Wednesday, April 30, 2008

South Africa: Women, Aids, and Violence.

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.

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

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.

HIV and AIDS in South Africa

South Africa is continuing to experience a severe HIV epidemic. 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. UNAIDS estimated that 320,000 people died of AIDS in 2006. The epidemic developed rapidly from the first case recorded in 1982,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. 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. 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.

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 integrateand reform the health services, 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. 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.

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. The Constitutional Court held that "Sections 27(1) and (2) of theConstitution 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-to child 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. 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," 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."Bymid-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.

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. 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. 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. SANAC symbolised the changes with its membership and co-chairing role for civil society. The process of developing the new NSP was described to AI as genuinely participatory by civil society
organizations. As summarised by the Joint Civil Society Monitoring Forum, the new plan proposed to expand the access toappropriate 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. 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.

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. 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. 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.

William Minter for


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