1. Krauss, Kate BA

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ALANDMARK study released recently by Physicians for Human Rights (PHR) has found a link between African women's cultural and legal disempowerment and their skyrocketing human immunodeficiency virus (HIV) infection rates. Currently, 75% of HIV-positive 15- to 25 year-olds in sub-Saharan Africa are female.


The study discovered a connection between widespread discriminatory views against women in Botswana and Swaziland and sexual risk-taking that often leads to HIV infection in those countries.


PHR's study, "Epidemic of Inequality: Women's Rights and HIV/AIDS in Botswana & Swaziland: An Evidence-based Report on Gender Inequity, Stigma and Discrimination," reports the results of a population-based study conducted in 2004 and 2005 with 1268 respondents in Botswana and 788 participants in Swaziland, designed to assess factors contributing to HIV infection. In addition, 24 people living with HIV/AIDS in Botswana and 58 people living with HIV/AIDS in Swaziland were interviewed, along with key informants in both countries.


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


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


While anecdotal evidence has strongly suggested a link between gender inequity and HIV infection, the PHR report suggests that women's rights must be made the top priority by the countries' leaders if HIV prevalence rate is to be reduced.


In Botswana, for example, 95% of women and 90% of men surveyed held at least 1 gender discriminatory belief. Botswana community survey participants who held 3 or more such beliefs had 2.7 the odds of those who held fewer beliefs to report having had unprotected sex in the prior year with a nonprimary partner.


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


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


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


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


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


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


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


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


PHR recommendations for alleviating the problem include funding local women's rights organizations, emphasizing women's rights in the reauthorization of the US President's Emergency Plan for AIDS Relief (PEPFAR), and pushing governments to secure confidentiality, counseling, and informed consent for those being tested for HIV. In addition, the countries were advised to focus on strengthening women's legal protections and building economic self-sufficiency for women. PHR also recommended supplying women with food as a short-term solution through the World Food Programme. The full report, including recommendations for the United States, international donors, and the Botswana and Swazi governments, can be accessed at


PHR mobilizes the health professions to advance the health and dignity of all people by protecting human rights. As a founding member of the International Campaign to Ban Landmines, PHR shared the 1997 Nobel Peace Prize.