The Vanishing Mothers of Africa

Editor's Note: The following is adapted from Stephen Lewis's keynote speech at the 2004 Microbicides Conference.

If there's one constant throughout the years I've been U.N. Special Envoy – years spent traversing the African continent – it's the thus-far irreversible vulnerability of women. It goes without saying that the virus has targeted women with a raging, Darwinian ferocity. It goes equally without saying that gender inequality is what sustains and nurtures the virus, causing women to be infected in ever greater, disproportionate numbers.

The report issued by UNAIDS on the eve of the 2002 International AIDS Conference identified startling percentages of infected women. UNICEF's Carol Bellamy used a phrase there that would become a mantra: "AIDS has a woman's face."

Women's acute vulnerability didn't happen overnight. What should shock us is how long the world took to focus. Why was it only in 2003 that a U.N. Task Force on the plight of women in Southern Africa was appointed? Why did it take until 2004 to form a Global Coalition on Women and AIDS? Why have we allowed a continuing pattern of sexual carnage so grave as to lose an entire generation of women and girls?

In 2003, Botswana did a study on HIV prevalence. In urban areas, for women and girls ages 15 to 19, the prevalence rate was 15.4 percent; for men and boys the same age, 1.2 percent. For women between 20 and 24, the rate was 29.7 percent; for men that age, 8.4 percent. For women between 25 and 29, the rate was 54.1 percent; for men, 29.7 percent. The reason we've observed – and still do, without taking decisive action – this wanton attack on women is because it's happening to women.

African countries, external powers, bilateral donors, even the U.N. – no one shouted from rhetorical rooftops or called an international conference, although in the 1990s it seemed that all we had time for were international conferences. This is the ultimate vindication of the feminist analysis. When the rights of women are involved, the world goes into reverse. For more than 20 years, the numbers of infected women grew exponentially.

Now, virtually half the infections in the world are among women – and in Africa the rate is 58 percent, rising to 75 percent between the ages of 15 and 24. This is a cataclysm. Yet while finally (after the doomsday clock passed midnight) we're starting to get agitated, little is changing. Believe me; on the ground, where women live and die, very little is changing.

A few years ago, I visited the prenatal health clinic in Kigali, Rwanda, meeting with women who had decided to take a course of nevirapine. They were excited and hopeful, but asked a poignant question: "We'll do anything to save our babies, but what about us?"

Back then, more than four years after antiretrovirals were in widespread use in the West, we simply watched the mothers die. Today, thanks to the Columbia School of Public Health, funded by several foundations and USAID, and working with the Elizabeth Glaser Foundation, UNICEF and governments, the strategy of PMTCT-Plus (Prevention of Mother to Child Transmission Plus) has begun in several countries, where the "Plus" represents treatment of the mothers and partners – indeed, the entire family.

But it's a slow, incremental process. In principle, the majority of such women will one day fall under public antiretroviral treatment through their ministries of health. But there's no guarantee of when, or if, that day will dawn. It's entirely possible that men will be at the front of the bus. Everything proceeds at a glacial pace when responding to the needs and rights of women.

We deplore patterns of sexual violence against women – violence that transmits the virus – but the malevolent patterns continue. We lament the use of rape as an instrument of war, but in eastern Congo and western Sudan, possibly the worst-known episodes of sexual cruelty and mutilation are occurring, and the world barely notices. We see Rwanda's women survivors, now suffering full-blown AIDS, demonstrating how such stories end.