28 April 2008
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The NSP notes that while the immediate determinants of the spread of HIV relates to behaviours such as unprotected sexual intercourse, multiple sexual partnerships, and some biological factors such as concurrent sexually transmitted infections (STIs), women"s socioeconomic disempowerment and the impact of gender-based violence contributed to women"s significantly higher infection rates. 43 Women are biologically more vulnerable than men to contracting the virus through unprotected vaginal intercourse.44 Available evidence globally, as well as evidence presented in this report, suggests that women are also put a greater risk of transmission due to the discriminatory impact of gender roles and stereotypes.
They are frequently unable to insist on condom use to protect themselves against the risk of HIV transmission by a male partner where they are economically, socially or culturally dependent on that partner or his family, or risk being subjected to violence as a result of suggesting condom use.45 Their exposure to sexual violence and intimate partner violence increases their risk of HIV infection over time.46 Women are less likely to have independent access to economic resources and recent research in South Africa has shown the direct positive correlation between women"s access to economic resources and their ability to protect themselves from HIV infection and against violence.47 In many countries, women also carry a disproportionate burden as carers once members of a household fall sick - a particular concern in a country like South Africa where AIDS affects a large part of the population.
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As examined in the following chapters of this report, the scale of incidents of sexual and other forms of violence against women has remained persistently high in South Africa, continuing to place women at risk of HIV in the immediate or longer term. Considerable effort has been put into reforming the legal framework, medico-legal, police and criminal justice responses to gender-based violence. Nevertheless, women"s lives continue to be scarred by violence or the threat of violence in under-policed, unsafe communities and in their homes. Nearly ten years after the Domestic Violence Act came into force and after the provision of training on their obligations by official and civil society organizations, there is still evidence that some members of the South African Police Service (SAPS) do not understand their legal responsibilities or do not feel under sufficient pressure to fulfil them. For women in abusive relationships, their access to places of safety also remains very difficult.
Violence against women is a persistent and devastating manifestation of gender-based discrimination. Other forms of discrimination in the social and cultural spheres can also act as barriers to women"s access to prevention, treatment and care for HIV. There has been extensive transformation since 1994 of the legal framework to entrench gender equality, protect women"s sexual and reproductive rights and their right not to be subjected to violence. However, the rural women whom AI interviewed were continuing to experience oppression in their relationships with male partners, within families and the wider community as a result of their low social status, economic marginalisation, and also in some cases because of their HIV status. These manifestations of their inequality as women were associated with a range of consequences, including abandonment, loss of their homes, failure to complete their education, inability to secure maintenance for their children, violations of their sexual and reproductive rights with an associated increased risk of HIV infection, and barriers to access to HIV-related health services and treatment adherence.
While there are many good reasons to test, and sound medical grounds for scaling up testing for HIV as recommended in the NSP, it is more complex in a context of gender inequality, poverty and violence. Where women are tested in greater numbers than men and with limited support, it can leave them vulnerable to stigma, discrimination, abandonment and violence.49 The women AI interviewed spoke of their own experiences of powerlessness, verbal and physical abuse, threats of violence and abandonment in response to disclosing their HIV status.
Finally, poverty is a powerful factor acting as a barrier to access to health services, particularly for rural women who are disproportionately represented among the poor and unemployed.
There has been a gradual improvement in the provision of HIV testing and counselling and preventative antiretroviral drugs to rape survivors, along with other initiatives to improve emergency medical and medico-legal services, but some survivors who lack economic resources and the support of NGOs still experience difficulties in adhering to treatment and remain at risk of HIV infection.
While ART and other essential treatments for people living with HIV and AIDS are available free of charge, the circumstances of the women whom AI interviewed in KwaZulu Natal and Mpumalanga provinces indicate that women living in rural areas who do not have a secure income face serious challenges and in some cases complete inability to access treatment and ongoing care because they cannot afford the transport costs to get to the hospitals. Their ability to adhere to treatment is also jeopardised because they cannot afford adequate food with which to take ART twice daily. Although some of the women did receive temporary disability grants, food supplements or other social assistance for their children"s welfare, their economic circumstances remained precarious and affected their ability to access or continue their treatment. In addition their access to health services is further compromised by systemic challenges within the health system, in particular shortages of staffing and delays in government implementation of aspects of the HIV and AIDS treatment programme,such as providing sufficient accessible health care facilities to provide ART.
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