To most people reading this, the important links between sexual and reproductive health (SRH) and HIV/AIDS are probably clear. Unfortunately, it's not always so clear that major global health donors see the links. The United States government has huge barriers for programs that fully integrate SRH and HIV/AIDS, such as the Global Gag Rule and the abstinence-until-marriage earmark in PEPFAR (President's Emergency Plan for AIDS Relief). Plus, even while U.S. funding for AIDS has gone up, money for family planning has gone down, making it hard to integrate programs with U.S. support. And, to this point, the Global Fund has supported essentially no proposals that integrate SRH and HIV/AIDS, despite its willingness to do so and the fact that it has none of the restrictions the U.S. has.
However, since the Global Fund is country driven and flexible and not prone to the ideologies that corrupt other AIDS-related efforts, it is the perfect vehicle for scaling up SRH-HIV programs. Once it's done in a country or two and the precedent is set, perhaps other countries will choose this approach and SRH-HIV/AIDS integration will become a lifesaving reality.
So, Rwanda is a test case as much as it is an example of innovation and commitment to its people's health. This year, Rwanda's Country Coordinating Mechanism for the Global Fund decided that the HIV prevention piece of its proposal would be based on the National Reproductive Health Policy. The policy focuses on six priority areas, which will all be integrated with HIV/AIDS programs if the Round 7 proposal is successful: safe motherhood and child health, family planning, prevention and treatment of STIs including HIV, adolescent reproductive health, prevention and management of sexual violence and social changes to increase women's decision-making power.
I was especially excited to be able to incorporate dramatically increased services for survivors of sexual and gender-based violence, because all too often people don't see clearly the connections between violence, reproductive health, and HIV/AIDS. But there are many. And Rwanda's history is a piece of the evidence base that supports these connections. During the 1994 genocide, there was a policy that HIV-positive genocideres should rape women in order to spread the disease. Estimates suggest that as many as 500,000 women were raped in those 100 days and 75 percent acquired HIV as a result. But interpersonal violence in Rwanda certainly didn't end with the genocide, so the country's commitment to seeking funding for national programs to address the physical, mental and emotional consequences of rape—including on sexual and reproductive health and including HIV—is yet another of the hopeful signs I saw in Rwanda.
The two weeks I spent in Rwanda were not easy. The history of genocide is impossible to overlook; every time I drove past the Hotel des Milles Collines, where the film Hotel Rwanda took place, whoever was in the car with me would invariably point it out, assuming I knew what happened there. One of the first questions strangers asked was "Do you still have your mother," a terrible reflection of the loss suffered by the Rwandan people. But Rwanda is doing well overall, especially considering its post-conflict status. HIV prevalence is still relatively low, and the country has been successful at implementing the previous grants it has received from the Global Fund. I have high hopes that it will succeed again in Round 7. If it does, it will have been rewarded for its courage in submitting a proposal unlike any that the Fund has supported in the past. And millions of Rwandans stand to benefit. Keep your fingers crossed!
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In South Africa, a woman is raped every 26 seconds.
Shocking, no? Let me add to it. Maybe you know all this already, but lest we get complacent I'm going to tell you again.
One out of three women in the world will be physically, sexually or emotionally abused in her lifetime.
20% of girls will be sexually abused before the age of 18. 10% of boys will experience the same tragedy.
In South Africa, a child is raped every 24 minutes.
]]>In South Africa, a woman is raped every 26 seconds.
Shocking, no? Let me add to it. Maybe you know all this already, but lest we get complacent I'm going to tell you again.
One out of three women in the world will be physically, sexually or emotionally abused in her lifetime.
20% of girls will be sexually abused before the age of 18. 10% of boys will experience the same tragedy.
In South Africa, a child is raped every 24 minutes.
You know someone who has been abused. Probably several someones. Someone in your family, your circle of friends, looking back at you from the mirror. Violence against women and children (VAWC) is a universal phenomenon that doesn't follow socio-economic or cultural lines but that potentially has disastrous consequences for the well-being of its victims in all circumstances.
One of these consequences is often HIV/AIDS (and sometimes the violence is also a result of HIV/AIDS). So in a country whose people are experiencing an incident of sexual violence every 26 seconds and whose population has one of the highest rates of HIV/AIDS in the world (18.8% as of 2006), it's impossible to ignore the connections. Or the fact that something has to be done about both crises—violence against women and children and HIV/AIDS—if the people are to survive and realize the dream that began when the apartheid regime was finally defeated.
Earlier this month I went to South Africa to meet activists who are working to change the deadly intersection of VAWC and HIV. Some come at the work from the VAWC angle, and some from HIV. But all of them have decided that the double scourge of violence and AIDS is the battle that South Africa now must win, the one that has replaced the fight against apartheid.
Before I left for South Africa, I kept wondering if South Africans would see HIV/AIDS as the primary issue facing their new democracy. Everywhere, people wore beaded red ribbons and mentioned HIV as the most important concern in South Africa. I even saw billboards for Project RED, which partners with corporations such as Gap and American Express to secure donations from certain products to the Global Fund to Fight AIDS, Tuberculosis and Malaria.
For me, one of the most interesting displays of the common fight against HIV/AIDS was in Soweto, the township outside Johannesburg that gained infamy for a student uprising in 1960 during which almost 70 students were gunned down by police. On the drive in to Soweto I saw signs for HIV testing and couples counseling and Project RED billboards. But I also noticed a lot of funeral homes and signs for funeral financing. It struck me that the omnipresent references to death were a sign that people are still dying at very high rates in Soweto. These deaths can literally break the financial back of surviving family members, not just because of funeral costs but because of the loss of breadwinners and caretakers. In the end, I felt that many South Africans outside my circle of AIDS professionals see the threat that AIDS really is to their country.
But I also wondered if the incredibly high prevalence of violence against women and children would be spoken about. If AIDS has associated stigma, I think it's possible that VAWC has even greater stigma. Its perpetrators are usually family members or trusted members of the community, its victims ordinarily society's lowest rung—women and children. There is a culture of silence surrounding VAWC that must be challenged and ultimately broken. That's why the Global AIDS Alliance has called our VAWC campaign "Zero Tolerance." We must begin talking about VAWC, challenging the belief that it is a private issue or that women bring it on themselves, changing gender norms and social expectations that devalue women and children, creating a new culture that refuses to tolerate violence and protects the right to health and safety of all people.
As it turned out, I saw few signs that the country has acknowledged VAWC as a national problem in the same way it has with HIV/AIDS. Yet, in the end, I came home with high hopes for South African women and children simultaneously at risk of HIV/AIDS and violence. There are so many groups doing outstanding work to create a culture of zero tolerance. The Treatment Action Campaign (TAC) has a new women's rights program, which has incorporated violence into TAC's world-famous grassroots work and includes monitoring sexual violence court cases brought by TAC's members. Sonke Gender Justice Network is conducting innovative programs that address the intersection of violence and HIV/AIDS, including a novel program to involve men in Prevention of Mother to Child Transmission (PMTCT) and women's HIV treatment. And the Center for the Study of Violence and Reconciliation is lending its research expertise to a national advocacy group working to pass a good Sexual Offenses Bill and to create a strong national action plan on gender-based violence, both of which contain language on links with HIV/AIDS.
Hopefully these outstanding efforts and a slowly emerging public awareness of VAWC will combine with South Africans' commitment to ending HIV/AIDS and lead to empowerment of the entire population, something that democracy alone has thus far failed to do. In the meantime, I'm inspired to continue our Zero Tolerance campaign with renewed vigor, because I know that the links between VAWC and HIV/AIDS are real and important to those on the ground. And I know that these people are grateful for our work in support of their goals, which may ultimately help liberate South Africa from the bonds of preventable death and injury, strengthening the entire country for the continued fight for human rights, economic independence and choice.
If you'd like to read more details about my trip and the groups with which I met, check out the blog I kept.
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