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 Letter from the editor
Mohammed Ali himself once said: “There are more pleasant things to do than beat up people…” Why then do we have a society that beats up women and children? As we prepare for “The 16 Days of Activism: No Violence Against Women” that runs from the 25th of November until the 10th of December and World AIDS Day 2009, we take a look at how women are affected by HIV and AIDS in Sub-Saharan Africa.
In an excellent article by Courtenay Sprague, an Associate Professor at the Graduate School of Business Administration at WITS, we take a look at how HIV has disproportionately affected women in Sub-Saharan Africa. Professor Sprague describes the vulnerability of women to HIV as a result of biological factors, gender inequality and violence. It is therefore no surprise that Stats SA reported that females have experienced a 240% increase in deaths from 1997 to 2004 (the same figure for males were 180%).
Addressing the impact of HIV on women and children in South Africa does not merely centre on support for the victims, but also support for those who have the power to change the imbalance in our society: our boys and men. It is therefore encouraging to see a new wave of leadership emerge in the struggle against HIV and AIDS such as the recently launched “Brother for Life” campaign. The importance of focusing on men is centred on the many prevailing norms including: “Men as decision makers influencing behaviour such as multiple concurrent partnerships, condom use and testing.” The campaign identity is based on the aim of creating a movement of good men that will ignite and spread throughout South Africa. The campaign will use the spirit of Brotherhood that exists strongly among men and encourage men to positively influence each other. The campaign seeks to encourage all South African men to open dialogue, debate and negotiate issues critical to preventing new HIV infections.
This example of an integrated pro-active response to the impact of HIV and AIDS will not only unite the brotherhood and sisterhood in South Africa in their fight against the disease, but create a future for our children where they can say: “My mother and father were equal partners in empowering me to be successful, healthy and happy.”
In this spring edition of AAAO we also provide you with a glimpse into a SA of 2025. Under the “Spring of Hope” scenario the world is full of hope and optimism as everything comes back to life after the cold and hardship of winter. In a SA characterized by low economic growth but some movement towards social cooperation and collaboration, a “Spring of Hope” scenario is a very realistic scenario for a future SA.
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Spotlight on sub-Saharan Africa: A look at the impact of the epidemic on the
women of sub-Saharan Africa.
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By Professor Courtney Sprague
In 2006, UNAIDS estimated that 17.3 million women were living with
HIV. Three quarters of those women (13.2 million) were living in
sub-Saharan Africa (SSA). Today roughly 60% of all adults with HIV
in sub-Saharan Africa are women (UNAIDS 2006). These figures must be
set against some larger trends. The evidence base of health and
development research demonstrates that there have been remarkable
health achievements in the last 50 years. The ‘global health
revolution’ has resulted in an additional four months of life
expectancy added each calendar year over the last three decades for
some countries – with significant reductions in |
maternal mortality. More than 10 years have been added to
women’s life expectancy in some countries as a result. But
African women are not enjoying these health achievements.
Instead, health outcomes in the continent reveal patterns of
premature illness and death, largely attributed to HIV/AIDS
(Jamison et al 2006; Doyal 2006; 2001; Médecins sans
Frontières 2001; Chen and Berlinguer 2001).
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Sub-Saharan African women of reproductive age are disproportionately
affected by HIV, with women in younger age groups four times more
likely to be HIV-infected than men. Women’s greater vulnerability
to, and risk of, HIV acquisition is both biological and social.
Biologically, women are more susceptible to contracting sexually
transmitted infections (STIs) than men, including HIV, due to the
greater area of mucous membrane exposed during sex (particularly
young women whose genital tracts are not fully developed), the
larger quantity of fluids that are transferred from men to women
during sex, and the higher viral content in male sexual fluids.
Micro-tears can also easily occur in women’s vaginal tissue as a
result of sex. And, many SSA countries are believed to have a large
number of untreated STIs. Individuals with untreated STIs are over
six times more likely than other individuals to pass on or acquire
HIV during sex: a genital sore caused by an STI increases the risk
of becoming infected with HIV from a single exposure by 10 to 300
times (UNAIDS
2004a-b).
Through increasing mortality, morbidity and related impacts, the
global HIV pandemic is illustrating the myriad ways in which gender
inequalities impact negatively on African women’s health. Women’s
unequal status and position in society is often at the centre of
such health inequalities (Dunkle
et al 2004). Sexual risk behaviour is associated with an
inability to negotiate condom use, peer pressure to have sex, and
‘coercive’ male dominated relationships (Matthews
2005; Jewkes
2002; Klugman 2000). Studies have demonstrated that social context and
position, as well as cultural factors and norms, have been
significant in increasing HIV transmission among African women (Government of South Africa 2007;
Jewkes, Penn-Kekana and Rose-Junius 2005).
The position of women in sub-Saharan Africa means that they are often born into inequity; an
inequity characterised by low socio-economic status, which
predisposes women to poverty, to malnutrition and to lack of control
over their own fertility. This restricts the range of
protections women have from contracting STIs, including HIV (Ackermann
and de Klerk 2002;
Bernstein and Juul Hansen 2006;
Sprague 2008).
Ackermann and de Klerk
and others observe that gender violence is widely understood
to be a large problem, though the exact levels are not known. Rape
is one of the least notified crimes (including child rape) (2002, p.
166). For example, in South Africa,
only an estimated 2,8% of rapes are reported (Ramsay
1999). As the WHO
states: “Gender-based violence is a major risk factor for the
ill health and lack of wellbeing of girls and women around the
world” (no date). A study conducted by researchers from the
University of the Witwatersrand in South Africa is illustrative, indicating that
more than 60% of women in
South Africa were regularly
battered by partners or spouses and 50%-60% of marriages were
reported to involve physical and sexual violence (Wood,
Jewkes and Maforah 1998). “Gender-based violence and gender
inequality are increasingly cited as important determinants of
women's HIV risk; yet empirical research on possible connections
remains limited” emphasise Dunkle et al (2004).
Given the burden of HIV infection and the associated social impacts,
the connections between gender, health and HIV cannot be dismissed (Gender
Medicine 2006;
Grown, Gupta and Pande 2005;
Klugman 1999).
Through research on access to and provision of healthcare and HIV
treatment and prevention, what is becoming clear is this: an
overlapping set of inequalities and disadvantage joins a cascade of
missed opportunities for healthcare, HIV prevention and treatment.
These factors, when combined, put women at further risk of ill
health and premature morbidity and mortality, while greatly
undermining their prospects for development. As HIV continues to
take a toll on women in our societies, now is the time to interrupt
this cycle of deprivation, inequality and ill health. There is no
more important time.
Courtenay Sprague is an Associate Professor at the Graduate School
of Business Administration, University of the Witwatersrand in South Africa (Wits). Her recent
research has focused on access to antiretroviral medicines
(particularly for women and children), social determinants of health
and health equity. She has conducted HIV-related training and
education for UNAIDS and produced health and HIV research for the
UNDP, Treatment Action Campaign, Human Rights Watch and USAID.
Courtenay has a double MA in international relations and resource
and environmental management from Boston University (USA);
and a PhD in development studies from Wits University.
Sources:
Ackermann, Leáne and Gerhardt de Klerk. 2002. Social Factors that
Make South African Women
Vulnerable to HIV Infection. Health Care for Women International
23: 163-172.
Bernstein, Stan and Charlotte Juul Hansen. 2006. Public Choices,
Private Decisions:
Sexual and Reproductive Health and the Millennium Development Goals.
New
York:
UNDP.
Chen, Lincoln and Giovanni Berlinguer. 2001. Health Equity in a
Globalizing World.
In: Evans et al, eds. Challenging Inequities to Health: From
Ethics to Action.
Oxford:
Oxford
University
Press.
Doyal, Leslie. 2006. How Well are Women Worldwide? Lancet 367
(June 10): 1893-1894.
Doyal, Leslie. 2001. Sex, Gender and Health: the Need for a New
Approach. British
Medical Journal
323: 1061-1063.
Doyal, Leslie. 2000. Gender Equity in Health: Debates and Dilemmas.
Social Science &
Medicine
51: 931-939.
Dunkle, K, Rachel Jewkes, H Brown, Glenda Gray, James McIntyre, and
S Harlow. 2004.
Gender-Based Violence, Relationship Power, and Risk of HIV Infection
in Women Attending Antenatal Clinics in South Africa.
Lancet 363:1415-21.
Matthews, Catherine. 2005. Reducing Sexual Risk Behaviours: Theory
and Research,
Successes and Challenges. In: Salim Abdool Karim and Quarraisha
Abdool Karim, eds. HIV/AIDS in South Africa.
Cambridge: Cambridge University
Press: 143-165.
Gender Medicine.
2006. Gender-Specific Aspects of the Burden of HIV/AIDS in South
Africa
– Communicable Diseases. Gender Medicine 3 (Supplement 1):
S22.
Government of South Africa. 2007. HIV & AIDS and
STI Strategic Plan for
South Africa (2007-2011). Pretoria: Dept of Health.
Grown, Caren, Geeta Rao Gupta, and Rohini Pande. 2005. Taking Action
to Improve
Women’s Health through Gender Equality and Women’s Empowerment
Lancet 365: 541-543.
Jamison, Dean, Richard Feachem, Malegapuru Makgoba, Eduard Bos,
Florence
Baingana, Karen Hofman, and Khama Rogo, eds. 2006. Disease and
Mortality in
Sub-Saharan Africa
(Second Edition).
Washington,
DC: the World Bank.
Jewkes, Rachel, Jonathan Levin, and Loveday Penn-Kekana. 2002a. Risk
Factors for
Domestic Violence: Findings from a South African Cross-Sectional
Study. Social
Science & Medicine
55: 1603-1617.
Jewkes, Rachel, Loveday Penn-Kekana and Hetty Rose-Junius. 2005. “If
They Rape Me,
I Can’t Blame Them”: Reflections on Gender in the Social Context of
Rape in
South Africa
and Namibia. Social Science &
Medicine 61: 1809-1820.
Klugman, Barbara. 2000. Sexual Rights in Southern Africa: A
Beijing
Discourse or a
Strategic Necessity? Health and Human Rights 4(2): 132-159.
Klugman, Barbara. 1999. Mainstreaming Gender Equality in Health
Policy. Agenda (AGI
Monograph): 48-70.
Médecins sans Frontières.2001. Fatal Imbalance: The Crisis in
Research and
Development for Drugs for Neglected
Diseases.
Geneva: MSF Access to Essential Medicines
Campaign and the Drugs for Neglected Diseases Working Group.
Ramsay, Sarah. 1999. Breaking the Silence Surrounding Rape.
Lancet 354 (9195) (11
December): 2018.
Sprague, Courtenay. 2008. Women’s Health, HIV/AIDS and the Workplace
in South
Africa.
African Journal of AIDS Research 7(3): 341-352.
UNAIDS. 2006. Fact Sheet. Sub-Saharan Africa. Geneva:
UNAIDS.
UNAIDS. 2004a. Living in a World with HIV/AIDS –
Information for Employees of the UN
System and their Families.
Geneva: UNAIDS.
UNAIDS. 2004b. Basic Facts About the AIDS Epidemic and Its Impact:
UNAIDS
Questions & Answers. Geneva, Joint United Nations Programme on
HIV/AIDS (UNAIDS).
Wood, K, F Maforah, and Rachel Jewkes. 1998. He Forced Me to Love
Him: Putting
Violence on the Adolescent Sexual Health Agenda. Social Science and
Medicine
1998. 47: 233-242.
World Health Organization (WHO). (undated). Gender Mainstreaming.
Geneva: WHO (the
Department of Gender, Women and Health).
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In this issue
Live the Future fact file
What does the Spring of Hope mean for the future of HIV and AIDS?
The season spring has been used in the name of the scenario as it
visually captures the essence of the scenario: in spring, the world is full of
hope and optimism as the world comes back to life after the cold and hardship of
winter. Spring is alive with possibility, new beginnings and the possibility of
a brighter future. In this scenario greater cooperation and coordination
improves economic and social conditions for increasing numbers of people.
The Spring of Hope looks at what our society and economy could look like
in 2025 if all the role players players (government, business, labour,
communities and individuals) take, or fail to take, certain actions.
Key Characteristics
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Idealistic broad-based but uncoordinated leadership led by communities
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Small duplicating partnerships
- Powerful pockets in civil society responding well
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Focus on acceptance and care
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Moderate behaviour change
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Better gender equality
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AIDS response: chronic, manageable disease
The focus
The Spring of Hope focuses on acceptance, care and cooperation. AIDS is
seen as a chronic disease and society learns to live with the epidemic despite
its devastating effect. Leadership is idealistic in certain pockets of
communities, but efforts are uncoordinated and not powerful on a national level.
Civil society becomes very strong in their response to AIDS and occasional
partnerships are formed with the public and private sector as well as
international donors to address the effect of HIV and AIDS. Churches play a key
role around care. These efforts largely remain fragmented and uncoordinated
leading to duplication and resulting in the unsustainable use of time and
resources. Business response to the epidemic is strong in the workplace and
community, however, due to a low GDP growth environment, business input is
mostly limited to those few who are employed.
Individual behaviour
Within this self-reliant society, certain pockets of the community become quite
powerful and encourage people to get tested. Just more than one third of South
Africans know their HIV status by 2010. More than 70% of the youth and around
40% of adults use condoms consistently. Those not in a long-term relationship
change partners less often due to pressure from society. Many communities
empathise and care for AIDS affected households, and encourage higher gender
equality and less sexual violence.
The new society
Low economic growth and an inadequate response to the HIV and AIDS epidemic
result in a South Africa
with low GDP per capita. Education remains poor, but life expectancy increases
slightly to 56 years by 2025. Not much improvement has been made in the Human
Development Index (HDI) since 2005. Skilled resources emigrate due to lack of
employment opportunities and poor service delivery. Most households are affected
by AIDS but communities form cooperatives and assist with healthcare provision.
The State Welfare system becomes overburdened and government resources are
limited. Shortage of skilled labour worsens with emigration and poor education
leading to the struggle of business to remain competitive globally. Foreign
direct investment reduces in this low growth environment. Funeral insurance
remains highly popular and the market for basic goods and services is strong.
What does the HIV epidemic look like by 2025?
The total number of people infected with HIV in
2025 will have reduced to 3.4 million. The estimated HIV prevalence rate amongst
the ages 20 to 64 will have reduced to 11%.
A
total of half a million South Africans will be in the final stages of the
disease and in need of antiretroviral treatment. AIDS deaths per annum will be
reduced to around 292 000.
Extract from: Metropolitan Holdings Ltd (June 2006).
Live the Future
– A Model to Respond to the Challenges of HIV and Aids in South Africa
on www.livethefuture.co.za
HIV and AIDS Vital Statistics for South Africa in 2009
| AIDS deaths per day | 1000 |
| New HIV infections per day | 1400 |
| People living with HIV | 5,7 million |
| Total AIDS deaths | 380 000 |
| Total new HIV infections | 501 000 |
| Total AIDS sick | 676 000* |
| Adults with AIDS, not on ART |
470 000 |
| Children with AIDS, not on ART | 26 000 |
| Adults on ART |
583 000 |
| Children on ART |
69 000 |
*Note: This includes people who have
not started ART and those who have started ART, but have since
discontinued treatment.
Source: Metropolitan AIDS Risk
Consulting from ASSA 2003 (Full) AIDS and Demographic model
Contact info:
Published by
Metropolitan Holdings
Editorial Board
Tersia Mdunge
(021) 940 6121
tmdunge@metropolitan.co.za
Nathea Nicolay
(021) 917 3090
nnicolay@metropolitan.co.za
Nosipiwo Ngxabazi
(021) 940 5150
nngxabazi@metropolitan.co.za
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