Violence and HIV/AIDS: Many Women Experience a Double Burden

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Supporting Social Change to Curb Violence and Eliminate HIV in Guyana, by Anne Stangl of ICRW

By Anne Stangl

*This blog originally appeared on ICRW

As I fly home from the humid, vibrant and bustling Georgetown, the capital city of Guyana, I am a bit overwhelmed by the daunting task the country faces to address the high levels of intimate partner violence, sexual assault, child abuse and suicide in the country.

Over the last week, my colleague Jocelyn Lehrer and I had the privilege of speaking with people working at community-based organizations throughout the country who are an integral part of tackling these challenges. Peer educators, social workers, nurses, counselors, people living with HIV, LGBT advocates, and survivors of violence all took time from their important work to speak with us about their efforts to create a path forward for Guyana.

My visit to the South American nation was the kick-off trip for ICRW’s grant work under Advancing Partners & Communities (APC), a USAID funded project, implemented by JSI Research & Training Institute, Inc., in partnership with FHI 360. ICRW is assisting in the implementation of the project in Guyana over the next three years, helping to strengthen the capacity of local organizations in Guyana to provide HIV prevention, care and treatment services to key populations at heightened risk of HIV infection, including women, men who have sex with men, transgender individuals and sex workers. Reaching these populations is critical for eliminating new HIV infections in Guyana, but extremely challenging, as these groups face high levels of stigma, discrimination and violence in society.

Given mounting global evidence that sexual assault and partner violence are directly linked with HIV infection, it is crucial for Guyana to tackle these key drivers of the HIV epidemic head-on.

During the trip, I learned of the great work these organizations and individuals are doing to support survivors of gender-based violence and to ultimately break the cycle of violence so that no woman or girl has to experience it in her daily life. From training police to be gender- and LGBT-sensitive, to supporting abused women, men and transgendered individuals in accessing justice, to sheltering women and children when their homes are unsafe, I could see firsthand that change is coming to communities in Guyana.

And while these conversations gave me great insight into the powerful individuals working to reduce violence in Guyana, I did see something worrying.

In interview after interview, themes began to emerge: Gender-based violence is pervasive. Services for survivors are limited or very difficult to access. Marginalized populations such as men who have sex with men, transgendered individuals and sex workers are at heightened risk of experiencing violence. Resources are limited for carrying out community- and national-level programs to change harmful gender norms and break the cycle of violence.

The stories shared by these frontline workers were reinforced daily by headlines in the local newspaper: a police officer charged with sexually assaulting a young man with a wooden police baton; a 23 year old who murdered his 14-year-old girlfriend and then hung himself. 

Despite these challenges and the ubiquitous headlines, I am cautiously optimistic about what we can accomplish.

On our final evening in Georgetown - the country’s largest urban center- we attended a production of “Before Her Parting” at the National Cultural Center. The play was written by Mosa Mathifa Telford, directed by Tivia Collins and staged by Merundoi Incorporated - a community-based organization that utilizes entertainment to educate the public, affect individuals’ attitudes and behaviors, and shift social norms. The gripping drama portrays a reality that’s all too common in Guyana in which young woman is murdered by her husband, who then kills himself. The plot could have been ripped straight from recent headlines.

The play also explores the intergenerational cycle of abuse that fosters violence generation after generation in Guyanese society: A woman is abused by her husband and is violent toward her son; her son grows up to beat and ultimately murder his wife, and the cycle continues. The play was followed by a facilitated discussion with the more than 400 audience members, ranging from students to teachers to civil servants, and a panel of speakers from various government institutions. It was heartening to hear these young Guyanese demand both action to reduce violence and expanded services to support survivors.

It is my hope that though USAID’s Advancing Partners and Communities Initiative, ICRW and John Snow International will be able to strengthen the capacity of local organizations so they are better equipped to respond to gender-based violence in Guyana and can continue to facilitate social norm changes to reduce violence and reduce the spread of HIV infection.

Above all, from my time in Guyana, I saw hope and determination. Hope that the next generation will not see the type of endemic violence that has pervaded Guyana for decades, and be determined to tackle these problems head-on. It’s important that those of us in the global community echo that hope and determination, too. We need to ensure that community workers and advocates have the tools to end these human rights violations as well as to empower women and girls to live free from fear of violence or abuse.

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Thank you to Anne for allowing us to share this post. If you would like to know more about what Anne does at ICRW, check out her twitter feed.

New HIV Bill in Uganda Will Harm Women, Children, and Families

Last week, the Government of Uganda took a major step back in the fight against HIV.

The bill, entitled “HIV Prevention and AIDS Control Bill,” that President Yoweri  Museveni is being asked to sign into law, criminalizes the transmission of HIV, makes it legal for doctors to disclose their patients’ HIV status to partners and families without consent, and, last but not least, calls for mandatory testing for pregnant women and their partners.

This new law would be a major step backward for a country that, for 30 years, has been a leader in tackling HIV head on. Ten years ago, I chose to do my dissertation research in Uganda because the country was on the forefront of using innovative, human-rights based approaches to combat the spread of HIV and to ensure that those living with HIV could lead full lives. Uganda was a veritable hotbed of innovative approaches to HIV prevention, care and treatment. Home-based HIV care and treatment, couples counseling, and positive prevention all emerged from Uganda and are now being implemented in countries around the world. Strong leadership and involvement of people living with HIV was a hallmark of these efforts.

But the news from Uganda marks a radical shift. Rather than exploring new ways to combat HIV and empower individuals, the bill stigmatizes and alienates people living with HIV and those who may be living with HIV. Instead of ramping up efforts to engage women in antenatal services to ‘get to zero’ new infant infections by 2015, a global goal set forward by UNAIDS in 2013, the bill infringes on women’s rights and will almost certainly lead to large reductions in the number of women attending antenatal care if enacted.

Such a back slide is worrying, in a country where 6.1% of pregnant women are living with HIV. In order to prevent transmission of HIV from mother to child (PMTCT), pregnant women must engage in what health officials call a ‘cascade’ of services, beginning with an HIV test.

Currently, about two-thirds of pregnant women test for HIV in Uganda. The next step for women who test positive is to begin taking antiretroviral therapy (ART). In Uganda, about 50% of pregnant women living with HIV receive ART. At birth, babies born to mothers living with HIV should receive oral Nevirapine followed by a 6-month course of antiretroviral prophylaxis. In Uganda, only 22% of infants born to mothers living with HIV receive antiretroviral prophylaxis. Stigma, or the fear of experiencing stigma, is one of the key challenges to improving the coverage of these critical PMTCT services.

Globally, stigma and discrimination have been revealed as among the most important barriers to pregnant women's acceptance of HIV testing during antenatal care, enrollment in PMTCT, and retention and adherence in these programs, all of which are critical to reducing transmission.  Indeed, it has been estimated that more than half of vertical transmissions in some settings can be attributed to the cumulative effect of stigma at each point of the cascade.  The new law in Uganda will only serve to fuel stigma and discrimination.

While getting all pregnant women to test for HIV is a good thing, making testing mandatory is not the way to go about it. Rather than increasing HIV testing, mandatory testing has been shown to lead some women to avoiding attending antenatal care altogether. As the PMTCT cascade of services is often only accessible through antenatal clinics, any policy that reduces clinic attendance is liable to increase the number of infants born with HIV. Coupling mandatory testing and criminalization is a double whammy, as those who test positive could face prosecution from partners who claim they were willfully infected. Adding the further injustice of dismantling provider confidentiality is the final nail in the coffin, both metaphorically and realistically. Under these circumstances, why would any Ugandan woman attend an antenatal clinic?

According to our friends at the International Community of Women Living with HIV,

“Women…will shy away from medical services, negatively impacting antenatal care attendance. The devastating result of this will be that more children are at risk of being infected through vertical transmission. Currently, by using proven strategies that emphasize voluntary counseling and testing, Uganda is striving toward zero infections from mother to child. However, Uganda’s gains could be lost if women are forced to test every time they visit a health facility.”

The truth is that throughout Uganda, women are already getting tested. Current testing approaches, including home-based testing and provider-initiated, or ‘opt-out’, testing have greatly increased HIV testing in Uganda over the last decade. This new legislation just serves as yet another repressive measure, targeted at women, but ultimately affecting men and entire families, to stigmatize anyone living with HIV.

The global community cannot stand-by and watch the erosion of decades of progress in reducing HIV transmission and in making sure that those living with HIV are able to receive quality care free from discrimination. We must not be complacent. The lives of thousands of mothers and children in Uganda hang in the balance.

So what can we do? Advocates, policy makers and researchers alike must urge President Museveni to weigh the risk of the reversals that could result from criminalization and mandatory testing under this legislation, in contrast to the tremendous gains Uganda has made from the policy of positive-living and a human rights-based approach to HIV prevention and management. Should the law be signed, we must not give up, but rather continue to urge the Government of Uganda to use all appropriate means to reconsider it, including during the development of regulations for its implementation by the Minister of Health. And lastly, we must encourage the Government of Uganda to once again be a leader in the global response to HIV by championing evidence-based, inclusive and supportive HIV policies instead of policies driven by fear and stigma. 

A Guest Post from Darby Hickey, from Best Practices Policy Project

Stigma kills. That’s an idea that, sadly, many communities understand and experience, including sex workers and people involved in sex trades. The pervasive social and governmental stigma and discrimination against those who trade sex for money or other needs is something that organizations fighting for the rights of sex workers are tackling head-on. Directly related to such stigma are laws that criminalize large swaths of commercial sex. This manifests through indifference and hostility from police, governmental authorities, and society when people who have traded sex for money are killed, attacked or raped—“they were asking for it” is the typical line.  It also manifests in persistent stereotypes of sex workers as “disease ridden” or “vectors of disease”, even as police the world over take condoms from sex workers or use them as evidence of criminal activity. 

 

The Best Practices Policy Project works to end such stigma and change laws through movement building and policy reform. An all-volunteer group composed of sex workers and allies, BPPP works largely on the national level in the U.S. to support other sex worker rights groups and to encourage the federal and local governments to protect the rights of people engaged in transactional sex in all its forms. Most recently we have been supporting the campaign of Monica Jones and SWOP-Phoenix to stop racist and gender profiling in Arizona and end a terrible program there that claims to give sex workers alternatives to jail but actually increases arrests and incarceration. We documented the work in Phoenix as an example of harmful policing practices in a report we submitted to the United Nations—which we used to pressure the U.S. government to address rights violations against sex workers.

One of the newer forms of stigma facing our communities is spread by some groups claiming to fight human trafficking. But instead of addressing this terrible phenomenon, these organizations claim that all commercial sex is violence and that the only solution is to increase criminal penalties and arrest people in order to save them. This approach not only does tremendous harm to sex workers, it also distracts from efforts to help people who actually experience coercion and exploitation, in the sex sector and the many other sectors where trafficking occurs. What’s more, these groups are now directly trying to undermine years of work to establish best practices for HIV interventions with sex workers. Well-financed organizations are attacking UNAIDS, for example, for its human rights approach to sex work, while also condemning extremely effective HIV outreach and treatment programs working with sex workers. Shockingly, groups promoting these “rescue” efforts view an increase of stigma as a positive development in their efforts to “eradicate” commercial sex.

From our perspective, criminalization and stigma go hand in hand, and we must combat both at the same time. When people are criminalized and stigmatized, they cannot claim their rights and are subject to serious rights violations. When sex workers and other people involved in sex trade are not criminalized they can better organize and demand protection of their human rights. Removing stigma helps people to see that sex workers are not deviants or victims but simply people trying to make a living just like others. When society and governments treat sex workers as human beings deserving of all the rights that any human has, people in the sex trades can be valued for their expertise. As sex workers all over the world say—we are not the problem, we are part of the solution.  

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We would like to thank Darby for her guest post. If you would like to see more about what Darby or the Best Practices Policy Project does, check out her twitter feed.

"Shuga" is Saving Lives in Nigeria - Mario Christodolou

Read the original post in its entirety here, at The Impatient Optimist: http://www.impatientoptimists.org/Posts/2014/01/Media-Can-Change-Lives-and-it-Can-Save-Lives

MARIO CHRISTODOULOU

January 06, 2014

Sophie has just had unprotected sex with her “Sugar Daddy” (a person who exchanges large amounts of money or gifts for sexual favours). While he goes to freshen up in the bathroom, she innocently snoops around the bedside drawer to reveal a box of pills—little does she know that they are antiretrovirals. She has unknowingly put herself at risk of HIV infection.

The scenario described above is from the new series of the MTV show Shuga, which has now landed in Nigeria. Condensed into this 60-second scene are issues related to transactional sex, negotiation of safer sex, HIV treatment, and HIV disclosure. But this depiction is just the tip of a gargantuan, mass-media behavior-change iceberg.

A scene from Shuga showing Sophie and Solomon in bed. Photo © MTV Staying Alive Foundation

Produced by the MTV Staying Alive Foundation in partnership with the Bill & Melinda Gates Foundation, US President’s Emergency Plan for AIDS Relief (PEPFAR), and the Nigerian National Agency for the Control of AIDS (NACA), the award-winning Shuga TV show has already had two hit seasons in Kenya. But Georgia Arnold, the Executive Director of the MTV Staying Alive Foundation and Executive Producer of Shuga, has a vision for the Shuga campaign in Nigeria that far exceeds anything attempted previously in Kenya.

“Shuga is a ground-breaking TV show that portrays the lives and loves of a group of young people. Seamlessly interwoven into the storylines are vital messages related to HIV and a wide range of other sexual health messages,” explains Arnold. “Alongside the TV series is a substantial mass-media campaign, which reaches our audience at all the points where they interact, improving their access to vital sexual and reproductive health messaging and directing them to the health services they need.”

As well as the TV show, the points of interaction that Arnold alludes to include a radio series, a mobile service (SMS), a comic book (focused on the domestic violence story line in the TV drama, aimed specifically at girls with low literacy levels), digital and social media, and a Skype service through which users can “call a character” from the show and share their thoughts.

Nii and Malaika in Shuga. Photo © MTV Staying Alive Foundation.

“The particular nature of stories and dramas not only deliver informational content but create emotional connections to characters and role models, which promote a better context for learning and behavior change than do factual presentations,” observes Victor Orozco, an economist at the World Bank and coordinator of their Africa HIV/AIDS Impact Evaluation Program. “TV could play an important role in introducing ideas to large segments of a society, especially segments where literacy is low and social norms discourage discussion of stigmatized issues such as HIV/AIDS and teen pregnancy.”

 Shuga series 3 aired for the first time on World AIDS Day, 2013, on more than 70 channels, with a potential audience of a half billion people.By keeping messages from the TV show at the forefront of people’s minds, the introduction of multimedia elements may have the potential to reinforce and promote positive behavior change. For example, sending weekly text messages can significantly increase adherence to antiretroviral treatment for people living with HIV. The Shuga campaign in Nigeria will aim to reinforce the messages of the Shuga TV show with a 360-degree campaign, including several social media and mobile components, such as text messaging and interactive voice recordings. Orozco is working with MTV to evaluate the behavior-change effects of the show and the additional impact of mobile messages through a randomized study.  

A character on the show is tested for HIV. Photo © MTV Staying Alive Foundation.

Shuga has made the journey from Kenya to Nigeria for several reasons. While some might argue that on the basis of prevalence, the need for a campaign like Shuga is greater in Kenya than in Nigeria—HIV prevalence in Kenya (6 percent) is double that of Nigeria (3 percent). However, Nigeria has the second highest number of people living with the disease, and while maternal mortality has significantly fallen since 1990 in the country, one in 13 women still die during childbirth. Additionally, of Nigeria’s burgeoning population of over 150 million, nearly a third are young people aged 10 to 24 years—a population that falls neatly into the MTV demographic and who will relate more closely with stories portrayed in Shuga.

These public health concerns are compounded by a severe lack of knowledge about HIV among young men and young women. “Comprehensive knowledge about HIV is defined as knowing that condom use and having just one HIV negative and faithful partner can reduce the chances of contracting HIV; knowing that a healthy-looking person can have HIV; rejecting the two most common misconceptions about HIV transmission—that HIV can be transmitted by mosquito bites and that HIV can be transmitted by supernatural means," explains Dr Emmanuel Alhassan, Director, Resource Mobilization at NACA. “However, only 22 percent of young women and 33 percent of young men [in Nigeria] have comprehensive knowledge about HIV.”

Shuga has the potential to displace the silence that has engulfed serious issues like HIV in Nigeria and beyond, and to fill the knowledge vacuum that such silence has created. Shuga series 3 aired for the first time on World AIDS Day, 2013, on more than 70 channels, with a potential audience of half billion people. With this kind of reach, the ability for this so-called entertainment education to inform, change attitudes, and even change behavior is undeniable.

However, Orozco notes that policy makers and funders might be seriously under-investing in such mass-media approaches due to lack of rigorous evidence. But with the support of the Gates Foundation and MTV Staying Alive, he and other researchers are remedying this by evaluating Shuga and creating a knowledge base of what methods works and what is worth scaling up in Nigeria and elsewhere.

“Our vision for Shuga is to see a transformation in attitudes about the way the world talks about sex, not as a dirty topic, or something that should be hidden, but something that is openly discussed: parent to child, peer to peer,” envisions Arnold. “Only by doing this will we see a real change in people’s attitudes about HIV and their knowledge about it. Only through open and honest dialogue can we can hope to save lives.”

Find links to the episodes that have aired so far here. 

Read the original post in its entirety here, at The Impatient Optimist: http://www.impatientoptimists.org/Posts/2014/01/Media-Can-Change-Lives-and-it-Can-Save-Lives

International Day of the Girl

International Day of the Girl encourages us to draw our attention to the inequalities facing young girls across the world. We are called to take a critical look at whether or not girls are given the same opportunities as boys in terms of access to education, financial stability, and sexual empowerment. Here at the Stigma Action Network, we are most concerned with how girls are affected by the HIV epidemic. After examining the data related to this topic, we ultimately found that:

• In sub-Saharan Africa, young women aged 15 to 24 are up to 8 times more likely than young men to be living with HIV.[1]
• Worldwide, young women account for 66% of young people living with HIV.[2]
•  Women living with HIV are more likely to experience violence as result of their status, than men living with HIV.[3]
• Prevalence of first forced sex among adolescent girls is as high as 48% in some countries, which further maintains the HIV epidemic.[4]

While these facts are indeed surprising, the factors that perpetuate them are even more alarming. Three of these most significant factors are outlined below.

• Girls’ Lack of Empowerment: According to global statistics, girls are significantly poorer, less educated, and as a result less financially and socially empowered than their male counterparts. This power imbalance reduces young women’s choices as they negotiate their sexual health and relationships, often giving them little choice in determining if and when to have sex, and in cases of consensual sex, whether that sex is safe. Furthermore, poverty prevents underprivileged girls from receiving adequate health care and education, and as such resources are essential in fighting the HIV epidemic, breaches in these areas may lead to HIV infection.

• Biology: The risk of becoming infected during unprotected sex is two to four times greater for women than for men, and for young girls, the risk can be even higher.[5] This biological disparity gives further evidence as to the importance of educating girls about their sexual health and rights, specifically as they relate to HIV.

• Culture: And lastly, cultural mores may encourage men to have many sexual partners.[6] This is particularly problematic surrounding the issue of child marriage, as such customs can facilitate the spread of HIV to girls in high-risk areas. And given that one-third of the world’s girls are married before they reach the age of 18, such practices can have quite widespread and devastating effects.[7]

As you can see, there are a multitude of socio-economic and biological factors that put girls at a higher risk of HIV. But what is the solution to this problem? And how can we curb these inequalities and give girls the power to take control of their sexual health?

Carol Bellamy, Executive Director of UNICEF offers up her thoughts:

“Education is crucial to success against the pandemic. 

In fact, UNICEF remains convinced that until an effective remedy is found,

 education is one of the most effective tools for curbing HIV/AIDS”

Luckily, the following organizations are contributing to the fight against HIV by educating girls about the importance of and how to protect themselves by engaging in safe sex! Here are a few #StigmaWarriors who are doing great work with girls on HIV education:

Girls Learn International, Inc

Girls Learn International, Inc. takes a unique approach to girls’ education by partnering American schools with schools in foreign countries where girls do not enjoy the same educational opportunities as boys. This organization functions as an after school program that offers service oriented learning to young girls. Participants in the US chapters learn of the challenges facing girls in their partner schools including child marriage, trafficking, poverty, sexual health, and educational disparities. Money that is raised domestically goes towards purchasing textbooks, teachers' salaries, meals, and transportation in partner schools. Girls Learn International, Inc. has 47 partnerships in the following countries where HIV rates are notably high: Afghanistan, Bangladesh, Cambodia, Ghana, India, Kenya, Nepal, Pakistan, Tanzania, Uganda, and Vietnam. Learn more about this organization and how you can help support the education of girls across the world. 

Maasai Girls Education Fund

On the Top 10 list of countries most affected by HIV/AIDS, Kenya comes in at #4. Girls living in poverty have less control over their sexual health, both because of lack of education and because of sexual abuse. "A large, national survey of secondary school girls in Kenya found that 40 per cent of those reporting sexual activity indicated that their first sexual experience was forced or that they were 'cheated into having sex.'"[8] The Maasai are nomadic pastoralists originating from the lower Nile valley with a strong traditional culture that often prevents females from receiving an adequate education. Only 48% of Maasai girls in Kenya enroll in school, and only 5% of those who enroll reach the secondary school level.[9] Such educational disparity can further facilitate the spread of HIV, as girls who remain uneducated are not only unable to make sexually sound decisions, but are also unable decisions that may secure a promising future. The Maasai Girls Education Fund works to combat this, however, by providing a safe environment where girls can receive a quality education. Donations to the Maasai Girls Education Fund go towards buying uniforms, books, and helping to pay tuition. What makes this organization stand out are their community workshops that attempt to reverse cultural beliefs and norms that discourage young girls from enrolling in and committing to school. And as enrollment in school is the best HIV prevention method available to girls (as noted by the World Bank), this organization’s work can surely make a difference.

Commit 2 Change

Young women are the victims of heavy abuse in India as well, in part because they are viewed as the less desirable of the two genders: over 25,000 of adolescent girls are malnourished and suffer from illness and medical neglect [10]. Commit 2 Change is dedicated to supporting female orphans in India by providing them with secondary education, with a particular emphasis on sexual health and HIV/AIDS prevention. Millions of children across the world have become orphaned after losing their parents to HIV/AIDS. Orphaned children are more likely to become impoverished and less likely to be enrolled in school as a result. A study done by UNICEF reveals that "the irony is that orphans are frequently deprived of quality education, which is the very thing they need to help protect themselves from HIV" [11]. India ranks #3 on the Top 10 countries most affected by HIV/AIDS.

The SAN congratulates the above-mentioned organizations (and others around the world!) who are doing great work to educate girls about safe sex and to prevent the spread of HIV among this particularly vulnerable population. However, The Girls Insights report conducted by the International Center for Research on Women found that "girls said they still lack even the most basic knowledge, autonomy and other assets critical for their health and empowerment." This demonstrates that even more must be done if we are to stop the spread of HIV and related stigma!

We hope that more organizations accept the challenge of incorporating sexual education, including education around HIV, into curriculum for young girls and adolescents. Programs must also be developed in a way that empowers girls to use this education to make sound decisions about their own sexual health. Together, with this sort of integrated approach, we can help girls gain control over their lives and futures, and help make a future without HIV a reality.

(Visit UNICEF for more details.)