In January 2004, Human Rights Watch conducted research in the Dominican Republic on human rights violations suffered by women living with HIV. We documented violations of the rights to bodily integrity, nondiscrimination, the highest attainable standard of health, work, information on health, and privacy.
We write to raise concerns about human rights violations suffered by women living with HIV/AIDS in the Dominican Republic, in connection with your review of the Dominican Republic’s fifth periodic report on its compliance with the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW). We believe these violations deserve special attention given the serious and growing nature of the epidemic in the Dominican Republic, in particular for women. HIV prevalence in the Caribbean as region is second only to that of sub-Saharan Africa. HIV prevalence in the Dominican Republic is among the highest in the region and is increasing at a faster rate among women than men.
In January 2004, Human Rights Watch, an independent nongovernmental organization, conducted research in the Dominican Republic on human rights violations suffered by women living with HIV. We documented violations of the rights to bodily integrity, nondiscrimination, the highest attainable standard of health, work, information on health, and privacy. These violations occurred in the form of involuntary and mandatory HIV testing, unauthorized disclosure of confidential HIV test results, and denial of work or adequate health services because of women’s HIV status. The findings of this research will be published in a report, currently under preparation, entitled “A Test of Inequality: Involuntary HIV Testing of Women in the Dominican Republic” before the CEDAW session in July. We will be happy to send advance copies to you before your July session.
We are also including in this letter information about pregnancy-based sex discrimination against women workers in the Dominican Republic’s free trade zones, which persists despite free trade zone officials’ denials. This discrimination is particularly worrying because it discourages women job seekers from looking for work and exacerbates an already unusually large gender gap in employment in the Dominican Republic. The briefing paper “Pregnancy-Based Sex Discrimination in the Dominican Republic’s Free Trade Zones: Implications for the U.S.-Central America Free Trade Agreement (CAFTA),” enclosed, is also based on our January 2004 research and is available in Spanish on the Human Rights Watch website at https://www.hrw.org/spanish/informes/2004/dr0404/ (Spanish).
Failure to Address Sex Discrimination in the Context of the HIV/AIDS Epidemic
Public awareness campaigns and sex education in the Dominican Republic have failed adequately to address the social biases and prejudices that contribute to putting women at increased risk of HIV infection. This is especially disappointing given that the CEDAW Committee already in 1998 noted “the failure of the Government to undertake comprehensive and systematic public awareness and information campaigns to change stereotypical attitudes that are detrimental to women’s equality” and “invite[d] the Government to strengthen educational programmes … on sexual and reproductive health, on combating HIV/AIDS, and on family planning” (paras. 334 and 349 of the CEDAW Committee’s concluding observations on the Dominican Republic from May 1998).
Sex education materials that have been used extensively in the Dominican Republic during the period under consideration (1998-2001) include information on the correct use of condoms, but fail to address the barriers that impede consistent use of condoms, especially for women. The same materials perpetuate a strong social bias against condom use by noting that condom use is necessary only outside of a long-term relationship or when engaging in so-called risky sexual activity. The materials may also severely hamper women’s ability to negotiate condom use, because they place blame for low condom use mainly with women. Such biased information may have dire consequences. Indeed, public awareness campaigns and sex education efforts implemented by the Dominican Republic’s government in this period may have been counterproductive, as surveys conducted in the Dominican Republic by Measure DHS+ might indicate (DHS surveys, cited as ENDESA surveys in the government’s fifth periodic report). Surveyed women displayed a significant drop in awareness between 1996 and 2002 with regard to both correct and incorrect methods to prevent HIV transmission, despite public campaigns and sex education. 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. This is a disturbing development for the Dominican Republic, where condom use already is among the lowest in Latin America and the Caribbean: approximately 2 percent depending on the age of the individual and 1.3 percent between long-term union partners and spouses (DHS-2002).
Mandatory HIV Testing as a Condition for Access to Work
Women who seek work in the tourism industry or the export processing zones—the two main employers of women in the Dominican Republic—are often tested for HIV as a condition to get a job, in violation of their right to nondiscrimination on the basis of health status in access to work and in the workplace. The practice also constitutes a violation of the Dominican Republic’s domestic AIDS law.
Women may be differently and more gravely affected than men by mandatory HIV testing as a condition for access to work. Mandatory HIV testing as a condition for work has the pervasive effect of discouraging job seekers from applying for jobs, due to their fear of having their HIV status revealed. Mandatory HIV testing as a condition to gain or retain work, though applied to both men and women, has a disproportionate and adverse effect on women workers, because of its widespread effect of discouraging those who know or believe they are HIV-positive from even looking for a job. Whereas men have employment opportunities in various industries, women workers tend to concentrate in the two industries that are most known to employ mandatory HIV testing, and where Human Rights Watch documented such testing.
Further, pervasive HIV testing practices as part of health care in the Dominican Republic results in more women than men knowing their HIV status in any one age group because women are more likely to seek health care services. This situation, as well as the fact that women already are severely underrepresented in the workplace, exacerbates the discouraging effect HIV testing as a condition for work has on women, because more women then men consciously will refrain from applying for jobs for fear of HIV testing.
The Dominican government has not provided adequate remedies for these abusive practices, allowing private employers to continue mandatory HIV testing with impunity. Further, the government has failed to convey to the general public that job seekers and employees have a legal right to refuse HIV testing and that the Ministry of Labor could provide legal assistance in cases of alleged discrimination on the basis of HIV status. The issues of mandatory HIV testing as a condition to gain or retain work is not addressed by the Dominican Republic government’s fifth periodic report to the CEDAW Committee.
Involuntary HIV Testing as Part of Prenatal Health Care
As mentioned in the Dominican Republic government’s fifth periodic report, the Dominican Republic has implemented a program to reduce the risk of parent-to-child HIV transmission in utero or during childbirth. According to government figures, this program has resulted in real advances in the reduction of parent-to-child HIV transmission, and has delivered HIV counseling services to a large number of pregnant women.
The CEDAW Committee advises in its General Recommendation 15 (1990) on avoidance of discrimination in national strategies for the prevention of HIV/AIDS that “programmes to combat AIDS should give special attention to the rights and needs of women and children, and to the factors relating to the reproductive role of women and their subordinate position in some societies which make them especially vulnerable to HIV infection.” This recommendation has not been followed by the Dominican Republic. The program to reduce the risk of parent-to-child HIV transmission as well as national norms regarding counseling and testing for HIV and other sexually transmitted infections are implemented in a manner that does not give women full information about their rights and choices. When women use public health services, especially prenatal care, they face involuntary HIV testing, disclosure of their confidential HIV test results, and abusive treatment by health personnel. Such practices violate the women’s rights to privacy and physical integrity, and may constitute coercive medical procedure prohibited by the International Covenant on Economic Social and Cultural Rights as a violation of the right to the highest attainable standard of health. The practices may also constitute a violation of CEDAW article 12 on nondiscrimination in the field of health care.
Involuntary HIV testing or testing without informed consent can have serious consequences on women’s enjoyment of their human rights to nondiscrimination, the highest attainable standard of health, and freedom from violence. Moreover, it is not necessary to violate the rights of pregnant women in order to reduce the risk of parent-to-child HIV transmission. The majority of women will choose voluntarily to get tested for HIV if they receive proper information and are guaranteed confidentiality, whereas studies show that some women will avoid essential health services if they know they will be tested for HIV against their will. Though involuntary testing may, of course, be accompanied by information to each tested individual, experience on the ground shows that, in practice, involuntary HIV testing will not be accompanied by quality counseling, because it is not necessary to pass on detailed information to women in order to obtain their consent. A very important opportunity to save the lives of currently HIV-negative women is therefore lost.
Mandatory or involuntary HIV testing at prenatal clinics will be administered, by definition, only to women. This, in combination with situations where medical personnel release confidential HIV test results with impunity—as Human Rights Watch has documented is the case in the Dominican Republic—creates a situation where women are known to be HIV-positive more frequently than men. This is particularly harmful to women in a cultural context such as the Dominican Republic where women—but not necessarily men—are expected to be faithful and where a woman is ultimately seen as responsible for her spouse’s infidelity. As a consequence, many women are blamed by their spouses and families for introducing HIV into their marriage or long-term union. These women subsequently may face violence, abandonment, and ostracism.
None of the policies adopted by the Dominican Republic to address the growing HIV crisis in the country seek to overcome these serious human rights consideration in a meaningful manner, and the Dominican Republic’s fifth periodic report to the CEDAW Committee does not address the abuses suffered by women living with HIV/AIDS.
Pregnancy-Based Sex Discrimination in Free Trade Zones
Human Rights Watch documented widespread sex discrimination on the basis of reproductive status in some factories operating in the Dominican Republic’s free trade zones in January 2004. We found that factories often obligate women workers and job seekers to undergo pregnancy testing as a condition for access to work or as a condition for maintaining their jobs. The Dominican government has done little to curb or end this practice.
Mandatory pregnancy testing as a condition for access to work constitutes sex discrimination in the workplace, prohibited by many international human rights treaties to which the Dominican Republic is a party, including CEDAW. Sex discrimination in the workplace is also prohibited by the country’s domestic laws. The Dominican government’s failure to act decisively to end such mandatory testing, investigate testing practices, and punish those who engage in them constitutes a breach of the country’s international human rights obligations. It also indicates a failure to act on some of the concerns highlighted by the CEDAW Committee in 1998, including the “considerable discrimination” suffered by women workers in the free trade zones in the Dominican Republic (para. 336 of the Committee’s Concluding Comments).
The Dominican Republic’s Compliance with CEDAW
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 sexual 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 when they receive or seek access to health care services. The Dominican Republic’s fifth periodic report to the CEDAW Committee fails to address pertinent concerns related to women living with HIV as they pertain to CEDAW obligations. The Dominican Republic should clarify the following issues during its upcoming presentation to the CEDAW Committee:
1. How does the Dominican Republic government address the manner in which the HIV epidemic affects women differently than men? What efforts are made to educate the public about the inequality between men and women that contributes to putting women at risk of HIV transmission in the Dominican Republic? What efforts are made to encourage condom use within marriages or long-term unions?
2. What steps are being taken to ensure that public and private entities do not conduct involuntary or mandatory HIV testing, in particular as a condition to gain or retain work, or as part of prenatal health care?
3. What steps have been taken to ensure that confidential HIV test results are not revealed, without authorization, to anyone other than the tested individual? What sanctions are available and implemented against health personnel and other who release confidential HIV test results without authorization?
4. What measures will the government take to ensure the full protection of women’s rights to nondiscrimination, bodily autonomy, and equality in the field of health care, in particular for women living with HIV/AIDS? In particular, what steps are taken to ensure that pregnant women receive adequate counseling and give informed consent to HIV testing, and that they understand and are encouraged to engage in available government programs to reduce the risk of parent-to-child HIV transmission?
5. What is the status of training efforts directed at work inspectors, health personnel, judges, magistrates, lawyers, and relevant local and national officials on the laws and regulations that prohibit involuntary testing for HIV?
The Dominican Republic’s fifth periodic report recognizes severe inequality in access to employment in the country, but fails to analyze the status of government efforts to prevent, punish, and redress pregnancy-based sex discrimination in the free trade zones. It also does not analyze the underlying causes of women’s inequality in the workplace. In this connection, the government should clarify to the CEDAW Committee in particular the following questions:
1. What steps are being taken to ensure that state authorities conduct thorough and proactive investigations of alleged workers’ rights violations, especially those involving pregnancy testing in the workplace?
2. What is the status of efforts to establish and impose appropriate penalties, including fines, to punish companies that engage in pregnancy-based discrimination?
3. What steps have been taken to ensure that women workers and job seekers who are discriminated against because of their sex know where and how to file a complaint?
We hope that this information is useful to the CEDAW Committee in its review of the Dominican Republic’s compliance with CEDAW. When our report on involuntary HIV testing of women living with HIV in the Dominican Republic is published, we will forward copies to all CEDAW members. If you have any questions, please do not hesitate to contact me.
Women’s Rights Division
Human Rights Watch