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Aristotle’s View of Women

Much of what's wrong today, between the genders, is because of his theories, still revered in our schools.

https://sites.google.com/site/chronologyofwomenshistory/essays/aristotle-s-view-of-women

The Greek philosopher Aristotle (384-324 B.C.) was Plato’s most brilliant student.  His biological theories have influenced the course of Western scientific inquiry up to modern times.  For example, his ideas about conception and embryology endured until the invention of the microscope in 1665 enabled scientists to observe the stages of the embryo’s development,  His description of women as defective or incomplete men, as quasi monsters, in fact, is still reflected in Freud’s late-19^th-century psychoanalytical theories about female sexuality.

Consistent with his theory that women were physically and psychologically incomplete, Aristotle maintained that men’s superiority lay in their greater size, strength, agility, and power of intellect.  Females, he believed, were mere matter, males were spirit and mind.  Pregnant women were merely vessels, or passive incubators, for the embryo, formed from the male seed alone.

Aristotle regarded women as unfit for freedom or political action, passive by nature, and subject to the rule of their husbands.  He took for granted that women’s proper sphere was the household; that they might assume political leadership was out of the question.  Pointing to the fall of Sparta as proof of women’s baneful influence on public affairs, he attributed the city’s demise to the excessive freedom – in education, physical training, and civic responsibilities shared with men – enjoyed by Spartan women.  The public/private polarization by which he justified withholding citizenship from Athenian women provided a rationale for maintaining women’s second class status in the West for many scholars.

Dahomey’s Women Warriors

http://www.smithsonianmag.com/history/dahomeys-women-warriors-88286072/?no-ist

One of Dahomeys' women warriors, with a musket, club, dagger—and her enemy's severed head. From Forbes, Dahomy and the Dahomans (1851).

For the better part of 200 years, thousands of female soldiers fought and died to expand the borders of their West African kingdom. Even their conquerors, the French, acknowledged their "prodigious bravery."

By Mike Dash

smithsonian.com September 23, 2011

It is noon on a humid Saturday in the fall of 1861, and a missionary by the name of Francesco Borghero has been summoned to a parade ground in Abomey, the capital of the small West African state of Dahomey. He is seated on one side of a huge, open square right in the center of the town–Dahomey is renowned as a “Black Sparta,” a fiercely militaristic society bent on conquest, whose soldiers strike fear into their enemies all along what is still known as the Slave Coast. The maneuvers begin in the face of a looming downpour, but King Glele is eager to show off the finest unit in his army to his European guest.

As Father Borghero fans himself, 3,000 heavily armed soldiers march into the square and begin a mock assault on a series of defenses designed to represent an enemy capital. The Dahomean troops are a fearsome sight, barefoot and bristling with clubs and knives. A few, known as Reapers, are armed with gleaming three-foot-long straight razors, each wielded two-handed and capable, the priest is told, of slicing a man clean in two.

The soldiers advance in silence, reconnoitering. Their first obstacle is a wall—huge piles of acacia branches bristling with needle-sharp thorns, forming a barricade that stretches nearly 440 yards. The troops rush it furiously, ignoring the wounds that the two-inch-long thorns inflict. After scrambling to the top, they mime hand-to-hand combat with imaginary defenders, fall back, scale the thorn wall a second time, then storm a group of huts and drag a group of cringing “prisoners” to where Glele stands, assessing their performance. The bravest are presented with belts made from acacia thorns. Proud to show themselves impervious to pain, the warriors strap their trophies around their waists.

The general who led the assault appears and gives a lengthy speech, comparing the valor of Dahomey’s warrior elite to that of European troops and suggesting that such equally brave peoples should never be enemies. Borghero listens, but his mind is wandering. He finds the general captivating: “slender but shapely, proud of bearing, but without affectation.” Not too tall, perhaps, nor excessively muscular. But then, of course, the general is a woman, as are all 3,000 of her troops. Father Borghero has been watching the King of Dahomey’s famed corps of “amazons,” as contemporary writers termed them—the only female soldiers in the world who then routinely served as combat troops.

Dahomey–renamed Benin in 1975–showing its location in West Africa. Map: CIA World Factbook.

When, or indeed why, Dahomey recruited its first female soldiers is not certain. Stanley Alpern, author of the only full-length Engish-language study of them, suggests it may have been in the 17th century, not long after the kingdom was founded by Dako, a leader of the Fon tribe, around 1625. One theory traces their origins to teams of female hunters known as gbeto, and certainly Dahomey was noted for its women hunters; a French naval surgeon named Repin reported in the 1850s that a group of 20 gbeto had attacked a herd of 40 elephants, killing three at the cost of several hunters gored and trampled. A Dahomean tradition relates that when King Gezo (1818-58) praised their courage, the gbeto cockily replied that “a nice manhunt would suit them even better,” so he drafted them drafted into his army. But Alpern cautions that there is no proof that such an incident occurred, and he prefers an alternate theory that suggests the women warriors came into existence as a palace guard in the 1720s.

Women had the advantage of being permitted in the palace precincts after dark (Dahomean men were not), and a bodyguard may have been formed, Alpern says, from among the king’s “third class” wives–those considered insufficiently beautiful to share his bed and who had not borne children. Contrary to 19th century gossip that portrayed the female soldiers as sexually voracious, Dahomey’s female soldiers were formally married to the king—and since he never actually had relations with any of them, marriage rendered them celibate.

Dahomey's female hunters, the gbeto, attack a herd of elephants.

At least one bit of evidence hints that Alpern is right to date the formation of the female corps to  the early 18th century: a French slaver named Jean-Pierre Thibault, who called at the Dahomean port of Ouidah in 1725, described seeing groups of third-rank wives armed with long poles and acting as police. And when, four years later, Dahomey’s women warriors made their first appearance in written history, they were helping to recapture the same port after it fell to a surprise attack by the Yoruba–a much more numerous tribe from the east who would henceforth be the Dahomeans’ chief enemies.

Dahomey’s female troops were not the only martial women of their time. There were at least a few contemporary examples of successful warrior queens, the best-known of whom was probably Nzinga of Matamba, one of the most important figures in 17th-century Angola—a ruler who fought the Portuguese, quaffed the blood of sacrificial victims, and kept a harem of 60 male concubines, whom she dressed in women’s clothes. Nor were female guards unknown; in the mid-19th century, King Mongkut of Siam (the same monarch memorably portrayed in quite a different light by Yul Brynner in The King and I) employed a bodyguard of 400 women. But Mongkut’s guards performed a ceremonial function, and the king could never bear to send them off to war. What made Dahomey’s women warriors unique was that they fought, and frequently died, for king and country. Even the most conservative estimates suggest that, in the course of just four major campaigns in the latter half of the 19th century, they lost at least 6,000 dead, and perhaps as many as 15,000. In their very last battles, against French troops equipped with vastly superior weaponry, about 1,500 women took the field, and only about 50 remained fit for active duty by the end.

King Gezo, who expanded the female corps from around 600 women to as many as 6,000. Picture: Wikicommons.

None of this, of course, explains why this female corps arose only in Dahomey. Historian Robin Law, of the University of Stirling, who has made a study of the subject, dismisses the idea that the Fon viewed men and women as equals in any meaningful sense; women fully trained as warriors, he points out, were thought to “become” men, usually at the moment they disemboweled their first enemy. Perhaps the most persuasive possibility is that the Fon were so badly outnumbered by the enemies who encircled them that Dahomey’s kings were forced to conscript women. The Yoruba alone were about ten times as numerous as the Fon.

Backing for this hypothesis can be found in the writings of Commodore Arthur Eardley Wilmot, a British naval officer who called at Dahomey in 1862 and observed that women heavily outnumbered men in its towns—a phenomenon that he attributed to a combination of military losses and the effects of the slave trade. Around the same time Western visitors to Abomey noticed a sharp jump in the number of female soldiers. Records suggest that there were about 600 women in the Dahomean army from the 1760s until the 1840s—at which point King Gezo expanded the corps to as many as 6,000.

No Dahomean records survive to explain Gezo’s expansion, but it was probably connected to a defeat he suffered at the hands of the Yoruba in 1844. Oral traditions suggest that, angered by Dahomean raids on their villages, an army from a tribal grouping known as the Egba mounted a surprise attack that that came close to capturing Gezo and did seize much of his royal regalia, including the king’s valuable umbrella and his sacred stool. “It has been said that only two amazon ‘companies’ existed before Gezo and that he created six new ones,” Alpern notes. “If so, it probably happened at this time.”

Women warriors parade outside the gates of a Dahomean town, with the severed heads of their defeated foes adorning the walls.

Recruiting women into the Dahomean army was not especially difficult, despite the requirement to climb thorn hedges and risk life and limb in battle. Most West African women lived lives of forced drudgery. Gezo’s female troops lived in his compound and were kept well supplied with tobacco, alcohol and slaves–as many as 50 to each warrior, according to the noted traveler Sir Richard Burton, who visited Dahomey in the 1860s. And “when amazons walked out of the palace,” notes Alpern, “they were preceded by a slave girl carrying a bell. The sound told every male to get out of their path, retire a certain distance, and look the other way.” To even touch these women meant death.

"Insensitivity training": female recruits look on as Dahomean troops hurl bound prisoners of war to a mob below.

While Gezo plotted his revenge against the Egba, his new female recruits were put through extensive training. The scaling of vicious thorn hedges was intended to foster the stoical acceptance of pain, and the women also wrestled one another and undertook survival training, being sent into the forest for up to nine days with minimal rations.

The aspect of Dahomean military custom that attracted most attention from European visitors, however, was “insensitivity training”—exposing unblooded troops to death. At one annual ceremony, new recruits of both sexes were required to mount a platform 16 feet high, pick up baskets containing bound and gagged prisoners of war, and hurl them over the parapet to a baying mob below. There are also accounts of female soldiers being ordered to carry out executions. Jean Bayol, a French naval officer who visited Abomey in December 1889, watched as a teenage recruit, a girl named Nanisca “who had not yet killed anyone,” was tested. Brought before a young prisoner who sat bound in a basket, she:

walked jauntily up to , swung her sword three times with both hands, then calmly cut the last flesh that attached the head to the trunk… She then squeezed the blood off her weapon and swallowed it.

It was this fierceness that most unnerved Western observers, and indeed Dahomey’s  African enemies. Not everyone agreed on the quality of the Dahomeans’ military preparedness—European observers were disdainful of the way in which the women handled their ancient flintlock muskets, most firing from the hip rather than aiming from the shoulder, but even the French agreed that they “excelled at hand-to-hand combat” and “handled admirably.”

For the most part, too, the enlarged female corps enjoyed considerable success in Gezo’s endless wars, specializing in pre-dawn attacks on unsuspecting enemy villages. It was only when they were thrown against the Egba capital, Abeokuta, that they tasted defeat. Two furious assaults on the town, in 1851 and 1864, failed dismally, partially because of Dahomean overconfidence, but mostly because Abeokuta was a formidable target—a huge town ringed with mud-brick walls and harboring a population of 50,000.

Béhanzin, the last king of an independent Dahomey.

By the late 1870s Dahomey had begun to temper its military ambitions. Most foreign observers suggest that the women’s corps was reduced to 1,500 soldiers at about this time, but attacks on the Yoruba continued. And the corps still existed 20 years later, when the kingdom at last found itself caught up in the “scramble for Africa,” which saw various European powers competing to absorb slices of the continent into their empires. Dahomey fell within the French sphere of influence, and there was already a small French colony at Porto-Novo when, in about 1889, female troops were involved in an incident that resulted in a full-scale war. According to local oral histories, the spark came when the Dahomeans attacked a village under French suzerainty whose chief tried to avert panic by assuring the inhabitants that the tricolor would protect them. “So you like this flag?” the Dahomean general asked when the settlement had been overrun. “Eh bien, it will serve you.” At the general’s signal, one of the women warriors beheaded the chief with one blow of her cutlass and carried his head back to her new king, Béhanzin, wrapped in the French standard.

The First Franco-Dahomean War, which ensued in 1890, resulted in two major battles, one of which took place in heavy rain at dawn outside Cotonou, on the Bight of Benin. Béhanzin’s army, which included female units, assaulted a French stockade but was driven back in hand-to-hand fighting. No quarter was given on either side, and Jean Bayol saw his chief gunner decapitated by a fighter he recognized as Nanisca, the young woman he had met three months earlier in Abomey as she executed a prisoner. Only the sheer firepower of their modern rifles won the day for the French, and in the battle’s aftermath Bayol found Nanisca lying dead. “The cleaver, with its curved blade, engraved with fetish symbols, was attached to her left wrist by a small cord,” he wrote, “and her right hand was clenched around the barrel of her carbine covered with cowries.”

In the uneasy peace that followed, Béhanzin did his best to equip his army with more modern weapons, but the Dahomeans were still no match for the large French force that was assembled to complete the conquest two years later. That seven-week war was fought even more fiercely than the first. There were 23 separate battles, and once again female troops were in the vanguard of Béhanzin’s forces. The women were the last to surrender, and even then—at least according to a rumor common in the French army of occupation—the survivors took their revenge on the French by covertly substituting themselves for Dahomean women who were taken into the enemy stockade. Each allowed herself to be seduced by French officer, waited for him to fall asleep, and then cut his throat with his own bayonet.

A group of women warriors in traditional dress. Picture: Wikicommons.

Their last enemies were full of praise for their courage. A French Foreign Legionnaire named Bern lauded them as “warrioresses… fight with extreme valor, always ahead of the other troops. They are outstandingly brave … well trained for combat and very disciplined.” A French Marine, Henri Morienval, thought them “remarkable for their courage and their ferocity… flung themselves on our bayonets with prodigious bravery.”

Most sources suggest that the last of Dahomey’s women warriors died in the 1940s, but Stanley Alpern disputes this. Pointing out that “a woman who had fought the French in her teens would have been no older than 69 in 1943,” he suggests, more pleasingly, that it is likely one or more survived long enough to see her country regain its independence in 1960. As late as 1978, a Beninese historian encountered an extremely old woman in the village of Kinta who convincingly claimed to have fought against the French in 1892. Her name was Nawi, and she died, aged well over 100, in November 1979. Probably she was the last.

What were they like, these scattered survivors of a storied regiment? Some proud but impoverished, it seems; others married; a few tough and argumentative, well capable, Alpern says, of “beating up men who dared to affront them.” And at least one of them still traumatized by her service, a reminder that some military experiences are universal. A Dahomean who grew up in Cotonou in the 1930s recalled that he regularly tormented an elderly woman he and his friends saw shuffling along the road, bent double by tiredness and age. He confided to the French writer Hélène Almeida-Topor that

one day, one of us throws a stone that hits another stone. The noise resounds, a spark flies. We suddenly see the old woman straighten up. Her face is transfigured. She begins to march proudly… Reaching a wall, she lies down on her belly and crawls on her elbows to get round it. She thinks she is holding a rifle because abruptly she shoulders and fires, then reloads her imaginary arm and fires again, imitating the sound of a salvo. Then she leaps, pounces on an imaginary enemy, rolls on the ground in furious hand-t0-hand combat, flattens the foe. With one hand she seems to pin him to the ground, and with the other stabs him repeatedly. Her cries betray her effort. She makes the gesture of cutting to the quick and stands up brandishing her trophy….

Female officers pictured in 1851, wearing symbolic horns of office on their heads.

She intones a song of victory and dances:

The blood flows,

You are dead.

The blood flows,

We have won.

The blood flows, it flows, it flows.

The blood flows,

The enemy is no more.

But suddenly she stops, dazed. Her body bends, hunches, How old she seems, older than before! She walks away with a hesitant step.

She is a former warrior, an adult explains…. The battles ended years ago, but she continues the war in her head.

Sources

Hélène Almeida-Topor. Les Amazones: Une Armée de Femmes dans l’Afrique Précoloniale. Paris: Editions Rochevignes, 1984; Stanley Alpern. Amazons of Black Sparta: The Women Warriors of Dahomey. London: C. Hurst & Co., 2011; Richard Burton. A Mission to Gelele, King of Dahome. London: RKP, 1966; Robin Law. ‘The ‘Amazons’ of Dahomey.’ Paideuma 39 (1993); J.A. Skertchley. Dahomey As It Is: Being a Narrative of Eight Months’ Residence in that Country, with a Full Account of the Notorious Annual Customs… London: Chapman & Hall, 1874.

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HIV STIGMA IN KENYAN WOMEN

January 9, 2013 · by Elisabeth Epstein · in Health. ·

Image courtesy of Aid for Africa

According to UNAIDS, approximately 32.7 million people around the world were living with HIV at the end of 2009; seventeen million of whom were women (UNAIDS, 2010).  The UNAIDS Commission, taking a human rights approach to HIV/AIDS, declared that women’s cultural vulnerability makes them more susceptible to disease exposure.  The report states the following:

In Sub-Saharan Africa, prevalence among teenage girls in some countries is five times higher than that of teenage boys.  Most of these infections occur as a result of unprotected heterosexual intercourse.  Women’s low economic and social status limits their power to negotiate the use of a condom, discuss infidelity with their partners, or leave risky relationships.  Such disempowerment increases their vulnerability to HIV.  Socio-economic and sexual discrimination thus experienced by women can ultimately become life threatening (Mwaura, 2008). 

In Kenya, estimated numbers of people living with HIV (PLHIV) range from 1,300,000 to 1,600,000, as many individuals fail to report their disease status (UNICEF, 2010). At 38 percent, death from HIV/AIDS and its complications is a Kenyan’s most likely cause of death, thereby forcing individuals to live in a constant state of awareness to the harsh reality of a positive HIV diagnosis (World Health Organization, 2006). With a countrywide HIV prevalence of 6.3 percent, the disease demonstrates itself to be highly virulent and lethal to equate to such a disproportionately high mortality rate (UNICEF, 2010).  As a result, many non-profit organizations currently work in Kenya to aid government efforts to control the HIV/AIDS epidemic.  However, the difficulties in treating the epidemic lie deeper than merely supplying sufficient antiretroviral medications and medical personnel.  In order to effectively contain and address the HIV/AIDS epidemic, health workers and government officials must also understand and work towards the elimination of the cultural stigma surrounding the epidemic in Kenya.  Although there are no hard indicators demonstrating whether or not women feel stigmatized by an HIV positive diagnosis, one can extrapolate its presence upon surveying surrounding lifestyle indicators including domestic abuse, women in the labor force, nutrition, and ideas of “womanhood.”

Stigma, “the condition of being considered unworthy of devalued in the estimation of others due to having an alleged fault or character trait,” is an unfortunate consequence for many Kenyans living with HIV/AIDS (Mwaura, 2008).  By reinforcing other prejudices, especially that of gender, HIV/AIDS-related stigma increases one’s vulnerabilities and exacerbates the impact of infection.  A violation of fundamental human rights, statistically higher levels of discriminatory and stigmatized practices are aimed towards women than their male counterparts.  In Kenya, the community perceives HIV positive women as a disgrace and a threat to the family’s social status, security and well-being, thereby stigmatizing the disease.  Culturally deemed worthless if unable to bear a child, cultural stigmas regarding motherhood thereby increase the possibility for mother-to-child (MTC) HIV transmission by pressuring high-risk women to have children (Mwaura, 2008).

Kenyan women often suffer as the victims of domestic abuse.  According to the Crime Scene Investigation Nairobi, 40,500 women in Nairobi reported being raped between December 30^th 2007 and June 20^th 2008; however, the actual figure could be more than three times higher since it is unable to account for unreported cases (Crime Scene Investigation, 2008; Institute of Economic Affairs: Kenya, 2008). To put that figure into perspective, that amounts to 30.2 reported cases for every 100,000 people whereas the United States reports only 3.5 cases (Harrendof et al, 2010). Unfortunately, the amount of rape cases is not surprising after accounting for relative attitudes towards domestic abuse.  In a study conducted by UNICEF, researchers found that 54 percent of men and 57 percent of women aged 15 to 19 thought that a husband was justified to beat his wife under certain circumstances (UNICEF, 2010).  Surprisingly, the females surveyed believed they “deserved it” to a higher extent than male survey participants, thus demonstrating a cultural passivity and a belief of male dominance among the females (UNICEF, 2010).  In the context of HIV/AIDS, these two traits do not bode well for women.

As women are disproportionately affected by the HIV epidemic, 3.5 percent men versus 6.7 percent women, some men feel women are to blame women for spreading the virus (Institute of Economic Affairs: Kenya, 2008).  Not surprisingly, one factor affecting the spread of HIV/AIDS in Kenya is the cultural acceptance of polygamous marital relationships.  Although women in polygamous relationships are only allowed one sexual partner, the husband is allowed to sexually experiment with unmarried women under the pretense of courting potential wives (Moogi Gwako, 1998).  In a report conducted by the Kenya National Bureau of Statistics, research showed that 21.5 percent of men aged 15 to 49 engaged in polygamous unions involving two or more wives in 2008 to 2009 (Kenya National Bureau of Statistics, 2010).  According to UNAIDS, HIV prevalence is twice as high in polygamous unions (12.9 percent) than in monogamous marriages (6.1 percent) (Human Rights Watch, 2008).  Women in polygamous marriages are therefore at higher risk for HIV infection, since every co-wife shares equal risk of infection.  In polygamous marriages, HIV positive women often blame other co-wives for the tragedies inflicted upon their lives and fear that husbands will ignore them in favor of disease-free wives and/or abandon them with their children (Moogi Gwako, 1998; Human Rights Watch, 2008).  This fear of the consequences of disease disclosure – abandonment, further poverty, the unknown – further stigmatizes the HIV epidemic (Human Rights Watch, 2008).

Additionally, in a society where many women believe beatings, both physical and sexual, are justifiable, many are hesitant to be forthright in coming forward with their diagnosis, as there may be negative repercussions in the form of physical violence from their husbands. In a 2007 study, investigators found that women in polygamous relationships were significantly more likely to report exposure to physical, emotional, sexual, and any/all types of violence than their monogamous peers (Lawoko, 2007).  However, if a woman does not disclose the information, the virus has the opportunity to spread to her husband and possibly others.  According to a survey conducted by the United Nations Statistics Division, 39.5 percent of Kenyan single women aged 15 to 24 used condoms during high-risk sexual intercourse in 2009.  After marriage, the percentage of women wearing condoms during high-risk sexual intercourse dropped to only four percent thereby endangering their lives and the lives of their husbands (Index Mundi, 2009).  Additionally, women’s passive attitude towards beatings only helps to make others in society agree that she deserved the harsh treatment, especially concerning the HIV/AIDS crisis.  If a woman experiences violence upon revealing her HIV status and does not attempt to fight back, she has only strengthened the stigma of the virus in the eyes of the surrounding women.  Therefore, until domestic violence is controlled and women gain equality in domestic relationships, stigma surrounding the HIV/AIDS epidemic will remain and disproportionately affect women in Kenyan society.

In addition to negatively affecting interpersonal relationships, the stigma associated with HIV positive women permeates throughout society in areas such as land rights. Beginning with the 1954 Swynnerton Plan and continuing throughout the post-independence era, Kenya’s land reform programs have long been criticized by scholars for limiting available land for vulnerable and disadvantaged groups thereby increasing food insecurities and escalating social and gender inequalities (Quan, 2000). In particular, researchers have deemed “rigiditization” a serious consequence that has negatively impacted a woman’s right to own land (Aliber & Walker, 2006).  Rigiditization, the process whereby “land adjudication inevitably introduces finiteness and rigidity and thus harshly disrupts the old flexible system,” appeared as a result of the influence of British colonialism and most closely resembles English property law (Aliber & Walker, 2006).  According to the recent report titled, A National Report on Kenya, the government claimed that its land adjudication and resettling programs have helped to solve issues of food insecurities and access to land rights (National Report on Kenya, 2006). However, for populations like the 3.8 million pastoralists throughout Kenya that live the traditional nomadic lifestyle that affords a more communal approach to land rights, the individualistic mindset surrounding the new land reform policies inevitably expropriates women from gaining ownership of the land by favoring societal male dominance (Smith, 2006).

In Kenyan society, women are at an inherent disadvantage when it comes to land ownership.  Recent land reform policies have done little to address this unfair standing. Under customary land tenure systems, women are forbidden to own or control land.  According to Lily Murei, Monitoring and Evaluation Officer for the Kenya Land Alliance (KLA), “we have different cultural systems [that] believe women cannot even be acknowledged to own land…[Y]ou talk of land and cows and all that property that men have, they also put women as part of their property” (Georgetown University, 2010). In 1985, the Kenyan Members of Parliament shelved a bill that would have created a central marriage registry and law that recognized a spouse’s equal right to property for reasons that it would interfere with a husband’s ability to “chastise” his wives (Human Rights Watch, 2003). With the adoption of land registration policies, which neglected to include women into its adjudication, all land ownership became directly transferred to the husband (FAO, 2011). The Constitution of Kenya condones gender discrimination yet protects private  (i.e. registered) property owners regardless of how it was acquired,[1] thereby further excluding women’s capabilities of owning property in the country’s traditionally patriarchal society.  Additionally, the Kenyan government has adopted over 75 laws regulating land rights, many of which conflict with each other, that create a highly complex and confusing system. Recently, the Kenyan Ministry of Lands increased the price of registering for a land title from $US 3 to $US 50, further increasing the inaccessibility of land ownership for poorer women, particularly those who are financially strained due to the high cost of living with HIV/AIDS (Wamai, 2009).  Today, only one percent of women own registered land titles and five percent are joint registered property owners with their husbands (World Bank, 2011).  For women with a positive HIV status, the process of owning property becomes increasingly more complicated.   

In a 2006 study, investigators studied the effects of a positive HIV/AIDS diagnosis on one’s ability to own property in Kenya.  Although the study did not demonstrate conclusive evidence on whether a positive HIV diagnosis limits one’s ability to own land, the study did successfully find four other HIV/AIDS and land rights related correlations: HIV/AIDS affected households will more likely experience food insecurity; HIV/AIDS enhances the vulnerabilities felt by women and children in regards to land rights; land disputes due to HIV/AIDS are rare yet on the rise; and some HIV positive women reported that their husbands divorced them after reporting their status, a marital status that puts them at a further disadvantage in gaining property rights (Aliber & Walker, 2006). What can be concluded from this study is that, although it is difficult to definitively conclude that an HIV positive diagnosis will exclude one from owning land outright, one can see the marked disadvantages that an HIV positive status carries in terms of issues surrounding land.

One particularly vulnerable population in Kenya is those women who have been widowed. Although widows only account for 4.4 percent of the Kenyan population,[2] they suffer from a significantly higher HIV/AIDS prevalence rate of 44.4 percent compared to 2.4 percent of those who have never married (Kenya National Bureau of Statistics, 2010; UNGASS, 2010). Widows’ land rights are further threatened as a result of HIV/AIDS through two major mechanisms. First, husbands may use land rights as loan collateral in order to pay for AIDS-related health problems (Aliber et al, 2004).  The average Kenyan spends over $US 51 annually in out of pocket HIV/AIDS expenditures, a difficult task considering 50 percent[3] of the population lives below the $US 1.25 per day poverty line and 40 percent[4] are unemployed (Kenya Ministry of Health, 2009; Central Intelligence Agency, 2011).  As medical expenses escalate, households affected by HIV/AIDS cut spending on clothing (21 percent), electricity (16 percent), food (6 percent), and other services (9 percent).  Although the spending cuts may not seem extravagant, 2.5 million Kenyans[5] report living in a state of chronic food insecurity prior to disease diagnosis (Economic Commission for Africa, 2004;USAID, 2010). Upon the husband dying, the widow is left with a debt that is beyond her financial capabilities (Aliber et al, 2004).  Widows are then forced to sell the land to pay for funeral and medical expenses, leaving them homeless and extremely vulnerable (USAID [2], 2007).

The second mechanism in which widows’ land rights are threatened stems from the fact that women can only access land rights through their husbands. Due to the current environmental issues of drought and land scarcity, some men do not own property but rather, live with their families. In such a case, the husband’s premature death potentially leads to any and all land confiscation from the widow, leaving the husband’s family with full legal property rights over the land and the widow and her children homeless and food insecure (Aliber et al, 2004). According to Kaori Izumi, an HIV and rural development officer at the FAO, widows of men who die from HIV/AIDS often are accused of bringing death into the family (Kimani, 2008). Consequently, the widow endures hardships including but not limited to social exclusion, eviction from the marital home, verbal harassment, and/or widow inheritance (Aliber et al, 2004).

Despite advances made in much of Kenya over the past decade regarding control of HIV/AIDS, the cultural traditions of the Luo tribe have precluded them from similar successes. The HIV/AIDS epidemic reached its peak in Kenya in 2000 with a prevalence rate of 13.4 percent.  From this peak, much of the country, out of fear of contracting HIV/AIDS, increased its condom usage over the past decade thereby contributing to a steadily decreasing disease prevalence rate (Avert, 2011). However, within the Luo tribe, traditions regarding sexual behavior and disease prevention have not changed (Human Rights Watch, 2003). The third largest ethnic group in Kenya,[6] the Luo tribe makes up approximately twelve percent of national population and has an HIV/AIDS prevalence rate around 20 percent, startlingly high when compared to the national prevalence of 6.3 percent (Kenya Information Guide, 2011). Widow inheritance, a common practice within the Luo Tribe, occurs after the passing of one’s husband.  Through a process known as ter (culturally sanctioned remarriage), a male relative of the deceased husband remarries the widow to replace guardianship (Sleap, 2001; Gunga, 2009).  According to Luo beliefs, the widow remains the wife of the deceased and ter is merely the process for regaining normalcy into society (Gunga, 2009). The woman becomes “cleansed” of death by performing sexual intercourse with a relative of her deceased husband (Schoofs, 1999).  In order to be properly cleansed, the custom proclaims sexual intercourse must be “skin to skin,” thereby foregoing the potential for condom usage (Wax, 2003). Unfortunately, the practice of unsafe sexual intercourse with an individual who has been exposed to bodily fluids infected with AIDS only serves as a high risk to further spread disease throughout the family (Schoofs, 1999). Unfortunately, the widow has little say in this inheritance process.

If the widow refuses to partake in the inheritance process, the tribe, in accordance to custom, bans her from entering her deceased husband’s family’s household and runs the risk of being labeled an ochot (whore).  Additionally, upon her death, if she has refused ter, her family will be denied the right to provide a proper burial by the tribe, adding to further cultural stigma surrounding the consequences of the disease (Muoso, 1999).  Women who had experienced wife inheritance described the practice as “not voluntary” but inevitably succumbed to the custom in order to keep their property and to stay in their communities (Human Rights Watch, 2003). Without a legislative protection for widows to legally resist inheritance, women become traded into other marriages as if a commodity and/or the inheritors merely take a woman for sexual pleasure only to seize her property (Schoofs, 1999).

In order to overcome the male dominance that permeates throughout society, women must have equal opportunities to assert themselves in the labor force.  As a result of given gender roles, when Kenyan men fall ill, households experience a significant loss of disposable income.  Without a source of economic and/or social support, women are significantly more likely to engage in activities that are inextricably linked to the spread of the HIV epidemic: widow inheritance and sex work (Mwaura, 2008).  In Kenya’s labor force of approximately 19.5 million people, 52 percent are female.  Although the data is seemingly equal, the data on women in the labor force is misleading as women are confined to employment often considered “women’s work,” or employment in the agricultural and educational sector. In 2000, women constituted 80 percent of the agricultural labor force, yet only owned five percent of the land (Library of Congress, 2007).  Education services ranked as the next highest employing sector for women at 45 percent female. However, within the teaching industry, gender disparities can certainly be found.  Male teachers control the profession with 56 percent of the teachers in primary school and 65 percent of the teachers for secondary school, thereby increasing the societal belief of male domination.  Similarly, industries considered “men’s work” such as construction, manufacturing, and communications had only employed females at 7, 18, and 21 percent respectively (Institute of Economic Affairs: Kenya, 2008).  The continual reinforcement of male domination from multiple societal aspects only serves as a source of anxiety for women infected with HIV.

Accessing the medical field, an industry dominated by men, raises anxieties for women who hope to learn more about their disease as their medical appointments confirm female weakness compared to the doctor’s male dominance.  Only 48 percent of people living with HIV currently receive medical treatment for the disease  (National AIDS Control Council, 2009).  The low percentage can most certainly be contributed to the stigmatization of the disease throughout society in addition to factors such as lack of access to medical centers, as Kenya suffers from a physician shortage with only one doctor for every 10,150 people (Library of Congress, 2007).  In areas with high HIV prevalence, where HIV testing and prevention of mother to child (MTC) interventions are standard components of primary care, women may avoid health centers due to HIV-related fears.  In a 2004 study, fears of compulsory HIV testing leading to unwanted disclosure caused pregnant women to avoid accessing healthcare from antenatal health clinics (Etiebet et al, 2004).  Adding further to patient anxieties, in a survey completed by the Health Policy Initiative, 31 percent of providers admitted to disclosing the HIV status to others; 25 percent of providers had been seen gossiping about a HIV positive status; and 20 percent of providers had told HIV infected women to not have children (USAID, 2007).  Pregnant HIV positive women often fall victim to discrimination while attending health clinics, as health practitioners are hesitant to work with the infected bodily fluids during labor and delivery (Mathole et al, 2006).  The professional mishandling by medical providers and the intense cultural stigma has had obvious effects in society’s education level of the disease.  Only 47 percent of males aged 15 to 24 and 34 percent of females of the same age had comprehensive correct knowledge of the disease, prevention strategies, symptoms, and its transmission (World Health Organization, 2010).

The structure of large Kenyan hospitals challenges the physician’s ability to keep patient confidentiality, thereby increasing women’s fears about unintentional status disclosure. The crowded maternity units, where two or more women often share one bed, create an atmosphere that proves difficult to provide confidential MTC services. A 2007 study, conducted by Turan et al, investigated how an HIV positive diagnosis influenced women’s decision regarding where to give birth.  Investigators found that the major reasoning for choosing home delivery over health care facilities included cost, positive aspects of home delivery, transportation, and fears of health facilities.  Over 50 percent of the health care facility fears were HIV-related.  Participant fears of health care facilities included wrongly being labeled HIV-positive, facing one’s HIV-positive status, unwanted disclosure and resultant stigma, discouraging health facility delivery, and being tested for HIV. Female participants agreed that the stress and anxiety of learning a HIV positive diagnosis could cause a person to become depressed, commit suicide, or die sooner (Turan et al, 2007).  Similarly, the results from a 2009 study conducted by Otieno et al suggest that stigma accounts for 78 percent of women’s reasoning as to why not to access HIV health care programs.  Although accessing maternal health care at clinics does not automatically declare one’s positive HIV status, healthy women perceived HIV inclusive care clinics to bear a higher social cost should anyone assume a positive diagnosis (Otieno et al, 2009).

When 80 percent of women work in the agricultural sector, it is important for the family’s livelihood that women stay in physically healthy condition. In a 2007 study, investigators discovered that women employed in the agricultural sector are significantly more likely to report exposure to physical, emotional, sexual, and any/all types of violence than women employed in other sectors; thus, the higher likelihood of sexual abuse presents a higher likelihood for HIV infection (Lawoko, 2007).  Upon HIV infection, at the point in the disease cycle when the woman no longer feels healthy enough to till the fields, the household food security becomes jeopardized.  Food preparation and production responsibilities shift to younger, more inexperienced family members.  Typically, it becomes the younger family members’ duty to balance food preparation with caring for the ill mother while the father works to make an income (World Food Programme, 2008). A 15-year-old child whose mother died of HIV and now stays with his 62-year-old father, stated, “During the day when someone has work to be done, I do get money and come to prepare food for my father and me, and then I go to sleep” (Nyambedha et al, 2003).[7]Consequently, the children’s lack of knowledge regarding food preparation and basic medical care further limits the available time to prepare adequate amounts of food.  In order to help buy food for the family, some orphaned children drop out of school and resort to paid labor (World Food Programme, 2008).  

The alternative situation, when elderly family members become the primary caretakers, also causes cultural consequences.  Traditional elder roles in a Kenyan society include presiding over meetings, ceremonies, and important community rituals.[8]  As respected members of the community, elders were never left to care for themselves, as it was understood that they needed help with daily tasks.  A 2003 study conducted by Nyambedha et al described the cultural impact of the elderly becoming caretakers for orphans due to rising HIV mortality rates.  Elderly participants ranged in age from 57 to 78 and addressed major problems that resulted from caring from orphaned children such as schooling (84 percent), food (48 percent), and medical care (20 percent).  Over the years, participants had accrued the responsibility for multiple orphans, most of whom were blood relatives. The responsibilities incorporated with raising several orphans revealed the elderly’s inability to survive on subsistence farming and/or income generating activities.  Some participants, who had been accustomed to remittances from their younger children, now found themselves unable to care for several orphaned children.  Elderly participant’s realization of their inability to care for loved ones caused high levels of emotional distress, some appearing “psychologically disturbed and lost hope in life altogether” (Nyambedha et al, 2003).

One of the most important barriers to access of healthcare involves food insecurity, an issue affecting up to 40 percent of households in the southeastern regions of Kenya (USAID [2], 2011). According to a 2008 study conducted by C. Unge et al, HIV positive individuals decline to begin Highly Active Antiretroviral Therapy (HAART), explaining that they do not want to take the medication because it makes them hungry and they lacked the necessary financial or agrarian resources for extra food. Interestingly, the most common reason behind not taking HAART was that patients felt overwhelmed by fear of taking medication on an empty stomach (Unge, 2008).  Consequently, many food insecure individuals never receive proper treatment and thereby serve as carriers for the HIV/AIDS epidemic. In order to successfully continue HAART, individuals must be adequately nourished.  If undernourished, unfavorable side effects such as heptatoxicity (liver damage), anemia, nausea, dizziness, and intolerable hunger are more likely to occur (Kuria, 2009).  In a country where 2.4 million people already suffer from moderate to high levels of food insecurity, medication with a side effect of “extreme hunger” does not bode well for patient adherence as many patients do not have extra food sources to relieve the hunger sensations with the escalating food prices[9] in the Kenyan economy (USAID, 2011). Furthermore, the inevitable negative side effects that occur as a result of taking HAART in food insecure environments only serve to intensify the stigma surrounding the disease.

In order to tackle the combined problem of food insecurity and the HIV/AIDS epidemic, patients must consume large amounts of key nutrients. Maize, the staple of the Kenyan diet that contributes to 36 percent of dietary caloric intake, lacks many of the required nutritious vitamins and therefore only hinders the treatment process.  Annually, the average Kenyan consumes 98 kilograms (215.6 pounds) and the poorest 25 percent of the population spends 28 percent of its income on maize (ACDIVOCA, 2011).  Therefore, the dietary habits of Kenyans infected with HIV result in an increased risk of disease progression, contributing to the stigmatization surrounding the disease.

Although 38 percent of Kenyans die from HIV/AIDS, many more family members endure the consequences of experiencing seeing a loved one suffering until their death.  Upon receiving a positive HIV diagnosis, the patient and his/her family members understand entirely too well the struggles that the future holds. According to the World Health Organization, in order to maintain stable body weight, nutrient intake must increase by ten percent in asymptomatic HIV infected adults and up to 20 to 30 percent in adults experiences symptoms, a seemingly impossible task for families already struggling to prepare enough food each day (World Health Organization, 2003).  Because nobody wants to bear this burden upon their family, thereby contributing to the stigmatization of the disease, only 29 percent of women and 22.8 percent of men aged 15 to 49 who received an HIV test within the past twelve months know the results (UNGASS, 2010).

One of the most pressing issues facing the HIV/AIDS epidemic is the mother-to-child transmission of the disease. As in any culture, one of the most important responsibilities of a Kenyan mother is to protect her children from any potential dangers or threats.  Unfortunately, a common mode of HIV disease transmission is from mother to child (MTC) through methods including pregnancy, labor and delivery, and breastfeeding.  Worldwide, approximately 420,000 new pediatric HIV infections occurred in 2007, almost all of which a result of MTC transmission (UNAIDS, 2007).  Of the said global incidence rate, 90 percent of new pediatric infections occurred in the resource-poor setting of Sub-Saharan Africa. In Kenya specifically, found that 44 percent of all MTC transmissions occurred as a result of breastfeeding, and 75 percent of all breast milk transmission took place within the child’s first six months of life (Nduati et al, 2000). As a result, an HIV positive mother is unable to completely defend her loved ones to the extent of a non-infected mother.

According to Owuor and Mburu (2004), the median length of time for a Kenyan mother to breastfeed her child is twenty months (Owuor & Mburu, 2004).  Strong cultural pressures to breastfeed for the traditional duration causes HIV positive mothers, who are encouraged to stop breastfeeding at six months in attempts to limit child exposure to the virus, to unintentionally disclose their HIV status to the community.  In a 2010 study conducted by Morgan et al, investigators interviewed eighteen HIV positive mothers, ten of whom had stopped breastfeeding and eight had continued.  Morgan et al found that all mothers who continued breastfeeding and 80 percent of those who stopped felt that it was abnormal to stop breastfeeding at six months.  According to the study, one mother faced pressure from her community to continue breastfeeding.  Additionally, six of the mothers who continued breastfeeding indicated that stopping prematurely points to a positive HIV status, a status that signifies promiscuity in the eyes of the community (Morgan et al, 2010).

To contest the growing numbers of children infected by HIV by MTC transmission, the World Health Organization created new HIV/AIDS guidelines for its prevention in 2010.  The guidelines suggested that all HIV positive mothers and their infants receive antiretroviral drugs; however, the guidelines failed to give any suggestion as to how low-income countries should provide large amounts of antiretroviral medications to those in need.  Regarding breastfeeding, the guidelines proposed that HIV positive women in the Global South breastfeed while on medication rather than risk feeding formula with unclean water (World Health Organization (2), 2010).  At 40 percent of the mortality rate for children less than five years, the consequences of diarrheal diseases from ingesting dirty water are much greater than that of potentially becoming infected with HIV through breast milk[10] (World Health Organization, 2006).  However, mothers still risk endangering the life of their child. Without access to antiretroviral therapy, fifteen to thirty percent of babies born of HIV infected mothers will become infected with the disease during labor or delivery.  An additional five to twenty percent will become infected through the mother’s infected breast milk (De Cock et al., 2000).  Although a step in the right direction, the guidelines neglect to give recommendations concerning the nutritional, economical, and social implications of the disease.  In the meantime, many HIV positive Kenyan mothers continue to lack access to antiretroviral therapy and, as a result, spread the virus to their children thereby exhibiting an inability to protect ones family that enhances the stigma of the HIV/AIDS epidemic.

Image courtesy of the Center for Strategic & International Studies

Recommendations

The aforementioned data demonstrates that stigma surrounding women contracting HIV/AIDS in Kenya is multidimensional and overwhelming, as are the steps necessary to combat stigma for the epidemic.  In order to alleviate the disease’s social taboo, the Kenyan government must first take steps to prioritize women’s rights.  Legal reforms within the Constitution of Kenya should prohibit any law that undermines the interest and/or dignity of women, focusing specific attention towards issues of domestic violence (Human Rights Watch, 2003).  Past attempts for political reform of this nature include the Sexual Offences Act[11] and the Domestic Violence (Family Protection) Bill,[12] both of which are still pending in Parliament.[13]  The Sexual Offences Act criminalized rape, sexual harassment and sex tourism but failed to forbid spousal rape, an act of violence in which thirteen percent of married Kenyan women have endured[14] (Immigration and Refugee Board of Canada, 2007; Kenya Bureau of Statistics, 2010). The national Penal Code also addresses assault against women but fails to comment on domestic violence (Immigration and Refugee Board of Canada, 2007).  In 2006, a report from the United Nations Committee on the Elimination of Discrimination Against Women (CEDAW) confirmed that Kenya lacks any laws criminalizing domestic abuse against women (United Nations, 2006).  To more effectively implement gender reforms, training and education for judges, lawyers, police, and other relevant local and national officials must also be established and upheld (Human Rights Watch, 2003).  In order for domestic violence to be taken seriously, the government must serve as a role model and enact laws to protect women.

As previously mentioned, Kenyan women do not legally enjoy many of the same rights to land ownership as their male counterparts[15] (Aliber et al, 2004).  To address this impropriety, property rights and inheritance laws must be enacted that guarantee every person equal rights to acquire and own property; protect spousal rights to inherit land in the event of a husband’s death; and prohibit discrimination based on sex and/or marital status (Human Rights Watch, 2003).  However, because the rule of law may not always have social legitimacy, other forms of gender equality programs must be used simultaneously.

The Dalai Lama once said, “Where ignorance is our master, there is no possibility of real peace” (Global Village Resources, 2011). Certainly true in reference to HIV/AIDS-related stigma, non-profit organizations and the Kenyan government must launch widespread and convincing awareness programs in order to inform the general public of issues surrounding women’s rights and the HIV/AIDS epidemic (Human Rights Watch, 2003). In 1986, Uganda, Kenya’s westward neighbor, launched the National AIDS Control Program (ACP) for early AIDS awareness.[16]  The program, which heavily focused on public service announcements, media campaigns, and community mobilization against HIV, should serve as a successful example for future Kenyan AIDS awareness programs (USAID, 2002). Through a variety of mediums, Kenya’s awareness programs should similarly educate the general public about how particular issues contribute to and/or prevent the spread of HIV/AIDS.  Examples of topics for discussion include domestic violence, polygamy, condoms, women’s property rights, widow inheritance, and breastfeeding.  Not only should educational awareness programs be implemented, but also non-profit organizations and/or the government must create safe zones in which all women feel comfortable discussing HIV/AIDS-related issues stigma-free.

For women, the stigma felt by crowded hospitals also poses as a barrier to HIV/AIDS treatment. One origin of inefficient access to hospital space is that Kenya’s annual national health expenditure is an exceptionally low $US14.20 per capita (Garrett, 2007).[17] Of that, only 44 percent of the resources earmarked for lower level health facilities reach the clinics and hospitals (Republic of Kenya, 2008).  In the future, the government must increase funding for health expenditures as well as improve its monitoring and evaluation to ensure funds reach their intended destinations.  Had all the funds and resources reached the designated targets, heath facilities could have had the potential to enhance their capabilities of managing HIV/AIDS patients in more enclosed private settings.

In order to decrease the amount of HIV/AIDS-related stigma, individuals must have increased access to food, especially that of increased nutritious quality. In the future, policies must be enacted that mandate that health facilities treat HIV/AIDS patients not only with HAART prescriptions but also with prescriptions for nutritious food, thus decreasing opportunity for HIV/AIDS-related stigma to arise surrounding the issue of food availability. The Academic Model for Providing Access to Health Care (AMPATH) program at the Moi Teaching and Referral Hospital (MTRH) in Eldoret, Kenya has already begun treating HIV/AIDS patients according to this model. Rather than only providing patients with HAART, AMPATH also prescribes patients monthly nutritional supplementation of fruit and vegetables in large enough quantities to feed the entire family.[18]  According to Dr. Joe Mamlin, Field Director of AMPATH, the hospital is one of the only medical institutions in the world that prescribes nutritional supplementation in addition to medication for AIDS afflicted patients (Mamlin, 2009). The hospital uses its four local production farms, each producing more than 4,000 kilograms (approximately 8818.5 pounds) of food per week, and additional supplements from the World Food Programme and USAID (Litjeh, Lim, 2009).  In a 2004 study conducted by the World Health Organization, the data overwhelmingly suggests positive health results for AMPATH patients whereby, in 365 days, the average overall CD4 count and mean weight change consistently improved[19] (World Health Organization, 2004).  The Kenyan government should learn from the AMPATH program and scale up the HIV/AIDS holistic treatment program in order to improve healthcare and diminish stigma for all HIV positive Kenyans.

Stigma related to the HIV epidemic is widely prevalent in Kenyan society and prohibits its prevention, diagnosis, treatment, and health education.  Women constantly experience situations of HIV stigma as it relates to all aspects of their lives – wifedom, widowhood, labor force, personal health, and motherhood.  To fight the AIDS epidemic must be synonymous with fighting HIV stigma, otherwise it will be a losing battle.

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[1] Article 64 states: “Private land consists of (a) registered land held by any person under any freehold tenure; (b) land held by any person under leasehold tenure; and (c) any other land declared private land under an Act of Parliament” (The Republic of Kenya, 2010).

[2] Data taken from women aged 15 to 49.  Data does not account for the number of women currently in polygamous relationships or inherited.

[3] 2000 estimate.

[4] 2008 estimate.

[5] Data collected from urban settings only.

[6] The Luo Tribe follows the Kikuyu and the Luhya in popularity.

[7] Approximately 2.4 million orphaned children currently live in Kenya, half of which owe their orphaned status to the HIV/AIDS epidemic (UNGASS, 2010).

[8] Traditions of the Luo tribe in Kenya.  Other tribes may have varied traditions regarding the elderly.

[9] Between 2008 and 2009, the average price for maize rose by 21 percent above normal (The World Bank, 2010).  Since then, food insecurities continued to escalate in Kenya and have risen to the point where maize prices in pastoral and coastal lowland areas have increased 130 and 105 percent above normal respectively (World Food Programme, 2011).

[10] The Kenyan under five mortality rate from HIV is 15 percent of the under five population, equating to 25 percent less than deaths related to diarrheal diseases.

[11] Published in 2006.

[12] Published in 2002.

[13] As of 2010.

[14] This figure is most likely highly underreported since marital rape is socially tolerated.  Social humiliation in combination with the feared economic consequences of losing access to the husband’s income stop women from reporting instances of marital rape.

[15] Women gain access to land through marriage but the husband owns the property.

[16] Among pregnant women in Kampala, HIV/AIDS prevalence peaked at 30 percent in 1992.  By 2000, HIV/AIDS prevalence had dropped to 11 percent.

[17] The United States spends $US 8,086 per capita annually on health expenditures (US Department of Health & Human Services, 2009).

[18] Patients often share food with family members; therefore, prescribed food must be large enough to feed the entire family in order to give adequate nutrition for the HIV infected patient.

[19] Mean CD₄ count rose from 150 to 220, while mean weight rose from 57 kg (125.4 lbs) to 60 kg (132 lbs).