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Poverty Brief - February 2003
Gender and HIV in Southern Africa:
A discussion with Stephen Lewis, UN Special Envoy on HIV/Aids


Pretoria, 29 January 2003


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One of SARPN's objectives is to promote discussion that will contribute to policy and action to reduce poverty and ameliorate its effects in the SADC region. HIV/Aids is having a major negative impact on the lives of poor people. SARPN invited invited Stephen Lewis, following the conclusion of his visit to Southern Africa with James Morris, to exchange views with a range of researchers, government officials, consultants, activists and donor representatives active in the fight against HIV/Aids in Southern Africa.

The discussion began with SARPN and the HSRC's programme on the Social Aspects of HIV/Aids and Health (SAHA) introducing their work. SARPN facilitator, Scott Drimie, noted that SARPN is a virtual network and knowledge repository housed in the HSRC's Integrated Rural and Regional Development programme. SARPN injects this knowledge into regional debates on poverty related issues in a number of ways including distributing information to an extensive e-mail distribution list of individuals, groups and networks around the region, and by maintaining a website that carries a wide range of poverty related material. The SARPN website now registers about 4 000 hits a day with growing regional impact. SARPN has convened discussions on the links between HIV/AIDS, children and poverty, HIV/Aids and land use, access to land and land reform programmes. Using the results of research is a key focus in its work, while it also works with communities on HIV/Aids and land issues. Late last year SARPN extended this focus to include food security. In March 2003, SARPN will be hosting a workshop on this subject that will feature a number of regional papers. (www.sarpn.org.za/rpp/hiv.php).

Olive Shisana, Executive Director of SAHA said the programme has worked with the Nelson Mandela Foundation to conduct the first representative, population based study of HIV/Aids prevalence in South Africa. The published report on the study is available at www.hsrc.ac.za. Previous prevalence studies have been based on testing done on pregnant women attending public antenatal clinics and therefore do not represent the population at large. The results of the SAHA study have contributed to government committing additional funds to the fight against HIV/Aids. Each province in South Africa now has HIV/Aids data on all population groups that can be used for planning. SAHA is now working with the WK Kellogg Foundation to extend the methodology of this study to a continent wide research programme.

After the introductions Stephen Lewis said that on his travels around the region to assess the HIV/Aids pandemic he had been overwhelmed by the vulnerability and predicament of women, and the fact that little was being done to address it. In his view, in Africa as elsewhere, gender relations are at the epicentre of the pandemic. In Africa two thirds of those infected are women in the 15 to 24 year age group, yet no government in the region is taking this seriously and there is no agency in the UN family that has taken up what is happening to women in a substantial way. HIV/Aids was resulting in the "feminisation of poverty in Southern Africa".

'The impact on women is a void lying at the heart of efforts to deal with the pandemic,' said Lewis. There appears to be little or no research into what is happening to women and no recognition of what the additional burdens of care and infection mean for women who already carry much of the daily work burden. The policy of voluntary home-based care adopted by countries in the region is an absurd misnomer for what amounts to additional forced labour for women. No one is looking at the human and financial costs of what this extra burden means in a situation where there is little or no outside support from government or other agencies. South Africa is the only country in the region that has any form of social safety net and even in South Africa there is no specific provision to help women with the burdens of care and infection resulting from the pandemic.

If the international community is to intervene effectively there has to be more research into how women's lives are being affected in every way as they try to keep the society going.

Following Stephen Lewis' brief presentation, the Chair, Richard Humphries, identified three main areas for discussion:
  • What research is being done and what research are donors funding in the areas identified?
  • Issues around women and gender.
  • Issues around HIV/Aids and safety nets in the region.


Discussion: during discussion a wide range of views were presented. These are captured below, followed by responses from Stephen Lewis

Research and funding
  • Donors want to see fairly short-term results that they can report to their governments and principals. As a result they are more likely to fund projects and programmes that involve implementation rather than research.
  • HIV/Aids is an area where research is needed in order to get results. Government and non- government stakeholders need to be asked about their information needs and a link established between research, policy and programmes.
  • We need to look at how HIV positive people can be directly involved in research, planning, action, monitoring and evaluation.
  • One of the key challenges facing research is to establish the appropriate link between social and economic policy so that economic growth has a direct impact on social policy.
  • Traditional research is necessary but we also need research that uses participatory methods to enable people and organisations to get involved in evaluation and implementation.
Policies and programmes
  • Governments are not providing adequate support for home- and community-based care.
  • The Aids tax in Zimbabwe gets money to communities through an effective organisational infrastructure. Can South Africa learn about funding or organisation from this experience?
  • The South African Treasury does not favour dedicated taxes but there has been significant growth in social spending since 2000. Funding for HIV/Aids has increased considerably to R1.8 billion over a three-year period. This has been augmented recently with an additional R3.3 billion. The Treasury, in conjunction with the Department of Health, is looking at antiretrovirals but there are still cost constraints. In the short term it is difficult for state departments to absorb such an exponential growth in funding and there is considerable underspend due to capacity constraints.
  • The Department of Social Development does face difficulties in extending delivery to community level but underspending is not a significant problem. The Department has spent 90 percent of its HIV/Aids budget and actually needs additional funds.
  • The Commission on Macroeconomics and Health is very important and should guide countries. However, countries should not use the lack of research as a reason not to start treatment where capacity is available. This is still cited as a reason in South Africa.
  • Home based care will not be successful until the issue of stigma is dealt with as people will not come forward and state they are positive, which is necessary for home based care programmes to work. Until then programmes targeting HIV/Aids will continue to degenerate into care for the elderly programmes.
  • Private sector treatment programmes are mainly reaching men, eg miners and assembly line workers. They do not reach many women who are the group most affected. The same is true of public sector programmes. In Malawi and Zambia, which are both starting pilot antiretroviral programmes with funds from the Global Fund, there is an assumption that men will be treated first.
  • Food is the first treatment. We need to look at ways of getting food to people before they get really sick. We also need indicators to assess their nutritional status.
  • A suggested way of getting treatment to women and children is to look at treating the household rather than the individual.
Stephen Lewis
  • Although countries in the region now have a much greater focus on the issue, and the denial that characterised the response of a number of governments is largely a thing of the past, no governments are treating the HIV/Aids pandemic as a national disaster. The same holds for the multilateral agencies.
  • The Bush statement that US$ 15 billion will be made available for HIV/Aids programmes indicates that money will be available for anti-retrovirals. The Global Fund is experiencing difficulties at present but the situation is likely to improve.
  • Financial and economic ministers should take note of economist Jeffrey Sach's views on the limitations of macro-economic policies. The monetarist assumption that growth will trickle down does not hold. When the disease burden is so great you have to deal with it first or you will not get to the poverty issue. States will not achieve growth unless they deal with disease. This is the flaw at the heart of Nepad in the original document, although discussions since then have addressed the issue (www.who.int).
In response to the last point it was noted that Nepad has addressed HIV/Aids directly but this is not well represented in the documentation. The Heads of State and Government Implementation Committee (HSIC) has adopted a plan of action dealing with the disease and there are policy guidelines for countries to follow.

Women
  • Young women in the Eastern Cape province are - it is claimed - coming to clinics in the hope that they will test positive so that they can qualify for a disability grant. It is sad that they should have such a limited view of the income opportunities open to them.
  • The HIV/AIDS Vaccine Ethics Group (HAVEG) at the University of Natal, part of the South African AIDS Vaccine Initiative (SAAVI), has drawn attention to the high risk of infection facing women, including the risk associated with participation in vaccine trials.
  • Some work on mental health, particularly prevalence studies of depression, indicates a substantial impact on women. One study indicated that more than a third of women with a child under 6 months of age in Khayelitsha were depressed.
  • People have said that HIV/Aids will be a setback for gender equality but no action is being taken to address this. None of the SADC countries have done anything about the legal framework that puts women at greater risk of infection. Mandatory testing will not address this issue. A way forward would be to develop a code on women and HIV/Aids in the same way as a code on employment and HIV/Aids was developed, and then to use this as an advocacy tool.
Stephen Lewis
  • International women's organisations have not intervened to help address the situation facing women on the continent.
Children
  • Do the issues facing women also relate to children? The South African Constitution protects the rights of children but this is not the case in most other countries in the region.
  • We do not have an adequate understanding of how children are experiencing the pandemic. As with adults they need to be more directly involved. Preliminary research shows that children have different issues to adults. For example there is an increased demand for child labour. We need to stop talking about orphans and start involving them.
  • It is ironic that it often takes a war or other catastrophe to focus attention on an existing problem. The dramatic increase in the number of orphans as a result of HIV/Aids is turning attention to what was already an issue.
Stephen Lewis
  • The problem of children seems intractable but there are powerful organisations like UNICEF and Save the Children Fund addressing the issue, unlike the situation with issues facing women [see above].
Stigma
  • Stigma is a big problem but much of it is due to the lack of access to treatment. Once treatment is available stigma starts to break down.
Conclusion

The exchange of views brought home to participants the enormity of the challenge facing sub-Saharan African countries in dealing with the social and economic impacts of HIV/Aids, and particularly the impact on women and children. While countries are making some progress on the prevention and treatment of HIV/Aids, little has been done on these wider impacts of the pandemic.

Researchers and activists have an important role to play in increasing understanding of the nature and extent of these impacts and in involving affected people, governments, the private sector and civil society in addressing them. In doing so they can contribute to the awareness of the pandemic and help to initiate the kind of 'national disaster' response that Lewis believes is necessary to combat HIV/Aids effectively in sub-Saharan Africa.

But researchers and NGOs need to ensure that their research outputs reaches decision-makers, at regional and national levels. Stephen Lewis indicated that he would appreciate receiving material generated by agencies in Southern Africa for use in his advocacy work. SARPN is prepared to assist in forwarding material to him.

SARPN specialist areas and contact details:

PRSPs: Richard Humphries (SARPN co-ordinator) at rhumphries@hsrc.ac.za (27-12-302 2873)
Land, HIV and Food Security issues: Dr Scott Drimie at sedrimie@hsrc.ac.za (27-12-302 2155)
Nepad/Trade issues: Ms Sanusha Naidu at snaidu@hsrc.ac.za (27-31-273 1406)
Communication and media issues: Nathi Kheswa at nkheswa@hsrc.ac.za (27-12-302 2229)

This Poverty Brief was compiled by Dick Cloete, Media Directions for SARPN


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