Over 20 million persons have died of AIDS in sub-Saharan Africa since the early 1980s, most of them adults under age thirty-five. Three quarters of the persons estimated to be living with the disease worldwide are in sub-Saharan Africa. It is a reflection of global health research priorities that the question of why HIV prevalence rates in Africa are so high compared to other parts of the world remains to a great degree a matter of speculation.2 Africa’s HIV/AIDS epidemic is distinctive in that more than half the persons living with the disease are women and girls,3 a higher proportion than in any other region.4 This aspect of the epidemic in Africa, as much as the overall high prevalence of HIV in the population, is a grossly neglected aspect of research on the epidemiology of the disease.
Although it is difficult to quantify clinically, there is strong evidence that women and girls are physiologically more vulnerable than men and boys to HIV infection through heterosexual sex.5
Vulnerability to HIV transmission is heightened for girls and young women because the vaginal lining is less well developed and the cervix more vulnerable to injury and erosion.6 The increased physiological risk borne by women and girls in Africa is compounded by the HIV risk they bear from subordination, discrimination, and inequality under the law.
It is only in the last few years that some consensus has emerged among experts that the subordination of women and girls in Africa and related human rights abuses constitute a major driving force of the AIDS epidemic on the continent. Even so, those abuses remain little studied and vastly underrepresented in policy discussions and decision-making. Relative to the scale and severity of these abuses faced by African women and girls, laws, policies, and programs to combat HIV/AIDS by protecting the rights of women and girls are negligible. The attitude of fatalistic resignation to gender inequality remains far too common while bold initiatives to address abuses against women and girls and their grave implications for HIV/AIDS are virtually nonexistent.
African girls and women face numerous human rights abuses at all stages of life—as children in school or, as is increasingly the situation of girls affected by HIV/AIDS, out of school; as adults, in long-term unions where decision-making authority over sex is too rarely theirs and where economic dependence and inequality under the law limit their options for redress; in widowhood where gender discrimination is the rule rather than the exception for inheritance and control of property; and in war and civil conflict where rape is used strategically as a weapon. Sexual abuse, violence, coercion and discrimination are the overarching violations they face at all stages of life.
This chapter summarizes the range of human rights abuses against women and girls that is fueling HIV/AIDS in Africa. The discussion that follows divides the abuses into eight overlapping categories: (1) abuses targeting girls; (2) risks facing women and girls in long-term unions; (3) the effects on susceptibility to HIV/AIDS of discrimination in property and inheritance rights; (4) persistence of at times deadly traditional practices; (5) the ways in which treatment of sex workers exacerbates the epidemic; (6) the failure to properly address wartime rape and related abuses; (7) the failure to provide timely assistance to rape victims; and (8) discrimination in access to basic health information and services. These topics are addressed in turn in the sections below.
In many countries of eastern and southern Africa, HIV prevalence among girls under age eighteen is four to seven times higher than among boys the same age, a disparity that means a lower average age of death from AIDS, as well as more deaths overall, among women than men. There is increasing evidence that abuses of the human rights of girls, especially sexual violence and other sexual abuse, contribute directly to this disparity in infection and mortality. Certainly consensual sex is part of this picture, but too many girls and young women find that coercion—physical, psychological or economic—figures importantly in their sexual experiences.7 In Africa, hundreds of thousands of girls, including many orphaned by AIDS or otherwise without parental care, suffer in virtual silence as governments fail to provide basic protections from sexual abuse that would lessen their vulnerability to HIV/AIDS.
Human Rights Watch’s work in a number of African countries, including Zambia, Togo, South Africa and Kenya, has documented several categories of abuse that heighten girls’ risk of HIV infection, including (1) abuse of girls who are heads of household or otherwise relied upon as breadwinners and have few options other than trading sex for their and their dependents’ survival, (2) sexual assault of girls by family members or guardians, particularly the shocking and all too common practice of abuse of orphan girls by men who are charged to assist or look after them, (3) abuse of girls who live on the street, of whom many are there because they are without parental care, (4) trafficking of girls for domestic or market work, and (5) rape and sexual assault against girls in school or going to and from school. In some parts of Africa, there is evidence that rape and sexual coercion of girls are fueled by men’s targeting for sex younger and younger girls who are assumed to be HIV-negative or seeking them out based on the myth that sex with virgins will cure AIDS. All of these situations of abuse must be addressed as part of combating the HIV/AIDS epidemic in Africa. Sexual abuse of boys was also reported to us, but abuse of girls is predominant.
Girls interviewed by Human Rights Watch in several African countries have recounted dramatic and, in some cases, nearly unimaginable abuses of their rights—violations of their childhood and their innocence—that have exposed them to sexual assault and sexual coercion. A good many of these depend on both the subordinate status of women and girls in Africa and the intransigent poverty that seems to fall first and most heavily on women and girls. These factors often conspire to force girls into hazardous working situations that expose them to sexual abuse with attendant risk of HIV infection. In 2002, Human Rights Watch spoke with over 100 girls in Zambia about their experiences of rape and sexual abuse. Margaret T., a fifteen-year-old Zambian girl with a young child, told Human Rights watch what happened when she was forced by poverty to work as a housemaid:
Sara A., twenty, interviewed by Human Rights Watch in Kafue outside Lusaka, Zambia, lost her father when she was a girl. Five of her siblings also died, three apparently from tuberculosis. She was unable to continue in secondary school because of financial pressures on the family. "I was seventeen when I left school. I wanted to be a journalist in Lusaka. That didn’t work, but I wanted to start working and find a job, even to be a maid. But if you look here, you can’t find any work," she said. She eventually found work serving drinks in a bar where, she said, the main money-making opportunities for girls were in trading sex.
Many girls interviewed by Human Rights Watch in Zambia echoed Sara A.’s view that trading sex was difficult to avoid if girls wanted to survive or help others in their households survive. Polly A. was sixteen. After her mother died, there was no one to take care of her and her siblings. “Our relatives refused to help us; they said we should take care of ourselves,” she said. “I was eight; my sisters were ten and thirteen. My elder brother took us, and we went to Livingstone [Zambian border town]. He stopped school and went looking for piece work, carrying heavy things. My sister started prostitution.”10
Workers in Zambian nongovernmental organizations (NGOs) that provide services for girls said they were at particular risk of being drawn into prostitution in border towns and trucking routes. Chirundu is on the Zambia-Zimbabwe border, and trucks are often stuck there for days waiting to cross. One NGO worker described the situation: “There’s no water in Chirundu, so rural girls carry twenty-liter containers and sell them for 500 kwacha [U.S. $0.12]. You can do that two or three times a day, or you can get 10,000 kwacha [U.S. $2.30] for an hour’s [sex] work. Once they end up at the border, it’s almost too late.”11 Dr. Kwasi Nimo of World Vision, which oversees a project in Chirundu, said the truckers call these girls “village chickens”:
Claire S. in western Kenya, who became the head of her household at age seventeen when her mother died, explained her struggle as a breadwinner for her remaining siblings:
I tried to do anything to keep us going – I made chapatis and sold them, I washed cars, and now I’m working for a woman with a small kiosk, but I don’t think it’s going to last. The government should lend money to people so they can start a business and be self-reliant. I may have to go into prostitution, and then I know I will get HIV and die. I would rather have a real business, but it is not easy.13
Trafficking of girls, a particularly shocking form of child labor, is sadly a common human rights violation in many parts of Africa. Child trafficking is a phenomenon that predates HIV/AIDS and only stands to grow much more widespread in the face of profound poverty, including the impoverishment of AIDS-affected families. Girls and boys are both trafficked in many parts of Africa, but girls are in some families the first to be withdrawn from school when families cannot pay school fees or need an extra source of income. Girls are also more likely to find that the work to which they are sent, even if it is not sex work, puts them at risk of sexual abuse.
In Togo, Human Rights Watch interviewed a number of girls trafficked into domestic work who were physically abused by men and boys in their workplaces sand faced high risk of sexual abuse on a regular basis. “Girls can be cornered in a bedroom. Sometimes someone abuses their kindness—they say ‘bring me a cigarette, bring me water’ and then they corner them,” said Professor Djassoa Gnansa of the University of Togo, who counsels trafficked children sheltered by the NGO Terre des Hommes in Lome.14
In addition to abuse they face in their places of work, girls trafficked in West Africa are sometimes left to fend for themselves at intermediate points in their trafficking voyages, a situation ripe for abuse. Birgit Schwarz, a German journalist who interviewed several trafficked children in Togo, told Human Rights Watch she met girls who, while waiting for boats to arrive in Nigeria, were raped, prostituted themselves, and sold their belongings to survive.15 All were reportedly abandoned by their intermediaries, the women who promised not only to accompany them to their destinations but to find them work or send them to school.
Human Rights Watch documented similar experiences. Some girls told us that, after being recruited in their villages, they were driven to meeting places in Nigeria where they were told to wait for a boat to arrive. The journey to Nigeria lasted about a day, with some traffickers stopping along the way to pick up other recruits. When they arrived in Nigeria, girls were brought to small towns and left to their own devices. They reported waiting up to two months with nothing to eat and nowhere to stay. Some slept outside; others slept in abandoned buildings. All had to scrounge for food or steal from the local market. “We waited for two months with nothing to do,” one girl said. “We would fight and hit each other. We did not have enough food to eat, so we would steal manioc from the market and get beaten by the shopkeeper.”16
HIV/AIDS is distinctive among the great infectious disease epidemics of human history in that most of the lives it claims are of young adults rather than of young children or the elderly. In many of the most affected countries, the vast majority of young adults are also parents. The rate of orphaning associated with HIV/AIDS is thus unprecedented in the history of human epidemics. The plight of millions of African children who have lost their parents to HIV/AIDS or whose parents or main caregivers are ill with HIV/AIDS constitutes one of the gravest humanitarian crises in history. It is frequently overlooked that this humanitarian crisis is also a human rights crisis.
Children orphaned and otherwise affected by HIV/AIDS face a wide range of human rights abuses. Virtually all of them either affect girls more often than boys or put girls in particularly risky circumstances. Some those that have been most consistently documented are discussed below.
In an investigation of HIV transmission risk linked to human rights abuse of girls, Human Rights Watch interviewed scores of Zambian girls who faced sexual abuse as a regular part of their lives. Nearly every abuse we heard about from these girls posed an even greater risk for girls who were orphaned or otherwise without parental care. In Zambia, a country of about 10 million persons, an estimated 600,000 to 1 million children have been orphaned by AIDS or are in households where a parent is ill with AIDS.17 A number of orphaned girls reported horrific abuse at the hands of the persons charged to be their guardians or care-givers, often suggesting that they were threatened with being turned out of the household, or worse, if they reported the abuse. Catherine R., seventeen, told Human Rights Watch:
Melanie Y., twelve, explained to Human Rights Watch what followed the death of her parents:
A social worker at a youth-friendly clinic in Lusaka, Zambia described to Human Rights Watch a case involving Joan S., now sixteen, who had been abused since the age of nine by her stepfather. Because she was afraid to tell her mother about the abuse, she told her aunt, who in turn told her mother. The mother’s reaction was to chase the girl out of the house. The case was never reported to the police. “They kept it within the family,” the social worker noted.20 Joan S. was eventually diagnosed with several sexually transmitted diseases.
Withdrawing children from school or not enrolling them at all appears to be a common coping mechanism for families affected by AIDS, which both impoverishes families and creates the need for children to help with care of an ill person or with bringing income into the family. A 1999 UNICEF report, for example, cites a study in rural Zambia that showed that 68 percent of orphans of school age were not enrolled in school compared to 48 percent of non-orphans.21 UNAIDS’ annual report on the state of the HIV/AIDS epidemic in 2000 noted that several studies have confirmed AIDS in the family as a direct cause of school dropout. For example, in a study of heavily AIDS-affected communities in Zimbabwe, 48 percent of primary school-age orphans had dropped out of school, most often at the time of a parent's illness or death, and of the children of secondary school age interviewed, there were no orphans who were able to stay in school.22 These aggregate figures, as alarming as they are, fail to highlight that in most countries the majority of school drop-outs associated with AIDS in the family are girls. Ministry of Education officials in Kenya told Human Rights Watch in 2001 that in the country’s Eastern Province, the region least affected by HIV/AIDS, 42 percent of primary school children passing into grade five were girls, but heavily AIDS-affected Nyanza Province, the corresponding figure for girls is only 6 percent.
It is not surprising that girls are pulled out of school first when a family is touched by HIV/AIDS. In investigating human rights abuses faced by orphans in several African countries, Human Rights Watch heard consistently from many respondents the view that girls are naturally more suited than boys to care for sick persons. Education for boys is more valued than for girls in many African communities, partly because of the belief that it will yield a greater long-run return on the family’s investment. For families economically strapped by AIDS, girls have immediately marketable skills as housemaids, child care workers and vendors or transporters in and around markets, and society does not disapprove when a school-aged girl is seen as a full-time laborer. In an interview with Human Rights Watch, an expert on child trafficking in Togo put it this way:
Tragically, girls in AIDS-affected families too often find themselves being relied upon as breadwinners by struggling relatives and see no alternative to trading sex for food or other elements of survival. HIV/AIDS both causes them to be laborers and makes their labor mortally dangerous.
When girls in AIDS-affected families are withdrawn from or not enrolled in school, a vicious cycle of HIV/AIDS risk is perpetuated. As noted above, whatever possibility schools offer for arming girls with knowledge of HIV transmission—and boys and girls with knowledge of appropriate sexual behavior—is negated by the widespread inability of orphans and other children in AIDS-affected families to be in the classroom. According to UNICEF, the biggest successes in lowering rates of HIV infection in Africa have been among girls and women who completed secondary school, not only because of information received in school but because these girls and women are more likely to “have the status and confidence to assert their rights.”24
In many African countries, inheritance rights of AIDS widows and orphans have not been respected or protected. The stigma and overwhelming mortality of HIV/AIDS are overlaid on a legal system that in many countries has long disadvantaged women through unequal property and inheritance laws (see discussion below). The unlawful appropriation of the property of AIDS widows and orphans by relatives or others in the “community” is widely documented in Africa. To the degree that their surviving mothers are disadvantaged by law and practice in keeping the property associated with their marriages, children are disadvantaged too, and then even more if their mothers die. Although widows and orphans from other causes may also experience the loss of their property and inheritance rights, many studies suggest that these abuses are much more severe and frequent when HIV/AIDS is in the picture. Ten-year-old Susan B., living with a neighbor in a Nairobi slum after her parents both died of AIDS, told Human Rights Watch an all too typical story:
Children’s deprivation when denied their inheritance rights is compounded by the paucity of options they have for legal recourse. Laws on child protection in many African countries are premised on the idea that children deprived of parental care will be looked after by members of their extended families. It is a tragic consequence of HIV/AIDS that in the communities most affected by AIDS—those most likely to have significant numbers of orphans—extended families are also most likely to be decimated by the disease. Children who might be able to find some assistance in seeking to be able to inherit property that may represent their only hope for not sinking into destitution may discover that courts in many African countries provide no avenue of redress for them. Juvenile courts are set up to deal with children in conflict with the law, and family courts that might be more appropriate for inheritance issues exist in only a few jurisdictions. A teacher in western Kenya who cares for two orphans in addition to her own children, note:
With respect to inheritance of property, girls are especially disadvantaged in the way that their mothers have been for centuries. A boy who reaches the age of majority in many countries will at least have the law on his side in claiming property and inheritance rights. Boys in AIDS-affected families may still suffer discrimination, but girls in similar situations will be doubly disadvantaged by inequality before the law and the stigma of HIV/AIDS.
The phenomenon of children orphaned by AIDS swelling the numbers of homeless children in Africa has been noted in the popular press and expert reports alike. In Lusaka, the Zambian capital, the population of street children more than doubled from 1991 to 1999, an increase the U.N. agencies in the country attribute largely to AIDS.27 Even in the Sudan, a country not reported to be among the most heavily affected by AIDS, church workers estimated in 1999 that thousands of AIDS orphans were among the street children of Khartoum.28 Nongovernmental organizations have documented many risks to street children. As the work of Human Rights Watch and others has shown, street children in Africa are likely to face police abuse and certainly face being treated as criminals rather than victims.29 A 2000 report by Save the Children-Sweden confirmed AIDS as an important part of what drives children to the streets. The same report concludes, based on extensive interviews with service providers in Kenya, Uganda, Tanzania, and Ethiopia that, almost inevitably, "an unprotected girl working on the streets will sooner or later end up working as a prostitute."30
As noted above, because of entrenched poverty and lack of educational and income-earning opportunities, girls in many parts of Africa, whether orphaned or not, are frequently forced to take on risky labor, including trading sex for survival. AIDS in the household often pushes families deeper into poverty because of medical care, difficulty of replacing lost earnings of an ill breadwinner, and eventually funeral expenses. It is not surprising, then, that orphaned girls and boys are more vulnerable to risks associated with hazardous labor than other children. A 2001 UNICEF study in six heavily AIDS-affected countries of eastern and southern Africa concluded that children's being in AIDS-affected families is a consistent and strong determinant of their being forced into the workplace, often into hazardous jobs. "The AIDS pandemic has turned African children into orphans and labourers," concludes the report. "It is safe to say that eastern and southern Africa will have a disproportionate number of . . . working children by 2015 unless immediate action is taken to reverse this trend."31
Human Rights Watch’s investigation of trafficking in west Africa, referred to above, concluded that orphans were especially vulnerable to being trafficked for their labor. In Tchamba, Togo, for example, we documented the case of a child being trafficked after her father had died of AIDS. Hodalo S., who was in primary school when her father became ill, told Human Rights Watch she was sent by her grandmother to live with an aunt,32 who then took her to Gabon to work. For a month she sold milk in the market without pay, and by the time she returned home her father had died.33 Human Rights Watch interviewed a social worker familiar with this case, and he said the health worker who cared for Hodalo S.’s father confirmed the diagnosis of HIV/AIDS. In other instances, orphans who were recruited by child traffickers were unable to identify their parents’ cause of death. There is an urgent need for further research on the connection between HIV/AIDS and child trafficking in Africa.
2 See, e.g., D.D. Brewer, S. Brody, E. Drucker, D. Gisselquist, S.F. Minkin, J. J. Potterat, R.B. Rothenberg, F. Vachon, “Mounting anomalies in the epidemiology of HIV in Africa: Cry the beloved paradigm,” International Journal of STDs and AIDS, vol. 14, no. 3, pp. 144-147, March 2003.
3 In this report, the word “child” refers to anyone under the age of eighteen and “girl” refers to female children under eighteen. Article 1 of the Convention on the Rights of the Child defines a child as “every human being under the age of eighteen years unless, under the law applicable to the child, majority is attained earlier.” Convention on the Rights of the Child, G.A. Res. 44/25, U.N. Doc. A/RES/44/25, ratified by all member states of the United Nations except the United States and Somalia.
4 UNAIDS, AIDS Epidemic Update December 2002 (Geneva, 2002), p. 8 [online], http://www.unaids.org/worldaidsday/2002/press/update/epiupdate_en.pdf (retrieved July 20, 2003).
5 A number of determinants of this higher risk have been cited, including the large surface area of the vagina and cervix, the high concentration of HIV in the semen of an infected man, and the fact that many of the other sexually transmitted diseases (STDs) that increase HIV risk are asymptomatic in women, which may lead to their being untreated for longer periods. Girls and women may also face discriminatory barriers to treatment of STDs, such as needing permission of a husband or male relative for certain services. See, e.g., Global Campaign for Microbicides, “About Microbicides: Women and HIV Risk,” at http://www.global-campaign.org/womenHIV.htm (retrieved July 24, 2003); UNAIDS, “AIDS: Five years since ICPD—Emerging issues and challenges for women, young people and infants,” Geneva, 1998, p.11, also at http://www.unaids.org/publications/documents/human/ gender/newsletter.pdf (retrieved July 22, 2003); and Population Information Program, Center for Communications Programs, The Johns Hopkins University Bloomberg School of Public Health, “Population Reports: Youth and HIV/AIDS,” vol. XXIX, no. 3, (Baltimore, MD, Fall 2001), p. 7.
6 See Population Information Program, p. 7.
7 See, e.g., Judith Mirsky, Beyond victims and villains: Addressing sexual violence in the education sector (London: Panos Institute, 2003), pp. 6-7.
8 Human Rights Watch interview, Lusaka, Zambia, May 22, 2002.
9 Human Rights Watch interview at Fountain of Hope, Lusaka, Zambia, May 23, 2002.
10 Human Rights Watch interview at Anglican Children’s Project, Lusaka, Zambia, May 18, 2002.
11 Human Rights Watch interview with Karen Doll Manda, Country Director, Family Health International, Lusaka, Zambia, May 21, 2002.
12 Human Rights Watch interview with Dr. Kwasi Nimo, World Vision, Lusaka, Zambia, May 22, 2002.
13 Human Rights Watch interview, Kisumu, Kenya, February 28, 2001.
14 Human Rights Watch interview, Lome, Togo, May 8, 2002.
15 Human Rights Watch telephone interview with Birgit Schwarz, New York, June 4, 2002.
16 Human Rights Watch interview, Bassar, Togo, May 3, 2002.
17 See, e.g. UNAIDS, “Report on the global HIV/AIDS epidemic 2002” (Geneva: July 2002), p. 190, and Government of the Republic of Zambia, “Orphans and Vulnerable Children: A Situation Analysis, Zambia 1999,” Joint USAID/UNICEF/SIDA Study Fund Project, November 1999, p. 151.
18 Human Rights Watch interview at YWCA, Lusaka, Zambia, May 22, 2002.
19 Human Rights Watch interview at Messiah Orphanage, Lusaka, Zambia, May 19, 2002.
20 Human Rights Watch interview with Jayne Kunda Mwila, Kalingalinga Health Centre, Lusaka, Zambia, May 30, 2002.
21 UNAIDS and UNICEF, Children Orphaned by AIDS: Front-line Responses from Eastern and Southern Africa (New York: United Nations, 1999), p.17.
22 UNAIDS, Report on the Global HIV/AIDS Epidemic: June 2000, pp.28-29.
23 Human Rights Watch interview with Victoire Lawson, project coordinator, BICE-Togo, Lome, May 14, 2002.
24 UNICEF, “A Fair Chance: Attaining Gender Equity in Basic Education by 2005,” New York: April 2003, p.2.
25 Human Rights Watch interview, Korogoro, Kenya, March 15, 2001.
26 Human Rights Watch interview, Kisumu, Kenya, March 3, 2001.
27 UNAIDS and UNICEF, Children Orphaned by AIDS: Front-line Responses from Eastern and Southern Africa (New York: United Nations, 1999), p.16.
28 See Nhial Bol, "AIDS Orphans Throng the Streets," Inter Press Service, January 13, 1999.
29 Human Rights Watch, Juvenile injustice:
30 Stefan Savenstedt, Gerd Savenstedt, and Terttu Haggstrom, East African Children of the Streets – A Question of Health (Stockholm: Save the Children-Sweden, 2000).
31 UNICEF Eastern and Southern Africa Regional Office, Child Workers in the Shadow of AIDS: Listening to the Children (Nairobi: UNICEF, 2001).
32 According to a 1998-1999 ASI study on the trafficking of girls between Benin and Gabon, the women responsible for trafficked girls are often called “auntie” to give an illusion of a familial bond. A.F. Adihou, “Trafficking of children between Benin and Gabon,” p. 10. Human Rights Watch was not able to confirm in most cases whether the “aunt” or “auntie” referred to by a trafficked child was indeed a relative by blood or marriage.
33 Human Rights Watch interview, Tchamba, Togo, May 2, 2002.