July 13, 2004

I. Summary

The growing HIV/AIDS epidemic in the Dominican Republic is unfolding in the context of entrenched inequality between men and women and significant levels of high-risk behavior, such as low condom use, multiple sex partners, and early sexual activity.This situation has put women at increased risk of HIV infection and exacerbated the consequences for women of HIV-related human rights violations in the workplace and the health care system.

The Dominican Republic's government has taken steps to address the HIV/AIDS crisis in the country, such as in 2002 creating a multi-sector body-called the Presidential AIDS Council (Consejo Presidencial del SIDA, COPRESIDA)-to coordinate and monitor national public and private sector efforts to prevent the spread of HIV/AIDS.The government has also implemented a national program to reduce parent-to-child HIV transmission, and has sought international funding for long-term AIDS treatment programs. These are clearly positive and necessary steps in the right direction, for which the government should be commended.

However, the government has failed to take seriously the link-well-established and analyzed in international public health and human rights literature-between the spread of the disease and entrenched sex inequality, violence against women, and social biases that otherwise limit women's autonomy and rights.As a consequence, the HIV/AIDS policies, programs, and plans the Dominican Republic designed and implemented have in some areas failed to address adequately the acute human rights violations suffered by women, and, in others, have contributed to these violations.

This report focuses on what Human Rights Watch believes are the two areas most immediately in need of reform.The first is discrimination against women in the workplace, in particular through involuntary HIV tests administered to workers and jobseekers.Our research showed that women who apply for positions in the tourism industry or the free trade zones-the two main employers of women-are often tested for HIV as a condition of work, in violation of their right to nondiscrimination in access to work and in the workplace.None of the governmental mechanisms designed to enforce work-related rights protections have addressed these abuses adequately, allowing private employers to continue the abuse with impunity.

Human Rights Watch also identified serious deficiencies in the administration of public health care to women.When women use public health services, especially prenatal care facilities, they are given grossly insufficient pre- and post-HIV test counseling, risk disclosure of their confidential HIV test results, and suffer abusive treatment by health personnel, including the delay or denial of medical procedures.Some women are subjected to pressure to be sterilized.

The routine release of confidential HIV test results, combined with the fact that women are more consistently offered HIV counseling and testing than are men, contribute to the perception that women are to blame for introducing HIV into their long-term unions.As a result, regardless of the actual source of the infection, many women who test positive for HIV are subject to ostracism, violence, or abandonment by spouses, long-term partners, or families.In the Dominican Republic, moreover, cultural norms dictate that women-but not necessarily men-should be faithful and that a woman is ultimately responsible even for her spouse's infidelity.

Our research shows that national norms regarding counseling and testing for HIV are implemented in a manner that does not give women full information about their rights and choices.In several cases we found that doctors and other health personnel made important decisions about women's lives and health without consulting the women.Women are prevented from giving their informed consent for subsequent tests and treatment, and an important HIV prevention tool has been lost by not giving women the support they need to protect themselves, their sexual partners, and their infants from HIV transmission in the future.The net result is the perpetuation of women's rights violations.

A draft bill, pending introduction in the Dominican Congress at the time of writing would offer all pregnant women HIV counseling and mandates testing unless the women explicitly decline the test (sometimes referred to as "opt-out testing").While the current version of the draft bill is less draconian than an earlier version, which called for mandatory testing for women, it would nonetheless have serious adverse consequences.Given the widespread lapses in HIV counseling documented in this report, "opt-out" testing could in practice become indistinguishable from mandatory testing in one significant respect: many women would not be given opportunity to make a genuinely informed decision as to whether to be tested.Unless serious efforts are made to guarantee quality and inclusive pre- and post-test counseling, this may result in violations of the right to informed consent.Given the rampant breaches of confidentiality also documented in this report, the new regime would be unlikely to contribute to overcome discrimination and abuse against women living with HIV.

The United Nations Joint Programme on HIV/AIDS, UNAIDS and the United Nations Office of the High Commissioner for Human Rights have consistently emphasized the importance of voluntariness, quality counseling, informed consent, and confidentiality in HIV testing and care as essential parts of HIV prevention strategies, notably in the United Nations International Guidelines on HIV/AIDS and Human Rights.This approach emphasizes the existence of a strong presumption in international human rights law in favor of systems that scrupulously respect the right to privacy through mechanisms of confidentiality, and informed consent.Before signing any proposed bill into law that explicitly or implicitly override these presumptions, the onus is on the Dominican government to demonstrate with concrete scientific evidence why such a limitation of rights is necessary and desirable.In any case, the government has an urgent obligation to women to guarantee essential pre- and post-test counseling for all tested individuals, as well as stringent confidentiality measures with a zero-tolerance policy for breaches of confidentiality.

The Dominican Republic has ratified international treaties requiring it to protect the human rights to privacy, physical integrity, the highest attainable standard of health, discrimination in access to work and in the workplace, and nondiscrimination on the basis of sex or health status such as being HIV-positive.These treaties include the International Covenant on Civil and Political Rights; the International Covenant on Economic, Social and Cultural Rights; and the Convention on the Elimination of all Forms of Discrimination against Women.

The report is based on interviews with women living with HIV in January 2004, in Santo Domingo, La Romana, San Pedro de Macors, Santiago, and Puerto Plata in the Dominican Republic.In addition, Human Rights Watch briefly surveyed a number of women and men working in the hotel industry and free trade zone factories in Puerto Plata and Playa Dorada on the northern coast.We also interviewed government officials, United Nations agencies, nongovernmental organizations (NGOs), health care providers, public health sector personnel, and relevant private sector actors.All names and identifying information of women living with HIV interviewed have been changed to protect their privacy.For the same reason, certain identifying information has been withheld for other interviewees where necessary.