HIV is the leading cause of death and disease in women of reproductive age around the world. Culture, history, and laws combine to deny women and girls equal access to HIV prevention and care.
The first chapter of this story is told in the numbers. The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that in 2007 one-half of the estimated 33 million people living with HIV worldwide—between 14.2 and 16.9 million—were women.
A look at three geographically distinct locations around the globe—Papua New Guinea in Oceania, the African nation of Botswana, and America south of the Mason-Dixon Line—gives a startling picture of the feminization of this modern-day pandemic.
Papua New Guinea. Papua New Guinea, known as PNG, is experiencing a generalized epidemic. According to the 2008 United Nations General Assembly Special Session on HIV/AIDS report for PNG, the number of infected young women is highest of any group and appears to be growing fastest. The explanation for this may be found in PNG customary law and its indigenous cultural norms. Only a quarter-century ago, tribes segregated men and women, with the village men living in a communal house and each woman living in a small house with her children. Polygamy continues to be widespread. PNG is a culture of gender inequality in the main. Violence against women has reached epidemic proportions. Although domestic violence is a crime, few cases are prosecuted because it is seen as a private matter. A key factor contributing to domestic abuse is the practice of a prospective groom paying a bride price. Women also continue to suffer widespread “sorcery-related” abuses, with some killed for allegedly practicing witchcraft. Violence against women, charges of sorcery, and the state’s failure to protect make for a fatal combination in PNG.
Cultural devaluing of women in PNG is rampant. Women have poorer access to health-care services and lower levels of educational attainment. Most women lack access to credit, and limited literacy poses barriers to their participation in the economic activities and political life of the country. When cultural mores and state inaction combine, already-vulnerable women become likely hosts for HIV. So it is that the majority of people now living with HIV in PNG are women.
Botswana. Unlike in PNG, in Botswana literacy is high and women outpace men in education. However, has the second-highest HIV/AIDS prevalence rate in southern and is experiencing a generalized epidemic, with an HIV prevalence rate in 2007 of 23.9 percent.
Here again, law and culture combine in ways that fuel the epidemic. Botswana is like PNG in that it has a dual legal system where common law and customary law exist side by side. Patrilineal inheritance is accorded legislative status in Botswana, thereby giving men control of land and property and effectively disenfranchising women. Abuse of women is widespread, characterized by men’s culturally sanctioned entitlement to sex “on demand” and the “cultural imperative” of a woman to prove her fertility before marriage by bearing children. Domestic violence against women is not prohibited by law, making it an ongoing and serious problem, while customary law permits husbands to discipline their wives as they would their minor children, including the use of corporal punishment.
As it does throughout southern Africa, the HIV/AIDS epidemic in Botswana disproportionately affects women. The numbers in Botswana are staggering: overall, females in the reproductive ages have been severely affected by HIV, with one-third of all women—29.4 percent—currently living with the virus.
The American South. The United States is, of course, a high-income country, but tradition and law combine again to make the plight of women in its southern states too much like that of their sisters in PNG and Botswana. Again, a culture of human rights violations has created an HIV epidemic out of control.
Cheap human labor was the backbone of the agrarian economy. With the housing of African slaves came pandemics of communicable diseases, many of which were found to be associated with a prevalence of dire poverty, poor nutrition, the climate, and the total legacy of slavery. That legacy of unequal health has been carried down to the HIV/AIDS epidemic. The Southern AIDS Coalition has reported that there were 26,347 newly diagnosed cases of HIV infection in the United States in 2007. Of those new diagnoses, 51.2 percent were diagnosed in the 17 southern states. AIDS rates among African American women have reached 39.8 per 100,000 compared with 1.8 among white women.
A snapshot of South Carolina helps to tell the story of HIV in the South. More than 4,200 women there live with HIV/AIDS. African American women in South Carolina account for an estimated 83 percent of new HIV infections among all women in the state: They make up 17 percent of South Carolina’s total population, but comprise 26 percent of all persons living with HIV/AIDS and 29 percent of all persons diagnosed with HIV-only in the state. South Carolina is number-one in the nation in heterosexual transmission of HIV, and heterosexual transmission was the most common reported risk for all women and girls, with more than 90 percent of women contracting HIV from their male partners.
Modern South Carolina law has not protected the right to health for its African American women or their children. More than 50 years ago, in 1956, the American Medical Association declared addiction to alcohol and other drugs to be a disease. Yet, South Carolina law holds that, rather than provide treatment for women suffering from such diseases, they must be incarcerated.
In 1989, the city of Charleston had a policy where the Medical University of South Carolina provided the city’s prosecutor’s office with information on pregnant and postpartum women. The prosecutor’s office then maintained detailed lists containing a woman’s name, drug test result, and other confidential information, including whether she “had AIDS” or had had an abortion. After more than a decade in place, the policy was invalidated by the U.S. Supreme Court in Ferguson v. City of Charleston, 532 U.S. 67 (2001). The Court noted specifically that “the policy made no mention of any change in the prenatal care of such patients, nor did it prescribe any special treatment for the newborns,” presumably thus allowing known HIV infections to go untreated. Meanwhile, one-third of all persons estimated to be living with AIDS in 2007 were women.
Conclusion. UNAIDS has recognized that the “drivers” of this epidemic—structural and social factors such as gender inequality, human rights violations, and stigma and discrimination that increase people’s vulnerability to HIV infection—are not easily measured. But the trends are clear: Human rights violations and gender inequality fuel the spread of HIV/AIDS. Where women are unequal before the law, with little to no control over their lives, their vulnerability to HIV infection increases. Where tradition and cultural mores deny women the same access to prevention and care as are granted to men, HIV spreads. Where the state and nongovernmental organizations fail in their efforts at gender equity, HIV flourishes.
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- This article is an abridged and edited version of one that originally appeared on page 4 of Human Rights, Spring 2010 (37:2).
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