Health-E News: No more victim blaming – preventing HIV in young women

Roughly 40km outside Durban lies the small town of Molweni. This is where Nontokozo Zakwe, now 26, grew up.

“One of the things I noticed growing up was that gender-based violence was the norm,” she says.

“And the mentality was: if it happens to you, get over it. If it didn’t kill you, you’re going to be okay.”

The first time “it” happened to Zakwe, she was just 11 years old.

“We had two options on our walk back home from school: the road, or the short cut past the river,” she says. Most days she took the road; but one day, after staying late, she took the short cut.

“Then this man, he raped me.”

Zakwe survived the attack and made her way home to her cousins and siblings. Her mother worked in another province, she didn’t know her father at that point, and her grandmother could only afford to come home one weekend a month from her job as a domestic worker on the other side of the country.

“But being from the kind of community I was from, when I got home I decided to sleep. I cried myself to sleep,” she remembers.

A visiting aunt woke Zakwe up that evening, pulled back the covers, noticed blood, and asked the young girl what had happened.

“When I told her, I could tell in her eyes she was sorry for me and wished it hadn’t happened. But there was nothing she could do except tell me I was going to be okay,” Zakwe says.

Not even a teenager yet, Zakwe was expected to overcome the trauma of that violent experience without any support – psycho-social, financial or otherwise – and remain HIV negative.

2,000 infections a week

It is against this backdrop of the lived experiences of many young women in South Africa that a staggering 2,000 new HIV infections occur in young women and girls every week. Over 70% of new HIV infections in people aged 12 to 24 in sub-Saharan Africa occur in young women and girls, who overwhelmingly bear the burden of the epidemic, according to research done by Professor Ayesha Kharsany from the Centre for the AIDS Programme of Research in South Africa.

In South Africa, one third of young women and girls experience abuse, 60% of young people don’t have matric, and about 70,000 babies annually are born to girls under the age of 18, according to the South African National Department of Health (DoH).

It is being increasingly acknowledged that the contexts in which young women and girls live, often patriarchal and violent in nature, need to be addressed in order to reduce new infections, and ultimately end Aids as a public health threat to the world.

Treatment and prevention campaigns alone, located in the health department, cannot address all the systemic drivers that make young women and girls more vulnerable to HIV than their male counterparts: poverty and gender inequality, as well as biological factors. These affect every facet of a girl’s life: her ability to stay in school, choose when to have children, her economic opportunities, and the gendered and sexual violence experienced by women that is endemic in South Africa.

It is in this context that a number of initiatives, backed by billions in international aid, have been launched in South Africa. They aim to address the contexts in which young women and girls live in order to help them reach their full potential, including changing long-held perceptions in communities that leave them unsafe from violence and HIV.

Two years ago Zakwe joined the DREAMS partnership as an ambassador and finally began to receive the psycho-social support she needed 15 years back. DREAMS is a global partnership aimed at improving the lives of young women and girls in 10 African countries – with the ultimate aim of reducing the rate of new HIV infections in this group.

Another HIV prevention campaign for young women and girls is She Conquers, led by the DoH, launched by then-Deputy President Cyril Ramaphosa, and most famous for the controversy over a number of billboards commissioned under its name in Gauteng.

A grave historical injustice

In his response to the State of the Nation (SONA) debate in February, Ramaphosa, the newly elected president, said:

“Another grave historical injustice that we need to correct is the economic inequality between men and women. It is a task that requires both a deliberate bias in economic policy towards the advancement of women and a fundamental shift in almost every aspect of social life.

“It recognises how patriarchal attitudes, poverty, social pressures, unemployment and lack of adequate health and other services conspire to reduce the prospects of young women – and then involves these women in overcoming these challenges.

“This is one of the ways we are working to build a nation that is prepared to confront the many different ways in which women are subjugated, marginalised and overlooked – a nation that wages a daily struggle against patriarchy, discrimination and intolerance.”

While Ramaphosa’s words are comforting, one is left to wonder why so little is known about this important initiative, and how it is working to tackle the multitude of obstacles mentioned.

What is DREAMS?

What are She Conquers and DREAMS exactly? What is happening on the ground to improve the lives of South African girls and young women? Are they reaching their intended audience and achieving their aims? And how can systems of power such as patriarchy, entrenched in society for centuries, be tackled by health-led programmes?

DREAMS is a global partnership, announced in December 2014, between the United States President’s Emergency Plan for AIDS Relief (PEPFAR), the Bill & Melinda Gates Foundation, Girl Effect, Johnson & Johnson, Gilead Sciences and ViiV Healthcare, aimed at reducing new HIV infections in girls and adolescent women by 40% by 2017. But the South African arm of the project started late, and the target has been shifted to 2019.

PEPFAR’s Caroline Schneider said the “ultimate goal is to help girls develop into Determined, Resilient, Empowered, AIDS-free, Mentored and Safe women” – the tenets the DREAMS name stands for.

Backed by $385-million [about R4.5-billion], the “ambitious” initiative aims to go “beyond the health sector” to address the social factors that drive young women and girls’ particular vulnerability to HIV, including GBV, poverty, school dropout, and gender inequality.

It was launched in 10 sub-Saharan African countries, with South Africa being allocated $66-million [about R770-million], when it began operating locally in 2016.

“DREAMS uses multiple evidence-based interventions, including post-violence care, parenting/caregiver programmes, and facilitating access to already available cash transfers and education subsidies,” explained Schneider.

It operates in five districts: eThekwini, uMgungundlovu and uMkhanyakude in KwaZulu-Natal, and Johannesburg and Ekurhuleni in Gauteng, and is facilitated through 20 implementing partners.

What is She Conquers?

Also launched in 2016, She Conquers is a government campaign “aimed to reach adolescent girls and young women aged 15-24 in South Africa who have high rates of HIV, as well as teen pregnancies”.

The DoH’s Dr Yogan Pillay said that more than R3-billion has been invested in the programme by three major donors: PEPFAR, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the German Development Bank (KFW).

He added that the campaign is being rolled out in three phases, the first being implemented in the 22 districts with the highest HIV burden. Based on what is learned, the interventions will be rolled out nationally.

The five targets to be achieved in three years are ambitious:

1. 
   

   Decrease new HIV infections in this group by at least 30%, from 90,000 per year to fewer than 60,000 per year;

   
   


2. 
   

   Decrease teen pregnancies, in particular under-18 deliveries, by at least 30%, from 73,000 to 50,000;

   
   


3. 
   

   Increase retention of this group in schools by 20%;

   
   


4. 
   

   Decrease sexual violence and GBV in this group by 10%;

   
   


5. 
   

   Increase economic opportunities for young people, particularly young women, by increasing youth employment by 10%.

   
   

It is unclear whether progress against these targets will be measured and reported in a way that allows the public and independent experts to hold these programmes accountable in a meaningful way.

There is also much confusion in the public domain as to what the campaign is, whether it is a communication and awareness initiative, or if it involves practical interventions. The confusion extends to how these initiatives are linked.

Health minister Dr Aaron Motsoaledi said:

“She Conquers became the South African expression of how to implement DREAMS”.

Schneider said the $66-million South African DREAMS funding allocation falls under the She Conquers umbrella, but that the money is not funding the local campaign directly.

“DREAMS is contributing to achieving the objectives of She Conquers. The US PEPFAR programs in the DREAMS focus districts are in line with the She Conquers strategy, and support She Conquers initiatives in those districts. We can’t speak to the overall She Conquers budget, as this is a Government of South Africa initiative,” she said.

Billboard controversy

She Conquers has been most visible in its communication campaign – particularly in the controversy surrounding two of the billboards it commissioned.

Social media erupted in September 2017 when a billboard next to the N1 in Johannesburg was erected with the tagline: “Who says girls don’t want to be on top?” In smaller letters underneath it reads: “Complete your matric, study hard and graduate!”

While the DoH rejected claims that the message contained sexual innuendo and therefore failed to address the context of violence and lack of support in which girls are expected to “study hard and graduate”, many on social media felt the message to be insulting.

Sexual and Reproductive Justice Coalition founder Marion Stevens said this kind of messaging fails to address the circumstances in which young women remain vulnerable and makes no mention of the challenges affecting their ability to stay in school or protect themselves from HIV. It also perpetuates the status quo: expecting girls themselves to rise above their trying circumstances, be resilient, and somehow succeed.

“With the black girl emoji attached to it and the sexual innuendo, it reinforces the harmful tropes of black women as hypersexualised, and places the burden on young black women to overcome obstacles that are out of their control. How can a young woman stay in school when she has to choose between buying food or paying school fees? Girls drop out because of a range of factors, such as food, security and transport,” she said.

Nicknaming the campaign #HeDecides, Stevens questioned who is actually responsible for constructing the She Conquers messaging, because the voices of young women themselves have been left out.

Long-standing HIV activist Yvette Raphael was involved in the initial conceptualisation of the She Conquers campaign, and said that the initial “consultations went well”.

“It looked like it was going to be an overarching campaign that would support very successful campaigns on the ground already working with women. But that is not the reality now. I don’t even know what to make of it – it’s very confusing,” she said.

Young women left out?

While the campaign was initially conceived as being youth-led, Raphael said that young women have been left out of campaign decisions on more than one occasion.

“I don’t think enough engaging of the target audience is happening and that’s why we are getting messages that are insulting to young women. Girls want to be on top – which young person would say that, outside of a relationship? Which young person can own that tagline?”

Raphael said that young women were asked to vote on a campaign name, but that name was never used; instead, “She Conquers” was chosen, without an explanation as to why the name chosen by the young women was ignored.

Motsoaledi said a young woman from Limpopo was responsible for the She Conquers name, and suggested it to the DoH through social media.

Raphael said the problem is that “old people are thinking they can think like young women”.

“She Conquers can only serve its purpose if it’s led by young people, and comes from them.”

She Conquers has set up a youth advisory committee located within the South African National AIDS Council (SANAC), consisting of nine young woman representatives who were elected at a She Conquers boot camp.

But members of this committee said they had little decision-making power.

The executive secretary for the committee, 23-year-old Koketso Rathumbu, said:

“The DoH is the one who facilitates and decides on the communication plan; and unfortunately, this was not shared with us, and there are no clear reasons as to why.”

While Rathumbu had positive things to say about the campaign – for example, that it is reaching some young women with beneficial interventions – she said that it is failing in other areas.

“We are advocating for the visibility of the campaign, over and above the media campaigns and billboards. We are fighting for more engagement and inclusivity at grassroots level, but it has been a challenge. Many people in rural areas, for example, are not being reached.”

She also said that if every stakeholder, including various government departments, were “synchronised”, then “She Conquers would be a success”.

“The biggest challenge we’ve had is getting different departments to play a role, not just Health – for example, the Department of Basic Education – to go into schools with the She Conquers plan. What we need and don’t have is a synchronised system that integrates all stakeholders.”

This could be why She Conquers is so confusing to the public, and even to the people involved in it. Conceived and led by the DoH, so far it has failed to integrate all sectors adequately.

To truly help young women and girls in South Africa, programmes will need to put them at the epicentre of decision-making. “She” can only “conquer” when “she” is actively engaged and listened to.

In this context, it is important to remember Ramaphosa’s final words on the epidemic of GBV in South Africa during his SONA response: