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African Journal of Reproductive Health
Women's Health and Action Research Centre
ISSN: 1118-4841
Vol. 6, Num. 3, 2002, pp. 30-37
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African Journal of Reproductive Health, Vol. 6, No. 3, December, 2002 pp.
30-37
Gender and Human Rights Dimensions
of HIV/AIDS in Nigeria
Nkoli I Aniekwu
Correspondence: Nkoli I. Aniekwu,
Department of Public Law, Faculty of Law, University of Benin, Benin City,
Nigeria
Code Number: rh02032
ABSTRACT
Until very recently, researchers
paid little attention to sex or gender issues in HIV/AIDS. When differences
between females and males on health matters were considered at all the focus
was clearly on womens' reproductive lives and not on factors affecting the
spread of the disease. There was hardly any consideration of the influence
of inequalities on the spread of HIV/AIDS and on outcomes of infection between
the sexes. Hitherto, health policies and programmes focused on biological aspects
of diagnosis, treatment and prevention. In this paper, the author seeks to
provide an understanding of the social factors as well as identification of
the capacity of human rights to develop an effective response to the disease.
It is a gender perspective on human rights with specific implications for women
in the context of HIV/AIDS. (Afr J Reprod Health 2002; 6[3]: 3037)
RÉSUMÉ
Dimensions sexistes et
des droits de l'homme par rapport au VIH/SIDA au Nigéria. Jusqu'à très
récemment, les chercheurs ont prêté peu d'attention aux problèmes des sexes
par rapport au VIH/SIDA. Quand on considérait les différences entre les
hommes et les femmes sur le plan de la santé, l'accent était clairement mis
sur la santé reproductive des femmes et non pas sur les facteurs qui concernent
la propagation de la maladie. On considérait à peine l'influence des inégalités
sur la propagation du VIH/SIDA et sur les résultats de l'infection entre
les sexes. Jusqu'ici, les politiques et les programmes de la santé ont concentré sur
les aspects biologiques du diagnostic, du traitement et de la prévention.
Dans cet article, l'auteur cherche à fournir une compréhension des facteurs
sociaux aussi bien qu'à identifier la capacité des droits de l'homme d'élaborer
une réponse efficace à la maladie. Il s'agit là d'une perspective sexiste
sur les droits de l'homme avec des implications spécifiques pour les femmes
dans le contexte du VIH/SIDA. (Rev Afr Santé Reprod 2002; 6[3]: 3037)
KEY WORDS: Gender,
human rights, HIV, AIDS, Nigeria
INTRODUCTION
It is now established that women are biologically more vulnerable to HIV/AIDS,
and more likely to contact infection from their male partners.1 The
combination of their sexuality and gender disadvantage in terms of cultural,
economic and social factors place them more at risk of infection than men.
At the Fourth World Conference on Women held in Beijing in 1995, emphasis on
gender equity and reproductive health rights were accepted as cornerstone for
the planning of effective health and prevention programmes by governments on
HIV/AIDS.
The risk of HIV infection during
unprotected vaginal intercourse is two to four times higher for women than
men. This is because semen contains a higher concentration of HIV than vaginal
secretions and can remain in the vagina for many hours after intercourse. Women
are also more likely than men to contact other sexually transmitted diseases
(STDs), which would increase their risk of infection with HIV. This vulnerability
is too often reinforced by social constraints on women's ability to protect
themselves and insist on safe sex. Social science and legal research, particularly
research that takes a gender approach to human rights, is helpful in understanding
how socio-cultural, legal and economic factors contribute to women's vulnerability
to HIV/AIDS infection in Nigeria. A gender approach to the disease considers
the critical roles that social and cultural factors play in the spread and
management of HIV/AIDS and the higher vulnerability and susceptibility of women
to infection.
The HIV/AIDS Pandemic:
A Global Concern
Around the world, STDs, particularly HIV/AIDS, continues to spread, killing
millions of women, men and children. At the end of 1998, UNAIDS and WHO estimated
that 33.4 million people were living with HIV infection including 13.8 million
women (43%) and 1.2 million children.2 The vast majority of people
living with HIV/AIDS are in developing countries 22.5 million in sub-Saharan
Africa (50% of whom are women), 6.7million in South and South East Asia, and
1.4 million in Latin America. These numbers are increasing every year. It is
estimated that more than 60 million people would be infected by 2005.
Governments, particularly those
in developing countries where the epidemic is mainly focused, cannot ignore
the statistics. The pandemic is concentrated in the poorest parts of the world
with 90% of HIV positive cases living in the developing world.1 Many
developing countries are continually experiencing exponential growth of HIV/AIDS
cases especially amongst women and children. Global spending on HIV/AIDS care,
research and prevention reflects this disparity. Developing countries, including
Nigeria, only receive about 12% of such resources despite having 95% of cases.3 Socioeconomic
factors contributing to the spread of HIV/AIDS disproportionately impact on
these countries and include poverty, illiteracy, gender inequality, increased
mobility of populations within and between countries , rapid industrialisation
involving movement of workers from villages to cities, and consequent breakdown
of traditional values.4 Because HIV/AIDS is becoming increasingly
concentrated in young women who are usually mothers, it has an immense impact
on life expectancy, exacerbates inequality (e.g., surviving orphans) and increases
the burden on health systems. Governance, development and human rights are
recognised as interdependent5, as HIV/AIDS undermines recent developmental
achievements.
In a few years of accelerated spread,
AIDS has become the leading cause of death in most developing African countries,
and may be the most important macroeconomic and social determinant of human
welfare and poverty.6 More than exclusively a health crisis, today,
AIDS is an emergency that affects many areas at once human rights, development,
economy and education.
In Africa, there have been examples
of regional and national initiatives and attempts by states and non-governmental
organisations to stem the tide of HIV transmission and develop effective national
responses to HIV/AIDS that respect human rights. In the past decade, there
has been increasing participation of governments, usually with community representations,
to give an accurate picture of the human rights dimension of the epidemic.
At the 10th international conference on STDs/ AIDS in Africa, an alliance of
mayors and municipal leaders was formed which issued the Abidjan Declaration
on 9 December 1997.3 The declaration states that the alliance commits
itself to search for solutions relevant to local needs and realities in accordance
with UN principles and national laws and regulations, in order to respond more
effectively to the epidemic. The creation of the alliance is to maximise commitment,
participation, leadership capacity and experience at the community level in
response to the challenge of HIV/AIDS epidemic in Africa.3
The International Partnership against
AIDS in Africa was born of the understanding that, in isolation, none of its
constituencies neither governments, nor civil society, nor the various national
and international organisations working against AIDS in Africa will succeed
in stopping the epidemic. Instead, a coalition or partnership approach promises
to magnify the contribution of all partners, while giving a clear leadership
role to African governments.7 According to Parker,8 the
global distribution of HIV is anything but democratic and equal. The geographic
distribution of HIV around the globe and in specific places is not random,
arbitrary, or a chance. It is shaped by issues of structural violence.
According to Parker, these multiple
forms of structural violence8 have resulted in two overriding global
trends in the HIV/AIDS pandemic, namely:
- Feminisation: All over
the world more and more women are contacting HIV/AIDS. In South Africa,
for example, the male/female ratio for HIV infection has increased dramatically
from 29:1 in 1985 to 2:1 in 2000.
- Pauperisation: Although
there is little available data on the classwise distribution of HIV/ AIDS,
data on education serves as a proxy. Today, the vast majority of cases
of HIV infected persons are those who have some primary education, or are
not literate.8
Thus, behavioral interventions
are not the answer. Short-term interventions can be undertaken but can only
be effectively accomplished if we understand the structural forces underlying
the HIV/AIDS epidemic.8
Gender Inequality and
Feminisation of HIV/AIDS in Nigeria
Although the majority of current HIV infections are still among men, AIDS
is becoming an increasingly female affair. In Nigeria response to the HIV/AIDS
epidemic started with a focus on high risk groups including commercial sex
workers. Men were advised to stay away from sex workers or use the condom.
Gradually, the focus shifted to high risk behaviour, which further emphasises
males using condom. It avoids addressing the gender issues in sexual relations women
do not use condoms, they negotiate use. The gender dimension was not addressed
until large numbers of women who were not commercial sex workers were getting
infected.9 Presently, it has been recognised that women's vulnerability
to HIV/AIDS is as a result of lack of knowledge and access to information,
economic dependence, and, in many cases, forced sex with their regular partners.
In Africa, there are already six
women with HIV for every five men.10 Of the estimated 5.8 million
HIV infections that occurred in 1999, nearly half were in women and about 590,000
occurred in children.10 Women now account for 42% of people living
with HIV. This increase in the number of HIV positive women reflects their
greater biological vulnerability to the disease.11 It is also a
consequence of the social constructions of female and male sexuality as well
as the profound inequalities that continue to characterise many heterosexual
relationships in Nigeria. Many women find the heterosexual relationship a difficult
one to negotiate as strategy for their own safety. Generally, and culturally,
sex continues to be defined primarily in terms of male desire with women being
the relatively passive recipients of male passions.11 Under these
circumstances, women often do not articulate their own needs and desires and
their own pleasure may be of little concern. Even in marriage most women cannot
assert their wish for safer sex, for their partner's fidelity, or for no sex
at all. As a result their health and invariably that of others are put at grave
risk. It is estimated that in parts of Africa 6080% of women infected with
HIV have only had one sexual partner.12 Though partner change increases
risk, most HIV positive women would have been infected through their male spouse
or regular partner.12 This also applies to young unmarried women
who are often sought after out by older men because of their presumed passivity
and freedom from infection.
Cultural pressures of this kind
are reinforced by gender inequalities in income and wealth. For many women,
economic and social security, and often their very survival, is dependent on
the support of a male partner.13 In Nigeria, economic globalisation
has benefited the rich (mostly men) but penalised the poor, less educated,
low skilled or unemployed. Women who are disproportionately poor, uneducated
and unemployed fall within this other group.14 More than 15 years
after the introduction of the Structural Adjustment Programme in Nigeria, the
consequences of the economic policy are glaringly tragic. Women are increasingly
resorting to risky sexual behaviours as part of multiple livelihood strategies.15 The
average Nigerian woman finds it increasingly hard to leave abusive or risk-bearing
relationships because of increased economic dependence.16 Under
these circumstances, many will prefer to risk unsafe sex in the face of more
immediate threats to their well being. More often than not, the poorer women
have the fewest choices, run the most risks, and are more likely to become
infected.15 When a woman becomes infected with HIV/AIDS, gender
inequalities in income and wealth invariably affects progression of the illness
and possibly her survival chances. In the final analysis, the combination of
physiological vulnerability and exposure contributes to a situation where women
are decisively more at risk of HIV infection than men.13
HIV/AIDS, Human Rights
and Inter- national Obligations
A rights-based prevention and protection approach recognises societal vulnerability
to HIV/AIDS, not just individual risk behaviour. It also recognises vulnerabilities
in different groups such as women and children. International human rights
norms provide coherent normative framework for analysis of the HIV/AIDS problem.17 They
also provide a legally binding foundation with procedural, institutional and
other accountability mechanisms to address the societal basis of vulnerability,
and implement change.18 Health and human rights are thus complementary
rather than conflicting goals. The range of human rights, whether found in
national or international human rights instruments, conventions and declarations,
more often than not address (reproductive) health issues and protects vulnerable
groups.
In the legal application of human
rights, it is important to identify those bound by legal duty to observe human
rights such as government agencies, those working under the authority of government
and those carrying out governmental responsibilities. The legal challenge is
to find not only the human rights protecting gender equality and health, but
also the rights that would contribute most effectively to future remedies.19 For
instance, a woman may have suffered because a family member was allowed to
veto or frustrate her request for necessary care. A remedy may be approached
by ensuring respect for a woman's confidentiality in requesting health care
and in applying human rights to achieve women's economic and social equality
in access to health care.
Sources of human rights to advance
gender equality and protect women's health are found in nearly all national
constitutions and in international and regional human rights treaties and declarations
based on the universal declaration of human rights.20 The universal
declaration itself was not proposed as a legally enforceable instrument but
it has gained legal acceptance and legal enforceability through a series of
international human rights conventions and charters. The primary modern human
rights treaty concerning women's rights is the Convention on the Elimination
of All Forms of Discrimination Against Women (the Women's Convention).21 This
convention reinforces the universal declarations' two initial legally binding
implementing covenants, namely, (i) the International Covenant on Civil and
Political Rights (the Political Covenant)22 and (ii) the International
Covenant on Economic, Social and Cultural Rights (the Economic Covenant).23 Additional
documents reflect widespread international consensus on issues of women's health
and human rights, notably, (i) the Cairo Programme of Action (the Cairo Programme)24 and
the Cairo Plus Five follow-up document25 developed respectively
at the 1994 UN Conference on Population and Development in Cairo, and its five
year review and (ii) the Beijing and Platform for Action (the Beijing Platform),26 developed
at the 1995 Fourth World Conference on Women in Beijing, and its five-year
review.27
Nigeria is a state party and signatory
to the above treaties and documents.28 Some of these conventions,
like the Women's Convention and the Economic Covenant, have monitoring bodies
to monitor compliance with treaty provisions. Unlike the national courts that
act only on occasions when parties bring cases before them, the treaty monitoring
bodies receive reports that member states must submit periodically, usually
at three to five-year intervals.28 In the specific area of womens
health, Nigeria as a member state is committed to report regularly to CEDAW
on what she has done to take all appropriate measures to eliminate discrimination
against women in the field of health care.29
With regard to specific articles
of the CEDAW relating to women's health, the General Recommendation on Women
and Health30 requires that in order to enable the Committee to evaluate
whether measures to elimination discrimination against women in the field of
health care are appropriate, state parties must report on their health legislation,
plans and policies for women with reliable data disaggregated by sex on the
incidence and severity of diseases and conditions hazardous to women's health
and nutrition and on the availability and cost-effectiveness of preventive
and curative measures. This Recommendation emphasises that reports to the Committee
must demonstrate that health legislation plans and policies are based on scientific
and ethical research and assessment of the health status and needs of women
in that country and must take into account ethical, regional or community variations
or practices based on religion, tradition or culture30
The General Recommendation also
adds that the committee requires state parties to report on what they have
done to address the magnitude of women's ill health, in particular when it
arises from preventable conditions such as tuberculosis and HIV/AIDS.31 It
further states that the issue of HIV/AIDS and other sexually transmitted diseases
are central to the rights of women and adolescent girls to sexual health, and
that state parties should ensure without prejudice and discrimination the right
to sexual health information, education and services for all women and girls.31
The Cairo Programme noted that
reproductive health eludes many of the world's people because of factors such
as inadequate levels of knowledge about human sexuality and inappropriate or
poor quality reproductive health information and service; the prevalence of
high-risk sexual behaviour; discriminatory social practices; negative attitudes
towards women and girls; and reproductive lives.24 It also recognises
that health services must be particularly sensitive to the needs of individual
women and adolescents and responsive to their often powerless situation, with
particular attention to those who are victims of sexual violence.24 The
programme further reiterated that referral for family planning services and
further diagnosis and treatment for complications of pregnancy, delivery and
abortion, infertility, reproductive tract infections, breast cancer and cancers
of the reproductive system, sexually transmitted diseases including HIV/ AIDS
should always be available as required.24
Similarly, the Beijing Platform26 emphasised
that women's right to the enjoyment of the highest standard of health must
be secured throughout the whole life cycle in equality with men. Women are
affected by many of the same health conditions as men but they experience them
differently. The prevalence among women of poverty and economic dependence,
their experience of violence, negative attitudes towards women and girls, racial
and other forms of discrimination, the limited power many women have over their
sexual and reproductive lives, and lack of influence in decision-making are
social realities that have adverse impact on their health.26 It
went on to add that health policies and social programmes often perpetuate
gender stereotypes and fail to consider socioeconomic disparities and other
differences among women and may not fully take account of the lack of autonomy
of women regarding their health.26
The above-mentioned treaties and
international instruments are binding on Nigeria as a member state that has
signed and ratified these documents. The Vienna Declaration and Programme of
Action affirmed that human rights, whether civil, political, economic, social
or cultural, are universal and indivisible.32 In 1996 the UN Commission
on Human Rights resolved that the term or other status used in several human
rights instruments should be interpreted to include health status including
HIV/AIDS and that discrimination on the basis of actual or presumed HIV/AIDS
status be prohibited.33 The duty to fully realise human rights obligations
in the HIV/AIDS context can best be approached by adopting a national framework
that can address issues of discrimination, vulnerability and equality.
Implementing
HIV/AIDS-Related Human Rights Standards in Nigeria
National Guidelines
Under national constitutions and international human rights treaties, governments
face a variety of obligations including general obligations that can be applied
to particular circumstances, care obligations, and immediate and long-term
obligations.19 Experience is growing on the protection and promotion
of human rights through a variety of legal, quasilegal and customary law systems.
The ways in which human rights are protected depend on national circumstances
and priorities, and the development of a national strategy for the protection
of rights will employ various means. Consideration should also be given to
special and vulnerable groups of persons such as women and children. The guidelines
advanced here is a gender perspective on HIV/AIDS-related human rights standards
and monitoring in Nigeria.
The Nigerian constitution protects
human rights that are already recognised in international instruments and other
consensus documents.34 In addition, there is need to create explicit
benchmarks and guidelines to implement and develop effective rights-based response
to gender inequality and HIV/AIDS.3 Government is the responsible
party under relevant international instruments to protect rights. However,
it is important to recognise that partnerships with other essential sectors
of the society are crucial for an effective response to the epidemic.
A proposal for national guidelines
on HIV/ AIDS and human rights should clarify the obligations contained in the
aforementioned international instruments.3 Key human rights with
specific implications for women in the context of HIV/AIDS are:
- Non-discrimination and
equality before the law, e.g., eliminating discrimination against people living
with HIV/AIDS especially vulnerable groups such as women, in the areas of
health care, employment, education, housing and social security. The disproportionate
impact of the disease on vulnerable populations makes the improvement of their
legal status and realisation of their human rights critical if an effective
response to the epidemic is to be achieved. Without full respect for human
rights, these groups (especially women) are not in a position to avoid infection
because they either do not receive prevention, education and information, or
cannot act on it, and when infected are disempowered to cope with the impact.3 The
most effective remedy is the enactment of general anti-discrimination legislation,
which prohibits unfair and irrelevant distinctions being made between infected
and non-infected persons.
- Health, e.g., ensuring
equal and adequate access to the means of prevention, treatment and care,
especially for vulnerable populations with lower social and legal status
(e.g., women
and children). In this regard, the state must adequately address the public
health issues raised by HIV/AIDS and specify that provisions applicable
to casually transmitted diseases are not inappropriately applied to HIV/AIDS
and
that they are consistent with international human rights obligations.3 Service
integration of HIV/AIDS prevention and STD diagnosis and treatment within reproductive
and family planning services is an important issue as well as free or low-cost
services addressing biological, legal, psychological and socio-cultural aspects
of women's health.35
- Education and information,
e.g., ensuring equal and adequate access to prevention, education and information.
As prevention is a main objective of HIV/AIDS programmes, people need information
and need to be educated about the virus and disease, mode of transmission and
means of protection. Information can be provided through pamphlets, posters,
newspapers, magazines, books, instructions on condom packaging, advertisements,
radio, television, films, videos, plays, the Internet, group meetings and assemblies.3
- Employment, e.g., prohibiting
dismissal of staff solely on the basis of their HIV status. Some areas of concern
in employment law are (i) that workers with HIV/AIDS are not subjected to unfair
discrimination and (ii) that appropriate prevention measures are available
for workers who are occupationally infected. Employees with HIV/AIDS are able
to lead reasonably long and productive lives particularly with recent advances
in anti-retroviral treatments.3
- Reproductive health. Apart
from increased biological susceptibility to infection, women's subordinate
status impairs their ability to deal with possible consequences of infection,
which require care and support (e.g. violence and abandonment by family). Systematic
discrimination in all facets of life but particularly education, health care
and employment disproportionately increases the risk of women becoming infected.
Education and prevention programmes are hindered where women lack the skills
to understand or the capacity to act upon the information contained in them.3
- Support services and legislative
reform. These services take the form of increased enhancement of men's participation
in HIV/AIDS prevention and treatment. This is because men have more sexual
partners than women and tend to control the frequency and form of intercourse,
and because women are physiologically more susceptible to the virus. It is
men's behaviour that determines how quickly and to whom the virus is spread.36 Legal
reform is a key component of campaigns to improve the status of women. The
impact of current laws on women is already being felt in Nigeria with a national
policy and plan of action to end female genital mutilation.37 In
addition, laws should be reviewed and reformed to ensure equality of women
regarding property and marital relations and access to employment and economic
opportunity especially in the context of an HIV/AIDS diagnosis. The HIV status
of a woman should not be treated differently from any other analogous medical
condition in making decisions regarding custody, fostering or adoption.3
CONCLUSION
In the final analysis, a gender perspective on HIV/AIDS and human rights must
take into consideration the impact of the epidemic on women. National guidelines
in these areas should implement the development of adequate, accessible and
effective HIV-related prevention and care education, information and services
by and for vulnerable communities such as women. They should examine issues
such as:
- The role of women at home
and in public life.
- The sexual and reproductive
rights of women and men, including women's ability to negotiate safer sex
and make reproductive choices.
- Strategies for increasing
educational and economic opportunities for women.
- Sensitising service deliverers
and improving health care and social support services for women.
- The impact of religious
and cultural traditions on women.
In particular, primary health services,
programmes and information campaigns should contain a gender perspective, and
harmful traditional practices including violence against women, sexual abuse,
exploitation, early marriage and female genital mutilation must be discouraged.
This paper is a contribution to national initiatives to promote compliance
with human rights principles and provide information on the critical role of
human rights in the overall response to the epidemic.
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Copyright 2002 - Women's Health
and Action Research Centre
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