Mary Wandia and Neelanjana Mukhia reflect on the struggle to free women from violence, the ravages of HIV/AIDS and the effects of conflict

Women and girls encounter violence in their homes, communities, schools, workplaces, streets, markets, police stations and hospitals. Violence, or the threat of it, not only causes physical and psychological harm to women and girls, it also limits their access to and participation in society because the fear of violence circumscribes their freedom of movement and of expression as well as their rights to privacy, security and health. The epidemic of violence against women has been a key focus for women’s rights movements for many decades. The movements for a long time fought to have violations of women’s human rights in the private sphere recognized knowing too well that it is within this space that the most insidious and vicious violations of women’s rights take place. They were aware that women’s empowerment and gender equality in all spheres cannot be achieved unless violence against women, the tool used to control, dominate and subordinate women and girls by men is not eliminated.

African women did not wait; they have been part and parcel of that fight that culminated in the 1993 United Nations Declaration ‘Women’s Rights are Human Rights’ and called for the elimination of violence against women in Vienna. The international community acknowledged that violence against women is a human rights violation that women experience at all stages of their life cycles in peace time and war. African women also joined global women’s movements in Beijing in 1994 where women’s human right to be free of violence and the threat of it was identified as one of the critical areas of concerns and actions for all stakeholders.

By the turn of the century, African women seized the opportunity to ensure that the Protocol to the African Charter on Human and People’s Rights on the Rights of Women in Africa (2003) supplements the provisions of the African Charter on Human and Peoples’ Rights and domesticates the Vienna and Beijing agreements on violence against women. The protocol breaks new ground in calling for African countries to protect women from all forms of violence through legislative measures, public awareness, and support in the form of health services, legal assistance, counseling and vocational training.

Beyond setting the legal and normative frameworks above, women went back to their communities, nations and regions to sensitize them to end violence against women through campaigns on ‘zero tolerance to violence against women’. They expended a lot of energy and creativity to develop different strategies to suit different contexts.

Unfortunately, their communities, nations and governments did not heed the campaigns. The onset of the HIV/AIDS pandemic found a bosom friend in the pandemic of violence against women. The intersection of the two pandemics remains a testimony of the cost of ignoring calls to end violence against women. The HIV/AIDS pandemic now wears a woman’s face. It remains a stark reminder that violation of rights in one sphere leads to more serious violations in other spheres resulting into compounded situations.

Human rights are interrelated and interdependent. That fact is brought home by the intersection of HIV and violence against women in Africa. Today, African women are bearing the brunt of the HIV pandemic –in sub-Saharan Africa an estimated 1.7 million people were newly infected with HIV in 2007, bringing to 22.5 million the total number of people living with the virus. Unlike other regions, the majority of people living with HIV in sub-Saharan Africa (61%) are women [2].

There are a number of reasons for this – women’s sexual physiology increases their risk of HIV; but much more importantly it is their social, economic and sexual subordination that increases their risk. Women are unable to negotiate safe sex or refuse sex with men because of violence or the fear of violence. They are at the receiving end of coercive sex. Women’s and girls’ economic subordination, lack of economic opportunities and choices may also contribute to their resorting to transactional sex.

Just as violence against women increases their risk to HIV, it is also a consequence of HIV sero status. HIV positive women as a result of their status are more likely to face stigma, discrimination, and violence and rights violations from their intimate partners, families, communities and states. There have been cases reported of HIV positive women being denied their sexual and reproductive rights by health practitioners merely because of their HIV status. HIV positive women also face the possibility of disinheritance and dispossession from their families. Gender inequality and violence against women often inhibit women’s and girls’ ability to take full advantage of crucial – even life-saving – services. A recent UNFPA/WHO report notes that, in the context of AIDS, “violence against a woman can interfere with her ability to access treatment and care, maintain adherence to antiretroviral therapy or feed her infant in the way she would like” [3].

In situations of conflict, the intersecting human rights and health crises of HIV and violence against women are exacerbated in situations of conflict. We know that the incidence of rape skyrocket during conflict as it is used as a weapon and tactic of war. Women and girls are targeted strategically for rape, sexual slavery and violence. HIV in combination with rape, violence and sexual slavery increases women’s risk exponentially. In Rwanda, it was reported that close to 500,000 women and girls were raped during the genocide.

In Rwanda, the WHO reports, “the HIV prevalence rate in rural areas dramatically increased from 1% before the start of the conflict in 1994 to 11% in 1997. In a survey of the women who survived the genocide, 17% were found to be HIV-positive. In another survey carried out by the Rwandan Association for Genocide Widows (AVEGA), 67% of women who survived rape had HIV” [4]. Women are also disproportionately affected as a result displacement, dispossession and collapsed health, law enforcement and other social infrastructures. A case in point, during the recent conflict in Kenya, HIV positive women were unable to access life saving ARV drugs because of displacement. And those who were raped could not access PEPs on time.

There has been attention given to violence against women by many stake holders for many decades. This is in large part due to the actions and advocacy of the global women’s movements. However, when it comes to the intersection of violence against women and HIV, and the increasing risk of women and girls to HIV, there has been little concerted effort. Governments have acted to address the HIV pandemic with many interventions – some of them have worked some have not. However, they have been largely blind to the reality of women’s risk to HIV and its key driver – violence against women. This blindness is not restricted to governments in Africa, multilateral agencies and bilateral donors in charge of defining the global AIDS response have been equally blind to the intersecting crises.

For the last couple of decades, these international agencies and national governments have put money, time and effort in to the ABC paradigm of HIV prevention. An intervention that disregards the reality of inequality and subordination women and girls face. Abstinence, Be Faithful, Condomise does not begin to consider the endemic violence against women and girls. Research has established that a large proportion of girls’ sexual initiation is coercive and that many women do not have control over whether or not they will use condoms during sex. Indeed many women cannot negotiate consensual sex. Given this reality those in international agencies and governments should have asked the question a long time ago – does ABC really work for women? Or for that matter do other HIV interventions work for women; have they been designed informed by the differential access women have to health services?

In order to bring greater attention to and action on the intersection of violence against women and HIV&AIDS by all actors at the international, regional and national levels, a campaign was launched in March 2007 – the Women Won’t Wait. End HIV and Violence against Women. NOW. The Women Won’t Wait campaign is led by a coalition of organizations and networks committed and working for many years to promoting women’s health and human rights in the struggle to comprehensively address HIV and end all forms of violence against women and girls now. Women Won’t Wait seeks to accelerate effective responses to the linkages of violence against all women and girls and HIV by tracking and, where necessary, calling for changes in the policies, programming and funding streams of national governments and international agencies [5].

Funding for programmes that focus on violence against women and girls in connection to HIV remains inadequate and inconsistent. Research conducted as part of the Women Won’t Wait: End HIV and violence against women and girls. Now. campaign entitled Show Us the Money: is violence against women on the HIV&AIDS donor agenda? illustrates the lack of concerted funding efforts aimed at fighting the twin pandemics. Released in March 2007, the report analyses the policies, programming and funding patterns of the largest public donors to HIV&AIDS: the Global Fund to Fight AIDS, Tuberculosis and Malaria, the President’s Emergency Fund for AIDS Relief (PEPFAR/US), and the UK Department for International Development (DFID), along with the World Bank, and UNAIDS (the Joint UN Programme on HIV/AIDS). In an era of increasing accountability, Show us the Money aims to hold donors responsible to basic health and human rights standards in their policies, programmes, and funding streams.

According to the report, whereas issues around violence against women may be acknowledged in HIV policy documents of major donors, such a focus is often absent from programming on the ground. HIV programme efforts rarely cite violence against women and girls as a major driver and consequence of the disease, nor measure its occurrence statistically. Separate funding streams for each create an ineffective and dysfunctional split in intervention efforts, which do little to address the root causes of either pandemic. Furthermore, it is almost impossible to track resources targeting their intersection, as none of these donors specifically track their programming for and funding to violence eradication efforts within their HIV and AIDS portfolios.

Having assessed the gaps in policy, programming and funding on the intersection, the campaign developed key demands of bilateral, multilateral and technical agencies; and national governments:
• Prominently, publicly and consistently underscore that violence against women and girls is a major driver and consequence of HIV&AIDS
• Significantly increase current funding for programmes to prevent and redress violence against women and girls in addition to broader and increased investment in sexual and reproductive health and rights
• Establish concrete targets on the elimination of violence against women and girls as a part of the Universal Access Process
• Achieve universal access to comprehensive sexual and reproductive health services by 2010; and rapidly scale up integrated SRHR and HIV services
• Achieve universal access to PMTCT+ services by 2010 by fully supporting and funding national PMTCT+ plans
• Expand training to 50% of all health care service providers by 2008 (with particular attention to those providing PMTCT) to recognize and respond to the signs and symptoms of violence as a routine part of HIV&AIDS testing, treatment, care and support, rising to 80% by 2010.
• Rapidly and massively scale up education about and the provision of post-exposure prophylaxis (PEP) and emergency contraception to survivors of sexual violence. These services should be available on demand at 50% of each country’s emergency care facilities by 2008, rising to 80% by 2010.
• Rapidly expand the distribution of female controlled prevention methods, including the distribution of the male and female condoms to women, men and transgender people. These services should be available on demand to 50% of all requesting it by 2008, rising to 80% by 2010.
• PMTCT+ services should be available on demand to 80% of those in need of PMTCT+ by 2008, rising to universal access to PMTCT+ services by 2010.
• Anti-violence education programmes operating in all communities where gender-based violence occurs.

Overall, the first year of the campaign has been a productive one; with several of the agencies we reviewed having taken bold steps toward making their operations more “gender-sensitive.” It is hoped that “gender-sensitivity” for these agencies includes a complex analysis and consistent effort to grapple with the intersection of HIV and violence against women and girls. The most significant steps were taken by the Global Fund to Fight AIDS, Tuberculosis and Malaria (and its effort to engage in a more gender-sensitive response to the three diseases) and UNAIDS. Indeed, among the agencies we reviewed, UNAIDS was the only one to introduce new activities specifically designed to confront violence against women and girls in the context of the HIV pandemic by including violence against women in their the 2005-2008 estimation of the Global Resource Needs.

We hope that other agencies will follow their lead in recognizing this dangerous synergy and taking action. Moreover, while we welcome the positive changes in policy and programming, one of the central problems identified in Show Us the Money remains: the means of measuring, tracking and quantifying support to violence against women and girls within HIV portfolios continues to lag far behind policy and programming efforts.

The waiting must end. Women’s movements throughout the world have long fought for concrete action to promote and protect the human rights of all women – including the rights to be free from violence, coercion, stigma and discrimination, and the right to achieve the highest attainable standard of health, including sexual and reproductive health. However, this global standard is rarely translated into policy and practice. In the case of the links between violence against women and girls and HIV, resulting in a deadly failure in policy and an abrogation of governments’ and donors’ accountability to respect, protect and fulfil the human rights of all.