“Where’s the Love?”: The Stigmatization of Women with HIV/AIDS in South Africa

A woman in South Africa with HIV or AIDS cannot talk to her family and friends about her HIV status because she fears that both she and her loved ones will be treated differently in the community. Mokgaetiji, a 38-year-old widow from Orange Farm, South Africa, did not tell her children because of her fear they would be traumatized at school. Mmamoroesi, a 33-year-old woman from Southern Sotho, claims that she avoids situations in which she has to explain her HIV status out of fear that she will be hurt (Lekganyane & du Plessis, 2011). The AIDS Foundation of South Africa records 5.6 million people living with HIV, placing South Africa higher than any other country in the world in the prevalence of HIV/AIDS. 60% of people with HIV/AIDS in South Africa are women between the ages of 12 and 35 (“HIV/AIDS in South Africa,” 2011). Additional research estimates that in some areas of South Africa, one in three women between the ages of 25 and 34 are living with HIV. The amount of women infected with HIV escalates the importance of the epidemic present in South Africa because women have an important role in the community as caregivers and are considered the economic backbone of development in many rural areas (Visser, 2012). Additionally, this large number of females with AIDS makes the issue of stigma even more poignant for South African women. Stigma, as presented in the cases of Mokgaetiji and Mmamoroesi, is defined as any negative thoughts, feelings, or actions against victims of HIV/AIDS. Stigma can be felt (anticipated or internal), leading to unwillingness to seek help or access resources, and can also be enacted (external stigma), leading to discrimination on the basis of HIV status or the association with someone who is living with HIV (Lekganyane & Plessis, 2011). Edwin Cameron, South Africa’s only openly gay and HIV-positive judge, commented on the issue of internalized stigma, claiming that “the person with HIV or at risk of it becomes self-condemnatory,” experiencing an “enacted form of discrimination, ostracism, hatred, rejection, condemnation, and judgment” toward one’s own self (Sara, 2013). It is both this internalized stigma and the fear of being externally stigmatized, as Mokgaetiji and Mmamoroesi were, that cause many women to neglect testing and treatment for their HIV status. The total HIV/AIDS treatment centers in South Africa have increased by 75% from 2009 to 2011, but the amount of people actually receiving treatment is quite low. A survey done in Cape Town found that most South Africans know about the treatments available for HIV/AIDS, but only one in five take advantage of them (Liekness & Simbayl, 2003). Contrary to popular scholarly belief, this suggests that lack of treatment and testing centers in South Africa are not the cause of the widespread epidemic of HIV/AIDS. It is this issue that redefines HIV/AIDS stigma as a “major driver of the HIV/AIDS pandemic through limiting people’s access to prevention, formal and informal care and more recently anti-retroviral treatment” (Campbell & Gibbs, 2009). In my research, I will analyze how the stigmatization of women with HIV/AIDS in South Africa is a key factor to undermining the care and treatment made available for them, and how the social constrictions of the area, including religion and presumptions about the disease, have served to isolate them from the rest of society.

Various studies have explored the connection between the stigmatization of HIV/AIDS and the stigmatization of women, specifically the stigmatization of female sexual desire. I When these gender stigmas interlock, such as with HIV positive women in South Africa, a general devaluation of women in many societies occurs. According to psychoanalytic psychologists, the stigmatization of identifiable out-groups, such as infected poor women, serves as a way for people to cope with the fear and uncertainty of the human condition. In other words, people project their fear of the randomness of illness and death onto out-groups as a means of distancing themselves from such threats (Campbell & Gibbs, 2009). Out-groups are not random, but are shaped by already existing contexts of society. The material contexts of HIV/AIDS stigma revolve around issues of poverty, lack of access to adequate health resources, and the burden faced by many people caring for someone living with HIV/AIDS. These contexts feed into the three inter-linked clusters of factors driving HIV/AIDS stigma: fear of infection, poverty, and poor HIV/AIDS management systems, and the sexual nature of HIV/AIDS (Campbell, Nair, & Maimane, 2006). For very real reasons, such as the sheer number of those infected with HIV/AIDS in South Africa, people are terrified of catching the disease or having to care for someone with HIV/AIDS. Such hidden fears often manifest as an irrational hatred for those already infected.

Negative attitudes towards HIV/AIDS infected women are quite prevalent in South Africa: 43% of people surveyed in Cape Town claimed that infected women should not be able to work with children and 41% stated that they should have limitations placed on their freedom (Simbayi et al., 2007). Anonymous surveys of 609 HIV-positive women diagnosed during pregnancy in Cape Town found that half (49%) of the women claimed they felt ashamed of their HIV status, 33% blamed themselves, and 27% saw their diagnosis as punishment. This is attributed to the fact that those infected with HIV/AIDS are often considered responsible in their communities for their condition because the disease is contracted by behaviors that are considered avoidable, such as unsafe sex and drug practices. 63% of women felt uncomfortable interacting with others and half of the women expected others to isolate them from society. High levels of internalized stigma are also associated with increased depression, decreased self-esteem and social support, as well as lower levels of infected disclosing their status to their partners (Visser, 2012).

This mistreatment towards women is fed by their vulnerability in society. Women in South Africa are more vulnerable to HIV infection than men because of biological susceptibility, low socioeconomic status, culturally defined gender roles, and high levels of domestic violence (Visser, 2012). Women’s economic dependency on a male partner makes it difficult for them to have the decision-making power to protect themselves from HIV. There are also gender behavior inequalities present between men and women: women are expected to be monogamous and satisfy their partner’s desires, while men are often encouraged by their communities to have multiple sexual partners. The fact that men have more sexual partners than women increases men’s susceptibility to contracting HIV, and in turn, increases the likelihood of their female partners also contracting the disease. Additionally, there is cultural resistance to condom use; women are not supposed to mention them if the partner denies the possibility. There is also evidence that men are more likely to resort to violence when denied their sexual wishes in attempts to establish dominance over their partner’s sexual activity (Visser, 2012). These factors feed into a high risk of women contracting HIV, even from their long-standing partners.

A woman with HIV/AIDS demonstrates the failure of the male, patriarchal society to enforce the patterns of women’s sexual behavior. Research shows that women in married relationships are verbally abused and/or beaten because her partner fears that he will contract the disease and lose control over the woman’s reproductive processes (Campbell & Gibbs, 2009). An infected woman also introduces issues in the conception of children, which is valued as a central dimension to both femininity and masculinity in South African society. A woman with HIV/AIDS automatically suggests a loss of control of male partners in reproduction, because of the possibility of transmission of the disease to the unborn child. The idea of a woman no longer able to reproduce without the fear of transmitting her disease to her unborn child not only results in verbal confrontations on her sexuality, labeling her as promiscuous and immoral, but also dishonors the woman’s partner and extended family. Many women, in order to adhere to the cultural norm that women’s worth is determined by their capacity to have children, do not disclose their HIV status so they can have more children and be respected in their communities (Visser, 2012). At the same time, HIV positive women who do get pregnant are judged by society. If the baby is born healthy, the mother uses it as proof that she is healthy. On the other hand, if the baby is born with HIV, the mother has no choice but to disclose her status and accept the community’s judgment. The fear of abandonment or violence from their domestic partners, reduced capability to conceive children, and reduced respect from their friends and extended family obstructs many women from receiving testing for their HIV status.

The severity of the HIV/AIDS stigmas directed towards South African women is directly related to its citizens’ sexual presumptions about the disease and their religious beliefs, which originated with the generation of the first HIV/AIDS outbreak. The possibility of the transmission of HIV/AIDS through close contact and the assumed promiscuity or recklessness of the victim are just a few of such presumptions still prevalent in the minds of the people of South Africa, even when the local HIV/AIDS clinics have proved them false. For example, a South African household survey found that 26% respondents indicated they would not be willing to share a meal with an HIV/AIDS victim, 18% would not sleep in the same room with someone living with HIV/AIDS, and 6% claimed they would not talk to an infected person (Kalichman & Liekness, 2010). Presumptions are not only formed about the physicality of HIV/AIDS, but also its spiritual associations. A survey done in Cape Town found that 11% of those surveyed believed that AIDS was caused by spirits and supernatural forces, while 21% claimed that they were unsure whether the causes of AIDS were natural or supernatural. This is related to the traditional South African belief that God and ancestors cause illness. Therefore, people who become ill are assumed to have done something to anger the spirits of ancestors or God. This fact feeds the stigma directed towards HIV/AIDS victims because it is believed that victims of HIV/AIDS brought it upon themselves through their spiritual disobedience. Research shows that those who believe in the supernatural cause of HIV/AIDS are significantly more likely to be misinformed about the details of AIDS and because of this, are more likely to endorse stigmatizing actions and beliefs towards those living with HIV/AIDS (Kalichman & Simbayi, 2010). This suggests that HIV/AIDS stigmas are not only fed by the supposed actions of the infected, but also the community’s lack of understanding about the disease.

Misinformation about HIV/AIDS is also related to reduced HIV/AIDS testing. Research also found that individuals who had not been tested for HIV/AIDS held significantly greater AIDS related stigmas than those who had been tested. For example, people who had not been tested for HIV/AIDS were more likely to agree that people with HIV/AIDS are dirty, should feel ashamed, and should feel guilty. Participants who were not tested were also more likely to believe that people infected with HIV/AIDS must have done something wrong in order to deserve their status; they were also more likely to assert that they would not be friends with someone who was HIV positive (Kalichman & Simbayi, 2003).

Another key factor to the stigmatizing beliefs present in South Africa directed towards women has to do with the association of sex, sin, and immorality. The church teaches that sex should be conducted within marriage, and that sex outside of marriage is sin. The high levels of HIV-positive people in South Africa only highlight the amount of unmarried people who are sexually active, and interchangeably, the amount of people who are supposedly ignoring the church’s teachings. The church, in turn, feels it has lost control over the people, and in order to regain this control, officials publicly label those with HIV/AIDS guilty of sin and immorality. Some church leaders even assert that their supposedly reckless sexual practices are a result of God’s punishment for evil, and that their behavior will initiate God’s final judgment, leading to the end of the world (Campbell, Nair, & Maimane, 2006). The fact that stigmatizing beliefs towards HIV/AIDS victims are supported and often caused by the church gives light to the elevated levels of stigma present in South Africa today. The church is, after all, the core of the South African community’s morality and the ultimate model of acceptable behavior.

The church not only attempts to decrease the amount of HIV/AIDS victims through externalized stigma, but also increased control over women’s sexuality. Traditional church leaders see it as their duty to ensure acceptable sexual behavior in the youth of their communities. One way in which they do this is the reinstated traditional practice of virginity testing, which rewards the girls that pass the test with gifts ranging from higher social status to virginity certificates (Campbell, Nair, & Maimane, 2006). This increased level of church officials’ control over women and their sexual practices serves as an example to the men of the community and their control over their female partner’s sexuality. Male partners’ control over women, as mentioned earlier, includes resistance to condom use and violence when denied sexual desires.

Just as misinformation about HIV/AIDS was the main force driving the belief that its cause was supernatural, misinformation about sex is one of the main factors driving the increased levels of girls who are sexually active outside of marriage. A study done in Cape Town, South Africa, researching women’s sexuality found that many parents simply deny the fact that their children have sexual desires and could be sexually active, even though the evidence supporting that fact is overwhelming. Mothers are hesitant to talk about sex with their daughters, resulting in young girls that do not know how to protect themselves from pregnancy and sexually transmitted diseases. Adults’ failure to face the reality of young people’s sexual desire and their rights to protect their sexual health is part the cause of the social exclusion and grouping of young people as sexually promiscuous and responsible for their HIV status (Campbell, Nair, & Maimane, 2006). If young people were educated on protecting themselves from sexual promiscuity and possible contraction of HIV/AIDS, the dark and shameful association with sex outside of marriage would not be as prevalent and the existence of stigma because of uninhibited sexual practices would decrease.

The stigmas directed towards women in South Africa with HIV/AIDS are directly related to the community’s fear of contracting the disease, men’s attempts to take advantage of women’s vulnerability, presumptions about the sexual nature of the infected, the attempted regulation of the church’s officials, and lack of sexual education. These sources of stigma not only wreak havoc on the women’s emotional capability to deal with the disease, but also their physical capability of treating it. Their fear of being judged or labeled prevents many women from receiving testing for their status, and/or receiving treatment. This presents a problem in solving the HIV/AIDS epidemic present in South Africa because treatment is available, but is not being utilized. Large philanthropic donors such as The Bill and Melinda Gates Foundation have enabled South Africa to increase the amount of HIV/AIDS clinics and the amount of awareness on topics such as safe sex, but little has changed because the stigmas directed towards HIV-positive women are still halting them from taking advantage of such treatments. It is this fact that increases the importance of understanding the effects, both physically and emotionally, of the stigmas directed towards women, and their ability to literally change the welfare of each one who is infected.

Increasing the levels of treatment is only a partial solution to a much bigger community problem. It is efforts directed towards the reduction of the stigma directed towards women with HIV that introduces an additional solution to the HIV/AIDS epidemic present in South Africa. To address these high levels of perceived community stigma and women’s fear of disclosing their HIV status, community interventions involving leaders and community-based organizations are needed. Although the help of worldwide organizations has increased the levels of treatment, it is only the help from the community that can directly influence the levels of community stigma. Research in South African communities has found that people who knew someone living with HIV/AIDS were less stigmatizing to others. Community stigma has also been found to decrease over time as knowledge of HIV/AIDS increases and more people know someone who is infected (Visser, 2012). Therefore, the goal of the community organizations should be to increase openness about HIV/AIDS and to demonstrate public support to those living with HIV/AIDS. A less stigmatizing community will only assist in public health efforts to decrease the HIV/AIDS epidemic present in South Africa. An additional suggestion of community-wide intervention is to address women’s vulnerability to HIV. This would include socioeconomic uplift programs and attention to gender inequality. Cultural practices that encourage gender inequality, such as traditional gender roles and violence towards women, should be challenged, and positive practices should be promoted. Such interventions could help women have the power to protect themselves from HIV and the harmful stigma that accompanies it. Even though HIV/AIDS is a chronic medical condition and treatment is necessary for its elimination, reducing its effects, seen in stigma, can also be quite influential in reducing the prevalence of HIV/AIDS in South Africa. Through reducing this stigma, treatment will be utilized, the socially placed barrier constricting HIV-positive women from the rest of society will be lifted, and a stronger sense of community will be restored to South Africa.