- Samuel Quay
The Disproportionate Burden of HIV-AIDS on African Women
Author: Samuel Quay
Research Director: Keeven Cheong Aik Wei
Source: Johnson & Johnson, A Journey to End HIV/AIDS by 2020 (2017)
Amongst the many developmental challenges which plague the African continent, sexually transmitted diseases (STDs) or HIV/AIDS is one of the most severe issues due to its disproportionate burden on females and the multifaceted nature of its causes. Additionally, as the virus can be spread via childbirth, its excessive spread could affect child mortality rates and even economic growth.
How Bad is the Situation?
According to the UN, Sub-Saharan Africa accounts for roughly two-thirds of all HIV cases globally, with females carrying a disproportionate burden of new infections. In 2020 alone, females aged 15-24 accounted for a quarter of all infections, despite representing only 10% of the population. Considering that these statistics are prone to underreporting, existing numbers may underestimate the true severity of the issue. Furthermore, as both genders suffer from rampant infection rates, aspects such as growth and productivity are also likely to be impacted.
What are the Causes?
Firstly, a cause of the prevalence of HIV/AIDS was the initial denialism on the part of many African governments. The most well-known example of HIV/AIDS denialism was in South Africa under the presidency of Thabo Mbeki. During his tenure between 1999 and 2008, Mbeki continually criticised the scientific consensus that HIV causes AIDS, and even went as far as to recruit a panel of “scientists” who shared his view (Sidley, 2000). In line with these views, Mbeki’s government denied and restricted a host of antiretroviral drugs to patients (Nattrass, 2008). While succeeding health minister Barbara Hogan declared that “The era of denialism is over completely in South Africa'' following Mbeki’s step down (Dugger, 2008), the decade of denialism undoubtedly contributed to the spread of the virus and led to approximately 300000 premature deaths (Roeder, 2014). Moreover, given South Africa’s size and prominence in the region, its denialism is likely to have impacted its neighbouring states as well, with some of them having prevalence rates higher than 30 percent (Goliber, 2002).
Secondly, a fundamental lack of political stability and violent conflict has led to the prevalence of HIV/AIDS. By 2000, over half of the African countries were embroiled in conflict, affecting one in five Africans (IFEOMA, 2011). Given the heavy resource burdens of these conflicts and the unstable political structures of these countries, it would be difficult to expect countries like Congo or Ethiopia to have mounted sustained and effective campaigns to slow the epidemic down. However, in addition to a lack of measures, aspects of these violent conflicts like rape have compounded the spread of HIV/AIDS among women. A 2010 report by the Congressional Research Service found militant groups of Chad, Ethiopia, Nigeria, Somalia, and Sudan guilty of weaponising rape and perpetuating sexual violence in their conflict zones (Arieff, 2010). More recently, forces of the Ethiopian government have been accused of mass raping members of the Tigrayan populace, causing hundreds of females to flee to hospitals (Kassa & Pujol-Mazzini, 2021). Furthermore, men who reportedly stayed behind during the Ugandan civil war increasingly participated in promiscuous activities with numerous women, and these activities contributed immensely to the virus’s spread (Mworozi, 1993). Hence, in addition to a lack of institutional response in politically unstable states, the breakdown in civility and morality has caused innumerable females to fall victim to the virus.
Lastly, existing marginalisation and fear of discrimination are likely to cause the virus’s spread. As the stigma surrounding HIV/AIDS has been well known to drive the virus out of the public eye, patients have been documented to withhold their positive status even from family and friends (Skinner & Mfecane, 2004). Furthermore, marginalised groups of women often lack access to education and the capacity to make important life decisions. In the case of the Oromo women of Ethiopia, many are forced into prostitution early in their lives, compounding their risks and exposure to the virus (Dugassa, 2005). In 2012, a study found the prevalence of HIV/AIDS amongst sex workers to be as high as 37% (United Nations, 2014).
What are the Consequences?
While HIV in itself is a severe medical condition with no known cure (Be in the Know, n.d.), the repercussions to health are only one of many worries and obstacles a woman must face once she is diagnosed with the virus.
In a study conducted in Cape Town, 40% of survey participants diagnosed with HIV experienced some form of stigma and discrimination due to their condition, with some participants reporting a loss of their jobs and even a place to stay (Simbayi et al., 2007). As many women already face discrimination and marginalisation (Messer, 2004), the additional social stigma associated with HIV/AIDS is likely to compound such mistreatment. In Malawi for example, STDs regardless of origin have commonly been referred to as a “woman’s disease” (RANKIN et al., 2005).
In an analysis of rural Tanzania, a study found the deterioration of the levirate marriage practice to be due to the prevalence of HIV/AIDS (Kudo, 2017). Levirate marriage is the practice of marrying a widow to the deceased’s direct relatives and has often been viewed as an indirect social safety net for the widow and her family. While the decline of levirate marriage has been associated with female empowerment (as the widows are thought to be better able to fend for themselves), the study found the likely cause of the practice’s decline to be due to the prevalence of HIV/AIDS instead. As many of these widows lack any education and the capacity to provide for themselves and their families, the deterioration of levirate marriage due to HIV/AIDS causes many of them to be stranded in rather dreadful situations. Furthermore, there have also been innumerable instances where the in-laws of a deceased seize the wife's inheritance (Alubo et al., 2002). Hence, along with the myriad of physical health complications which come with HIV/AIDS, women are also likely to face increased disempowerment and stigmatisation.
What are some useful interventions?
The prevalence of HIV/AIDS in Africa is due to a host of extremely complex and deeply ingrained issues in the African continent. Similar to other aspects of economic development, the most effective solutions are often grounded in significant institutional overhaul and cultural change. However, many economists and scientists alike believe in the importance of alleviating the issue within specific contexts, opting to conduct randomised controlled trials to determine the most effective interventions. Adopting many similarities to a medical trial, a randomised controlled trial investigates the effectiveness of one/multiple intervention(s) while randomising between controlled and intervention groups (Hariton & Locascio, 2018). This randomisation process ensures that the different experimental groups do not differ significantly, and doing so allows for the intervention effect to be isolated and more effectively estimated.
For example, comprehensive STD programs have been shown to reduce the prevalence of HIV/AIDS significantly. Conducted in rural Tanzania, the program involved the establishment of an STD testing clinic, training healthcare staff in testing procedures, improving the supply of drugs to treat STDs, and having regular checks by programme officers and health educators to nearby villagers (Grosskurth et al., 1995). The program produced significant results, and it highlights the sheer amount of resources necessary to alleviate the issue even on a small scale.
By contrast, other less-comprehensive interventions investigated the effect of factors such as male circumcision (Wawer et al., 2009), latex diaphragm, and lubricant gels in reducing infection rates among females (Padian et al., 2007). These trials did not produce significant intervention effects and these preventive measures are not considered effective preventive measures. Most existing literature stresses the importance of sexual education and condom use in preventing HIV/AIDS (Wangamati, 2020).
Hence, apart from significant institutional and cultural change, randomised controlled trials provide us with a glimpse of some of the measures which may alleviate the issue. Unfortunately, the nature and results of these trials are highly context-specific and thus cannot be extrapolated.
Widely considered the most lethal epidemic in the history of mankind (RWJF, 2021), African women bear a disproportionate burden of HIV/AIDS cases and deaths. In dealing with the issue of economic development as a whole, stabilising the HIV/AIDS situation may prove pivotal, as it allows for the progression of women’s rights and a healthier workforce. As Singaporeans, our ability to contribute to the alleviation of HIV/AIDS in Africa is limited but still plausible. As RCTs tend to be conducted by Non-governmental organisations (NGOs) and academic institutions, they are always in need of monetary support. Furthermore, it would be great to continually update yourself on RCTs that produce significant intervention effects, and support any organisation which intends to take advantage of these results to improve development.
Alubo, O., Zwandor, A., Jolayemi, T., & Omudu, E. (2002). Acceptance and stigmatization of PLWA in Nigeria. AIDS Care, 14(1), 117–126. https://doi.org/10.1080/09540120220097991
Arieff, A. (2010, November 30). Sexual Violence in African Conflicts. Congressional Research Service. https://sgp.fas.org/crs/row/R40956.pdf
Be in the Know. (n.d.). HIV cure. https://www.beintheknow.org/hiv-and-stis/understanding-hiv-and-aids/hiv-cure
Dugassa, B. F. (2007, February 23). Women’s Rights and Health: The Case of Oromo Women in Ethiopia. Health Care for Women International, 26(2), 149–169. https://doi.org/10.1080/07399330590905594
Dugger, C. W. (2008, November 26). Harvard Study Finds Heavy Costs for South Africa’s Misguided AIDS Policies. The New York Times. https://www.nytimes.com/2008/11/26/world/africa/26aids.html
Goliber, T. (2002, July 2). The Status of the HIV/AIDS Epidemic in Sub-Saharan Africa. PRB. https://www.prb.org/resources/the-status-of-the-hiv-aids-epidemic-in-sub-saharan-africa/
Grosskurth, H., Todd, J., Mwijarubi, E., Mayaud, P., Nicoll, A., ka-Gina, G., Newell, J., Grosskurth, H., Todd, J., Mayaud, P., Nicoll, A., Newell, J., Mabey, D., Hayes, R., Mosha, F., Senkoro, K., Changalucha, J., Klokke, A., Mwijarubi, E., . . . Mugeye, K. (1995, August 26). Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania: randomised controlled trial. The Lancet, 346(8974), 530–536. https://doi.org/10.1016/s0140-6736(95)91380-7
Hariton, E., & Locascio, J. J. (2018, June 19). Randomised controlled trials - the gold standard for effectiveness research. BJOG: An International Journal of Obstetrics & Gynaecology, 125(13), 1716. https://doi.org/10.1111/1471-0528.15199
Ifeoma, E. E. (2011). The Nature Of Conflict In Africa And Its Impact On African International Relations: The Case Of Darfur. World Affairs: The Journal of International Issues, 15(3), 88–112. https://www.jstor.org/stable/48504830
Kassa, L., & Pujol-Mazzini, A. (2021, March 27). ‘We’re here to make you HIV positive’: Hundreds of women rush to Tigray hospitals as soldiers use rape as weapon of war. The Telegraph. https://www.telegraph.co.uk/global-health/women-and-girls/make-hiv-positive-hundreds-women-rush-tigray-hospitals-soldiers/
Kudo, Y. (2017). Why is the practice of levirate marriage disappearing in Africa? HIV/AIDS as an agent of institutional change. IDE Discussion Papers 627. https://ideas.repec.org/p/jet/dpaper/dpaper627.html
Messer, D. E. (2004, February 24). Breaking the Conspiracy of Silence: Christian Churches and the Global AIDS Crisis [E-book]. Fortress Press. https://www.amazon.com/Breaking-Conspiracy-Silence-Christian-Churches/dp/0800636414
Mworozi, E. A. (1993). AIDS and civil war: A devil’s alliance. Dislocation caused by civil strife in Africa provides fertile ground for the spread of HIV. AIDS Anal Afr., 3(6), 8–10. https://pubmed.ncbi.nlm.nih.gov/12287724/#:~:text=During%20civil%20wars%20through%20increased,promiscuous%20sexual%20activities%20for%20survival.
Nattrass, N. (2008, February 07). AIDS and the Scientific Governance of Medicine in Post-Apartheid South Africa. African Affairs, 107(427), 157–176. https://doi.org/10.1093/afraf/adm087
Padian, N. S., van der Straten, A., Ramjee, G., Chipato, T., de Bruyn, G., Blanchard, K., Shiboski, S., Montgomery, E. T., Fancher, H., Cheng, H., Rosenblum, M., van der Laan, M., Jewell, N., & McIntyre, J. (2007, July 13). Diaphragm and lubricant gel for prevention of HIV acquisition in southern African women: a randomised controlled trial. The Lancet, 370(9583), 251–261. https://doi.org/10.1016/s0140-6736(07)60950-7
Rankin, S. H., Lindgren, T., Rankin, W. W., & Ng’oma, J. (2006, August 05). Donkey Work: Women, Religion, and HIV/AIDS in Malawi. Health Care for Women International, 26(1), 4–16. https://doi.org/10.1080/07399330590885803
Roeder, A. (2014, February 19). The cost of South Africa’s misguided AIDS policies. Harvard T.H. Chan School of Public Health. https://www.hsph.harvard.edu/news/magazine/spr09aids/#:%7E:text=The%20human%20cost%20of%20South%20Africa’s%20misguided%20AIDS%20policies&text=More%20than%20330%2C000%20people%20died,that%20could%20have%20been%20prevented.
RWJF. (2021, November 19). The Five Deadliest Outbreaks and Pandemics in History. https://www.rwjf.org/en/blog/2013/12/the_five_deadliesto.html
Sidley, P. (2000, May 13). Mbeki appoints team to look at cause of AIDS. PubMed Central. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1127296/
Simbayi, L. C., Kalichman, S., Strebel, A., Cloete, A., Henda, N., & Mqeketo, A. (2007). Internalized stigma, discrimination, and depression among men and women living with HIV/AIDS in Cape Town, South Africa. Social Science & Medicine, 64(9), 1823–1831. https://doi.org/10.1016/j.socscimed.2007.01.006
Skinner, D., & Mfecane, S. (2004). Stigma, discrimination and the implications for people living with HIV/AIDS in South Africa. SAHARA-J: Journal of Social Aspects of HIV/AIDS, 1(3), 157–164. https://doi.org/10.1080/17290376.2004.9724838
United Nations. (2014, October). Sex Workers. UNAIDS. https://www.unaids.org/sites/default/files/media_asset/06_Sexworkers.pdf
Wangamati, C. K. (2020). Comprehensive sexuality education in sub-Saharan Africa: adaptation and implementation challenges in universal access for children and adolescents. Sexual and Reproductive Health Matters, 28(2), 1851346. https://doi.org/10.1080/26410397.2020.1851346
Wawer, M. J., Makumbi, F., Kigozi, G., Serwadda, D., Watya, S., Nalugoda, F., Buwembo, D., Ssempijja, V., Kiwanuka, N., Moulton, L. H., Sewankambo, N. K., Reynolds, S. J., Quinn, T. C., Opendi, P., Iga, B., Ridzon, R., Laeyendecker, O., & Gray, R. H. (2009, July 18). Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial. The Lancet, 374(9685), 229–237. https://doi.org/10.1016/s0140-6736(09)60998-3