The Fourth Wave Violence, Gender, Culture & HIV in the 21st Century The Fourth Wave Violence, Gender, Culture & HIV in the 21st Century editors Jennifer F. Klot and Vinh-Kim Nguyen series editors Saniye Gülser Corat and Lydia Ruprecht A publication developed in the context of a project led by the UNESCO Division for Gender Equality of the Bureau of Strategic Planning in collaboration with the Division for Cultural Policies and Intercultural Dialogue of the Culture Sector. © 2009 UNESCO All rights reserved. No part of this book may be reproduced in any form without written permission from the publisher. Published by UNESCO The designations employed and the presentation of material throughout this publication do not imply the expression of any opinion whatsoever on the part of UNESCO concerning the legal status of any country, territory or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The ideas and opinions expressed in this publication are those of the authors and do not necessarily reflect the views of UNESCO and its Member States. Library of Congress Cataloging-in-Publication Data The fourth wave : violence, gender, culture, and HIV in the 21st century / edited by Jennifer F. Klot and Vinh-Kim Nguyen. p. cm. Includes bibliographical references. ISBN 978-0-9841257-1-5 1. AIDS (Disease)—Social aspects. 2. Sex customs. 3. Sexual abuse victims. I. Klot, Jennifer F. II. Nguyen, Vinh-Kim. RC606.6.F68 2009 362.196’9792—dc22 2009040366 Contents foreword 11 Saniye Gülser Corat and Lydia Ruprecht introduction 15 Jennifer F. Klot and Vinh-Kim Nguyen section i: the new geography of hiv introductory essay 29 Veena Das chapter 1 37 Globalization and gendered vulnerabilities to HIV and AIDS in sub-Saharan Africa Colleen O’Manique chapter 2 53 Social exclusion: The gendering of adolescent HIV risk in South Africa Kelly K. Hallman chapter 3 81 HIV, male labour migration and female risk environments in the southern Caucasus Cynthia J. Buckley chapter 4 103 HIV, sexual violence and exploitation during post-conflict transitions: The case of Sierra Leone Johannes John-Langba chapter 5 117 The price of liberation: Economy, gender and HIV and AIDS in China Shao Jing chapter 6 139 Masculinity + HIV = risk: Exploring the relationship between masculinities, education and HIV in the Caribbean David Plummer section ii: cultures of intervention introductory essay 159 Didier Fassin chapter 7 163 Representations of African women and AIDS in Bono’s (PRODUCT) RED Lisa Ann Richey chapter 8 189 The life course of nevirapine and the culture of response to the global HIV & AIDS pandemic: Travelling in an emergency Alton Phillips chapter 9 217 Horizontal approaches: Social protection and the response to HIV in Brazil Inês Dourado, Vera Paiva and Francisco Inácio Bastos chapter 10 245 How should we understand sexual violence and HIV and AIDS in conflict contexts? Judy El-Bushra section iii: cultures of response introductory essay 271 Mary Crewe chapter 11 279 Colonial silences, gender and sexuality: Unpacking international HIV and AIDS policy culture Hakan Seckinelgin chapter 12 295 ‘Sleeping with my dead husband’s brother!’ The impact of HIV and AIDS on widowhood and widow inheritance in Kampala, Uganda Stella Nyanzi, Margaret Emodu-Walakira and Wilberforce Serwaniko chapter 13 319 An epidemic of meanings: HIV and AIDS in Iran and the significance of history, language and gender Orkideh Behrouzan chapter 14 347 Beyond the new geography of dissident gender-sexual identity categories: Masculinities, homosexualities and intimate partner violence in Namibia Robert Lorway chapter 15 365 Neglecting gender in HIV prevention and treatment programmes: Notes from experiences in West Africa Joséphine Aho and Vinh-Kim Nguyen chapter 16 379 AIDS, gender and access to antiretroviral treatment in South Africa Nicoli Nattrass section iv: cultures of measurement introductory essay 401 Philip Setel chapter 17 407 Epidemiological fallacies: Beyond methodological individualism Catherine Pirkle chapter 18 423 Measuring the gendered consequences of AIDS: Household dynamics and poverty in South Africa Jeremy Seekings chapter 19 445 Measuring the impacts of the HIV epidemic on household structure and gender relations Patrick Heuveline chapter 20 461 Behind the scenes of sex and sexual debut: Unpacking measurement Charlotte Watts chapter 21 473 From unpaid to paid care work: The macroeconomic implications of HIV and AIDS on women’s time-tax burdens Rania Antonopoulos and Taun Toay abstracts 503 contributors 515 index 523 Foreword Saniye Gülser Corat and Lydia Ruprecht In this third decade of the AIDS pandemic, and despite strengthened political and financial commitments to women’s empowerment and gender-responsive programming, women – and particularly young women and girls – constitute a growing proportion of those affected and infected (see UNAIDS, 2008; and UNAIDS/WHO, 2006). This trend can be attributed in part to inadequate or inappropriate imple- mentation of policy commitments to gender equality (see Forss and Kruse, 2004; UNAIDS, 2007; and UNIFEM, 2008). However, this is only half the story. In different settings and epidemics, mainstream approaches ignore the most basic driver of the pandemic: the unequal power relations between women and men, girls and boys. The power structures that determine women’s and men’s different abilities to protect themselves from infection; to access quality preven- tion, treatment and care; and to cope with the consequences of the pandemic are poorly understood. These structures have also received scant policy atten- tion, making it difficult for practitioners and policy-makers to understand the specificities of each epidemic and to identify what should be done differently to address them. We must develop more sophisticated analyses of how gender dynamics operate in a given cultural context so that we can formulate appropriate policy responses. Only on this basis can we design programmes that challenge dis- empowering and harmful gender norms that perpetuate women’s vulnerability (UNAIDS, 2009). If we do not do this, the effectiveness of intervention strate- gies and prevention policies will continue to be limited. 11 In order to respond to gaps in awareness and understanding, the UNESCO Division for Gender Equality, in collaboration with the Division for Cultural Policies and Intercultural Dialogue, commissioned the Social Science Research Council (SSRC) to co-publish this volume that seeks to explore the sociocultural and gendered drivers of vulnerability and disempowerment. This work has been undertaken in the context of UNESCO’s firm com- mitment to gender equality as one of its two global priorities, alongside a fo- cus on Africa. It also reflects the organization’s ongoing efforts to promote its conviction that quality HIV and AIDS programmes must be based on holistic, rights-based and culturally appropriate approaches that seek to involve people living with HIV in a meaningful way and to promote and foster gender equality (UNESCO, 2007). We recognize the difficulty of operationalizing these policy commitments and hope that this publication will support decision-makers and practitioners working at both international and national levels by providing gendered analy- ses of epidemics and responses to them and by shedding new light on well- known challenges. By placing gender and culture at the centre of the discussion, this volume aims to help our readers articulate new entry points for effective gender-responsive and – hopefully – gender-transformative interventions that support tailored strategies. We thank all the contributors who have made this intellectual exploration possible. UNESCO is pleased to have collaborated with the SSRC, Jennifer Klot and Vinh-Kim Nguyen to make this important contribution to the growing body of knowledge on gender, culture and HIV. 12 References Forss, K. and Kruse, S. E. 2004. An Evaluation of UNESCO’s Response to HIV/AIDS. Oslo, Centre for Health and Social Development. UNAIDS (Joint United Nations Programme on HIV/AIDS). 2007. Programme Coordinating Board (PCB) Archive, 20th PCB meeting, June. http://www.unaids. org/en/AboutUNAIDS/Governance/PCBArchive/20070625-pcb20.asp (Accessed 13 June 2009.) ——. 2008. 2008 Report on the Global AIDS Epidemic. Geneva, UNAIDS. ——. 2009. UNAIDS Action Framework: Addressing Women, Girls, Gender Equality and HIV. Geneva, UNAIDS. UNAIDS/WHO (Joint United Nations Programme on HIV/AIDS/World Health Organization). 2006. AIDS Epidemic Update. Geneva, UNAIDS/WHO. UNESCO (United Nations Educational, Scientific and Cultural Organization). 2007. UNESCO’s Strategy for Responding to HIV and AIDS. Paris, UNESCO. UNIFEM (United Nations Development Fund for Women). 2008. Transforming the National AIDS Response – Mainstreaming Gender Equality and Women’s Human Rights into the ‘Three Ones’. New York, UNIFEM. 13 Introduction Jennifer F. Klot and Vinh-Kim Nguyen The HIV and AIDS pandemic both fuels and is fuelled by inequalities across gender, race, ethnicity and class. Its effects vary across different settings and regions of the world and are also shaped by armed conflicts, natural disasters, environmental degradation, state incapacities, famine and poverty. Its refrac- tory impacts on women and girls – and humanity writ large – are nothing short of catastrophic. The third decade of the pandemic is characterized by subepidemics that are now coursing through many parts of the globe and among groups previous- ly considered to be unaffected. Growing