By Michael Healy and Yanis Ben Amor
In Ruhiira, Uganda, one of 14 clusters of Millennium Villages across sub-Saharan Africa, combating HIV, including Mother to Child Transmission (MTCT), through sensitization campaigns, condoms, and antiretrovirals (ARVs) is only half the battle. Addressing the other half—a deeply ingrained culture of female disempowerment— is an unavoidable challenge, which is dangerously neglected. The victimization of females through cross-generational sex serves as a major vector for the spread of HIV. It is common and it is getting worse.
In September 2009, to strengthen HIV activities within the MVP sites, UNAIDS and MVP signed a memorandum of understanding to establish “MTCT-Free Zones”. In these designated zones, which include Ruhiira, coordinated application of rights-based and evidence-informed best-practice in PMTCT could be amplified by community engagement and support, to provide access to high quality services that meet WHO guidelines and to overcome social barriers to the uptake and continuation of PMTCT regimens. Mother-to-child transmission of HIV can be virtually eliminated through a four-prong strategy implemented simultaneously:
- Preventing women of child-bearing age from acquiring HIV infection;
- Preventing unintended pregnancies among women living with HIV;
- Preventing HIV transmission from women living with HIV to their children and
- Provision of care, treatment and support to mothers living with HIV, their children and their families.
In low resource settings, implementation of this comprehensive response faces a host of well-documented obstacles, including a lack of activities centered on prevention of new infections. In that context, our team focused on determining sexual practices among young adults age 18 to 24 in Ruhiira in order to establish appropriate prevention strategies. And our findings are worrisome.
We had the opportunity to meet Irene, a 21 year-old woman who lives 3km from the village trading-center. Sipping tea and seated in a room full of her peers, she shared her story:
I am now married to a 26-year-old shopkeeper and have three sons…but my first sexual experience came when I was twelve…It was with a very big man…He already had a wife and four children…Now, I knew it was wrong, but many of my friends were doing it too…We would meet at lodges in the trading-center at night. He would give me small gifts and sometimes money to buy things…I really thought he loved me. Until one day, I asked him if he could help me pay for school. He told me, “what do you need school for? I have a home and many goats. I can provide for you.” But when I asked him to marry me as his second-wife, he refused.
Irene later told us that at one point she had “four of these big men that she would see on different nights.” She was having sex in exchange for pocket money and school fees—money she couldn’t get from her parents. When asked if she would use condoms, she replied, “many girls won’t use condoms because they either don’t know how, they fear it will break off and lodge in their uterus, or they feel as if they have no right to challenge the man’s decision not to use one because he has paid or given her gifts.” Men told us they refuse because “these girls are young and healthy, and therefore safe.”
In Ruhiira, stories like Irene’s are all too common. Our surveys consistently report that today, seven to eight out of every ten girls around the ages of twelve or thirteen are having sex with older men, in exchange for gifts or money. When a focus group of adult men were asked about cross-generational sex, they unanimously agreed that “it is getting worse.”
One man elaborated on the cyclic nature of cross-generational sex by saying,
If you get AIDS you should not die alone…I am 24 and, now, if I marry a girl of 22 years it is likely that she will have had sex with twenty or thirty men by that time. I maybe will have slept with two or three. Now, there is a good chance she may be infected with HIV. There is also a good chance she will give it to me. But, what am I to do? These are the girls I will get married to… Though later I, too, will have the chance to get another younger girl on the side. If I give HIV to that one, it is fine because it wasn’t my fault I was infected. It is just how things work and now I at least won’t have to die alone.
In the village, most men and women agree that “80 percent of married men have extramarital sex.” Often, their wives are powerless to stop them. Attending a women’s financial cooperative during a market day one afternoon we met Hilda, a married, 30 year-old mother of one. Speaking in a low voice Hilda told us, “my husband is [HIV] positive. I am negative… Now, I know he has a few women on the side. Here, most men do… But what I need to know is if there is a pill I can take that will protect me from the infection, yet allow me to get pregnant. I only have one child.”
When we asked Hilda about her opinion of condoms, we were surprised that she thought they were a good thing. Our recent surveys of the Ruhiira cluster indicate that very few people are using condoms despite on-going campaigns to promote use. One woman told us, “If ten people in the entire village were using them it would be a lot.”
For Hilda, sensitization on condom-use was not her problem. She, like a good number of women in Ruhiira, knows the benefits of a condom. “I have attended a few health talks… The thing is, we can only suggest to our husbands to use condoms. It is up to them to decide…even if we know they are having sex on the side.” But, “most men don’t attend health talks. They often say they have another obligation or that such talks are for females, the care-takers of the house.”
Gender discrimination, and more specifically cross-generational sex, is a major player in the spread of HIV and it negatively impacts the lives of all members of the community. In particular, the practice victimizes young women directly. It damages their self-esteem and causes many girls to believe their only option for self-improvement necessitates early, often unprotected, sexual activity. From an early age, girls like Irene begin to believe that in order to obtain agency in their lives, they must find it through their relationships with men. With time, this ingrained way of thinking persists, leaving women like Hilda with little confidence in their ability to protect themselves during sexual intercourse.
Empowering young women to avoid the negative consequences of cross-generational sex must go beyond awareness. There must be an effort to eliminate the incentives for participating in the practice. This includes improving the limited financial empowerment of young women (in contrast to their male peers who often have support from the family to obtain “pocket money and school fees”), as well as raising low self-esteem, and building social support networks.
If the MVP is to achieve a sustainable HIV prevention program in Ruhiira, the needs of young women must be better addressed. Through our project, we had the opportunity to hold focus-group discussions with over 200 individuals in the village and hear the stories of men, women, and adolescents. Their knowledge and suggestions have led us to the idea of creating a new type of Adolescent Center. The new Center, which is geared toward addressing the roots of gender discrimination, will function as a youth-led system of business enterprise that subsidizes services such as education, mentorship, life-skills courses, healthcare, and recreation. Though still underway, the success of the project may be our best hope of breaking this vicious cycle of female victimization.
Michael Healy is a medical student, College of Physicians and Surgeons, Columbia University
Yanis Ben Amor is Director, HIV/ AIDS and Tuberculosis Initiative at the Millennium Villages Project