New Report on HIV/AIDS in Africa First to Link Discriminatory Beliefs against Women with Vulnerability to AIDS

For Immediate Release

A landmark study released today by Physicians for Human Rights (PHR) connects widespread discriminatory views against women in Botswana and Swaziland to sexual risk-taking and, in turn, to extremely high HIV prevalence. Seventy-five percent of HIV-positive 15-25 year-olds in sub-Saharan Africa are female.
 
PHR's study, Epidemic of Inequality: Women's Rights and HIV/AIDS in Botswana & Swaziland: An Evidence-based Report on Gender Inequity, Stigma and Discrimination reports the results of a population-based study conducted in 2004 and 2005 with 1,268 respondents in Botswana and 788 participants in Swaziland, designed to assess factors contributing to HIV infection. In
addition, 24 people living with HIV/AIDS in Botswana and 58 people living with HIV/AIDS in Swaziland were interviewed, along with key informants in both countries. The full report can be accessed here. 

Four key factors were found to contribute to women's vulnerability to HIV: women's lack of control over sexual decision-making, including the decision to use a condom, and multiple sexual partners by both women and men; the prevalence of HIV-related stigma and discrimination (which hinders testing and disclosure of status); gender-discriminatory beliefs, which were associated with sexual risk-taking; and a failure of traditional and government leadership to promote the equality, autonomy, and economic independence of women.
 
"If we are to reduce the continuing, extraordinary HIV prevalence in Botswana and Swaziland, particularly among women, the countries' leaders need to enforce women's legal rights, and offer them sufficient food and economic opportunities to gain agency in their own lives. Men and women must be educated and supported to acknowledge women's equal status with men and abandon these prejudices and risky sexual practices. The impact of women's lack of power should not be underestimated," said PHR's Senior Research Associate Karen Leiter, JD, MPH, lead investigator of the study.
 
While anecdotal evidence has strongly suggested a link between gender inequity and HIV infection, PHR has conducted the first rigorous, large-scale field survey of gender discriminatory beliefs and analyzed their association with sexual behavior. The report suggests that women's rights must be made the top priority by the countries' leaders if HIV prevalence is to be reduced.

In Botswana, for example, 95% of women and 90% of men surveyed held at least one gender discriminatory belief. Botswana community survey participants who held three or more such beliefs had 2.7 the odds of those who held fewer beliefs to report having had unprotected sex in the prior year with a non-primary partner. Discriminatory beliefs  accept and reflect upon women's inferior legal cultural and socioeconomic status.
 
For example, 19% of all community survey respondents in Botswana agreed with the statement that it is more important that a woman respect her spouse or partner than it is for a man to respect his spouse or partner.
 
Interviews indicated that many HIV-positive women are forced to engage in risky sex with men in exchange for food for themselves and their children. As one interviewee put it, "Woman are having sex because they are hungry. If you give them food, they would not need to have sex to eat."
 
According to PHR research, the very fear of being subject to HIV-related stigma  (as opposed to the actual experience of it)—being abandoned by friends or shunned at work, for instance—was pervasive. For instance, in Botswana, 30% of women and men believed that testing positive and disclosure would lead to the break up of their marriage or relationship.
 
Interviews conducted by PHR and its partners indicate that women in Botswana and Swaziland frequently do not have the option to make decisions about having sex due to their lesser legal status.    
 
"Here in Swaziland, the husband is the one that bosses you around so there is nothing you can do without him. My rights lie with my husband. He decides whether we use condoms. I don't have a choice about prevention."—an HIV-positive interviewee 
 
In interviews, people living with AIDS highlighted women's dependency on male partners as the most significant contribution to women's greater vulnerability to HIV when compared to men. Testimony also revealed that women's lesser status in Botswana fosters ongoing harm to women even after they become infected, and increases the precariousness of their ability to meet basic needs for food, shelter and transport.
 
Participants in Swaziland repeatedly pointed to a lack of political leadership—from government officials and traditional leaders—in protecting and empowering vulnerable women and girls.
 
"HIV/AIDS interventions focused solely on individual behavior will not address the factors creating vulnerability to HIV for women and men in Botswana and Swaziland, nor protect the rights and assure the wellbeing of those living with AIDS. National leaders, with the assistance of foreign donors and others, are obligated under international law to change the inequitable social, legal, and economic conditions of women's lives which facilitate HIV transmission and impede testing, care and treatment," said Leiter. 
 
PHR's study also examined the following:

• Obligations of Botswana and Swaziland to fulfill international human rights legal standards, including the right to health and the right of women to live and have a healthy life
• Prevalence of accurate beliefs regarding the prevention and transmission of HIV
• Prevalence of HIV testing in the community survey sample and experiences with barriers and facilitators to testing
• Prevalence of stigmatizing or discriminatory beliefs regarding PLWA
• Projected experiences/responses should the participant or their partner test positive for HIV
• Prevalence of sexual risk-taking: multiple sexual partnerships (serial or concurrent), unprotected sex with a non-primary partner, lack of control over sexual-decision making, condom non-use, opinions/practice of abstinence
• Prevalence of beliefs in women's rights (and association with sexual risk-taking)
• Perceptions of why women and men are (differentially) vulnerable to HIV/AIDS

A background chapter on HIV/AIDS in Southern Africa, including discussion of the dimensions of the epidemic and its consequences, drivers of the epidemic including stigma and discrimination and gender inequality, and national and international responses is available.  
 
The study was designed and implemented by PHR and two local field partners: Members of the Faculty of Nursing at the University of Botswana in Gaborone, Botswana, and Women and Law in Southern Africa Research Trust (WLSA) in Mbabane, Swaziland.
 
Physicians for Human Rights Recommends the following: 
 
To the Government of Botswana:

I. Comprehensively Advance Women's Human Rights and Address Violations

• Systematically end gender discrimination in marriage, inheritance, property and employment laws and harmonize laws with international human rights instruments.
• Strengthen and enact pending Domestic Violence Bill to end impunity for gender-based violence and ensure women have recourse and protection from violence in all its forms.
• Reform and strengthen the Women's Affairs Department by partnering with civil society organizations in the process of drafting the gender policy and the report to Committee on the Elimination of Discrimination against Women (CEDAW); support documentation of discrimination to inform policymaking and implementation of reforms.

II. Mitigate Poverty and Meet Basic Needs

• Expand existing aid programs to assist vulnerable populations, in particular PLWA and poor women, to meet basic needs for food sufficiency, potable water and irrigation, and shelter.
• Provide skills training and sustainable programs, directed at creating economic opportunities particularly for women, PLWA and families affected by HIV/AIDS.

III. Eradicate HIV/AIDS-Related Stigma and Discrimination and Assure PLWA Rights

• Adopt comprehensive legislation and policy addressing HIV/AIDS and employment, and strengthen enforcement of prohibitions against discrimination.
• Adapt a systematic and coordinated approach to public education, addressing key knowledge gaps in prevention, support and rights, including messages that address risk, vulnerability and fear of stigma directly and integrate gender concerns.
• Support those seeking testing with resources to overcome barriers such as lack of food or transport and with protection from discrimination and partner violence through guidelines and training of personnel.

To the US Government:

• Mandate that the Government ensure that the "3 Cs" (confidentiality, counseling and informed consent) are implemented and monitored in all HIV testing programs; provide technical assistance as necessary.
• In PEPFAR reauthorization legislation, clearly identify gender inequality as a key issue propelling the AIDS pandemic, and require that a gender focus be incorporated into PEPFAR-funded prevention, treatment and care programs. Increase PEPFAR's investment in programs that promote women's and girls' access to income and resources, support primary and secondary education for girls and strengthen women's legal rights.

To All Donors:

• Mobilize resources, including financial, informational and technical assistance to build skills and capacity in the Ministries, Attorney General's Office and Parliament to draft and implement gender reforms.
• Provide training, technical assistance and financial resources to women's organizations and other civil society actors to undertake advocacy, civic education and mobilization, and popular campaigns relating to women's rights.
• Support PLWA organizations and networks to increase their visibility and services by funding the expansion and coordination of national networks, training officers for NGOs and support capacity building for community mobilization efforts.

Recommendations To the Government of Swaziland:
 
I. Comprehensively Advance Women's Human Rights and Address Violations

• Systematically end discrimination in marriage, inheritance, property and employment laws, and harmonize laws with international human rights instruments, to ensure that women and men enjoy equal status under civil law and to enable women to have equal access to economic resources, such as credit, land ownership and inherited property.
• Enact domestic and sexual violence legislation to end impunity for gender-based violence and ensure women recourse and protection from violence in all its forms, including marital rape.
• Build capacity in the Attorney General's Office and the Gender Desk at the Ministry of Home Affairs.

II. Mitigate Poverty and Meet Basic Needs

• Mobilize donors, local organizations and farmers to assist vulnerable populations, in particular PLWA and poor women, to meet basic needs for food sufficiency, potable water and irrigation, and shelter.
• Undertake efforts to strengthen rural livelihoods, including providing land for communities and PLWA for both subsistence and commercial farming to improve nutrition and raise resources.
• Provide skills training and sustainable programs directed at creating economic opportunities particularly for women, PLWA and families affected by HIV/AIDS.

III. Eradicate HIV/AIDS-Related Stigma and Discrimination and Assure PLWA Rights

• Create a coordinated media campaign, including television and radio messages on prevention and testing, including messages that address risk, vulnerability and stigma directly and integrate gender concerns.
• Work with PLWA groups and other civil society organizations to create or adapt and widely disseminate information on prevention, testing and treatment.

To the US Government:

• Increase and sustain funding, including through USAID, for HIV/AIDS prevention, testing and treatment in Swaziland and assure that funded programs, including public education campaigns, promote women's rights and empowerment.
• In the short-term, increase funding to the World Food Programme; in the longer term, adopt policies and legislation that promote the local population's capacity for self-sufficiency in food production.

To All Donors:

• Mobilize resources, including financial, informational and technical assistance to build skills and capacity in the Ministries, Attorney General's Office and Parliament to draft and implement gender reforms.
• Provide training, technical assistance and financial resources to women's organizations, the PLWA network and organizations and other civil society actors to foster collaborations and undertake political advocacy, civic education and community mobilization.
• Increase food aid and aid for other basic needs, particularly to poor women and PLWA, including supporting food and farming initiatives and economic empowerment programs to foster local capacity.
• Assist the government to scale-up and monitor current HIV testing and ARV treatment programs.

Physicians for Human Rights (PHR) is a New York-based advocacy organization that uses science and medicine to prevent mass atrocities and severe human rights violations. Learn more here.