HIV in Haiti is spread by violence – and little is done to prevent attacks

PORT-AU-PRINCE, Haiti — Dieula sits in a circle of women on the tiled floor of a dimly lit room here, discussing the sexual violence that makes HIV infection an ever-present danger for Haitian women.

"The woman in Haiti doesn't have rights," she says. "Only men have rights to decide." The rest of the women in the group agree. She adds, quietly: "Our misery increases every day."

The women, all of them rape survivors, belong to the Commission of Women Victims for Victims, or KOFAVIV, a community rape-crisis organization trying to call attention to the plight that too many Haitian women face. In September 2006, 150 members of the group marched through the streets of the Haitian capital, black masks representing the silencing they feel and the anonymity of their masked attackers.

Since KOFAVIV began in 2004, the organization has counseled more than 1,000 rape victims in Port-au-Prince. That's only a fraction of the Haitian women who have been victimized. According to a survey reported in the August 2006 issue of The Lancet, an estimated 35,000 women and girls were sexually assaulted in Port-au-Prince during the 22 months of the interim government that followed the ouster of President Jean-Bertrand Aristide in early 2004. Three percent of all female survey respondents reported sexual violence; half of the victims were minors. Haitian women's rights activists say that many of the women they counsel have been left to cope not only with physical and psychological scars, but also with HIV infections transmitted by their attackers.

Haiti's HIV/AIDS infection rate of 3.8 percent among people ages 15 to 49 is already the highest in the Western Hemisphere, and public health experts and human rights activists warn that rape is threatening to spread HIV even more virulently.

In a country where poverty and political instability allow rapists to escape punishment, sexual assault has long been not just a random crime but also a deliberate weapon of political and social oppression. Yet now, according to KOFAVIV activist Malya Villard, Haitian women's knowledge of contracting HIV through consensual sex actually has put them at even greater risk, because if they attempt to refuse sex, they might be raped.

"In the working-class areas, women have learned about HIV, so men are forcing them," she says. "The guys have in their mind that they are the commander of the woman. That's why they force."

Scant funding for women's security

The link that can be made between HIV/AIDS and sexual assault in Haiti is a difficult problem for the President's Emergency Plan for AIDS Relief (PEPFAR), the Bush administration's five-year, $15 billion effort to combat HIV/AIDS in developing countries. As one of PEPFAR's 15 "focus countries," Haiti received more than $28 million in U.S. aid in 2004, $51.8 million in 2005 and $55.6 million in 2006.

But of the $13.8 million that PEPFAR spent on HIV/AIDS prevention in 2005, the biggest portion — $3.6 million, or more than a quarter of the money – went to fund programs that promote abstinence and faithfulness within marriage. In comparison, little PEPFAR money has been spent protecting women from being forced to have sex against their will. There are no programs funded that improve women's security or highlight the need for economic opportunities. Unless those priorities are changed, critics in the U.S. and Haiti say, the U.S.-funded effort to fight the disease's spread in Haiti may fail.

Debate in the United States has zeroed in on the sexual prevention plan that PEPFAR endorses. The Abstinence, Be Faithful, and correct and consistent Condom use, or so-called ABC, approach is derided by those who promote the use of condoms for catering to faith-based interests and by supporters of abstinence and fidelity approaches for promoting sexual activity through condom distribution.

One particularly controversial component of the ABC approach is the earmark that Congress passed in 2003 requiring that at least two-thirds of sexual transmission prevention funds support abstinence until marriage and fidelity programs in each of the focus countries.

Women's rights advocates in Haiti say none of the three prevention approaches– abstinence, fidelity or condom use — is sufficient. No matter how persuasive the messages are, they aren't going to help Haitian women who are forced to have sex against their will, they say.

As KOFAVIV project coordinator Anne Sosin said, "ABC works in a context where women are able to exercise their sexual rights, but women in Haiti are victims of a wide range of violations. Many of the victims of KOFAVIV who are HIV-positive contracted the virus through rape."

Violence against women is endemic in Haitian culture. For generations, Haitian law was a carryover from the Napoleonic Code, which defined rape not as a crime but as a transgression against morals — in other words, an attack on a woman's honor more than her body. The effect of the Napoleonic Code meant that women who alleged rape endured public scrutiny of their "morality" and that the rape of a non-virgin was considered a less serious offense.

The stigma attached to rape means that it's rarely reported. When it is, too often nothing is done. According to Sosin, there has been only one successful prosecution of a rape case in Haiti in 2006.

In recent years, in the absence of law and order in Haiti, women and girls have become easy targets for the gangs that rule the streets. "They are terrorizing the population, using rape as a way of regulating communities," said Nadine Puechguirbal, the U.N.'s senior gender adviser to its stabilization mission in Haiti. Gangs have moved into female-headed households where they won't be challenged.

"Police aren't able to protect civilians against gangs," an officer in CIMO, Haiti's special police, admitted to the International Consortium of Investigative Journalists (ICIJ). He said security has always been used as a political tool in Haiti, and that most police stations don't even have a patrol car, or gas for one. The gangs are better equipped, he said, and have more firepower.

Catherine Maternowska, a professor of anthropology and social medicine at the University of California, San Francisco, who has conducted research in the country over the past two decades, says the street violence in Haiti has increased since 1986 with the unraveling of the brutal Duvalier dictatorship. The more efforts there were to enforce democracy and the people's movement, she said, the more repression there was and rape began to be used politically. Rape continues to be used by gangs to claim turf or to repress certain populations.

For Haitian males, whose opportunities in life often are starkly limited, "one of their last sources of power is through sexual transactions," Maternowska said. Unfortunately, men's frustration often turns to violence. Gang rapes are a common factor in the disintegration of society in Haiti, she said, and "there's nothing to protect [women] when something does happen. Rapes are likely to happen every evening, all over the town of Port-au-Prince."

Maternowska knows that violence firsthand. In April 2005, she and two other women were kidnapped and terrorized by four gunmen until they managed to persuade the captors to let them go unharmed. "At that point, when the four of them [had] the guns … on my body and they were kidnapping me and taking me away and fighting about how to rape me and execute me — and that was sort of a turning point personally. And I haven't been back since."

Most Haitian women don't have the option to leave.

Violent attacks leave long-lasting effects

Yolette Jeanty is the director of Kay Fanm, a Haitian group that works with women who are victims of domestic violence.

Behind the high walls of the shelter where she works, Jeanty says she tries to refer women infected with HIV to clinics or hospitals for medical services. Medical care is necessary, she says, because more cases are very violent. Many times, rapists use sharp metal instruments attached to themselves to assault women. Most victims of those kinds of attacks can't bear children and "usually have long-term hemorrhaging," she said.

Violent attacks put Haitian women at much greater danger of HIV infection than consensual sex. According to Dr. Paul Zeitz, executive director of the Global AIDS Alliance, "There are biological, cultural and economic factors that make women more susceptible. Women are biologically at risk because the HIV virus can more easily penetrate vaginal mucus during intercourse. The cells are fragile and brittle. In addition, ulcerative STDs [sexually transmitted diseases] are an important co-factor in facilitating the spread of the virus."

Also, gang members committing these crimes are more likely to be infected. Rapists are part of a high-risk group in Haiti that is ill-informed about HIV and has no incentive to get tested. They don't know their HIV status, and, according to Sosin, they are often discriminated against by social services for being young men from poor neighborhoods.

PEPFAR's prevention spending in Haiti — $3.6 million in 2005 — goes, in large part, to programs that promote abstinence and being faithful within relationships (the "A" and "B" components of the ABC approach). The funding, for example, is underwriting development of a radio soap opera "focused upon a family situation in which children/adolescents face hard questions of peer pressure and personal desire that relate to abstinence and fidelity issues."

Other faith-based groups from the United States, including World Vision and World Concern, are receiving funds to disseminate the abstinence and be faithful messages to youth through church and community groups.

Given those priorities, community leaders are concerned that the Bush administration's global effort to fight HIV/AIDS, through its PEPFAR program, is not doing enough to confront the problem of rape. KOFAVIV's Sosin said that outside of GHESKIO (Le Group Haitien d'Etude du Sarcome de Kaposi et des Infections Opportunistes), the nation's leading HIV/AIDS research organization and clinic, she's not aware of other programs that receive PEPFAR funding. She doesn't know of other U.S. initiatives that address the link between sexual assault, forms of violence against women, gender inequality and HIV/AIDS. "Most of the money spent has very little impact at the community level," she said.

Repeated requests to the U.S. government for an interview to respond to these concerns were denied.

The start of several abstinence and fidelity programs in Haiti were delayed as a result of security concerns. World Vision and World Concern held off initiating their programs because of inadequate security. PEPFAR staff even moved from their U.S. Agency for International Development (USAID) offices here to a hotel in Miami for several meetings. Other meetings with outside partners were held in Hotel Montana, high up in the hills of Port-au-Prince and far from the communities being discussed.

Nongovernmental organizations receiving U.S. funding are still sorting through the grants' restrictions. The American Red Cross receives more than $7 million in PEPFAR funding for its HIV prevention program in Haiti, Tanzania and Guyana. Judi Harris, the health delegate for the Red Cross in Haiti, isn't sure whether abstinence and fidelity prevention teachings alone are appropriate for the youth her program addresses. The Red Cross works with numerous neighborhoods in Port-au-Prince, including the desperately poor community of Cité Soleil.

Harris' program teaches a curriculum called "Together We Can". Although the contract American Red Cross signed specifies that the 10- to 14-year-olds they work with be taught the "Abstinence" and "Be Faithful" components of the ABC approach, and that abstinence is the key message, Harris said the curriculum is being adapted for the younger population to fit the Haitian context.

Michelle Moloney-Kitts, chief of the program services division at the U.S Office of the Global AIDS Coordinator (OGAC), which oversees PEPFAR, says that the U.S. has its priorities straight. Because the age of sex initiation is so young in Haiti — often 12 or 13 — and because Haiti's epidemic involves a significant transmission within high-risk populations, abstinence is the correct approach for Haitian youth and young couples, she says. In addition, the "B" and "C" teachings — "Be Faithful" and "correct and consistent Condom use — are appropriate for the high-risk populations, she says.

Yet, according to a recent article in Social Science and Medicine, some U.S. and Haitian doctors have expressed concern about the way HIV/AIDS prevention is being taught. "The standard format for prevention education for HIV infection and other STDs may have very limited utility in settings where forced sex and severe economic vulnerability are so frequent as to be ordinary. For example, a woman who is trying to practice 'safe sex,' or abstinence, may actually place herself at greater risk of physical and/or sexual violence," it says.

Some signs of progress

Across the road from Cité de Dieu is GHESKIO (Le Group Haitien d'Etude du Sarcome de Kaposi et des Infections Opportunistes), the nation's leading HIV/AIDS research organization and clinic. Behind a wall and past a security guard who serves primarily as a director of traffic is a large open building and a long line of people waiting for services in the hot sun. Inside, Dr. Jean William Pape, the amiable director and founder, says that GHESKIO centers see many victims of rape and that he recognizes that abstinence as a prevention strategy is not possible in most cases.

GHESKIO, which received a $2 million U.S. grant for HIV/AIDS treatment and laboratory infrastructure in 2005, is one of the few PEPFAR-funded organizations in Haiti that treats women who have been raped. The organization works in conjunction with the Haitian Ministry of Public Health and Population and provides post-exposure prophylaxis, a powerful dose of antiretroviral drugs that may prevent a rape victim from developing an HIV infection.

In addition, as of August 2006, along with the Minister for Women's Affairs, GHESKIO planned to launch the country's first 24-hour hotline for victims of sexual violence and to staff several centers where women could come for help. Pape hopes to link GHESKIO's rape patients with advocates who will help the patients get government services and advise them on navigating the Haitian court system.

Carolle Charles, a sociology professor at Baruch College in New York and a board member of Dwa Fanm, a Haitian-American women's rights group, says that these kinds of services are desperately needed. Creating rape crisis centers provides a tangible, concrete role for outside funders. "There is no rape crisis facility," she said. "That's one of the problems that women have been complaining about — there's no place to go" for help.

And there are other ways that U.S. funding could help Haiti deal with its problems.

Farah Tanis, the co-founder of Dwa Fanm, says that the country needs help in strengthening its law enforcement and justice systems, so that police and courts would prosecute the offenders.

Fifty-five million dollars in U.S. aid money has been appropriated for women's justice and empowerment programs in several African countries, including South Africa, Kenya, Zambia and Benin. Money has yet to be appropriated for this purpose in Haiti. PEPFAR's Moloney-Kitts says it's true that staff members were forced to move from their USAID offices to a hotel in Miami for several meetings due to security, and she recognizes that, "[In Haiti], we need an effective department of justice and some rule of law,"

But Puechguirbal, from the U.N. mission, says an additional problem in Haiti is that "women don't trust the police because sometimes they are the abusers."

There are some signs of progress. In 2005, Haiti finally changed its archaic rape law, at least temporarily, when a presidential decree ordered that sexual assault be recognized as a crime and not only as an assault against honor. But to become permanent, the law needs to be passed by the newly elected Haitian Parliament.

Brian Concannon, director of the Institute for Justice and Democracy in Haiti, says that René Préval, who was elected president in May 2006, had good programs for judicial reform in Haiti the last time he was in power. "Of course there's hope" that Préval will change the justice system, Concannon said. "There is huge support for judicial reform by the Haitian people." But he predicted that it will take several years until the justice system has changed significantly.

Although PEPFAR hasn't sufficiently addressed the issue of rape in Haiti through its prevention programs, the U.S. government recognizes a major problem. As a USAID Haiti Transition Initiative field report noted in March 2006, "Gangs in Port-au-Prince have been using rape as a conscious tool to terrorize citizens and increase their influence and power."

A separate USAID gender assessment that was published in June 2006 describes a total breakdown of the social order in poor urban communities and says, "The single gender issue most often cited and emphasized by women's advocacy groups is violence against women. The worst violence against women is occurring in urban areas and appears to be related to gangs. Efforts to reduce this violence should be a priority."

The link between violence against women and the transmission of HIV seems to have not yet been incorporated into the U.S. government-funded HIV prevention programs. But bipartisan legislation that is making its way through Congress could change that.

The Protection Against Transmission of HIV for Women and Youth Act, also known as the PATHWAY Act, introduced by Rep. Barbara Lee, D-Calif., with 85 co-sponsors, would require that PEPFAR create a prevention strategy that addresses female vulnerability to HIV, including taking action to protect women and girls from violence.

"Women and girls are increasingly bearing the brunt of the HIV/AIDS pandemic," Lee said. "But our current HIV prevention policy is not effectively addressing the key social, economic and cultural factors that put them at risk of contracting HIV. My bill lays out a comprehensive and integrated HIV prevention strategy that recognizes the realities that women face and empowers them to take control of their own lives, so that sound public health policy and the needs of people on the ground can dictate how we spend our money."

Meanwhile, KOFAVIV's support group for women victims of rape continues to meet weekly. Eramithe, another victim of violence sitting in the circle on the floor, tells the story of a woman who came in the day before. "A woman's husband was out of the house for a couple days, [she asked him to take an] HIV test and he beat her badly." Eramithe tucks her legs under her pink dress as she continues. "Countries have to take real action in providing support to women and children who have survived political violence."