The global HIV/AIDS pandemic is taking a catastrophic toll on women and
girls. The number of HIV infections among women and girls has risen in every
region in recent years, and in sub-Saharan Africa, women and girls constitute
nearly 60 percent of those living with HIV. In some countries, the HIV
infection rates for girls are many times higher than for boys. The rising
number of HIV infections among women and girls is directly related to violence
against women and their unequal legal, economic, and social status.
The global HIV/AIDS pandemic is taking a catastrophic toll on women and girls.
The number of HIV infections among women and girls has risen in every region
in recent years, and in sub-Saharan Africa, women and girls constitute nearly
60 percent of those living with HIV. In some countries, the HIV infection
rates for girls are many times higher than for boys. The rising number of HIV
infections among women and girls is directly related to violence against women
and their unequal legal, economic, and social status.
Abuses of womens and girls human rights impede their access to HIV/AIDS
information and services, including testing and treatment. Those who do obtain
HIV services sometimes face disclosure of their confidential HIV test results
by public health officials without the womens consent. This heightens
womens risk of being ostracized by their communities and abused by their
Governments around the world have done far too little to combat the
entrenched, chronic abuses of womens and girls human rights that put
them at risk of HIV. Misguided HIV/AIDS programs and policies, such as those
emphasizing abstinence until marriage, ignore the brutal realities many women
and girls face. By failing to enact and effectively enforce laws on domestic
violence, marital rape, womens equal property rights, and sexual abuse of
girls, and by tolerating customs and traditions that subordinate women,
governments are enabling HIV/AIDS to continue claiming the lives of women and
Chronic Abuses Made Deadlier by HIV/AIDS
Human Rights Watch has interviewed hundreds of women and girls living with HIV
around the world. Their accounts are harrowing, ranging from trafficking to
rape during armed conflict. This briefing paper focuses on the links between
HIV/AIDS and abuses of womens and girls human rights that literally hit
closest to home:
- domestic violence, including marital rape
- violations of property and inheritance rights
- the harmful traditional practices of bride price, widow inheritance, and
ritual sexual cleansing and
- sexual abuse of girls.
These abuses are perpetrated by families and tolerated by governments.
They are among the most pervasive and dangerous abuses for women and
girls. In the context of HIV/AIDS, they can be lethal.
Domestic violence is not only inherently dehumanizing, it is a central cause
of womens HIV exposure. Domestic violence limits womens capacity to
resist sex and to insist on their spouses fidelity or condom use. Yet most
countries dismally fail to prevent domestic violence, prosecute or otherwise
punish perpetrators, or provide health or legal services to survivors. Most do
not even recognize its link with HIV/AIDS. Marital rape is rarely treated as a
Human Rights Watch has interviewed woman after woman across Africa and in the
Caribbean, many of whom said that domestic violence and spousal rape caused or
contributed to their HIV infection. Hadija Namaganda, a Ugandan woman living
with HIV, told Human Rights Watch that her husband routinely forced her to
have unprotected sex with him and beat her viciously. Himself HIV-positive, he
once attacked her so violently that he bit off half of her left ear. When he
lay dying of AIDS and was too weak to beat her, he ordered his younger brother
to do so. Gabriela Lpez, a twenty-four-year-old Dominican woman with five
children, told Human Rights Watch that she became infected with HIV after
repeated rapes by her husband. After she tested positive for HIV, her husband
abandoned her and their children.
Studies have shown that domestic violence contributes to higher HIV infection
rates. A recent South African study found significantly higher rates of HIV
infection in women who were physically abused, sexually assaulted, or
otherwise mistreated by their intimate male partners.
Abuses of Womens Property and Inheritance Rights
In some regions, most prominently in sub-Saharan Africa, women are denied
equal property rights.
- Many widows are barred by law and custom from inheriting property,
evicted from their lands and homes by in-laws, and stripped of their
- Divorced women are often expelled from their homes with only the clothes
on their backs.
A womans access to property usually hinges on her relationship to a man.
When the relationship ends, the woman stands a good chance of losing her home,
land, livestock, household goods, and other property. While this
discrimination stems from customs that favor men for inheritance and property
ownership, it is also enabled by government policies and laws that
discriminate in inheritance and divorce matters.
In countries like Kenya, where twice as many women are HIV-positive as men,
the AIDS epidemic magnifies the devastation of womens property violations.
AIDS deaths expected in the coming years in Africa will result in millions
more women becoming widows at younger ages than would otherwise be the case.
These women and their children will likely face not only stigma against people
affected by HIV/AIDS, but also deprivations caused by property rights
Imelda Orimba, a Kenyan widow with AIDS, told Human Rights Watch that when her
husband died, she told her in-laws that she had AIDS and wanted to stay in the
house. They grabbed her property anyway. She recalled: I told my in-laws
I'm sick . . . but they took everything. I had to start over. . . . They took
sofa sets, household materials, cows, a goat, and land. I said, Why are you
taking these things when you know my condition? My in-laws do not believe
in AIDS. They said that witchcraft killed my husband.
Children orphaned and affected by HIV/AIDS, especially girls, are also at risk
of property-grabbing when their parents are sick or die. A sixteen-year-old
orphan girl in Zambia told Human Rights Watch that after her father died,
The relatives grabbed all our property, even my clothes. I didnt even
get a single spoon. This was my fathers relatives. When her mother died,
she ended up living with an uncle who sexually abused her and who is feared to
Divorced and separated women fare no better. Many countries have no statutory
law on division of family property upon divorce, leaving the matter to the
discretion of judges or traditional leaders. Countless divorced women have
told Human Rights Watch that they have no hope of prevailing in property
rights claims due to the biases against women among judges and traditional
authorities. Denying women equal property rights upon divorce also facilitates
domestic violence, again posing the risk of HIV. Women in Kenya and Uganda
told us that they remained in violent relationships because leaving would mean
losing their homes and other material belongings.
Harmful Traditional Practices
Traditional practices of some communities heighten the HIV risk for women and
girls. While customs are important to community identities and human rights
law supports the preservation of customs and traditions, this cannot be at the
expense of womens and girls rights and health. Just as discriminatory
statutes must be amended to protect womens and girls rights, harmful
traditional practices must be transformed to eliminate abusive aspects.
Human Rights Watch has documented the dangers of a number of traditional
practices in the context of HIV/AIDS, including:
- payment of bride price
- widow inheritance and
- ritual sexual cleansing.
The payment of bride price by a mans family to his future wifes family
is a considerable obstacle for women attempting to leave abusive
relationships. Though the intent may be to show appreciation to the brides
parents and reinforce relations between families, bride price is perceived by
many to be an outright purchase of a wife. Masturah Tibegwya, a Ugandan woman,
told us, They take you as property so if the man comes for sex you dont
say no. A study of several districts in Uganda found that 62 percent of the
respondents identified bride price as a major cause of domestic violence, as
it encouraged men to beat wives who did not measure up. This dynamic
also obstructs womens ability to negotiate safer sex.
In some places, widows are coerced into engaging in risky sexual practices
upon the death of their husband. These practices include widow
inheritance (also known as wife inheritance) and ritual sexual
cleansing. Widow inheritance is where a male relative of the dead
husband takes over the widow as a wife, sometimes in a polygamous family.
Cleansing usually involves sex with a social outcast who is paid by the
dead husbands family, supposedly to cleanse the woman of her dead
husbands evil spirits. In both of these practices, safer sex is seldom
practiced and sex is often coerced. While some women consent to these
practices, others are coerced into them in order to stay in their homes and
keep their property. Rejecting these practices can result in social exclusion
or rape. Succumbing to them can contribute to HIV infection.
Emily Owino, a Kenyan widow, told us that shortly after her husband died, her
in-laws took all her possessionsincluding farm equipment, livestock,
household goods, and clothing. They insisted that she be cleansed by
having sex with a social outcast as a condition of staying in her home. They
paid a herdsman the equivalent of U.S. 6 to have sex with Owino, against her
will and without a condom. She told us, I tried to refuse, but my in-laws
said I must be cleansed or theyd beat me and chase me out of my home.
The in-laws eventually forced her out of her home anyway. She and her children
were homeless until someone offered her a small, leaky shack. No longer able
to afford school fees, her children had to drop out of school.
Sexual Abuse of Girls
In many countries in sub-Saharan Africa, HIV prevalence among girls under age
eighteen is four to seven times higher than among boys the same age, and girls
have a lower average age of death from AIDS. Sexual abuse contributes directly
to this disparity in HIV infection and mortality. Coercionphysical,
psychological, and economiclooms large in many girls sexual experiences.
Yet governments are failing to provide basic protections from sexual abuse
that would lessen girls vulnerability to AIDS.
Sexual abuse of girls by male family members is frequently kept secret, and
law enforcement agencies are often complicit in hiding the abuses. In Zambia,
where nearly 17 percent of the population aged fifteen to forty-nine is living
with HIV, girls told Human Rights Watch of sexual and other physical abuse at
the hands of uncles, stepfathers, fathers, cousins, and brothers. Orphan girls
dependent on their abusers said they feared losing support, including for
schooling, if they revealed the abuse. A twelve-year-old girl told Human
Rights Watch, My uncle used to beat me with electricity wires. Before I
went to live my uncle and auntie, I stayed with my big sisters mother, and
my brother used to take me in the bush. Then he raped me. I was eight or nine.
I was scared. He said Im going to beat you if you ever tell
HIV Information and Services: Insensitivity to Womens and Girls
HIV prevention, testing, and treatment programs are central to fighting AIDS.
Yet insensitivity to the concerns of women and girls in these programs often
make the solution part of the problem.
Misguided HIV Policies and Programs
HIV risk is fundamentally linked to abuses of womens and girls rights,
yet prevention policies and programs often ignore this link. A prime example
of misguided HIV prevention programs are those that emphasize an ABC
approach (A for abstinence, B for be faithful, and C for
condom use) over programs promoting womens and girls rights. ABC
programs advocate behavioral changes that do not address the social realities
limiting womens and girls sexual autonomy and putting them at risk of
HIV. Many women and girls cannot abstain from being brutally raped,
cannot stop their husbands infidelity, and lack the negotiating power
within their abusive relationship to insist on condom use. Sules Kiliesa, a
Ugandan widow, told Human Rights Watch that her husband would beat me to
the point that he was too ashamed to take me to the doctor. He forced me to
have sex with him and beat me if I refused. . . . Even when he was
HIV-positive he still wanted sex. He refused to use a condom. He said he
cannot eat sweets with the paper [wrapper] on.
The focus on marriage as a preventive factor in HIV policies (as in
abstinence until marriage programs) is also misguided. In some
countries, married young women have higher HIV prevalence than their unmarried
counterparts. A recent study among sexually active young women in Kenya and
Zambia found that HIV infection levels were 10 percent higher for married than
for sexually active unmarried girls. In rural Uganda, another study found that
88 percent of young women living with HIV were married. Another disturbing
study in Zambia found that only 11 percent of women believed they had the
right to ask their husbands to use a condomeven if he had proven to be
unfaithful and was HIV-positive.
Abusive HIV Testing Practices
Testing for HIV is the first step toward obtaining necessary support and
treatment. But if testing is done without respect for womens human rights
it can have devastating consequences.
Women who test positive for HIV are at increased risk for domestic violence
and social exclusion. Sadly, many women Human Rights Watch interviewed said
that health workers had disclosed the womens confidential HIV test results
without their consent. Moreover, some women described grossly inadequate
pre-and post-HIV test counseling, calling into question whether the tests were
truly voluntary. In some cases, HIV-positive women had necessary medical
procedures denied due to discriminatory attitudes of health care providers.
Rosa Polanco, an HIV-positive Dominican woman, told Human Rights Watch that
when she was hospitalized for a liver disease, her doctor disclosed her
HIV-positive status to her daughters without her consent. When Polancos
mother discovered her status, she evicted Polanco from the home she had shared
with her parents and children. Having no money and no hope for employment in a
country where many employers deny work to people with HIV, Polanco moved to a
makeshift wooden shack without sanitation, electricity, or running water in a
dangerous, remote informal settlement.
As health care providers around the world rush to embrace provider-initiated
rather than patient-initiated HIV testing, more women will have the
opportunity to test for HIV. But unless testing protocols adequately address
the need to protect womens rights to informed consent and confidentiality,
women will also face dangers in their homes and communities. There is an
urgent need for greater clarity on what provider-initiated HIV testing means,
and what counseling, confidentiality, and other rights protections must
accompany such testing. At a minimum, such measures must ensure that women
know their options and are given tools to adequately deal with the
consequences of both a negative and a positive test result. Meanwhile,
governments must act now to ensure that confidentiality measures are in place
Rape Survivors Denied Post-Exposure Prophylaxis
HIV post-exposure prophylaxis (PEP), a short course of treatment with
antiretroviral medicines administered after rape, can keep rape from being a
death sentence by reducing the risk of HIV infection from an HIV-positive
attacker. PEP is the standard of care for rape survivors in wealthy countries.
Poorer countries have begun to offer PEP to rape survivors, but not without
In South Africa, for example, the explosive AIDS epidemic and shocking rates
of rape and sexual violence make an effective PEP program critical.
Unfortunately, Human Rights Watch found that government inaction and
misinformation from high-level officials have undermined the effectiveness of
its program to provide rape survivors with PEP. The governments failure to
provide adequate information and training on PEP has left both service
providers and rape survivors in the dark. Many rape survivors did not receive
PEP services simply because neither they nor police and nurses helping them
had any idea that such services existed. Poor women and girls and those living
in rural areas were often denied access to PEP altogether.
Inequalities in Access to HIV Treatment
As countries gear up for massively expanded antiretroviral treatment programs,
urgent attention is needed to ensure that women and girls will access ARVs
equitably. Due to pervasive discrimination, women are less likely than men to
have the income or assets needed to pay for antiretroviral therapy. Even where
treatment is free, basic costs like diagnostic tests or transportation to the
hospital may be out of reach of women. In some families, men determine whether
women and girls will be allowed to leave the home and take time away from
household duties to visit health centers. When male and female family members
are HIV-positive and resources are scarce, evidence in some countries shows
that men are the first to receive treatment. If a woman defies a man and seeks
treatment anyway, there can be violent consequences.
Many Ugandan women told Human Rights Watch that violence, or the fear of
violence, prevents them from freely obtaining HIV/AIDS testing and treatment.
Service providers reported that many women came to them secretly, fearing that
their husbands would beat them if they sought HIV testing or medical
attention. Jane Nabulya, a Ugandan woman, said that she secretly tested for
HIV in 1999 when she found out her husband had AIDS. She explained: I was
scared to tell him that I had tested HIV-positive. He used to say that the
woman who gives him AIDS, I will chop off her feet. I have never told
In Kenya and Uganda, women told Human Rights Watch that they could not reach
HIV testing and treatment centers because they had no money to travel or pay
for care, were too afraid to ask abusive husbands for funds, or were not
allowed to leave the home. Rebecca Samanya told us, I got counseling after
he [her husband] had died. I wanted to go before but I didnt have the
means. I wouldnt ask him. He would quarrel [fight]. Many widows told us
that after they had been denied inheritance and lost everything to
property-grabbing in-laws, they had no money to survive, much less pay for
antiretroviral therapy and other health care.
The disproportionate impact of AIDS on women and girls is no accident. It is
the direct result of the pervasive abuses of their human rights. Despite the
growing consensus that HIV/AIDS is a womens rights issue, little has been
done to change laws and practices that violate womens rights, put them at
risk of HIV/AIDS, and impede their access to HIV information and services.
Combating the rights abuses that put women and girls at risk of HIV is
essential to turning around the AIDS crisis. Concrete policy measures are
urgently needed and can have immediate and long-term impact. Governments, with
the support of donors and international organizations, must act urgently to
stop the abuses of womens and girls rights that fuel the AIDS epidemic
and impede societys response.
Recommendations for Action
Human Rights Watch calls on all governments, donors, and international
organizations to address gender inequity as an abuse in its own right and as a
central element of HIV/AIDS policy and programs. Essential first steps