The cost of liberation

Ufrieda Ho, Spotlight

A moment of true liberation came for Thembi Mahlathi when she was standing at a supermarket check-out queue. In her shopping basket, for the first time, were sanitary pads that she could afford.

“I was so happy that I could finally afford sanitary pads – I think I bought four packs,” says the 28-year-old paralegal, remembering the day she was finally earning enough to pay for her own pads.

It was a moment of empowerment, says Mahlathi – the direct opposite to how she felt as a nine-year-old girl, when her cycle started. She remembers her confusion, and not knowing what was happening to her body. She didn’t tell her mother though; she couldn’t.

“I always heard my mother and her friends saying things like, ‘If a girl starts menstruating young, then she’s messing around with boys’; so I was too scared to tell my mom,” she says.

She sneaked the odd sanitary pad from her mother; but because pads were a luxury in the home, she knew her mom would notice eventually. Mahlathi resorted to cutting up a few old T-shirts, folding them into the shape of pads, and jamming them into her panties.

“I had one for the morning and one for the afternoon, and I carried a plastic bag with me so I could take the dirty one home to wash,” she says.

When Mahlathi was 13, her mother found out by chance that she was menstruating. Even then, Mahlathi never told her mom she had been menstruating for years already. Her mother gave her some pads, but there were never enough; and when her mom lost her job and they only had her father’s wages, pads became a luxury item again.

“We both had to use T-shirt pads then, or sometimes we used a stack of tissues. I don’t think my dad understood that pads were something we needed, and that sometimes I needed more than one pack a month, because I have a heavy flow.”

The T-shirt pads were a nightmare. She couldn’t concentrate in class, worrying about an accident that could soil her yellow uniform, and the humiliation and mocking that was in store for girls who did have accidents. The thought of perhaps being called up to write something on the blackboard while she was having her period was pure terror.

“I really wanted to play netball, but I couldn’t; because that pad would move around, and the players wore mini-skirts,” says Mahlathi, who went to a school in Tembisa, east of Johannesburg.

Fear of embarrassment, lack of information, having no one to turn to for answers about her changing body, and the grinding realisation that there was no money for basics in her home marked much of her growing-up years.

“Poverty – I don’t want to go back there,” she says.

Mahlathi says she’s now able to speak openly about menstruation and poverty because as a mom to two daughters, aged 11 and six, she wants better for them.

“I don’t want any girl to go through what I went through. And I want my 11-year-old to be prepared, and to know that what is happening to her body is normal,” she says.

Mahlathi believes schools need better education programmes to teach girls and boys about menstruation, and that myths and superstition must be dispelled. She says schools should also be making pads available to girls, so that girls don’t have to resort to making ineffective alternatives like her T-shirt pads, or feel embarrassed about not being are able to afford pads.

Nowadays, Mahlathi never forgets to pack a pad in her daughter’s schoolbag. She also never forgets that liberation, for a poor girl-child, can cost as little as R20 or R30 a month.

DREAMS and She Conquers

Amy Green, Health-e News

An estimated 2 000 new HIV infections occur in young women and girls every week in South Africa. Two high-profile programmes are aiming to address this crisis. In this joint Spotlight/Health-e News Service special investigation, we go beyond the bells and whistles and ask what difference these programmes are really making.

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

“One of the things I noticed growing up was that gender-based violence (GBV) 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 after school, she decided to use the short cut, because it was getting dark.

“Then this man, he raped me.”

Zakwe survived the attack and made her way home, where she lived with a number of 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, she told me everything was going to be okay. I could tell in her eyes she was sorry for me and wished it hadn’t happened, but that she felt there was nothing she could do except tell me I was going to be okay,” Zakwe says.

“We were forced not to talk about things. Talking that could help us heal. One can imagine, these experiences – experienced by many young girls, around the country – can leave you vulnerable to HIV, teen pregnancy and other problems.”

At the age of 11, not even a teenager yet, Zakwe was expected to overcome the trauma of that violent experience, stay in school, and avoid early pregnancy, without any support – psycho-social, financial or otherwise – jn becoming a successful HIV-negative adult.

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 per cent 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 per cent of young people do not have a matric qualification, 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, which are often patriarchal and violent in nature, need to be addressed in order to make any meaningful impact on reducing new infections, and ultimately ending AIDS as a public health threat to the world.

Treatment and prevention campaigns alone, located in the health department, cannot by themselves 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. On the face of it, 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.

It was only two years ago, when Zakwe joined the DREAMS partnership as an ambassador, that she began to receive the psycho-social support she needed 15 years ago.

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 prevention campaign for young women and girls looking to tackle the societal problems driving their vulnerability to HIV 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 on Tuesday 20 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.

“One of the programmes where we have sought to integrate various approaches is the ‘She Conquers’ initiative, which aims to empower adolescent girls and young women to reduce HIV infections, tackle gender-based violence, keep girls in school and increase economic opportunities.

“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, as they acknowledge the difficult situations in which young women and girls live, as well as the patriarchal nature of our society, 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 only in place for a few years?

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 per cent by 2017. But the South African arm of the project started late, and the target has been shifted to 2019.

PEPFAR’s Caroline Schneider told Spotlight/Health-e that to achieve this, 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 U$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 drop-out, and gender inequality in the form of “economic disadvantage” and “discriminatory cultural norms”.

It was launched in 10 sub-Saharan African countries, with South Africa being allocated U$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”. Like DREAMS, it aims to do this by looking at the problems in society that make this group particularly vulnerable.

This is according to the DoH’s Dr Yogan Pillay, who 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, with the first phase being implemented in the 22 districts with the highest HIV burden, “where the need is the greatest”. Based on what is learned in these areas, the interventions will be rolled out nationally.

The five targets to be achieved in the 22 priority districts for the three-year-long campaign are ambitious:

  1. Decrease new HIV infections in this group by at least 30 per cent, 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 per cent, from 73 000 to 50 000;
  3. Increase retention of this group in schools by 20 per cent;
  4. Decrease sexual violence and GBV in this group by 10 per cent;
  5. Increase economic opportunities for young people, particularly young women, by increasing youth employment by 10 per cent.

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; and if it is adequately responding to the needs of girls and young women: the people it aims to benefit.

The confusion extends to how these initiatives are linked.

Health minister Dr Aaron Motsoaledi told Spotlight that “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 directly funding the local campaign.

“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.

Pillay said She Conquers is a “combination of awareness and practical projects”. But many activists have questioned, firstly, if the campaign is adequately raising awareness in a nuanced way that speaks to the myriad societal ills preventing girls and women from staying safe; and secondly, whether the other interventions are reaching those affected.

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 last year 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 that instead of trying to address the circumstances in which young women remain vulnerable, this kind of messaging only 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 hyper-sexualised, 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 to buy food for herself and others in the household instead of paying school fees? Girls drop out because of a range of factors, such as food, security and transport,” she said.

In this type of messaging, Stevens said, there is no mention of the challenges affecting their ability to stay in school or protect themselves from HIV.

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 bootcamp.

But members of this committee told Spotlight that they do not have much decision-making power.

The executive secretary for the committee, 23-year-old Koketso Rathumbu, said the committee was not involved in formulating the messaging for the communications campaign, including the controversial billboards.

“The DoH is the one who facilitates and decides on the communication plan; and unfortunately, this was not shared with us, and there no clear reasons as to why – we have made a request,” she said.

While Rathumbu had positive things to say about the campaign – for example, that it is getting people talking about these issues, and 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 of and led by the DoH, so far it has failed to adequately integrate all sectors.

Who is in charge?

The Medical Research Council’s Dr Fareed Abdullah (a former SANAC CEO) said that SANAC – as a body designed to facilitate multi-sectoral collaboration between various government departments, civil society and other stakeholders – should be responsible for the running of the She Conquers campaign. It should also be the seat responsible for the coordination of various partners working on HIV prevention in young women under the She Conquers banner, including the DREAMS partnership and others.

Pillay admitted that She Conquers is “supposed to be a programme that links various initiatives under one banner”, but that “coordination is not an easy thing to do”. While Ramaphosa was deputy president, he asked that SANAC take on this role – indirectly acknowledging that the DoH cannot fulfil the mandate on its own.

But the confusion around the programme continues. While Pillay said that handing over the running of She Conquers to SANAC had been done as early as last year, SANAC spokesperson Kanya Ndaki told Spotlight a different story.

“SANAC is not responsible for the overall running of the She Conquers campaign, but this is something we are working towards. We are hosting a summit on young women and girls in March, and will be bringing all the partners involved to reflect on what has worked, so that we can coordinate the response better,” she said.

Ndaki said that the She Conquers campaign has been led by the DoH, but “we want to change that. We want it to be a multi-sectoral response, and SANAC is best placed to provide that multi-sectoral coordination.”

She added that while locating the running of She Conquers has been discussed on various platforms, it has not been finalised; but it is expected to be at the March summit.

Moreover, according to Schneider, DREAMS and its funding “was intended to spark investment globally in adolescent girls and young women programming, with biomedical, structural, and behavioural interventions, using multi-sectoral approaches”.

But when asked if there has been any domestic investment in She Conquers on top of the international aid, Pillay said no – “just the money we have. We have already made it clear from the beginning, from government, the funding will be a reprioritisation of existing funding,” he said.

But Abdullah made the point that the programme – should any impact it makes be sustained – “cannot only be funded by donors, and the South African Government also needs to make significant investments in this programme”.

Will young women have access to PrEP?

Abdullah also said that “one of the key weaknesses of the programme is the very limited offering of pre-exposure prophylaxis (PrEP)”. PrEP consists of a daily dose of antiretroviral medication to prevent HIV infection, and has been shown to be highly effective if taken as indicated.

The World Health Organisation recommends PrEP for young women in areas where the rate of new HIV infections is high; but according to Abdullah, even though this is “one of the most effective interventions” in existence for HIV prevention, “South Africa has limited PrEP to a few pilot sites”.

This is despite the fact that the latest National Strategic Plan (NSP) for HIV, tuberculosis and sexually transmitted infections makes provision for the implementation of PrEP for populations at a high risk of acquiring HIV.

Abdullah has been critical of the NSP, saying it limits PrEP access. The Plan’s targets are that between 2018 and 2022, there should be just over 104 000 new PrEP users. PrEP will be offered to young women, female sex workers, men who have sex with men, and people who inject drugs.

According to Pillay, through She Conquers, PrEP is slowly being rolled out: it was made available to young women at nine university campuses in October 2017. Only 26 people were initiated on PrEP during the first month; after that, the programme was stalled, because universities were closing for the end-of-year holidays. Those who had started PrEP were given a supply for the holidays.

Since February, two more university campus clinics have begun offering PrEP, bringing the total to 11; but the DoH does not have data on new uptake at these sites for 2018.

Pillay said: “During the next six months, PrEP will be made available at some 20 primary healthcare clinics in the 22 She Conquers priority sub-districts.”

The aim is to offer PrEP to between 5 000 and 8 000 young women over the next year.

There are multiple programmes running under the She Conquers banner that are doing important and effective work. But the success of any HIV-prevention campaign that seeks to solve systemic issues in society such as violence and gender inequality will rely on the successful integration of every actor on every level.

To truly help young women and girls in South Africa, programmes will need to put them and their views, voices and suggestions 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:

“It is a social issue that must engage, involve and mobilise the whole of society.We must be prepared, as government, to acknowledge where we have failed our people. Where we have made mistakes, we will correct them.”

Improving SRHR access for queers in South Africa

Melusi Dlamini, AIDS Foundation South Africa

Melusi Dlamini shares his take on the state of play when it comes to the Sexual

Melusi Dlamini (Image: LookingRoom)

and Reproductive Health Rights (SRHR) of the LGBTQIA+ community.

The overlaps between our progressive constitution and SRHR policies should enable a more effective realisation of SRHR rights for LGBTQIA+ persons; however, we are far from achieving this. There remain glaring gaps between policy and the lived realities of homosexual, bisexual and gender-nonconforming persons. While more than half (51%) of South Africans agree that human rights and inherent protections should be for all, seven out of 10 (72%) still believe that same-sex relations are ‘wrong’.

This is according to a survey by The Other Foundation titled Progessive Prudes – A survey of attitudes towards homosexuality & gender nonconformity in South Africa. South Africa remains a divided society on many fronts, and these divisions are reflected in the treatment and quality of services most queer persons receive. I use the word ‘queer’ here as an inclusive term, to signify the sexual orientations and gender identities that are normally encompassed by LGBTQIA+.

Instances of queer folk being victimised in public institutions are a dime a dozen. The trauma and humiliation suffered by queer persons demonstrates that accessing services is not a given. As a result, most of the queer persons I have encountered through my work usually have to think of all these possibilities before even approaching any public institution. This can have very serious repercussions if it relates to one’s health.

The National Strategic Plan and Accessing SRHR

Sexual and reproductive health rights (SRHR) are about the intersecting issues and concerns that affect the lives of all individuals. Most importantly, these rights – like any others – are legally recognised and protected.

Many queer persons depend on the public healthcare system; even so, access is not automatic. Factors such as gender and income inequality, unemployment, and living in a rural or urban setting have a profound effect on how or whether queer persons are able to access SRHR.

In addition, many queer persons struggle with issues such as mental wellness, owing to the internal and external pressures they experience. For queer persons, SRHR means having service providers who are not only ‘sensitised’, but also able to competently provide access to comprehensive services.

As a result, the role of public institutions is important, and the implementation of the National LGBTQIA+ HIV Plan is central.

The LGBTQIA+ plan is a great example of how South Africa is showing the intention to realise SRHR for queer persons. While the plan acknowledges the importance of reducing HIV infections among ‘key populations’, it is also important to expand psychosocial support and empowerment. The experiences of queer persons are not limited to sexual and reproductive concerns, and the range of services that offer inclusive and comprehensive information should reflect this.

 

Melusi Dlamini is the Sexual and Reproductive Health Rights Training Officer at the AIDS Foundation of South Africa. His interests include improving access to sexual and reproductive health rights for young people, as well as issues of social justice. Melusi has also worked with queer youth in Durban on creating safe spaces and access to healthcare. He is also a PhD candidate at the University of KwaZulu-Natal, with a specific interest in young masculinities in South Africa.

 

The needs of queer folk in SA

by Thuthukile Mbatha, Spotlight

June 2017 saw the launch of South Africa’s first Lesbian Gay Bisexual Transgender Queer Intersex Asexual Plus (LGBTQIA+) HIV Plan 2017-2022.

Luckyboy Mkhondwana, National Training Co-ordinator at the Treatment Action Campaign

The plan, which was launched under the banner of the South African National AIDS Council, seeks to address some of the many issues affecting the various communities that are part of the LGBTQIA+ community, with all their varied and unique needs. However, nine months have passed, and still there has been no meaningful attempt to implement the plan.

Luckyboy Mkhondwana is the National Training Co-ordinator at the Treatment Action Campaign, and a long-time campaigner and advocate for the rights of the LGBTQIA+ community. He took Spotlight through the gaps that exist in the policy and its implementation.

Do you think that the Sexual and Reproductive Health Rights (SRHR) needs of queer folk are addressed in the public health sector?

No, there are a lot of gaps that need to be addressed. For instance, if a lesbian woman misses her period and goes to a public clinic to find out about the possible cause of the delay, she will be asked about the last time she had sex, and a pregnancy test would be done on her. This is unfair, and disrespectful to her sexual orientation.

Moreover, the judgement received by gay men when they go to public health clinics for screening and treatment of sexually transmitted diseases (STIs) discourages them from going back to the clinic when sick. For instance, if a gay man has warts on the anus, it is not easy to seek medical help, because some healthcare providers will judge him – especially since they are used to seeing warts on the genitals, not on the anus. This has led to many gay men living with untreated STIs. The only clinics that are sensitised to offer non-judgmental health services are the facilities that work with organisations such as the Anova Health Institute; which are not accessible to all gay men, due to where they are located.

Would you say the LGBTQIA+ HIV Plan 2017-2022 addresses the needs of queer folk?

I think the plan is a good document, full of promise – but there is no implementation. It has been nine months, but we have not seen anything on the ground. I am curious to know what they will report on, when it is time for review.

What should be the specific SRHR priorities for queer folk?

The LGBTQIA+I HIV Plan seeks to offer a core package of health services, and it includes confidentiality. However, that is not practised on the ground. If a trans woman visits a clinic, the healthcare providers usually call their peers to stare at the trans woman. They look at her as if she is in a circus, because she is wearing female clothes. There is a good chance that the nurse assisting the trans woman would disclose to his or her colleagues the reason for her visit.

The plan further suggests that the LGBTQIA+ community should have access to HIV-prevention tools; whereas in reality, only a few have access to tools such as Pre-Exposure Prophylaxis (PrEP). If one lives far from the Anova Health Institute centres, one cannot access such services.

There are no lubricants for the trans women and men who have sex with men (MSM) communities. These should be freely available in public health facilities, just as male condoms are easily accessible. A 500ml bottle of lubricant costs R85 or more in a pharmacy, and not all can afford to buy it.

One of the goals of the plan is to reduce HIV prevalence and incidence rates. It continues to highlight the importance of increased access to HIV prevention tools. However, it is very difficult to gain access to dental dams, finger cots and PrEP in the public sector, to protect against new HIV infections.

A dental dam, like a condom, is a barrier method. It is a thin, square piece of rubber which is placed over the labia or anus during oral-vaginal or oral-anal intercourse. Dental dams are most often made of thin latex rubber; however, for those allergic to latex, they are also available in silicone.

A finger cot is a ‘glove’ that covers only one finger. It is basically a ‘finger condom’. Finger cots are often recommended as a safer sex device for fingering.

Access to Human Papilloma Virus and screening is difficult for some lesbian women and trans men who have not gone for gender reassignment. When they go for a Pap smear test, they are asked why they require such services, because they are men. Healthcare providers judge them based on how they look. You may find that some had previously engaged in sexual intercourse with heterosexual men, meaning they too are at risk of contracting the two diseases.

In general, all service providers must be sensitised and taught how to address queer folk. The assumption that we are all either women or men is offensive. Gender non-binary groups are usually the victims of that offense.

An investment in mental health is key to the provision of SRHR, because the two are linked. There is a great demand for psychosocial support among queer folk, since they endure much discrimination at home, in their workplaces, and in their societies in general. A number of them engage in reckless behaviour, including substance abuse and casual sex, to numb the pain. This kind of behaviour poses a threat to their health, since it exposes them to the risk of HIV infection.

Lastly, the plan stresses the importance of recruiting LGBTQIA+ communities through peer educators. However, no recruitment has happened on the ground. Even when it comes to HIV testing, only the non-profit organisations visit LGBTQIA+ spaces to offer the services to them.

Can we say that all queer folk would have similar SRHR needs?

No, [the solutions to] our needs need to be tailor-made to suit each individual. Not every woman wants contraception; queer women need dental dams or finger cots, whereas a trans woman may need a lubricant. Also, the SRHR needs of one trans woman could differ from those of another trans woman, just as heterosexual women may have different preferred contraceptives.

What are the biggest challenges for queer folk trying to access health care in clinics and hospitals?

Stigma and discrimination prevent a lot of people from accessing healthcare services. This is the major barrier for queer folk.

What would you change tomorrow if you had the power, in terms of SRHR for queer folk?

I would ensure that the individual SRHR needs of queer folk are prioritised – I wouldn’t assume that a one-size-fits-all approach will work. I would ensure that healthcare providers are properly sensitised, and that I would be able to go to a clinic and get everything that I need, without fear of being judged.

What is TAC doing to address the SRHR needs of queer folk?

We have an LGBTQIA+ sector in seven provinces. We have been struggling to get funding for LGBTQIA+ advocacy work; however, we have incorporated LGBTQIA+ work in most of our work and campaigns, including treatment literacy programmes. Funders prefer funding service-provider organisations, because they can quantify how many queer folk they have reached, recruited and assisted; whereas advocacy is hard to quantify.

Cutting-edge youth services

by Thuthukile Mbatha, Spotlight

The Desmond Tutu HIV Foundation (DTHF) is implementing a number of innovative youth-focused health services around Cape Town. Others could learn from their approach and successes.

The DTHF Youth Centre was established in 2011; situated in Masiphumelele

Professor Linda-Gail Bekker, Director at the Desmond Tutu HIV Foundation. (Image: Thom Pierce)

township, it is at the forefront of trying to find answers to the tough questions regarding young people and access to healthcare services. The foundation is specifically interested in innovative HIV research, and even more so where it intersects with young people’s issues. Simply, they want to find innovative health-delivery mechanisms that keep young people healthy, HIV-free, and without the burden of teenage pregnancy and similar challenges.

The adolescent girls and young women division focuses on sexual and reproductive health rights, mental health, HIV, life skills, and sero-neutral service delivery. ‘Sero-neutral services’ means that everyone is treated the same, irrespective of their HIV status.

The DTHF’s director, Professor Linda-Gail Bekker, has been at the helm for over 10 years, and has led a team trying to figure out how young adolescents can be ethically involved in HIV prevention research. This is because the laws against HIV research on adolescents are very tough, prompted by the assumption that because adolescents are below the age of consent, they are therefore vulnerable. However, the DTHF has made great strides in fighting for adolescents to be included in HIV research trials.

The DTHF has been involved in adolescent PrEP studies, including PlusPills, the 3P project, and the ADAPT study. The Foundation has also conducted HIV vaccine studies (SASHA) and HIV self-testing studies. “Our current range of research (treatment, prevention, socio-behavioural, structural) is vast, but we are always looking to explore and expand the evidence base around what works for adolescents. Permission to conduct research is sought through our ethics committee, and is – rightly – a strict process. We take great measures to adhere to ethical guidelines around adolescent research, and work with our ethics committee and youth advisory board to make sure we go about this in the best way. To best serve adolescents and meet their needs, we need to know what works; so this research is important to do,” says Bekker.

Responding to a question regarding the emphasis on young women, Bekker says: “Young people, particularly young women and girls, are disproportionately affected by the HIV epidemic, and are at high risk for infection. Young people are also undergoing a unique phase of life, characterised by biological and physiological changes, increased risk-taking behaviour, etc.; and so it is important to have services and strategies that are specifically tailored to them.

“The foundation employs a harm-reduction approach, as opposed to a ‘prevent sex from happening’ strategy,” Bekker explains from her office on UCT’s medical campus. In 2005, the foundation conducted a survey at Masiphumelele township in Cape Town’s southern suburbs, and found that many young women they spoke to were already infected with HIV. One of the outcomes of their survey was information that a contributing factor to the high HIV incidence rates was that young women had no-one to talk to about sex.

The DTHF is now running a number of youth programmes at youth centres, such as the Philippi Village and Hannan Crusaid Youth Clinics (in Philippi and Gugulethu respectively); the Masiphumelele Youth Centre; and the Tutu Teen Truck (mobile service). These include the Health Zone (where young people learn about sexual and reproductive health rights, for example), an Edu Zone (where learners are assisted with school homework), a Fun Zone (where young people participate in sports), the Women of Worth study (see article on page 29), and 18-month internships – offered to youth who have graduated from the Zimele programme, and no longer fit the targeted age category of 10-24 years; these interns run the Zones.

The DTHF delivers youth-friendly sexual and reproductive health services through various platforms, including the Tutu Teen Truck (a mobile clinic delivering health services to young people) and youth-friendly clinics (mobile health facilities providing services that are targeted at and designed for young people). About 4 000 young women use the youth centres, and 300 of those are on Pre-Exposure Prophylaxis (PrEP). This form of PrEP is an antiretroviral drug called TRUVADA, taken daily by HIV-negative people to prevent HIV acquisition.

Innovative reward system

The programme uses some innovative systems to keep track of the young people. Every young person who is part of the youth programme has a unique identifier, logging in using a fingerprint on the biometric machine at the entrance, at which point their medical file is uploaded on the healthcare provider’s computer.

To encourage young people to stay healthy and HIV-free, the foundation has a reward system for all its young members through which they earn points for doing all the vital tests. Undergoing an HIV test gets you double points. This initiative is also aimed at normalising HIV among young people. The ‘currency’ used for the points system is the ‘Tutu’ – three Tutus are equivalent to R1. These can be exchanged for food vouchers. An HIV test is rewarded with 100 Tutus. According to Bekker, “You’ll find a 19-year-old boy asking his friends if they have done an HIV test yet, because he is short of Tutus.” The youth use Tutus to buy a number of items from a local mall or an onsite café.

If someone has a negative test result, they are reminded about the importance of staying HIV-negative, and encouraged to use available HIV-prevention tools. A person who tests positive will receive the same number of Tutu rewards. “We do not penalise mistakes, because that doesn’t work well,” says Bekker. This means that young people get rewards regardless of their HIV status; however, they receive different packages of care. For instance, a person who tests positive would be offered counselling, encouraged to go onto treatment, and advised to encourage their partners to be tested as well.

The Tutu reward system is also aimed at preparing the youth for the grown-up world, and teaching the importance of saving. This is part of positive youth development. The foundation offers 18-month internships to youth who have graduated from the programme, from age 24. The internships involve running the three Zones for younger people, and teaching life skills. There are two interns for each Zone. Most young people relate better to their peers. “What I’m really passionate about doing for this country is to develop a cadre of community healthcare workers who are adolescents,” says Bekker.

The Tutu Teen Truck

According to Bekker, the Youth Centre has been criticised for its perceived inability to be scaled up, as it would not be possible for the government to replicate the same programmes for the entire country. But there are some important elements of the programme that the government could apply, and which are cost effective. The Tutu Teen Truck is one of them. It takes the elements of the sexual and reproductive health services and puts them in a funky-looking truck, which is an “adult-free and adolescent-aware environment”. It is brightly painted, and designed to be attractive to young people. The staff are properly sensitised and trained to be adolescent-friendly.

A range of services is offered to 12- to 24-year-olds. Bekker is trying to get the government to approve the provision of antiretroviral therapy (ART) through the Truck, so that young people – whatever their test results – can get appropriate care and support as part of a combination prevention strategy, without delay.

The Truck travels around Mitchells Plain, Klipfontein and Mfuleni townships, and stops in areas with high HIV prevalence. It draws the attention of young people by playing loud music. It operates every Monday to Friday from 12pm to 6pm, as well as some Saturdays. It offers a range of contraceptives and sexually-transmitted illness (STI) screening interventions, through the use of a GeneXpert machine installed in the truck – a machine mainly used to detect TB, via sputum samples, but which can also be used to test for various other diseases.

A person’s sample is inserted into the GeneXpert, which then conducts an antigen test. “A large number of young people are walking around with untreated gonorrhoea and chlamydia that we are missing, so this offers same-time STI detection and treatment,” says Bekker. The truck also offers tuberculosis (TB) screening to young people suspected of having the infection. Those who require abortion services are referred to health facilities in their neighbourhood that offer such services. “A lot of the young people who use these services just need to talk to someone who will not judge them in any way,” Bekker adds.

To explore the cost-effectiveness of providing effective youth-friendly services to young people, the same elements of the youth centre and the Tutu Teen Truck are being piloted in some public health facilities. The Global Fund to Fight AIDS, Tuberculosis and Malaria has funded a three-year programme aimed at 22 000 young women and adolescent girls between the ages of 10 and 24 years, in the Klipfontein and Mitchells Plain areas. Alongside the DTHF youth centres, the foundation has identified 24 public health facilities in the Mitchells Plain and Klipfontein health sub-district where they could render the same youth-friendly services to young women and girls. In all of these facilities, they are guided by the National Adolescent and Youth Policy 2017.

Part of the Global Fund grant is used to pay peer navigators at government clinics. A peer navigator is a young person who welcomes young people at the clinic as they arrive at the door, and directs them to the relevant staff. Each clinic also has an adolescent-youth-friendly service champion who has been identified at the clinic. This could be anyone at the clinic: a nurse, a security guard or an administrator, for example. The role of the champion is to ensure that youth-friendly services are rendered to young people without prejudice.

The Foundation is currently developing what is called an ‘adolescent pack’, which outlines how nurses should treat adolescents in clinics. This was prompted by the fact that traditionally, nurses only operate using ‘adult’ and ‘child’ packs; they do not know how to address adolescent health issues, which are largely sexual- and reproductive-health-related. Every clinic staff member – including the security guards, nurses and cleaners – is trained in how to render youth-friendly services.

On top of these programmes, the Foundation has approached all the high schools in the sub-districts to find out from the headmasters what kind of services they would allow to be provided in their schools. Some choose contraception only; others want the comprehensive sexual- and reproductive-health package. Again through the Global Fund grant, the foundation has hired four nurses who visit all the schools that require these services. Some schools only allow counselling to be offered to learners, and nothing else.

Keeping girls in school

The DTHF has another initiative, called the Keeping Girls in School programme, which targets 15- to 19-year-old girls, with the aim of keeping them in school. Young women and girls are taught about their reproductive organs, and the importance of HIV and pregnancy prevention. This initiative is run by peer educators in schools; through the initiative, the foundation supplies sanitary pads and tampons to female learners.

The DTHF is also conducting a study called Women of Worth, targeting 19- to 24-year-old girls out of school. The study aims to enrol 10 000 young women in order to equip them with self-empowerment skills, in 12 sessions. These sessions cover a variety of issues, such as gender-based violence, sexual and reproductive health, and how to prepare for the job market; a type of life-skills training.

Of the 10 000 young women, 5 000 will receive a cash incentive as part of the study. This research aims to establish whether a cash incentive could help improve health outcomes. The sessions offered include topics such as self-empowerment, sex talks dealing with HIV, STIs and family planning, gender-based violence, personal finance management, and so on.

The study will assess how well these programmes work. Half of the participants will be randomly selected to receive a cash incentive and the empowerment course, whereas the other half will only receive the empowerment course. The study will establish whether these young women’s health outcomes are significantly improved by them attending empowerment sessions and receiving a cash incentive. The cash incentive is an example of behavioural economics, based on the assumption that a lot of young women get into difficult relationships because they want cash. The cash transfer is dependent on their involvement in the study. After completing the 12 sessions, the young women will graduate, and some will be enrolled in the learnership programme in the DTHF – provided they finish and excel during the two-year period of the programme. The majority of the young women in the study already have a child, and come from very poor backgrounds.

“Unless we try to address the socio-economic challenges that young women face on a daily basis, through equipping them with income-generation skills, we can offer as many contraceptives and HIV-prevention tools as we want; but we will not see any progress,” says Bekker. The young women who have completed the programme are encouraged to recruit their peers to enrol as well.

There is a parallel programme targeting young men, in which participants discuss men’s issues and how to treat women. The sessions are a ‘woman no-go zone’. Both the Women of Worth programme and the men’s health component include a session on LGBTI needs and issues. Every young person has a tailor-made programme meant to address issues specifically related to them.

“If all these programmes do not work in three years, I will know that we had a fair try,” says Bekker.

 

Bill would roll back right to choose

 

Thabang Pooe, SECTION27

A new Bill threatens the very essence of a woman’s right to bodily integrity and reproductive decision-making, as well as the right to dignity.

Wednesday 31 January 2018 marked the 21st anniversary of the adoption of

Abortion Adverts, Cape Town, South Africa (Image: Egg Images, Alamy)

the Choice on Termination of Pregnancy Act (CTOPA). CTOPA states clearly that every woman, regardless of her age, has the right to a safe abortion. The rationale of the Act is to determine under which circumstances and conditions a woman may terminate a pregnancy.

CTOPA sets the context in its preamble:

“Recognising the values of human dignity, the achievement of equality, security of the person, non-racialism and non-sexism, and the advancement of human rights and freedoms which underlie a democratic South Africa;

Recognising that the Constitution protects the right of persons to make decisions concerning reproduction and to security in and control over their bodies;

Recognising that both women and men have the right to be informed of and to have access to safe, effective, affordable and acceptable methods of fertility regulation of their choice, and that women have the right of access to appropriate health care services to ensure safe pregnancy and childbirth;

Recognising that the State has the responsibility to provide reproductive health to all, and also to provide safe conditions under which the right of choice can be exercised without fear or harm.”

Clearly, the Act places a woman’s agency and autonomy centre stage.

Nevertheless, there are still serious challenges facing the implementation of CTOPA nationwide. According to HEARD’s, South Africa Fact Sheet on Unsafe Abortion, there is an estimated 50% of abortions in South Africa that occur outside of designated health facilities. Healthcare provider objections to providing abortion procedures result in fewer than half of government-designated facilities providing abortion services. The lack of real access to abortion services – due to lack of facilities and equipment required, and widespread ‘conscientious objection’ to abortion on the part of healthcare workers (including outside the legislated perimeters of such objection) – already violate women’s rights.

This points to the need for policy shifts that will enhance access to legal and safe abortion services for women in South Africa – unlike the amendments to CTOPA tabled in Parliament by Member of Parliament (MP) Cheryllyn Dudley in July last year. Dudley, MP for the African Christian Democratic Party, published a draft private member’s Bill, proposing certain amendments to CTOPA.

The stated objects of the draft Bill are to “delete certain circumstances in which a pregnancy may be terminated”; and to “ensure that a pregnant woman has access to ultrasound examinations and sufficient mandatory counselling to enable her to make a fully informed choice regarding the termination of her pregnancy”. This would include providing for mandatory counselling of women seeking abortions, including showing them images of foetuses in wombs.

The draft legislation is also intended to tighten conditions for allowing a woman to have an abortion in the second trimester, by requiring that a social worker must agree with a doctor’s determination that continued pregnancy would significantly affect the woman’s social or economic circumstances. Further, it would scrap provisions that permit a third-trimester abortion if there is a risk of injury to the foetus.

The Bill has been met with fierce opposition; mainly because in reality, the draft Bill aims to limit women’s ability to access safe abortions in health facilities around the country – thereby limiting, without justification, a woman’s constitutional right to equality; dignity; bodily and psychological integrity, which includes the right to make decisions concerning reproduction; privacy; and access to healthcare services, including reproductive health care.

Perhaps it is necessary to look at the proposed provisions more carefully.

 

The Bill eliminates two important circumstances in which women are currently able to terminate a pregnancy:

where the continued pregnancy would significantly affect the social or economic circumstances of the woman; and

where the continued pregnancy would pose a risk of injury to the foetus.

 

This is further exacerbated by the Bill requiring that the gestation period calculated is confirmed through an ultrasound examination, and introducing additional requirements for facilities that may provide abortion services – namely that the facilities must give access to ultrasound equipment and ultrasound examinations, and must give counselling.

These provisions are problematic on multiple fronts.

Firstly, our Constitution recognises that women have control over their bodies and reproductive capacities. This is located in a woman’s right to bodily integrity and reproductive decision-making, as well as the right to dignity. Forcing women to carry a foetus to term is an invasion of these rights.

Furthermore: properly understood, these rights ensure that the decision to terminate or not is made within the actual context of women’s lives; the removal of the ability of women to obtain an abortion – for social or economic reasons, or if the continued pregnancy would pose a risk of injury to the foetus – violates women’s rights to equality and bodily integrity.

Secondly, not all public facilities (as designated by CTOPA) will have ultrasound equipment or the expertise to undertake the tests that would be required by the draft Bill. In truth, ultrasound machines and healthcare workers able to operate them are frequently only found in major hospitals – and not at clinics, which is where women often seek (and are entitled to seek) abortion services. The unavailability of equipment or personnel would be an additional and unreasonable barrier to accessing abortion services. The additional restriction would also not improve the health outcomes of women accessing these services.

 

The Bill proposes mandatory counselling that includes showing images of the foetus in the womb.

In reality, the Bill seeks to introduce fear and shame into the counselling process by requiring that women be exposed to images of a foetus, including electronic pictures, diagrams and photographs. This is hidden under the guise of ‘informed consent’. The proposal to force this kind of counselling on a woman who seeks an abortion not only violates the woman’s dignity, but may serve as a barrier to access. This contradicts the rationale of the Act, which is to provide important reproductive health services to women in a way that respects their dignity.

Studies have already shown that currently, the way counselling is conducted amounts more to rhetorical scare-tactics, which construct abortion as firstly, a medical procedure associated with a wide range of extreme consequences; and secondly, as an act that contravenes the accepted purpose of ‘mothers’ (pregnant women) to protect their ‘babies’ (foetuses). The Bill would only serve to add to this, in violation of our legislative framework.

In sum, the proposals in the draft private member’s Bill seek to roll back the advances in sexual and reproductive health rights gained by women in South Africa since our democracy.

This was never an easy battle. The debate we ought to be having should not be around frustrating an already difficult process, but rather on how we may ensure that these services are meaningfully accessible to all women, irrespective of age or social status.

Contraception: DBE Draft Policy on the Prevention and Management of Learner Pregnancy

Thabang Pooe, SECTION27

The results of the last Annual School Survey, released in 2017, sent shock waves through the country. According to the survey, an estimated 15 740 learners fell pregnant in the previous academic school year – that’s roughly 43 every day. This was described by Minister of Education Angie Motshekga as a major social, systemic and fiscal challenge – not only for the basic education sector, but crucially, for national development.

Teenage pregnancy among school girls impacts negatively on the girl’s ability to complete her schooling. In many cases, girls who fall pregnant while in school drop out and rarely return to school post-pregnancy, thus ending any prospect of further education or access to the labour market.

It is in this context that the Department of Basic Education introduced the draft Policy on the Prevention and Management of Learner Pregnancy for public comment. The DBE acknowledges its central role in the social sector’s collective response to this challenge, and sets out in this policy its goals, guiding principles and policy themes, to stabilise and reduce the incidence of learner pregnancy and its adverse effects on the education system.

The policy not only seeks to address the high rate of pregnancy among learners, but also the context within which this occurs – the familial and social context. It further seeks to provide options for reducing the number of unintended and unwanted pregnancies, the management of pre- and post-natal implications, the limiting effects of the associated stigma and discrimination, and importantly, the retention and re-enrolment of affected learners into school.

Of significance is that this policy seeks to ensure the accessible provision of information on prevention, choice of termination of pregnancy, care, counselling and support, frameworks for impact mitigation, and guidelines for systematic management and implementation. This it aims to do through the provision of comprehensive, quality sexuality education and access to adolescent and youth-friendly sexual and reproductive health services.

The policy further asserts the constitutional right of pregnant learners to continue and complete their basic education without stigma or discrimination. Specifically, it confirms that there should be no exclusion of pregnant learners, who must be allowed to remain in school during their pregnancy and return as soon after giving birth as is appropriate for both the learner and her child.

For its part, the school is required to accommodate the reasonable needs of the learner to ensure that her right to education is not disrupted or ended by pregnancy or birth. It thus promotes the right of girls to education by ensuring they are not excluded from school as a result of falling pregnant and giving birth, and providing a supportive environment for the continuation of learning.

Comments on the draft policy were due to be submitted by 10 March 2018.

We are failing young women in South Africa

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

Thuthukile Mbatha, guest editor on this special youth edition of Spotlight

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

Teenage girls on their way to school in Soweto, Gauteng. The best time to teach young people about sexual
and reproductive health is when they are at school. (Image: Rosa Irene Betancourt, Alamy)

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.

Young women: Seven myths about menstruation and reproductive health

Lerato Makate, Spotlight

Sexual and reproductive health education being taught in South African

Activists demand free sanitary pads for school girls at the 2016 AIDS conference in
Durban during Minister of Health Aaron Motsoaledi’s speech

schools has left some female learners and young women feeling less confident about the right time to engage in sexual activity, about what to do when their menstrual cycle comes, and even about understanding how contraceptives should be used.

This is according to nursing sister Anna Moloi, the acting head of Department of the Campus Health Clinic Services at the University of the Witwatersrand.

Moloi says the clinic has had several encounters and consultations with female students – mostly in their first year of tertiary education – who were experiencing their menstrual cycle for the first time, and did not understand what was happening or what they needed to do.

She says that as a result, the clinic has seen the need to conduct thorough consultations, including one-on-one sessions, explaining to these young women the process their bodies are undergoing.

“A lot of them, especially the young ones [students], will come with menstrual pains. What we normally do is to advise them on what menstruation is; because in high school, they do not get a lot of [reproductive health] education,” Moloi says.

Menstruation, or having periods, is normal vaginal bleeding that occurs as part of a woman’s monthly cycle. Every month, the female body prepares for pregnancy. If no pregnancy occurs, the uterus, or womb, sheds its lining. The menstrual blood is partly blood and partly tissue from inside the uterus. It passes out of the body through the vagina.

Periods usually start between the ages of 11 and 14, and continue until menopause at about age 51. They usually last from three to five days. Besides bleeding from the vagina, there may be:

  • Abdominal or pelvic cramping pain
  • Lower back pain
  • Bloating and sore breasts
  • Food cravings
  • Mood swings and irritability
  • Headache and fatigue

Explaining the persistent myths concerning women’s menstrual cycles, Moloi says there are still many young women who need accurate information on and a thorough explanation of sexual activity and how it can affect the menstrual cycle. Despite the sexual and reproductive health education taught in South Africa’s schools, many young women continue to believe these myths about menstruation.

Here are seven menstruation and sexual reproductive health myths:

  1. You will not get pregnant if you ‘douche’ after sex. Many people wonder if douching with either regular douching fluid or bubbly cooldrink (such as Coca-Cola) can get all the sperm out after sex, effectively preventing pregnancy. The truth is that it won’t. Biologically, women’s vaginal muscles contract during orgasm as the body’s way of bringing the semen toward her eggs; so even if you douche immediately after sex, some of the sperm will already be too deep to be flushed out. Plus, douching with soda or other liquids not meant for that purpose can cause irritation and infection, which is also not a good thing.
  2. If you do not have a condom, you can use a balloon. No plastic baggie/rubber band or balloon/twist-tie combination will provide the protection of a traditional, approved condom. And it may not even stay on. The ones you’ll find on shop shelves are electronically tested to meet strict standards of strength, reliability, and resistance to tearing. Frankly, it costs about the same amount of money to buy the real thing, which offers far more reliable protection. Also, many clinics will give you free condoms.
  3. You will not fall pregnant if you have sex while standing up, or if the woman is on top during sexual activity. If you have vaginal intercourse, it doesn’t matter if you’re up, down, sideways or even under water; the woman can still get pregnant. The one ‘position’ that won’t cause pregnancy is oral sex, because no semen enters the woman’s vagina – though oral sex does have its own set of health risks, including STD transmission.
  4. You will not fall pregnant if you have sex during ‘safe times’, i.e. various periods during the menstrual cycle and ovulation cycle. While the average female’s monthly cycle may be 29 days, others may have a cycle that varies from 20 to 40 days, or even longer. A woman’s likelihood of falling pregnant rises and falls throughout her ovulation cycle; the likelihood that a woman will fall pregnant one to two days after she starts bleeding is nearly zero. But the likelihood increases with each successive day, even though she’s still bleeding. At roughly day 13 after starting her period, her chance of pregnancy is an estimated 9 per cent. While these numbers may be low, it means a woman can never be 100 per cent assured that she won’t fall pregnant during her period.
  5.  You will not fall pregnant the first time you have sex. It is thought by many people that sex for the first time will not get a woman pregnant. This is far from the truth; having sex without the use of contraception can get a woman pregnant, irrespective of whether she is having sex for the first time or has had it plenty of times before. Pregnancy depends on fertility, which can be a very irregular thing. It might take months or even years of desperate trying for some women to conceive, while others might conceive whenever they have sex, even if it is their first time and they have no desire to be pregnant. Pregnancy is a possibility every time a woman and a man engage in intercourse. The only requirement is that a sperm must reach an egg.
  6. Because you have started using the pill, you will not fall pregnant. This is a myth; it is incorrect information. The pill is 99 per cent effective in preventing pregnancy. Even so, every year between two and eight per cent of women who use it become pregnant.
  7. If you urinate after sex, you will not fall pregnant. This is a myth, and a misconception about or misunderstanding of female anatomy, by both men and women. For people with vaginas, the tube you urinate through (the urethra) is not the same tube a penis ejaculates into during sex (the vagina). Many people don’t realize these are two separate holes, because the urethra is often very tiny, and right next to the vaginal opening. Urinating after sex won’t rinse sperm out of the vagina, because you don’t urinate out of your vagina.

Lesedi Mashinini, a first-year film and television student, shared her experience.

“In primary school, they taught us about menstruation, sex, and all that. But in high school, I don’t remember them teaching us. I don’t remember a lot of details from when I learned about having my periods,” Mashinini says.

“I know how to take care of myself during my period because of help from my sister and my mom, about what I had to do the first time I had it. So now, I’m more confident about what I need to do.”

Marona Seekane, a postgraduate student, says that menstruation as a topic was only covered properly and thoroughly in Life Sciences from about Grade 10 in high school; and it was only then that she started feeling as though she knew what was happening in her body.

“I don’t think that sex education was done properly, because almost all the knowledge that I have, I read up on by myself. The basics were covered in Life Orientation, where we were told that sex without protection would lead to STIs, pregnancy and HIV,” Seekane says.

“Things like HPV I only learned about when I got to varsity. I only started feeling confident about sexual health after I had done some research of my own.”