When women from the predominantly rural Vulindela district in KwaZulu-Natal first began participating in an HIV-prevention trial many were unable to negotiate the use of condoms or even discuss safe sex with their partners. But as they used the discreet antiretroviral (ARV) microbicide gel, for the first time women – who bear the brunt of the HIV epidemic in Africa – were in control of an HIV-prevention method.

The microbicide applicator. Credit: CAPRISA

And empowerment for almost 900 women turned into hope for millions of women across Africa when the study showed a 39 percent success rate in the prevention of HIV and a 54 percent success rate in the prevention of herpes.

The groundbreaking research, which was first to use the ARV drug tenofovir as a gel, was released by the Centre for AIDS Programme of Research in South Africa (CAPRISA) at the XVIII International AIDS Conference in Vienna, Austria on Jul. 20.

“For me these women are champions for agreeing to use an unknown product. It needs to be investigated further to verify the results but the women are part of the break through,” said Mukelisiwe Mlotshwa, the research nurse and team leader for clinical procedures of the CAPRISA 004 microbicide trial.

The research dealt with the safety and effectiveness of the ARV microbicide gel and 889 randomly selection women considered to be at high risk of HIV infection participated. The study was conducted in the most affected HIV areas of South Africa, both of which are in KwaZulu Natal: Vulindlela, a rural area which has high rates of unemployment and a high migrant population; and Durban, an urban area.

The study was also double-blinded, meaning that the researcher as well as the participating women did not know whether they were receiving the tenofovir gel or the placebo gel.

Women were advised to use the gel up to 12 hours before sex and soon after having sex with a maximum of two doses in 24 hours. Those participating used the gel for a minimum of one year and a maximum of two and a half years.

Mlotshwa said the product played an important role in the women’s lives. “Most of these women used to say that ‘this product is so nice and so discreet’, so much so that their partner never knew they were using it at all. They told us that their partner could not feel anything as well.”

Even though the gel is seen as a discreet substance, nearly 70 percent of the women participating in the trial did disclose to their partners that they were using the microbicide gel. Only six percent of the partners reported a dislike for the women to use the gel.

Dr. Janet Frohlich, CAPRISA’s Vulindlela Clinical Research Site Director, explained to IPS that microbicides are a type of a gel substance which women can insert into the vagina or rectum which “we hope to show with this trial can help in the prevention of the spread of HIV.”

The microbicide gel contains one percent tenofovir, a common ARV drug used widely in the treatment of HIV.

If other studies prove the gel to be effective and confirm the results, the use of the gel would become widespread and offer women a higher level of protection, resulting in preventing over half a million new HIV infections in South Africa alone over the next decade estimate researchers.

Frohlich said that the research is a milestone as there are eleven trials with six different kinds of microbicide products, but this is the first trial of its kind to use ARVs. “As we know ARVs can be used in the prevention of HIV, and a gel can help in the prevention of transmission in heterosexual couples,” said Frohlich.

Women have never had the complete power to protect themselves against HIV infection, till now. “Like Ghana was Africa’s hope at the World Cup, this trial is for all of Africa. Women across Africa and globally who are not able to negotiate condom usage can now prevent HIV and herpes transmission on their own. Women now have the control over their health and well being,” explained Frohlich.

Doctor Quarraisha Abdool Karim, Associate Director of CAPRISA, study co-principal investigator and Associate Professor of Epidemiology at Columbia University agreed.

“This new technology has the potential to alter the course of the HIV epidemic, especially in southern Africa where young women bear the brunt of this devastating disease,” she said.

Empowerment

When the trial started women were counselled on risk reduction and condom use, and the importance of building relationships with their partners.

“We explained to the women that you cannot negotiate using a condom in bed. It’s too late. It must be done before,” Mlotshwa said.

“At the monthly check ups, you could see the women growing. You can see them becoming empowered and confident in their personal relationships.”

The counselling during CAPRISA 004 trial was so successful that morning health talks started for the women in the area.

“It was nice to see them growing in the study. They are now sharing information on HIV prevention amongst themselves,” Mlotshwa said.

The Next Step

“The study really needs to be confirmed,” insists Frohlich.

“We need to look at the different dosages of tenofovir ARV in the microbicide trail. This trial only used one percent of tenofovir. We also need to look at different ARVs.”

Frohlich said VOICE (Vaginal and oral intervention to curb the epidemic) trial, which is part of a set of trials across the globe, will help verify the CAPRISA 004 results. “The VOICE trial is being conducted through the Microbicide Trails Network, which a number of sites are conducting. The trial uses two ARVs; one is tenofovir and the other truvada and compares them to a placebo. CAPRISA is also participating and this will help us judge the study and confirm results.”

The CAPRISA 004 trial is funded by both the United States government as well as the South African government though the department of science and technology.

“Once the trial is confirmed, we will need to licence the product. Once this is done it needs to be made available to women. But as an ARV product, women will need to come to clinics every six months for checkups, like with any other ARV treatments.”

By Zahira Kharsany
JOHANNESBURG, Apr 8 2009 (IPS)

The Rome Statute, adopted in July 1998, enabled the formation of the International Criminal Court (ICC) in 2002. Since then the ICC has issued 12 arrest warrants, all against Africans.

The focus on Africa has led to criticism that the ICC only targets African and marginalised countries. This criticism has increased in recent months following the indictment of a sitting head of state, Sudan’s Omar al-Bashir.

An arrest warrant was issued in March for the Sudanese president, charging him with crimes against humanity including murder, rape and torture as well as war crimes in the Darfur region in Sudan.

Richard Dicker, programme director for international justice at Human Rights Watch, who advocated for the formation of the ICC in the 1990s, spoke to Zahira Kharsany about the reality behind the court and how the indictment has changed the ICC landscape. Excerpts of the interview follow.

IPS: There has been substantial criticism of the International Criminal Court (ICC) yet you argue that it is important for Africa. Why? Richard Dicker: I think some of the criticism is simply an effort to deflect attention from the enormous crimes committed against innocent people and the effort to bring those most responsible for those crimes to justice. What is important about the International Criminal Court is that it is time to bring justice for the mass slaughter of innocent people, the use of rape as a weapon of war and intimidation, the forced displacement of whole populations on account of their ethnicity or race, the court is trying to do that and serve African victims. The court is in favour of bringing justice to victims of horrific crimes for whom there would be no justice were it not for the international criminal court.

IPS: You were one of those that advocated for the establishment of the ICC even though the International Court of Justice was already in place. RD: It is important to understand that the court of justice is a very different type of court that deals with a very different set of laws and set of issues, for example the ICJ [International Court of Justice] covers boundary disputes, disputes over fishing rights, disputes over seizure of assets by one government over another government. All of these are what you might call civil law between states.

The ICC deals with individual responsibility for the most serious of crimes there are, genocide, crimes against humanity and war crimes. Thus the ICC is not duplicating the important work that the ICJ does and, given the impunity that is associated with these kinds of crimes in the latter part of the 20th century, the need for a permanent court to address these issues when a national authority is unable to do so was outstanding.

IPS: Since its launch in 2002, do you think that the ICC has fulfilled its mandate? RD: I think the ICC has made a lot of progress. It’s really only been six years since it came into being, since the judges were elected, since the prosecutor was elected, since they began to build a staff. In that six-year period the prosecutor has opened investigations in four different countries, the court has issued 12 arrest warrants, the prosecutor is considering opening investigations in other countries including Colombia, Afghanistan, Georgia, Kenya and one or two others.

So I think there has been a great deal of activity, a great deal of energy on the part of this court and for example witnesses have come forward to give testimony feeling confident that they will be protected by this court, victims have come forward to participate, not simply as witnesses but as actual participants in these trails. I think there is a great deal of positive that the court has achieved.

At the same time Human Rights Watch (HRW) sees shortcomings in the court’s work.

IPS: For the first time the ICC has issued a warrant for a sitting head of state. What challenges face the ICC especially since it seems that Omar al-Bashir has the support of neighbouring countries? RD: Lets be clear: the warrant issued for Omar al-Bashir transformed the landscape. I think it has brought a great deal of attention and a great deal of criticism – most of which I believe is unprincipled and driven by self interest motives. Nonetheless it certainly sparked a storm of controversy about the ICC. It reminds me of the controversy that existed in the United States when the Bush administration back in 2003/2004 tried to derail the court from really ever getting up off the ground.

In other words, the court is under assault from some particular Arab states, from some particular African states that are not party to the court treaty, who are functioning as surrogates for Omar al-Bashir and they have generated an enormous amount of distortion and propaganda about what this court is. Ultimately, as serious as this assault is, it will fail.

IPS: Can the same principles that led to Bashir’s indictment be used against powerful governments and people such as former U.S. president George Bush on the issue of torture? RD: I think that is an important question. HRW has worked tirelessly for the last five years to try and press for the creation in the United States of an independent commission to investigate allegations of torture for which George W Bush and others may be responsible.

Our view is that there needs to be efforts made by U.S. authorities to investigate and if, the evidence shows that criminal charges should be filed, we’d like to see that at least there be an opportunity in U.S. courts to pursue that. If not, I think those responsible – and I’m not saying that George W Bush is because I don’t have all the evidence – but there needs to be an investigation and if the investigation shows that there is a basis to charge him, and if courts in the United States don’t do their jobs to press for such a trial then I think we need to look beyond the U.S.

Sadly the U.S. is not a party to the Rome Statute [it is not one the countries that signed on to the establishment of the ICC] so there is not a jurisdictional basis here for the ICC to have authority over a former U.S. president or a U.S. official.

I think what that shows is the real unevenness that exists in the landscape when it comes to international justice. That’s a reality I don’t want to deny or cover-up. The fact is that leaders of those powerful governments are better insulated and protected from the reach of international justice. That is shameful and we have to work to minimise that disparity or that unevenness so that even the officials of the most powerful state such as the U.S. and the Russian federation, if their national courts don’t investigate allegations of mass crimes, then they too will be liable for investigation and prosecution by the ICC.

We are not there; we are not at that point yet. We have a ways to go to get to that point but that is the direction this whole process has to move in, to bring justice and to have legitimacy.

IPS: There is this criticism that the International Criminal Court (ICC) only targets weak and marginalised governments in Africa. Are you concerned that this perception may erode support in Africa? RD: Absolutely I’m concerned. I think that it is a damaging perception. All the more damaging because this court was created really by an alliance and a unity between active, vigorous participation of African states, Latin American states, European states and some states from Asia. And to see that unity fractured by distorted allegations that the court is unfairly targeting African personalities, I think is quite serious, and I believe that the engine that is driving this comes from Khartoum and similarly motivated or oriented governments that fear international justice, that fear accountability and will do anything to stop it. I think it will be stopped, but it is serious and shouldn’t be taken lightly.

The court needs to do more to get out to the communities most affected by the crimes in Africa and explain its mission and mandate more clearly to those communities. I think part of the reason this has had the currency it’s had is because the court is not done enough to explain in itself to these communities where the crimes have been committed.

Excerpt:

By Zahira Kharsany
JOHANNESBURG, Jan 23 2009 (IPS)

South Africa’s constitution is often celebrated for its protection of social and economic rights; but how readily can this protection be invoked by the most vulnerable?

Jackie Dugard Credit:

This question is one that may be considered at the first ever World Conference on Constitutional Justice, taking place in Cape Town on Feb. 23-24. Senior legal personnel from 93 countries will discuss the influence of constitutional courts on societies around the world and the development of global human rights jurisprudence.

To examine the host nation’s own experience of constitutional rights, IPS spoke to Jackie Dugard, a senior research officer at the Centre for Applied Legal Studies (CALS). Dugard was part of the legal team that won an important case in Johannesburg in 2008.

With support from CALS, Lindiwe Mazibuko and other residents of Phiri township successfully challenged the constitutionality of prepaid water meters being installed by the City of Johannesburg. A judge agreed that the city had to provide them conventional water meters and that the free basic water allowance of 6 kilolitres of water per household is insufficient.

Predictably, the case is under appeal, and is expected to eventually become the first water rights case to reach South Africa’s Constitutional Court.

IPS: How has the performance of the constitutional rights been in South Africa? Jackie Dugard: South Africa’s record, in general, on civil and political rights has been good. I think the Constitutional Court and other courts have been extremely good at defending people’s rights.

The problem has been socio-economic rights, because there have been so few cases and their decisions haven’t advanced a rights or violations-based interpretation of socio-economic rights. There has been only six socio-economic rights case in 14 years (three on housing, two on healthcare and one on social security).

Mounting a socio-economic case is extremely difficult. It’s very hard for people without huge resources and organisations to draw and mount these kinds of cases because the kind of evidence you have to put before the courts about the policies and reasonableness of the policies is just incredibly difficult.

In addition, although the Constitutional Court, formally, has the ability to hear direct access claims (ones that haven’t been through the rest of the judicial hierarchy), unfortunately, the South African Constitutional Court has interpreted the rules of direct access very narrowly, and has only allowed direct access in about eight cases and never to remedy a situation of a poor/disempowered person who might otherwise not have his/her claim heard in the normal hierarchy.

This is the opposite practice to the highest courts in countries like India, Columbia, Costa Rica, where the highest court actively promotes and facilitates direct access, to allow poor people who may not otherwise be able to bring their cases through the whole judicial hierarchy.

Unfortunately in South Africa we haven’t gone that progressive route. So I think for poor people the only way they can have their cases heard, if they are about socio-economic rights, is through partnering with the few legal interest organisations that exist.

So socio-economic rights in South Africa are a double-edged sword. On the one hand, South Africa can be proud of having entrenched socio-economic rights in the constitution and the Constitutional Court is looked at as an example of how these rights have been made justiciable.

But there has been a lot of criticism of how they have been adjudicated. Instead of adopting a minimum core content or violations approach, the Constitutional Court has adopted a weaker standard – the test of reasonableness.

Essentially this reasonable test is a very complicated, laborious difficult thing. Because it means you have to really become more of an expert in government policies then they are. That requires time, resources, focus etcetera which again many organisations don’t have.

The last reason why I think socio-economic cases have not come to the fore is that so far the remedy that the courts have offered is not tangible to the people. Because the whole thing revolves around the reasonableness of the government policy, the remedy has been to remedy the policy. So classically what happened in the famous Grootboom case, around the issue of housing, is she died recently before she ever got a house.

Many poor communities ask: What’s the point? What’s the point of going to court? What’s the point in launching these enormous battles when in fact you don’t get anything in the end?

I think we have an extraordinary constitution. I believe unfortunately that the courts have not actually persuaded it to the extent of its power.

IPS: Leading up to the world conference, do you think this is beneficial to constitutional courts across the world? What has South Africa got to offer the 93 countries attending? JD: Yes I think we do. I think it is a very positive thing. What is interesting to do is to share experiences, particularly with Latin America about what they do to facilitate poor people’s voice in court. I think this is our big failing.

Apart from the criminal justice system, that’s all defensive. When somebody is caught up in the criminal justice system they are provided with defence, but the issue obviously then is, it’s not a proactive utilisation of the laws.

That’s the interesting thing about socio-economic rights, particularly regarding the positive obligations perspective. In terms of negative obligations, for example, if you going to be evicted from your house then yes of course you act. But it’s on these positive obligations that you really see whether people look to law as one of their answers or one of their potential answers. I think the jury is out on that.

Essentially what’s interesting to look at other courts and to have this exchange with other courts is to see how other courts are dealing with these issues. There are courts actually with much less high profile then South Africa, South Africa is always lauded, but other countries are quietly doing it every day.

I gather in Brazil judges regularly when someone comes to them and says ‘I’ve got cancer, I can’t afford the drugs’, the judge will write a prescription and say ‘go to the pharmacy and get it for free’.

Law is a conservative profession; it is as essentially you applying something which exists. So it tends to ossify unless you have dynamism within it. So I think these sorts of exchanges are a form of dynamism.

Almost, if not, all South African judges have studied law without much reference to socio-economic rights jurisprudence. So many judges don’t know where to look to get inspiration on how to tackle these socio-economic rights cases. I think that hopefully some interesting things will come out from the conference.

Excerpt:

The latest UNAIDS Report estimated that 33 million people around the globe are living with HIV; 22 million in Sub-Saharan Africa alone. Around 2.7 million new HIV infections occurred worldwide in 2007. However, encouraging new data suggests there have been significant gains in preventing new infections in several African countries with high prevalence rates.

According to the report, changes in sexual behaviour in Rwanda and Zimbabwe have led to a decline in the number of new HIV infections, while young people in countries such as Burkina Faso, Ethiopia, Ghana, Malawi, Uganda and Zambia are waiting longer to have sexual intercourse.

There is a new emphasis amongst AIDS campaigners on “knowing your epidemic”, that is to say analysing the local situation in terms of the specific factors driving the epidemic and knowing precisely who is infected and then seeking the best way to act on this information.

Rwanda is classified among the ten African countries most severely affected by HIV/AIDS pandemic. But, recognising the negative development impact of the disease, the government has demonstrated strong commitment to both HIV prevention and treatment.

Among its successful initiatives is an effort to involve male partners in the prevention of mother to child transmission.

“When I look back to 2004, we just had 6 percent of male partners accompanying their wives to check up clinics,” says doctor Anita Asiimwe, executive secretary of the National Aids Control Commission in Rwanda, “but today we have figures as high as 64 percent.”

As a result, the stigma related to HIV/AIDS has been reduced and the number of women who visit pre-natal clinics for checkups has increased. Asiimwe says women take hope from knowing they can rely on the support of their partners in countering the disease and its effects.

“When the father knows why the woman is doing this, then they are they are able to protect them from the other members of the family or society. The man can stand in and explain that, no me and my wife have decided not to breastfeed so there are no questions.”

According to government statistics, the AIDS prevalence rate in Rwanda had fallen to three percent in 2008, down from seven percent in 2000. Almost 90 percent of children born to HIV+ mothers are virus-free; a huge gain on the less than 40 percent rate just two years ago.

The news from Kenya is not so encouraging. Two studies done on the general population indicate that HIV/AIDS is on the increase. The 2003 Kenya demographic health survey – which is the most recent survey done – showed an HIV/AIDS prevalence of 6.7 percent. The Kenya AIDS Indicator Survey released in 2008 shows the prevalence rate to have risen to 7.8 percent by end of last year.

Health experts say Kenya’s prevention strategy has failed to effectively target specific high risk groups that seem to be driving the epidemic.

“It is not good enough to just continue talking about VCTs [voluntary counselling and testing] as usual, we must now begin to look at individuals who fall into high risk groups and be able to target preventable strategies to these specific groups; people who sell sex, people who buy sex, regardless of the kind of sex they buy,” Omu Anzala, director of the Kenya AIDS Vaccine Initiative told IPS.

The focus of preventive messages is now shifting from awareness creation – over 90 percent of Kenyans are aware of HIV/AIDS – to addressing specific risk groups. For example, the current HIV/AIDS messages do not address the needs of homosexuals and drug users.

Anzala says new messaging must be combined with ensuring that those already infected and in need of treatment are put on anti-retroviral therapy (ART). Despite efforts to provide effective treatment and monitoring, the emergence of resistant strains of HIV remains a key challenge.

Some vital tests like viral load and liver function tests are very expensive, costing over 60 dollars for a single test. Yet without them, proper management of antiretroviral treatment is impossible.

“Those are the things that now must be looked at critically as we roll out and put more and more people on antiretroviral drugs. By failing to do that, we are just again brewing up a problem that is going to explode more in the near future,” warns Anzala.

In South Africa, an extremely high background prevalence of HIV increases the probability of new infections, particularly among young women aged 18-24, according to Quarraisha Abdool Karim, associate scientific director at the Centre for the Aids Programme of Research in South Africa (CAPRISA). Sexual relationships with older men often put young women in a vulnerable position in terms of demanding safer sex, or knowing their partner’s sexual history or status.

“We still have a standardised cookie cutter approach to prevention – ABC (Abstinence-Be faithful-Condom use),” says Quarraisha. “We are still not discussing protective effects of medical male circumcision. We are not targeting our intervention. We do not have adequate coverage of interventions that work, knowledge of HIV status and personal risk is low.”

By contrast, Ethiopia’s HIV prevalence stands at 2.2 percent – for men. But according to Berhane Kelkay, an Ethiopian AIDS activist, the prevalence rate for Ethiopian women is nearly 20 percent higher.

“The reason why women are more vulnerable is due to early marriages arranged by families in various regions, violence such as abduction, rape and circumcisions. The other reason is also because prostitution is rampant in most towns of the country.”

Kelkay has been living with the virus for 16 years, and is head of the National Network of Positive Women which is a network of 22 associations of positive women all over the Ethiopia.

When she officially started campaigning against the virus three years ago, she was the only woman head of an HIV/AIDS association. Now all the associations in her network are led by women.

Kelkay believes there has been some progress in the fight against AIDS, but there is much more to be done. “There is indeed an achievement from our campaign,” Berhane said. “But I am far from being satisfied. Still people are being infected with the virus. I don’t feel really satisfied until I see the last person to be caught with the virus.”

*Eunice Wanjiru in Kigali, Joyce Mulama in Nairobi, and Michael Chebsi in Addis Ababa contributed to this report.