ABSTRACT Millions of people currently live with HIV/AIDS around the world. Regionally, SubSaharan Africa is most affected, with some national HIV-prevalence rates reaching 30%. In Namibia, prevalence has recently dipped to 19.7%, after years of increasing levels. Women in Namibia account for more than half of new infections. Though prostitutes are not included as a group entity in national HIV surveys, it is estimated that HIV-prevalence levels among them are much higher than the national average.
Two forms of prostitution exist in Namibia, both of which are criminalised through the Combating of Immoral Practices (Act 21 of 1980): exchange sex work and classic sex work. Since prostitution is illegal, sex workers are forced underground and become more vulnerable to HIV-infection. However, very little has been written about sex work in Namibia, and therefore no figures on prostitution are available. Failure to monitor HIV-prevalence rates among prostitutes can have the unwanted consequence that rates spread quicker than anticipated. The AIDS epidemic has highlighted the importance of access to adequate health care.
The right to health is included in the UN International Covenant on Economic, Social and Cultural Rights (ICESCR), of which Namibia is a signatory. However, people living with HIV/AIDS (PLWHA) often face discrimination and stigma, in particular those who are engaged in sex work. They suffer discrimination twice over, and may thereby be hindered to access health care. The fieldwork study undertaken in preparation for this thesis found that many sex workers in the township of Katutura, on the outskirts of Windhoek, were denied access to health care. The right to education is also of relevance here; as the 2000 Namibian Demographic and Health Survey (NDHS) concluded that knowledge about HIV/AIDS, and how it can be prevented, correlated with the respondents’ level of education
The respondents had acquired more extensive knowledge about HIV/AIDS had they attended school for several years. The National AIDS Control Programme (NACOP) embraces a human rights approach; however, both the above mentioned rights are violated daily in Katutura. Access to health care is in an HIV/AIDS context key to the possibility to lead a somewhat normal life with the infection.
Within the concept of access is the availability of antiretroviral medication (ARVs), the prices of which has recently decreased on the global market but still remain out of reach for many countries. Namibia aims to supply ARVs for thousands of HIV-infected people; however, despite a pledge that this medication is available free of charge this study shows that for the very poor, AIDS treatment still remains out of reach.
ACKNOWLEDGEMENTS For your time, advice, help, suggestions and support, thank you: Delme Cupido, Basilia Ngairo and Naomi Kisting of the Legal Assistance Centre; Father Hermann Klein-Hitpass of the Catholic Church of Windhoek; Gloria Billy of UNAIDS Namibia; Tom Fox and Debie LeBeau of the University of Namibia; Nancy Muniaro of the Resource Centre at the Ministry of Health and Social Services; Abner Xoagub, Chief of Health Programs at the Ministry of Health and Social Services, Eva Liljekvist and Bengt Sundgren of the Africa Groups of Sweden; Göran Hedebro, Ewa Nunes Sörenson and Susanne Mattsson of the Swedish Embassy; Edward Rheis and Edwardt Xoagub of the Combating of Prostitution through Education and Development Organisation; and personnel at the Resource Centre at the Ministry of Women Affairs and Child Welfare.
Special thanks to Peter Johansson, my most excellent and devoted supervisor at Göteborg University, for keeping me on track and patiently answering all of my questions, even the non-relevant. Thank you also for providing emotional support when I needed it the most. In addition, my deepest and most heartfelt thanks to my friends and family who supported me during the difficult weeks, in particular Hattie, Grahame, Gunlög, Anders, Martin, Emilie, Claudio, Hilde, and Rebecca. Thank you also to Jamie for proofreading. Of course, my most grateful thanks go to the women of the townships of Katutura and Babylon, who so willingly spent time with me and told me their life stories. I can only hold a humble hope that this study will benefit you in some way or another.
PROSTITUTION, HIV/AIDS AND HUMAN RIGHTS: A CASE STUDY OF SEX WORKERS IN THE TOWNSHIP OF KATUTURA, NAMIBIA
LIST OF ABBREVIATIONS AIDS ALU ART ARV ICESCR Acquired Immune Deficiency Syndrome Aids Law Unit Antiretroviral therapy Antiretroviral (drugs) International Covenant on Economic, Social and Cultural Rights Combating Prostitution through Education and Development Organisation Commercial sex worker Human Immunodeficiency Syndrome Katutura State Hospital Legal Assistance Centre Ministry of Health and Social Services Ministry of Basic Education, Sport and Culture Mother-to-Child Transmission (Third) Medium Term Plan National AIDS Control Programme Namibia Demographic and Health Survey Non-governmental organisation United Nations Office of the High Commissioner for Human Rights People Living with HIV and AIDS Sexually transmitted infection/disease South-West African People’s Organisation
CSW HIV KSH LAC MoHSS MBESC MTCT MTP (II or III) NACOP NDHS NGO OHCHR
PLWHA STI/STD SWAPO
PROSTITUTION, HIV/AIDS AND HUMAN RIGHTS: A CASE STUDY OF SEX WORKERS IN THE TOWNSHIP OF KATUTURA, NAMIBIA
UNAIDS UNam UNDHR VCT WHO
United Nations Joint Programme on HIV/AIDS University of Namibia United Nations Universal Declaration of Human Rights Voluntary Counselling and Testing World Health Organisation
PROSTITUTION, HIV/AIDS AND HUMAN RIGHTS: A CASE STUDY OF SEX WORKERS IN THE TOWNSHIP OF KATUTURA, NAMIBIA
GLOSSARY Antiretroviral drugs (ARVs) CD4 cells Medication that fight retroviruses, such as HIV The CD4 cells, found in the lymphocytes, are critical cells in activating the cellular immune response which is targeted by HIV. A reduced CD4 count indicate that the HIV infection is progressing An unusually sharp increase in the amount of people falling ill in a certain disease, limited to a relatively short period of time A global epidemic An informal drinking house, found mostly in Namibia’s townships or poorer areas. Renowned for being ‘working areas’ for sex workers, some shebeen owners provide a separate room where transactional sex can take place
More than twenty years have now passed since the world witnessed the onset of the AIDS epidemic. During those early years, when AIDS was still believed to affect only gay men or intravenous drug users, no one could predict the devastating impact the disease would cause around the world. We know plenty more about AIDS today: for instance, the ways in which the virus is transmitted and that it can infect any individual, regardless of gender, race and sexual preference. We also know that AIDS is not curable, that it inevitably leads to death, and that this process is long and often painful.
However, we have created medication and developed treatments which enhances and prolongs the life of an AIDS-patient – something that was not possible twenty years ago. Something else we have learnt in the last couple of decades is that violations of basic human rights expose people to an increased risk of contracting the HIV-virus. Already vulnerable people, for instance those who are poor and uneducated, become increasingly susceptible to HIV-infection when they are denied access to education and health care.
Bridging the research gap between HIV/AIDS, prostitution and human rights, this thesis provides a unique analysis of sex workers in Namibia. Sex workers constitute a group of people vulnerable to an increased risk of contracting HIV. Though HIV/AIDS itself is a topic widely researched; in a prostitution context, our knowledge is quite limited. Several studies concerned with both topics exist today; however, no such research focusing on Namibia has yet been published. It is therefore the aim of this thesis to concentrate on prostitution, HIV/AIDS and human rights in a Namibian context.Because no other study has focused exclusively on sex workers from the townships, this thesis will do so, while providing an examination on related human rights violations and its implications for the national attempts to stem the rate of new HIV-infections. No data is available on HIV-prevalence in the Namibian townships alone. The Ministry of Health and Social Services (MoHSS), though having conducted several studies on general health in Namibia, does not possess any figures which reveal HIV-prevalence in the townships; the available data
concerns Windhoek as a whole. Neither does the MoHSS have any data related to prostitution. It is therefore impossible to establish such facts as the number of sex workers operating in Namibia today, and how high HIV-prevalence is among them. Considering that in developing nations infection is mostly transmitted through heterosexual sex, this lack of statistics is very unfortunate.
We also know today that the AIDS epidemic is an unbearable burden for many countries. Underdeveloped nations are now financially crippled with the strains of trying to provide treatment and medication for thousands of people infected with HIV. Poverty is here one aspect of the AIDS epidemic which needs to be taken into account, as poorer nations struggle to be able to afford antiretroviral medication (ARVs) for HIV-positive citizens.
Poverty also plays a role on an individual level, since many people are denied access to treatment and medication if they are unable to pay for it. In this context it may be argued that the human rights framework can provide a structure within which an effective response to the HIV/AIDS epidemic can take shape. Therefore, the thesis aims to examine human rights in the HIV/AIDS context, in particular since the Namibian national HIV/AIDS response includes a rights approach.
This thesis is the concluding course component of the Master’s degree in Human Rights at the School of Global Studies, University of Göteborg. The fieldwork study carried out in preparation for the thesis was conducted in Windhoek, Namibia, during April and May of 2005. 1.1 PURPOSE AND QUESTIONS
The purpose of the thesis is to provide an analysis of the link between prostitution, HIV/AIDS and human rights. The thesis will use as its starting point a qualitative study of the accessibility of AIDS treatment for prostitutes in the township of Katutura, Namibia. The questions being asked are: which human rights are most relevant in this particular context? To what extent are these rights upheld in Katutura?
No other area in the world has suffered as many AIDS-related deaths as Southern Africa. Therefore, geographically focusing on this region in a study of human rights in an HIV/AIDS context seemed a natural choice. Namibia, one of the region’s most hard-hit countries by the AIDS epidemic, has had a National AIDS Control Programme (NACOP) in place since 1990, which encompasses a human rights approach. The combination of these factors makes Namibia an interesting example to study.
Unfortunately, in many parts of the world, people living with HIV/AIDS (PLWHA) are forced to endure daily violations of their basic human rights. Many PLWHA experience discrimination and stigma, and may, for example, suffer rejection from family members and work colleagues. This situation is no different in Namibia. Therefore, human rights in a discrimination context will be discussed in this thesis; however only for the purpose of providing an overall picture of the situation. Focus of the thesis will be on the right to health, the right to education, and access to health care. All ofthese topics are in an HIV/AIDS context individually concerned with discrimination and stigma.
Prostitution in Katutura has never before been examined in detail. Therefore, this study focuses exclusively on prostitutes living and working there. The study has been limited to a small sample group of fifteen informants. Due to the lack of previous research, to concentrate this study on township dwellers fills a void in Namibian HIV/AIDS research. The informants were not specifically chosen out of a larger group; on the contrary, they constitute those prostitutes who were willing to be interviewed1.
An academic debate exists over which of the terms ‘prostitution’ and ‘sex work’ should be preferred. The thesis will discuss this topic in a separate section. Throughout the thesis, both ‘prostitute’ and ‘sex worker’ will be used intermittently, as the purpose here is not to establish which term is the most appropriate. Both terms are used here simply for descriptive reasons.
METHODOLOGY AND MATERIAL
1.3.1 The interviews In the initial stage of the research, I interviewed clergyman Father Hermann KleinHitpass, who managed a Catholic charity centre (hereafter ‘the centre’) open to prostitutes in the Katutura area. Thrice weekly, meetings led by Father Hermann took place here, during which prostitutes could meet up and conduct Bible studies, have a meal, and receive some basic food products.
Аather Hermann initially met the sex workers while driving around the township area aiming to inform them about condoms and the risk of contracting HIV. (Supplied by the government’s AIDS programme, condoms were also distributed for free at the centre.) The sex workers then received an invitation to join the meetings at the centre. I visited the centre twice a week, whereby Father Hermann facilitated interviews with the sex workers.
Maykut and Morehouse (1994) argue that a randomly selected sample ‘increases the likelihood that the sample accurately represents the [general] population (…)’2. In this study, it cannot be expected that the sample group is representative of the general population; however, it could be regarded as representative of sex workers in the townships of Windhoek. Though my sample group was small, clear patterns of the rates of HIV infection, the sex workers’ educational background and the reasons why they entered sex work, emerged through my research. Interestingly, these patterns paralleled those found by a 2002 study conducted by the non-profit law firm Legal Assistance Centre (LAC)3, which represents the only other study on the topics of prostitution in Namibia.
In total, fifteen in-depth semi-structured interviews were conducted with the prostitutes. Though the informants varied in ethnic and linguistic origin, the majority
Maykut, P. and Morehouse, R., 1994: Beginning Qualitative Research: A Philosophic and Practical Guide, London and New York: Routledge Falmer, p. 56 3
Legal Assistance Centre, 2002: Whose body is it? Commercial sex work and the law in Namibia, Windhoek, LAC, p. 79ff
of them spoke English to an understandable degree4. However, in some instances it was necessary to use the services of a translator. The translator later became one of my informants, using a method described by Maykut and Morehouse as ‘reducing the power differential between the researcher and the research participants by involving the participants as collaborators’5.
During the initial interviews I did get the feeling that the informants were not entirely comfortable with my presence, but when the translator joined me I saw a noticeable change in their attitude. Being able to speak their own language, and not having to concentrate on speaking English, made some informants relax considerably. Visiting the centre twice a week was also part of my intention to attempt to ‘reduce the power differential’.
Showing up every Monday and Friday at exactly the same time, I hoped to become known to the informants as reliable. It also gave me the opportunity to get to know some informants quite well; as I made sure I had a chat with every informant I had previously interviewed. In addition, I became known to future informants. Some women hesitated to approach me for weeks, and only found the courage to come and talk to me when I had become a familiar face at the centre.
Moreover, the private nature of the topics I was interested in discussing made it necessary to strongly emphasise that the informants’ anonymity would be guaranteed. As Bless and Higson-Smith (2000) point out, anonymity does not constrain social research, as the interest lies more in group data than individual statistics6.
One difficulty I encountered was to decide if or how to reward the informants for the interviews. Initially, I considered giving them money, though I worried that the news that cash payments were being rewarded for interviews would inspire some prostitutes to come and talk to me for that reason alone.Wanting to avoid situations
Since independence in 1990, English is the official language in Namibia; however, Afrikaans is still used extensively as the common language between different ethnic groups. 5 6
Maykut and Morehouse, 1994: Beginning Qualitative Research, p. 71
Bless, C. and Higson-Smith, C., 2000: Fundamentals of Social Research Methods: An African Perspective, Johannesburg: Juta & Co, p. 100
where the informants submitted answers that they thought I wanted to hear rather than what was really the truth, I therefore decided that no rewards would be distributed until all interviews were finished. In collaboration with Father Hermann, the informants were all given a food package, as well as photographs which they had themselves requested.
I found that in-depth interviews were a preferred method to, for example, focus groups or questionnaires. Though the informants were all literate, their knowledge of written English was limited, and a questionnaire would have caused more confusion than it would have assisted in my research. Having prepared the questions beforehand, all answers and any additional questions were written down by hand during the interviews.
To confirm that I had understood everything correctly, I repeated the answers given to me by the informants. Maykut and Morehouse state that it is significant that people’s exact words are written down during interviews, since it is the aim of the researcher to understand the precise setting that is the focus of the study7.
Therefore, my informants were also offered to read my notes from each interview. This simple but effective method ensured that the information relayed to me was correct. My original intention had been to tape record all interviews, however, as it turned out it was easier without the use of a recorder. Due to the language barriers, it would have been difficult to clearly understand what was said on the tape. In addition, conducting follow-up interviews with the informants, or even meeting with them again for clarifications, would have proven difficult since there was no guarantee that they might be at the centre during my next visit. By verifying all interview answers immediately, I avoided any possible misunderstandings.
Additional interviews include the two founders of the first NGO established with the sole aim to assist and facilitate the lives of prostitutes in Windhoek, the Combating Prostitution through Education and Development Organisation (CPTEDO), as well
Maykut and Morehouse, 1994: Beginning Qualitative Research, p. 76
as with the Chief of Health Programs at the Ministry of Health and Social Services (MoHSS) Abner Xoagub, conducted via email. 1.3.2 Secondary resources Only twice has research been conducted with the specific aim to describe the situation for prostitutes, once in Windhoek and once in the coastal town of Walvis Bay8.
Governmental institutions were involved only as advisors in these research projects, which has the implication that the government has never undertaken any study whatsoever regarding prostitution. Related material (such as general health statistics) was, however, relatively easy to find. The resource centres of the Legal Assistance Centre (LAC), the World Health Organisation (WHO), the MoHSS and the Ministry of Women’s Affairs, were made available to me, which was extraordinarily helpful. However, due to the lack of previous research, the great majority of my firsthand sources are the interviews with the sex workers. Almost exclusively, other sources are secondary.
On site in Windhoek, I made several attempts to meet with members of the Ministry of Health and Social Services (MoHSS). As a response to the increasing threat of HIV and AIDS, a national AIDS control programme (the NACOP) was set up in 19909, and I was particularly interested in interviewing its representatives, but despite numerous phone calls I was never granted an interview.
By an incredible stroke of luck, however, I met the Chief of Health Programs on the very same day as my departure from Namibia. I was then granted the kind permission to conduct an interview via email, which took place during a couple of weeks in July. Apart from the information submitted to me in that interview, my sources on the NACOP are official documents obtained from the MoHSS.
Despite the obvious need for more research of this kind, the Walvis Bay study has due to its incomplete nature not been used as a reference here. The Ministry of Health and Social Services (MoHSS): The National Strategic Plan on HIV/AIDS (Medium Term Plan III 2004-2009), p. i 9
The interview with the MoHSS Chief of Health Programs proved invaluable since he supplied me with statistics that I had previously been unable to locate. Survey reports and official documents (such as the National Strategic Plan on HIV/AIDS) also provided necessary data with which to compare findings from the interviews. 1.4 DISPOSITION
After a brief overview of the HIV/AIDS situation in the world, including a presentation of current statistics, this thesis will in chapter two examine HIV/AIDS in a Namibian context. A brief description of Namibia’s road to independence will be provided for the purpose of contextualising the discussions that follow. For similar reasons, a summary of public health law and international health obligations will be presented. The last part of this chapter will discuss HIV/AIDS in a human rights context.
Chapter three will begin by examining previous research on sex work and HIV/AIDS, in a general sense as well as in a Namibian setting. After results from the 2000 Namibian Demographic and Health Survey (NDHS) is revealed, the thesis will discuss the terms ‘prostitution’ and ‘sex work’. A look at the legal instruments concerning prostitution in Namibia will follow. The second half of this chapter concerns the findings of the fieldwork study undertaken in preparation for this thesis.
Finally, chapter four examines the National AIDS Control Programme (NACOP) and several related human rights (and dimensions thereof). For instance, discrimination and stigma, as experienced by many individuals affected by HIV/AIDS, is discussed in detail. In addition, access to health care is looked at, in particular access in Katutura.
In its concluding chapter, the thesis discusses some possible ways forward, and opportunities for future research are listed. Included here is a further discussion on
how human rights are linked to HIV/AIDS, in particular in context of the NACOP. The implications of poverty and how underdeveloped nations are prevented from accessing antiretroviral treatment (ART) are also discussed.
BACKGROUND: HUMAN RIGHTS AND HIV/AIDS
This chapter will analyse the links between HIV/AIDS and human rights in several contexts. The discussion begins by providing statistics on the current HIV/AIDS situation in the world, with a focus on underdeveloped nations. HIV/AIDS from a Namibian perspective will then be discussed. The chapter will also examine, in brief, public health law and international law obligations.
CURRENT FIGURES ON HIV/AIDS
More than twenty years after AIDS was first diagnosed, there is still no cure for the disease, nor for the virus that causes it. Millions of people have already died of AIDS, and, as Barnett and Blaikie (1992) notes, in the absence of a cure and/or vaccine, millions more will perish10. In this bleak context, it is particularly important that special attention is paid to the African continent. More than 90% of all adult HIVinfections are in developing countries11, and as many African countries are poor and underdeveloped, their already scarce resources are under enormous pressure to cope with adequate care for the sick and dying.
Figures from the United Nations Office of the High Commissioner for Human Rights (OHCHR) reveal that about 38 million people live with HIV or AIDS today, and that over 70% of these live in Africa12. Sub-Saharan Africa is the worst hit region in the world by HIV and AIDS, with millions of people living with the virus at the end of 2004. A great majority of the world’s HIV-positive people are found in the age group 15-49 years old, which has devastating effects on several dimensions of 10 11
Barnett, T. and Blaikie, P., 1992: AIDS in Africa: Its present and future impact, London: Belhaven Press, p. 5
Rao, V., Gupta, I., and Jana, S., 2000: Sex Workers and the Cost of Safe Sex: The Compensating Differential for Condom Use in Calcutta, World Bank: Policy Research Working Paper 2334, p. 3
Baylies, C. and Bujra, J. (eds.), 2000: AIDS, Sexuality and Gender in Africa: Collective strategies and struggles in Tanzania and Zambia, London and New York: Routledge, p. xi
society. As the majority of the workforce, people in this age group constitute the backbone of a nation’s economy. In addition, individuals in this age group are simultaneously parents and caretakers of their own mothers and fathers. Thus the loss of a majority of people 15-49 years old is catastrophic, leading to the creation of thousands of orphans an