NEWS
HOW BEST CAN SA ADDRESS THE HORRIFIC IMPACT OF HIV/ AIDS ON WOMEN AND
GIRLS?
REPORT OF THE JMCIQLSW: NOVEMBER 2001.
Introduction:
The Joint Monitoring Committee on the Improvement of the Quality of Life & Status of Women (JMCIQLSW) held hearings in October and November on “How best can South Africa address the impact of HIV/AIDS on women and girls?” The Committee’s brief is to monitor Government’s implementation of CEDAW and the BPFA in relation to improving the quality of life and status of women. The Committee is guided by the needs of the poorest women (the majority of whom are African women). The Committee’s priority is to monitor how government is addressing the impact of poverty, HIV/AIDS and violence on women. The Beijing Platform of Action includes “the girl child”. While women across race, class, religion and culture experience violence and HIV/AIDS, poor women are more vulnerable and have fewer options. This emerged in all three sets of hearings the Committee held: on Poverty; Violence, and, most recently, the HIV/AIDS hearings. The Committee’s activity on these three priorities has encompassed hearings in Parliament; workshops in rural areas, provincial meetings and a workshop in Parliament of 200 women, most of whom came from rural areas.
During the HIV/AIDS hearings there were numerous oral and written submissions presented as well as reports that the committee scrutinised. The views of both civil society and Government were contained in the above. Departments which presented orally to the Committee included Health, Trade and Industry, Social Development and Education (The Committee also received their written reports). The fact is that South Africa has a strong legal framework, has initiated very important programmes through different departments such as Health, Education, Welfare and Labour. The government and the private sector, labour and organizations in civil society have engaged in a Partnership against AIDS. People Living With Aids have initiated a number of organizations in civil society. There is a vast amount of energy, commitment, dedication and work that is being done, and the hearings confirmed this. The hearings reflected on and acknowledged the invaluable work that is being done by Government led by President Thabo Mbeki and the Minister of Health, Manto Tshabalala-Msimang.
The Health Committee was invited to co-chair and participate in the hearings and the JMC on Children, Youth and Disabled Persons made a presentation to the hearings. The organizations from civil society included people living with Aids.
The Committee also heard from the UNAIDS and the World Health Organization (W.H.O.)
Members of the Committee were committed to finding solutions to this crisis that faces every one of us. There are members of this committee who daily take on the responsibility of caring for members of their families and communities who have HIV/AIDS. These hearings have posed painful personal and political challenges. The Committee was guided in the hearings by an approach of clarifying the difficulties, problems and barriers in a search for solutions.
This report examines:
*the extent and nature of the crisis HIV/AIDS poses to all South Africans.
*some of the contributing factors to the spread of HIV/AIDS in SA.
*the impact on women and girls
*recommendations: prevention and treatment
Government’s STD/HIV/AIDS/Review 1997:
In July 1997, a National STD/HIV/AIDS Review by five teams of national, provincial and international experts was conducted. The Review found the following:
*the need for leadership and political and public commitment;
*the importance of meaningful involvement of people living with AIDS;
*the need for an interdepartmental and intersectoral response;
*the critical capacity building requirements;
*the close collaboration with the TB programme; and
*the urgency needed to address human rights abuses and to reduce stigmatisation
The Committee hearings completely supports all the above findings of Government’s review.
It recognizes the number of positive aspects that characterize Government’s response to the HIV and AIDS epidemic. This is reflected in the Minister of Health’s document: “HIV/AIDS in South Africa Challenges, Obstacles and Responses”. These include successes with:
· Programmes targeting youth – In this regard, we observe that:
o Life skills and HIV/AIDS education programmes are now a compulsory part of the curriculum. It is envisaged that it will be available in all primary and secondary schools by 2003.
o As a result of public awareness efforts, there has been a significant increase in the number of calls to the AIDS help line.
· The HIV Surveillance programme - South Africa has been recognised and hailed by UNAIDS/WHO and other experts as having one of the best methodologies for HIV prevalence surveillance in the world.
· The STI management programme – A programme to strengthen STI management and surveillance using the syndromic management and microbiological approach has been implemented. This has resulted in reductions in STD incidence in 3 provinces. This programme will now be rolled out to other provinces.
· The Treatment of opportunistic infections and STI’s – Government has placed a strong emphasis on improving the quality of life through treating and managing opportunistic infections and STI’s. Every person that presents at public health care facilities, irrespective of HIV status, receives treatment.
· Vaccine research – Human clinical trials of 4 vaccines are due to start within 24 months.
A. The Extent and Nature of the Problem:
At the Declaration of the Partnership against Aids in 1998, President Thabo Mbeki declared:
“HIV/AIDS is among us. It is real. It is spreading. We can only win against HIV/AIDS if we join hands to save our nation. For too long we have closed our eyes as a nation, hoping the truth was not so real. For many years, we have allowed the HI Virus to spread, and at a rate in our country which is one of the fastest in the world. Every single day a further 1500 people in South Africa get infected. To date, more than 3 million people have been infected. The danger is real. Many more face the danger of being infected by HIV/AIDS….HIV/AIDS walks with us. It travels with us wherever we go. It is there when we play sport. It is there when we sing and dance. Many of us have grieved for orphans left with no one to fend for them. We have experienced AIDS in the groans of wasted lives. We have carried it in small and big coffins to many graveyards. At times we did not know that we were burying AIDS victims. At other times we knew, but chose to remain silent. And when the time comes for each of us to make a personal precautionary decision, we fall prey to doubt and false confidence. We hope that HIV/AIDS is someone else’s problem. HIV/AIDS is not someone else’s problem. It is my problem. It is your problem. By allowing it to spread, we face the danger that half of our youth will not reach adulthood. Their education will be wasted. The economy will shrink. There will be a large number of sick people whom the health system will not be able to maintain. Our dreams as a people will be shattered. ….As Partners against AIDS, together we pledge to care!….As partners against AIDS, together we pledge to pool our resources and to commit our brainpower!…there is no other moment but the present to take action. I thank you for your attention and urge you to act now.”
STIGMA:
In July 2000, the family of Albertina & Walter Sisulu, took a courageous, inspiring, yet undoubtedly painful public position to speak out as a family, about the loss of a granddaughter to HIV/AIDS. Society blames and shames those with HIV/AIDS. The extent of the stigma was gruesomely evident when Gugu Dlamini publicly disclosed that
she was living with HIV/AIDS. She was stoned to death in KZN in 1998 for “shaming her community”. The Sisulus’ action is one of a growing number of actions to destigmatise HIV/AIDS.
The hearings revealed that stigma leads families to focus on opportunistic infections rather than providing the underlying cause on both death certificates and to society. Throughout the hearings the problem of the stigma attached to people with HIV/AIDS was repeatedly raised as a central challenge in effectively addressing HIV/AIDS. (W.H.O. Submission, amongst others).
Government’s HIV/AIDS/STD Strategic Plan for South Africa 2000 – 2005 says:
1. Introduction
“During the last two decades, the HIV pandemic has entered our consciousness as an incomprehensible calamity. HIV-AIDS has already taken a terrible human toll, laying claim to millions of lives, inflicting pain and grief, causing fear and uncertainty and threatening economic devastation”…
“ In sub- Sahara Africa, more than a quarter of young adults are infected with HIV. Assuming that no cure is found, it is estimated that more than 40 million people globally will be living with HIV by 2000. The impact of the epidemic on the economy is already being felt in most countries. Life expectancy has been significantly reduced as many people in the 15 – 49 year age group are now dying of AIDS…”
“In South Africa, despite our best efforts, the HIV infection rate has increased significantly over the past 5 years. This increase in the infection rate calls for a renewed commitment from all South Africans.” [Pg 6]
[Pg 8, 9,10]
Recent estimates suggest that of all people living with HIV in the world, 6 out of every 10 men, 8 out of every 10 women, and 9 out of every 10 children are in sub-Saharan Africa. These figures provide sufficient evidence to make HIV-AIDS both a regional and a national priority. Data from the Department of Health’s annual National HIV Seroprevalance Surveys of women attending Antenatal Clinics for the past 9 years provide a good estimate of HIV prevalence and trends over time in South Africa.
From 1990- 1999, it went from 0.7% to 22.4%
and it ranges from7.1% in the Western Cape to 32.5% in KZN.
Additional information from the survey reveals that:
- the HIV epidemic in South Africa is one of the fastest growing epidemics in the world
- young women aged 20-30 have the highest prevalence rates and
- Young women under 20 years had the highest percentage increase compared to other age groups in 1998 compared to 1997
These and other data clearly indicate that the HIV epidemic is severely affecting the young black and economically poor populations of South Africa.
Currently there are 4.2 million South Africans living with HIV. It is estimated that in 1998, over 1,600 people were infected with HIV each day - translating to more than 550 000 people infected each year.
It is estimated that by the year 2005, there will be 6 million South Africans infected with HIV and almost 1 million children under the age of 15 whose mothers will have died of AIDS. Aids is not a notifiable disease in South Africa and voluntary reporting seriously underestimates the number of people living with Aids. It is estimated that there were approximately 165,000 people living with AIDS and 120,000 AIDS deaths in 1998.
Projections indicate that by 2002 a quarter of a million South Africans will die of AIDS each year, and that this figure will rise to more than a million by 2008. Average life expectancy is expected to fall from approximately 60 years to 40 years between 1998 and 2008.
Major causes and determinants of the epidemic in South Africa:
The immediate determinants of the epidemic include behavioral factors such as unprotected sexual intercourse and multiple sexual partners and biological factors such as the high prevalence of Sexual Transmitted Diseases (STD’s).
The underlying causes include socio-economic factors such as poverty, migrant labor, commercial sex (workers), and the low status of women, illiteracy, and the lack of formal education, stigma and discrimination.”
………………………………………………………………………
The Committee’s hearings confirmed the extent and seriousness of the problem as described above in Government’s HIV/AIDS STD Strategic Plan. The Committee agrees with the Minister that the majority of those who are attending the ante-natal clinics which participate in the department’s survey are poor, young African women. (The seroprevalence rates from blood tests reflects that the prevalence rate went from 0.7% to 22.4 % between 1990 –1999). The hearings started from the same premise as Government’s plan that HIV causes AIDS. It therefore did not enter the terrain of the debate reflected in the Report of the Presidential Advisory Panel between those who do not believe that HIV causes AIDS, those who don’t believe that AIDS exists and those who believe that HIV causes AIDS.
TOWARDS SOLUTIONS:
The Committee recommends a holistic integrated response that encompasses prevention and treatment; that addresses HIV/AIDS, Poverty and Gender-Based Violence; and that is driven by people living with AIDS.
B. Why is HIV/AIDS so widespread in South Africa: Some key factors
The horrific impact of Apartheid’s migrant labour system, influx control, the homelands system and single sex hostels directly contributed to widespread poverty and gender inequality. The Committee agreed that in attempting to address HIV/Aids it is critical to acknowledge the different sexual orientations that exist in society. Two hidden (though now well documented) aspects of single sex hostels are male homosexuality (described as ‘matanyola’ in rural Sekhukhune and ‘isitabane’ in KZN) and the sex-work industry that grew around the hostels. In addition, Apartheid imprisoned thousands of South Africans in appalling conditions. The practice of male rape and homosexuality are common features of prisons across the world, and several studies document these within South African prisons.
The UNDP Report on HIV/AIDS and Human Development in South Africa states that “The migrant labour system prevented workers from settling permanently and establishing families where they worked. This resulted in oscillatory migration patterns, where workers in urban areas maintained links with their families in rural homesteads, and moved between urban workplaces on a weekly, monthly or annual basis, depending on distances. Oscillatory migration is a major factor in the spread of HIV and other sexually transmitted diseases in SA. Despite the demise of the apartheid government, oscillatory migration is still part of the reality of many South African’s lives because of the uneven development across provinces and countries and a lack of waged work.”
UNRISD & UNAIDS: “Aids in the context of development” (Dec. 2000), states: “Two strategies adopted by desperate people are particularly conducive to the spread of HIV/AIDS. The first is migration in search of work ….The second is poverty-driven sex-work. Both place men and women in high risk situations, in which institutions providing support for stable family relations are absent.”
Patriarchal definitions of masculinity, misogyny (hatred of women) and HIV/AIDS
In Janet Bujra’s article, (Targeting men for a change: Aids discourse and activism in Africa) in Agenda no 44 she quotes Chenjerai Shire: “In urban areas where men were diminished as wage laborers, they “ inhabited a masculinity that regarded women as… whores whose presence in male spaces such as beer halls, evoked extreme forms of misogyny. Any form of violence was legitimised within the male space of the beer hall. Male attitudes towards women in towns were reflected in the language of the beer hall: “…it’s a woman, let it be beaten”…Such attitudes remained entrenched in male spaces.”
Apartheid institutionalised violence, including gender based violence, and gave it a respectable façade – it entrenched the violence inherent in patriarchal religions and traditions – it is no surprise therefore that relationships between men and women in South Africa are today characterised by a power imbalance that often manifests in violence. The hearings reinforced the fact that the spread of HIV-AIDS is driven by gender inequality, poverty and violence.
*In many communities, women and girls are being blamed for the spread of HIV*
C. HIV/AIDS intersection with Gender based Violence and Poverty:
Women’s vulnerability to HIV/AIDS stem from a range of social, economic, biological, cultural and legal factors (Whelan D, Gender and HIV/AIDS: Taking stock of Research and Programs. UNAIDS 1999).
In the UNAIDS Report on the Global HIV-AIDS epidemic, June 2000 the following is reflected
· In sub-Sahara Africa, 55% of adult infections are among women
· The highest number of new cases is among girls of 15-19
· World-wide, women are contracting HIV at a faster rate than men.
· Most women are infected by a partner to whom they are faithful
· Women may transmit HIV to their babies, via pregnancy or breast feeding
· Women take the major responsibility for caring for the sick or orphans
The hearings found that language e.g. Mother to child transmission can reinforce the blaming in society’s mind and does not convey the full picture that it is Parent to Child Transmission (PTCT). The fact as reflected above is that most women are infected by a male partner to whom they are faithful and this is how women then transmit it to their babies. The Committee recommends that the PTCT be used instead of MTCT.
The Gendered Economic and Political Reality:
Across the world women have
*less access to power, wealth and resources than men (in South Africa, African women are the majority of the poorest and will therefore benefit most from the eradication of poverty through employment creation and a strong social security system)
*less ownership of land and property than men (in South Africa, African women are the majority of the homeless and landless). One of the most important pieces of legislation in this regard, ‘‘The Customary Law on Inheritance and Succession is yet to be passed.
*inferior legal status to men (South Africa faces the challenge of translating its excellent legislative framework in relation to the rights of women as well as in relation to HIV-AIDS, to lived reality through its judiciary, its police services and public awareness and commitment)
*minimal or non-existent representation on decision-making bodies (while South Africa’s Parliament has led the way in ensuring 30% representation, other sectors of society have been slow to follow, e.g. religion, the media, sport)
*women have little or no control over their own bodies and fertility (this despite the Constitutional provision and such progressive legislation as the Termination of Pregnancy Act) [Legislation such as the Sexual Offenses Law, Legalisation of Sex Work, Legislation against Trafficking in women and children has yet to be passed]
1. The Committee therefores agrees with government that poverty eradication,
employment creation and the development of a strong social system are priority. The Committee applauds government for its initiative in the 1998/1999 Budget Review, to ensure that the Budget is gender-responsive, and strongly recommends that this be re-integrated into the 2002 Budget and Medium Term Expenditure Framework.
2. The Committee recommends that urgent attention be paid to :
(a) implementation and resourcing of existing legislation such as the Equality
Act, the Domestic Violence Act, etc.
(b) the urgent enactment of laws such as the Sexual Offences Act, and the
Customary Law on Inheritance and Succession
(c) legislation to examine the Legalisation of sex work and the Prohibition of
trafficking in women and children must be urgently initiated.
Biology
Medical doctors and scientists who presented at the hearings explained why the risk of HIV infection during unprotected sex is 2-4 times higher for women than for men in terms of women and men’s physiology:
1. Women have a larger surface area of vaginal and cervical mucosa exposed to their partner’s secretions during sexual intercourse.
2. Semen infected with HIV also carries a larger concentration of the virus than vaginal fluids.
D. What needs to be addressed to ensure that ABC works effectively?
The hearings heard that women trying to get men to Abstain, Be faithful and Condomise face rejection, beating and even death. The hearings heard that ABC couldn’t work in a context where there are so many socio-cultural barriers to women’s sexual autonomy. The committee therefore recommends that these socio-cultural barriers be addressed urgently. ANC Deputy Secretary General, Thenjiwe Mtinsto said at the opening of the special women’s hearings of the TRC, …..Because always, always in anger and frustration, men use women’s bodies as a terrain of struggle, as a battleground”.
*Violence against women and forced sex contribute to the risk of HIV infection.
There are at least four ways in which the dual epidemics of HIV and gender violence may overlap in women’s lives. [Maman et.al. 2000: The Intersections of HIV and violence: directions for future research and interventions” in “Social Science and Medicine” quoted in CSVR submission (L. Vetten)]:
1. Rape may increase the risk to women and girls of contracting HIV. Typically, rape does not occur in circumstances where a condom will be used. The violent nature of rape creates a higher risk of genital injury and bleeding (increasing the risk of HIV transmission), while, in cases of gang rape, exposure to multiple assailants may also contribute to the increased risk of transmission.
2. Abusive relationships (including other forms of abuse besides that of a physical nature) may limit women’s ability to negotiate safer sex.
3. Women who have a history of childhood sexual abuse may engage in riskier sexual behavior as adolescents or adults, increasing their risk of HIV infection.
4. Women who receive HIV counseling and testing may be at risk of partner violence should they disclose their HIV status
The hearings heard that ignorance about sex in women and girls is viewed as a sign of purity and too much knowledge is regarded a sign of immorality. Taking the lead sexually is part of the gender construction of being a man, willing submission is part of the gender construction of being a women.
Young girls speak of the pressure to have sex with boyfriends and the difficulty of insisting on a condom without appearing unattractively well informed about sex.
The societal double standard gives men license to be sexually adventurous without taking responsibility for their actions, while controlling female sexuality, and blaming women for the spread of STD’s (even though in most cases the disease was acquired from their sole sexual partners).
Childbearing and satisfying her husband are key expectations for a wife even if she is aware that he is not monogamous. Refusal can result in rejection, divorce and violence. It is difficult if not impossible, to persuade a reluctant man to use a condom and negotiate for safer sex. Insistence on condom use invites suspicion of infidelity.
Studies that confirm the above:
1. Domestic Violence:
Vetten, 1995:At least 1 person in Gauteng is killed by her partner every 6 days.
Jewkes et al. al: A community-based prevalence study found that 26,8% of women in Eastern Cape, 28.4% in Mpumalanga and 19.1% in the Northern Province had been physically abused in their lifetimes by a partner of ex-partner.
Emotional and financial abuse: 51,4% in Eastern Cape, 50% in Mpumalanga, 39.6% in Northern Province.
Abraham et.al, 1999: In a study of men working in Cape Town Municipalities, approximately 44% admitted to abusing their partners.
Martin et.al. (in Vetten): Indian men who physically and sexually abuse their wives were more likely engage in extra marital affairs and contract STD’s so placing their wives at a risk of STD’s and HIV.
Vetten states that: “It is suggested that females are dying sooner of Aids than men. Answers to these questions (below) might help us understand role of domestic violence:
*How does living in relationships which are emotionally and physically stressful affect susceptibility to HIV-related illnesses?
*Are females more or less likely to tolerate abuse in the context of HIV infection?
*How might ongoing battles with the legal system affect stress levels (e.g. custody, domestic violence)?
*How does a positive diagnosis affect a relationship over time?
*Are abusive men more likely than non-abusive men to have extra-marital affairs?
*What effect does being HIV positive have on an abusive man?
*Might such a diagnosis increase, decrease or change the nature of violence?”
Vetten & Ngwane’s research in progress shows that: Married females who request safer sex practices may either be accused of extra marital affairs or of accusing their husbands of being unfaithful. Alleged female infidelity is the most common factor preceding men’s murder of female partners.
In Agenda 39 (1998)Abdool Karim Q:“Females with Aids – The imperative for gendered prognosis and prevention policy. Her study of females in rural and peri-urban setting in KZN showed that most females in marital/ permanent relationships accept that their husbands or partners have other sexual partners but they have little power/ leverage in relationships to negotiate safer sex.
2. Rape:
The South African Law Commission in 1999 estimated (on the basis that one in 35 rapes are reported), that 1,636 810 rapes were committed in South Africa in 1998 alone. Interpol (1999) places South Africa no. 1 in terms of reported rapes.
Maman’s et.al. study in Tanzania (2001) – The most significant aspect of its finding is of an association between violence and HIV infection. The strong consistently positively relationship between a prior history of experience of violence (by single and married women and girls) and HIV infection.
3. Sexual Violence & Young Women:
loveLife 2000 Study :
*39% of young girls between 12 – 17 years state that they have been forced to have sex .
*33% are afraid to say “No” to sex.
*55% agreed with the statement: “There are times I don’t want to have sex but my boyfriend insists on having sex”
Varga and Makubalo’s 1996 st.dy quoted in Agenda No 28: “Sexual Non-Negotiation”: 58% of young African girls avoided discussing or requesting use of condoms for fear of violence / rejection by partners. In some communities, young men are expected to have sexual intercourse to prove they are not impotent.
CIET Africa’s survey (2000): 32% of young men: “forcing sex with someone you know is never sexual violence”
Campbell et. al. in Vetten: In dating relationships females requiring condom use are seen as “loose”, “experienced”, “sleeping around”.
4. Sex Workers:
In the context of poverty and unemployment, many women may resort to sex work to feed their children. The Reproductive Rights Health Unit Study showed: “In South Africa, economic survival is the central motivation for sex workers”. Most sex workers are driven by the need to generate income for themselves, their children and other family members. They supported a median of 2 dependents with their earnings.
“The attitude of some clients to violence was best summed up by the client who said, “I bought it, I own it”. In another survey, 31% of the respondents had been forced to have sex against their will.
Vetten and Dladla’s research shows sex workers in Johannesburg 2000 who can’t afford bail and admission of guilt fines were expected by police to provide sex in exchange for release.
Abdool Karim (1998): Sex workers at truck stops faced violent reactions, loss of clients, or a cut of ± 25% income for insisting on condom use.
5. SEX WITH A VIRGIN IS BELIEVED TO CURE HIV/AIDS
This belief has now extended to include all vulnerable groups: babies, children, old women, disabled children and women etc.
The loveLife Study (2000) revealed that 1 in 4 young South Africans do not know that this is a myth.
MRC, August 2000, reports “the belief that having sex with a virgin can cleanse a man of HIV has wide currency in Sub-Saharan South Africa. Participants in sexual health promotion workshops in South Africa indicated this in the pre-workshop questionnaire.”
The studies done by Kim (2000) and Leclerc–Madlala (1997) “Infect one Infect all …” shows that the myth is widely believed. They conclude that virginity testing under these circumstances increase the risk to young girls of rape
Rape of young girls is increasing across the country.
In Sept 2001 Minister Tshwete revealed in Parliament that child rape doubled in the last year.
6. Patriarchal Religious organisations and teachings (churches, mosques, temples, and synagogues) reinforce all the above. Women and sex are often equated with sin, lust and temptation. Menstruation is seen as dirty. Sex is often presented as only acceptable for procreation. There is little space for women and men to discuss sex and sexuality in an open, respectful manner that honours each other.
Masimanyane’s Study, commissioned by the Committee, and conducted in 5 provinces, found a wide spread lack of understanding of the disease, much confusion and the prevalence of many myths amongst participants. Participants raised the role of the Church in perpetuating silence, forbidding condoms, and spreading stigma (“God’s judgment”)
7. Specific cultural practices that contribute to the spread of HIV/AIDS that (were detailed in the hearings as major contributory factors) were: dry sex, polygamy, widow inheritance, virginity testing. son preference, child marriages and abducting and raping girls and women into marriage were detailed in the hearings as major contributory factors.
It is clear that the subordination and oppression of women and girls has become the most urgent threat to public health
The Role of men in the spread of HIV/AIDS:
The Committee concluded that it is men who are raping children and young women and old women in the hope of being cured. It is men, normally, who take the initiative, and decide where, when and how sexual intercourse takes place. In most communities, men tend to also have more sexual partners than women (polygamy, use of sex workers services). These are part of what has become “masculine ideals”, to be “real men”. Abstinence and monogamy are often seen as unnatural for men, who are try to prove themselves by frequent sexual encounters.
E. RECOMMENDATIONS: PREVENTION AND TREATMENT:
Government’s HIV/AIDS/STD Strategic Plan: (Appendix 1: pp18 – 24):
Government’s Strategic Plan starts with the observation that “despite our best efforts, the HIV infection rate has increased significantly over the past 5 years”.
This requires that all existing programmes be evaluated and identify areas that need strengthening. The hearings emphasized the need to “Do what we are doing as well as we possibly can” in terms of addressing HIV/Aids, Poverty and Gender-Based Violence.
The Committee recommends that a gender perspective be integrated into this evaluation of all strategies, objectives and programmes. The key priority has to be to build gender equality and address the poverty and violence that women and girls experience. Women cannot be seen simply as vulnerable victims. Government policies and programmes have to recognize empower women and girls as agents of change.
This evaluation has to address the need for a massive public education campaign to show how sexual inequality, violence and the rape-of-virgin-myth is spreading HIV/AIDS. This campaign has to draw on studies which show that only 1,1% of the public believes what is in the media on HIV/AIDS whilst 47% believe doctors and nurses, in better equipping health workers to make a powerful contribution.
The unequal power relations between men and women, especially in relation to sexual rights has to be at the center of the strategy.
The Committee strongly recommends that Government Strategy has to start from the recognition that sexual inequality is driving the spread of the epidemic. The Beijing Platform of Action states that sexual rights means that women and men, girls and boys have a right to:
· Control over their bodies
· Only have sex when, with whom and how they want to
· Decide about their sexuality
· Not be forced to have sex through the use of violence or non-physical force
· Have sexual enjoyment
· Be protected from the risk of disease such as HIV and other sexually transmitted diseases
· Have access to responsive services that help them deal with concerns in relation to their sexual health
· All these must be present, they are not mutually exclusive
The hearings recommend a clear, phased-in “operational plan” (See Government’s HIV/AIDS/STD Strategy Plan p6) with specific timeframes and clear budget allocations for both prevention and treatment.
The Committee endorses the priority areas and goals of South Africa’s Strategic HIV/AIDS/STD
Plan viz.:
Priority Area 1: Prevention
Goal 1: Promote safe and healthy sexual behavior
Goal 2: Improve the management and control of STDs
Goal 3: Reduce mother-to-child transmission (MTCT)
Goal 4: Address issues relating to blood transfusion and HIV
Goal 5: Provide appropriate post-exposure services
Goal 6: Improve access to Voluntary HIV Counselling and Testing (VCT)
Priority Area 2: Treatment, Care and Support
Goal 7: Provide treatment, care and support services in health facilities
Goal 8: Provide adequate treatment, care and support services in communities
Goal 9: Develop and expand the provision of care to children and orphans
Priority Area 3: Research, Monitoring and Surveillance
Goal 10: Ensure AIDS vaccine development
Goal 11: Investigate treatment and care options
Goal 12: Conduct policy research
Goal 13: Conduct regular surveillance
Priority Area 4: Human and Legal Rights
Goal 14: Create an appropriate social environment
Goal 15: Develop an appropriate legal and policy environment
The Committee Endorses and strongly recommends Female-Controlled Prevention and Treatment such as:
1. The search for female-controlled methods of prevention such as female condoms and microbicides receive a major proportion of research funding.
2. Research must be engaged to ascertain the differences between men and women in disease progression, opportunistic infections and management of treatment. At present, women account for only 12% of trial participants. [V. Tallis – 2001]
3. Women’s HIV/AIDS treatment issues must go beyond their reproductive role [Agenda 2000].
4. The Committee supports the development of a vaccine.
5. The Committee supports the development of Home-Based Care (as presented by the Department of Social Development) with the proviso that it eases women and girls’ disproportionate burden of caring for those who are HIV+ and ensures they do not neglect their own health and become further economically marginalized (especially in light of the growing number of households headed by girl children) and that men must be involved as carers.
6. Cultural practices must be examined to ensure they are not infringing the Constitutional right to “bodily integrity of the girl child”.
7. STDs and AIDS must not be treated as women’s issues. Men must be encouraged to assume responsibility for their role and this must be reflected in prevention and treatment programmes.
8. A holistic approach should encompass nutrition and addressing stress levels through exercise, vitamins and minerals and alternative health approaches such as traditional medicine, homeopathy, naturopathy, yoga etc
The Committee believes that it is imperative that men, and boys recognize the role they can play in stopping the spread of HIV-AIDS.
The Committee therefore calls on all men to:
· Respect women and children as equal partners in building a new society
· Redefine masculinity from its present aggressive domineering characteristics that are tied closely to sexual ego.
· Educate each other
· Reclaim your humanity
· Mobilize against abuse and violence
· Stop the myths and stereotypes
· Build a culture of peace within yourselves and in your relationships
· Change your sexual behavior
· Build equality in your home, workplaces and society as a whole.
The Committee believes that together, as women and men, girls and boys we can redefine and reclaim our humanity and each of us has a role and responsibility to do so.
Poverty and access to treatment:
The Health Committee last year held hearings on HIV/AIDS and made the observation in the introduction to its report that “lives are being lost when this is avoidable…Due to the conflict of interest inherent in big business in terms of profiteering (i.e. the pharmaceutical industry) and the historic and current poor allocation and management of government resources the HIV/AIDS crisis will only increase. Profits are being put before health and people in the developing world will continue to be the victims of this attitude.”
“Poverty is the main reason why babies are not vaccinated, why clean water and sanitation are not provided, why curative drugs and other treatments are unavailable and why mothers die in childbirth. … Every year in the developing world 12.2 million children under 5 years die, most of them from causes, which could be prevented for just a few US cents per child. They die largely because of world indifference, but most of all they die because they are poor …” – President Mbeki at the opening of the 13th International Aids Conference.
The hearings found that rich and middle-class people in South Africa who have HIV/AIDS can choose to access anti-retroviral treatment, have access to good nutrition and a healthy lifestyle. Like rich people in Europe and the US they are able to have a good quality of life despite having HIV/AIDS. Poor people who have HIV/AIDS, the majority of whom are African, young and female, have no such option available to them. To often they have limited access to the basics of water, nutrition, good healthcare, including treatment.
Parent to Child Transmission/MTCT as it is more commonly known:
“Government’s Strategic Plan” see P30: Goal 2 – Investigate retroviral use in treatment and care: Review and revise policy on ARV’s to reduce MTCT
* The Department of Health’s Report: Report on Confidential Enquiries into Maternal Deaths in South Africa, 1998” states: “While caring for AIDS patients and this is going to increase rapidly in the next few years. While there is very little potential for cure at present, much can be done to improve the quality of life and improve the pregnancy outcome. The use of prophylactic antibiotics in women with AIDS, the supplementation of their diet with vitamins and minerals, an altered lifestyle, specific management in labour, and the selective use of antiviral therapy to prevent vertical transmission of the virus can all impact on the well-being of the HIV-positive women. It is essential that national guidelines for the management of pregnant HIV-positive women and the management of pregnant women with AIDS are drawn up urgently. The role of prophylactic antibiotics for HIV –positive women (as opposed to women with AIDS) during labour needs to be investigated. It is clear that women with AIDS should be given antibiotic cover during labour”. The Committee endorses the holistic approach.
* The Department of Health HIV/AIDS Policy Guideline; “Prevention and Treatment of Opportunistic and HIV Related Disease in Adults” August 2000, p9: “Current research also strongly indicates that suppressing HIV viral activity and replication with anti-retroviral therapy (ART) or Highly Active Anti-Retroviral Therapy (HAART) combinations prolong life and prevent opportunistic infections.”
* Last year the Minister of Health, Comrade Manto Tshabalala- Msimang, in her speech to Parliament indicated “…Before we can make a decision on the use of Nevirapine, we require the medicine to be registered, as well as the results of the same study” (the SAINT study)
The Committee heard that:
1. The SAINT study was concluded in July 2000. It found that the administration of a single dose of Nevirapine to mother and child reduced HIV transmission by 50%
Since 8 January the Committee was informed the cost of this treatment has
been reduced from R30 per mother to child to R10
2. The Committee was also informed that Nevirapine is now registered by the Medicines Control Council (M.C.C). The Medicines Control Council only registers medicines once it has decided that the benefits outweigh the risks .
* “New Data on the Prevention of MTCT of HIV and their policy implications” was released by WHO/UNAIDS. January 2001, after a meeting of Technical Consultants, expert scientists and programme managers from various regions, HIV infected mothers, representatives from NGOs involved in the implementation MTCT and UN agencies. South Africa was represented by its Chief Director of HIV/AIDS and STDs in the Department of Health, Dr Nono Simelela. Two of the key conclusions were:
1. On breastfeeding and alternative feeding: feasible, affordable, sustainable and safe avoidance of all breastfeeding by HIV infected mothers is recommended. Otherwise, exclusive breastfeeding is recommended during the first months of life. This must be based on counseling the women.
2. The World Health Organisation (WHO) Technical Consultation concluded that the benefit of decreasing mother-to-child HIV transmission with these antiretroviral drug prophylaxis regimes greatly outweighs concerns related to development of drug resistance.
Affordability:
The Committee heard from several submissions and reports that implementation of PTCT would cost less than 1% of the health budget.
The costing by amongst others, health economist, Martin Henscher, who was commissioned by the Health Department itself, took into account voluntary counselling and testing, the required one dose (of Nevirapine) to the mother during labour and one dose to the baby at birth and 6 months free supply of Infant Formula.
The estimates presented to the Committee were that PTCT could save the lives of 60 – 70 000 babies a year. Henscher’s study concluded that the Nevirapine programme might actually achieve an overall saving of R270 million i.e. additional savings after paying for its own costs.
A study by Nattrass, an economist at UCT showed: “saving children from HIV infection by implementing a MTCT programme will save the state money because the costs of a MTCT programme are less than the costs associated with treating the additional children who would be born HIV-positive if no MTCT programme was in place. No credible economic argument to the effect that the South African Government cannot afford a programme to reduce MTCT of HIV. This is particularly the case in relation to the Nevirapine intervention which entails a single dose to the mother and child”.
The Committee concluded on the basis of the range of evidence presented to it that, in relation to PTCT, the benefits out weigh the risk and it is affordable. It can end the “unnecessary loss of life” referred to in the Health Committee’s Report. The Committee recommends that the: The Department of Health should develop its operational plan in relation to PTCT, as required by Government’s HIV/AIDS/STD Strategic Plan with a clear timetable, implementation programme and budget. The recommendation is that it start with existing capacity in its tertiary institutions and the pilot sites, whilst using this to build and strengthen capacity elsewhere (see submissions from HSRC and others)
The Committee believes women must exercise their right to choice in relation to their own health after being informed fully of the benefits and side effects of ARV treatment, TOP, treatment for opportunistic infections, mode of delivery, breastfeeding vs. formula etc. The Committee recommends that this would give effect and help alleviate the plight of poor women.
What can be done to treat HIV/AIDS contracted after rape? See: Goal 5 (p23) of Government’s Strategic Plan “Provide services: Review research on use of ARV to prevent HIV transmission following sexual assault”-
Women can access post-exposure prophylaxis in the private sector. The committee heard the example of Netcare (the largest private hospital group in South Africa with 48 hospitals and clinics). Dr Adrienne Wulfsohn, head of Netcare’s rape clinics, has been conducting research into rape for two years and has assessed more than 700 survivors to whom they have given AZT and 3TC (or more recently Combovir). Their finding is that not one person given ARVs within 72 hours sero-converted.
In late 1998, Dr Josh Bamberger, a San Francisco doctor attached to its health department began studying the impact of PEP after rape on more than 200 women. By October 2000, the State of California issued guidelines for post-exposure prophylaxis (PEP) after rape based on the outcome of Bamberger’s study.
A study delivered to the Durban AIDS conference in July by scientists, Jean-Pierre Benais and a team from France had identical results: of 100 rape survivors given anti-retrovirals from five Parisian clinics since June 1999, not one had sero-converted.
Given this research the Centres for Disease Control in Atlanta, USA (CDC) embarked on writing new guidelines for PEP after rape. The 1998 CDC guidelines, based on needle stick injuries, suggested that triple therapy (such as AZT, 3TC and Crixivan) taken soon after a rape would probably ensure that 81% of patients would not become HIV+.
Thus far, no rape survivor who was HIV negative on the day of the rape, and who takes antiretrovirals after rape develops HIV, even when it can be proven that his or her rapist or rapists were HIV+ - in other words ARVs taken within 72 hours after rape or high-risk sex are 100% HIV preventative.
The California guidelines note: “PEP medications taken soon after exposure to HIV can prevent HIV infection …”(Submission by C. Smith, 2001; Does PEP (ARVs) after Rape Work?)
The Committee recommended the following:
The high and shocking levels of rape (the most recent being the reported rape of babies – linked to the myth that HIV/AIDS can be cured by raping a virgin) demands an urgent response from the State. At present there is no access to treatment in the public sector for these babies, children and women. An Expert Committee needs to be urgently convened by Government to examine recommendations for best practice and develop a guideline for use of ARVs as post-exposure prophylaxis for rape. The Committee believes outrage at the horror of these rapes has to be converted into action to prevent the additional tragedy of the rape survivor (baby, child or woman) contracting HIV/AIDS.
Is treatment for ALL a pipedream?
The multi-national pharmaceutical companies make massive profits from drugs for medication. In 1999, they made a profit of $27.5 billion (Source Fortune Magazine, April 2000.) The drug companies’ influence has been greatly magnified because U.S. trade officials have put the full weight of American trade pressures to work on their behalf. Pharmaceutical manufacturers gave $23 million in the last election cycle to both parties, although 69% went to the Republicans. It also spends approximately $75 million on lobbying every year.
However, even in the U.S., the cost of drugs is provoking questions about whether the continued research and development really depends on giving companies a 20 year monopoly to charge whatever price they choose, since they are often marketing other people’s discoveries (Tina Rosenberg: The NY Times Magazine, 2001)
This year, the Government’s of the U.S. and Canada, in the face of the Anthrax threat, (which has only claimed 4 lives by comparison to the millions who have HIV/AIDS) over-rode all their own arguments against poor countries using the provisions in the WTO and TRIPS to access affordable generic equivalents.
Has any developing country been able to offer free treatment for all those with HIV/AIDS?
The Committee hearings were presented with many other countries experiences. These included Uganda, Botswana, Ivory Coast, Senegal, Thailand and Brazil, amongst others.
Brazil is the only developing country, which has provided free treatment for all its citizens who have HIV/AIDS
There are many similarities between Brazil and South Africa, Brazils gini-co-efficient is very similar to South Africa’s (a measurement of the inequality of society – the divide between the rich and the poor). South Africa’s is 0.60 and Brazil’s is 0.63.
In the early ‘90’s Brazil according to all predictions, was heading for an AIDS crisis of devastating proportions. It developed a comprehensive and vigorous prevention and treatment campaign in the mid 90’s. It produced generic equivalents in its own state laboratories.
Since 1997, virtually every AIDS patient in Brazil, for whom it is medically indicated, gets, free, the same ARV’s that keep rich Americans healthy. In 2000 HIV/AIDS drugs cost Brazil 4% ($ 444 million) of its Health Budget. (The decline in opportunistic infections from 1997- 1999 saved the country $ 422 million). The cost saving from declining hospitalization and treatment for opportunistic infections offset approximately 85% of the cost of the drugs.
The treatment programme has cut the HIV/AIDS mortality rate nationally by about 50% to date. Hospitalization from all HIV/AIDS related diseases has dropped by 80%. The incidence of TB in HIV + patients has dropped by half.
The economic benefits (through halving the expected infection rates), is increased productivity of those who no longer need to stay at home or care for the sick.
Brazil has offered to transfer all its technology and provide training in the practicalities of treating countries that want to make drugs and will supply them to patients free.
The treatment and prevention programs complement each other – The availability of lifesaving treatment is a powerful incentive for people to get an HIV/AIDS test and learn how to prevent the spread of HIV/AIDS and further disease.
How did Brazil deal with the problems of:
1. Health System Too Fragile?
On a shaky foundation of its public health service, Brazil built a well-run network of HIV/AIDS clinics
2. “Uneducated people can’t stick to the complicated regime of pills?”
Brazilian HIV/AIDS patients have proved they are just as able to take their medicine on time (69% achieved 80% adherence) as patients in the U.S. (72% achieved 80% adherence).
“The main criticism from developed countries was that we did not have the conditions for ARV treatment.” They said it would be dangerous for other countries, that we would create resistance “ (Texeira, Head of Brazils AIDS programme). What Brazil has done is to provide patients with the help and training to take the medicine correctly. Poor people with HIV/AIDS get free bus passes. Clinics work with local churches and Lions Clubs to provide food and baby formula. PLWA’s counsel new patients in waiting rooms of clinics and hospitals. It has used its well organized network of civic groups to build support for the program, designing it and making it work”
4. “Treating HIV/AIDS is too expensive”
Brazil’s programme pays for itself. It has prevented hundreds of thousands of new hospitalization, cut the transmission rate, helped to stabilize the epidemic and improved the overall state of public health in Brazil. It can afford to treat AIDS because it does not pay market prices for anti-retroviral drugs. Instead Brazil largely, produces its own generic equivalents.
[Dawn Informs, August 2001]
What can South Africa do in relation to providing affordable medicine?:
1. South Africa has passed a far-reaching law and Government emerged victorious from a court challenge posed by the pharmaceutical industry:
The Medicines & Related Substances Control Amendment Act, No 90 of 1997 (Medicines Act).
The Act allows:-
-generic substitution of medicines no longer under patent.
- a pricing committee- that will set up “transparent pricing mechanisms”. Pharmaceutical companies will have to justify the prices they charge.
- allows for international tendering for medicines in the public sector
“Measurements to ensure supply of more affordable medicines”. Section 15c of the Medicines Act allows for Parallel Importation i.e. to buy drugs from countries where prices are already lower.
The Committee recommends that SA use it’s rights in terms of this law.
2.Article 7 of TRIPS clearly provides that patent rights should not conflict with “social and economic welfare” objectives of Member States.
Article 8 of TRIPS: Principles: a. “Members may in formulating or amending either their laws and regulations, adopt measures necessary to protect public health and nutrition, and to promote the public interest in sectors of vital importance to their socio-economic and technological development, provided that such measures are consistent with the provisions of this agreement”.
b.”Appropriate measures, provided that they are consistent with the provisions of this Agreement, may be needed to prevent the abuse of intellectual property rights by right holders or the resort to practices which unreasonably restrain trade or adversely affect the international transfer of technology”.
The Committee recommends that South Africa should take steps to ensure that nothing in the TRIPS(Trade Related Aspects of Intellectual Property Rights) agreement shall prevent South Africa as a member of WTO taking measures to protect public health. Between now and 2006, when all signatories to TRIPS i.e. all members of WTO, must give drug companies 20 years patent protection on inventions they have patented, SA should explore ways of evaluating and changing this rule if necessary, to effect Articles 7 & 8 of TRIPS itself.
3.The Joint Monitoring Committee on the Improvement of Quality of Life and Status of Women endorses the Recommendations the Health Committee made on the basis of its hearings on HIV/AIDS last year. ie:
· Use the Patent Act of 1975 to permit affordable access to HIV/AIDS drugs. Compulsory licensing / parallel importing must be implemented
· Intellectual Property Rights must not be put before the patients’ rights involved in clinical trials
· The Department of Health to review patents on AIDS-related drugs
· Close monitoring and evaluation of Clinical Trials to be continued.
· The Medicines Control Council needs to report on the efficacy of drugs proposed for clinical trials before patients are involved in these trials
· Discussions need to be held between the Department of Trade and Industry and the Department of Health regarding TRIPS
· Voluntary Associations and Unions to play a role in changing attitudes of Health Workers towards people with HIV/AIDS
· All people living with HIV/AIDS must receive equal treatment
4. The Committee supports the recommendations made by the HSRC” Evidence Based Treatment”: by Dr. Olive Shisana, that South Africa should:
-Implement President Clinton’s Executive Order that encourages Sub-Saharan countries to use the options in the TRIPS agreement to import or use compulsory licensing to gain access to drugs for HIV/AIDS related illnesses.
- Import ARV’s and other drugs from countries like Brazil and Thailand without being sanctioned, given that many poor governments in developing countries do not have to comply with the TRIPS agreement until year 2006 (unfortunately some are rushing to comply with the restrictive trade policies that deprive them cheaper drugs)
- Work with countries such as Brazil and Thailand to learn the technology to produce these drugs.
- Negotiate cheaper prices for diagnostic kits and reagents (or even bulk purchase for regions)
- Establish sustainable financing mechanisms to ensure reliable distribution and access to drugs
-Begin providing these locally produced or imported ARV’s in all tertiary facilities, which by definition have the necessary infrastructure.
The HIV/AIDS/STD Strategic Plan (p5) says that each department has to produce an “operational plan”. The hearings identified that the critical area that lacks an operational plan is the specific treatment of HIV/AIDS itself. The Committee supports the view that it is critical to address the cause(hiv/aids) rather than just the symptoms(opportunistic diseases). South Africa can access and eventually learn to produce, good quality generic equivalents in a way that is affordable and sustainable.
Scientists and Doctors who presented to the Committee explained the need for clinical management of all potentially toxic drugs (as is presently done in relation to drugs for cancer), as a routine part of effective and good health care. Presentations and reports during the hearings reiterated that nurses and healthworkers can be trained on the possible side effects and how to deal with them. They describe how demoralizing it is to be unable to treat HIV/AIDS itself. The Centre for Disease Control’s Guidelines for the use of Antiretroviral Agents in HIV Infected Adults and Adolescents which deals with the timing and management of ARV for US Practitioners (that the President referred to) are useful in this regard “Treatment, should be offered to all patients with the acute HIV syndrome, those within 6 months of HIV seroconversion, and all patients with symptoms ascribed to HIV infection” (p11 of the Guideline). One of the Authors of the Guidelines, Dr Robert Schooley states in an interview:"There is no question there are side effects from these drugs. But I would rather deal with the side-effects than death”
CONCLUSION:
At the 13th International Aids Conference in Durban, Nelson Mandela said the following:
“ It is never my custom to use words lightly. If twenty seven years in prison have done anything to us, it was to use the silence of solitude to make us understand how precious words are and how real speech is in its impact is upon the way people live and die…
Now, however the ordinary people of the continent and the world – and particularly the poor on our continent, will again carry a disproportionate burden of this scourge- would if anyone cared to ask their opinions, wish that the dispute about the primacy of politics or science be put on the backburner and that we proceed to address the needs and concerns of those suffering and dying. And this can only be done in partnership. I come from a long tradition of collective leadership, consultative decision-making and joint action towards the common good. We have overcome much that many thought insurmountable through an adherence to those practices. In the face of the grave threat posed by HIV/Aids, we have to rise above our differences and combine our efforts to save our people. History will judge us harshly if we fail to do so and right now. Let us not equivocate: a tragedy of unprecedented proportion is unfolding in Africa. Aids today in Africa is claiming more lives than the sum of all wars, famines and floods, and the ravages of such deadly diseases as malaria…One quarter of a century after the Soweto riots, children’s lives are again on the line, and this time the enemy is AIDS.”
* These hearings have been very limited in terms of the scope of outreach to organizations and individuals. The Committee therefore recommends that MP’s utilize the Constituency period to hold hearings on HIV/AIDS, Poverty and Gender Based Violence. The Committee will provide guidelines and questionnaire to assist MP’s in this task.
The Committee concludes that the key is to expand women’s economic, political and social choices so poverty, violence and HIV/AIDS do not decide for her.
The Committee concludes that if we operationalise all aspects of prevention and treatment –as spelt out in Government’s HIV Strategic Plan Government will make a major impact on the lives of poor women. Women can then make their own well-informed choices.
The worst legacy of apartheid was to destroy our sense of self and community – it clearly succeeded with large numbers of people who like the men (fathers, uncles, brothers, grandfathers…) who are raping babies, do so in the context where the life of women and children are not valued. The inherent human values of love, peace and joy have been replaced by hate, fear and pain as the hallmark of human experience.
The Committee concludes that the challenge is to rebuild a culture of peace and revalue the life of each and every one.
The hearings confirmed that that in partnership, drawing on the experience, expertise and unique talents present in each individual sector and community in South African society, we can together defeat this legacy.
As President Thabo Mbeki said at the 3rd International Aids Conference:” The message is that we are a country and a continent driven by hope and not despair and resignation to a cruel fate” That hope is reflected in Scamto Print (loveLife) Issue 17’s editoral: “…. lets listen to our brains and our hearts, and do what’s right for us. And maybe some day soon, when we talk about AIDS, it will be to tell our grandchildren about the time when it existed”.
Attached to this report is Appendix A : Summaries of Written and Oral Submissions on the Impact of HIV/AIDS on women and girls. This appendix has been drafted for the Committee by Carmine Rustin, who works for Parliament’s Research Unit and Shereen Dawood, who works for the ANC Study Group of the Joint Monitoring Committee on the Improvement of Quality of Life & Status of Women.
They helped organize the hearings, sat through them and have meticulously summarized the key points that were made, in both the written and oral submissions. Most of the written submissions received have been summarized. The full list is attached as Appendix B, which has been compiled by Carmine and the Committee’s Clerk, Suné Pauw.(who also set up the hearings with Fuad Holliday). The work of Carmine, Shereen, Suné, Fuad and Kim Davids (secretary to the Chair), have been invaluable to these hearings.
The Committee unanimously adopted this report at its last meeting for the year on November14, 2001. The Committee thanked the Chair, Pregs Govender, for compiling and writing this report on its behalf.
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Pregs Govender
Chair: JMC on Improvement of Quality of Life & Status of Women
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Priscilla Themba
Deputy Chair: JMC on Improvement of Quality of Life and Status of Women
APPENDIX A
SUMMARIES OF WRITTEN AND ORAL SUBMISSIONS ON THE IMPACT OF HIV AND AIDS ON WOMEN AND GIRLS
Written Submissions
Note: The letters at the end of the title indicates the number assigned to the documents for reference purposes.
Adolescent Women, Sexual Violence and HIV. Jonathan Stadler, Reproductive Health Research Unit (RHRU). [Q]
The paper moves from the premise that there are gender and age disparities with regard to HIV. In particular, young adolescent women are susceptible to infection. The paper looks at the reasons for this and suggests some recommendations. Some of the reasons considered are rape and sexual violence, sexual coercion and young women having sexual relations with older men. Some recommendations in addressing the above takes cognisance of the fact that:
· Adolescent women need to be recognised as a vulnerable group.
· Sexual abuse and coercion against women needs to be prioritised.
· The role of men in sexual violence should be recognised. They should be exposed and action taken.
· Boys need to be socialised into responsible adults that respect gender equality.
Adelaide Advice Centre – [N]
Adelaide Advice Centre was supposed to present their paper at the public hearings. As this did not happen, the paper is briefly summarised.
The aim of the paper is to highlight and reduce the unnecessary fear and anxiety about HIV and AIDS and misinformation about HIV transmission. It also shares information on the realities of those living with HIV and AIDS. They call on community involvement in addressing the pandemic. Churches and volunteers should be part of educating others about HIV and AIDS. The paper also deals with the impact of HIV and AIDS on development and it highlights some factors that facilitate the spread of HIV, including poverty, migrancy and access to health care.
Agenda No. 39 1998. AIDS: Counting the Costs [X]
This edition of Agenda is dedicated to HIV and AIDS with a focus on women. The articles include:
· AIDS is a crisis for women: Vicci Tallis – The author provides an overview of AIDS and its impact on women. She states that interventions and programmes have not been implemented in a gendered context. This is vital as it takes into account women’s rights as a central concern.
· Women and AIDS – the imperative for a gendered prognosis and prevention policy: Quarraisha Abdool Karim – The paper presents a framework for understanding HIV and AIDS and women. The author argues for holistic interventions, which recognises the role of gender inequality in the spread of the disease.
· A positive view: Promise Mthembu – This article deals with the author’s story and account of living with HIV. One of the major concerns for HIV positive women is prejudice. The author argues that HIV positive women also have rights and that these should be recognised.
· The Links between gender violence and HIV and AIDS: Betsi Pendry – This paper presents a report back on a seminar that, amongst others, highlighted the link between violence against women and HIV transmission and underscoring the role of gender inequality in HIV transmission.
· The power of the small group – from crisis to disclosure: Vishantie Sewpaul and Thobile Mahlalela - This article recounts the story of young mothers who learn about their HIV status through their babies. The women shared their experiences through participation in a support group which has also evolved to deal with issues of advocacy and lobbying.
· The search for female-controlled methods of HIV prevention: Helen Rees – The author argues that women are more vulnerable to infection of both STD’s and HIV. Women’s ability to negotiate safe sex is often compromised. In the paper, the author argues that there is a real urgency around the need to develop female-controlled methods for HIV and STD prevention which would allow women to take control for barrier protection during sex.
· Gender as an obstacle to condom use: HIV prevention amongst commercial sex-workers in a mining community: Catherine Campbell, Yodwa Mzaidume and Brain Williams – The authors demonstrate the need and importance of peer education through which women can address issues of sexual identity and social norms that have previously worked against condom use.
· Ethics and consent – women in vaccine research: Kitty Barrett – The article illustrates that women are often excluded from medical research and thus research that is important and relevant for women may not take place. As a result, the medication that is developed may not be effective for women. In the paper, the author deals with issues of information supplied to women and issues of voluntary consent for AIDS research.
· Making an informed choice – discourses and practices surrounding breastfeeding and AIDS: Gill Seidel – This paper focuses on the tensions and contradictions between the manner in which HIV is transmitted through breastfeeding and the arguments that are in support for breastfeeding in various institutions such as the medical profession.
· Off target messages – poverty, risk and sexual rights: Hilda Adams and Anita Marshall – The authors look at messages, training and awareness interventions and the reasons why they are having little impact. The also put forward some recommendations to improve the effectiveness of HIV and AIDS interventions.
· Shosholoza’s goals: educate men in soccer: Gethwana Makhaye – This paper focuses on the efforts made by an AIDS project to target men in soccer structures in Kwazulu-Natal. This is an effort to mobilise men to recognise the threat of HIV in their lives and to take responsibility for prevention and care efforts.
· Trade union women speak up on HIV/AIDS: Saranel Benjamin and Chuck Einloth – The authors detail the concerns raised by trade union women on the effects of the epidemic on their lives.
Agenda No. 44 2000. AIDS: Global concerns for women. [Y]
The following articles appeared in this edition of agenda:
· Targeting men for change: AIDS discourse and activism in Africa: Janet Bujra – The aim of the paper is to focus on and explore the implications of campaigns that focus on men. It also looks at issues of masculinity and how the enactment of masculinity might affect the spread of the disease or how it might change it.
· Uniting across global boundaries – HIV positive women in global perspective: Sue O’ Sullivan – This article introduces the International Community of Women Living with HIV and AIDS (ICW) to readers. It is an organisation that developed out of the recognition that HIV positive women lacked support and that information was not always available to them. It’s aim is to improve the situation of women living with HIV by challenging discrimination and stigma.
· Empowering women to prevent HIV: the microbicide advocacy agenda: Megan Gottemoeller – This article deals with the issue of microbicides. The author argues that research into and the development of microbicides should be given top priority.
· Promoting male involvement in reproductive health: Pranitha Maharaj – In this article, the author argues that the involvement of men in reproductive health is essential to improving the health status of women. Reproductive programmes that have directly involved men have been successful in increasing the support of men for family planning and the prevention of STD’s. The article suggests some recommendations for involving men.
· Campaign for access to treatment: Anneke Meerkotter, Nathan Geffen and Elize Petoors – The authors argue that given treatment and access to essential drugs, the people living with HIV can live longer and healthier lives than was possible a few years ago. The article deals with barriers to treatment, which mostly centres on cost. Other barriers include the poor state of health infrastructures (e.g. many clinics don’t have an uninterrupted electricity supply, and water supply).
· Caucus lobbies for global women: Joyce Hunter and Mabel Bianco – The authors provide information on the International AIDS Women’s Caucus (IAWC), which was borne out of the crucial need for women to organise and have a voice at international conferences and forums on HIV and AIDS. It also looks at the space that they will create at the 13th International AIDS Conference to discuss issues pertaining to women and HIV and AIDS.
· Gendering the response to HIV/AIDS challenging gender inequality: Vicci Tallis – Vicci Tallis argues that many HIV and AIDS programmes don’t take gender into consideration. She argues that gender inequality needs to be incorporated into HIV and AIDS programmes in a structured way. She further states that incorporating gender into internal policies and external programmes and projects of AIDS service providers are necessary to impact on the HIV and AIDS epidemic.
· African Renaissance: where are the women?: Sisonke Msimang – The article looks at what the African Renaissance is. The authors argues that it means very little for most South Africa, especially women. Women are also particularly silent on the issue of the Renaissance.
· The judiciary fails working mothers: Clare Wyllie – The article deals with the Labour Appeal Court ruling against a women executive, Beverley Whitehead, who claimed that Woolworths had discriminated against her on the basis of her pregnancy. The author argues that this has serious implications for women in the labour market.
· Gender representations in advertising: no time for change?: Lena Slachmuijlder – This article reports on a research study on gender and advertising commissioned for the Commission on Gender Equality. The research was motivated by a recognition of the powerful influences of advertising on society and the potential of advertising to either challenge or perpetuate negative gender stereotypes.
An enhanced response to HIV/AIDS and Tuberculosis in the Public Health Sector – Key components and funding requirements, 2002/03 – 2004/05. Department of Health, July 2001. [1G]
The document outlines the impact that HIV and AIDS will have on various sectors of society. It acknowledges that unless a cure is found for HIV or a breakthrough is made in prevention technologies, the disease will have a profound impact. The impact of HIV and AIDS will be felt significantly in the health sector as well. The document outlines the components of an enhanced health sector response to HIV and AIDS and TB. It also sets out the funding requirements of such a response over the MTEF cycle from 2002/03 to 2004/05.
Centre for the Study of Violence and Reconciliation. Taking steps to address the links between violence against women and HIV and AIDS in South Africa. [1K]
The paper deals with the intersection between HIV and AIDS and gender violence in women’s lives. This intersection is evident in rape, abusive relationships, sexual behaviour of women and in the event of women receiving HIV counseling and testing, which may result in partner violence. The authors state that few programmes address this intersection. Some recommendations are put forward to address the information and intervention gaps. Amongst these are:
· Voluntary counseling and testing services should also focus on issues of domestic violence.
· Integrating the work of violence against women and the HIV and AIDS sector.
· Prioritising the development of microbicides.
· Ensuring that shelters for abused women are also accessible to HIV positive women.
CASE report on HIV/AIDS, 2001. [I]
The Joint Monitoring Committee on the Improvement of Quality of Life and Status of Women requested that the Community Agency for Social Enquiry (CASE) conduct a survey of HIV and AIDS service organisations. The objectives of the study were to:
· Find out what types of AIDS projects and programmes exist and in what areas.
· Investigate the focus and target groups of service-type activities.
· What funding and other resources are provided for service-type activities and by whom?
· Arrive at suggestions as to how Government can assist organisations to provide services so as to help people, households and communities affected and infected by HIV and AIDS.
A total of 61 organisations were sampled from the SA AIDS Directory of which 35 completed questionnaires were received.
Suggestions made with regards to how Government can assist organisations included:
· Government must put more resources into awareness and prevention campaigns.
· Issue a statement that HIV causes AIDS to dispel any confusion.
· Government must establish or fund drop-in centres that can provide information on HIV and AIDS related matters.
· Government must develop clear policy guidelines and training for health care workers.
· Funding proposals should be fast-tracked through key Government Departments and training for relevant staff should be undertaken to facilitate this.
· Government should have programmes focusing on stigma.
· Government should provide low-cost anti-retrovirals, especially to pregnant women.
· Government should provide access to clean water, particularly in rural areas.
Dawn Informs Supplement – August 2001 [W]
The August edition of Dawn covers issues relating to Trade, AIDS, Public Health and Human Rights. The following presents a summary of the articles in this supplement.
· Brazil – People First, Profits Later
The article written by Jane Glavao, who works in the Health Ministry National STD and AIDS Coordinating Committee International Cooperation, outlines why Brazil has been successful in the Brazilian policy of anti-retroviral medication distribution.
It is stated that one of the key lessons from the Brazilian response to the HIV and AIDS epidemic has been the importance of mobilising civil society, especially people living with HIV and AIDS, to participate in decision making processes at the earliest stage. This process has helped to maintain and expand the rights of HIV and AIDS victims in Brazil.
Key elements in the success of the distribution system were:
o The existence of a united Health System.
o A network of professionals trained in HIV and AIDS diagnosis.
o The strengthening of public laboratories.
o Criteria for the administering of anti-retrovirals.
o Patient support.
The cost is totally funded by the National Treasury through the Health Ministry.
Brazil’s universal distribution policy has been possible due to the innovative approach of disregarding certain patents. The President has also issued a decree, which is allowed for under the World Trade Organisations agreement, that compulsory licensing is allowed in cases of national emergency and public interest.
· Victory in Drugs battle. US withdrawal of WTO Case against Brazil
The article deals with the withdrawal of the United States’ (US) complaint with the World Trade Organization (WTO) that sought sanctions against Brazil for allowing the use of life-saving generic HIV and AIDS drugs. The US withdrew the case on the eve of the United Nations (UN) General Assembly Special Session on HIV and AIDS. This was as a result of active lobbying by the diverse group of people. These people have been supporting efforts to make medicines more affordable to poor people throughout the world.
The United Nations, World Bank and medical professionals have lauded the Brazilian AIDS programme as one of most successful in the world. During the 1990’s, local manufacture of cheap generics reduced treatment costs by 70% and allowed the government to prescribe free anti-retrovirals to HIV and AIDS patients. Since 1996 Brazil has halved the mortality rate, decreased hospitalization by 80% and reduced the rate of mother-to-child-transmission.
Brazil is setting an example for other developing countries. It has shown that despite opposition from the US and powerful drug companies, a developing country can run a successful AIDS programme.
Department of Education’s HIV and AIDS Strategy. Presentation to the Education Portfolio Committee, 28 May 2001. [1C]
The document states that there is a need to protect the education system to ensure the continued supply and demand of education. It has to develop tools and planning models to facilitate analysis and understanding of the impact. It discusses some of the initiatives undertaken in the curriculum. It includes a HIV and AIDS life skills policy in the new 2005 curriculum, a grant by Government to address HIV and AIDS within the curriculum as part of the integrated approach with the Department of Health and Social Development. It also aims to support the inclusion of HIV and AIDS into the pre-service training of tertiary institutions.
Within the HIV and AIDS and learners initiative, the Department is looking at establishing an identification and support system for learners in distress and /or orphaned by HIV and AIDS. It also endeavours to promote the school as a center of support and hope for communities. The HIV and AIDS and work programme focuses on, amongst others, a workplace programme developed and adapted for schools as a workplace.
Engendering the Response to HIV/AIDS in South Africa. National Gender Summit, 2001. E. Maluleke, Department of Health, Gender Focal Point & T. Braam, Sonke Development Agency. [V]
This paper was presented at the National Gender Summit. It outlines the national response to HIV and AIDS by the State and civil society in South Africa. It also argues that an engendered response to the HIV epidemic is needed to address the epidemic at all levels of cause, effect and manifestation. The paper addresses HIV and AIDS as a gendered issue and looks at women’s vulnerability, issues of care and support and treatment. A SWOT (Strengths Weakenesses Opportunity and Threats) analysis is done of the response to HIV to date, with a specific focus on Governments Strategic Plan. An important acknowledgment in the analysis is the fact that the strategic framework for dealing with HIV and AIDS is gender blind and that it does not integrate key gender considerations into its respective areas for intervention. The paper concludes with key recommendations as to how gender can be incorporated into the country’s response to HIV and AIDS.
HIV infection and in-hospital mortality at an academic hospital in South Africa. Karen Zwi, John Peltifor, Neil Soderlund and Tammy Meyer [1I]
The aim of the study was to report on the impact that the rapid increase in HIV infection in children hospitalised at Chris Hani Baragwanath hospital had on in-hospital mortality. The study reviewed the hospital discharge records from January 1992 to the end of 1996. In brief, the mortality rate of children had increased at the hospital as a result of HIV infection. Nearly half the deaths in 1996 were HIV related. HIV infection seriously threatens the advances made on child survival in South Africa over the last few decades.
HIV/AIDS/STD Strategic plan for South Africa 2000-2005. February 2000. [T]
The document is a broad national strategic plan designed to guide the country’s response to the epidemic. It was initiated by the Health Minister, Dr. Tshabalala-Msimang in response to the President’s challenge to society to become actively involved in initiatives to address HIV and AIDS. The priority areas covered in the plan are prevention; treatment; care and support; legal and human rights and monitoring, research and evaluation.
Home-based care for people with HIV and AIDS in South Africa. What will it cost? Centre for Health Policy, Department of Community Health, University of Witwatersrand. [1F]
The study states that given the high levels of HIV infection in South Africa, public health services are likely to face increasing demands. As the building of hospitals is not a viable option (given the financial implications), alternative models of care for people living with HIV and AIDS are more feasible. These alternatives include home-based care. The study was undertaken to assess how much these models would cost if implemented on a large scale. It found that the total annual economic costs, including the costs of donated goods, ranged between R326 302 to R935 598.
Masimanyane Report on Women and HIV and AIDS. Information accessed from 5 provinces in the course of research into Government’s implementation of CEDAW and the Beijing Platform of Action [1E]
The Joint Monitoring Committee on the Improvement of Quality of Life and Status of Women commissioned the research done by Masimanyane to assess whether the quality of life of women and girls had changed since Government’s ratification of CEDAW and the Beijing Platform of Action. The report is based on the anecdotal information of 1127 women and 322 men interviewed. The following themes were raised:
· The extent of the epidemic: People’s understanding of the epidemic differed considerably. People in urban areas tended to believe that HIV was a problem in their communities. However, it was discovered that despite high levels of knowledge on HIV and AIDS, there was still some people who had little or no knowledge about the disease. Many people also had misconceptions about the disease.
· Attitudes towards women with HIV and AIDS: The report states that there is a significant amount of prejudice, fear and ignorance around the diseases. People who are infected are often isolated by communities. Women also face many challenges with regard to HIV and AIDS. These include the difficulty around negotiating safer sex practices.
· Health care provision for women with HIV and AIDS: Many women raised problems around the availability of pre-and post-test counseling at clinics and hospitals. Health care facilities were also reported as being poorly staffed and equipped. Women also faced specific problems with transport when being taken to hospital, problems of breastfeeding because they lacked access to or money for alternative forms of feeding.
· Racism and HIV and AIDS: Many of the black people were resentful of white people teaching them about HIV and AIDS. There are also misconceptions along racial lines about HIV and AIDS.
· Poverty and HIV and AIDS: Poverty impacts on HIV and AIDS. People were often faced with the challenge on whether to buy food with the money they had or whether to pay for transport and buy the medication that they need.
Several recommendations were made. These include:
· Government must provide support to women by making drugs and immune boosters available.
· Disclosure should be made safe before it is encouraged.
· HIV and AIDS must be de-stigmatised.
Educating of communities and health workers.
Ministry of Health (Brazil). National Drug Policy. February 2001. [1L]
The Brazil’s Ministry of Health’s policy for care of people living with HIV and AIDS includes the organisation of health services, support to people living with HIV and AIDS, support non-governmental organizations. It also includes the creation of a programme for the free and universal access to anti-retroviral drugs through the public health network.
This ‘free access to anti-retrovirals’ programme started in the early 1990’s with the distribution of AZT. The programme was later expanded and consolidated by a Congressional Bill sanctioned by the President. This gives every patient access to all medication required for his or her treatment. The document also outlines the national production, procurement and distribution of drugs.
A private company first produced AZT in 1993. Public sector production of AZT was started in 1994. The document furthermore outlines the impact on anti-retrovirals and patient adherence to therapy.
Preliminary Report – The National Children’s forum on HIV/AIDS co-ordinated by the Children’s Institute, University of Cape Town. [1D]
90 children from all over South Africa came together in Cape Town to talk about how HIV and AIDS impacts on their lives. The objectives of the forum were to:
· Produce a memorandum of action which captured issues raised by children to ensure that decision-makers make a commitment to address these issues.
· Raise awareness of the impact of HIV and AIDS on children.
· Provide feedback on the implementation of policies and legislation relevant to children and families made vulnerable by HIV and AIDS.
· Develop capacity and will of key role players to engage children and youth in decision-making processes at all levels.
Children discussed issues that they face daily and the problems they experience. The issues raised provided an indication of the poor implementation of existing policies. This highlights the need for decision-makers and service providers to provide an immediate and practical response to their problems.
Presidential AIDS Advisory Panel Report (March 2001)
Local and international scientists were invited to form part of an Presidential AIDS Advisory Panel to inform discussions in a number of issues relating to AIDS. The terms of reference as detailed in the report were:
1. The following questions needed to be addressed in dealing with this issue of the evidence of viral aetiology of AIDS and related concerns about pathogenesis and diagnosis:
a. What causes the immune deficiency that leads to death from AIDS?
b. What is the most efficacious response to this cause or causes?
c. Why is HIV/AIDS in sub-Saharan Africa heterosexually transmitted while in the western world it is said to be largely homosexually transmitted?
2. What is the role of therapeutic interventions in the context of developing countries? This should cover therapeutic interventions in the following contexts:
- In patients with AIDS
- In HIV-positive patients
- In the prevention of mother-to-child transmission
- In the prevention of HIV transmission following occupational injury
- In preventing HIV transmission following rape
3. Prevention of HIV/AIDS
The discussions above should be underpinned by considerations of the social and economic context, especially poverty and other prevalent co-existing diseases and the infrastructural realities of developing countries.
The report also makes recommendations and sets out areas where future research may be required.
South African Association of Women Graduates. Research Report. Being female in South Africa. Hazel Bowan and Judith Cornelissen, 2001.
Phase 1: Growing up female in South Africa. Years 10 – 19.
Different themes emerged in the study. These concerned family and living circumstances, education and careers, social life and topics that the girls favoured with regards to the media. With regards to the education theme, most respondents indicated that they did not experience any gender discrimination in school. In instances where they had, this was related to playing different sports than boys, being expected to behave like ladies and being treated differently by teachers.
Sex education was evident as a responsibility that should be undertaken by schools and youth groups and that it was still a taboo subject in the home. 8 out of 10 girls indicated that sex before marriage was not right but approximately 2 out of 10 were sexually active. 75% of these girls were not using contraceptives.
The survey indicated that “girls of South Africa are generally confident, happy people who enjoy school and are aware of issues that surround them such as HIV/AIDS but there appears to be little gender sensitisation. Most avoid smoking, alcohol and drugs and are not in favour of sex before marriage. They know what they want to do after completing their schooling; most want to study further and know where they want to study. Given the South Africa statistics of violence through gangsterism, rape and domestic circumstances, the overall picture presented by the respondents is very positive and offers much for the future of the country” (p. 74).
Phase 2: Years 19 - 54
The survey indicated that most respondents in this age group had a secondary school qualification and that respondents were mainly in professional positions, although these were non-supervisory. The research results indicated that nationally Coloured and Black women had their children between the ages of 15 and 24 whilst White and Asian women had their children between 25-29 years. The majority of respondents felt that sex before marriage was acceptable. Only half of the respondents who were sexually active indicated that they take precautions against HIV and AIDS. Women across race groups indicated that they have witnessed and experienced various forms of violence.
Phase 3: Being a female senior citizen in South Africa. Years 55 – 80+
Just more than half the respondents indicated that they had secondary schooling whilst 4 out of 10 indicated that they had no further qualifications. The results showed that the women have mainly worked in traditional service roles and in supporting roles. The respondents indicted that they have been discriminated against in the home and the workplace. The report further also indicates that the majority of women have ‘not been sexually harassed, assaulted or experienced a number of other forms of violence’, yet the amount of violence that respondents reported they have experienced or witnessed is unacceptable. Women lacked knowledge about menopause, which could also account for women not having regular medical examinations.
South African Law Commission (SALC) Interim Reports on aspects of the law relating to AIDS
SALC has a number of interim reports on the above. It includes:
· First Interim Report (February 1997) – Issues on disposable syringes, needle and other hazardous material; universal workplace infection control measures; national compulsory standard for condoms; regulations relating to communicable diseases and the notification of notifiable medical conditions; national policy on HIV testing and informed consent are discussed.
· Second Interim Report (April 1998) – Looks at pre-employment HIV testing.
· Third Interim Report (April 1998) – Discusses HIV and AIDS and discrimination in schools.
· Fourth Interim Report (November 2000) – Looks at the issue of compulsory HIV testing of persons arrested in sexual offence cases.
· Fifth Interim Report (April 2001) – Discusses the need for a statutory offence aimed at harmful HIV-related behaviour.
Statement of concern on women and HIV and AIDS – Agenda [M]
A number of organisations, including Agenda, the AIDS Law Project, Gender Research Project, Commission on Gender Equality and the Treatment Action Campaign endorsed a statement of concern pertaining to women and HIV and AIDS. The statement calls on Government and President Mbeki to act in a manner that ensures women’s concerns are recognised in HIV and AIDS prevention, treatment and care. The organizations also call on AIDS service organisations, NGO’s and civil society to challenge unequal gender relations and gender subordination of women by encouraging open discussions about gender power relations and HIV and AIDS.
Technical report in the impact of criminalisation of sex work on vulnerability to violence, exploitation and the risk of sexually transmitted infections including HIV. Delany. S, Rees. H, George. R, Lethoba. J, Mecoamere. D, Molawa. T, Masuku. P, Ngqokomashe. F, Mokoena. G and Koetle. N, RHRU. [Z]
The paper is informed by the research work undertaken by the RHRU on the sex industry in Johannesburg. It states that the criminalisation of sex work has the following impact on adult commercial sex work:
· Creates a barrier with regard to accessing health care and other social welfare services.
· Sex workers are continually exposed to violence from clients and regular partners as well as the police. They are thus denied the right to freedom and security.
· As a result of the above, they are increasingly more vulnerable to sexually transmitted infections, including HIV.
· Sex workers are unable to secure protection from police. Instead, they are often harassed, intimidated and assaulted by police.
· They are denied the right to freely enter the occupation of sex work. Sex work is furthermore not recognised as a form of work.
· As a result of the former point, sex workers are denied the right to fair labour practices and have no recourse to legislative measures.
· Sex workers are discriminated against and penalised, whereas their clients do not incur criminal sanction.
· Sex workers are unfairly discriminated against on the basis of sex.
The paper presents evidence from research as well as literature to support the above assertions.
The impact of HIV/AIDS on adult mortality on South Africa. Medical Research Council (MRC) Technical Report, September 2000. [1H]
The study undertaken by the MRC’s Burden of Disease shows that:
· The pattern of mortality has shifted from old people dying of natural causes to young people, especially women, dying.
· The change in mortality pattern fits several AIDS models.
· The mortality pattern is different for men and women.
· The burden and the impact of the AIDS epidemic for the next decade is broadly predictable from the models.
· The differing patterns of mortality and prevalence calls for different intervention strategies in different parts of the country.
The role of Poverty Relief and home-based care within the National Integrated plan for HIV/AIDS. By Jolene Adams and Marritt Claassens, Budget Information Service, Idasa. [1A]
The paper looks at the budget allocations made to the Poverty Relief Programme and the Home and Community Based Care (HCBC) support programme within the National Integrated Plan for HIV and AIDS (NIP). It also examines the initial problems experienced during the implementation phase of the National Integrated Plan from a Social Development perspective. The findings were:
· HIV/AIDS Grant: A grant of R450 million was made available for the implementation of the National Integrated Plan over a period of 3 years.
· HCBC: An amount of R12.5 million was allocated to provincial Departments of Social Development to implement the HCBC support programme.
· Poverty Relief Programme: The programme was allocated R50.4 million with a projected allocation of R225 million over the medium term. The HIV and AIDS component of the poverty relief programme was allocated R5 million in 2001/02.
· Limited priority given to HCBC: HCBC is given low priority in NIP which is evident from the allocation it received (10%).
· Targeting for HIV/AIDS programme: The report states that because of stigma, it is difficult to assess whether the target group actually benefits from the allocations, as they are unwilling to make use of services in certain instances because of the fear of stigmatization and isolation from the community.
· Problems with funding mechanisms at a local level: Both the HCBC (conditional grant) and special allocation (Poverty Relief Programme) are characterised by under-spending problems related to capacity at a national and provincial level.
UNAIDS Case Study – July 2000. Evaluation of the 100% condom programme in Thailand [R]
This case study documents the history and how the programme was initiated in a Province in Thailand as well as the evaluation of the condom programme. Thailand had recognised that the HIV and AIDS problem was a serious one and deserved to be prioritised on the national agenda. Sporadic testing of HIV in 1988 and its shocking results led to more systematic monitoring thereof. By mid-1989 a national sentinel sero-surveillance system had been established. Testing revealed that HIV was growing fast amongst brothel-based sex workers and young Thai men. Most new HIV infections were occurring through commercial sex.
A new approach was piloted in 1 province promoting condom use in commercial sex work. This approach was called the 100% condom programme. All establishments in the province were required that sex workers use condoms in every sex act. Implementation of this programme saw a significant drop in Sexually Transmitted Diseases (STD). The evaluation revealed that the 100% condom programme, in combination with the national condom promotion campaign, is effective in significantly increasing condom use in sex work throughout the country.
UNAIDS/IPU Geneva, Switzerland, 1999. Handbook for Legislators on HIV/AIDS, Law, Human Rights: Action to combat HIV/AIDS in view of its devastating Human, Economic, and Social Impact. [S]
This handbook is a joint project by UNAIDS and the Inter-Parliamentary Union (IPU). As stated in the foreword, the purpose of the handbook is to assist parliamentarians and other elected officials in promulgating and enacting effective legislation and law reform to address and fight HIV and AIDS. The handbook provides examples of best legislative and regulatory practices gathered around the world. It sets out 12 guidelines as contained in the International Guidelines on HIV/AIDS and Human Rights (1998) published by the Office of the UN High Commission or Human Right and the Joint UN Programme on HIV/AIDS (UNAIDS). It contains measures that legislators can take to protect human rights and promote public health in response to HIV and AIDS.
UNAIDS and WHO – AIDS epidemic update, December 2000. [G]
The report provides an overview of the HIV and AIDS epidemic in the world at the end of 2000. Some of the statistics revealed are:
People newly infected with HIV in 2000 Total 5.3 million
Adults 4.7 million
Women 2.2 million
Children <15 yrs 600 000
AIDS deaths in 2000 Total 3 million
Adults 2.5 million
Women 1.3 million
Children <15 yrs 500 000
The report documents the status of HIV and AIDS by region. It furthermore looks at factors driving sexual transmission, communities supporting orphans and the issue of a low cost model for care. It also provides a case study of Kenya where government has started investing in a prevention programme for government workers. Lastly, the report looks at the importance of political leadership in the fight against HIV.
Oral Submissions
AIDS Legal Network (ALN) – Mary Caesar [H]
(see paper presented – “HIV, AIDS & Law Reform: Reducing the Impact on and the Vulnerability of Women and Girl Children” )
The AIDS legal Network is national network of concerned organisations and individuals committed to the promotion and advancement of the principles of non-discrimination, equality and rights in relation to all persons affected by HIV and AIDS, through lobbying, training, advocacy, and litigation undertaken by the affiliates at a national and provincial level (p.1).
· Challenges to the AIDS include recognising that HIV and AIDS has specific gender implications for women and that women can only change their behaviour if they have the power, legal protection, opportunity and ability to make and implement decisions that impact on their lives.
· The AIDS Legal Network thus makes several recommendations relating to the law reform process as well as including Mother-To-Child-Transmission (MTCT), Rape and HIV.
o Law Reform process (see paper for full discussion):
· Government must adopt a broader understanding of the law reform process.
· An enabling legal environment should be created.
· Effective law enforcement should be prioritised.
· Government should adopt legislation that brings about the realisation of socio-economic rights.
· Government should adopt a gendered approach to law making.
o MTCT (see paper): Women with HIV have no legal right to claim AZT or Nevirapine from the State. ALN recommends that the Department of Health provide Nevirapine as this would be a cost effective way of dealing with the epidemic. Other recommendations include:
· Formulating a comprehensive policy on mother to child transmission of HIV.
· Providing VCT before and during pregnancy.
· Making AZT or Nevirapine available during pregnancy and labour.
· Providing cost effective birthing options which would reduce the risk of transmission from mother to child.
· Developing a policy of informing HIV positive mothers of the risk of breastfeeding and the options available.
· Providing formula feed.
o Rape and HIV (see paper):
· Government should formulate a policy on rape and HIV.
· Rape survivors should be given accurate information and counselling on:
· The risk of HIV transmission as a result of rape.
· The possibility of infecting an unborn child or partner.
· The advantages and disadvantages of testing the survivor and the sexual offender.
· The effect of Post Exposure Prophylaxis (PEP) in reducing the risk of HIV.
· Strengthen laws around rape, HIV and AIDS.
· PEP needs to be provided by the State. It needs to be easily accessible to women, e.g. at pharmacies.
· Gaps in the legal framework:
· Medical Schemes Act, 131 of 1998 (Section 29) – It should provide more effective ways for women to gain medical benefits for HIV and AIDS illnesses.
· Correctional Services Act, 8 of 1959 (Section 24) – It should implement more stringent rules on the way women are dealt with by correctional officials.
· Marriage Act, 25 of 1961 (Section 24) – Must assess whether the age of consent for marriage is appropriate.
· Compensation for Occupational Injuries and Diseases Act, 130 of 1993 (Section 65) – Examine the right to claim compensation when the injury results in transmission of HIV.
· Unemployment Insurance Act, 30 of 1966 (Section 33, 36, and 37) – Examine the limit on benefits.
· Female circumcision should be regulated.
· Seduction – needs to be looked at as a possible protection for women (Common law).
Department of Education [1B]
Ministerial Advisor on HIV and AIDS – Kgobati Magome
· HIV and AIDS is a priority area for the Department of Education. The HIV and AIDS programme is contained within the Tirisano programme of the Department.
· The HIV and AIDS programme has various projects. These include:
o A threat to the Education System – This programme looks at analysis of the impact of HIV and AIDS on the education system. It also aims to improve the monitoring and evaluation programmes to guide the Departments response to HIV and its impact and to update all education policies and legislation to take the projected impact into account.
o HIV and AIDS in the curriculum – This incorporates life skills into the curriculum at all levels and educators are trained and resourced. There is a component that focuses on the curriculum and girls. It deals with, amongst others, understanding power relations in adolescent relationships, assertiveness, analysing situations and judging risks, and understanding how the body works.
o HIV and AIDS and Children in distress – The objective in this project is to establish a system to identify orphans/children in distress and provide a support and care programme for these learners.
o HIV and AIDS in the workplace – This project creates an open and supportive environment for people living with HIV and AIDS. It is also aimed at developing a workplace policy for all employees at a national and provincial level including educators. The last objective is to make prevention and precaution tools available and accessible.
o HIV and AIDS awareness, information and advocacy – This project raises HIV and AIDS awareness amongst educators and learners, as well as communicates the departments HIV and AIDS programme to all stakeholders.
o HIV and AIDS: Early Childhood development – The objectives of this programme includes raising awareness amongst learners and educators at this level and ensuring that life skills are integrated into the curriculum.
o HIV and AIDS in Higher Education - This project aims to advocate higher education institutions to develop HIV and AIDS programmes.
o Implementation of the Strategic Plan and Refinement of Strategy – This project looks at mainstreaming HIV and AIDS into all education components and programmes, ensuring effective implementation and to develop structures, capacity and resources to drive development and implementation of policies and strategies, strengthen partnerships and integrate relevant HIV and AIDS objectives into performance criteria for senior managers.
· The Department of Education receives 50% (R150million) of the conditional grant given to the Departments of Health, Education and Social Development. The Department of Education then distributes the money amongst the 9 Provinces based on certain criteria.
· Progress to date includes:
o All 9 Provinces are implementing HIV and AIDS into the curricula.
o HIV and AIDS programmes as well as sexuality issues have been infused into sports, arts and cultural activities.
o The safe schools programme is gaining momentum.
o There is a strengthened partnership with other Government departments.
· Challenges facing the Department:
o Implementation differs from Province to Province.
o The National Department is intensifying monitoring and provision of support to strengthen implementation.
o National Policies and legislation is strongly enforced.
Director of Human Resources – Palesa Tyobeka
Engendering the budget (see paper submitted for a more comprehensive account of the presentation.):
· The presentation focused on issues and challenges to gender equity, important building blocks guiding the development of programmes and resource allocation and progress made in the department since 1994.
· The budget and gender equity: The concept of engendering the budget is a new one for the Department. This still presents a big challenge to the Department. There are no mechanisms in place to monitor the extent to which the budget benefits women.
· Various challenges present itself to the department which pertains to gender equity. These include:
o Ensuring access to and completion of basic education.
o Improving access to vocational training, science and technology.
o Improving access to and achievement in all areas of higher education.
o Eradicating illiteracy among women.
o Developing non-discriminatory learning processes
o Providing safe, healthy and secure learning environments.
o Ensuring access to institutional governance and management roles.
Department of Health - Mr. Cornelius Lebeloe
· Major Causes and Determinants of the Epidemic in South Africa
o Immediate determinants include behavioural factors such as unprotected sexual intercourse and multiple sexual partners and biological factors such as the high prevalence of sexually transmitted diseases.
o Underlying causes include socio-economic factors such as poverty, migrant labour, commercial sex workers, the low status of women, illiteracy, the lack of formal education, stigma and discrimination. The national HIV/AIDS and STD Strategic Plan must address all these immediate determinants and underlying causes.
· Impact on Household
o Loss of income if breadwinner is ill – medical expenses increases and don’t meet needs of family members.
o Impact on schools – learners infected, drop-out at schools, prevalence high among teachers.
o Impact on women and often outcasts in societies – most cases are women. Sex workers – called survival – commercial policy.
· HIV Strategic Plan – Goals, Objectives, Strategies and Lead Agencies
o Developed in consultation with stakeholders.
o Key intervention – prevention, treatment, care and support, research, monitoring and evaluation, human and legal rights.
· Priority Area 1: Prevention
o Promote safe and healthy sexual behaviour
o Improve the management and control of STDs
o Reduce mother-to child transmission (MTCT)
o Address issues relating to blood transfusion and HIV
o Provide appropriate post-exposure services
o Improve access to voluntary HIV testing and counselling (VTC)
· Treatment, Care and Support
o Provide treatment, care and support services in health facilities.
o Provide adequate treatment, care and support services in communities.
o Develop and expand the provision of care to children and orphans.
· Research, Monitoring and Evaluation
o Ensure AIDS vaccine development
o Investigate treatment and care options
o Conduct policy research
o Conduct regular surveillance
· Human and Legal Rights
o Create an appropriate social environment
o Develop an appropriate legal and policy environment
· Priority Area 2: Treatment, Care and Support - OBJECTIVES
o Provide treatment, care and support for people living with and affected by HIV and AIDS.
o Treatment guidelines distributed and training currently happening.
o Establish poverty alleviation projects to address the root causes of HIV/AIDS/STDs and TB.
o Ensure appropriate practices in the private sector and medical insurance industry for the care and treatment of HIV positive clients.
o Provide adequate treatment, care and support services in communities – develop and implement models of community home-based care in all provinces – increase acceptability to community home-based care.
o Develop and expand the provision of care to children and orphans. Develop and implement programmes to support the health and social needs of children affected by HIV and AIDS and implement measures to facilitate adoption of AIDS orphans.
· Priority Area 3: Research, Monitoring and Surveillance - OBECTIVES
o Ensure AIDS Vaccine Development – support efforts to develop a HIV vaccine.
o Investigate treatment and care options – review and revise policy on anti-retroviral use for reducing mother-to child HIV transmission. Conduct research on the cost-effectiveness of other forms of non-retroviral treatment and prophylaxis and conduct research on the effectiveness of traditional medicines.
o Conduct policy research – conduct HIV and AIDS studies in selected departments and provinces and conduct research to determine HIV incidence.
o Conduct regular surveillance – develop mechanisms for long and short-term training to improve the capacities of provincial and district staff to conduct HIV/AIDS/STD related operations, research, surveillance and research, conduct national surveillance on HIV and STD risk behaviours, especially among youth.
Department of Health (Western Cape) – Dr. F. Abdullah
· Khayelitsha is fairly representative of peri-urban South Africa.
· There are no hospitals in Khayelitsha; they have 3 community health centers, 2 midwife obstetrics and 8 clinics offering child health, TB and STD services.
· The mother-to-child programme started in January 1999. It consists of a voluntary counseling and testing (VCT) section. AZT was first provided at 36 weeks and in labour. This changed a year later to 34 weeks.
· Formula feed is provided for the first 6 months.
· Medication is provided to babies to reduce pneumonia.
· Infants are tested at 9 months and at 18 months.
· They have had 18 788 antendees.
· The programme claims to have treated more women than the number of women that have been treated in Uganda.
· 74% of the women accepted VCT.
· Over a 2 year period, 19% tested HIV positive.
· A number of lessons can be learnt from this programme.
· Individual counseling works better than group counseling.
· The Elisa test is ineffective for counselling purposes. They now use the rapid tests.
· AZT is self-administered in the labour ward.
· The rate for 9 months follow-up is better than the 18 months follow-up.
· The programme has now been expanded to new sites using Nevirapine.
· These sites are George, Paarl, Worcester, Nyanga district, Langa and Bonteheuwel districts.
· The programme will be expanded in phase 2 to areas such as the South Peninsula, Oostenberg area, Plettenberg Bay, Caledon, Atlantis and Mitchell’s Plain.
· It is difficult to have this service in the rural areas where there are mobile clinics.
· A larger proportion of the budget was approved for the prevention of mother-to-child-transmission programme next year. This will cost less than 1% of the Provincial budget.
Department of Social Development – Ms. A. Bester [L]
This information was taken from the slide presentation and handout
· Gender and HIV/AIDS
o Gender Inequality increases women’s risks of contracting HIV and AIDS and limit women’s access to resources for coping with HIV and AIDS. This increases women’s share of burden. HIV and AIDS perpetuates and exacerbates gender inequality.
· Women and Poverty
o Women are more likely to be poor. Studies on poverty in SA show that the poorest households are usually headed by women. Education opportunities for girls are increasing but are not commensurate with opportunities for boys. Women in employment are likely to earn less than their male counterparts.
· Violence against Women
o Women and girls are more likely to be victims of domestic violence and sexual abuse than men. Women and girls are more likely to be victims of rape than men.
· Impact of HIV and AIDS on women
o Increased risk of contracting HIV and AIDS. Reports of other countries suggest higher infection rates amongst teenage girls and younger women than their male counterparts. Reports suggest that this derives from women’s social and economic status relative to men.
o Infected women are more likely to lose jobs if they had them. They are stigmatised as spreaders of HIV and AIDS. They have no access to social assistance other than applying for disability grants for themselves or for a Child Support Grant if they have children under 7 years. Unless they have access to food and health care, their life expectancy is reduced drastically. This impact extends to their children. Hey fear of what will happen to their children when they die.
o Women are expected to be the care givers. This disrupts the education of girls. They experience a loss of jobs and reduced earnings. Grandmothers have to support grandchildren often on a single social grant.
Department’s Response
· Response attempts to address the immediate needs of women infected and affected by HIV and AIDS as well as the broader issue of gender inequality.
· Responses are mainstreamed in Department’s framework for combating HIV and AIDS.
· Department’s responses are informed by interactions with affected women and communities.
· Home-based and community-based care programmes are being introduced.
· Poverty alleviation programmes focused on HIV and AIDS and economic empowerment of women.
· Advocacy campaigns and partnerships with women (including young women).
· Improving access to social assistance.
· Victim empowerment and domestic violence.
· Training and capacity building.
· Research and information.
· Home-based and community based care
o 3 programmes – joint projects with Department of Health and Provinces.
o The projects are funded and managed by the National Department using HIV and AIDS funds (5 projects).
o National projects are funded from the poverty relief fund – This totals 17 projects (provinces also have HIV and AIDS related projects funded from the Poverty Relief Fund)
o Target groups are vulnerable children and women. Assistance is provided to women. Material assistance (mainly food). Other assistance is in the forms of counselling and support groups, accessing social assistance, welfare services and poverty alleviation programmes, home-based care for women and their families, information to assist women as caregivers and life skills to prevent infection.
· Poverty Relief Programme (PRP)
o PRP has targeted women since its inception. About two-thirds of beneficiaries of Department’s are women.
o From 1998/99 to 2000/2001 – managed R363 million in PRP funds/2868 projects to value of R329.795 m/payments of R289.913 m to projects.
o In 2000/2001 – transferred R9.73 million to HIV ad AIDS projects initiated by communities and Faith-Based Organisations.
o Women’s Flagship Programme: This is funded from PRP and special allocation for Flagship Programme – 16 projects operating (2 per province, except KZN and Northern Cape) – 801 women and 913 children are benefiting.
o 2001/02 to 2003/04 – support income-generating activities for women in rural areas (100 projects).
o Established 144 rural food production clusters of 100 households each, with emphasis on households affected by HIV and AIDS.
o Support 100 community-based projects providing care and support for households affected by HIV and AIDS.
· Social assistance
o Women are a significant proportion of social assistance beneficiaries either directly or through their role as caregivers.
o Information and communication campaigns are run to inform women about social grants, especially the Child Support Grant.
o Limitations of coverage of grants in context of HIV and AIDS are being investigated by a Committee of inquiry into Comprehensive Social Security.
o Improving administration of social security is underway.
· Victim Empowerment
o VEP provides care and support and life skills for women (and children). There are 66 projects at provincial level providing 24hr one-stop service for women (reach 2500 per month)
o 34 national projects included the training 255 social workers and lay counsellors in Domestic Violence Act. Directory of Services produced. Survey of shelters for abused women.
· Advocacy Work and Partnerships
o 16 days of activism – “no violence against women” includes men as partners in combating violence against women and sharing responsibility to reduce HIV/AIDS.
o Working on partnerships with loveLife – training girls and boys as ‘groundbreakers’ to promote HIV and AIDS awareness, life skills training, involving youth in home-based and community-based programmes.
o Partnerships with aid organizations.
o Partnerships with faith-based organizations (FBO) – already supporting HIV and AIDS projects of FBOs. Working with FBOs to involve them more comprehensively in HIV and AIDS programmes.
· Building Capacity
· Home-based care and poverty relief programmes include building capacity of women.
· Launched HIV and AIDS capacity building programme for Government officials. It includes understanding impact of HIV and AIDS on women.
· Requests received to extend programme to NGOs and CBOs.
· Information Base
o Started audit/survey of all HBC and CBC projects in country (with the Department of Health).
o The survey identifies services offered, target groups, sources of funding, governance structures, etc.
o The survey will be used to scale up response and identify areas not covered.
o The survey will serve as basis for monitoring system.
Budget Allocation
Programme Budget Allocation
· HBC/CBC 2000/01: R6.8 million
2001/02: R13.4 millon
· Poverty Relief 2000/01: R120 million plus R37.678
Million roll-over from 1999/2000
2001/02: R50 million. Of this R10 million is for Flagship type projects; R5 million is for community HIV/AIDS support; R10.88 million is for food security.
· Flagship Programme 2000/01: R1.612 million plus R650
000 form Poverty Relief allocation
2001/02: integrated with PRP
· Victim Empowerment 2000/01: R2.3 million
2001/02: Nil
· Challenges and Responses
o Addressing the problem of stigma.
o Provide tangible assistance to people affected (access to social grants, counselling, health care, etc.).
o Education of communities where HBC and CBC projects are located.
o Support to national campaigns – young men as partners in fight and faith – based organisations.
o Scaling up response to meet demand – direct more support to community-based projects. Strengthen partnerships with FBOs. Other partnerships with business and labour. Promoting volunteerism and involvement of youth.
o Ensuring protection of children which include prioritising orphans and infected children in new Child Care legislation. National guidelines and protocols to apply to all HBC and CBC projects funded by government.
o Access to social assistance – interim national procedures for dealing with applications for disability grants and social relief in distress. Mechanisms to check that participants who are eligible for social assistance receive grants. Long term options on grants are being investigated by the Committee on Social Security.
o Food Security – strengthen food security component of HBC and CBC Programme. Integrated Food Security Strategy being developed by Government.
o Budgetary Issues – discussions with Treasury on funding for HBC and increasing social relief budgets. Lack of funding for Victim Empowerment Programme.
Department of Trade and Industry – Stella Dlamini and Kgomotso Kasankola
· The presentation focused on the work of the Quality of Worklife Unit in the Department of Trade and Industry which focuses on HIV and AIDS initiatives and programmes.
· The objectives of the unit are to:
o Provide access to health and wellness programmes for all employees in the Department.
o Ensure an integrated workforce committed to the goals of the Department.
o Facilitate a coordinated, integrated occupational safety and health programmes.
o Facilitate the management trends on employee wellness and health issues.
o Facilitate policy reviews, design and implement health programmes.
o Facilitate retirement process, and integrate retirees into life without work.
· In order to meet these objectives, various interventions are in place. These include:
o Maintaining a referral system. If employees need counselling, they will conduct these sessions or refer the candidate to an external provider.
o Establishing a comprehensive, integrated HIV and AIDS programme. This programme also works with the family.
o Establishing a life skills programme and diversity management programme. This programme deals with the conditions of HIV and how the individual deals with his or her circumstances.
· The Gender Office is a new office in the Department. It is currently developing a booklet on HIV and AIDS and its impact on business. It also has a partnership with Eskom to educate SMME’s about the implications of HIV and AIDS.
· It furthermore has partnerships with the Department of Health.
· An impact study is underway on the national economy. Partners in this venture are Ntsika and Khula Enterprises.
· The Department has a HIV and AIDS policy which looks at creating a caring environment for employees, providing equal opportunities for staff and creating a safe and healthy working environment.
· The Departmental strategy on HIV and AIDS focuses on:
o Training of staff and peer counsellors.
o Counselling programmes.
o Partnerships with other organisations.
o Community outreach programmes.
o Impact analysis and surveillance programmes.
The Department is planning to review the commitments and coordinate an internal campaign, establish a referral system and train counselors and managers.
Groote Schuur Hospital (GSH)
Professor Denny [K]
· The vast majority of women are not on ARV. Hysterectomies are increasing on young women and women with HIV and AIDS. This happens at the advanced stages of HIV.
· There is an overload of cases and the hospital do not readily admit HIV women. This enables them to see to others that can be treated.
· Infectious diseases – There is an increase in cervical cancer in HIV women. There is a definite need to develop a cervical cancer policy to work in conjunction with HIV and AIDS. Treatment facilities at GSH have been downsized. There is a long period of waiting to be tested. More resources are needed at these hospitals.
· Sometimes GSH can treat cancer but cannot treat HIV. The provision of expensive tertiary treatment should be complemented by treatment of HIV.
· Develop forensic protocol of men and women who have been raped. Majority of women don’t report rape to police. Only 50% of women present to medical facilities. 1/10 000 women are murdered when raped. It is essential to provide PEP to women who have been raped. Necessary to provide standard medication when a woman has been raped. Tertiary institutions to play an important role in this.
Recommendations
· Women who are HIV should be offered ARV;
· Cervical cancer should be prioritised;
· The State should adopt a national policy on rape. This requires a multi-disciplinary response;
· Prevention of rape should be a national priority;
· STIs should be vigorously treated;
· Conduct research that impacts on the quality of life of women by tertiary institutions.
Professor Besser [J]
· Don’t know how many people in general population have HIV. Only know what % of pregnant women have HIV.
· HIV is responsible for more deaths in pregnancy than any other condition.
· ARV makes a difference.
· Effective Caesareans make a difference – 50% reduction in transmission – but expensive to do and there is a risk of infection.
The following has been taken from slide presentation of Prof. Besser, Groote Schuur – For tables/statistics/graphs etc. please refer to handout – these are just the relevant points.
· 25% of childbearing women in South Africa are infected with the HIV virus;
· The Western Cape has the lowest HIV prevalence among South Africa’s provinces – currently approximately 8% infection rate;
· HIV is responsible for more deaths in pregnancy than any other medical condition;
· Effective interventions make a difference for example anti-retroviral therapy and elective caesarean sections.
· Elective caesarean section – meta-analysis and European collaborative study demonstrate a 50% reduction in transmission with caesarean section (C/S) before the onset of labour; a 50% reduction in subsets of women both treated and untreated with anti-retroviral therapy but greater infectious morbidity associated with caesarean section.
· Mode of delivery and vertical transmission – meta-analysis of 15 US and European studies of 8533 mother-child pairs compared elective C/S before labour with Other models of delivery including non-elective C/S, instrumental and spontaneous vaginal birth showed a significant reduction in risk with elective C/S.
· Effective interventions make a difference. These include anti-retroviral therapy, effective caesarean sections and alternatives to breast feeding.
· The unequivocal support of Government with education programs, health promotion activities and community action make a difference, e.g. Uganda, Thailand.
· With regard to feeding the baby, there has been an accumulation of evidence demonstrating HIV transmission through breast milk. Increased duration of breast feeding is associated with higher rates of transmission. Breastfeeding from HIV (+) mother has 14-29% risk of infection over 1-2 years. Higher rate associated with sero-conversion of the child during breast feeding.
· Western Cape Roll-Out for MTCT is 95% coverage by June 2002 – see table showing which areas have been covered.
· Triage – HIV not homogenous conditions; establish criteria for site of care; train providers to screen patients.
· Programs and Research: “Mothers to Mothers-to-be” is a programme where the graduates of the maternal HIV clinic at GSH return after delivery to serve as mentors for pregnant women; to provide health education and emotional support; encourage adherence to anti-retroviral and medical therapy; encourage adherence to selected feeding program. The mentors benefit from sustained relationship with structured medical service.
· Programs and Research: A Post-exposure prophylaxis study which was funded by Bristol-Myers “Secure the Future”, offer voluntary counselling and testing to women with unknown HIV status. After the delivery they offer anti-retroviral therapy to the baby starting in first 24 hours of life and evaluate transmission from mother to baby.
· Programs and Research: MIRIAD – Mother Infant Rapid Intervention at Delivery – CDC/PACTG study; HIV counselling and testing in labour; anti-retroviral therapy to mother during labour; formula feeding; Study – HIV transmission rates; acceptability of in-labour HIV testing to providers and patients.
· Future Strategies – More effective anti-retroviral therapy to reduce transmission to less than 2%; keep mothers healthy after delivery; support families and empower women, counselling, treat family as a unit.
· What should be the regimen of choice for MTCT – anti-retroviral regimens: - AZT; AZT+3TC; Nevirapine (NVP); HAART.
Educational Programmes
· In Holland, they have had some good programmes on sex education and also have lower pregnancy rates.
· Programmes from Holland looks at peers teaching younger children about pregnancy, STD’s and then HIV.
· GSH did a study on knowledge of sex and reproductive cycle. Only a small percentage of women know when they would fall pregnant in their cycle.
· MTCT programmes – have to start at the communities and involve communities. It has to be combined programme of primary and tertiary care.
· You need to continue to care for the mother after childcare. Otherwise fail in struggle to reduce infant and children mortality.
Human Sciences Research Council - Dr Olive Shisana [U, O]
· Understanding the way in which policies are made and the complexities thereof, will assist in examining opportunities and challenges South Africa faces in applying evidence to address HIV and AIDS.
· The presentation covered 3 examples of safe and effective HIV and AIDS interventions namely, the:
o Treatment of sexually transmitted infections to reduce HIV infections.
o The use of highly active anti-retroviral treatment (HAART) to reduce new AIDS cases and prolong life.
o The use of Zidovudine to prevent the transmission of HIV from mother to child.
· South Africa has 4.7 million HIV positive people. The World Health Organization (WHO) estimates that 250 000 South African died from AIDS related illness in 2000.
· Nearly half of the people estimated to be living with HIV in the SADC region are South African.
· The life expectancy of South Africans is expected to decline.
· In South Africa, women have higher infection rates than men.
· Globally, about 1.3 million children were infected with HIV in 1999. 90% of these infections were as a result from transmission of HIV from mother to child.
· Sexually transmitted infections as co-factors in HIV transmission:
o Evidence suggests that new HIV infections can be prevented through the appropriate management of sexually transmitted infections (STI).
o Studies have suggested that STI is a significant risk factor in HIV infection.
o Research has informed policy makers in adopting policy around the management of STI’s. However, there is a delay in implementation.
o Training health workers to adopt an empathic attitude towards patients could increase implementation. Health workers should also be trained to use the correct syndromic management of STI among men and diagnose and treat STI among women. Countries should furthermore have essential drug programmes that ensure the rational use, timely and adequate distribution of medicines.
· HIV and AIDS is the leading cause of death on the African continent despite the availability of effective anti-retroviral therapy. Countries can intervene through highly active anti-retroviral therapy to reduce:
o New HIV infections
o The occurrence of opportunistic infection
o New AIDS cases
o AIDS deaths
o Evidence in Uganda and in the Ivory Coast indicates that AIDS patients in developing countries can be managed successfully (they do take their medications regularly and are responding to treatment).
o Developing countries state the following reasons for not providing anti-retrovirals (ARV’s):
- The high cost of ARV’s charged by pharmaceutical companies.
- The high cost of infrastructure necessary to use these drugs (this includes costs for testing and monitoring CD4 cell counts, etc).
- Voluntary counselling and testing (VCT) is not always available in most facilities.
- Poor health systems’ capacity to cope with the HIV and AIDS epidemic.
o The HSRC states that given the cost of drugs, it is necessary for developing countries to use the provisions in the TRIPS agreement and remove some of these obstacles. This would allow more than 20% of the population to be saved in time. These countries can:
- Implement former President Clinton’s executive order that encourages sub-Saharan countries to use the options in the TRIPS agreement to import or use compulsory licensing to gain access to drugs for HIV and AIDS related illnesses.
- Import ARV’s and other drugs from countries like Brazil and Thailand without being sanctioned, given that many poor countries do not comply with the TRIPS agreement as yet.
- Work with these countries and learn the technology to produce these drugs.
- Negotiate cheaper prices for diagnostic kits and reagents.
- Establish sustainable financing mechanisms to ensure reliable distribution and access to drugs.
- Begin by providing these locally produced or imported ARV’s in all tertiary facilities, which ought to have the necessary infrastructure.
· Prevention of mother-to-child-transmission of HIV
o Research results have indicated that the use of long course Zidovudine can prevent mother-to-child-transmission. However, this regimen is complex and expensive for developing countries to adopt. It is most appropriate for developed countries where women can afford not to breast-feed and the health system is adequately equipped to routinely administer this intervention.
o Other studies have indicated that short course Zidovudine is both effective and safe in preventing transmission from mother-to-child. WHO has drafted guidelines for a mother-to-child programme. Many Governments argue that they cannot introduce such a programme as their health services are under-funded.
o Another barrier to establishing such services is establishing VCT services throughout the country.
o Government furthermore need to prioritise formula feeding for HIV positive women who choose not to breast-feed. Instant infant formula might also be an option to consider.
Joint Monitoring Committee on Children, Youth and People with Disabilities – Ms M. Bogopane
· SA children are particularly vulnerable, especially orphans and this constitutes a national emergency.
· Children are both infected and affected. They become infected through mother to child transmission, sexual abuse and through unsafe health practices (circumcision in boys and through genital mutilation, although this is not common in SA). Affected children are often abandoned or orphaned as a result of HIV and AIDS.
· In developing countries, children have the same diseases as children that are infected. Infected children however have more opportunistic diseases and more severe diseases.
· Children are often double orphans. This is when both parents have died. These children are likely to die of preventable diseases as they are not likely to be immunised.
· Children are assuming more responsibility for the household. They are caring for the sick and assuming responsibilities when are not yet ready for it. They are entering the labour force earlier and thus leave school earlier. Exploitation of children is increasing and the age of girls entering prostitution is dropping to 9 years of age.
· Girl prostitution is stigmatised and therefore it also reduces opportunities to education.
· Abuse, especially of girls, has only recently been recognised as a significant factor in HIV and AIDS. Various myths of child sexual abuse exist including:
o Prevention theories: You choose a young girl as a partner and thus not get HIV, as children are not perceived to be at risk.
o Cleansing theory: If you have HIV and AIDS, you can cleanse yourself by sleeping with a child.
o Redistribution theory: This entails the spreading of the disease, targeting young children.
· Street children and children with disabilities are at risk.
· More research needs to be conducted on the use of ARV’s when using other medication, e.g. medication for epilepsy.
· Children have stated that poverty affects them most. They are also affected by issues concerning access to health care, lack of privacy at health care centers and their status are often revealed without their consent. They require proper housing and support.
Speak Out! – Charlene Smith [F]
Speak Out is an organisation of rape survivors, those who have experienced domestic violence or other severe forms of violence, those infected with HIV and their families and those acting against violence and HIV. Speak Out! cooperates with other organisations that assist rape survivors as well as with hospitals and clinics.
· Practices of rape are now more violent and virgin rape is increasing dramatically. In South Africa, male rape is still not a crime but this is increasing. Older women, over the age of 70, are being raped. It is believed that these women are virgins because they haven’t had sex for a while. The presenter believes that in this context, people are raping others (virgins) because there is no treatment available.
· Women are becoming more vulnerable. The risk of being gang raped is increasing.
· The presenter stated that it is problematic that clinics in rural areas close at 4pm and open at 8am. Most rapes happen at night and time is important in treating rape survivors.
· She reported that research done by Netcare clinics in South Africa, revealed that none of the rape survivors, to whom they have given PEP to within 72 hours after the rape occurred, had sero-converted.
· The report by Netcare estimates that it will cost the State R200 to give ARV’s for rape survivors and R1.20 to do the rapid test. The costs for treating HIV+ adults or children will cost the State hundreds of thousands of rand (see paper presented).
· Recommendations: (see paper for full list)
The presenter made stated that the high rates of rape and HIV need to be acknowledged and that action is required. We need to find cutting edge solutions to change the situation. Some of the solutions suggested were:
o The need for peer mediation and conflict resolution programmes in schools.
o Anti-retroviral Treatment for all children, women and men raped.
o Programmes to prevent MTCT available to all who attend State hospitals or clinics.
o Tax benefits to employers who have HIV/STI clinics in the workplace.
o Compulsory testing of alleged rapists. This will contribute to the rape survivors peace of mind because even though the rape survivor receive PEP, he or she has to go for repeat testing for a whole year.
o Food garden campaigns to boost the nutritional needs of children and those infected with HIV.
Other comments:
· We need to look at sexual violence and HIV as an opportunity and come up with cutting edge solutions to this.
There has to be a multi-disciplinary approach to deal with HIV. While there is an emphasis on rape counselling, rape should not happen. Need conflict resolution programmes amongst young children.
Treatment Action Campaign (TAC)
Presentations were made by Zackie Achmat, Thembisa Mhlongo, Sipho Mthathi, Anneke Meerkotter: Papers presented were:
· Mother to Child Transmission of HIV. [A]
· Treatment Issues for Women. Discussion Document. [C]
· Microbicides . A TAC Discussion Document. [B]
Zackie Achmat
· HIV and AIDS impacts dramatically on women. Women are biologically more affected. The economic and social impacts of HIV on women are greater.
· TAC believes that HIV and AIDS can be brought under control in a period of 10-15years. Strategies to achieve this include behavioural change, Mother-To-Child-Transmission (MTCT) programmes, use of female and male condoms and by using microbicides. These strategies together with treatment can bring the epidemic under control.
· Within this framework, poverty reduction and access to a basic income grant becomes critical.
· TAC believes that Government is not doing the right thing. The way that the National leaders, the President, and Government are dealing with HIV and AIDS sets the epidemic back.
Thembisa Mhlongo
Ms Mhlongo reported that she looked after an HIV positive child and that the child died on 11 September. Her speech was filled with emotion and it was clear that she was very hurt by the death of her child, Sibongile. She made the following recommendations:
· All measures should be taken to prevent and treat all children with HIV.
· Women should be given the opportunity to prevent children from getting HIV.
· All nurses and doctors should be trained properly. Women and other HIV people suffer because of the attitudes of nurses and doctors.
Anneke Meerkotter
· The number of HIV positive people has increased dramatically.
· Young women are especially vulnerable.
· According to the Department of Health’s Antenatal Survey (ANC), 1 in 4 women are HIV positive, many of whom don’t know their status.
· HIV can be transmitted from mother to child during birth and during breastfeeding.
· To try and reduce the infection from mother to child, Nevirapine is given during birth. Nevirapine is used in South Africa as it is cheap and only 1 dose is given. However, it is not provided to all women.
· The Department of Health is providing Nevirapine at pilot sites to pregnant women. The World Health Organisation (WHO) has said that there is no justification to continue to do research on mother to child transmission and not providing medication or Nevirapine to pregnant women.
· Research has shown that MTCT can be prevented and it is the responsibility of Government to prevent it.
· To prevent MTCT, it would cost less than 1% of the health budget. It would also alleviate some of the burden on mothers and on caregivers.
· TAC is taking Government to court and is asking for a national programme to provide medication, give formula milk and for doctors to prescribe Nevirapine.
· The focus of Government is still on providing male condoms. This takes away women’s ability to negotiate sex. It is difficult for younger women to negotiate safe sex.
Recommendations:
· Government should make female condoms more available and accessible.
· Government should also be doing more research on microbicides.
· Condoms should be provided in schools.
· Most HIV infections happen unwittingly. There is a need for more voluntary counselling and testing services (VCT). However, people don’t make use of these services where they are available. This is because there are no incentives to use them and people are scared and concerned about stigma.
· The focus should also be on people consenting to testing and not forced testing. Sex workers and prisoners should be forced to test as this assumes that they are high-risk groups.
Sipho Mthathi
· The Constitution of South Africa provides a legal framework within which Government should make health services available.
· South Africa has also signed the Convention on the Elimination of All forms of Violence Against Women (CEDAW) agreement where it has committed itself to eliminate all forms of discrimination in providing, amongst others, reproductive health services.
· The majority of people using these services are poor, black women. Women in Khayelitsha (which has a MTCT programme) opted to be tested because there were incentives to treatment and prevention for children.
· The committee should look at ways in which the State can improve public health services to women. This can be done through an MTCT programme. But it is important that more women get tested and thus know their status. The earlier women get to know their status, the earlier they can thus seek treatment.
· Government focuses on treating opportunistic infections. This is however not enough. When opportunistic diseases are treated, you are merely treating the symptoms of AIDS. It does not prevent the HIV virus from replicating in your body. TAC is calling for a pilot programme on the use of anti-retrovirals. There is a need to treat opportunistic infections as well use anti-retrovirals.
· The Minister of Health has said that Government does not have money for anti-retrovirals. The message conveyed is problematic. The message being conveyed is one of problems but there is a need to look at the solutions. Enough research has been done to provide solutions.
· A study amongst teenagers has shown that many suffer from herpes. This causes sores and needs specific treatment. This treatment is not available in public health hospitals and clinics. Within our legal framework, Government needs to start providing this treatment.
· TB prevalence is increasing in South Africa. Yet, nurses are relying on ‘old knowledge’ to treat TB which does not take into account the relation between TB and HIV. There is a need for training of health workers especially in the use of the HIV guidelines issued by the Department of Health.
· In Brazil, anti-retroviral use has been able to reduce the number of TB infections by half in a space of a year. This has reduced the burden placed on public health services.
Other comments by TAC:
HIV is fuelling other epidemics and should receive priority. TAC is unhappy with the Members of Parliament in the Finance and Health committees. The budget of the Department of Health has not increased dramatically. Dr. Nkomo needs to ensure that the medicines are available.
TAC recommends that anti-retrovirals be used. Health care workers need training. The organisation however acknowledges that some people have died even whilst getting anti-retrovirals whilst others have improved. Costs are a problem with anti-retrovirals. But Government has been given an offer by Aspen to reproduce anti-retrovirals at lower costs.
The Minister of Health needs to be asked what research the Department is doing on microbicides?
The Committee should also call on the Medicines Control Council (MCC) and look at the proportion of women who are being used in the testing of medicines. Drugs are mostly tested on men.
UNAIDS – Bunmi Makinwa, UNAIDS Intercountry Team for Eastern and Southern Africa [D]
Mr. Makinwa‘s presentation closely followed the structure of his paper which was provided at the hearings. The following are some of the comments he made:
· The burden of HIV and AIDS on women and girls are of a biological and physical nature; social/economic and tradition; and often due to policy and legislation.
· The impact is also great because women and children (with the focus on the girl child) are often widowers and orphans. This increases their exposure:
o to risks
o they have a lack of access to education, poor renumeration and salary and are marginalised
o face biased laws and low social status.
· Responses to the epidemic should take into consideration that women are infected or otherwise carry the burden. Programmes need to take gender related needs into account.
· The International experience of prevention and care - Several countries have made significant gains in the fight against HIV and AIDS. These include Uganda, Senegal and Thailand.
· Uganda: (see page 2 for full discussion) – The country has strong political support for the control of the epidemic. It has seen a number of different intervention strategies. There is a high level of HIV and AIDS awareness (over 80%). HIV, sexually transmitted diseases and AIDS is on the decrease in Uganda.
· Some of the elements of success in its programmes include:
o Multisectoral approach.
o Community involvement.
o Strong programmes nationwide.
o Involvement of People living with HIV and AIDS.
o Openness on the epidemic.
· Senegal (see discussion on page 3) – Senegal had a programme for the treatment of STD’s long before HIV and AIDS became an epidemic. HIV and AIDS prevalence is estimated at about 1.8%.
· One of the successes of its intervention strategies is that when aid organisations came into the country, Government policy informed the decision of where the organisations should go and for which areas the resources should be earmarked.
· Thailand (pg. 3) – Thailand has an effective HIV surveillance system in place. They have data available to track prevalence, temporal trends and incidence.
· Elements of success include:
· Information.
· Media.
· Condom campaign.
· Multisectoral approach.
· Workshops and group interaction.
· Community involvement.
· Involvement of People living with HIV and AIDS.
· Research institutions.
Recommendations
· The Government of South Africa, along with Parliament, should continue to build its partnership with the UN theme group on HIV and AIDS in SA.
· A broad approach to care is needed and not only one that looks at anti-retroviral (ARV) access. Drug affordability is important and also need to include:
o Sustainable national financing for drug procurement
o The national and local health infrastructure required for providing care
o Ensuring good nutrition
· Anti-retroviral use is only sensible if it’s long-term sustainability is ensured, if there is sufficient infrastructure to deliver the drugs safely and effectively and if opportunistic infections are being treated.
· The presenter urged the Members to provide the right leadership that is needed to secure a reversal of the AIDS epidemic.
· UNAIDS supports the HIV/AIDS and STD Strategic Plan for South Africa. The response provides a viable approach to reducing the burden of HIV and AIDS on our society in SA. The UNAIDS supports its implementation, vigorously.
Western Cape AIDS Training Information and Counselling Centre (ATICC) - Wilfred Jewel [E]
ATICC was formed in the late 1980’s. It is a training organisation and services the Metropole Region of the Western Cape. It provides training, information, counselling and testing, support and referral, condom distribution, consultancy and networking.
· At a legal level one needs to be knowledgeable about the rights of a client. To this effect, they have a 4 day training programme. It includes looking at women’s role, their vulnerability, cultural issues, pregnancy, HIV and AIDS and mother-to-child-transmission.
· ATICC offers a 15 day HIV/AIDS/STI/TB counselling course. It includes amongst others issues pertaining to testing and drug trials, self-awareness and value systems, etc.
· They experience problems relating to lack of support and the counselors go through depression.
· ATICC’s programmes have also been evaluated by the Psychology Departments of University of the Western Cape, University of Cape Town and the University of Natal.
· The presenter stated that it is good to have the MTCT sites as well as the Voluntary Counselling and Testing (VCT) programmes. Yet we need strategise around partner notification programmes.
· The training programme of the Western Cape ATICC was utilised on a national level as a model for the criteria on which the minimum standards of HIV and AIDS, STD, and TB information training and counselling was built in South Africa.
Women’s Health Project -
Sexual Rights Campaign – the campaign is a joint effort of:
The National Network on Violence against Women, National AIDS Convention of South Africa; National Association of People Living with AIDS, Planned Parenthood Association of South Africa, the Joint Enrichment Project, Young Men’s Christian Association; Women’s Health Project and community based organisations throughout South Africa.
· Violence against Women as reached epidemic levels in South Africa. This is evident in the following facts:
· South Africa has the highest ratio of reported rape cases per 100 000 people in the world;
· It is estimated that one in six women are in abusive relationships and one woman is killed by her partner every six days;
· Many young women report that men used violence when initiating sex with them;
· In 4 provinces in South Africa, abuse by a partner or an ex-partner increased by more than 50% between 1998 and 1999. The range of abuse included sexual, physical, economic and emotional.
· The problem in terms of Sexual Rights – As a result of unequal power relations between women and men, young women are vulnerable or coerced into unwanted sex, which places them at risk of unwanted pregnancy and sexually transmitted diseases, including HIV and low self-esteem.
· What does Sexual Rights mean?
“The human rights of women include their rights to have control over and decide freely and responsibly on matters related to their sexuality, free of coercion, discrimination and violence. Equal relationships between women and men in matters of sexual relationships and reproduction, including full respect for the integrity of the person, require mutual respect, consent and shared responsibility for sexual behaviour and its consequences” (Fourth World Conference on Women, Beijing, 1995). The South African government committed to this agreement.
· Sexual rights also means that women and men have a right to:
· Control their bodies
· Only have sex when, with whom and how they want to
· Decide about their sexuality
· Not be forced to have sex through the use of violence or non-physical force
· Have sexual enjoyment
· Be protected from the risk of disease such as HIV and other sexually transmitted diseases
· Have access to responsive services that help them deal with concerns in relation to their sexual health
· All these must be present, they are not mutually exclusive.
· The Sexual Rights Campaign aims to:
· Build a new vision of masculinity in which real men take responsibility for their sexual behaviour, do not force women into sex, do not expose women to disease or unwanted pregnancy.
· Build a new vision of femininity in which all women can claim their sexual rights.
· Build a culture of equality and mutual respect in sexual relations between men and women.
· End women’s and girls’ vulnerability to violence, AIDS and unwanted pregnancy.
· Reclaim sex as a positive and pleasurable human experience.
· The Sexual Rights Campaign involves the following steps:
o Advocating national and provincial politicians and decision makers.
o Identifying priority actions to promote sexual rights amongst the police and justice sector, the health sector, the education sector and youth .
o Training trainers and running sexual rights workshops in which individuals and groups identify and subsequently take up specific action to promote sexual rights at community level.
o Reaching out to the public through print media, radio talk shows and posters.
o Bringing together all of the findings of this process for the development of a Sexual Rights Charter (mid-2001).
o Disseminating the Charter and winning commitment of different sectors to implement the charter in their daily work and lives.
· HIV in SOUTH AFRICA, 2000 - 4.7 million are infected (total population = 40.6, that is 11.6%). This is based on the Antenatal survey – HIV prevalence.
· The investigation into violence committed against women revealed that:
o SA – highest number of violence against women
o Many young people said that men used violence to gain sex.
· Sexual health of young people: 64% of youth had past sexual experience at 18 years or younger.
o 3% under age 12.
o 16% between ages 13 – 14
o 45% between 16-18
o of the youth who had a child, most of them (two-thirds) had not planned the pregnancy.
· In South Africa the ABC strategy (Abstain, Be faithful and Condomise) does not seem to be effective. Strategies do not address the problems.
World Health Organisation (WHO) – Dr W Shasha [P]
· The epidemic has been out of control for the last 20 years. One needs to identify areas of major challenges, namely:
1. stigma
2. MTCT
3. strengthening the health system
· Current statistics will be sent to the Committee. HIV and AIDS is denoted as a crisis as it is a bigger threat to health and development.
· In South Africa, the health system thus far has been good in terms of the issue of communicable diseases. TB, polio, measles has been addressed properly.
· Infection route of HIV in Africa
Sex 90%
MTCT 7%
Other 3%
This will differ from country to country.
· The number of HIV infections and deaths in Africa are:
Africa Other
Infected 25 million 11 million
Deaths 17 million 5 million
· The prediction of child mortality due to HIV and AIDS include the following:
o Botswana in 2010, if there is no AIDS, child mortality will be less than 50% per 1000 live births. Mortality because of virus will be more than 3 times provided not much is done.
o The same applies to Kenya where mortality will double.
o In Zambia, the mortality rates will more than double.
o Zimbabwe will see an increase 3 and a half fold.
· The key element in fighting the disease is Stigma. South Africa has been good with other communicable diseases but not with HIV/AIDS. This is largely due to Stigma. South Africa is not an exception. Research in Uganda and India found that :
1. Government will not reveal reports. UNAIDS website has much of the information. Stigma often leads to Governments denying the extent of HIV and AIDS. WHO has to be careful when talking of diseases in countries without speaking to Governments. At a Government level, many deny the reality of HIV until they come to terms with it and address the stigma attached to it.
2. In communities and families, the HIV infected person is stigmatised. If a person applies for jobs and has HIV, he or she will be discriminated against. The family wonders if it is safe to use utensils. In extreme cases, this has led to people being killed.
· What can be done about stigma, to reduce effects of stigma?
o In South Africa, antenatal surveys (ANC) are used as a way of monitoring the prevalence. This is limited but effective to an extent. We need to look not only at pregnant women but others strategies.
o Other communicable diseases are notifiable. This should be done with HIV and AIDS so that it is also notifiable and regarded as harmless.
o In Cuba, people are informed and then given the necessary treatment. We can take a lesson from Cuba.
o The UN system has identified discrimination against HIV as unacceptable.
o In 1988, WHO passed a resolution to ask countries to pass laws that do not accept discrimination. In spite of laws, discrimination continues.
o Politicians as leaders should be tested. If leaders are subjected to voluntary testing, the attitude at the top encourages the rest of the country.
o Companies should be offered incentives if they have policies or mechanisms in place to address the issue of stigma or provide health care facilities for people infected.
· Strategies Embarked Upon:
o Prevention of MTCT – The country has won the case against pharmaceuticals. This created expectations that the country would embark aggressively on MTCT programmes. Botswana and Uganda have embarked on MTCT but both still at an experimental stage and one needs to see the difference this has made and its impact. South Africa is not far behind. The pilot sites are encouraging.
o Issue of essential drugs and medicine – WHO brought out experts and encouraged the relationship between NGOs and government.
· Support
o Continuum of treatment and support in the context of mitigating treatment of opportunistic infections and voluntary counselling should all be done together.
o There is a strong recommendation that the health system must be strengthened to be able to embark on other strategies, such as treatment. Should also be able to treat other STIs, TB. Training of managers of health institutions. We do have schools of public health and expertise needed.
o We need to engage traditional leaders effectively.
o Prevention of MTCT – Nevirapine and AZT seen to have had some success. More research needs to be conducted.
· The South African Government has clarified how development and integrated development works. Both urban and rural can be undertaken and this has to take into account how one can prevent the spread of the disease.
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