Thuthukile Mbatha, Guest Editor, Spotlight
Note: This is the editorial from a special print edition of Spotlight guest-edited by young people.
Every week in South Africa, around two thousand young women and girls
between the ages of 15 and 24 become HIV positive. More than one in ten women and girls in this age group are living with HIV.
On the back of these shocking statistics, many targeted programmes have
been launched in South Africa. Whether these programmes are what is needed, and whether the state is fulfilling its duties to young women and girls, are key questions we discuss in this youth-focused and youth-edited issue of Spotlight.
On paper, the rights of women and girls in South Africa – or that subset of rights we call sexual and reproductive health and rights (SRHR) – are relatively well protected. The Constitution enshrines the right to bodily integrity, the right to access healthcare services, the right to education, the right to dignity, and the right not to be discriminated against.
Specific laws such as the Sexual Offences Act and the Choice on Termination of Pregnancy Act provide specific protections and affirm specific rights. Policies such as the Department of Basic Education National Policy on HIV, STIs and TB, and strategies such as the National Strategic Plan on HIV, TB and STIs 2017-2022 further guide the implementation of state programmes aimed at the realisation of these rights.
And yet, despite this generally enabling legal framework, the reality in South Africa is that most young women – and young men, for that matter – grow up poor, and with limited education. Only around 40% of young people matriculate by age 20. Around two thirds of youth 25 and younger are unemployed (under the expanded definition that includes people who have stopped looking for work).
Most girls grow up in highly patriarchal communities, often communities with high rates of gender-based violence. The criminal justice system is often unresponsive and downright dysfunctional when it comes to prosecuting gender-based violence.
Doctors without Borders (MSF) estimates that one in four women in the Rustenburg area has been raped at least once in their lives, and that the vast majority of them did not tell a healthcare worker about the rape. Reliable national figures are hard to find, but it seems many rapes are not reported; and even when they are, dockets often go missing, or police bungle the investigation.
The 2014 Khayelitsha Commission of Inquiry, led by Advocate Vusi Pikoli and Judge Kate O’Regan, grew out of frustration with exactly this kind of dysfunction. Despite the excellent work of the commission and its impressive report, four years later the criminal justice system remains severely dysfunctional in areas where mainly poor people live.
It is within this dire socio-economic context that we should consider that many women and girls struggle to access the tools that may protect them against unwanted pregnancy and HIV infection. Making condoms and other contraceptives easily available to learners remains taboo in many schools.
Youth-friendly healthcare services remain the exception to the rule. While we know that young women at high risk of becoming HIV positive can benefit from oral pre-exposure prophylaxis (PrEP), the rollout of PrEP to young women has been stalled by a lack of political will, and an overly cautious public-health approach that pays scant regard to the rights of young women.
It is not surprising that in such socio-economic conditions, and with such
limited access to available prevention methods, as many as six per cent of girls aged 15 to 19 fall pregnant every year – according to one report, that amounted to around 15 000 pregnancies among girls in school in 2015. The two thousand new HIV infections in girls aged 15 to 24 every week are also not all that surprising, given the context sketched above.
Though the personal cost to young women is clearly very high, there is surely also a high societal cost. While most women living with HIV can live perfectly normal lives thanks to antiretroviral therapy, the infection does still require lifelong treatment and care – which come at significant cost, either to the state or to individuals. The minority of women who develop serious secondary infections such as tuberculosis or crypto will face additional costs. Possibly even more disruptive to a young woman’s prospects is an unwanted pregnancy – something that could mean an end to one’s formal education, or which could make it harder to hold down a job.
Together, unwanted pregnancies and HIV infection constitute a kind of poverty trap: poor people are more likely to experience unwanted pregnancies and to contract HIV, and this then makes them and their children more likely to be poor in future. The struggle for SRHR is not a struggle for some abstract ideal, but a struggle to help women break out of this cycle of poverty and disease.
Faced with such a complex set of socio-economic factors, one should be sceptical of supposed quick fixes for the dual problems of HIV and unwanted pregnancy. For example, while anti-sugar daddy campaigns might provide convenient scapegoats, there are real questions as to whether such campaigns will make any difference without addressing the underlying social and economic realities.
Fortunately, however, we do have programmes that are approaching these complex issues with seriousness, and a more sophisticated understanding of the complexities involved. Perhaps foremost among youth-focused interventions is the innovative work done by the Desmond Tutu Foundation in and around Cape Town – see our article on page 35 about their youth-friendly clinics, the Tutu truck, and their trial of conditional cash transfers.
Confirming what works in programmes such as that of the Desmond Tutu Foundation and then scaling that up, as well as addressing the ongoing crisis of South Africa’s dysfunctional education system, must be a national priority in the coming years. In his response to replies to the State of the Nation Address in February, new South African President Cyril Ramaphosa said that “we must confront the social and economic factors that prevent young women from completing school, entering higher education and graduating”, and that “we must all work together to tackle the chauvinism experienced by women in the workplace and other social settings”.
The president identified the She Conquers campaign as government’s key programme in this regard (see our article on DREAMS and She Conquers on page 22). While such big programmes are welcome, as are the donor dollars that often fund them, there are questions to be asked as to whether these programmes really meet the needs of young women.
But along with these longer-term and overarching solutions, there are things that can be done right now – such as ensuring that condoms are freely available at all schools, and dramatically expanding access to PrEP. Whether these interventions will be implemented is mainly a question of political will. And whether the political will is there to follow through on President Ramaphosa’s welcome words on the role of women in our society remains an open question.
Ultimately, we can measure the state and President Ramaphosa’s response to the dual crises of HIV and unwanted pregnancy by the answers to a few simple questions:
- Do all young women and girls in South Africa have easy access to comprehensive sex education?
- Do all young women and girls in South Africa have easy access to condoms and other forms of contraception?
- Do all young women and girls in South Africa have easy access to professional termination of pregnancy services?
- Do all young women and girls in South Africa at significant risk of contracting HIV have easy access to pre-exposure prophylaxis (PrEP)?
- Do all young women and girls in South Africa have access to high-quality secondary and tertiary education?
- Do all young women and girls in South Africa have safe and easy access to appropriate police and medical services in cases of rape or other forms of sexual violence?
At present, the state is failing abysmally at most of these measures. Look at the lives of young women in Khayelitsha, in Rustenburg, in Lusikisiki, in Ermelo. It is there in our dilapidated schools and in our dangerous and poorly-lit streets, for all to see.
While this remains the case, all the positive rhetoric and advertising campaigns about empowering young women will ring hollow. The large-scale infringement of the sexual and reproductive rights of young women and girls in South Africa will continue; and the poverty trap fuelled by HIV and unwanted pregnancy will ride roughshod over our futures.
Thuthukile Mbatha has been a researcher at SECTION27 since 8 January 2014.