CSIS Remarks

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					                                 Remarks for Panel
                                        on the
                 Acute Vulnerability of Women & Girls to HIV/AIDS

                                          at
            Destabilizing Consequences of the Global HIV/AIDS Pandemic

                               a conference hosted by
              The Center for Strategic and International Studies (CSIS)
                              Task Force on HIV/AIDS

                                           by
                                Geeta Rao Gupta, PhD
                 International Center for Research on Women (ICRW)
                                  Washington, D.C.

                                     February 26, 2003




I would like to thank CSIS for inviting me to speak on this panel and in particular I would
like to thank Janet Fleischman. It is honor to have the opportunity to address this
audience. Much of what I will say will complement what Kathleen and Paula said and
some of it will repeat what they said. But I believe it bears repetition because it is my
intent to ensure that you will not forget all that is said here this morning. Quite frankly, it
is my intent today to rob you of your sleep tonight. I want you to lie awake at night and
think about what you can do in your job to translate what you have heard today into
action.


I will focus my remarks on President Bush’s proposed five-year $15 billion Emergency
Plan for AIDS Relief. This Plan could represent a historic turning point in the U.S.
response to this epidemic if it draws from the lessons of the past. It could represent a
historic turning point in the U.S. response to AIDS if it prioritizes public health and
scientific imperatives over political pressures and the dictates that emerge from the
misguided morality of a few. It offers an opportunity – an unprecedented one – for this
Administration and Congress to show its true commitment to combating HIV/AIDS, not
just through increased resources but also by setting priorities for the allocation of those



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resources for the kinds of prevention, treatment, care and support programs that we know
through experience and evidence work. It is critical that this new plan steer clear of the
temptation to gain political favor or press forward with an ideological agenda. We have
been in this epidemic for two decades and during that time we have learned a lot on how
to contain this epidemic. But we also have a growing numbers of sick and infected
persons. There is neither time nor any excuse for a mis-step, and following ideological or
political priorities rather than science at this stage in the epidemic would definitely be a
mis-step. It would be fatal – it will cost us lives, and in the countries that are hardest hit
in Africa or in countries that sit on the cusp of a raging epidemic like India, those that die
because of such mistaken priorities can number in the tens of millions: a haunting reality
that should serve as an effective antidote to any ideological or political posturing!


The most important lesson from the past is the one that is the focus of this panel – women
and girls, both here and abroad, bear a disproportionate burden of this epidemic and need
our attention and resources. Addressing their needs and constraints, and recognizing the
care and support they provide for those who are sick, dying or orphaned, is key to
containing the spread of this disease. I want to outline seven actions that we must
prioritize in order to empower women in this epidemic – seven actions that we at ICRW
have already communicated to President Bush as critical if he wants to unlock the
solutions to this epidemic:


First, increase women’s access to economic assets such as land and property – assets that
are marketable and can serve as collateral – assets that can provide women with a source
of livelihood and shelter – assets that can protect women affected by this epidemic and
their families from extreme poverty and destitution. Assets are an important way to
assure economic security for women and can protect them from the necessity of
exchanging sex for income, food or shelter. Ownership and control over property
signifies command over productive resources which enables women to make choices
regarding livelihoods, provides security against poverty, and promotes autonomy.




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There are many countries in which women still do not have the right to own or inherit
land and property – and even where such laws exist most land and property is owned by
men because of the poor enforcement of the laws. We need to push for the land reforms
that incorporate specific provisions that give women equal land rights, protect their
interests, and prevent their exclusion from access to and use of land – land reforms such
as these are HIV/AIDS interventions and we must remember that.


Second, we must do all that we can to promote zero tolerance for violence against
women. The link between violence against women (domestic violence, rape, sexual
abuse) and HIV infection is increasingly evident – it contributes to the spread of HIV
both directly and indirectly. As has already been said, we need judicial and legislative
reform to ensure that women are protected and that perpetrators are penalized. But more
importantly we need to put in place the systems and institutions that can enforce the
legislation. We need training programs for judicial and law enforcement personnel to
change the traditional attitudes that often stand in the way of proper enforcement. And we
need an appropriate mix of legal, psychological, social, medical, and educational support
services for women who experience violence. We also know that improving women’s
educational and economic opportunities acts as a protective factor. But most importantly
we need to bring about a change in the threshold of acceptability of violence against
women – much like we did to reduce the acceptability of smoking – for that we need
leadership at the highest levels and a massive public education and media campaign
targeted to communities and governments and supported by mechanisms of
accountability.


Third, we must focus priority attention on the needs of preadolescents and adolescents
within this epidemic. They have the fastest rate of new HIV infections and in the fourteen
countries included in the Presidents Emergency Plan there are more than 6 million young
people between 15-24 years of age who are living with HIV. More than two thirds of
those are women. We must provide all young people, infected and uninfected, with full
and complete prevention education. Warning preadolescents and adolescents about the
risk of early and unsafe sexual behavior and promoting abstinence are the right things to



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do but must be accompanied by full information on how they can protect themselves once
they are sexually active. We know the value of information and we know that
information on sexuality does not cause promiscuity. We also know that there are
millions of adolescent girls globally who are at risk of infection within marriage –
abstinence is clearly irrelevant for them – and keeping them ignorant of the value of
using condoms or other forms of safer sex is lethal. We know that condoms are not
perfect – there are sometimes errors in their use and they offer slightly less than 100
percent protection even when correctly used. Condoms sometimes fail but let us not
forget, so does abstinence! More importantly though, condoms are the most effective
prevention tool we currently have and we have evidence to show that they successfully
avert infections. Any information that contravenes this truth is unscientific and must not
be tolerated – it is unethical and costs lives.


Fourth, we must accelerate and intensify the development and distribution of women-
controlled prevention options. Current techniques to prevent HIV infection are often not
feasible or available for women because condoms are essentially a male-controlled
technology. Ensuring greater accessibility of the female condom (by reducing its cost and
increasing its availability) and an acceleration in the development of microbicides would
greatly help to achieve the prevention goals described in the Emergency Plan for AIDS
Relief. Microbicides are a class of substances under development that women can apply
topically to prevent HIV and other sexually transmitted infections. More than 60 potential
microbicides are currently in the pipeline and many researchers believe that with
increased funding and coordination, a microbicide could be available to women in five to
seven years. The NIH, principally through the National Institute of Allergy and Infectious
Diseases, spends the majority of federal dollars in this area. What is desperately needed is
for Dr. Tony Fauci, as the head of NIAID, to establish a microbicides branch dedicated to
research and development and to provide this branch of NIAID with the appropriate staff
and funding. It would also be useful for leaders on the Hill to enquire at the NIH’s Office
of AIDS Research as to when the federal plan on microbicides research will be made
available to Congress and the public. Microbicides could change the course of the




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epidemic once available – all it needs now is strong leadership to ensure that resources
are devoted to the necessary R&D.


Fifth, we must support the needs of women caregivers – those in hospitals and clinics and
those in households, with particular attention to nurses (who are mostly women), who are
rapidly burning out with the death and infection around them, and to older women and
adolescents heads of households. They provide the care and support to those who are
sick, dying or orphaned, with little, if any, support, information, or resources while
governments watch and wax eloquent about the wonders of caring, loving nursing and
home based care. This has implications for the health and well being of those women and
their families but as the famine in Southern Africa has shown us, it also has consequences
for household well being and food security. Burdened with the responsibility of caring for
the sick and dying, or raising multiple orphans, women are unable to adapt as they once
did to conditions of drought or to put in the extra effort needed to coax from the land food
for their families. Helping them requires programs that provide access to information,
services, and support, but also access to economic resources such as credit and
agricultural technologies and know-how to grow food crops that have shorter cropping
cycles, that generate a higher yield, are more nutritious and less labor intensive. These
types of agricultural inputs are now AIDS care and support interventions and must be
funded as such.


Sixth, we must find ways to reduce HIV/AIDS related stigma and discrimination. One
definitive way to diminish the stigmatizing association of AIDS with death is to assure
that treatment, of all types, is available for all. I am pleased to hear that some part of the
President’s fund will be used for this purpose. We have waited too long for this to happen
and it has cost us far too many lives. Another way to reduce stigma is through leadership
at every level that models non-stigmatizing behavior and calls on others to follow. One
example of stigmatizing language in current US policy discussions that affects our
responses is the reference to orphans and HIV infected children as innocent victims. Such
language stigmatizes all those who live with HIV by differentiating some from the others.
One of the lessons the past has taught us is that the costs of punishing those who we



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believe from our superior moral stance have transgressed, are borne ultimately by all –
not just by those who we stigmatize – because stigma fuels this epidemic, it ensures the
spread of infection as those who are stigmatized go underground – stigma sets this
epidemic on fire and ensures its continued spread. It would be useful to remember this
before questioning the use of federal funds to provide stigma-free HIV prevention and
care services to sex workers internationally, as certain members in Congress have chosen
to do.


And finally, we must increase women’s access to services by encouraging rather than
undermining the integration of reproductive health, family planning, and HIV/AIDS
services. Women and men seeking family planning and reproductive health services are
those most in need of accurate, lifesaving information on HIV and AIDS, along with
condoms and treatment for sexually transmitted diseases. The application of the global
gag rule to HIV/AIDS funds will force a separation of services -- that is shortsighted and
very expensive both in terms of lives and money.


In conclusion, let me say that even as I make these recommendations I know that they are
completely inadequate for those countries that are the hardest hit by the epidemic, where,
as you heard from Stephen Lewis at your last meeting, we are now beginning to hear
reports of an epidemic of sexual violence against younger and younger children and rates
of infection that the mind simply cannot comprehend. My friend Quarraisha Abdool
Karim, a well known epidemiologist from South Africa, who is visiting DC briefly,
talked to me yesterday about family planning clinics in a rural community in Kwazulu
Natal, filled with girls between the ages of 12 to 16, there to get contraception not
because they have boyfriends but because they are likely to be raped and want to avoid
the unwanted pregnancy. She told me of a survey that she had conducted in prenatal
clinics in the same district through which she found that 39% of the prenatal clinic
attendees were younger than 19 years, with the youngest being 12 years of age, the
majority with unwanted pregnancies, and with an alarmingly high HIV prevalence rate of
25.8%. She told me about her attempts to get information on the nature of the sexual
abuse girls experience but finding that the girls were too young to know the names of



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different parts of their body and so could not report for police action where and how they
had been abused. She told me about watching horror struck as girl after girl pointed out to
every orifice in the body in the diagram that she had drawn on paper to help them report
the nature of the sexual abuse. And she told me about a recent national seroprevalence
study in South Africa done by the South African Human Sciences Research Council and
supported by the Mandela Foundation which found a national HIV prevalence rate of 5.6
percent among children aged 2-14 years, an age group we rarely talk about in the context
of AIDS and about her desperate search for humane and safe abortion services for
pregnant children. I listened with blinding frustration that we sit here in DC attending
meetings spending endless talking about the values of abstinence and the need to restrict
AIDS funding by applying the global gag rule when communities are falling apart and
children are screaming silently. In South Africa, like in many other southern African
countries, the epidemic has torn apart the social fabric of family and community life and
has left scores of young girls and boys exposed without adult protection, unsafe in places
that were traditionally safe havens – home, schools, and communities. These
communities need help and resources – not resources tied up with a hundred caveats:
such as, “only through faith based groups” or only to those who do this or don’t do that –
but resources that can be disbursed quickly and in small amounts to community based
groups or dedicated bands of experts who are dealing with a nightmare. There are many
groups already doing good work – they would benefit greatly from a small injection of
resources. We need to set in place the systems to make that happen. This is my plea. It
can be done but it requires courage, leadership and a commitment to contain this
epidemic without caving in to political or ideological pressures. This is my plea. I say to
all of you who currently work on the Hill, in the White House, in USAID, in the State
Department, in HHS, NIH, CDC and so on, you have worked so hard for the last two
decades on this epidemic – we applaud you – but we need you more now than ever
before. I say to you, all I have is the podium but you have the power of your position.
President Bush’s Emergency Plan for AIDS Relief provides an opportunity – take that
opportunity boldly and do the right thing, without any caveats, ifs, or buts. Thank you.




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