Africa: New report on HIV/AIDS in Africa - First to link discriminatory beliefs against women with vulnerability to AIDS

PHR's study, Epidemic of Inequality: Women's Rights and HIV/AIDS in Botswana & Swaziland: An Evidence-based Report on Gender Inequity, Stigma and Discrimination reports the results of a population-based study conducted in 2004 and 2005 with 1,268 respondents in Botswana and 788 participants in Swaziland, designed to assess factors contributing to HIV infection. In addition, 24 people living with HIV/AIDS in Botswana and 58 people living with HIV/AIDS in Swaziland were interviewed, along with key informants in both countries. The full report can be accessed here.

Four key factors were found to contribute to women's vulnerability to HIV: women's lack of control over sexual decision-making, including the decision to use a condom, and multiple sexual partners by both women and men; the prevalence of HIV-related stigma and discrimination (which hinders testing and disclosure of status); gender-discriminatory beliefs, which were associated with sexual risk-taking; and a failure of traditional and government leadership to promote the equality, autonomy, and economic independence of women.

"If we are to reduce the continuing, extraordinary HIV prevalence in Botswana and Swaziland, particularly among women, the countries' leaders need to enforce women's legal rights, and offer them sufficient food and economic opportunities to gain agency in their own lives. Men and women must be educated and supported to acknowledge women's equal status with men and abandon these prejudices and risky sexual practices. The impact of women's lack of power cannot be underestimated," said PHR's Senior Research Associate Karen Leiter, JD, MPH, lead investigator of the study.

While anecdotal evidence has strongly suggested a link between gender inequity and HIV infection, PHR has conducted the first rigorous, large-scale field survey of gender discriminatory beliefs and analyzed their association with sexual behavior. The report suggests that women's rights must be made the top priority by the countries' leaders if HIV prevalence is to be reduced.

In Botswana, for example, 95% of women and 90% of men surveyed held at least one gender discriminatory belief. Botswana community survey participants who held three or more such beliefs had 2.7 the odds of those who held fewer beliefs to report having had unprotected sex in the prior year with a non-primary partner. Discriminatory beliefs accept and reflect upon women's inferior legal cultural and socioeconomic status.

For example, 19% of all community survey respondents in Botswana agreed with the statement that it is more important that a woman respect her spouse or partner than it is for a man to respect his spouse or partner.

Interviews indicated that many HIV-positive women are forced to engage in risky sex with men in exchange for food for themselves and their children. As one interviewee put it, "Woman are having sex because they are hungry. If you give them food, they would not need to have sex to eat."

According to PHR research, the very fear of being subject to HIV-related stigma (as opposed to the actual experience of it)—being abandoned by friends or shunned at work, for instance—was pervasive. For instance, in Botswana, 30% of women and men believed that testing positive and disclosure would lead to the break up of their marriage or relationship.

Interviews conducted by PHR and its partners indicate that women in Botswana and Swaziland frequently do not have the option to make decisions about having sex due to their lesser legal status.

"Here in Swaziland, the husband is the one that bosses you around so there is nothing you can do without him. My rights lie with my husband. He decides whether we use condoms. I don't have a choice about prevention." — an HIV-positive interviewee

In interviews, people living with AIDS highlighted women's dependency on male partners as the most significant contribution to women's greater vulnerability to HIV when compared to men. Testimony also revealed that women's lesser status in Botswana fosters ongoing harm to women even after they become infected, and increases the precariousness of their ability to meet basic needs for food, shelter and transport.

Participants in Swaziland repeatedly pointed to a lack of political leadership—from government officials and traditional leaders—in protecting and empowering vulnerable women and girls.

"HIV/AIDS interventions focused solely on individual behavior will not address the factors creating vulnerability to HIV for women and men in Botswana and Swaziland, nor protect the rights and assure the wellbeing of those living with AIDS. National leaders, with the assistance of foreign donors and others, are obligated under international law to change the inequitable social, legal, and economic conditions of women's lives which facilitate HIV transmission and impede testing, care and treatment," said Leiter.

PHR's study also examined the following:

*Obligations of Botswana and Swaziland to fulfill international human rights legal standards, including the right to health and the right of women to live and have a healthy life

*Prevalence of accurate beliefs regarding the prevention and transmission of HIV

*Prevalence of HIV testing in the community survey sample and experiences with barriers and facilitators to testing

*Prevalence of stigmatizing or discriminatory beliefs regarding PLWA

*Projected experiences/responses should the participant or their partner test positive for HIV

*Prevalence of sexual risk-taking: multiple sexual partnerships (serial or concurrent), unprotected sex with a non-primary partner, lack of control over sexual-decision making, condom non-use, opinions/practice of abstinence

*Prevalence of beliefs in women's rights (and association with sexual risk-taking)

*Perceptions of why women and men are (differentially) vulnerable to HIV/AIDS

A background chapter on HIV/AIDS in Southern Africa, including discussion of the dimensions of the epidemic and its consequences, drivers of the epidemic including stigma and discrimination and gender inequality, and national and international responses is available.

The study was designed and implemented by PHR and two local field partners: Members of the Faculty of Nursing at the University of Botswana in Gaborone, Botswana, and Women and Law in Southern Africa Research Trust (WLSA) in Mbabane, Swaziland.

25 May 2007