Ten years ago, when Prudence Mabele discovered she had HIV, she was told to abandon her studies. She was working towards her degree in analytical chemistry at a time when HIV was neither understood nor tolerated in South Africa. "There were a lot of problems then", she said. "They didn't understand a lot about AIDS, so they told me to leave what I was doing because I was going to infect staff and students. They thought if I was at the laboratory I would infect people."

In a decade when there was a dearth of knowledge about HIV transmission, there proved an abundance of opportunity for proactive leadership. Prudence joined 59 other HIV-positive women to form the Positive Women's Network (PWN); today it has 2,000 members throughout South Africa. In such a forum, women began to speak about issues that directly affected them, such as how to discuss their HIV status with a spouse or how to cope with stigma. They also taught each other skills like weaving that could help them generate income. In other words, South African women, finding their families and communities unwilling or unable to support them, learned to support themselves and each other.

In South Africa, AIDS has disproportionately infected and affected women, who comprise the majority of participants in community organizations and care activities for the sick, and the majority of people infected with HIV/AIDS in the country. In May 2006, the Joint United Nations Programme on HIV/AIDS (UNAIDS) released the 2006 Report on the global AIDS epidemic, which states that women account for the bulk of the epidemic: 58 per cent of HIV-positive South Africans are women, or 3.1 million out of 5.5 million infected among adults aged 15 and over. A study conducted by the South African Department of Health in 2004 found that almost one in three pregnant mothers who received antenatal testing was HIV-positive. UNAIDS identified South Africa as the country with the highest number of women infected with HIV/AIDS in the world, almost double the number in India and over triple that in neighbouring Zimbabwe.

Prudence Mabele (right), leader of the Positive Women's Network, delivering HIV pins to Pfizer in Johannesburg, South Africa. Photo/Positive Woman's Network

HIV infection among women worldwide has risen. While the infection rate among both men and women in sub-Saharan Africa in 1985 was roughly equal, UNAIDS estimates that today women comprise 59 per cent of adults living with HIV,1 while among youth the gender imbalance is even more striking. Young women between the ages of 18 and 24 are three times more likely to be infected than men in the same age group. The changing demographic, or feminization, of AIDS is what made UN Secretary-General Kofi Annan declare recently that AIDS has "a woman's face", and UN Special Envoy for HIV/AIDS in Africa Stephen Lewis describe the loss of young women in sub-Saharan Africa as "a pandemic within a pandemic".

While many women have taken action to help counsel each other and prevent the further spread of AIDS, they find themselves combating both biological factors and entrenched social norms. During sexual intercourse, the statistical probability of infection for women is higher than men, since men carry a higher viral load or concentration of HIV in semen than is produced by the female's vaginal fluid.2 However, biology cannot explain entirely the gender nature of the epidemic, as the proportion of women infected with AIDS differs vastly between countries and cultures.

In countries where gender inequality is large, women are at particular risk for contracting the disease. One great failure of prevention efforts is that an option does not exist for women to independently prevent sexual transmission of the virus. The male condom is often not a realistic option for women who live in countries where families and communities are patriarchal, as in South Africa. It is also an especially contentious issue, particularly for married couples, as women have limited leverage and bargaining power; des-pite its obvious limitations, there is no other alternative prevention for them. Microbicides, a clear gel that a woman can use before intercourse, are still undergoing testing and have not been disseminated. And female condoms are not available in clinics.

HIV transmission is also linked to education and economic status. South Africa differs from many countries in the region because girls' enrolment rate in schools outnumbers that of boys in primary and secondary, as well as in higher education. But despite these statistics, girls face an unequal environment in school. There have been repeated reports from provinces in the country about girls being forced to have sex with teachers for being late to class or in exchange for food at lunchtime. This environment not only increases the rate of HIV/AIDS among youths but also decreases the girls' feeling of empowerment and agency.

Poverty also increases the rate of HIV incidence. In South Africa, women make only 70 per cent of what men earn, which already puts them at a disadvantage for attaining self-sufficiency. Poverty rates are much higher among women, with 60 per cent of female-headed versus 31 per cent of male-headed households, falling below the poverty line. Women's vulnerability often forces them into sexual relationships that they otherwise would not engage in and gives men more leverage for taking on multiple wives. In addition, the HIV/AIDS situation in South Africa has been exacerbated by men's migration to cities for mining and other job opportunities. Men's separation from their wives and their proximity to other women who know nothing about their lifestyle put women at risk for contracting the virus.

While universal drug access has increasingly spread to the poorest areas and patients, the proliferation of clinics has not managed to erode one of the most destructive characteristics of AIDS: stigma. Women who have received antiretroviral treatment have been known to crush and hide the medicine under the bed so that no packaging or pills could be traced to them. A study conducted in 2002 demonstrated that upon disclosing one's status, one in ten people was met with outward antagonism. "There was this woman who, when she tested positive and told her husband, her husband poured boiling water on her face, even on the child", said Elizabeth Gordon of the United Nations Development Programme (UNDP) in South Africa.

Women in Africa attending an HIV-and-AIDS awareness session UNAIDS/AVECC/H. Vincent

Stigma due to AIDS is a reality in many African countries, but it is made particularly virulent in South Africa because of the country's conflicted history with the illness. Whereas certain countries in the region, such as the United Republic of Tanzania, snapped into action when they were hit with the epidemic, the South African Government still seems wary to acknowledge the devastation caused by the disease. President Thabo Mbeki had promoted the notion that HIV did not necessarily cause AIDS. "Does HIV cause AIDS? How? Indeed, HIV contributes, but other things contribute as well", he told the Parliament in 2000, pointing to poverty and malnutrition as the core reasons for the sickness. The Minister of Health followed the President's lead, voicing public support for the use of vitamin supplements over antiretroviral treatment.

The recent rape trial of former Deputy President Jacob Zuma in early 2006 was a low-point for HIV prevention and women's rights. While testifying in support of his innocence in court, he admitted to having unprotected sex with a woman he knew was HIV-positive, but maintained that he took a shower afterwards which, he claimed, eliminated the chance of transmission. Mr. Zuma's subsequent acquittal underscores the gender inequality in the country, where a woman is estimated to be raped every 17 seconds. Violence against women is one of the leading reasons why the HIV rate among this vulnerable group has skyrocketed in South Africa.

Arguably, a heavy burden of the disease also falls on women who are not necessarily infected. Because of traditional gender roles, women account for the majority of caregivers for the sick-the consuming nature of this work is unfathomable. As AIDS progresses, family members will usually become bedridden, requiring constant supervision and care for their most basic needs. Once the infected individual dies, children are left behind-a phenomenon that has become a pandemic of its own. In South Africa alone, there are 1.1 million AIDS orphans and by 2010 the number is estimated to increase to approximately 3 million. Again the burden falls on women, as over 60 per cent of these orphans end up being cared for by their grandmothers.3 There have been efforts to equip grandmothers with the capacity to support orphans they have taken in; for example, the "Gogo Grannies" programme in the Alexandra township, outside Johannesburg, gives grandmothers a plot of land and seeds to grow and sell food.

Many organizations in South Africa have acknowledged the particular vulnerability of women to HIV/AIDS and have worked to incorporate women's interests and live-lihoods into their programmes. The United Nations has been particularly active in gender mainstreaming in South Africa in its HIV/AIDS programmes. Nonetheless, gender-specific projects should not always trump those that are gender-blind. Love Life, one of the country's most active campaigns in promoting positive sex messages to youths, does not target only the most vulnerable populations through its projects. "Our target group is equally young men and young women", said its Deputy Chief Executive Officer, Grace Matlhape. "Even as you focus on issues that render women vulnerable [to HIV], you will have limited returns if men are not brought into the fold."

Notes

1. www.unifem.org/gender_issues/hiv_aids/ and
   www.unaids.org/en/HIV_data/2006/GlobalReport/
   
   
2. www.genderlinks.org.za/
   
   
3. Steinberg M., Johnson S. et al. (2002), "Hitting home: how households cope with the HIV/AIDS epidemic" Henry J. Kaiser Foundation and Health Systems Trust, available at www.avert.org/aidssouthafrica.htm