Fighting for Women: HIV Prevention in Sub-Saharan Africa
Love, hope, and care are expectations among married women and those in relationships. Marriage and childbearing are highly valued in African cultures, and girls are expected to be married by age 16. When that age comes and goes and no suitors are making marriage proposals, she becomes the talk of the village and faces ridicule and name-calling.
In our parents' day, married women were safe in their homes, and their key threat was domestic violence. Childbearing was required to protect their marriages -- if they chose not to have many children, they could lose their husband as he might marry a second wife who was willing to have more children. Women who refused birth control did so not because they wanted more children, but because their husbands demanded it.
The tide of AIDS has changed the African journey for women and now young girls as well. Up until the '90s married women had few fears of contracting HIV -- that was a song for sex workers or single people. They never considered that their husbands were sleeping with people who are vulnerable to HIV. But recently, there has been a call for women to wake up and see that they have no bargaining power to protect themselves from the virus by demanding condoms as singles are able to.
According to the World Health Organization, 50% of all people living with HIV are women. In sub-Saharan Africa, that number rises to 61%. Young women (15-24 years) are three to six times more likely to be infected than men in the same age group. Worldwide, HIV rates are high among sex workers (the great majority of whom are young women), ranging from 6% in Vietnam to 73% in urban parts of Ethiopia. In some Asian countries such as Cambodia and India, women are increasingly infected with HIV within the context of marriage.
Eastern and Southern Africa continue to be the epicenter of the HIV epidemic. Southern Africa in particular experiences the most severe HIV epidemics in the world, with 34% of all people with HIV globally residing in its 10 countries.
Surveys in several countries show that more men than women have multiple partners. But the number of women using condoms with their partners is lower -- only 38% use them regularly. Testing rates are low too. In 2007, only 18% of pregnant women in low- and middle-income countries received HIV tests.
While only 33% of pregnant women living with HIV received meds to prevent transmission to their children, this was a substantial increase compared with only 10% in 2004. Fortunately, access to HIV meds is increasing, from 7% in 2003 to 37% in 2010. In some countries, women have access to treatment in proportion to the expected need. But though women live longer than men in most parts of the world, WHO estimates that AIDS has driven women's life expectancy below that of men in Kenya, Malawi, Zambia, and Zimbabwe.
My country, Malawi, has a population of over 13 million, and nearly a million are living with HIV -- as many as in the U.S. More women (13%) than men (10%) have the virus, and women get infected at a younger age -- 4% of women aged 15-19 have HIV compared with less than 1% of men that age. The number of women with HIV remains higher than men until age 30 and again outpaces that of men after age 40.
In 2011, 9% of Malawi women who had never married were HIV positive, 12% of married women, 19% of those who were divorced, and 41% of widows. While 71% of sex workers are positive, it may be surprising to learn that 56% of all new infections in Malawi occur in people in stable sexual relationships -- people who were previously considered to be at low risk.
About 88% of all new HIV infections in Malawi and other sub- Saharan countries, including Zimbabwe, South Africa, Uganda, and Zambia, are acquired heterosexually. Several factors account for this, but one significant driver is that more people are having sex with multiple partners: in Malawi, 26% among men and 8% among women. The root causes for this are poverty among women and girls and a lack of information on the dangers of this practice.
Surveys in Malawi show that only 47% of men and 30% of women have ever used a condom. Among those aged 15-24, that drops to 13% and 2%. There is limited education on condoms and limited availability, especially in rural areas. This has serious implications for women and girls, since disempowerment, along with the traditional feminine and masculine roles, makes them unable to negotiate safer sex.
The situation in South Africa and other African countries is also very much the same, with young women being at greater risk. In 2005, 17% of women aged 15-24 had HIV, compared with 4% of men. This results from a number of factors: poverty, violence against women, cultural traditions that promote intergenerational sex, a preference for "dry sex" (without using a lube), and a high prevalence of sexually transmitted infections (STIs). In addition, an aggressive government response against HIV began only recently in that country.
Labour migration has played a major role in the spread of HIV in Southern Africa. During the era of apartheid, South Africa was a major recipient of migrant labour from neighboring countries like Zimbabwe, Botswana, and Swaziland, and even from countries farther away, like Zambia and Malawi. Some authors have described "circular migration", where individuals cycle through urban and rural areas in search of jobs. The number of men and women migrating is very different -- over 90% of migrant workers are men, who often have other partners while away from home and then infect their spouses.
This has at least three important implications. First, the men transmit HIV and other STIs to their wives back home during their holidays or upon their return. Second, they also bring infections acquired in their homeland to the migrant labour camps in the host countries and infect women there. Finally, since there are more men than women, female sex workers have multiple partners, and 70% of their clients are married men. Some men have multiple partners to prove they are "real men".
Women and girls are also affected by gender-based violence such as rape and are often unable to negotiate for condom use. Due to male dominance in certain societies, women have little or no access to HIV testing and meds to prevent transmission of HIV during childbirth without the approval of their husbands. Some cultures continue to subject women and girls to forced marriages, in which unprotected sex is usually required. Although sex work is criminalized in Malawi, transactional sex is common and informal. Women and girls acquire their daily needs -- money, food, phone cards, rent, and clothes -- in exchange for sex. When hunger strikes, many men leave their homes without saying anything and women are forced to sell their bodies for food. Some of these girls are orphans who have no one to support them, forcing them to marry at younger ages. Most of them are abused and their rights are violated.
In a study of 200 girls in Zimbabwe, those without a mother were more likely to be sexually active, to have had an STI, to have been pregnant, and to have been infected with HIV. Girls without a father were more likely to have been homeless and to be out of school. Another study reported higher HIV rates among orphaned girls aged 15 to 19 years (17%), as opposed to non-orphan girls (14%). These authors also found that orphans had an earlier age of sexual debut and were likely to have multiple partners. Survival mechanisms are very different between the sexes because boys have opportunities for work while girls often have sex work as their only option.
The high HIV prevalence among girl orphans in sub-Saharan Africa might be explained by sexual exposure or they may have been infected at birth. The latter, however, could not be the case in Zimbabwe, since HIV treatment has not been used long enough to affect the survival of infants and children who acquire HIV at birth. Such a possibility is likely to be increasingly probable as HIV treatment expands in southern Africa and more children infected at birth survive to reach adolescence.
"Property grabbing" is another problem. When a woman's husband dies, his relatives will come and claim ownership of the family property and demand a share of whatever money and household goods are left. This leaves the wife with limited or no resources, forcing her into transactional sex. Another barrier is limited information about HIV and individual rights. Studies have shown that 66% of women in sub-Saharan Africa are educated about HIV, compared with 80% of men. Among young people aged 15-24, however, only 37% of boys and 25% of girls were able to correctly identify ways of preventing sexual transmission of HIV and to reject myths about the disease.
Women are made particularly vulnerable by cultural practices that stigmatize them as the ones who infect their spouses. They are often divorced and driven out of their homes upon testing positive.
I checked the Republic of Malawi Constitution to see how my country's laws address the discrimination many women face. I discovered that it prohibits this kind of discrimination on a number of grounds. Section 19 enshrines the right to human dignity, protecting people from discrimination on the basis of their HIV status. But these provisions are not enforced, so there is an imperative need for advocacy to demand their enforcement. We must also empower women and girls with the knowledge of the mechanisms available to address instances where their rights have been violated.
Section 22 of the Constitution enumerates several rights relating to marriage. It prohibits forced marriages and recognizes the family as the natural and fundamental unit of society. In spite of this, forced marriages are common in Malawi. A major drawback to Section 22 is that even though the minimum age for marriage is 18, it also states that people between 15 and 18 can get married with the consent of their parents. With that provision, girls become vulnerable to early marriage because of the social and economic challenges their parents face. It's estimated that in 2002, 38% of girls aged 15 to 19 were married. Early marriage increases their vulnerability and subjects them to family life at the expense of education and economic independence. Such social and economic dependence on men makes them unable to negotiate safer sex.
The rights of women to equality and protection from abuse are expressly guaranteed in Section 24. But there are gross violations of the rights of women in Malawi when it comes to access to property, right to health care without approval from husbands, marital rape, etc. We must educate them on their rights and responsibilities, and mobilize as a community to change the cultural perceptions of women.
Treatment for HIV-positive mothers as well as their children is essential, since motherless children are far less likely to survive. In high-income countries, widespread testing and treatment has cut mother-to-child transmission rates to about 2%. But in low- and middle-income countries, only 45% of the 1.4 million pregnant women with HIV received HIV treatment in 2008.
Efforts from global partners like the Global Fund, PEPFAR, WHO, and African countries with high HIV rates should prioritize interventions that empower women to make informed choices and that address the key drivers of their vulnerability.
Abstinence entails either delaying the initiation of sex or practicing secondary abstinence (a prolonged period without sex for people who have previously been sexually active). But evidence for the success of this approach is sparse despite widespread abstinence messages, particularly through schools and faith-based efforts. In areas with a high number of people with HIV, postponement of sex simply delays infection. But abstinence does enable young women to complete school and increase their economic opportunities; increases the chance of informed decision-making about when, with whom, and how to have sex; and can empower them to communicate their desire to prevent HIV and unwanted pregnancies.
Monogamy: To reduce HIV risk among women, we also need more efforts targeted at men, who must take greater responsibility for their actions. The risk of relationships that involve frequent partner change needs to be addressed. This requires engaging men as much as possible, as research has shown that more men are in polygamous relationships and a larger percentage of men have multiple sexual partnerships than women.
Condoms: Among women, condoms are generally viewed as less acceptable in longterm partnerships based on love and trust, but more acceptable in casual relationships. Negative attitudes toward condoms are often grounded in traditional sex roles, unavailability of condoms, and a lack of self-esteem leading to difficulties in negotiating condom use. Furthermore, peer pressure and stigma inhibits their use. Limited access to female condoms and their higher costs have limited the use of this woman-initiated method. The need for coaching and mentoring, peer talks, and interpersonal communication on condoms is worth investing resources on.
Livelihoods: HIV interventions alone without addressing women's economic situations will take much longer to achieve change. HIV is highly linked to poverty and food insecurity among women and girls in Africa, so approaches like village savings and loans, help with income-generating activities, distribution of food during the dry season, introduction of modern farming techniques, livestock production, farmer cooperatives, and training from agricultural services staff, must be used hand-in-hand with HIV prevention efforts.
Gender Inequalities: Cultural beliefs, traditions, and religious practices negatively affect women and girls more than men. We must be more proactive in confronting these practices as they also increase gender-based violence, property grabbing, and the spread of HIV and STIs. All services targeting women should involve men as well, including HIV testing, family planning, and prevention of HIV during childbirth. It is imperative for African nations to increase a more open dialogue between men and women if we are to change the practices that socialization has placed on them. Community talk shows, social forums, and direct campaigns should be promoted to deal with the negative role of governments. Programs must go beyond seeing women as passive recipients and engage them as active participants in decisions that affect them. Funders, including PEPFAR and the Global Fund, should support interventions that aim for high levels of empowerment, ownership, and meaningful participation by putting beneficiaries in charge of development.
Reducing the impact of HIV requires that the needs of women be addressed globally, nationally, and locally. Reversing the factors contributing to their HIV risk -- inequality, poverty, lack of economic and educational opportunity, lack of legal and human rights protections, traditional gender roles -- is critical for success. HIV prevention targeting women and girls is a priority that the developed world should focus on. We are achieving a lot and saving lives, but greater resources could bring the epidemic to an end in our lifetime.
The Foundation for Community and Capacity Development (FOCCAD) is a Malawi not-for-profit organization founded in 2002 to create local solutions to social, human, and health issues. We provide basic services, capacity building, and mentoring. We also provide an opportunity for networking, information sharing, and advocating for a better AIDS response in Malawi.
FOCCAD promotes HIV prevention among girls through peer education, condom distribution, radio campaigns, sports, talent shows, and radio and text messages. Another project provides vocational training to women and girls in tailoring, welding, carpentry, and other trades.
FOCCAD provides transportation money for pregnant and breastfeeding women to go to health facilities, does door-to-door HIV testing, produces anti-stigma campaigns and theatre outreaches, runs HIV support groups, conducts peer education, and does outreach at football games to attract men.
FOCCAD supports women farmers to enhance their leadership role in agriculture and help them run small businesses by providing training in business skills, irrigation support, and mentoring.
Dan Eddie Nthara (2013 Community Solutions Program Fellow) is the Executive Director of FOCCAD.