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South Africa: Women, AIDS, and Violence, 1
AfricaFocus Bulletin
Apr 28, 2008 (080428)
(Reposted from sources cited below)
Editor's Note
"Despite gradual improvements in the government's response to the
HIV epidemic and the adoption of a widely-welcomed five-year plan,
five and a half million South Africans are HIV-infected - one of
the highest numbers in any country in the world. Fifty-five percent
of them are women. South African women under 25 are three to four
times more likely to be HIV-infected than men in the same age
group. ... the level of new HIV infections amongst women in South
Africa continues to increase, while overall incidence of the
disease has levelled off." - Amnesty International
In a report released in March, based on interviews in two South
African provinces and extensive consultation with South African
agencies involved with the issue, Amnesty International provides a
detailed portrait of the situation of rural women, and the
interaction among violence, poverty, and the risk of HIV/AIDS. The
report's title, quoting one of the women interviewed, is "I am at
the lowest end of all."
The full 124-page report is available at
http://www.amnesty.org/en/library/info/AFR53/001/2008/en
In this and another issue sent out today, AfricaFocus Bulletin
provides brief excerpts from the report's overview and the section
on violence against women. The overview also provides a useful
concise survey of the development of the AIDS epidemic in South
Africa, including the debates about government policy and the
active role of civil society.
For previous AfricaFocus Bulletins on related issues, see
http://www.africafocus.org/healthexp.php
++++++++++++++++++++++end editor's note+++++++++++++++++++++++
"I am at the lowest end of all"
Rural women living with HIV face human rights abuses in South
Africa
March 2008 AI Index: AFR 53/001/2008
Amnesty International
[Excerpts from preface and introduction only. For full 124-page
report, including footnotes and references, see
http://www.amnesty.org/en/library/info/AFR53/001/2008/en]
Summary Table of Contents
- Introduction
- HIV and AIDS in South Africa
- The female face of the HIV epidemic: the impact of
discrimination, violence and poverty
- Violence against women and HIV
- Sexual violence and its consequences
- Domestic Violence as a long-term threat to women"s health
- Caring for the survivors: overcoming barriers to their right to
health
- Reducing the risk of HIV transmission: The provision of
post-exposure prophylaxis (PEP)
- Gender-based discrimination as a barrier to prevention,
treatment and care for HIV
- Legal Framework
- Now social status and vulnerability to HIV infection and its
consequences
- Denial of women"s sexual and reproductive rights
- Gender-based discrimination & access to treatment for women
living with HIV
- HIV testing and disclosure of results
- Human rights standards
- Abuses and abandonment of HIV-infected women by their partners
- Men"s reluctance to test
- Poverty as a barrier to the realization of rural women"s right
to health
- Consequences of poverty for rural women living with HIV
- Lack of access to adequate food
- Accessibility of health services: distance and transport costs as
barriers
- Availability and accessibility of health services: barriers to
treatment and care
- Increasing the availability and accessibility of accredited
facilities.
- Conclusion
- Recommendations to the Government of South Africa
Recommendations to Second Governments and donor institutions
Preface
In South Africa in late 2006 a new spirit seemed to have taken hold
in public discussions on how to achieve a more concerted,
effective response to the country"s epidemic of HIV infection. The
ensuing collaborative efforts, which drew in health department
officials, civil society organizations and medical specialists,
resulted eventually in agreement on a number of issues: notably
that the challenges posed by persistent poverty as well as violence
and other forms of discrimination against women had to be
addressed as part of an effective overall response to the epidemic
and the realization of the right to health of those affected and
infected by HIV. The consensus on this and other issues was
reflected in a new plan adopted by Cabinet in May 2007 to guide
the work of the next five years.2
This report, which reflects research undertaken by Amnesty
International (AI) in 2006 and 2007, provides an analysis of
patterns of human rights abuses against women who are exposed to
the risk of or are already living with HIV in rural contexts of
widespread poverty and unemployment. It draws on the testimonies
of 37 women who, to varying extents, had experienced incidents of
violence from intimate partners or strangers, were unable to secure
a stable income, faced periods of hunger, but were striving to
maintain their access to health services and adhere to treatment
despite the consequences of poverty, stigma and their low social
status.
The women involved were interviewed by AI in Mpumalanga and KwaZulu
Natal provinces, in collaboration with local service providing
organisations with whom AI has worked for some years. The
interviews were conducted with the assistance of interpreters in
most cases and the support of the organizations" lay-counsellors.
The interviewees" identities have been protected throughout this
report to ensure their right to privacy and to avoid any possible
harmful consequences resulting from their identification.
Identifying place names have also been excluded when referring to
their testimonies.
While there were singular aspects to each of their stories, some
common themes emerged which pointed towards wider, more systemic
factors which affected the women"s ability to realize their right
to health. In the following chapters some of these factors are
examined, including the direct and indirect impact of gender-based
violence, discriminatory attitudes and gender stereotypes, and
economic marginalisation. In attempting to assess their effects, AI
has drawn on information provided to it in meetings and other
communications with nongovernmental and government sector service
providers, human rights and advocacy organizations, policy
development and research institutions, health professionals and
government officials.
The report"s analysis has also benefited from some of the extensive
published research undertaken by South African and international
organizations. Finally, the report"s analysis and conclusions are
underpinned by a framework of human rights standards which reflect
the consensus of the international community. South Africa since
1994 has participated in the further development of these
standards, as well as shown its acceptance of them through its
commitments made under key international human rights treaties.
This report and associated campaign are intended as contributions
towards South African efforts to overcome the legacies of the past
and address current human rights abuses.
Introduction
HIV and AIDS in South Africa
South Africa is continuing to experience a severe HIV epidemic.5
Five and a half million South Africans are HIV-infected, the
highest number of people in any one country in the world.
Fifty-five per cent of them are women.6 UNAIDS estimated that
320,000 people died of AIDS in 2006.7 The epidemic developed
rapidly from the first case recorded in 1982,8 to a national
prevalence rate of at least 16 per cent in 2005.
The epidemic had begun during a period of extreme state violence
and political and racial oppression which included government
imposed states of emergency from 1985 to 1990, and continued to
develop while the country was largely preoccupied with the efforts
to negotiate the end of the apartheid system and National Party
rule and securing the transition to nonracial democracy in 1994.
Initially perceived in South Africa as a disease particularly
affecting gay men and people receiving blood transfusions, it
became apparent that HIV and AIDS was not confined to particular
"at-risk" groups but was becoming a generalised epidemic in
certain communities.9 From 1991 onwards the majority of
transmissions in South Africa were through heterosexual
intercourse. In 1993 the national prevalence rate amongst pregnant
women attending antenatal clinics was 4.0 per cent; in 1996 it was
14.2 per cent; and by 1999 22.4 per cent of pregnant women
attending antenatal clinics were HIV-infected.10 In 2005 data from
a population survey indicated that 16.2 per cent of adults 15 to 49
years were infected, while UNAIDS, using antenatal clinic data,
published an estimate of 18.8 per cent prevalence for adults 15 to
49 years of age.11
This desperate situation was unfolding while the country from 1994
was engaged in remarkable legal and institutional transformations
which began to affect every sphere of life. These changes included
the finalisation and adoption in 1996 of a constitution with a
legally enforceable bill of rights protecting, among others, the
right to equality, to bodily and psychological integrity, to
freedom from violence from either public or private sources, and to
the realization of the right to health without discrimination on
any grounds. Within this framework institutional reforms were
initiated, for instance, to improve access to education and to
employment for "historically disadvantaged groups", to integrate
and reform the health services,12 as well as the policing and
criminal justice systems with the intention to improve service
delivery for all South Africans without discrimination.
Despite the relentless upward trend in HIV infection rates, the
government"s initial responses to the epidemic were slow and
erratic during the Mandela presidency.13 From late 1999 the
government of President Thabo Mbeki took a direction which turned
a public health emergency into a matter of political conflict. For
whatever complex reasons, President Mbeki"s decision publicly to
question the link between the virus and the onset of AIDS, as well
as the efficacy and safety of the then known drug treatments,
precipitated a period of confusion and demoralisation within
government departments and the public health services and disputes
between national and some provincial governments over responses to
the epidemic. Adding to these consequences was a growing bitter
conflict with sectors of civil society, including medical
practitioners, who were pressing for access to antiretroviral
treatment for HIV-infected pregnant women and others with AIDS.
There was a loss of strong unified leadership at a critical
juncture in the life of the epidemic and a further delay in access
to life-saving medicines for those with AIDS who were dependent on
the public sector for health services.14
In late 2001 the Treatment Action Campaign (TAC)15 obtained an
order in the Pretoria High Court requiring the government to
supply antiretroviral medication to pregnant women to prevent
transmission of the virus to their babies. The High Court ruling
was confirmed by the Constitutional Court in July 2002 after the
Department of Health appealed the High Court decision.16 The
Constitutional Court held that "Sections 27(1) and (2) of the
Constitution require the government to devise and implement within
its available resources a comprehensive and co-ordinated programme
to realize progressively the rights of pregnant women and their
newborn children to have access to health services to combat
mother-tochild transmission of HIV".
In November 2003 the Minister of Health, Dr Manto
Tshabalala-Msimang, announced the government"s decision to provide
antiretroviral treatment in the public health sector within the
framework of the National Operational Plan for Comprehensive HIV
and AIDS Management, Treatment, Care and Support (NOP).
Antiretroviral therapy (ART) finally and slowly began to be
provided in public sector hospitals from 2004.17 The "roll-out" of
treatment occurred at a pace below the targets indicated in the
NOP and was dogged by an atmosphere of distrust of government
intentions. Advocacy groups observed that the Cabinet-approved NOP
had "committed the state in 2003 to placing approximately 645,740
people on ARV treatment in the public sector by the end of 2006/7
financial year,"18 but according to Department of Health
information, "approximately 250,000 people had been initiated on
ARV treatment in the public health sector by this time."19 By
mid-2006, 200,000 adults were on treatment while an estimated
511,000 still needed to begin ART.20 The numbers had risen to
303,788 patients on treatment by May 2007, according to the
government"s MDGs Mid-Term report, and to 408, 218 by the
following November.21
The tensions between government and civil society over responses to
the HIV epidemic appeared to reach a nadir at the XVI
International AIDS Conference in Toronto in August 2006. The
promotion by the Minister of Health at the conference of a
diet-based treatment for AIDS led to further national and
international pressure and criticism of the government. 22 The
Deputy President, Phumzile Mlambo-Ngcuka, as Chairperson of the
reconstituted South African National AIDS Council (SANAC), began
to have an increasingly prominent role in the oversight of the
response to the epidemic and the development of the new national
strategic plan.23 As described in the NSP which was adopted by
SANAC in April 2007 and the Cabinet in the following month, the
final version of the plan had been developed through an intensive
and consultative process over a six month period.24 SANAC
symbolised the changes with its membership and co-chairing role
for civil society. 25 The process of developing the new NSP was
described to AI as genuinely participatory by civil society
organizations.26 As summarised by the Joint Civil Society
Monitoring Forum, the new plan proposed to expand the access to
appropriate treatment, care and support to 80 per cent of all HIV
positive individuals by 2011; create a social environment which
encouraged HIV testing, and promote, protect and monitor human
rights involved in these interventions.
Some uncertainties still remained, however, when in August 2007 the
goodwill developed during this process was put at risk by the
dismissal by President Mbeki of the Deputy Minister of Health,
Nozizwe Madlala-Routledge, after she participated in an AIDS
conference in Spain without his formal approval.27 The Deputy
Minister had been an active participant in the development of the
NSP. In a further sign of unresolved issues, public controversy
intensified in late 2007 over the delays in producing new
guidelines and budget for the provision of dual therapy treatment
to pregnant women prior to labour and to their new born babies to
prevent HIV transmission, consistent with revised WHO guidelines
and in compliance with the ruling of the Constitutional Court in
2002. Approval of the new guidelines appeared imminent in
September, but they had still not been produced by the following
February. While the Western Cape Province had implemented since
2004 the dual therapy regime and had reduced infant infection
rates reportedly to less than 10 per cent, other provinces
continued to use single therapy treatment while awaiting national
authorisation. The Southern African HIV Clinicians Society
expressed concern that children were continuing to be infected
unnecessarily. In KwaZulu Natal Province, a hospital doctor, who in
2007 had raised concerns with the Department of Health about the
delays, was charged in February with misconduct for accepting
outside funds to implement dual therapy at his hospital. Although
the departmental charge was later dropped, the incident and
associated public outcry indicated that the new spirit of
collaboration which had helped create the NSP was still fragile.28
The female face of the HIV epidemic: the impact of discrimination,
violence and poverty
"The HIV epidemic and AIDS [in South Africa] is clearly feminized,
pointing to gender vulnerability that demands urgent attention as
part of the broader women empowerment and protection. In view of
the high prevalence and incidence of HIV amongst women, it is
critical that their strong involvement in and benefiting from the
HIV and AIDS response becomes a priority." (NSP)36
Women are particularly affected by HIV and AIDS. As noted by the
Executive Director of UNAIDS in his opening address at the July
2007 International Women"s Summit, "the most significant
development of the AIDS epidemic is its growing feminization. What
entered history 25 years ago as a disease of white gay men is now
increasingly affecting women all over the world."37 Of the 40
million people living with HIV globally in 2007, almost half are
women - reaching 60 per cent in sub-Saharan Africa.38 In South
Africa, women under 25 are three to four times more likely to be
HIV-infected than men in the same age group.39 Significantly, the
level of new HIV infections amongst women in South Africa continues
to increase, while overall incidence of the disease has levelled
off.40 Data presented to the Third South African AIDS Conference
in June 2007 indicated that of the more than 500,000 new
infections in 2005, the highest incidence occurred in young women
aged 15 to 24 years.41 Provincial antenatal clinic prevalence
rates vary considerably, ranging from 15.7 per cent in the Western
Cape to 39.1 per cent in KwaZulu Natal.42
The NSP notes that while the immediate determinants of the spread
of HIV relates to behaviours such as unprotected sexual
intercourse, multiple sexual partnerships, and some biological
factors such as concurrent sexually transmitted infections (STIs),
women"s socioeconomic disempowerment and the impact of
gender-based violence contributed to women"s significantly higher
infection rates. 43 Women are biologically more vulnerable than men
to contracting the virus through unprotected vaginal
intercourse.44 Available evidence globally, as well as evidence
presented in this report, suggests that women are also put a
greater risk of transmission due to the discriminatory impact of
gender roles and stereotypes.
They are frequently unable to insist on condom use to protect
themselves against the risk of HIV transmission by a male partner
where they are economically, socially or culturally dependent on
that partner or his family, or risk being subjected to violence as
a result of suggesting condom use.45 Their exposure to sexual
violence and intimate partner violence increases their risk of HIV
infection over time.46 Women are less likely to have independent
access to economic resources and recent research in South Africa
has shown the direct positive correlation between women"s access
to economic resources and their ability to protect themselves from
HIV infection and against violence.47 In many countries, women also
carry a disproportionate burden as carers once members of a
household fall sick - a particular concern in a country like South
Africa where AIDS affects a large part of the population.
...
As examined in the following chapters of this report, the scale of
incidents of sexual and other forms of violence against women has
remained persistently high in South Africa, continuing to place
women at risk of HIV in the immediate or longer term. Considerable
effort has been put into reforming the legal framework,
medico-legal, police and criminal justice responses to gender-based
violence. Nevertheless, women"s lives continue to be scarred by
violence or the threat of violence in under-policed, unsafe
communities and in their homes. Nearly ten years after the
Domestic Violence Act came into force and after the provision of
training on their obligations by official and civil society
organizations, there is still evidence that some members of the
South African Police Service (SAPS) do not understand their legal
responsibilities or do not feel under sufficient pressure to fulfil
them. For women in abusive relationships, their access to places
of safety also remains very difficult.
Violence against women is a persistent and devastating
manifestation of gender-based discrimination. Other forms of
discrimination in the social and cultural spheres can also act as
barriers to women"s access to prevention, treatment and care for
HIV. There has been extensive transformation since 1994 of the
legal framework to entrench gender equality, protect women"s
sexual and reproductive rights and their right not to be subjected
to violence. However, the rural women whom AI interviewed were
continuing to experience oppression in their relationships with
male partners, within families and the wider community as a result
of their low social status, economic marginalisation, and also in
some cases because of their HIV status. These manifestations of
their inequality as women were associated with a range of
consequences, including abandonment, loss of their homes, failure
to complete their education, inability to secure maintenance for
their children, violations of their sexual and reproductive rights
with an associated increased risk of HIV infection, and barriers to
access to HIV-related health services and treatment adherence.
While there are many good reasons to test, and sound medical
grounds for scaling up testing for HIV as recommended in the NSP,
it is more complex in a context of gender inequality, poverty and
violence. Where women are tested in greater numbers than men and
with limited support, it can leave them vulnerable to stigma,
discrimination, abandonment and violence.49 The women AI
interviewed spoke of their own experiences of powerlessness,
verbal and physical abuse, threats of violence and abandonment in
response to disclosing their HIV status.
Finally, poverty is a powerful factor acting as a barrier to access
to health services, particularly for rural women who are
disproportionately represented among the poor and unemployed.
There has been a gradual improvement in the provision of HIV
testing and counselling and preventative antiretroviral drugs to
rape survivors, along with other initiatives to improve emergency
medical and medico-legal services, but some survivors who lack
economic resources and the support of NGOs still experience
difficulties in adhering to treatment and remain at risk of HIV
infection.
While ART and other essential treatments for people living with
HIV and AIDS are available free of charge, the circumstances of the
women whom AI interviewed in KwaZulu Natal and Mpumalanga provinces
indicate that women living in rural areas who do not have a secure
income face serious challenges and in some cases complete inability
to access treatment and ongoing care because they cannot afford
the transport costs to get to the hospitals. Their ability to
adhere to treatment is also jeopardised because they cannot afford
adequate food with which to take ART twice daily. Although some of
the women did receive temporary disability grants, food supplements
or other social assistance for their children"s welfare, their
economic circumstances remained precarious and affected their
ability to access or continue their treatment. In addition their
access to health services is further compromised by systemic
challenges within the health system, in particular shortages of
staffing and delays in government implementation of aspects of the
HIV and AIDS treatment programme,such as providing sufficient
accessible health care facilities to provide ART.
AfricaFocus Bulletin is an independent electronic publication
providing reposted commentary and analysis on African issues, with
a particular focus on U.S. and international policies. AfricaFocus
Bulletin is edited by William Minter.
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