The Spread of HIV Through Sexual Violence Against Women

EXTREME LACK OF EMPOWERMENT OF WOMEN IN MANY PARTS OF THE WORLD

Change and challenge is in the wind as 2008 comes to an end. The same is true when examining this month’s ReachMD XM 160 special series - Focus on Global Medicine. We take a look at both the changes and the challenges impacting global medicine.

You are listening to ReachMD, The Channel for Medical Professionals. Women around the world are more at risk of getting infected with HIV in part because of their social and economic vulnerability. The extreme lack of empowerment of women in many parts of the world indicates the need for men to act to help protect women from the scourge of HIV infection. Welcome to the Clinician’s Roundtable. I am Dr. Cathleen Margolin and joining me from Toronto, Canada is Stephen Lewis, co-director of AIDS Free World, former UN Special Envoyfor HIV AIDS in Africa and former Deputy Executive Director of UNICEF.

DR. CATHLEEN MARGOLIN:

Welcome Stephen Lewis.

DR. STEPHEN LEWIS:

Thank you.

DR. CATHLEEN MARGOLIN:

Let's start with the enormously difficult behavior to address and one that is causing extreme physical and emotional trauma to women as well as promoting spread of HIV, sexual violence against women. Tell us a bit about what some women and girls are facing right now.

DR. STEPHEN LEWIS:

It's almost impossible to put into words this contagion of sexual violence that tends to come with states, countries that are frayedat the edges and are destabilized by disease or conflicts. This contagion is unbelievable. In South Africa, there are over 52,000 rapes during the course of the year, the highest number relative to per capita,I think, possibly in the world. We know that those are the reported rapes, they are not the full story by any means, they probably represent 10% of what's actually happening. WHO recently did a fascinating study of physical and sexual violence around the world. They chose 14 countries, they interviewed 25,000 women, the lowest level of physical and sexual violence was something in the vicinity of 14% or so in Japan and over 70% in rural Ethiopia, with United States, United Kingdom, and Canada in the latest studies being in the 30% range, but where the sexual phenomenon, the rape and sexual violence occurring right out of control is in conflict. I was recently in Liberia; I was told by the UNICEF representative that more than 50% of the reported rapes are assaults on girls between the ages of 10 and 14. I mean that's beyond the capacity of the mind to absorb, and in the Eastern Congo at the moment, there is a positive war on women where women are seen to be the vehicles through whom you can subdue entire families and communities. It is no longer rape as a weapon of war, it is rape as a strategy of war where the strategy is to engage in sexual violence against women so damaging the prey almost beyond credulity that it takes the breath away using mutilation, and amputation, and knives, and guns; imagine shooting a gun into the vagina of a woman. There is a medical term used in the Little Panzi Hospital in the City of Bukavu in the eastern region of the Congo called vaginal destruction where the sexual and reproductive organs of the women are so damaged that they are virtually beyond surgical repair and the surgery, which is done is very difficult as you can imagine and this is pretty awful everywhere.

DR. CATHLEEN MARGOLIN:

This is among other things a health crisis. What do you feel can be done to protect these girls, women, and their families?

DR. STEPHEN LEWIS:

Cathleen, I genuinely don’t know of every avenue. There are number of things that can be done, but haven’t been done. In some of these countries like the Congo and Liberia, there are huge peacekeeping contingents. There are 17,000 peacekeepers in the Congo and nearly 1000 police. They have been instructed by United Nations Security Council resolutions that they have to provide protection against sexual violence. That's part of their mandate, their obligation, it's not some amorphous wish, and yet it's not happening, and the use of the forces to move around the country to areas where women are at particular risk, to provide 24-hour service in communities that we know are at risk, it's just not happening, and I sure the peacekeeping forces could be much better deployed. There needs to be much more by way of rape crisis centers and counseling at clinics and surgical possibilities in communities like Bukavu and Goma where the women who are raped are taken. There needs to be what Eve Ensler, the Vagina Monologues who was magnificent on all of this whose writings have stirred even the Security Council of the United Nations. She has her organization called V-Day, the NGO, and they have build what are called cities of joy, which are really safe houses where the women who have been surgically repaired can recover in security. There are lots of ways you can do work on the ground, but the notable absence has been the United Nations; I mean it really is distressing that only now, and I will concede, that now the United Nations is beginning to get its act together. If they are honest, they will also can see that it's only now, but for the longest time the UN on the ground that could have done so much has done so little and that simply complements the passivity and indifference of the International Community.

DR. CATHLEEN MARGOLIN:

It's certain that man must step up to protect these most vulnerable woman, but what can you foresee as a way for women to become eventually empowered enough to have a voice that is heard regarding sexual violence and the protection of their own bodies.

DR. STEPHEN LEWIS:

Well, I think there are 3 ways really, number 1 is that the external community should find ways of empowering the women economically that’s desperately important, and people like Mohammed Younis, who advocate micro-credit are entirely on the right track of getting money into the hands of the women, small amounts of money, so that they can do small tasks, which whether it's a garden on the one hand or sewing and developing lines of clothes on the other and selling them at market and earning some income and having some independence, which they are now denied. I mean one of the problems of course are the transmission of the virus is that when you are sexually assaulted so much damage is done internally that it creates fissures through which the virus can be transmitted and all of these women are so much at risk even in domestic and marital relationships if they had some economic independence it would mean the world. Secondly, the United Nations is right at the moment considering the creation of an International Agency for Women, and if we can get that idea through, and I think it may happen before the end of this year then we will finally have an agency that represents 52% of the world’s population, which has organizational power on the ground to influence policy to provide protection, to ring the alarm bells, to support the activist women on the ground, and that’s the third way that in all of these areas even in the most beleaguered areas of sexual violence and it's by no means just Africa, it happened with the Khmer Rouge in Cambodia, look at the Balkanswhere people are serving time for war crimes, which were rooted in sexual violence. If you can give to the activist women on the ground even in the middle of the worst adversity, if you can give them support, they are the strength, the community activist mobilizing the women themselves to protect each other and to network with each other that’s a very powerful tool.

DR. CATHLEEN MARGOLIN:

I would like to dramatically change tracks to talk about a different public health behavior that could be quite helpful in decreasing infection and that's male circumcision. Can you tell us how important male circumcision is to the prevention of HIV and why?

DR. STEPHEN LEWIS:

I think it is tremendously important, it is ironically the most hopeful preventive technology that is emerged in the last couple of years. I mean I am one of those people, who feel that we can never stop looking for a vaccine or a microbicide, but we have had setbacks in the science on both of those recently, so they are still a number of years away, but male circumcision according to 3 studies done in Uganda, Kenya, and South Africa reduces infection for the men if they are circumcised by 60%, that is a phenomenal rate of reduction. Now, unfortunately, it doesn’t seem as though the same protection is given to the women and some women are very concerned that if the circumcised male who happens to be infected engages in sex too quickly after the surgery it may well increase the transmission or indeed even if the male is not infected it may increase transmission, but if you can give decent counseling to the men after they are circumcised and explain to them the need to stay away from unprotected sex completely if possible, be very, very careful in what they do in their sexual behavior then the study show that male circumcision is really terribly important, and a number of countries Kenya, Rwanda, Namibia, Swaziland in particular, they are all working to increase surgery for circumcision.

DR. CATHLEEN MARGOLIN:

And what has been the attitude of the men in those parts of the world when they are presented with that information and the opportunity for circumcision?

DR. STEPHEN LEWIS:

They are lining up in Swaziland, they are lining up in Rwanda. The surgeons can’t keep up with the demand, and it would seem that when the men fully understand the procedure and the value of the procedure, they respond to it. There are some cultural groups of course, who are against circumcision and my feeling is you know if they are against it, they are against it and you don't waste your time with them, you attempt to communicate to the majority of men, who will be prepared to accept the procedure.

DR. CATHLEEN MARGOLIN:

And what are the actions that are being taken by the World Health Organization or perhaps Doctors Without Borders in supporting this movement?

DR. STEPHEN LEWIS:

The World Health Organization and UNAIDS, the organization that coordinates UN activity on AIDS, they have come out very, very strongly in support of male circumcision unequivocal and they are on the ground doing the best they can to make sure that the surgery is available.

DR. CATHLEEN MARGOLIN:

Why don’t we implement male circumcision as a prescribed intervention in other parts of the world?

DR. STEPHEN LEWIS:

Well, it's interesting, I guess there would be first of all if HIV and AIDS weren'tof high prevalence, were of very low prevalence, and confined to the high-risk groups, men having sex with men, sex workers themselves, that kind of think, then injecting drug users, etc., but there would be I think a reluctance in some countries to impose on a mandatory basis a medical procedure, human rights activist would see it I think as a violation of human rights, so it's unlikely to happen, but it is more and more likely to happen in the high-prevalence countries of Africa as they realize the benefits.

DR. CATHLEEN MARGOLIN:

Thank you for listening to the Clinician’s Roundtableon ReachMD, The Channel for Medical Professionals. I am Dr. Cathleen Margolin and my guest has been Stephen Lewis, Co-Director of AIDS Free World and former UN Special Envoy for HIV/AIDS in Africa.

Stephen Lewis thank you for this conversation.

DR. STEPHEN LEWIS:

It's been a pleasure.

Thank you for listening to our special series - Focus on Global Medicine. As we celebrate this annual holiday season, everyone at ReachMD wishes you and your family a Happy Holiday and a successful New Year.

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You are listening to Reach MD XM160, The Channel for Medical Professionals. I am Dr. Lisa Mazzullo, join me this week I will be speaking with Marilyn Keith, she is the key leader in implementing legal policies, strategy for reproductive health, and we will be discussing the challenges of that in this new election year.

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