July 13, 2004

III. Background

The Dominican Republic: Economy and Health

The Dominican Republic shares the Island of Hispaniola in the Caribbean with Haiti.The population of the Dominican Republic is approximately 8.5 million,with children under fifteen representing 33 percent of the total population.[1]The country's economy traditionally depended on the sugar cane industry, though the tourism industry and export processing zones have been central to the country's development strategy over the past two decades.[2]In fact, the tourism industry and the export processing industry in the country's free trade zones were in large part responsible for making the Dominican Republic's economy one of the world's fastest growing in the 1990s.[3]Since 1998, the Dominican Republic's economic growth has dropped significantly, though it is still quite high compared to economic growth in the region as a whole.[4]

Economic growth has not led to a notable increase in the country's investment in its health sector.As a percentage of the gross domestic product (GDP), public expenditure on health was consistently around 1.5 percent from 1991 to 2001.[5]This figure, compared to that of other countries with similar levels of development, such as Colombia and Venezuela, is quite low.[6]Nevertheless, the Dominican Republic has a health system that reaches a large proportion of the population at least for some services.At 99 percent, the proportion of pregnant women who receive professional maternal health care-in their home or at a clinic-is the highest in Latin America and the Caribbean, though maternal mortality still is higher than in Brazil, for example, where only 80 percent of pregnant women receive professional prenatal health care.[7]

Women's Status

Women in the Dominican Republic suffer from many forms of inequality, discrimination, and social exclusion.Even though literacy and primary education enrollment levels in the Dominican Republic are relatively high for both women and men,[8] women are significantly underrepresented in the job market.Many women are subject to domestic violence or to severe limitations of their possibilities for social interaction and movement at the hands of their husbands or long-term partners.[9]

In a 2002 survey conducted by Measure DHS+ (DHS survey), an international organization that conducts regular health-related surveys in a number of countries worldwide, over half of the Dominican women interviewed who lived in a long-term union reported that their husbands or male partners expected them to disclose their whereabouts at all times.Eighteen percent of these women said their husband or male partner actively limited their access to friends, and 11 percent reported that he limited their access to family as well.[10]

Limited social interaction and movement within a long-term union may be a precursor to domestic violence, since it creates an environment where women are expected to submit to male authority.The 2002 DHS survey found that 24 percent of adult women in the Dominican Republic had suffered some form of physical abuse.[11]The same survey found that 27 percent of the surveyed women had suffered physical, sexual, or emotional abuse at the hands of their spouse or other partner in a long-tern union, and 5 percent suffered all three types of abuse.[12]According to government figures, domestic violence was the fourth leading cause of death for women in 2000.[13]In 2003, 83 percent of female homicide victims were killed by their current or past spouses or long-term partners.[14]There are only five police stations in the country specialized to receive complaints concerning domestic violence (so-called "Friends of Women" stations), and only one functioning domestic violence shelter, which is run by an NGO.[15]

Women do not have equal access to work, and are not treated with equality in the workplace.A 2002 World Bank study showed that women earned only 76 percent of what men earned for equivalent work (63 percent in rural areas), and were more than twice as likely to be unemployed.[16]This was confirmed in the 2002 DHS survey, in which male interviewees were almost twice as likely to have been employed during the twelve months prior to the interview as female interviewees.For those married or in a long-term union at the time of the survey, 52.3 percent of the women reported being unemployed during the past twelve months, compared to only 3 percent of the men.[17]

Mariana Santos, an NGO health worker, explained to Human Rights Watch that this economic inequality between women and men reinforces male control over women in long-term unions.As she put it: "[The man] does not give her the money that she needs, he manipulates her with money.We are a poor country, and many women depend on [their husbands]."[18]

The women Human Rights Watch interviewed reported several instances where control over the economic resources in the family was directly related to physical abuse.Rosa Polanco, for example, a thirty-year-old widow, told Human Rights Watch that her husband hit her on many occasions "because I reproached him for giving me little money."[19]Joel Valerio, an organizer who runs NGO workshops on gender equality in Santiago's free trade zones, recounted explanations he frequently heard men give at workshops."The men say 'it is true that we hit [women], but there are reasons: she is unfaithful, she spends too much money. I am the man, I decide.'"[20]

For Haitian women and Dominican women of Haitian descent living in the Dominican Republic, the discrimination they suffer as women is likely to intersect with discrimination because of their race or nationality.[21]Ernestina Abreu, an NGO community worker who assists women of Haitian descent in their access to health care, told Human Rights Watch that the women she worked with suffer discrimination as women, as Haitians, and because of their lack of economic resources.Abreu said that the doctors at the public hospital made condescending remarks to Haitian women that they would not make to Dominican women: "They say to the women: 'Go somewhere else, we don't have services for Dominican women, so much less for you' or 'when you were doing it [i.e. having sex], you weren't screaming, don't deny your color.'They say this because supposedly black people don't feel pain."[22]

Women Living with HIV/AIDS

More than two million people are living with HIV in Latin America and the Caribbean.[23]About one quarter of these people live in the Caribbean, where approximately half of them are women.[24]Haiti and the Dominican Republic are at the epicenter of the HIV/AIDS epidemic in Latin America and the Caribbean.At approximately 2 percent of the adult population, HIV prevalence[25] in the Dominican Republic is second in the Caribbean only to that of Haiti.According to the Dominican Republic government, prevalence is increasing at a faster rate among women than men.[26]

The leading cause of death of Dominican women of reproductive age-defined as women between fifteen and forty-nine-is now HIV/AIDS.[27]By the end of 2001, women of that age group constituted 51 percent of all people in the Dominican Republic living with HIV or AIDS.[28]Of those recently infected with HIV, the proportion of women is greater.[29]UNAIDS estimates that over 70 percent of new HIV transmissions happen through heterosexual sex,[30]which means the proportion of women as opposed to men living with HIV or AIDS is likely to grow.[31]

Physiological factors put women and girls at higher risk for infection through unprotected vaginal sex, and economic inequality hampers women's ability to negotiate condom use.Because of social expectations regarding women's fidelity, women are often blamed for introducing HIV into their long-term union or marriage."It is easier to forgive a man for having HIV than a woman.Men are supposed to run around [i.e. have sex outside their marriage or long-term union]," Sergia Galvn, director of an NGO working on women's health issues, explained to Human Rights Watch.[32]Cristina Francisca Luis, community educator from a Haitian-Dominican women's organization, said women even sometimes blame themselves when they end up contracting HIV as a result of their husband's infidelity: "The woman tells herself: 'If I had been a good woman, he would have stayed home.'She blames herself.'If I had been good company, he would not have run around.'"[33]

The social bias that women are faithful and ultimately responsible for their husband or long-term partner's infidelity compounds the fear felt by many women of being known to be HIV-positive.The fear of HIV status disclosure is not unfounded.The domestic AIDS law requires sexual partner notification of people living with HIV.The law stipulates that the HIV-positive person may notify their sexual partners themselves or may defer notification to medical personnel.[34]This fear is further propelled by the prevalence of domestic violence.Several women told Human Rights Watch that their long-term partners repeatedly threatened them with violence as retribution for having a sexually transmitted infection, including HIV."I was always afraid.[My husband] said if you have something [a sexually transmitted infection], I will kill you," recalled Judelka de la Cruz.[35]Rosana Ramrez had a similar experience: "He said, you better be careful not to do anything bad."[36]Both de la Cruz and Ramrez were unable to negotiate condom use with their husbands, whom they believed were the source of their HIV infection.

Women are more likely to have been tested for HIV than men-and thus probably more likely to know their status and to have their status known by others-reinforcing the perception that they are to blame for introducing HIV into their long-term unions.The 2002 DHS survey indicates that, at age nineteen, women were three times as likely to say that they had been tested for HIV as men.At age forty, two-thirds of women in the Dominican Republic said that they had been tested for HIV, whereas less than 40 percent of men did.[37]

The relatively high proportion of both men and women who have been tested for HIV[38] is in part related to the fact that both men and women may be subject to involuntary HIV testing as a condition to gain employment.[39]As mentioned, women are less likely to be formally employed than men, but when they are, they tend to work in sectors- such as services, tourism, and the export-processing free trade zones-where companies are known to test for HIV as a condition for employment.[40]Many women are also tested when they use government prenatal health care, which obviously does not apply to men.In fact, if women were not tested during pregnancy, the likelihood of them knowingly being tested for HIV would be the same as for men.[41]

Public Awareness Campaigns, Sex Education, and Condom Use

The Dominican Republic has launched several public awareness campaigns regarding HIV/AIDS, most focusing on the elimination of common prejudices in the community regarding people living with HIV/AIDS, or identifying certain situations of high-risk behavior.[42]While providing needed information, the campaigns have so far generally failed to address directly the social biases and prejudices that contribute to putting women at increased risk of HIV infection.Only one very short campaign several years ago, recalled only vaguely by an HIV/AIDS expert, focused on helping women to learn condom negotiation skills.[43]

Secondary schools are required to provide sex education for students thirteen years and older.[44]In recent years the most commonly used textbook in public schools is a book republished in 2002 by the Presidential AIDS Council: Learning is Living.[45]Though this book includes explicit information on the correct use of condoms, it fails to address the barriers that impede consistent use of condoms, especially for women.The book wrongly announces that "the vast majority of those who are sexually active use condoms," and continues: "some men don't like to use [condoms], principally because they don't want to look bad in the eyes of women."[46]It also wrongly states that condom use is necessary only for "dangerous" persons such as sex workers, men who have sex with men, and unfaithful husbands.[47] The book presents marital sex as the safest HIV prevention option-after abstinence-and counsels that the wives of unfaithful husbands "should be strong and demand that their husbands use condoms," while failing to recognize that women in many cases may be unable to demand condom use for fear of violence or for fear of being thought unfaithful themselves.[48]

These assertions place the burden for increasing condom use almost exclusively on women and fly in the face of reality.The use of condoms in the Dominican Republic is among the lowest in Latin America and the Caribbean: around 2 percent depending on the age of the individual and 1.3 percent between long-term partners and spouses.[49]This sex education perpetuates a strong social bias against condom use and implies that those who use condoms belong to "dangerous" groups, with the stigma and discrimination that might entail.

Low rates of condom use in the Domincan Republic are in part the product of social biases, most of which have been ignored or are perpetuated by the sex education materials.Most women Human Rights Watch interviewed said they were unable to negotiate condom use, and assumed their partners were faithful or that the men used condoms with other sexual partners.Olga Lpez, thirty-six, explained why she did not use condoms with her ex-husband, who she believes infected her with HIV: "He was my partner, and that's what all women will tell you.I did not think I was at risk.Here we consider at risk those who do sex work or have several partners."[50]Alesandra Ebrito, whose husband died of AIDS four years ago, recalled: "I thought condoms were for casual sex. I thought that he was faithful."[51]Rosana Ramrez told Human Rights Watch that her husband told her he did not need to use condoms with her, because "he says that when he runs around [i.e. has sex with other women], he puts it on."[52]Judelka de la Cruz, thirty-one, said that her husband accused her of infidelity or of being HIV-positive every time she asked him to use a condom, so to avoid the accusation, she stopped asking.[53]

Public campaigns and sex education can contribute to change the behavioral patterns that contribute to HIV transmission by challenging popular attitudes toward, for example, condom use.To be successful, however, the campaigns and education must take into account the behavioral patterns they propose to change, which, in the Dominican Republic, include extremely low use of condoms and high levels of sexual inequality and violence against women.By failing to address these issues, the campaigns have been inadequate.While not necessarily directly related to such inadequacies, it is noteworthy that surveyed women in 1996 and 2002 displayed a significantly drop in awareness with regard to both correct and incorrect methods to prevent HIV transmission, despite public campaigns and sex education.[54]The proportion of surveyed women who, unprompted, mentioned condom use as a specific method to avoid HIV infection fell almost 10 percentage points in this time period.

[1] United Nations Development Program, "Human Development Indicators 2003," data from 2001 [online] http://hdr.undp.org/reports/global/2003/indicator/cty_f_DOM.html (retrieved April 5, 2004).

[2] Consejo Nacional de Zonas Francas de Exportacin de la Repblica Dominicana [National Council of Export Free Trade Zones of the Dominican Republic, CNZFE], "Informe Estadstico 2002" [Statistical Report 2002], 2002 [online] http://www.cnzfe.gov.do/documentos/informes/Informe_Estadistico_2002_en_Espanol.pdf (retrieved March 23, 2004); and Magdalena Rathe, Dayana Lora, and Laura Rathe, Impacto Socio-Econmico del VIH-SIDA en el Sector Turstico de la Repblica Dominicana: Un Estudio de Caso en la Costa Este [Socio-Economic Impacto of HIV/AIDS in the Tourist Sector in the Dominican Republic: A Case Study on the East Coast] (Santo Domingo: Fundacin Plenitud, March 2003).

[3] World Bank Caribbean Country Management Unit, A Review of Gender Issues in the Dominican Republic, Haiti and Jamaica,Report No. 21866-LAC (Washington, D.C.: World Bank, 2002), p. 5.

[4] World Development Indicators Database, "Dominican Republic Data Profile" (Washington, D.C.: World Bank, 2003) [online] http://devdata.worldbank.org/external/CPProfile.asp?SelectedCountry=DOM&CCODE=DOM&CNAME=Dominican+Republic&PTYPE=CP (retrieved on April 13, 2004); and World Development Indicators Database, "Latin America and Caribbean Data Profile" (Washington D.C.: World Bank, 2003) [online] http://devdata.worldbank.org/external/CPProfile.asp?SelectedCountry=LAC&CCODE=LAC&CNAME=Latin+America+%26+Caribbean&PTYPE=CP (retrieved April 13, 2004).

[5] Demographic and Health Surveys, Repblica Dominicana: Encuesta Demogrfica y de Salud 2002 [Dominican Republic: Demographic and Health Survey 2002] (Calverton, Maryland: Measure DHS+, 2003), p. 8.

[6]Venezuela's annual national health expenditure as a percentage of GDP was 8.8 percent in 2002.The figure was 9.3 percent for Colombia, also in 2002.Pan American Health Organization, "Venezuela, Core Health Data Selected Indicators. Data Updated to 2002" [online] http://www.paho.org/English/DD/AIS/cp_862.htm (retrieved March 15, 2004); and Pan American Health Organization, "Colombia, Core Health Data Selected Indicators. Data Updated to 2002" [online] http://www.paho.org/English/DD/AIS/cp_170.htm (retrieved March 15, 2004).

[7] Demographic and Health Surveys, Repblica Dominicana: Encuesta Demogrfica y de Salud 2002, p. xxvii; and Pan American Health Organization, "MORTALIDAD MATERNA - PERINATAL - INFANTIL (Amrica Latina y Caribe)" [Maternal mortality Perinatal mortality Infant Mortality (Latin America and the Caribbean)] [online] http://www.paho.org/spanish/clap/05mort.htm (retrieved March 11, 2004).

[8] In 2000, 16.3 percent of women and 16.3 percent of men were reported to be illiterate in the Dominican Republic.Ninety-three percent of girls were enrolled in primary school that same year, compared to 92 percent of boys.See World Bank, "Gender Stats, Summary Country Profile, Dominican Republic" [online] http://devdata.worldbank.org/genderstats/genderRpt.asp?rpt=profile&cty=DOM,Dominican%20Republic&hm=home (retrieved April 8, 2004).

[9] For the purpose of this report, "long-term union" refers to a couple who live together as if they were married, even though they may not be legally married."Long-term partner" refers to a person in a spouse-like relationship.

[10] Demographic and Health Surveys, Repblica Dominicana: Encuesta Demogrfica y de Salud 2002, table 12.5.1, p. 288.

[11] Ibid., table 12.2.2, p. 283

[12] Ibid., table 12.6.1, p. 290

[13] Secretara de Estado de la Mujer [Ministry for Women, SEM], Estadsticas para la Planificacin Social con Perspectiva de Gnero [Statistics for Social Planning with a Gender Perspective] (Santo Domingo: Secretara de Estado de la Mujer, 2000).

[14] Human Rights Watch phone interview with Susi Pola, journalist, Santiago, April 29, 2004.The numbers were compiled by Susi Pola from police records, court files, medical records, and press.See also, Mara Isabel Soldevila, "El Amor No Mata, El Amor No Puede Matar" [Love Does Not Kill, Love Cannot Kill] A Primera Plana Ao 1 No. 2, February 2002 [online] http://www.aprimeraplana.org/www/No.2/index.html (retrieved April 16, 2004) (citing similar earlier statistics).

[15] Human Rights Watch phone interview with Mildred Baeltr, head, Area of Violence Against Women [Area de Violencia Contra la Mujer], Ministry for Women [Secretara de Estado de la Mujer, SEM], Santo Domingo, March 26, 2004.Another NGO-run shelter was expected to open in May 2004.There are no immediate plans for the government to run shelters. Ibid.

[16] World Bank Caribbean Country Management Unit, A Review of Gender Issues in the Dominican Republic, Haiti and Jamaica, pp. 21-25.

[17] Demographic and Health Surveys, Repblica Dominicana: Encuesta Demogrfica y de Salud 2002, tables 3.5, p. 58, and 3.18, p. 75.

[18] Human Rights Watch interview with Mariana Santos, health worker, Association for the Well-Being of the Family [Asociacin Pro-Bienestar de la Familia, PROFAMILIA], Santiago, January 17, 2004.

[19] Human Rights Watch interview with Rosa Polanco, Santiago, January 17, 2004.

[20] Human Rights Watch interview with Joel Valerio, health team member, One-Respe, Santiago, January 16, 2004.

[21] Human Rights Watch has documented the deep-rooted nature of the racially or ethnically motivated discrimination against Haitians and those of Haitian descent in the Dominican Republic.See Human Rights Watch, "Illegal People: Haitians and Dominico-Haitians in the Dominican Republic," A Human Rights Watch Report Vol. 14 No. 1(B) (New York: Human Rights Watch, 2002); and Human Rights Watch, "A Troubled Year: Haitians in the Dominican Republic," A Human Rights Watch Report(New York: Human Rights Watch, 1992).

[22] Human Rights Watch interview with Ernestina Abreu, health team member, One-Respe, Santiago, January 16, 2004.

[23] Joint United Nations Programme on HIV/AIDS, AIDS epidemic update, December 2003 (Geneva: UNAIDS, December 2003), UNAIDS/03.39E, p. 23.

[24] Joint United Nations Programme on HIV/AIDS, Report on the global HIV/AIDS epidemic (Geneva: UNAIDS, July 2002), UNAIDS/02.26E p. 198.

[25] Prevalence refers to the percentage of HIV-positive people in a given population.Incidence refers to the rate at which people become infected.Studies in sub-Saharan Africa have shown that incidence may be high or rising while prevalence is falling.See Helen Epstein, "AIDS: The Lessons of Uganda," New York Review of Books, July 5, 2001, p. 18.

[26] Secretara de Estado de Salud Pblica y Asistencia Social [Ministry on Public Health and Social Support], Normas y Procedimientos Nacionales para la Atencin de las Infecciones de Transmisin Sexual (ITS) [National Norms and Procedures for the Care of Sexually Transmitted Infections (STI)], Series of National Norms No. 25, Second Edition (Santo Domingo: Secretara de Estado de Salud Pblica y Asistencia Social, 2003), p. 16.

[27] Joint United Nations Programme on HIV/AIDS, Dominican Republic [online] http://www.unaids.org/en/geographical+area/by+country/dominican+republic.asp(retrieved February 25, 2004).

[28] Joint United Nations Programme on HIV/AIDS, Report on the global HIV/AIDS epidemic, p. 198.

[29] Joint United Nations Programme on HIV/AIDS, Dominican Republic, Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections, 2002 Update (Geneva: UNAIDS, 2002).

[30] The United Status Agency for International Development (USAID) "El VIH y el SIDA en la Repblica Dominicana y la intervencin de USAID" [HIV and AIDS in the Dominican Republic and USAID Intervention] [online] http://www.usaid.gov/espanol/hiv_dr.pdf (retrieved April 30, 2004).

[31] During unprotected heterosexual vaginal sex, women and girls are physiologically more vulnerable to HIV infection than men and boys.Factors that contribute to this increased risk include the larger surface area of the vagina and cervix, and the high concentration of HIV in the semen of an infected man.See, e.g., Global Campaign for Microbicides, "About Microbicides: Women and HIV Risk," [online] http://www.global-campaign.org/womenhiv.htm (retrieved April 5, 2004); Joint United Nations Programme on HIV/AIDS, "AIDS: Five Years since ICPD-Emerging Issues and Challenges for Women, Young People and Infants" (Geneva: UNAIDS, 1998), p. 11; The Population Information Program, Center for Communications Programs, "Population Reports: Youth and HIV/AIDS," vol. 23, no. 3 (Washington, D.C: John Hopkins University, Fall 2001), p. 7.

[32] Human Rights Watch interview with Sergia Galvn, director, Collective for Women and Health [Colectiva Mujer y Salud], Santo Domingo, January 9, 2004.

[33] Human Rights Watch interview with Cristina Francisca Luis, community educator, Movement of Dominican-Haitian Women [Movimiento de Mujeres Dominico-Haitianas, MUDHA], January 9, 2004.

[34] Ley 55-93 sobre SIDA [Law 55-93 regarding AIDS], signed into law on December 31, 1993 (AIDS law), article 21.Mandatory notification of HIV test results to sexual partners may translate into fear of HIV testing for some women, who have witnessed the abandonment and ostracism of women living with HIV in their community.

[35] Human Rights Watch interview with Judelka de la Cruz, La Romana, January 12, 2004.

[36] Human Rights Watch interview with Rosana Ramrez, San Pedro de Macors, January 14, 2004.

[37] Demographic and Health Surveys, Repblica Dominicana: Encuesta Demogrfica y de Salud 2002, table 11.6.2 p. 249 and table 11.18 p. 269. The Demographic and Health Survey only measures the extent to which the interviewees know that they have been tested for HIV.

[38] By comparison, in the United States, approximately 45 percent of the total population (age eighteen to sixty-four) said they had been tested for HIV in 2001.Centers for Disease Control and Prevention, "HIV Testing United States, 2001" [online] http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5223a2.htm(retrieved April 13, 2004).In Latin America and the Caribbean, around 20 percent of the total population said they had be tested for HIV voluntarily in various countries across the region in the late nineties.Demographic and Health Surveys, "Data Tables (HIV/AIDS Surveys Indicator Database)" [online] http://www.measuredhs.com/hivdata/data/start.cfm?action=new_table&userid=13599&usertabid=14901&CFID=906887&CFTOKEN=30905045 (retrieved April 13, 2004).

[39] HIV/AIDS experts agree that "HIV counseling and testing is a critical entry point for both prevention and [antiretroviral treatment] services."Global HIV Prevention Working Group, "HIV Prevention in the Era of Expanded Treatment Access" June 10, 2004 [online] http://www.kff.org/hivaids/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=36965 (retrieved June 17, 2004)However, in the case of involuntary HIV testing as a condition to retain or gain work there is no treatment benefit to the individual who tests positive, and no prevention benefit for the state.

[40] Banco Central de la Repblica Dominicana, Departamento de Cuentas Nacionales y Estadsticas Econmicas [Central Bank of the Dominican Republic, Department of National Accounts and Economic Statistics] "Poblacin de 10 aos y ms por Condicin de Actividad segn Gnero y Rama de Actividad Econmica" [Population over 10 years of Age by Activity, Gender, and Economic Branch] (Santo Domingo: Banco Central de la Repblica Dominicana, April 2002) [online]http://www.bancentral.gov.do/mt_rama.html (retrieved March 15, 2004).

[41] Demographic and Health Surveys, Repblica Dominicana: Encuesta Demogrfica y de Salud 2002, Tables 11.6.2 p. 249 and 11.18 p. 269.

[42] Human Rights Watch interview with Rosa Flores, director, Unit for Attention to Sexually Transmitted Infections [Unidad de Attencin a las Infecciones Sexualmente Transmetidas], Main Office on Control of Sexually Transmitted Infections, HIV and AIDS [Direccin General de Control de las ITS/VIH y SIDA, DIGECITSS], January 27, 2004.

[43] Ibid.Flores also did not recall the exact timing of the campaign.

[44] Human Rights Watch interview with Irma Levasseur, director, Office of Orientation and Psychology [Direccin de Orientacin y Psicologa], Ministry of Education [Secretara de Estado de Educacin, SEE], January 29, 2004.Private schools may design their own sex education programs, whereas public schools follow guidelines developed by the Ministry of Education.Teachers may recommend any textbook to the pupils.

[45] Ibid.The book was initially published in the early 1990s under the coordination of Family Health International (FHI).Human Rights Watch phone interview with Csar Castellanos, associate researcher, National Health Institute (Instituto Nacional de la Salud, INSALUD), Santo Domingo, April 22, 2004.

[46] Presidential AIDS Council [Consejo Presidencial de SIDA, COPRESIDA], Aprender es Vivir: Serie Mdulos Educativos Dirigidos A Adolescentes [Learning is Living: Series Educational Lessons Directed at Adolescents] (Santo Domingo: COPRESIDA, 2002), p. 38.

[47]Ibid., p. 37.

[48] Ibid.

[49] Demographic and Health Surveys, Repblica Dominicana: Encuesta Demogrfica y de Salud 2002, table 5.3, p. 99.By comparison, in Nicaragua, where a similar proportion of women use modern contraceptive methods, 8.7 percent of sexually active women (3.3 percent of women in marriages or long-term unions) use condoms.Demographic and Health Surveys, Nicaragua: Encuesta Demogrfica y de Salud 2001 [Nicaragua: Demographic and Health Survey 2001] (Calverton, Maryland: Measure DHS+, 2001), table 5.4.2, p. 100.In Colombia, also with a similar coverage of modern contraceptive methods, the percentage of women using condoms is 21.2 percent for sexually active women and 6.1 percent for women in marriages or long-term unions. Demographic and Health Surveys, Colombia: Encuesta Demogrfica y de Salud 2000 [Colombia: Demographic and Health Survey 2000] (Calverton, Maryland: Measure DHS+, 2000), table 5.4, p. 56.

[50] Human Rights Watch interview with Olga Lpez, Santiago, January 19, 2004.

[51] Human Rights Watch interview with Alesandra Ebrito, San Pedro de Macors, January 14, 2004.

[52] Human Rights Watch interview with Rosana Ramrez, San Pedro de Macors, January 14, 2004.

[53] Human Rights Watch interview with Judelka de la Cruz, La Romana, January 12, 2004.

[54] Demographic and Health Surveys, Repblica Dominicana: Encuesta Demogrfica y de Salud 2002, table 11.1, p. 238; and Demographic and Health Surveys, Repblica Dominicana: Encuesta Demogrfica y de Salud 1996 [Dominican Republic: Demographic and Health Survey 1996] (Calverton, Maryland: Measure DHS+, 1996), table 10.5, p. 171.