In a busy Mozambique clinic, a 25-year-old mother says she won’t tell her estranged husband she has HIV for fear she will be blamed and beaten.
“Very often here women won’t tell their partners or ex-partners that they’re HIV-infected,” said Sifronia Filipe, an educator at the clinic where the mom is being treated for AIDS. “She is scared he will leave her or will tell the neighborhood and the neighbors will discriminate against her.”
It’s a scene oft repeated across sub-Saharan Africa, where young women account for a quarter of new HIV infections and where AIDS remains a devastating scourge. The problem is especially acute in southern nations like Mozambique, where 7 percent of all teenage girls are HIV positive. That number doubles to 15 percent by age 25, according to a report by the Joint United Nations Program on HIV/AIDS released last week.
Protecting young mothers will be critical if the world is to meet a UN target of eliminating new HIV infections among children by 2015. At an international AIDS meeting that started in Melbourne yesterday, public figures from Burmese political activist Aung San Suu Kyi to Virgin Group founder Richard Branson will lead a call to fight stigma and discrimination, which has blighted progress in poorer nations.
“Some people, if they find out they’re HIV-positive, they will change hospitals or scratch out their test result on their medical records,” said Aleny Couto, head of the HIV program with the Mozambique government’s Ministry of Health. “We still have stigma in this country, which is still a very big obstacle.”
It’s been three decades since AIDS began ravaging populations around the globe. While new infections have fallen to the lowest level this century and AIDS-related deaths are at a seven-year low, a “youth bulge” experienced by many countries with the highest HIV prevalence means that the number of young people living with HIV or at risk of becoming infected will increase in the next five years, the New York-based Population Council said last week.
More than two out of three of the 35 million people living with HIV are in sub-Saharan Africa, according to the report by UNAIDS. The 86-page document lists human rights violations, stigma and discrimination as the No. 1 reasons why people with HIV are being left behind.
A so-called Melbourne Declaration prepared for this week’s meeting affirms that stigma and discrimination “have no place in any effective response to HIV,” said Francoise Barre-Sinoussi, the conference’s co-chair, who was awarded a Nobel prize in 2008 for discovering HIV.
As the meeting opened yesterday, Barre-Sinoussi invited dozens of representatives of HIV research and advocacy groups to the stage as she paid her respects to the passengers and crew who died on board flight MH17 from Amsterdam to Kuala Lumpur. Former International AIDS Society President Joep Lange and his partner, Jacqueline van Tongeren, were among the dead.
As long as HIV stigma exists, people are likely to hide or ignore their status, creating a barrier to treatment that puts their health and the health of their partners and children at risk.
“In sub-Saharan Africa, adolescent girls and young women are up to five times more likely to get HIV as young men, and HIV is the biggest killer among women of reproductive age in low- and middle-income countries,” said Michael Kirby, an HIV campaigner and Australia’s longest-serving judge, who also spoke at the opening ceremony.
“Gender-based violence, lack of legal protection and inequality fuel the spread among this highly vulnerable group, and stigma and discrimination are root causes of the inequality,” Kirby said in an e-mail.
In Mozambique, a former Portuguese colony that was in the grip of civil war from 1977 to 1992, the number of people living with HIV has swelled to 1.6 million, with an average of 317 new infections occurring daily. Teenage girls, among whom 21 percent are sexually active, are especially vulnerable, according to the UNAIDS report.
An “unacceptably high” prevalence of HIV women from age 15 to 24 is seen in almost every country in eastern and southern Africa, UNAIDS said in the document, calling the data “stark and worrisome.”
Migrant laborers working in South African mines and their partners are among those at greatest risk of HIV. A job in the mines means living away for months in an area with an active sex industry, a 2012 study by the World Bank of mines, migration and HIV/AIDS in Southern Africa found.
South African Mines
A survey of more than 700 Mozambican miners working in neighboring South Africa found 75 percent who tested positive for HIV didn’t know their status. In the absence of routine sexual health screening, infections are often noted first in pregnant women attending antenatal clinics.
Whether it’s the male or the female who introduces HIV into a relationship, broaching the topic and treating the infection is often difficult, says José Enrique Zelaya Bonilla, director of UNAIDS in Mozambique.
“We have seen that if the man knows that he is HIV-positive only after the woman is known to be infected, she is deemed responsible,” Bonilla said. “That has other effects. For example, when the man dies, his family will take all the belongings from her.”
Burn the House
People might also burn the house so that the widow doesn’t get his property, according to Bonilla.
In South Africa, the country with the most people living with the virus, women sometimes spurn lifesaving antiretroviral therapy to hide their HIV infection from partners, said Elsie Mbedzi, a social worker with Witkoppen Health & Welfare Centre, which fields about 100,000 visits from low-income patients a year on the outskirts of Johannesburg.
That fear can be a barrier to virus-suppressing treatment, which itself helps halt the spread of HIV. For every 10 percent increase in treatment coverage, there’s a 1 percent decline in the percentage of new infections among people living with HIV, according to the UNAIDS report.
Pregnant women have been the sentinels since 1998, when the drug nevirapine became available to prevent transmission of HIV from mother to baby, said Deborah Birx, U.S. ambassador at large and coordinator of U.S. government activities to combat HIV. In high-burden countries, removing the foreskins of men to cut infection risk has widened the pool of people tested.
Women “have always come forward more readily,” skewing HIV prevalence data, Birx said in an interview at the Melbourne meeting. “The good thing about voluntary medical male circumcision is that it’s finally getting men in and tested.”
Worldwide, 22 million people still don’t have access to HIV treatment, UNAIDS Executive Director Michel Sidibe told the meeting yesterday.
“If we accelerate a scale-up of all HIV services by 2020, we will be on track to end the epidemic by 2030,” Sidibe said. “If not, we risk significantly increasing the time it would take, adding a decade, if not more.”
Transmission from mother to newborn can also be avoided with antiretroviral therapy, though two in five pregnant women with HIV in sub-Saharan Africa don’t take preventive steps, according to a study published in March.
“If a woman knows she was infected when she’s pregnant, she initiates treatment, but it is difficult for her to let her husband know that he might be infected and would also need treatment,” UNAIDS’s Bonilla said. There is also a risk that a mother will stop taking her medication and won’t have her baby tested, “so the health service has lost contact with this possible HIV-infected newborn.”
The Mozambican mom who learned she had AIDS in February says she tested negative for HIV when she was pregnant with her 4-year-old son.
Such a rapid progression would be unusual, said Filipe, the educator at the Maputo clinic that’s also treating her for tuberculosis. It’s possible the woman misunderstood her HIV diagnosis, didn’t receive it, or was in denial, Filipe said.
AIDS killed about 82,000 people in Mozambique last year, 13 percent more than in 2005. That made the nation of 25.8 million people one of only three countries in sub-Saharan Africa to register an increase in AIDS-related mortality over that period, according to UNAIDS.
Former NBA veteran Earvin “Magic” Johnson, 54, helped erode stigma in the U.S. when he publicly disclosed his HIV-positive status more than two decades ago. In Mozambique, there is a dearth of positive role models, said the health ministry’s Couto. No political leaders or celebrities have talked publicly and openly about having the infection.
“In this country? Never,” she said in an interview at a clinic in Maputo. “Magic Johnson, he said he had HIV and the use of condoms in the U.S. went up. In Mozambique, we are still not having that kind of recognition.”
Antiretroviral medicines, which counter HIV’s hold on the immune system, are provided free thanks to international donors such as the U.S. President’s Emergency Plan for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis and Malaria. But if the rate of new infections continues, funding will be strained.
“It would be unsustainable,” said Benjamin Gobet, an adviser with UNAIDS in Maputo. “If some funding issues are not arranged for next year, there will be a shortage of antiretrovirals.”
Filipe, the HIV educator in Maputo, says she sees some signs of progress.
“There are many men who don’t know their status and go around infecting women, but luckily we have seen an evolution,” Filipe says. “More and more women are demanding to use a condom.”