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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 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

++++++++++++++++++++++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]

Summary Table of Contents

  1. Introduction
    • HIV and AIDS in South Africa
    • The female face of the HIV epidemic: the impact of discrimination, violence and poverty
  2. 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)
  3. 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
  4. HIV testing and disclosure of results
    • Human rights standards
    • Abuses and abandonment of HIV-infected women by their partners
    • Men"s reluctance to test
  5. 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.
  6. Conclusion
  7. Recommendations to the Government of South Africa

Recommendations to Second Governments and donor institutions


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.


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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