rw8Y6U0Fbg4J:www.sahrc.org.za/sahrc_cms/downloads/Layla%2520
Cassim%2520and%2520Crawford.DOC+the+right+to+dignity&hl=en
&ct=clnk&cd=30&gl=ke]
5. Article 4 of the Protocol.
6. Bond, J. E. 2003. International Intersectionality: A Theoretical and Pragmatic
Exploration of Women’s International Human Rights Violations, 52 Emory L.J.
71 (Winter 2003).
7. Report of the Secretary General, In Depth Study on all Forms of Violence
Against Women, (6th July 2006). A/61/122/Add.1.
8. Article 4(2)(i) of the Protocol.
9. Breathing Life Into The African Union Protocol On Women’s Rights In Africa.
2006. Solidarity for Africa Women’s Rights & African Union Women, Gender
and Development Directorate, p.6.
10. Article 12(1) of the CEDAW.
11. Ibid.
12. Article 16(1)(e) of the CEDAW.
13. Centre for Reproductive Rights (CRR) briefing paper. The Protocol on the
Rights of Women :An instrument of advancing Reproductive and Sexual Rights.
[http://www.crlp.org/pdf/rr2k-1.pdf]
14. Article 14(2)(a) of the Protocol.
15. Delport, E. 2007. In: Burnett, P., Karmali, S. & Maniji, F. Eds. Grace, Tenacity
and Eloquence: The struggle for Women’s Rights in Africa. Fahamu & Solidarity
for African Women’s Rights.
Caroline Muriithi is a human rights lawyer at
Equality Now, based in Nairobi, Kenya.
For more information and/or comments,
please contact her on + 254 20 271 9832 or at
muthonicus@gmail.com.
13
The AU Protocol on the Rights of Women
March 2007 ALQ
Introduction2
Violence against women and girls is a major
contributor to death and illness amongst women, as
well as to social isolation, restrictions on freedom of
movement, and loss of personal autonomy. Research
confirms that violence, and particularly intimate
partner violence, also is a leading factor in the
increasing ‘feminisation’ of the global AIDS pandemic,
resulting in disproportionately higher rates of HIV
infection amongst women and girls. Simultaneously,
evidence confirms HIV and AIDS as both a cause and
a consequence of the gender-based violence, stigma
and discrimination that women and girls face in their
families and communities, in peace and in conflict
settings, by state and non-state actors, and within and
outside of intimate partnerships.
For more than two decades, international women’s
movements have fought for both international
recognition of, and concrete action to promote, the
human rights of all women. At the core of this are the
principles that every woman has the human right to be
free from violence, coercion, stigma and discrimination,
and that every individual has the right to achieve the
highest attainable standard of health, including sexual
and reproductive health. Founded in these core values,
the following essay is addressed to the intersecting
health and human rights crises of HIV and AIDS and
gender-based violence, with an emphasis on violence
against women and girls. The essay seeks to define
and identify some of the critical issues surrounding the
intersection of gender-based violence and HIV and AIDS
from an analytical perspective that sets gender equality
and women’s empowerment at the core of any effective
initiative. It is anchored in the contention that inadequate
attention has been paid to gender-based violence and
HIV and AIDS as intersecting and mutually reinforcing
crises. At the same time, there are promising practices
being spearheaded by women’s rights organisations that
deserve greater support and attention, particularly as
models to be replicated and/or scaled up.
The article first sets out the importance of
understanding the intersection of HIV and AIDS and
gender-based violence. It stresses that gender-based
violence is rooted in gender inequality, and has a
lethal dynamic by itself and in combination with HIV
and AIDS. Next, it provides information about how
differences in race, ethnicity, language, sexuality, age,
and many other social factors have a significant and
differential impact on the effect of both gender-based
violence and HIV and AIDS on the lives of women and
girls in various communities. Third, it highlights some
of the key obstacles and challenges to comprehensively
addressing the intersection of gender-based violence
and HIV and AIDS, and the barrier this presents to
effective prevention, services and advocacy. Fourth, it
emphasises the importance of a comprehensive, gender
and human rights sensitive-response to both HIV and
AIDS and gender-based violence, providing some of
the key elements of such an approach. The potential
heightened risk of violence against women and girls
engendered by strategies such as ‘provider initiated’
testing practices that are not fully gender-sensitive
and human rights-based underscores the urgency of
‘globalising’ such a comprehensive approach. Finally, it
concludes by offering examples of promising practices
from colleagues in a variety of countries, communities
and circumstances.
14 Intersecting health and human rights crises
ALQ March 2007
Rights are too often overlooked…
HIV and AIDS and gender-based violence – Intersecting health and
human rights crises
Two pandemics threaten the health, lives and rights of women throughout the world:
one is HIV and AIDS and the other is gender-based violence against women and girls.
Susana T. Fried1
HIV and AIDS and gender-based violence:
Intersecting health and human rights crises
As colleagues at the Center for Women’s Global
Leadership have stated succinctly,
…around the world, women are facing a
catastrophic assault on their bodies, rights and
health as a result of the prevalence of both HIV
and the unrelenting omnipresence of violence
against women.3
Each constitutes a crisis on its own, and the
combination produces a particularly potent poison.
Increasingly, women are dealing with the way violence
places them at greater risk of contracting HIV, while
women who are living with HIV are more likely to be
targets of violence, because of the additional layers
of discrimination and stigma they face. Elements of
the AIDS testing and treatment machinery may also
bring risk, such as the danger of violence connected
to disclosure of HIV serostatus or coercive testing in
the guise of VCT (voluntary counselling and testing),
or the insidious treatment of women as ‘vectors of
disease’, as in the case of PMTCT (prevention of
mother-to-child transmission) programmes that fail
to treat pregnant women who are living with HIV as
patients or clients with rights, but rather only as, and
nothing more than, child-bearers.
An increasing number of analysts and observers are
noting that violence against women is a cause of HIV,
as well as a consequence.4 A recent article in Clarin, a
national newspaper in Argentina, notes that
…[s]exual violence directly increases women’s
risk of HIV infection, be it through rape within
or outside a relationship, trafficking of women,
sexual exploitation and commerce or sexual
violence committed in armed conflict. All of
these, according to [Mabel] Bianco [founder of
FEIM, Fundacíon para Estudio y Investigacíon de
la Mujer, Buenos Aires, Argentina], are forms of
violence that expose women to HIV transmission.
Only 10 percent of sexual abuses and rapes are
reported. Women who do not report sexual abuse
or rape are also not accepting prophylactic
treatment after possible exposure to HIV and this
is how the probability of infection increases.5
…increasingly, women are dealing
with the way violence places them at
greater risk of contracting HIV, while
women who are living with HIV are more
likely to be targets of violence,
because of the additional layers of
discrimination and stigma…
A report in the UN-sponsored IRIN/PLUSNEWS,
makes this point painfully clear:
A Zambian nongovernmental organisation (NGO)
revealed this week that it records eight cases of
rape of young girls every week at its centre in the
capital, Lusaka. The statistics were released by the
Young Women’s Christian Association (YWCA) of
Zambia to mark the start of the global campaign,
‘16 Days of Activism Against Gender Violence’,
which runs from 25 November – International Day
for the Elimination of Violence Against Women
– until International Human Rights Day on 10
December. Katembu Kaumba, YWCA’s executive
director, said alongside the abuse of girls, the
organisation’s shelter in Lusaka also recorded
10 cases of rape of adult women every week…
‘Nationally, the figure is much higher – about
12 every week’, said Superintendent Presphord
Kasale, who heads the Victims Support Unit of the
Lusaka Division of the Zambia Police Service.6
Noting the linkage between violence against women
and HIV and AIDS, the UN Special Rapporteur’s 2005
report to the UN Commission on Human Rights stressed
that ‘[t]he lack of respect for women’s rights both fuels
the epidemic and exacerbates its impact’.7 However,
governments, donors, multilateral institutions,
international organisations and many civil society
actors have failed to fully integrate programming for
15
Intersecting health and human rights crises
March 2007 ALQ
gender equality and women’s empowerment into their
HIV and AIDS, or indeed, their gender-based violence
programming.
…the situation is exacerbated by the
all-too-frequent lack of accountability
and political will by governments and
donors – only in rare instances have
states fully committed to protecting and
promoting women’s human rights…
The situation is exacerbated by the all-toofrequent
lack of accountability and political will by
governments and donors – only in rare instances have
states fully committed to protecting and promoting
women’s human rights in relation to violence or
HIV prevention, including development of policies
encouraging swift investigation of abuses and direct
punishment for perpetrators. Government actors are
generally unwilling to address abuses committed by
soldiers, police and other agents of the state, as well as
the sexual violence that takes place within the family,
community and other traditionally ‘private spheres’. 8
This latter point is of particular concern to women, as
much of the violence they face takes place within this
private arena and is inflicted by non-state actors, like
husbands and other family members. Among donors,
the level of funding for efforts to address genderbased
violence remains extremely small,9 while the
integration of violence against women programming
in the much larger pot of funding for HIV and AIDS is
scant and hard to find.10
The diversity of women and girls: Social
factors and risks
A recent resolution on HIV and AIDS and human
rights by the UN Human Rights Council notes with
concern that
…an estimated 95 per cent of all people infected
with HIV live in the developing world, mostly in
conditions of poverty, underdevelopment, conflict
and inadequate measures for the prevention,
care and treatment of HIV infection, and that
marginalized groups in these societies are even
more vulnerable to HIV infection and the impact
of AIDS….11
However, such a multi-faceted analysis must go
further and deeper. Gender inequality and violence
against women often inhibits women’s and girls’
ability to take full advantage of crucial – even lifesaving-
services. First, women victims/survivors of
violence have different experiences and different
options available to them than girls who are victims/
survivors. Age is a key factor in determining risk and
vulnerability to both gender-based violence and to HIV
and AIDS. A recent study by the WHO found that as
many as 30% of women in some locations reported that
their first sexual experience was coerced or forced. 12
The younger the women were at the time of sexual
initiation, the higher the chance that it was violent.13
Moreover, HIV and AIDS is fast becoming a girls’
epidemic: The WHO notes that
…[y]oung people (aged 15-24) account for half
of all new HIV infections, and of infected youths,
two-thirds are female. In parts of sub-Saharan
Africa, teen girls are six times more likely to be
infected than male peers. The burden of care also
falls on girls who may leave school to care for
sick relatives.14
…the younger the women were at the
time of sexual initiation, the higher the
chance that it was violent…
Furthermore, age-related risks do not only
correspond to youth. Patterns of wife-inheritance in
some communities have been noted to fuel the spread
of HIV.15 In some communities, older women, in
particular, may be targeted for rape in connection to
HIV and AIDS. For instance, during a recent trip, UN
special envoy on HIV/AIDS in Africa, Stephen Lewis,
16 Intersecting health and human rights crises
ALQ March 2007
reported hearing disturbing statistics: ‘Rapes of women
and girls were escalating every month, and half the
girls sexually assaulted were under 12’.16 Lewis noted
that an even more startling pattern also emerged. He
commented that
…a significant number of women aged 65 to
80 were also raped. The men who did it were
confident they could have unprotected sex with
them without getting AIDS.17
…women who are infected with HIV
face a range of real or potential human
rights abuses – from non-consensual
testing and disclosure of results, to
stigmatisation, isolation and shunning by
their families and communities, to threats
of, or actual violence…
Other elements of social location also effect
women’s and girls’ vulnerability to both violence and
HIV and AIDS. Women who are infected with HIV face
a range of real or potential human rights abuses – from
non-consensual testing and disclosure of results, to
stigmatisation, isolation and shunning by their families
and communities, to threats of, or actual violence
committed against them. Marginalised racial, ethnic
or cultural status exacerbates the risk of contracting
HIV and AIDS. In the United States, for example, the
Kaiser Family Foundation reports that ‘[r]acial and
ethnic minorities have been disproportionately affected
by HIV/AIDS since the beginning of the epidemic, and
minority Americans now represent the majority of new
AIDS cases (71%) and of those estimated to be living
with AIDS (64%) in 2003’ with African-Americans
and Latinos accounting for a disproportionate share
of new AIDS diagnoses.18 Moreover, women of colour
are particularly hard hit with African American women
accounting for 67% of estimated new AIDS diagnoses
among women in 2003, while Latinas account for 16%.19
Discrimination and a hostile legal and political
environment seriously circumscribe efforts to address
the health and rights of marginalised communities.
Cases such as HIV outreach workers being arrested
on sodomy charges, or as sex workers (using evidence
of carrying condoms as an indication of prostitution)
are simply the tip of the iceberg.20 Various forms of
‘minority’ status also indicate risk. For example, the
estimated HIV prevalence rate amongst self-identified
gay men in South Africa may be as high as 30%, while
the rates for transgender individuals may be even
higher. Amongst sex workers, available data from 2000
shows that slightly over 50% of sex workers were HIVpositive.
21 In Nepal, an HIV prevalence rate amongst
men who have sex with men of 3.9%22, exists alongside
a long-term and consistent pattern of serious violence
and abuse of metis (transgender persons).23 Moreover,
while women who have sex with women are generally
considered to be a ‘low risk’ group, the calculation
changes when lesbians are targeted for violence.24 For
example, due to the high incidence of rape, HIV and
AIDS rates amongst black South African lesbians are
reportedly as high as in the general population.25 And
even where HIV appears to be on the rise amongst
lesbians, as in Thailand, prevention information is
rarely addressed specifically to them.26
…a significant number of women
aged 65 to 80 were also raped. The
men who did it were confident they
could have unprotected sex with them
without getting AIDS…
The former UN Special Rapporteur on violence
against women, Radhika Coomaraswamy, documented
the combined impact of gender and race in her
extensive report on international, regional and national
developments in the area of violence against women:
1994-2003, covering her years as Special Rapporteur.
For example, in the case of violence against women in
17
Intersecting health and human rights crises
March 2007 ALQ
Costa Rica, the Special Rapporteur found that
…[d]omestic violence against black women is
more widespread, especially between couples
made of a white man and a black woman. Black
women tend to be more reluctant in filing
complaints. It is a clear case of intersection of
gender and race which multiplies the impact of
domestic violence against women.27
Other institutional issues, such as profiling of
particular groups (including in, but not limited to,
situations related to the war on terrorism), historic and
persistent discriminatory practices against racial and
ethnic minorities by the police and other state actors,
amongst other circumstances, can lead to perpetrators of
violence against women in racially diverse communities
acting with virtual impunity. Agents of the state often
are protected against appropriate investigation and
punishment. Thus they, along with other perpetrators
of abuse, are able to act with impunity. The result is
not only unrelenting gender-based violence, but the
exacerbation of HIV and AIDS.
…due to the high incidence of rape,
HIV and AIDS rates amongst black
South African lesbians are reportedly
as high as in the general population…
Obstacles and strategies
The lack of adequate human and financial resources
cannot be underscored enough as both cause and effect
of the compartmentalisation of violence against women
and HIV and AIDS.28 This resource issue cuts through
almost all of these critical challenges and serves as an
example of how they are interlinked. Without adequate
funding, research and campaigning may fail to reach
potential impact, adequately document their experiences
in a way that facilitates replication, and are unable to be
scaled up. However, while more funding is crucial, it
will only mitigate, but not arrest, either HIV and AIDS
or violence against women, nor will it achieve gender
equality, without a clear understanding and analysis of
the impact of policy, programming and funding.
…HIV and AIDS funding … fails to
interrogate its gender bias, and therefore,
often fails to reduce HIV infections
amongst women, or mitigate its more
general impact on women and girls…
The current framework for HIV and AIDS funding
(inclusive of the acronyms of VCT [voluntary
counselling and testing], ABC [abstain, be faithful,
use condoms], PMTCT [prevention of mother-to-child
transmission] amongst others) fails to interrogate
its gender bias, and therefore, often fails to reduce
HIV infections amongst women, or mitigate its more
general impact on women and girls. This includes, for
example, PMTCT programmes that treat women only in
the context of childbearing, VCT programmes that fail
to understand that ‘voluntary’ can become coercion in
a context of gender inequality and a pervasive threat of
violence, or that ABC initiatives generally ignore the
fact that many women and girls are not in a position
to negotiate the conditions of a sexual encounter.
The current axiom of universal access to prevention,
treatment, support and care will not reach its goals
nor halt the feminisation of the pandemic without a
gender-sensitive realignment fully anchored in human
rights norms and standards. Nor will a ‘results-based’
focus that emphasises quantity over quality necessarily
protect the rights of women.
The need for comprehensive, gender-sensitive
and human rights-based responses
A gender- and human rights sensitive approach
to HIV and AIDS and gender-based violence are
essential to finding innovative and effective solutions.
18 Intersecting health and human rights crises
ALQ March 2007
Addressing the human rights implications of HIV
and AIDS and violence against women requires
grappling with gender inequality and other forms of
discrimination at all levels – from policy reform to
community education. Moreover, the links between
human rights, HIV and AIDS and violence against
women must be made in practical ways that have
immediate impact on women’s lives. Women benefit
most when ‘rights-based approaches’, including
principles of non-discrimination, accountability,
transparency, and participation are used in provision
of services, as well as in advocacy efforts.29
…the links between human rights, HIV
and AIDS and violence against women
must be made in practical ways that
have immediate impact on
women’s lives…
Take, for example, initiatives focusing on the
prevention of mother-to-child transmission (PMTCT).
The availability of medications that can block the
transmission of HIV during pregnancy, childbirth and
the postnatal period has created new opportunities to
slow the spread of HIV and AIDS. Governments have
begun establishing programmes to facilitate access to
these medications for pregnant women. These initiatives
enable pregnant women to reduce significantly the
chances that their infants will be born with HIV. While
the benefits of PMTCT programmes are immense
– for individual women, their children, and societies
alike – it is crucial that governments implement these
programmes with a keen awareness of the experiences
of all women living with HIV and AIDS and with
respect for their human rights. PMTCT programmes
are primarily conceived as prevention programmes for
infants. This focus on prevention leaves the concerns
of women living with HIV and AIDS largely invisible.
In many contexts, the women are forgotten after they
deliver healthy infants. In addition, in any healthcare
setting in which women are under the care of providers,
however, women receiving treatment have rights as
patients. These rights are too often overlooked. These
encompass their right to privacy and to physical
integrity, including their right not to be tested for HIV
without their informed choice or consent, or to have
their HIV status disclosed without their permission.
Promising practices: Lessons from women’s
rights and HIV and AIDS organisations
The progress of discerning and distilling promising
practices is a lynchpin of an effective response.
Governments, multilateral institutions and donors
must engage in a dialogue with civil society in order to
draw important lessons that will allow for governments
and donors to provide the resources for scaling up
effective gender and human rights-based strategies,
and to support the social movements within which
these new, innovative and/or effective strategies are
grown. A number of these innovative programmes
have been featured in Strengthening Resistance:
Confronting Violence Against Women and HIV/AIDS,
a 2006 publication of the Center for Women’s Global
Leadership.
From street theatre to telenovelas/soap operas
to traditional lobbying, activists in both genderbased
violence and HIV and AIDS communities
are beginning to focus attention to ways both crises
interact in a negative spiral.30 The use of media has,
in several cases, provided promising results. Soul
City in South Africa is one of the most well-known
‘infotainment’ outlets addressing HIV and AIDS and,
with some frequency, gender-based violence. Another
is Puntos de Encuentro in Managua, Nicaragua. Their
concern with exhibiting an integrated approach formed
the basis for a Sexto Sentido, one of Nicaragua’s most
popular soap operas. One storyline involves Gabriel, a
young, popular character who discovers he is infected
with HIV as a result of his having had unprotected sex
with Martha, an equally treasured soon-to-be divorced
woman who has unknowingly contracted HIV from a
philandering husband, who refuses to wear a condom.
19
Intersecting health and human rights crises
March 2007 ALQ
…PMTCT programmes are primarily
conceived as prevention programmes for
infants. This focus … leaves the concerns
of women living with HIV and AIDS
largely invisible…
Cultural stereotypes involving sex workers and other
sexually active women, and myths involving condom
use and the virtues of machismo, are systematically
undermined – and reframed – as the story progresses.
And opportunities to revisit the issues presented are
provided to people who view a special edition of
the soap opera story, now being packaged for use
with youth and other audiences around the country
and abroad.31
Another promising practice involves the pairing of
HIV and AIDS and gender-based violence initiatives.
One such endeavour involves the Institute for Social
Development Studies (ISDS) and the Center for
Studies and Applied Sciences in Gender-Family-
Women and Adolescents (CSAGA), both based in
Hanoi, Viet Nam, conducted with the support of the
Program on International Health and Human Rights at
the Harvard University School of Public Health in the
United States. ISDS and their violence against women
services-focused partner, CSAGA, determined how
they could best share resources to collect and analyse
relevant data, as well as train counsellors to use that
information to inform their everyday work with clients.
As Nguyen of ISDS says:
Our objective became to see the linkages between
HIV and violence and use those findings to
provide training for counsellors, and then, later
on, conduct advocacy with the public through
mass media channels32.
Since the inauguration of their hotline services in
1997, CSAGA had been keeping track of anonymous
data on the types of calls its counsellors had received.
These hotlines have been quite active: on average,
3,000 calls per year have involved violence against
women alone. Six notebooks containing summaries of
counsellors’ conversations with callers over the years
also provided rich sources of data for research on both
violence and HIV and AIDS. Interestingly, despite the
rich amounts of data, and while overall findings have
yet to be reported, the groups found few connections
between the issues were made by counsellors or callers.
In fact, says Nguyen:
Very, very few of the summaries are about HIV and
violence…In the counsellor’s minds…there’s no
linkage of the issues, so they don’t have a related
question to ask – they just follow the complaint of
the customer.
The information ISDS gleaned from both investigations
is currently being used to help structure a focus group
session with several long time CSAGA counsellors and a
training session for their colleagues. An evaluation will be
conducted at the end of this year.33
…governments and donors must
fully grapple with the fact that
the category of ‘women and girls’
encompasses a vast array of different
groups of women and girls…
A third example involves paying attention to the
experiences of women living with HIV and AIDS when
designing responses and services. One such organisation
is Creatíon Positiva, a member of the International
Community of Women Living with HIV/AIDS based
in Barcelona, Spain. Creación Positiva delivers a wide
variety of HIV-related services to women and men,
including individual and group support, research, and
community-wide workshops on a broad range of topics.
‘In a typical year, we might work individually with about
35 men and 100 women’, says programme coordinator
Montse Pineda. She adds:
…We connect with people by putting our flyers
in hospitals, through our website, and by word
of mouth. We have workshops on prevention and
on sexuality – not safe sex, but comprehensive
workshops on sexuality … In 2005, the organisation
20 Intersecting health and human rights crises
ALQ March 2007
conducted six of these [romantic love] workshops
on November 25, the International Day Against
Violence Against Women.34
Creación Positiva has been attentive to the connection
between violence against women and HIV and AIDS
since early on. Pineda says:
Because we have worked with women for many
years, we saw that there was an important link
between violence against women and HIV and
AIDS … Many of the women we work with have
lived with violence and we saw we had to make
the issue explicit.
Today, as a result of their participation in the global
16 Days of Activism Against Gender Violence campaign
and other activities, Creación Positiva’s influence now
extends beyond the regional level in several respects.
The organisation, for example, has also published two
research studies,
…including the biggest study done so far in Spain
on the needs of women who are HIV positive. The
study included 258 women, and includes data on
violence and HIV positive women. It was the only
such study carried out for 2004 and 2005.
Other national work includes playing both
advisory and research roles on a nationwide study of
stigmatisation. As Pineda puts it, ‘We are a reference
point in Spain’.35
Recommendations
The following recommendations build on the
collective knowledge, experience and analysis of
partners in the ‘Women Won’t Wait. End HIV and
Violence Against Women and Girls. Now.’ campaign and
their colleagues from many regions.
• In devising services and distributing resources,
governments and donors must fully grapple with
the fact that the category of ‘women and girls’
encompasses a vast array of different groups of
women and girls, whether identified by age, race,
language, sexuality, indigenous or refugee status,
etc. And this diversity also reflects specific and
varying needs with regard to prevention of,
protection from, and response to both HIV and
AIDS and gender-based violence.
…health policies or practices can create
risks in women’s and girls’ lives, whether
as a result of mandatory or forced testing,
or breaches of confidentiality and
rights to privacy…
• Governments, donors and service providers must
pay attention to the need to ensure women’s
informed choice and consent, and of the persistent
threats of violence women face in their everyday
lives. Critical to this sensitivity is an understanding
of how access to services and other interventions
varies according to a woman’s race, sexuality,
class, rural or urban location, age, status as
indigenous, etc. Without careful attention to the
importance of such differences, health policies or
practices can create risks in women’s and girls’
lives, whether as a result of mandatory or forced
testing, or breaches of confidentiality and rights
to privacy, especially in relation to disclosure of
HIV status and partner notification policies.
• Governments, donors, multilateral institutions,
international organisations and national civil
society actors must support and facilitate greater
communication amongst sectors, organisations
and social movements. Such diverse participation
in policy dialogues will enrich the possibility
of devising and implementing the strongest
responses to gender-based violence, HIV and
AIDS and their intersection.
• Governments, with the support of donors, need
to increase the level of resources for training
legal and social service providers. For example,
healthcare providers must be well-acquainted with
human rights approaches to service delivery and
health policy development, while judges, lawyers,
policy and prosecutors must fully understand the
21
Intersecting health and human rights crises
March 2007 ALQ
importance of gender- and human rights sensitive
responses to gender-based violence and HIV
and AIDS.
…governments must create or change
legislation to promote … programmes
that are equipped to address violence
and HIV and AIDS in straightforward,
meaningful ways…
• Governments must create or change legislation
to promote non-discrimination, and also must
commit to funding initiatives and programmes
that are equipped to address violence and HIV
and AIDS in straightforward, meaningful ways,
including, for example, the provision of postexposure
prophylaxis (PEP) to survivors of sexual
assault; medically accurate, evidence-informed
information without restriction or censorship; and
comprehensive sexuality education and detailed
information about HIV prevention, treatment
care and support. This includes a focus on the
rights of women in their own individual right as
citizens.
• Governments must commit themselves to working
toward changing discriminatory attitudes and
address ‘taboo topics’, including sexuality, sex
work, drug use, and the rights of women to
control their own bodies, sexuality and decisionmaking
about families and parenting, in line with
their international human rights obligations.
• Governments must uphold fundamental human
rights standards in creating prevention, protection
and actions to address gender-based violence
and HIV and AIDS. These standards include
requirements of informed consent, confidentiality
and choice, provider-patient confidentiality,
appropriate and accessible health, social and
legal services without discrimination.
• Governments, with the support of donors,
multilateral institutions, international organisations
and a diverse range of civil society groups, must
support community-wide education and information
initiatives in order to combat the fear, silence and
myths surrounding HIV and AIDS and genderbased
violence.
Ultimately, in devising interventions, governments,
with the support of donors, multilateral agencies,
and international organisations must draw on the
experiences of women’s rights and women and HIV
and AIDS organisations and build their participation
into the policymaking, implementation, monitoring and
evaluation processes. This includes a policy process
centred on advancing and protecting women’s human
rights. They must, for instance, promote women’s status
in both the home and the public sphere at the same
time that they ensure, for example, that government
clinics promote and protect women’s rights and provide
protection for women living with HIV and AIDS, who
might suffer abuse.
…support community-wide education
and information initiatives in order
to combat the fear, silence and myths
surrounding HIV and AIDS and genderbased
violence…
In the end, it is crucial to assert that addressing
violence against women and girls must be a central
principle of all human rights, health, humanitarian and
development programming. Moreover, gender-sensitive
efforts require striving toward a greater goal – achieving
gender equality, women’s empowerment and creating
the conditions for safe, healthy, consensual and diverse
sexualities and life choices for all, including safe and
pleasurable sexuality for all people, including people
who are living with HIV and those who are not.
22 Intersecting health and human rights crises
ALQ March 2007
FOOTNOTES:
1. Susana T. Fried is the author of ‘Show Us the Money: Is violence against
women on the HIV&AIDS donor agenda?’ produced as part of the campaign
Women Won’t Wait: End HIV and violence against women and girls. Now.
For more information about the campaign go to www.womenwontwait.org.
The submission and this adaptation was produced with the support of Actionaid
International.
2. This piece is adapted from a submission made to the UN Secretary-General’s
report on HIV and Human Rights in December 2006. The submission was
made by The Center for Women’s Global Leadership (US), in collaboration
with Action Aid International, Action Canada for Population and Development/
ACPD (Canada), Center for Health and Gender Equity/CHANGE (US),
Center for Reproductive Rights (US), Fundación para Estudio e Investigación
de la Mujer /FEIM (Argentina), Gestos- Soropositividade, Comunicação e
Gênero (Brazil), International AIDS Women’s Caucus, International Women’s
Health Coalition/IWHC (US), Latin American and Caribbean Women´s Health
Network/LACWHN, in reference to Resolution 2005/84 (adopted by consensus
on 21 April 2005) calling for the UN Secretary General to prepare a report on
steps taken to promote and implement programs to address the urgent HIVrelated
human rights of women, children and vulnerable groups in the context of
prevention, care and access to treatment as described in the Guidelines on HIV/
AIDS and Human Rights for the Human Rights Council. Neelanjana Mukhia
(Actionaid International), Laura Katzive (Center for Reproductive Rights) and
Cynthia Rothschild (Center for Women’s Global Leadership) made invaluable
contributions to the submission. However, the content and opinions remain the
responsibility of the author.
3. Rothschild, C., Reilly, M.A. & Nordstrom, S.A. 2006. Strengthening Resistance:
Confronting Violence Against Women and HIV/AIDS. New Jersey, USA: Center
for Women’s Global Leadership, p.4. Hereafter referred to as ‘Strengthening
Resistance’.
4. See, for example, Abrahams, N., Jewkes, R.K., Hoffman, M. &
Laubsher, R. 2004.’Sexual violence against intimate partners in Cape
Town, South Africa: Prevalence and risk factors reported by men’. In:
Bulletin of the World Health Organization. 82:330-337; Garcia-Moreno,
C., Jansen, H.A., Ellsberg, M; Heise, L. & Watts, C. 2005. WHO Multicountry
Study on Women’s Health and Domestic Violence against Women.
World Health Organization and PATH. (hereafter referred to as the WHO
Multi-country Study); Maman, S., et al. 2000. ‘The intersections of HIV
and violence: Directions for future research and interventions’. In: Soc
Sci Med 2000;50(4):459-78; Go, V., Sethulakshmi, C.J., Bentley, M.E. et
al. 2003. ‘When HIV prevention messages and gender norms clash: The
impact of domestic violence on women’s HIV risk in slums of Chennai,
India’. In: AIDS and Behavior. 7(3):263-272; van der Straten, A., King,
R., Grinstead, O. et al. 1998. ‘Sexual Coercion, physical violence and
HIV infection among women in steady relationships in Kigali, Rwanda’.
In: AIDS and Behavior. 2(1):61-73; among others.
5. ‘The Drama of Sexual violence’, In: Clarín, November 22, 2006.
6. Mulenga, N. 2006. ‘Zambia: More than 10 girls raped each week’, IRIN/
PLUSNEWS, Johannesburg, 27 November 2006. [http://www.irinnews. org/
report.asp?ReportID=56528&SelectRegion=Southern_Africa#]
7. Ertürk, Y. 2005. Integration of the human rights of women and the gender
perspective: the intersections of violence against women and HIV/AIDS. Report of
the Special Rapporteur on violence against women, its causes and consequences,
UN doc: E/CN.4/2005/72 17 January 2005, paragraph 16, p.7.
8. Strengthening Resistance, p.7.
9. AWID and Just Associates. 2006. ‘Where is the money for women’s
rights? Assessing the resources and the role of donors in the promotion
of women’s rights and the support of women’s rights organizations’.
Toronto: AWID.
10. Fried, S.T. 2007. Women Won’t Wait Campaign, Show Us the Money:
is violence against women on the HIV&AIDS donor agenda? Washington
D.C.: Action Aid.
11. ‘The protection of human rights in the context of human
immunodeficiency virus (HIV) and acquired immunodeficiency
syndrome (AIDS)’, Human Rights Resolution 2005/84.
12. World Health Organization (WHO). 2006. Multi-country study on women’s
health and domestic violence against women, p.51. [http://www.who.int/
gender/violence/who_multicountry_study/en/].
13. Ibid.
14. WHO. 2004. ‘Women, girls and HIV/AIDS’, In: Advocacy Note, World AIDS
Day, 2004, p.4.
15. HRW. 2003. Double Standards: Women’s Property Rights Violations in
Kenya. New York; International Center for Research on Women. 2006. ‘Reducing
Women’s and Girls’ Vulnerability to HIV/AIDS by Strengthening their Property
and Inheritance Rights’. Information Bulletin, May 2006. ICRW: Washington,
DC.
16. Ward, O. 2006. ‘World’s women have an advocate, More than half the
globe’s people need their own UN agency: Stephen Lewis’. In: Toronto
Star, 1 July 2006.
17. Ibid.
18. Kaiser Family Foundation. 2005. The HIV/AIDS Epidemic in the United
States. HIV/AIDS Policy Fact Sheet, p.2.
19. Ibid.
20. In a recent article in Medical News Today, Anjali Gopalan of the
Naz Foundation India Trust, an organisation working on HIV care and
prevention with diverse communities commented ‘the police harass health
outreach workers working on HIV prevention among the gay community.
Volunteers are prevented from distributing condoms among prisoners by
officials who cite these antiquated laws’. ‘Gay Rights Groups in India
Protest Arrest of MSM, HIV/AIDS Advocates Say Antiquated Laws
Hinder Prevention’. In: Medical News Today, 13 January 2006, [http://
www.medicalnewstoday.com/medicalnews.php?newsid=36093]
21. UNAIDS/WHO. Epidemiological Fact Sheet South Africa.
22. UNAIDS. 2006. Report on the global AIDS epidemic, p.516.
23. Documented by the Blue Diamond Society [http://www.bds.org.np/]
24. Erturk, Y. 2005. Intersections of Violence Against Women and HIV/
AIDS: Report of the Special Rapporteur on violence against women, its
causes and consequences. UN Doc: E/CN.4/2005/72, 17 January 2005,
paragraph 27.
25. Swedish International Development Agency (SIDA). Sexual Orientation and
Gender Identity Issues in Development, p.41. [http://www.sida.se/shared/jsp/
download.jsp?f=SIDA4948en_Sexual+Orientation+web.pdf&a=4855]
26. Parivudhiphongs, A. 2005. ‘Dare to Care’. In: Bangkok Post, April 8, 2005.
27. Coomaraswamy, R. 2003. (Special Rapporteur on violence against
women), 2003. Report to the UN Commission on Human Rights,
International, regional and national developments in the area of violence
against women: 1994-2003. UN Doc. E/CN.4/2003/75/Add.1 paragraph
1347.
28. Strengthening Resistance, p.7.
29. Ibid, p.14.
30. Strengthening Resistance, press release.
31. Strengthening Resistance, p.21.
32. Ibid, p.21.
33. Ibid.
34. Ibid, p.22.
35. Ibid, p.23.
Susana T Fried is currently based at the
Consulting Services for Gender, Sexuality and
Human Rights; Advocacy, Program
Development, Research and Training. For more
information and/or comments, please contact
her on +1 718 791 6863 or at
susana.fried@mail.com.
23
Intersecting health and human rights crises
March 2007 ALQ
Introduction
The current democratic dispensation is not only
fragile, but also bedevilled by flagrant disregard for the
rule of law. The issue of rights generally does not exist
in a typical military dictatorship, the kind of which
Nigerians experienced for more than three decades. The
polity is gradually becoming conducive for the citizenry to
appreciate and to demand their rights.
There is a link between political climate and
leadership of a nation and the sexual and reproductive
health rights of its people. They are all interrelated. One
thing leads to another and nothing occurs in isolation in
life, whether good or bad. This article will discuss the
extent to which sexual and reproductive health rights are
accessible and realisable in Nigeria and how this links
to existing challenges and realities of the HIV and AIDS
epidemics. Sexual and reproductive health issues take a
centre stage in the HIV and AIDS realities in Nigeria,
since sexual and reproductive health is inseparable from
HIV and AIDS. They are like a double edged sword,
representing both causes and consequences. Sexual
and reproductive health rights problems constitute the
hydrocarbon fuel, while HIV and AIDS is the wild
fire. The resultant ashes represent the lives of millions
infected and affected by HIV and AIDS.
Adolescent health
Adolescence marks the developmental transition from
childhood to adulthood, and a time when many important
social, economic, biological and demographic events set
the stage for adult life. The World Health Organisation
(WHO) defines adolescents as individuals in the 10-19
year age group.
This stage is crucial to the future health of young
people. Mismanagement of this period impacts
negatively on the physical, mental and social well-being
of young people. No doubt, there is a strong link between
adolescence and HIV and AIDS. And this is due, at least
in part, to the virtual non-existence of adolescent health
rights and services.
One of the basic rights of adolescents is the right
to correct and timely sex and reproductive health
education. Although this problem is multifactorial,
family institution and culture play a vital role. Healthy
sex education is a taboo in most Nigerian cultures and
traditional homes. The parents ‘abhor it’, the school
teachers ‘frown at it’, the clergies call it ‘a sin’, and the
government ‘neglects it’.
The prevailing socio-economic climate does not
offer adolescents the opportunities to develop their
human and social capital through qualitative schooling
and work-related training. In primary and secondary
schools, sexual harassment of female students by male
teachers seems to have become part of the curriculum.
Over 1000 female students in Nigerian primary and
secondary schools once protested to the Federal Minister
of Education over the increasing incidence of sexual
harassment in their schools. This situation poses great
danger and exposes young people to HIV and AIDS. A
sexual advance to a child, or an adolescent, by her male
teacher is not only criminal, but also a sign of moral
bankruptcy and abuse of responsibility. This is sexual
harassment, an offence that should be punishable by law,
even if it is only to serve as a deterrent to others. These
One thing leads to another…
Sexual and Reproductive Health Rights in Nigeria
Nigeria is unarguably the most populous African and Black nation
on earth. For the first time since political independence from
British colonialism in 1960 democracy has managed to survive
for up to seven years at a stretch.
Busari Olusegun
24Sexual and reproductive health rights in Nigeria
ALQ March 2007
are teachers that should educate their students with life
skills and constructive sex education to enable young
people to achieve optimal, safe psychosexual growth and
development. The adolescent girl is much more affected,
as a result of restrictive gender definition. The lives of
these girls are characterised by limited education, lack of
economic and social opportunities, early marriage and
childbearing, as well as limited influence on decisions
affecting their lives. Adolescent girls typically make the
transition to adulthood amidst constraints in life options
that are highly gender defined, with few social assets,
and with limited control over economic resources.
…sexual and reproductive health rights
problems constitute the hydrocarbon fuel,
while HIV and AIDS is the wild fire. The
resultant ashes represent the lives
of millions infected and affected
by HIV and AIDS…
All of these factors place adolescent girls at increased
risk of HIV and AIDS and other STIs. There is a need for
the development of adolescent friendly health services, as a
way to encourage earlier and safer health seeking behaviour
amongst adolescents. Some of the basic principles of
adolescent friendly health services are: confidentiality and
privacy; acceptability to local community; involvement of
adolescents in the planning and monitoring of services;
and accessibility.
Condom Use
The condom remains an effective tool to reduce
sexual transmission of HIV and other sexually transmitted
infections (STIs), even for people living with HIV and
AIDS, who are sexually active. It is also an effective barrier
contraceptive device. But there are so many obstacles.
The fact is that condoms are still not widely used in
Nigeria. As and when condoms are used, the problems of
inconsistent and incorrect use are recurring decimals. The
non-availability factor is very prominent. Sexually active
people in the rural areas do not know where to turn to to
get condoms – and even if they were to turn everywhere,
condoms are no where to be found. Furthermore, the
quality of condoms in the market is also a big problem.
In a place, where regulatory agencies have failed woefully
to ensure circulation of good quality condoms, and where
profit-making is exalted above the value of life, it may
seem more reasonable to avoid using condoms, than to
have a false sense of security.
The ban imposed by religious institutions on condoms,
describing the condom as a ‘satanic instrument’ is still in
effect. A condom is called ‘an agent of sin’, and anyone
who uses a condom is ‘a sinner and hell bound’.
Overall, there seems to be little or no change in risky
behaviours, unprotected sex is ‘a natural thing’ and to
have STIs as a man is a matter of pride and an emblem of
sexual and physical maturity. With all these problems with
condoms, there seems to be no end in sight to the decimation
of lives by HIV and AIDS, while the transmission of HIV
continues as the hand of a clock ticks away.
Legality or otherwise of ‘abortion’: The plague
of unsafe procedures
Although, the controversial issue of legality or otherwise
of ‘abortion’ is not a subject for discussion here, it remains
a critical factor in the context of sexual and reproductive
health. According to the Nigerian Constitution, ‘abortion’
is illegal, except for therapeutic purposes. But unprotected
sex and its consequences, unwanted pregnancies, continue
unabated. The sad reality is that unwanted pregnancies are
relieved under-cover, as pregnant girls and women secretly
visit ‘under-the-bridge quack clinics’ and ‘nursing homes’.
Some non-medical personnel use medical equipments to
perform ‘abortions’.
Stigma, societal ridicule and rejection, and fear of
the law have driven ‘abortion practices’ into secrecy,
where little or no emphasis is laid on aseptic procedures.
Unsterilised and sub-standard instruments are used in
unhygienic environments, with no safety or antiseptic
precautions. Unsafe ‘abortions’ continue to contribute
substantially to reproductive morbidity and mortality
25
Sexual and reproductive health rights in Nigeria
March 2007 ALQ
worldwide, especially amongst poor women in developing
countries. Every year 70,000 – 100,000 women die from
unsafe abortions, 99% of them in developing countries.
…unprotected sex is ‘a natural thing’
and to have STIs as a man is a matter of
pride and an emblem of sexual
and physical maturity…
If HIV infected women are pregnant and do not want
the pregnancy, because there is no access to prevention of
mother to child transmission of HIV programmes (PMTCT),
can therapeutic abortion be performed? This is one of the
so many questions that are begging for answers. As far as I
am concerned, there is a form of abortion, I call ‘coercive
abortion’. I am living with HIV and have the desire to have
a child. I am a poor woman with a wage not enough to buy
antiretroviral drugs. There is no PMTCT service within my
reach and I am already pregnant. Though I want a child, I
still dread the possibility of having an HIV infected baby.
So, I decide to have a secret abortion. Where? Of course, in
a tiny dirty clinic in a slum somewhere, because it is illegal!
That is what I call a ‘coercive abortion’, in that I have been
coerced by forces beyond my human control to take that
step. So, ‘coercive abortions’ are common in resource-poor
settings of the world, where abortion is illegal.
The majority of unsafe abortions amongst adolescents
take place, because the pregnancy is unwanted and
unplanned. This also shows that the use of contraceptives
is poor amongst young people. The provision of adequate
knowledge on contraceptive services, as well as ensuring
the availability of, and access to, emergency contraceptives
are vitally important in this context.1
Gender-based inequalities and violence
Gender inequalities have been recognised as a major
structural factor that facilitates HIV transmission. There is
interplay between gender norms and violence and sexual
reproductive health and HIV outcomes. Gender-based
violence has important implications for sexual and
reproductive health and sexual behaviour. The power
imbalances are expressed in sexual relationships and seem to
confer on men the ability to determine women’s sexual and
reproductive health choices, including the use of a condom.2
It is, however, sad to note that, despite what the public
is being made to believe about government’s unwavering
commitment to address HIV and AIDS, there are no definite
policies to either challenge patriarchal gender norms or to
address gender-based violence. Although, gender-based
violence has been internationally recognised as a violation
of women’s human rights, as well as women’s sexual and
reproductive health rights, there is no part of the constitution
that accommodates this issue. There are virtually no sexual
and reproductive health services to provide care and support
for victims of gender-based violence.
Addressing biased gender norms and masculinities
in sexual and reproductive health policy and programme
context will, arguably, contribute to the improvement of
the health and rights of women and children, as well as of
men.3 Additionally, women need assistance in acquiring skills
to become economically productive, including economic
literacy, access to savings and formal sector employment.
Antenatal, labour and postnatal health services
About 70-80% of deliveries still take place at homes.4
These deliveries occur an under unhygienic ambience,
placing the lives of both the child and the mother in grave
danger. Quality antenatal services are not available for
the majority of Nigerian pregnant women. The traditional
birth attendants sometime add salt to injury promoting
more complications, in that their blades or scissors are
often not well sterilised and, thus, these instruments can
be a potential medium for transmission of blood-borne
infections, such as Hepatitis C and B, and HIV.
Pregnant women infected with HIV are particularly
at risk, since there is no access to specialised antenatal,
labour and postnatal services that reduce the risk of
mother to child transmission of HIV. Some women hide
their pregnancy and prefer to deliver at home, because of
intimidating stigma and rejection by the society, including
some healthcare workers.5
26Sexual and reproductive health rights in Nigeria
ALQ March 2007
Treatment of sexually transmitted infections
Non-HIV sexually transmitted infections (STIs)
are the major cause of disease burden, after maternity
related causes, in young adult women in developing
countries. Untreated STIs are thought to account
for 15% of foetal wastage and 30-50% of antenatal
infections. STIs are also associated with about 3-5
times increased risk of HIV transmission.6
Stigma associated with STIs has further impacted
on patients’ rights to come out and seek adequate
treatment, as and when it is available. In some places,
it is not only the lack of adequate services, but also
the lack of qualified health professionals to make
appropriate diagnosis and institute effective treatment.
Another perennial problem is the issue of fake and
substandard antimicrobial drugs that are in circulation.
Currently, I am not aware of any programme addressing
herpes simplex virus (HSV), which is becoming
increasingly common.
All these problems additively deny clients their
rights to good quality sexual and reproductive health
and also expose people to an increased risk of HIV
infection. There is an urgent need for affordable, rapid,
point of care screening tests for STIs in all public health
infrastructures, including antenatal care settings.
Female genital mutilation/cutting
Female genital mutilation (FGM) is one of the cultural
realities that are fuelling HIV and AIDS in Africa. This
traditional practice affects an estimated 130 million girls
and women, mainly in Africa. It is a harmful practice that
violates international standards for girls’ and women’s
rights and often leads to serious health problems. It is one
of the practices that has brought untold pains to women
for a very long time. No doubt, this unsafe procedure has
contributed to the feminisation of HIV and AIDS in Africa.
FGM, which often involves the partial, total excision, and
sometimes sewing up, of the female genitalia or other
deliberate injury to the female genital organ for mostly
cultural reason, is a practical source of HIV transmission
and its perpetuation in Africa.7
…adolescent girls typically make
the transition to adulthood amidst
constraints in life options that are highly
gender defined, with few social assets,
and with limited control over
economic resources…
According to the WHO, there are an estimated 100
million circumcised women in the world. The majority
of these women are in Africa where the practice is mostly
carried out on girls under the age of 10 years. FGM is a
practice that is rooted in ignorance, myths and traditional
mores. Young women are coerced, and in some instances
charmed, into doing it. In some societies, parents who
refuse to circumcise their female children are stigmatised,
discriminated against, or may even be sent away from
a local village. For a young woman to be identified as
uncircumcised is to be seen as sexually promiscuous
and ridiculed.8
Traditional doctors, community elders and local
experts, who often claim to be the custodians of culture
and traditions, carry out this ‘heinous act’ in the most
unhygienic places. In most instances, unsterilised sharp
instruments are used to perform this procedure with
multiple usage and high risk of transmission of infections,
such as HIV and hepatitis B and C. Many young girls have
been infected with HIV in Africa, especially in countries
where the practice is rampant, through this harmful act.
Other repercussions of FGM/C include heavy blood
loss, psychological trauma, difficulties during childbirth,
gynaecological problems and at times even death.
Female genital mutilation and cutting is a very serious
issue and needs to be addressed with all seriousness, if the
response to HIV and AIDS, and child/girl child abuse, in
Africa is to be successful. There is, as of yet, no coordinated
approach to end this practice in Nigeria.
Child marriages
Child marriage violates girls’ human rights and adversely
27
Sexual and reproductive health rights in Nigeria
March 2007 ALQ
affects their health and well-being. In northern Nigeria,
child marriage is the norm, where 45% of girls are married
by age 15 and 73 % are married by age 18. Poverty plays a
major role in the decision to marry off girls early.
…female genital mutilation (FGM) is one
of the cultural realities that are fuelling
HIV and AIDS in Africa. This traditional
practice affects an estimated 130 million
girls and women, mainly in Africa…
Child marriage is a gory example of cross generational
sexual practice as the husbands of the child brides are
considerably older than their wives; the average age
difference between husband and wife is 12 years and is
often increased to 18 years in polygamous marriages.
Child marriages mostly occur in a part of the country
where polygamous marriage is a religious and cultural
practice, and where women are confined to ‘purdah’
and men expected to express their masculinity at ‘sexual
prowess’ outside the boundaries of home. The man comes
home infected with HIV in a setting, where religion
forbids condom use and men make most household and
family decisions, not only concerning major issues, but
also about mundane matters, such as purchases for daily
needs and composition of meals. Negotiation for condom
use is an affront on the man’s superiority and morality, and
often degenerates into violence and economic sanctions
on the woman, or she may even be sent away. Thus, child
marriage is a breeding ground for HIV transmission in
northern Nigeria.9
Prevention of mother to child transmission
(PMTCT)
Mother to child transmission (MTCT) of HIV is
responsible for 90% of HIV infections in children
worldwide. Therefore, PMTCT is a programme of hope for
both the HIV infected mothers and their unborn children.
I consider access to PMTCT services as a fundamental
human right of both the mother and the unborn child.
Procreation is a natural and biological right for everyone,
irrespective of a person’s HIV status. Thus, the presence of
HIV in a woman of child bearing age should never be an
obstacle to her desire to have a child, or even children, if
there is a free and accessible effective PMTCT programme
in place.10
In Nigeria, however, PMTCT is a good programme
on policy papers, but not in reality. In Nigerian reality,
PMTCT programmes and services are characterised by
weak grassroots presence; by health workers who lack the
basic capacity; and a policy/programme framework that is
too fragile to administer and implement the programme
effectively, which, as argued, is worse than the complete
absence of PMTCT programmes and services.
FOOTNOTES:
1. Olukoya, A.A. et.al. 2001. ‘Unsafe abortion in adolescents’. In: Int J Gynaecol
Obstet 2001; 75:131-147.
2. See also Jewkes, R. 2004. ‘Intimate partner violence: causation and primary
prevention’. In: Lancet 2004; 359:1423-1429.
3. See also Weiss, E. et al. 2000. ‘Gender, sexuality and HIV: Making a difference
in the lives of young men in developing countries’. In: Sexual and Relationship
Therapy, 15:233-234.
4. International Institute for Population Sciences (IIPS) and ORC Macro. 2000.
National Family Health Survey (NFHS-2), 1998-99: India. Mumbai: IIPS.
5. See also Ogundele, M.O. & Coulter, J.B.S. 2003. ‘HIV transmission through
breastfeeding: Problems and prevention. In: Ann Trop Paediatr 2003; 23:91-
106.
6. International Institute for Population Sciences (IIPS) and ORC Macro. 2000.
National Family Health Survey (NFHS-2), 1998-99: India. Mumbai: IIPS.
7. Centre for Development and Population Activities (CEDPA). 2005. The
abandonment of female genital mutilation. FGM Abandonment Project Fact
Sheet. Washington DC: CEDPA.
8. United Nations Children’s Fund/Inocenti Research Centre (UNICEF/IRC).
2005. Changing a harmful social convention: Female genital mutilation. Inocenti
Digest. Florence, Italy. UNICEF/IRC.
9. See also Clark, S., Bruce, J., & Dude, A. 2005. Protecting girls from HIV/
AIDS: The case against child and adolescent marriage. Unpublished manuscript;
Haberland, N., Chong, E. & Bracken, H. 2003. ‘Married adolescents: An
overview’. Paper presented at the WHO/UNFA/Population Council Technical
Consultation on Married Adolescent, 9-12 December, 2003. Geneva; Santhya,
K.G. & Shireen, J. 2003. ‘Sexual and reproductive health needs of married
adolescent girls’. In: Economic and Political Weekly 2003; 38(41):4370-4377.
10. See also Ogundele, M.O. & Coulter, J.B.S. 2003. ‘HIV transmission through
breastfeeding: Problems and prevention. In: Ann Trop Paediatr 2003;23:91-106.
Busari Olusegun is the Executive Director
at the Lifecare AIDS Foundation, Nigeria;
and a Consultant Physician at the Federal
Medical Centre, Ido-Ekiti, Nigeria. For
additional information and/or comments,
please contact him on +234 805 9843 414 or
lifecareaidsfoundation@yahoo.com .
28Sexual and reproductive health rights in Nigeria
ALQ March 2007
Introduction
Globally, women are the face of the AIDS epidemic,
constituting about 60% of people infected in sub-
Saharan Africa alone. Most of the women are not aware
of their HIV status until they are tested during ante-natal
visits. Many women living with HIV and AIDS face a
major challenge of accessing and receiving adequate
sexual and reproductive health services. This is often
complicated by stigma and discrimination, which in
most cases result in denial, infringement and violation
of their rights. Women’s sexual and reproductive
rights have always been a subject for discussion and
contestation. Women have the right of a satisfying
and safe sex life; have the capacity to reproduce; and
the freedom to decide when and how often to do so.
Although all women have the same rights and similar
needs for sexual and reproductive healthcare, women
living with HIV and AIDS require additional care and
counselling during their reproductive cycle. Research
suggests that most women who are HIV positive do
not receive information, support, referrals and related
services necessary to meet their specific sexual and
reproductive health rights and needs. This article
is going to explore some of the specific sexual and
reproductive health rights issues of women living with
HIV and AIDS.
Understanding realities of women living with
HIV and AIDS
Despite the growing recognition of sexual and
reproductive health rights for women living with HIV
and AIDS, there are still factors that make such rights
only a dream for most women.
For many women, an HIV diagnosis brings
about significant changes in the way they enact
their sexuality and how they feel about sexual
relationships.1
It is commonly believed that HIV seropositive
women should not get pregnant. If they are pregnant,
they are either frowned at or advised or pressurised to
terminate their pregnancies. Some women have been
denied contraceptives. When women living with HIV
are pregnant, the emphasis is often on saving the unborn
child’s life, neglecting the health of the women.
Infection with HIV can affect woman’s sexual health
in different ways, including decreased sexual desire
or satisfaction; feeling guilty or ashamed; resentment
towards a sexual partner; and sometimes infertility. In
societies where women are expected to have children,
women living with HIV, who opt not to have children,
must contend with both social disapproval of being
childless and the suspicions and prejudices surrounding
their HIV positive status. Most women have to seek
29
Sexual and reproductive health rights in the context of HIV and AIDS
March 2007 ALQ
In the absence of informed choice…
Sexual and reproductive health rights in the context of HIV and AIDS
Nomampondo Barnabas
Women have the right
l To decide with who, when, how or not to have sex
l To decide whether or not to terminate a pregnancy. Termination of pregnancy is performed based
on only the woman’s informed consent.
l To make a decision whether or not to terminate their pregnancy, because of their HIV seropositive
status, without coercion
l To be assisted and supported to make an informed decision/choice
consent from their partners regarding their sexual and
reproductive health. Choices about fertility and family
size are in most cases not taken by women, but instead
by their partners.2
…the primary right that has been violated for
everyone is the right to accurate and detailed
information … from a human rights perspective
also we should see people as intelligent human
beings who are much more likely to make rational
decisions if they are given the facts rather
than hiding the facts for fear that they will do
something risky.3
Challenges
Women living with HIV and AIDS face many
challenges to exercise their rights. One of the major
challenges that contribute to the violation of sexual and
reproductive health rights for women infected with HIV
is that men/partners often lack knowledge and skills
to support women living with HIV and AIDS. There is
also a lack of exploration on alternatives to biological
parenting, such as foster care or adoption.
…women need to obtain consent from
in-laws to seek services, or may even be
inherited by the spouse’s relative after
death of their spouse…
Other challenges include lack of information, as well
as structural barriers:
Lack of information – There is generally limited
knowledge about the availability of facilities offering
sexual and reproductive healthcare services to women
and specifically to women who are seropositive for
HIV. Moreover, in the instances where this knowledge
is available, access to these facilities is restricted by
inadequate infrastructure, such as inaccessibility, due to
long distances and the costs of transport. Sexual and
reproductive health information, care and counselling
to assist women living with HIV and AIDS to make
decisions about their sexual and reproductive healthcare,
are very limited.
Structural barriers to improving the sexual and
reproductive health of women living with HIV and
AIDS
• High illiteracy rates and lack of decision making
power – Rural women or illiterate women
experience difficulty to access information
and services. Poverty and long distances to
services further limit the access to services and
information.
• Role of culture and inequity in relationships
– Cultural norms and women’s status affect
women’s ability to access services. For instance,
women need to obtain consent from in-laws to
seek services, or may even be inherited by the
spouse’s relative after death of their spouse.
Our culture is a problem sometimes because
there is a belief that a man’s word is final
– so this gives women less opportunity to
decide on sexual and reproductive issues.
If a woman is married and lobola has been
paid, even the in-laws believe they have
something to say.4
• Power in sexual relationships – In most cases,
male partners dominate the actual act of sex.
Women also encounter enormous difficulties
with partners in monogamous relationships to
use barrier methods, such as condoms.
He does not force me to have sex with him,
but he does emotionally because if I refuse
then I don’t get money, he might leave me
for another woman or won’t talk to me.
This spoils the mood of the house, so I feel
obliged.5
• High prevalence of domestic violence – Many
women experience and fear violence in their
relationships. Some do not seek treatment for
sexual and reproductive health problems for fear
of violence or abandonment or being blamed by
their partners for bringing the infection into the
relationship. Domestic violence is viewed as a
30Sexual and reproductive health rights in the context of HIV and AIDS
ALQ March 2007
private family matter and is often sanctioned by
other family members (in-laws).
Women believe they can accept abuse from
men because they are financially dependent
on them. Men have to decide about sexual
activities.6
…domestic violence is viewed as a private
family matter and is often sanctioned by
other family members (in-laws)…
• Perceived societal roles versus individual rights –
Women often experience pressure to have children,
due to cultural norms prescribing that a woman’s
role is to bear children. Women living with HIV
and AIDS face discrimination when they decide
or choose not to have children. In addition, their
ability to make their own decisions regarding
sterilisation is often limited.
Irrespective of all these challenges, it is imperative
that the decision of women whether or not to have sex,
or to have a child, has to be an open and free negotiation
process, irrespective of her HIV status.
Recommendations
The following are some of the measures to address the
above challenges and to ensure women’s access to quality
sexual and reproductive health.
• Increase education and awareness on sexual and
reproductive health needs for women living with
HIV and AIDS.
• Provision of effective sexual and reproductive
healthcare for women living with HIV and AIDS
should be guided first and foremost by a rightsbased
approach. Policies and programmes should
identify and address gaps through advocacy,
strategic planning and collaborative commitments
to bridge the reality of existing services and
women’s desires and rights to fulfil their sexual
and reproductive health needs.
• Greater involvement of women living with HIV
and AIDS – The complexities of the lives and
circumstances of women living with HIV and
AIDS require their involvement in policy-making
and programme designing in order to effectively
address issues that concern their lives.
• Build support for sexual and reproductive health
rights of women living with HIV and AIDS –
Leadership and participation of women living with
HIV and AIDS is crucial in designing, planning
and implementing the support. Promote sexual and
reproductive health of women living with HIV and
AIDS in everyday life and policy formulation.
• Ensure that the health sector can meet the needs
of women living with HIV and AIDS by various
means, including ongoing education and training,
and adequate resource allocation. Develop a
comprehensive sexual and reproductive health
and HIV and AIDS curriculum for all training
institutions.
• Implement programmes that will meet the sexual
and reproductive health needs for women living
with HIV and AIDS within the health systems and
ensure that these programmes are understood and
supported at the highest political level.
Scope of sexual and reproductive health
services
Widening the scope of sexual and reproductive
health services also means offering a greater range
of actual services than currently provided. Currently,
there is unevenness of health providers’ understanding
of sexual and reproductive health of women living with
HIV and ability to respond to the needs of women living
with HIV.
In order to provide adequate and effective sexual and
reproductive health services for women living with HIV
and AIDS, various factors need to be taken into account,
including:7
• Promoting sexual health – Some of the specific
actions that are needed to promote sexual and
reproductive health needs of women living with
31
Sexual and reproductive health rights in the context of HIV and AIDS
March 2007 ALQ
HIV and AIDS include addressing the particular
sexual and reproductive health needs of women
living with HIV and AIDS, as well as ensuring the
availability of relevant and appropriate information
and counselling.
…women living with HIV should not be
discouraged, instead be given accurate
information during counselling,
including the reassurance that it is
allright to have children…
• Family planning counselling – Access to family
planning counselling for women living with HIV
should be a priority in sexual and reproductive health
services. This service can assist women living with
HIV and AIDS to consider their choices and make
informed decisions about pregnancy and contraceptive
use that will suit their needs and lifestyle. This should
be integrated into all phases of HIV care and treatment.
Barrier contraceptives should be particularly
promoted for women who are not planning to become
pregnant. Actually, ‘dual protection’ should be highly
recommended. In addition, the potential effects of a
pregnancy on HIV progression and the implications
for family planning; and the risk of transmitting HIV
to the unborn child are information that should be part
of family planning counselling.
• Counselling for women infected with HIV who
are planning a pregnancy – Women living with
HIV should not be discouraged, instead be given
accurate information during counselling, including
the reassurance that it is allright to have children.
However, women living with HIV need special
counselling, support and guidance throughout the
process in areas, such as the timing of conception,
so that conception occurs as and when their medical
status has been optimised. They also need to be advised
on precautions to take to reduce the risk of mother to
child transmission of HIV during pregnancy, labour
and delivery. Prior to that, women living with HIV and
AIDS should also be informed about different options
of parenting without having to go through pregnancy,
such as adoption and fostering.
• Counselling during pregnancy, childbirth and post
delivery – Many women in abusive relationships are
at increased risk of experiencing domestic violence
during pregnancy with consequences both for her and
the baby, such as spontaneous miscarriage and preterm
labour. Throughout pregnancy, delivery and post
delivery periods, emphasis of counselling should be
placed on promoting healthy practices for the wellness
of the mother and the baby. This should involve
interventions to reduce the risk of mother to child
transmission of HIV and to avoid re-infections during
pregnancy. Care should be provided in a sensitive
and confidential manner, considering the stigma and
discrimination that is associated with HIV.
• Termination of pregnancy – Even where contraceptive
services are available, unintended pregnancies
still occur for various reasons or under certain
circumstances, such as the partner may be opposed
to contraceptives or condom use; and the woman
may be coerced or forced to have sex. There is also
a need to ensure that safe termination of pregnancy
is available and accessible to women living with HIV
and AIDS. Termination of pregnancy counselling
should be provided by a trained person and is to be
non-directive, non-judgmental and confidential. If
the healthcare worker suspects coercion, the woman
should be referred for additional counselling in an
endeavour to ensure fully informed and free decision
making. Being pressurised or coerced to undergo
a termination of pregnancy is a violation of human
rights. All women, who, regardless of their HIV
status, choose a termination of pregnancy are to be
treated with respect, non-judgmental attitudes and
have access to appropriate care and referral.
Sexual and reproductive health of women
receiving antiretroviral treatment
There are a number of factors that need to be considered so
32Sexual and reproductive health rights in the context of HIV and AIDS
ALQ March 2007
as to ensure the sexual and reproductive health of women
receiving antiretroviral treatment. These include that:
• For equity, humanitarian and moral reasons,
women must have access to antiretroviral therapy
when needed. Antiretroviral therapy for women
is an essential component of initiatives to reduce
maternal morbidity and mortality, prevent mother
to child transmission of HIV and secure the health
and sexual well-being of a woman living with HIV
and AIDS.
• Although women living with HIV and AIDS may
differ in the presentation and response to treatment,
standard treatment protocols are effective for
women receiving antiretroviral treatment (ART).
In addition, the possibility of unplanned or
unintended pregnancy must be considered when
selecting an ART regimen for women.
…in the absence of informed choices and
adequate sexual and reproductive health
services, women living with HIV and
AIDS are even at a greater risk of
morbidity and mortality…
• ART programmes need to be sensitive to women
needs, especially in relation to their sexual and
reproductive health.
• Special efforts to support adherence may be needed
during pregnancy, delivery and post delivery.
• Making ART widely available to include partners
and children will also ensure that women are
not tempted to share their treatment with other
family members, which may not be an appropriate
regimen for these other groups.
Conclusion
Every woman has the right to have sex and the
right to decide whether or not to have children. This
is a universally recognised fundamental human right
for a woman. However, women living with HIV and
AIDS are being systematically discouraged to practice
this right. Sexual and reproductive health services for
women living with HIV and AIDS have to incorporate
all standard reproductive healthcare offered to every
woman. Moreover, this care should be curtailed to
meet the specific needs of women living with HIV and
AIDS, irrespective of their sexual activity.
Through lack of information, stigma and discrimination,
women who are infected with HIV are often denied their
sexual and reproductive health rights. In the absence of
informed choices and adequate sexual and reproductive
health services, women living with HIV and AIDS are
even at a greater risk of morbidity and mortality.
…I think the services should be more humane.
They should see women as complete people and
not only as reproducers or HIV positive. Women
are still devalued…8
…[HIV positive women] need services… I don’t
differ form other women who are not positive.
Well, there is the virus in my blood… I have the
same rights…9
FOOTNOTES:
1. Bell, E. & Orza, L. 2006.’Understanding positive women’s realities’. In:
Exchange on HIV/AIDS, Sexuality and Gender, 2006(3):1-4.
2. The State of the World Population Report. 2005. Chapter Four.
3. EngenderHealth/Harvard University/ICW/Ipas/UNFPA. 2006. Sexual and
reproductive health of HIV positive women and adolescent girls: A dialogue on
rights, policies and services. p.9.
4. Policy Project. 2005. Meeting the reproductive health needs of HIV positive
women in Swaziland. Policy Project.
5. Ibid.
6. Ibid.
7. See also World Health Organisation. 2006. Sexual and reproductive health
of women living with HIV/AIDS: Guidelines on care, treatment and support for
women living with HIV/AIDS and their children. WHO.
8. EngenderHealth/UNFPA. 2006. Sexual and reproductive health needs of
women and adolescent girls living with HIV. p.17.
9. EngenderHealth/UNFPA. 2006. Sexual and reproductive health needs of
women and adolescent girls living with HIV. p.45.
Nomampondo Barnabas is the Head of the
Community Programme at the Centre for the
AIDS Programme of Research in South Africa
(CAPRISA). For more information and/or
comments, please contact her on 031 260 4555
or at Barnabasn@ukzn.ac.za.
33
Sexual and reproductive health rights in the context of HIV and AIDS
March 2007 ALQ
We, a group of representatives from women in
civil society having met on 8 – 9 March 2007, at
Liban Conference Centre in Johannesburg, have
drafted this declaration, on the proviso that the
key concerns raised by this group are integrated
into the National Strategic Plan (NSP).
Preamble
We, the women’s sector of civil society, salute
the government of South Africa for developing
the NSP and engaging civil society in the
process. We acknowledge that government has
recognised the challenges facing the sector
and responded through the NSP.
We pledge our commitment and support to
ensure the integrated implementation of the
NSP through partnership. We recognise the
centrality of addressing women’s position in
society as fundamental to address HIV and AIDS
in South Africa. Only a gender transformatory
response built on active partnership between
government and civil society, will address the
vulnerability of women.
We believe
n That the Constitution of South Africa which
guarantees our right to equality, freedom and
dignity provides a strong basis for centering
women’s rights, particularly sexual and reproductive
rights, in the response to HIV and AIDS.
n That South Africa’s commitments to
international conventions, instruments and treaties
further consolidate government’s obligations to
women’s rights.
n That patriarchy continues to reinforce the
oppression and marginalisation of women and
girls in this country.
n That women have the right and the ability to
participate meaningfully and lead in all decision
making processes at policy, legislative and
programme level.
n That adequate resource allocation is critical for
efficient and effective implementation of the NSP.
We recognise
n The gains that have been made in terms of
advancing a women’s rights agenda.
n That, despite these gains, women and girls
are the most vulnerable and affected by both HIV
and AIDS, because of their biological and socioeconomic
status.
n That South Africa has extremely high levels of
violence against women and children, including
rape, sexual assault and domestic violence.
n Maternal mortality and morbidity remains
unacceptably high.
n Women are diverse in terms of their daily lived
Civil Society Women’s Sector Declaration of Commitment1
to the
HIV & AIDS and STIs National Strategic Plan 2007 – 2011
34National view
ALQ March 2007
realities and identities including ‘race’, class, sexual
orientation, disability, pregnancy status, HIV status,
age and nationality.
n That for successful implementation, the
women’s sector of civil society must be in full
partnership, be meaningfully involved, lead and
be adequately resourced.
n The need to strengthen the women’s civil
society sector.
We therefore commit to
n Play our role in the implementation of the
NSP through active partnership around critical
areas, such as policy formulation, support and
coordination, capacity building, research and
strengthening the capacity of the sector to play its
part.
n Build the capacity of the sector to be
sustainable, unified, networked and accountable.
n Fulfil our responsibility to work in partnership to
ensure the effective implementation of the NSP.
n Hold government accountable for the NSP and
other relevant, existing policies that affect women
and girls, through monitoring and advocacy.
And urge government to
n Recognise that women’s rights are fundamental
in addressing HIV and AIDS in the effective
implementation of the NSP and show leadership in
the areas of gender consciousness and sexuality.
n Fully acknowledge, support and strengthen
the contributions made by women in civil society
and communities.
n Recognise that the implementation of the NSP
will only be achieved with full partnership with
women in civil society.
n Accelerate efforts to address violence against
women and children to ensure that access to
prevention, protection and empowerment services
for all women, including women living with HIV,
girls and young women, pregnant women, sex
workers, lesbian, bisexual, transsexual and intersex
women and refugees is adequately resourced.
n Commit adequate resources through longterm
commitments to women in civil society.
n Review macro-economic policy to ensure that
poverty and unemployment are addressed and
privatisation of health services, which further deepens
women’s and girls’ vulnerability, are addressed.
n Address human resource challenges to ensure
the optimal implementation of the NSP so that
there will be no exploitation of women’s labour at
a community level.
n Establish functional mechanisms that will
facilitate an integrated, comprehensive and rights
based approach within government and between
government and civil society.
Let us move forward in a spirit of solidarity,
as a people committed to implementing the
NSP, in ways that fundamentally transforms
the inequality between women and men and
entrenches women’s autonomy over their own
health, bodies and lives.
FOOTNOTES:
1. This Declaration is a draft prepared and agreed in principle on
09 March 2007 at the Civil Society Women’s Sector Meeting. This
meeting took place before the final version of the National Strategic
Plan (NSP) was launched. For more information and updates on this
Declaration go to www.womensnet.org.za
35
National view
March 2007 ALQ
A multisectorial, multidisciplinary, decentralised
and community-based approach is reducing HIV and
AIDS infection rates in Rwanda. This has been achieved
through a system involving adequate policies, fast field
information collection, sensitisation and follow-up by
stakeholders in HIV prevention. This system impacts on
stigma reduction, voluntary HIV testing, home-based
care promotion, and the adherence to HIV associations
so as to respond to the challenges of the pandemic
disease.
Country situational analysis
Rwanda is a very youthful country, with nearly
50% of the population under the age of 17. The
country is amongst the ten countries in Africa most
severely affected by HIV and AIDS. Rwanda is facing
a generalised epidemic. National estimates indicate
that in 2005, the adult prevalence rate is in the range
of 4% to 11% amongst women attending antenatal
care services and 3% amongst the general population.
An estimated 250 000 adults and children were living
with HIV and AIDS at the end of 2003. Prevalence rates
have been documented to be higher in urban areas,
than in rural areas. In 2003, the HIV prevalence in Kigali,
the Rwandan capital, amongst women attending
antenatal clinics was 13.2%. Outside major urban areas,
the median prevalence amongst pregnant women
tested for HIV was 3.1%. Prevalence rates appear to
have stabilised in urban areas, but continue to rise
slightly in rural areas. An estimated 160 000 children
younger than 17 years had lost one or more parent to
the disease at the end of 2003. The burden of HIV and
tuberculosis (TB) co-infection is high (estimated to be
between 40% and 60%).2
Factors contributing to the rapid spread of the
disease include the low levels of awareness about HIV
and AIDS, high incidences of multiple sex partners, low
rates of condom use, early onset of sexual activity, and
the overall civil crisis of the 1990s, especially during the
1994 genocide.
Solution to address HIV and AIDS expansion
Currently, Rwanda has developed national policies
on HIV testing and treatment. In 2002, the Treatment
and Research AIDS Center was established to expand
access to HIV testing and counselling, prevention of
mother-to-child transmission, and clinical care and
support for people living with HIV and AIDS, including
antiretroviral therapy. Guidelines for antiretroviral
therapy, voluntary counselling and testing for HIV,
treatment of opportunistic infections and prevention
of mother-to-child transmission have been developed
and recently revised, so as to adhere to international
standards. Guidelines for antiretroviral therapy for
children are being developed. With support from the
Global Fund to Fight AIDS, Tuberculosis and Malaria,
Rwanda plans to establish a national network on
voluntary counselling and testing for HIV, with the
objective of expanding the number of sites at the
provincial level.
Multiple coordinating bodies have been created
in the past three years at national and decentralised
levels:
Government structures:
• In 2000, the National AIDS Control Commission
was created, under the Office of the President
to coordinate a multisectoral programme;
• In 2001, the Treatment and Research AIDS
36Regional View
ALQ March 2007
HIV and AIDS on the decline
due to innovative measures…
Experiences from Rwanda
Emmanuel Habumuremyi1
Centre was created, to coordinate monitoring
and evaluation of care, treatment and drug
stocks and reports to the Commission. Minister
of State for major epidemics was appointed in
2002, within the Ministry of Health. In 2006, there
was the decentralisation of the Commission
(within government administrative restructures)
for representation in 30 District Committees for
the Fight against AIDS; and
Non-governmental structures:
• Coordinating umbrella organisations that
represent people living with HIV, youth, faithbased
organisations, women, private sector,
media and cluster of HIV (Government of
Rwanda and Development partners) is in place
and it is very active.
To better monitor the effectiveness of these
structures, measures to operationalise and harmonise
standard operating procedures have been put in place,
such as a mapping of activities of all implementing
agencies, who now sign memoranda of understanding
with the National AIDS Control Commission.
Field information collection
According to the Ambassador Mark Dybul, U.S.
Global AIDS Coordinator,
People living with HIV in the developing world
deserve high-quality treatment and care, and this
innovative partnership will ensure that health
workers and program managers get the timely,
relevant information they need – even when they
serve patients in the most remote areas.
Today, Rwanda is using a system that uses cell
phones to bolster HIV and AIDS care and the system’s
impact in Rwanda. The system, which was created by a
USA-based company Voxiva3, allows health workers to
send reports using a cell phone directly from the field to
a central database. The system was launched in Rwanda
two years ago to identify people living with HIV and
AIDS. It now connects 75% of the country’s 340 clinics
and covers 32,000 people. Each time a person living
with HIV is entered into the system, the information
is sent to a central database in Kigali. Weekly reports
are also created to cover data, including clinics’ stocks
of antiretroviral drugs, and monthly reports cover the
number of people with access to antiretrovirals.
In addition, clinics receive messages with
information about laboratory tests and drug recall
alerts sent by the Ministry of Health. According to the
Rwandan HIV/AIDS Minister, Dr Innocent Nyaruhirira,
by identifying individual patients in a central database,
the Ministry of Health can follow-up on individual
patients, even when they change clinics, since mobile
phones are almost everywhere in Rwanda.
Under the initiative called ‘Phones-for-Health’, health
workers in the field can access software loaded on a
standard Motorola cell phone to enter HIV and AIDS
and health information into a central database in real
time.
Health workers will also be able to use the system to
order medicine, send alerts, download treatment
guidelines, training materials and access other
appropriate information…Managers at the
regional and national level can access information
in real-time via a web based database. [Paul
Meyer, Chairman of Voxiva ]4
Rwandan authorities in charge of HIV and AIDS
prevention see that with TRACnet, Rwanda has a
powerful tool to manage the HIV and AIDS programme
and deliver care to Rwanda’s patients affected by HIV
and AIDS. Healthcare workers use something as simple
as a cell phone – even where there is no electricity – to
report on the number of patients on treatment, drug
stock levels and other key data needed. According to
the CNLS Executive Secretary, Dr Binagwaho,
…Rwanda is the first country in Africa with a
national-scale, real-time information system to
manage its HIV and AIDS programme.
Mechanisms taken to hinder AIDS progress
Home-based care
Delivering care at home has been a means to
support people living with AIDS in Rwanda since the
beginning of the epidemic. The formal concept of
37
Regional View
March 2007 ALQ
home-based care in Rwanda began with a small set
of programmes in 2001. In 2003, a more structured
set of home-based care (HBC) programmes were
launched, and within six months, HBC in Rwanda
expanded tremendously.5
Although the current set of HBC programmes
is relatively new and small in scale, an unofficial
estimate suggests that there are up to 30 HBC
programmes. Current HBC programmes are primarily
financed by international donors, including the U.S.
Agency for International Development (USAID), and
are established by non-governmental organisations,
such as Médecins Sans Frontieres, World Vision,
Africare, Family Health International (FHI), and CARE
International.
Food security and nutritional support tend to be
central in responding to the needs of households
coping with HIV. In response, USAID, through the
Food for Peace Programme and Emergency Food
Programme, and the U.N. World Food Programme
(WFP) donate supplemental food rations for
individuals living with HIV and AIDS and their families.
Given the increase in HBC programmes in Rwanda,
the government of Rwanda has developed guidelines
for home-based care. Guidelines tend to focus on
technical concepts of HIV infection and steps for
health professionals in assisting people living with
HIV and AIDS, including paediatric HIV and AIDS and
palliative care. While current guidelines do not extend
to discussions of antiretroviral therapy at home
and issues of drug resistance, a few programmes
have extended to include counselling to discuss
ARV treatment adherence, to ensure ARV regimen
compliance, and to avoid drug resistance.6
The role of Protection and Care for Families against
HIV/AIDS (PACFA)
The Protection and Care for Families against HIV/
AIDS (PACFA), which has recently marked its five year
anniversary, is also playing a big role in HIV and AIDS
reduction in Rwanda.
PACFA’s efforts in the last five years are aimed at
ensuring that there are no new HIV infections,
poverty reduction and, the development of a highly
skilled and educated population.7
An initiative of the First Lady, Mrs Jeannette Kagame,
PACFA was created following a summit of First Ladies
of Sub-Saharan Africa on children and HIV and AIDS
prevention, held in May 2001 in Kigali. The First Ladies at
the conference signed ‘The Kigali Declaration’, formally
committing to mobilise resources to improve the lives
and lessen the suffering of vulnerable populations.
HIV and AIDS associations
In Rwanda, people living with HIV and AIDS are
creating associations to sensitise the population on
how to avoid HIV. These associations are urged to
come together and form cooperatives, so as to reap
from the advantages that accrue thereto. There is,
however, a problem of low income for some of the
associations, which would require them to work with
the associations that have sufficient funds.
The National Commission against HIV/AIDS
(CNLS) has a deliberate policy of helping out the
associations, as long as they amalgamate into bigger
bodies through which they can access different forms
of assistance. Some measures have been taken by
the CNLS, in collaboration with the Rwanda Network
of People Living with HIV/AIDS (RRP+), after realising
that many a time the funds meant for the grassroots
AIDS associations do not reach these associations, as
they are often used up by their leaders. The decision
was taken to create fairness, because different donors
give support at different times, which in most cases
benefits associations with better access to the donor
community, often at the expense of the very remote
that may be severely affected by HIV and AIDS.
This system will, therefore, help distributing the
resources to all beneficiaries equally. CNLS being
responsible for policies on AIDS, will act as a central
conduit through which all aid will be coordinated.
Conclusion
A lot has been done to prevent the progress of HIV
and AIDS in Rwanda. However, there remains much
ignorance about HIV and AIDS, requiring a huge
38Regional View
ALQ March 2007
effort to promote public awareness. Moreover, the
ongoing initiatives to put HIV and AIDS at the centre
of the world’s development agenda, have enormous
potential for mobilising the vastly increased political
and financial resources required to bring the epidemic
under control and to care for affected individuals and
communities.
In conclusion, some of the key challenges
threatening the adequate response to HIV and AIDS in
Rwanda include the following:
• Prevention and behavioural change: Behavioural
change remains a barrier and communication
messages are conflicting for the youth. Further
efforts need to be made for predictable and
sustainable financing of the national plan to
facilitate universal access. The current national
plan proposes to address this issue.
• T here is need to enhance access to health
services and to promote contraceptive use with
a particular emphasis on the dual protection
function of barrier methods. The rate of condom
use is still very low, (only 2.4 % of the population
use condoms);
• T he small number and low uptake of voluntary
counselling and testing (VCT) for HIV services;
• Urgent need to promote prevention of mother
to child transmission (PMTCT), through capacity
building;
• Care for people living with HIV and AIDS:
Although a national association of people living
with HIV and AIDS was recently created, there
is little coordination amongst the associations
and little external support; and
• Hiring and training health district workers and
improving the HIV and AIDS drug distribution
mechanism.
FOOTNOTES:
1. Andrew Ward from the ‘phone-for-health’ programme, working
in partnership with the GSM Association’s Development Fund, the
US President’s Emergency Plan for AIDS Relief (PEPFAR), Accenture
Development Partnership, Motorola, MTN and Voxiva, provided
invaluable information and comments to the article.
2. See also Kayirangwa, E., Hanson, J., Munyakazi, L. & Kabeja, A.
‘Current trends in Rwanda’s HIV/AIDS epidemic,’ Sexually Transmitted
Infections, [http://sti.bmj.com/cgi/content/full/82/suppl_1/i27];
Office of the United States Global AIDS Coordinator. 2006. HIV/AIDS
Situation in Rwanda; WHO. 2005. Rwanda: Summery country profile
for HIV/AIDS treatment scale-up.
3. For more information go to www.voxiva.net.
4. This system by Voxiva is called TRACnet.
5. See also Chandler, R., Decker C., & Nziyige, B. 2004. Estimating the
cost of providing home-based care for HIV/AIDS in Rwanda. Partners for
Health Reformplus, June 2004.
6. See also Ministry of Health. 2006. National guidelines for food
and nutrition support and care for people living with HIV/AIDS in
Rwanda, Kigali.
7. ‘PACFA Marks Anniversary’. In: The New Times, February 10, 2007:
[www.newtimes.co.rw]
Emmanuel Habumuremyi is the Content
Team Leader at the Rwanda Development
Gateway, based at the National University
of Rwanda. For more information and/or
comments, please contact him on
+250 08487899 or at emmahab@yahoo.fr.
39
Regional View
March 2007 ALQ
40Comment/Making a
point
ALQ March 2007
The above scenarios are common in South Africa.
Clarence’s case is known as ‘proxy testing’, whereby
one partner (typically male) send their sexual partners
(typically female) to be tested for HIV. In Michelle’s
case, men are abandoning responsibility, because of
female partners’ HIV status. Why are these scenarios
happening? What causes men to not seek voluntary
counselling and testing (VCT) services? This article
will explore various factors involved in men’s lack of
utilisation of VCT services, and explore strategies to get
more men to take responsibility, get tested for HIV, and
seek additional HIV and AIDS-related services when
appropriate.
Men and VCT
Examining most data on voluntary counselling and
testing (VCT) in South Africa, men are much less likely
to be testing for HIV. With an adult HIV-prevalence rate
of over 20 percent1, South Africa’s AIDS epidemic is one
of the most severe in the world. In 2002, it was estimated
that there were 6.5 million people in South Africa living
with HIV and AIDS.2 It is clear that men play a key role
in fuelling South Africa’s high rates of HIV infection.
Over the past several years, numerous governmental and
non-governmental organisations in South Africa have
adopted large-scale national programmes that target
men for HIV prevention. Although efforts to reach
men with prevention messages have been established,
men’s participation in voluntary counselling and testing
(VCT) services continues to be extremely low. Recent
national studies in South Africa found that only one in
five South Africans who are aware of VCT have been
tested for HIV3, and that men accounted for only 21%
of all clients receiving VCT4.
Men’s utilisation of HIV testing is of great
importance. Research conducted in developed and
developing countries has shown that VCT can reduce
high risk sexual practices, decrease rates of sexually
transmitted infections, and reduce HIV transmission.5,6
Men’s participation in VCT has also been associated
with increased support and involvement in prevention
of mother-to-child transmission (PMTCT) programmes.
A study in Nairobi found that HIV-infected women,
whose partners came to the antenatal clinic for VCT,
were more likely to receive nevirapine during followup,
avoid breastfeeding their infant, and report condom
use.7 Men’s utilisation of VCT also has implications
Fear Factor
Voluntary Counselling and Testing for HIV and
Masculinity in South Africa
Kent Klindera, Dumisani Rebombo, Andrew Levack
Clarence’s male cousin recently died from HIV. Clarence
had never really thought of his own status, because
HIV had never really hit so close to home. It was a
disease of ‘them’ not ‘us.’ In his days, Clarence certainly
had numerous partners. Even today, although he has
a girlfriend, he also occasionally has sex with other
women. He knows he is safe, because his girlfriend
was recently tested for HIV and told him she was HIV
negative. As long as she continues to test negative for
HIV, Clarence is not afraid.
Michelle had been dating Sipho for over three years
– never being tested for HIV. They had been trying to
get pregnant for many months and finally it happened.
Upon Michelle’s first anti-natal visit, she was informed
that she tested positive for HIV and should consider
enrolling iton a PMTCT programme. When she arrived
home in deep despair to inform Sipho of her HIV status,
Sipho would not believe her story and accused her of
infidelity. He subsequently moved out of the house and
claims the child can not be his, since Michelle has HIV.
Sipho is now refusing to test himself for HIV.
for uptake of antiretroviral treatment. A study in
Johannesburg conducted between April and June of
2004 reported that women accessing antiretroviral
medication outnumbered men by a ratio of 2 to 1.8
The same study reported that women’s CD4 count at
initiation of treatment was significantly higher than
men’s, which suggests that men’s reluctance to know
their HIV status often leads men to seek treatment only
when they become ill.
There have been several studies in South Africa and
the region that looked at factors associated with VCT
utilisation. A study in a township in Cape Town found
that compared to people who had been tested for HIV,
individuals who were not tested for HIV demonstrated
significantly greater AIDS related stigma.9 Such
stigma included negative beliefs about people living
with HIV and AIDS, shamefulness of the behaviour of
people with HIV and AIDS, and the endorsement of
social sanctions against people with HIV and AIDS.10
A study of mineworkers in South Africa found that the
major identified barriers to VCT were fear of testing
HIV positive and potential consequences, such as
stigmatisation, disease and death.11 The same study also
found that only 14% of men would be more likely to access
VCT, if antiretroviral therapy became available. Focus
groups with factory workers in Zimbabwe found reasons
for not wanting to test for HIV included confidentiality
concerns, fear of death, and stigmatisation. Men who
wanted to know their HIV test results cited concern over
past risk, desiring peace of mind, and wanting to plan
their family’s future.12
EngenderHealth Men and VCT Study13
In 2005, EngenderHealth conducted a study in
Soweto, South Africa, to determine causes of the
imbalance between men’s and women’s utilisation of
VCT. Five focus groups were carried out with samesex
groups of men and women living in Soweto. Male
focus group participants also completed a short survey
to determine their HIV testing history and preference
for HIV service delivery. Six individual interviews
were carried out with men living in Soweto, who had
previously tested for HIV. Seven individual interviews
were also carried out with women who have participated
in PMTCT programmes.
Results from this study, citing the reasons for men
not testing for HIV, fell into three realms: individual
factors, societal factors and institutional factors. In
terms of individual factors, the data indicated that fear
of one’s HIV status was a leading factor inhibiting men
to seek VCT. Additional individual factors included
assuming that a partner’s HIV status is one’s own, no
value seen in knowing one’s HIV status, and no sense
of vulnerability to HIV. Societal factors that contributed
to men not utilising VCT included stigma and men’s
gender socialisation. Institutional factors included poor
treatment by nurses and confidentiality concerns.
Examining the lead individual factor of fear of one’s
HIV test results, which is related to the societal factor
of stigma, highlighted various issues linked heavily to
issues of gender. These fears included fear of the stigma
associated with HIV and AIDS, fear of death, as well
as the fear of being seen as weak. Indeed, traditional
gender roles portray men as strong and risk takers. Men
and boys are told not to cry; not to share their emotions;
and not to show that they are in pain. Thus, if a man
is suffering from an illness, he is perceived to be less
of a man and more like a weak woman. Thus, testing
for HIV would be a sign of weakness, especially if a
man is to be open about his HIV positive status. As is
quite common, men who are living with HIV and AIDS
often wait too long to seek treatment (often too late), as
they fear being emasculated. During this waiting period,
or should it be called a ‘hiding period’, most men hide
their fears. These men pretend to be strong and come
up with various excuses to not seek care, such as the
clinics and hospitals are not ‘male-friendly’. In fact, it
is often argued that the clinics are not ‘human friendly’,
yet, women continue to utilise these services.
EngenderHealth/Men as Partners (MAP)
Response
Clearly, a new form of masculinity is needed. As
mentioned above, traditional gender roles limit men’s
involvement in HIV and AIDS efforts. However;
clearly men are needed to be involved. To address these
discrepancies, EngenderHealth implements the Men as
Partners (MAP) programme. MAP is a global initiative
designed to work with men on HIV and AIDS and
reproductive health issues within a gender framework.
41
Comment/Making a point
March 2007 ALQ
MAP is based on the realisation that current gender roles
give men the power to influence women’s reproductive
health; that these roles put men at risk by associating
risky health practices with manhood; and that men have
a positive role to play in improving
their own health and the health of their
families. It also addresses factors that
inhibit men’s health themselves.
MAP began in South Africa in
1998 through a collaboration between
EngenderHealth and the Planned
Parenthood Association of South
Africa (PPASA). The programme
involves running workshops with
men, training male ‘transformation
agents’ (e.g. peer educators), raising
community awareness related to
gender and sexual and reproductive health (SRH),
mobilising community to take action, and working to
modify and establish just policies that work to support
MAP goals.
MAP uses a human rights framework to enable men to
recognise the ways in which contemporary gender roles
mirror the oppressive relations of power characteristic
of Apartheid. This oppression has devastating health
consequences for women, placing them at risk of
violence, limiting women’s ability to negotiate the terms
and conditions of sex and severely compromising their
sexual and reproductive health, including increasing
women’s vulnerability to HIV and AIDS and placing
the burden of care and support for people living with
AIDS squarely on women’s shoulders. In the service of
promoting gender equality and protecting women from
HIV and AIDS, MAP draws the connections
between sexism and racism and other forms
of oppression, and strives to get men to
see the ways in which gender equality is a
fundamental human right of comparable
importance to those fought for during
the anti-apartheid years. This approach
connects gender equality to South Africa’s
rich tradition of social justice activism and
situates it squarely within human rights
discourses and traditions embraced by most
South African men. Many MAP educators
come from activist backgrounds and apply
their expertise to devising strategies that get men to
take a proactive stand for gender equality and against
women’s oppression.
Specifically related to HIV and AIDS, MAP recognises
that contemporary gender roles can compromise men’s
sexual and reproductive health by encouraging men to
equate a range of risky behaviours – the use of violence,
alcohol and substance use, the pursuit of multiple sexual
partners, the domination of women – with being manly,
while simultaneously encouraging men to view healthseeking
behaviours as a sign of weakness. A number of
studies demonstrate clearly that such gender roles leave
42
ALQ March 2007
Comment/Making a point
men especially vulnerable to HIV infection, decrease the
likelihood that they will seek HIV testing, and increase
the likelihood of contributing to actions and situations
that could spread the HI virus. Noar and Morokoff
(2001) have documented the effects of ‘masculinity
ideology’ on condom usage and sexual and reproductive
health in general and indicate that traditional men’s
gender roles lead to ‘more negative condom attitudes
and less consistent condom use’ and promote ‘beliefs
that sexual relationships are adversarial’.14
Similarly, a recent study of antiretroviral treatment
in Johannesburg15, conducted between April and
June of 2004, reported that women accessing ARVs
‘outnumbered men by a ration of 2 to 1’. This same
study reported that women’s CD4 count at initiation of
treatment was also significantly higher than men’s (100
cells/μl in women and 85 cells/μl in men) and concluded
by saying:
The observation that two thirds of
patients were female, with 23% of
women referred from prevention
of mother to child transmission
programmes, underscore the need for
programmes that target HIV-infected
men.16
These f indings were similar to those
reported on in a study of VCT uptake in the
Khayelitsha clinic outside Cape Town, South
Africa, where 70% were women.17
Behaviour Change Community Strategies/
Picture Story Cards
MAP integrated behaviour change communication
strategies into its efforts to assist men in redefining
masculinity. A key aspect of behaviour change is
motivation. Thus, MAP focuses on methods to motivate
men to take action for change. Specifically related to
VCT, EngenderHealth is focusing on the ‘fear factor’
to convince men to not be afraid – and overcome the
fear factor. Thus, one campaign MAP has utilised is the
concept of ‘strength’, with the tag line of ‘My Strength
is not for Hurting’. Working in partnership with the
Western Cape Office of the Premier and a US-based
NGO Men can Stop Rape, EngenderHealth/MAP has a
poster campaign encouraging men to show their strength
by getting tested for HIV.
Similarly, EngenderHealth/MAP, in partnership with
the United Nations Development Fund, is
employing an additional strategy utilising
‘picture story cards’. These cards detail
personal stories of men and women dealing
with issues of HIV and AIDS and genderbased
violence. The cards are based on true
stories, and work to motivate men to be more
responsible. They are based on the reality
that men are supposed to be brave and strong
– thus, men should be able to face their fears
and get tested for HIV; or stop harassing
women. The cards work to motivate men
43
Comment/Making a point
March 2007 ALQ
(and women) to take action related to HIV and AIDS,
including VCT, and gender-based violence. Based on
the MAP methodology, the cards utilise social learning
theory to motivate men to redefine masculinity – with
emphasis placed on achieving gender equality. The cards,
amongst other things, address issues of confronting fears
related to getting tested for HIV; sharing housework
with partners; reducing sexual harassment and child
sexual abuse; and accepting gay and lesbian people.
EngenderHealth and its MAP programme partners
will continue to address the fear factor related to men
and VCT. For too long, men have left themselves behind
in the gender movement. It is time that men take more
action to limit the spread and impact of HIV and AIDS
and gender-based violence. One way to act is to get
tested for HIV and to take responsibility.
Hopefully, men like Clarence and Sipho mentioned
above have read this article and are reconsidering their
actions. Please help us in spreading the message.
FOOTNOTES:
1. UNAIDS. 2002. Report on the global AIDS epidemic.
2. Dorrington, R., Bradshaw, D. & Budlender, D. 2002. HIV/AIDS
profile of the provinces of South Africa – Indicators for 2002. Cape
Town: Centre for Actuarial Research, Medical Research Council and the
Actuarial Society of South Africa.
3. Shisana, O. & Simbayi, L. 2002. Nelson Mandela/HSRC study of
HIV/AIDS: South African national HIV prevalence, behavioural risks,
and mass media household survey 2002. Cape Town, South Africa:
Human Sciences Research Council.
4. Magongo, B. et al. 2002. National Report on the Assessment of the
Public Sector’s Voluntary Counselling and Testing programme. Durban,
South Africa: Health Systems Trust.
5. Kamb, M. et. al. 1998. ‘Efficacy of Risk-Reduction Counselling
to Prevent Human Immunodeficiency Virus and Sexually Transmitted
Diseases’. In: JAMA 1998; 280(13):1161-1167.
6. ‘Voluntary HIV-1 Counseling and Testing Efficacy Study Group.
Efficacy of voluntary HIV-1 counselling and testing in individuals and
couples in Kenya, Tanzania, and Trinidad: A randomised trial’. In:
Lancet 2000; 356:103-112.
7. Farquhar, C. et. al. 2004. ‘Antenatal Couple Counseling Increases
Uptake of Interventions to Prevent HIV-1 Transmission’. In: Journal of
Acquired Immune Deficiency Syndrome, 2004; 37(5):1620-1626.
8. Hudspeth, J. et al. 2004. ‘Access and early outcomes of a public South
Africa adult antiretroviral clinic’. In: The Southern African Journal of
Epidemiology and Infection 2004; 19(2):48-51.
9. Kalichman, S. & Simbayi, L. 2003. ‘HIV testing attitudes, AIDS
stigma, and voluntary HIV counselling in a black township in Cape
Town, South Africa’. In: Sexually Transmitted Infections 2003; 79:442-
447.
10. Ibid.
11. Day, J.H. et al. 2003. ‘Attitudes to HIV voluntary counselling
and testing among mineworkers in South Africa: Will availability of
antiretroviral therapy encourage testing?’. In: AIDS Care 2003; 5:665-
672.
12. Machekano, R., McFarland, W., Bassett, M., & Mandel, J.
2000. ‘Views and attitudes towards HIV voluntary counseling and
testing among urban men: Harare, Zimbabwe.’ Presented at the XIII
International AIDS Conference, Durban, South Africa, June 2000.
13. Levack, B.A. 2005. Understanding Men’s Low Utilization of HIV
Voluntary Counselling and Testing and Men’s Role in Efforts to Prevent
Mother-to-Child HIV Transmission in Soweto, South Africa. Thesis
submitted for Masters in Public Health, University of Washington,
Seattle, USA.
14. Noar, S.M. & Morokoff, P.J. 2001. ‘The Relationship between
Masculinity Ideology, Condom Attitudes, and Condom Use Stage of
Change: A Structural Equation Modeling Approach’. In: International
Journal of Men’s Health, 1(1).
15. Personal correspondence with Dr. F. Venter, University of
Witwatersrand, October 11, 2004, based on unpublished data of
a retrospective medical file review of all adult patients on ARV
treatment during the first 10 weeks of a public antiretroviral clinic
in Johannesburg, South Africa, focusing on demographics, clinical
presentation, and response to antiretroviral treatment.
16. Ibid.
17. Coetzee, D. et al. 2004. ‘Outcomes after two years of providing
antiretroviral treatment in Khayelitsha, South Africa’. In: AIDS 2004,
18(6):887-95.
Kent Klindera is the Senior Technical Advisor on
Gender Youth at EngenderHealth/South Africa
(kklindera@engenderhealth.org), Dumisani
Rebombo is the Multi-sectoral Programme
Officer at EngenderHealth/South Africa
(drebombo@engenderhealth.org), and Andrew
Levack is the Men as Partners Programme Global
Director (alevack@engenderhealth.org) and
lead investigator for the VCT study. For more
information and/or comments, please contact
Kent on +27 72 709 1534 or at
kklindera@engenderhealth.org .
Comment/Making a point
ALQ March 2007
Suite 6F, Waverley Business Park,
Mowbray, 7700
PO Box 13834, Mowbray 7705,
Cape Town, South Africa
Tel: +27 21 447-8435
Fax: +27 21 447-9946
E-mail: alncpt@aln.org.za
Website: www.aln.org.za
44
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