Schoolgirl Nomasonto Masango giggles as she lists all the things she and her friends want boyfriends to buy them. “If you have an older boyfriend, he can buy you things and it is nice to show your friends that you have things,” says Nomasonto. The most prized items are cell phones, jewelry and fashionable clothes. But they can also be as humble as school stationery, food and cold drinks.
Nomasonto appears oblivious to the danger she faces from older men with cash. She is six times more likely to become infected with HIV from a man over the age of 24 than from a boy her own age, according to research conducted in Vulindlela, her semi-rural village in South Africa.
In Southern Africa, the HIV statistics for young women are shockingly high. In Nomasonto’s village, for example, over half the young women aged between 20 and 24 are already living with HIV, while less than a third of men the same age have HIV.
Worldwide, a quarter of all new HIV infections are of women aged between 15 and 24. The vast majority of these young women live in sub-Saharan Africa, where six out of every 10 people living with HIV are women. AIDS is still the biggest killer of women of child-bearing age in Africa.
Southern African countries carry a very high burden of HIV (in Swaziland, a quarter of adults have the virus), while the risk moderates in East and Central Africa and is relatively small in West Africa.
The odds are stacked against women in the fight against HIV, with biology as well as social, cultural and economic factors conspiring to make women much more vulnerable to the virus than are men.
Physiologically, women are up to four times more vulnerable to HIV infection than men. There are several reasons. Infected semen remains in the cervix for some time, there is a large surface area in the vagina and cervix exposed to the virus, and the vagina is more susceptible to small tears during sex. Young women’s cervixes are even more vulnerable, particularly when they first start having sex.
But perhaps the most compelling risk factor is women’s lack of power to ensure they have safe sex. There is a large body of evidence pointing to the fact that many women are simply unable to abstain from sex, guarantee that their partners will be faithful or insist on the use of condoms — the famous “ABC” mantra of AIDS educators.
The Global Campaign for Microbicides (GCM), a civil society group headquartered in the US and active in several African countries, bluntly describes the HIV prevention messages “encouraging abstinence, mutual monogamy and male condom use” as having “little relevance for the majority of women at risk; even less for those in resource poor settings.”
“In spite of our best efforts, there are still millions of women who are simply unable to implement any of the current prevention strategies,” says the GCM. “As a result, infections among women and young girls are rising.” The group advocates the development of a vaginal gel (microbicide), which women could control, to prevent HIV infection.
In many African countries, particularly where people have been displaced by war, women are extremely vulnerable to sexual violence and “transactional sex,” or exchanging sex for goods. Even in countries where there is no war, such as South Africa, the common notion that masculinity means sexual dominance has led to high levels of coercive sex. In one survey, 40 per cent of young South African women reported being sexually abused before they reached the age of 19.
‘It was meaningless’
But many African women get infected within stable relationships and marriages. A study in Kenya and Zambia found that young, married women under the age of 20 had a higher HIV rate than did unmarried women — mostly because they had married older men.
But this problem does not only affect young women. For many African women, their only risk factor for HIV was that they were married.
Ugandan AIDS activist Beatrice Were was a virgin when she married, but she discovered shortly after her husband died that she had been infected with HIV by him. “I had abstained and remained faithful, but ultimately it was meaningless,” she explains. “And so I was left at 22, widowed with two baby daughters, and enveloped by a cloud of bitterness that took years to disperse.”
Ms. Were became one of the first women in Uganda to publicly declare her HIV status. She started the National Community of Women Living with AIDS (NACWOLA) in 1993, one of the first organizations on the African continent aimed specifically at supporting women with HIV and lobbying for their rights.
Ms. Were’s NACWOLA was one of the most successful lobby groups for HIV positive women, campaigning for mother-to-child treatment and access to anti-retroviral medications (ARVs) as well as giving support and comfort to some 40,000 women.
South Africa’s Treatment Action Campaign (TAC) is arguably one of the world’s most successful HIV activist organizations. Although not exclusively for women, the TAC has led a number of campaigns aimed at improving women’s access to treatment. In 2001, the TAC successfully used the courts to force the South African government to roll out a national campaign for the prevention of mother-to-child HIV infection. It has also campaigned tirelessly for access to anti-retroviral medicines, including cheaper generic ARVs.
More recently, the TAC has turned its attention to lobbying the public health system in South Africa to start vaccinating women against the human papilloma virus (HPV), which causes cervical cancer. HIV positive women are far more susceptible to being infected with HPV.
There are dozens of AIDS activist organizations in Africa, most led by people living with HIV. But many are facing severe budget restraints as donor funding dries up.
Rwanda’s first lady, Jeanette Kagame, has ensured that the Organization of African First Ladies is active in lobbying and fundraising for HIV programmes, including for women living with HIV.
Not just knowledge, but power
It has taken some time for policy-makers to realize that women need not only knowledge about how to protect themselves from HIV. In many cases, they also need the power to insist that men use condoms.
At a High Level Meeting of the UN General Assembly on AIDS in June 2011, member states pledged to:
- eliminate gender inequalities and gender-based abuse and violence,
- increase the capacity of women and adolescent girls to protect themselves from the risk of HIV infection through the provision of health care and services,
- ensure that women can exercise their right to have control over, and decide freely and responsibly on, matters related to their sexuality in order to increase their ability to protect themselves from HIV infection, free of coercion, discrimination and violence, and
- take all necessary measures to create an enabling environment for the empowerment of women and strengthen their economic independence.
Lack of funds
However, at the very moment when attention is finally being paid to the role of gender inequality as a major trigger in the spread of HIV, the fight against the virus is being increasingly threatened by a lack of funds. Donor funding in Africa peaked in 2008, but donations are now declining as the global economic recession takes its toll.
The US President’s Emergency Plan for AIDS Relief (Pepfar) has been reducing funding allocations since 2008. It is trying to transfer responsibility for treatment to governments in the countries where it donates funds. As a result, Uganda reported that since last year it has had to ration ARVs for new patients because of a lack of funds. Many other countries are slowing down on treatment, prevention and care, while shortages of ARVs are becoming common in many clinics and hospitals on the continent.
The Global Fund to Fight AIDS, Tuberculosis and Malaria announced after its September 2011 board meeting that it is facing “resource constraints,” and is “revising down” the grant money it has to disperse to countries in need. Some of its grant money may only be available in late 2013.
As it stands, only four out of ten Africans who need anti-retroviral medication are able to get it. Only half of African HIV-positive mothers receive ARV treatment to prevent their babies from getting the virus during pregnancy and birth.
Rather than seeing funding reduced, the global effort to combat HIV/AIDS “needs increased support,” argues Dr. Peter Mugyenyi, director of the Joint Clinical Research Centre in Kampala, the largest ARV treatment facility in Uganda. UN Women, the world body’s agency on gender issues, agrees, emphasizing that “more resources are needed, and strategies and programmes must be targeted to women in particular.”
For women in Africa, it is literally a matter of life or death.