"FreeSpirit_uk" <FreeSpirit_uk@myway.com> wrote in message

perhaps some background will be useful
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AMNESTY INTERNATIONAL

LIBRARY  AFRICA  CENTRAL AFRICA  RWANDA
AI Index: AFR 47/007/2004        6 April 2004

Rwanda:
"Marked for Death", rape survivors living with HIV/AIDS in Rwanda

"During the genocide, the militia at the barriers said they would protect me, but instead they
kept me and raped me in their homes. One militia member would keep me for two or three days,
and then another would choose me. If killers came to their house, the militia member would say
I was his sister. I had to stay with these men because I would have been killed otherwise. The
conditions were very favourable for HIV transmission. I managed to flee Kigali, and when I
returned, I learned that my husband had been killed. My husband was a Hutu, and he had gotten a
Hutu identity card for me because he hoped it would protect me. Because I had this card, I was
denied assistance from IBUKA [support organization for genocide survivors] for my children or
from the government fund for genocide survivors".

-Francine, HIV-positive, Kigali

"In 1998, I was leaving for boarding school in Gisenyi. Just before reaching the town...we were
ambushed by the abacengezi [insurgents]...The taxi rolled over, and as the passengers fled the
vehicle, the abacengezi chopped them with machetes. I managed to hide under corpses but heard
the rebels saying they would get fuel to burn the bodies. I cried out, and they stabbed
me...and carried me into the forest...There were other women and girls there too, from
different parts of the country who were kidnapped under similar circumstances. ... Members of
the militia came each night to rape me, until one night a militia member announced that I was
his, that he was my "husband". I only thought of escaping to my family...We had to flee
constantly because they were being chased by the Rwandese army. During a major offensive of the
government military in Gishwati forest, I managed to flee when everyone else was
dispersed...then returned home...A few years later, an RPF soldier came to my house and wanted
to have sex with me. I tried to convince him that I was HIV-positive and couldn't have sex. It
was like a rape. Because he was a soldier, I felt I couldn't shout. He wanted to marry me, and
since he was a soldier I felt I had no choice. I made him get tested the day after the rape,
and it turned out he was already HIV-positive. I married him against my will. My hopes have
been dashed. I have finished my studies. I am very upset because my family pinned all their
hopes on me, sacrificed to have me educated, but I fear I will soon be dead and my family
members will not benefit from their sacrifice".

Angèle, HIV positive, Kigali-Ngali

I. Introduction

In April 1994, Rwanda suffered one hundred days of violence, targeted at the Tutsi and moderate
Hutu population. Ten years later, the consequences of the violence have not been dealt with
adequately, neither by the international community nor by the Rwandan government. Survivors of
violence still cry out for medical care; survivors and families of victims clamour for justice
that is slow in coming. Women continue to die from diseases related to HIV/AIDS, which some of
them contracted as a result of rape during the 1994 genocide and armed conflict. Survivors of
rape and their families face human rights violations that themselves lead to further and
overlapping violations: survivors of sexual violence may have contracted HIV/AIDS, as a result
of which they and their families often face stigma, which can in turn lead to loss of
employment, difficulty in asserting property rights, and a loss of civil and political rights.

Although not all cases of HIV/AIDS among rape survivors can be traced to the sexual violence
they survived, the mass rape during 1994 contributed significantly to the spread of the virus
in Rwanda, particularly as rates of HIV transmission during sexual violence are believed to be
high. The HIV/AIDS pandemic in Africa grows worse daily, though the international response has
been lukewarm. It is in this context, ten years after the start of the Rwandan genocide and war
and as part of its Stop Violence Against Women campaign, that Amnesty International is making
an appeal to the Rwandan government and international community to expand access to healthcare
and justice for survivors of rape and their families.

Violence against women and girls constituted a well-documented and tragically widespread
component of the genocide and war strategy in 1994. In the 1998 Akayesu judgment at the UN
International Criminal Tribunal for Rwanda (ICTR), prosecutors were successfully able to
demonstrate that genocidal intent spurred extensive sexual violence during the genocide, as
determined from individual testimonies regarding the stated intent of the perpetrators and the
investigation of sexual violence occurring in a widespread fashion across the country. During
the genocide, women and girls-predominantly but not exclusively Tutsi-survived or succumbed to
extraordinary acts of violence. Many were raped at barriers erected by the interahamwe youth
militia and/or held as sexual captives in exchange for temporary protection from interahamwe
militia and the military. Their bodies and spirits were mutilated, humiliated and scarred.

The Rwandan Patriotic Army (RPA) was likewise responsible for sexual and other violence during
its military advance, sometimes in reprisal against the Hutu population. The extent and nature
of these crimes is less well-known, and very few of the suspected perpetrators have been
brought to justice. While the impact of sexual violence perpetrated during the genocide and war
constitutes the focus of this report, it is important to note that the phenomenon of rape
neither began nor ended in 1994. Sexual violence and forced marriage continue to be perpetrated
by members of the current Rwandese military (Rwandan Defence Forces or RDF), security forces
and unpaid militias. These assaults are sometimes reported but are again seldom prosecuted.
Gender-based violence has been a persistent feature of the human rights violations committed by
Rwandese security forces in the Democratic Republic of Congo (DRC)/Zaire and in the post-war
insurgencies in Rwanda.

For some women, the violence began during the 1990 conflict, or during spates of ethnic killing
decades earlier.(1) Though no baseline studies exist from before the genocide and war,
anecdotal evidence suggests that domestic and sexual violence have increased significantly
since then.(2) The economic and social vulnerability of women and girls, among other factors,
has in the past and continues today to leave them exposed to sexual violence. The availability
of small arms in the region increases the capacity of perpetrators to commit acts of sexual
violence and other crimes. The overwhelming impunity of members of the armed forces, Local
Defence Forces (an armed but unpaid local militia) and others in position of authority likewise
hampers efforts to combat the problem.

For some of these women, the killing has yet to claim its last victims. AVEGA, an association
for genocide widows, carried out a study in 2000 of 1125 women who survived rape during the
genocide and found that 66.7% had HIV.(3) AVEGA also estimates that 80.9% of survivors of
violence during the genocide remained traumatized in 1999.(4) According to a UN report, at
least 250,000 women were raped during the genocide, a large number of whom were subsequently
executed. Of the survivors, 70% are estimated to have been infected with HIV. AVEGA estimates
that 200 of its members have died of AIDS since 2001, when the organization set up an HIV/AIDS
support centre. AVEGA had 618 members living with HIV in January 2004, though this number
represents only those members who had been tested for HIV in three of the 12 provinces in the
country.(5) As of March 2004, only 28 of these women were receiving life-prolonging
anti-retroviral (ARV) treatment (22 from AVEGA, 6 from other sources), though the number is
expected to increase this year. Other HIV-positive AVEGA members benefit from free antibiotics
to control opportunistic infections.

Associations of people living with HIV/AIDS (PLWHA) in Rwanda routinely bury members,
casualties of the long wait for the government and international community to respond to their
needs. In some cases, survivors of rape have passed the infection on to their partners or
children.

Policy advisors in Rwanda told Amnesty International delegates that the number of patients
clinically in need of life-prolonging anti-retroviral (ARV) therapy is estimated at between
50,000 and 100,000. As of January 2004, only approximately 2,000 Rwandese were being treated
with ARVs. Approximately 50,000 Rwandese per year die of AIDS(6). By the end of 2004, an
estimated 3,000 to 5,000 Rwandese will receive ARVs.

Of course, the state of health of a person living with HIV/AIDS depends on far more than access
to medication: proper nutrition, psychological well-being, decent housing and personal and
financial security can all have a dramatic impact on the physical health of such an individual.
Average per capita annual GDP is $US252, and, according to Rwandese government documents, 60%
of Rwandese are estimated to live below the poverty line.(7) More than half of the population
lacks access to clean water, and 40% of Rwandese are undernourished.(8) Only an estimated 28%
of Rwandese households affected by HIV/AIDS are able to afford even basic health care; many
families borrow money, sell assets, including land, or decide to forego healthcare. Under these
conditions, it is clear that a holistic approach is needed if ARV treatment is to be effective,
including improving living conditions of PLWHA and reducing the burden on their families or
those caring for them.

II. Context: discrimination against women

In recent years, the status of women in Rwanda and the importance of women's rights have been
significantly elevated. Rwanda now boasts the highest percentage of woman parliamentarians in
the world (48.8%), and legislation on land rights, marriage, child rape and violence against
women has been amended to contribute to the protection of women's rights. Nevertheless,
customary law, which often overrides written law, remains biased against women with regard to
inheritance and land ownership, thus often placing the woman in a position of dependency. Many
customary practices reinforce the patriarchal system in Rwanda. The level of education of
women, and hence their access to information and means of empowerment, has generally been much
lower than that of men, though this imbalance is changing.

II.1. Discrimination and sexual violence

The low status of women and difficulty in seeking redress leave many women and girls vulnerable
to sexual violence. In some areas, relatives of a male who has died, been imprisoned or left
the country will expect to be able to have sexual relations with his female partner.

Domestic workers are particularly vulnerable to rape, and often fear reporting sexual assault
or harassment for fear of losing their jobs and disappointing their families. Other women find
themselves vulnerable to soldiers, Local Defence Forces, neighbours and male relatives who
demand sex or wish to exchange food or other goods for sex. Following rape survivors rarely
bring their cases to the police, but rather families will find a financial solution to
compensate for the abuse; the survivor may even be forced to marry the perpetrator in order to
"normalize" relations between the families concerned.

Poverty and insecure living circumstances, including unprotected housing that fails to protect
women from unwanted sexual advances from neighbours and passers-by, may ultimately result in
unwanted pregnancies and sexually transmitted diseases. Children of both sexes have also been
frequent victims of rape in recent years, a phenomenon fuelled by traditional healers'
exhortations that having sex with a virgin will make the perpetrator wealthy or cure him of
HIV/AIDS.

II.2. Stigmatisation of survivors of sexual violence

If the status of the average married Rwandese woman is often low, it is still higher than that
of a widow or a rape survivor. Demeaning attitudes exhibited toward women who have been raped
are not exclusive to men: several women told Amnesty International how they had been humiliated
and tormented by female community members or even their own daughters following their rape.

The children of the genocide themselves can face severe discrimination, belittled as offspring
of interahamwe, and are sometimes called the "enfants mauvais souvenir" or children of bad
memories, even by their mothers. The mothers may also be humiliated and marginalized by the
community as a result. Other women or girls are driven to infanticide; a majority of women and
girls with whom Amnesty International delegates spoke in March 2003 in the former women's
prison in Byumba were serving long prison sentences, including life imprisonment, for abortion
or infanticide, though not necessarily from 1994.

II.3. Poverty, discrimination and loss of sexual autonomy

Discrimination against women in Rwanda extends to sexual health and family planning choices.
Like women in many countries, women across Rwanda find it difficult to control their
reproductive health and their sexuality, often because of extreme poverty, their economic
dependence or social inferiority to their husbands and their lack of access to health care and
contraception. Domestic violence is believed to be rampant, with a high percentage of women
suffering routine battery and assaults, though the figures of a recent baseline survey carried
out by International Rescue Committee have not yet been published. Domestic violence, or even
the threat of violence, decreases a woman's ability to negotiate her sexual autonomy, making
her more vulnerable to HIV infection.

Women's diminished access to radios, community meetings and written information sources lessens
their access to information and education about sexual health and contraception.(9) Abortion
remains illegal in Rwanda and, for many women and medical personnel, contravenes religious
beliefs. Women and girls must therefore either carry an unwanted pregnancy to term or attempt
to end the pregnancy illegally, sometimes with serious, sometimes fatal, health consequences.

III. Rape as a tool of genocide

"Like so many others, my husband was killed during the war, and I was raped by two assailants.
Most of my family died".
Jeanne Musabe, age 50, Nyamirambo (Kigali)

In a well-established pattern of systematized brutality and humiliation, Rwandese women and
girls suffered a range of gender-specific violence such as rape, various forms of genital
mutilation, hacking off of breasts, sexual slavery, forced abortion and forced marriage. The
United Nations Special Rapporteur of the Commission on Human Rights, René Degni-Segui,
estimated in 1996 that between 250,000 and 500,000 rapes were committed during the genocide.
Women and girls were systematically subjected to rape, including gang rape(10), inflicted even
on pregnant women or women who had just given birth. Some were killed or seriously injured by
having arrows, spears or other objects pushed into their vaginas or by being shot in the
genitals. Tutsi women were given as rewards to men who "excelled" at killing Tutsi, and many
were forced to submit to sex in exchange for temporary security, particularly at roadblocks.
Degradation was integral to the physical violence, with some women being made to parade naked
or perform various humiliating acts at the bidding of soldiers and militia. As reported in
human rights literature and to Amnesty International delegates, the genitalia of Tutsi women
were sometimes cut off and displayed, and some women reported seeing members of the militia or
military rape corpses. Assailants sometimes mutilated or chopped off body parts deemed
characteristic of Tutsi women, such as thin fingers or long noses.

While the violence was directed primarily at Tutsi women during the genocide, Hutu wives of
Tutsi men sometimes suffered particular brutality. Moderate Hutu women, those who attempted to
protect Tutsi, or Hutu women and girls who were thought to look like Tutsis were also raped and
brutalized. Some perpetrators took advantage of the lawless atmosphere to rape Hutu women and
girls. Both Hutu and Tutsi women were vulnerable to rape and other forms of aggression as they
attempted to flee to safety or as they sought shelter in refugee camps. Hutu women were also
raped during and after the Rwanda Patriotic Army (RPA) advance in the country, sometimes as a
reprisal action directed against the Hutu population. Very few perpetrators of these rapes have
been prosecuted.

Women and men alike were brutalized by torture, murder, grave injury and severe psychological
trauma in their homes, in schools, hospitals, fields and churches. Survivors reported to
Amnesty International that family members had been asked to kill their own relatives and were
themselves killed, if they refused or even if they complied. Injured persons were often left to
die, sometimes thrown into latrines. Some survivors felt particularly aggrieved that they were
forced to flout custom by being prevented from burying the dead, and instead made to let their
bodies rot in the street.

IV. Legacies of the conflict

"During the war, the militia came and would look for young men to kill and for girls to have
sex. For one week, I had sex with a different one each night, and they threatened to kill
me...Now I am the head of the household. Fortunately, my younger siblings have gotten
assistance for their school fees, and I have been taking anti-retrovirals for nine months. I
want to get married and find someone who will help take care of my brother and sister.
Sometimes people ask to marry me, but I have to say no because I don't want to infect my
potential husband. I feel different from other young people, who have their whole lives ahead
of them". Clémentine, Kigali-Ngali, age 30.

IV.1. Psychological trauma, guilt and ostracization

During the genocide and war, women and girls suffered or witnessed acts of indescribable
brutality, including the murder of family members and loved ones. Husbands, brothers and
children were anguished by the physical and psychological assaults on their female family
members. The violence has left many Rwandese profoundly traumatized, far beyond the capacity of
support organizations to assist meaningfully in most cases. In a 1999 study, 80.9% of people
surveyed reported symptoms of trauma.(11)

Women and girls who suffered sexual violence during the genocide and war sometimes faced severe
stigmatisation and marginalization if and when their assault became known. Many have kept
silent about the horrors they had endured as a result. Some women said people in their
communities who knew they had been raped assumed they had a sexually transmitted disease,
particularly HIV. Several women said candidly that they combated feelings of guilt for having
survived and having been raped, and said that community members told them that, if they had
survived, they must have collaborated with perpetrators of the genocide. Some women had been
affected by grave medical problems such as fistula that contributed further to their
ostracization.(12) Some were unable to marry or were abandoned by their husbands. Many of the
women interviewed by Amnesty International said they had not sought medical help immediately,
even if it was available, because they wished to conceal the fact that they had been raped. Ten
years later, the greatest medical issues many women face, particularly women affected by
HIV/AIDS, are psychological problems. One woman, who had not only been raped but lost two
children and her husband in 1994, said, "I have gone to the hospital four times for psychiatric
treatments... It is still very bad for me, and it is hard to find someone to talk to."

IV.2. Differential impact on women and girls

The after-effects of the violence have often impacted women with particular severity. Following
the genocide and war, women constituted a majority of the population and were left with new
burdens of generating income, caring for the injured, sick and disabled and taking in orphans.
Women were left to cope with these difficult circumstances while grappling with their own
illnesses, injuries, grief and trauma.

The genocide, war and ensuing instability in the region have created a complex series of
ramifications for women and their families, often differentially affecting women. Women or
girls may have been left as the only breadwinner in their families or pressured into
"opportune" marriages. Some families lost their land, housing and assets during the genocide
and war, thereby augmenting the strains on family resources and eroding social cohesion. Girls
may have been left orphaned and are more likely to have been deprived of education, as they are
often expected to take on childcare roles or find work as domestic servants. Young women may be
forced to sell sex to provide for themselves and their siblings, sometimes being forced to live
in the street. Survivors of rape may have been rejected by their partners, families or
communities.

"My husband was imprisoned one week after the war, though nobody has come to accuse him...I
suspect my brother-in-law of infecting me... After my husband was imprisoned, his brother
started coming around and insisted that I had to have sex with him in order to confirm that I
was still part of the family. Eventually I had to give in. ... I worry because I had
extramarital relations and about what will happen when my husband returns from prison. I will
be kicked out and my children will be maltreated by the new wife. I refuse to keep silent and
contaminate him...All of this happened only because of the war. My husband was my confidante-he
wouldn't be in jail, and I wouldn't be infected, if it weren't for the war".

Florence, Kigali-Ngali

Providers in the family may have been imprisoned, gone into exile or sent to fight, again
leaving women (or indeed children) with the charge of providing food-including having to
transport it to the prison-and becoming sole care-takers of the family. Malnutrition and other
health problems are often the natural consequence of these stresses for many women and
children. Women have been left to care for countless orphans, even as poverty in the country
worsens, and some women care for children born to them as a result of rape. Family members may
have been left with lasting health consequences or disability as a result of injuries sustained
in 1994 and often rely on women and girls to tend to them.

IV.3. Land and inheritance issues

Some widows lost their land when it was reclaimed by their husband's family or by Rwandese who
returned in the months and years following the RPA victory, or during the "villagization"
process that sometimes forcibly attempted to group dispersed rural inhabitants into villages.
During a decade of refugee returns, displacement, "villagization" programs and seizures of land
by powerful individuals, land has changed hands frequently; women's claim to land, even if
codified in law, has been particularly difficult to enforce.

IV.4. Legacies of the genocide and war that contribute to HIV transmission

Some girls and young women said they had been turned out of their homes when family incomes
were deemed inadequate to provide for everyone. Widows and orphan girls were rendered
particularly vulnerable to forced marriage, rape by neighbours or strangers, or sexual abuse by
employers, particularly if they worked as domestic servants. Sex work seemed the only option
for destitute and traumatized women and girls, some of whom had survived sexual violence.
Economic problems force women into staying in abusive relationships or submitting to unwelcome
sexual advances. Meanwhile the generalized trauma undoubtedly continues to exacerbate sexual
and domestic violence, women's groups and medical professionals speculated to Amnesty
International delegates. According to Rwandese government figures, an estimated 80% of sex
workers are infected with HIV.(13)

While HIV transmission is obviously not the only problem facing women and girls, the
after-effects of the genocide, war and ongoing regional conflict on women and girls contribute
significantly to their risk of exposure to the virus. They may engage in "survival sex"-that
is, sexual encounters entered into in exchange for food, shelter, school fees or other
goods.(14) Up to 400,000 children are missing one or both parents, whether to violence, AIDS or
other causes. These children may be forced to wander the streets as vendors or may simply find
themselves homeless, where they are vulnerable to rape or may engage in survival sex. Some
women and girls engaged in survival sex or prostitution are themselves survivors of sexual
violence and may suffer from serious trauma and depression.

"I married in 1995. I heard that my husband might have HIV, but my father was dead and my
mother was in prison. I had five brothers and sisters to take care of, and I had to get married
so they would have money for school fees". HIV-positive woman, Kigali

"After the war, we saw that our family was decimated...My little sister for whom I care is a
pseudo-prostitute because she has no money. She says that she will continue this lifestyle even
if she becomes HIV-positive. She says she looks at my health degrading and insists that wants
to taste life before she dies". HIV-positive woman from Kigali-Ngali

"Some of the street children are orphans from 1994...The Local Defence Forces tell [street]
children that if they have sex with them, they will be protected. We hear of many cases of
girls being raped...they call sex for protection umuswati, which is Kinyarwanda slang for the
female genital organ". Joseph, from support organization for Rwandese street children

V. International legal framework

International human rights and humanitarian law provide comprehensive guarantees of the rights
of women and girls to protection from sexual violence and abuse. International law requires
states to address persistent violations of human rights and take measures to prevent their
occurrence. With respect to violations of bodily integrity, states have a duty to prosecute
abuse, whether an agent of the state or a private citizen commits the violation. For example,
Article 2 of the International Covenant on Civil and Political Rights (ICCPR) to which Rwanda
is a party requires governments to provide an effective remedy for abuses and to ensure the
rights to life and security of the person of all individuals in their jurisdiction, without
distinction of any kind including sex. When states routinely fail to respond to evidence of
sexual violence and abuse of women and girls, they send the message that such attacks can be
committed with impunity. In so doing, states fail to take the minimum steps necessary to
protect the right of women and girls to physical integrity.

Perpetrators of sexual violence, including rape, can be held accountable under international
law for acts of genocide, war crimes or crimes against humanity. Rape and other forms of sexual
violence are explicitly condemned as war crimes, both in internal and international conflicts.
Common article 3 of the 1949 Geneva Convention, to which Rwanda is a state party, is applicable
to armed conflicts not of an international character and is binding on all parties to a
conflict. It prohibits "[violence to life and person, in particular murder of all kinds,
mutilation, cruel treatment and torture" and "outrages upon personal dignity, in particular,
humiliating and degrading treatment". The "fundamental guarantees" of Protocol II Additional to
the Geneva Conventions, also applicable to non-international armed conflicts, protect civilians
and requires that "they shall in all circumstances be treated humanely, without any adverse
distinction. It is prohibited to order that there shall be no survivors." Protocol II prohibits
"violence to the life, health and physical or mental well-being of persons, in particular
murder as well as cruel treatment such as torture, mutilation or any form of corporal
punishment", "outrages upon personal dignity, in particular humiliating and degrading
treatment, rape, enforced prostitution and any form of indecent assault" and "slavery and the
slave trade in all their forms". Rwanda acceded to Protocol II in 1984.

The widespread or systematic commission of acts of sexual violence against a civilian
population may be prosecuted as crimes against humanity, regardless of whether they took place
in the context of war or peace. As recognized in the Rome Statute of the International Criminal
Court, rape and other forms of sexual violence of comparable gravity may be considered crimes
against humanity when they are committed as part of a widespread or systematic attack directed
against any civilian population, with knowledge of the attack. The Rome Statute includes in its
definition of rape, the invasion of "the body of a person by conduct resulting in penetration,
however slight, of any part of the body of the victim or of the perpetrator with a sexual
organ, or of the anal or genital opening of the victim with any object or any other part of the
body."

The 1948 Convention on the Prevention and Punishment of the Crime of Genocide ("the Genocide
Convention"), to which Rwanda is a state party, defines genocides as "any of the following acts
committed with the intent to destroy, in whole or in part, a national, ethnic, racial or
religious group, as such:

(a) Killing members of the group;
(b) Causing serious bodily or mental harm to members of the group;
(c) Deliberately inflicting on the group conditions of life calculated to bring about its
physical destruction in whole or in part;
(d) Imposing measures intended to prevent births within the group;
(e) Forcibly transferring children of the group to another group."

Sexual violence includes rape and attempted rape, and such acts as forcing a person to strip
naked in public, forcing two victims to perform sexual acts on one another or harm one another
in a sexual manner, mutilating a person's genitals or a woman's breasts, and sexual slavery.
The appeals chamber judgment of the UN International Criminal Tribunal for the former
Yugoslavia (ICTY) in the 2002 Foca case define rape as "[t]he sexual penetration, however
slight: (a) of the vagina or anus of the victim by the penis of the perpetrator or any other
object used by the perpetrator; or (b) [of] the mouth of the victim by the penis of the
perpetrator; where such sexual penetration occurs without the consent of the victim. Consent
for this purpose must be consent given voluntarily, as a result of the victim's free will,
assessed in the context of the surrounding circumstances. The mens rea is the intention to
effect this sexual penetration, and the knowledge that it occurs without the consent of the
victim.(15)

The landmark 1998 Akayesu judgment at the ICTR articulates a broad definition of rape,
including more than physical penetration or even sexual contact: "a physical invasion of a
sexual nature, committed on a person under circumstances which are coercive. The Tribunal
considers sexual violence, which includes rape, as any act of a sexual nature that is committed
on a person under circumstances that are coercive. Sexual violence is not limited to physical
invasion of the human body and may include acts which do not involve penetration or even
physical contact... The Tribunal notes in this context that coercive circumstances need not be
evidenced by a show of physical force. Threats, intimidation, extortion and other forms of
duress which prey on fear or desperation may constitute coercion, and coercion may be inherent
in certain circumstances, such as armed conflict or the military presence of interahamwe among
refugee Tutsi women at the bureau communal."(16) The Akayesu judgment for the first time noted
that rape and sexual violence could be prosecuted as constitutive elements of genocide. The
Akayesu decision further represents an important evolution from previously existing definitions
of rape, including Article 27 of the Fourth Geneva Convention, which regards rape as an attack
against a woman's honour or decency, rather than as a physical assault. The language of the
Akayesu decision clearly describes rape as an assault on physical integrity, thus elevating
rape to the status of other grave crimes, rather than reinforcing the pre-existing notion that
it was a lesser or private crime.

The first convictions by the ICTY for rape as a crime against humanity came in the Kunarac,
Kovac, and Vukovic decision of 22 February 2001, when the court found that the crimes of the
accused comprised part of a systematic attack against Muslim civilians, intended to drive the
Muslims out of the region. The defendants were also convicted of enslavement as a crime against
humanity, thus setting a legal standard for sexual enslavement as a crime against humanity.

The Akayesu definition of rape is reinforced by the Kunarac decision, which rejects the notion
that the victim need show resistance to force. Rather, under the ruling, force or threat of
force provide sufficiently clear evidence of non-consent; coercive circumstances-without
necessitating physical force-were deemed sufficient to determine the absence of consent.

Rwanda ratified the Convention on the Elimination of All Forms of Discrimination against Women
(CEDAW) in 1981, but has not signed its Optional Protocol. CEDAW recognizes that many women's
rights abuses emanate from society and culture, and compels governments to take appropriate
measures to correct these abuses. CEDAW requires governments to "modify the social and cultural
patterns of conduct of men and women, with a view to achieving the elimination of prejudices
and customary and all other practices which are based on the idea of the inferiority or the
superiority of either of the sexes or on stereotyped roles for men and women".(17) The
Committee on the Elimination of Discrimination against Women, which monitors application of
CEDAW, issued in 1992 General Recommendation 19, which specifies that gender-based violence is
a form of discrimination that gravely affects women's enjoyment of their human rights:
"[g]ender-based violence, which impairs or nullifies the enjoyment by women of human rights and
fundamental freedoms under general international law or under human rights conventions, is
discrimination within the meaning of article 1 of the Convention". The Committee includes as
examples of violence rape and other forms of sexual assault the denial of reproductive health
services and battering. According to Article 2 of CEDAW, states must "pursue by all appropriate
means and without delay a policy of eliminating discrimination against women" by taking "all
appropriate measures to eliminate discrimination against women by any person, organization or
enterprise". This obligation extends to violence against women in the context of armed
conflict. In reference to the impact of violence against women, the Committee states that
"wars, armed conflicts and the occupation of territories often lead to increased prostitution,
trafficking in women and sexual assault of women, which requires specific protective and
punitive measures".

The Recommendation 19 comment on Article 6 of CEDAW contains language that is especially
relevant for women and girls left destitute following the genocide and war: "Poverty and
unemployment force many women, including young girls, into prostitution. Sex workers are
especially vulnerable to violence because their status, which may be unlawful, tends to
marginalize them. They need the equal protection of laws against rape and other forms of
violence." The Committee notes, in its comment on Articles 16 and 5, that the "lack of economic
independence forces many women to stay in violent relationships. The abrogation of their family
responsibilities by men can be a form of violence, and coercion. These forms of violence put
women's health at risk and impair their ability to participate in family life and public life
on a basis of equality." This comment is of particular importance for women with grave
illnesses such a HIV/AIDS who may be neglected or abandoned by their husbands on the basis of
their infection, their inability or unwillingness to reproduce or their incapacity to work.

In General Recommendation 24, the Committee affirms that access to health care, including
reproductive health is a basic right under the Convention. Furthermore, it requires states to
eliminate discrimination against women in their access to healthcare services throughout the
life cycle, particularly in the areas of family planning, pregnancy, confinement and during the
post-natal period. Article 12 of CEDAW calls on states to provide "equal access to health care
services...including family planning".

The Protocol to the African Charter on Human and Peoples' Rights on the Rights of Women in
Africa, which Rwanda signed on 19 December 2003, requires governments to eliminate violence
against women as well as gender discrimination. The Protocol is far-reaching and innovative in
its definitions and substantive provisions. Its provisions include equal access to justice and
equal protection before the law; the right to adequate food and drinking water; the right to
equal access to education and other economic, social and cultural rights. Article 14 concerns
women's reproductive rights and health. It includes the right to contraception and "the right
to self protection and to be protected against sexually transmitted infections, including
HIV/AIDS" and "the right to be informed on one's health status and on the health status of
one's partner, particularly if affected with sexually transmitted infections, including
HIV/AIDS, in accordance with internationally recognised standards and best practices."

Article 14.2 also requires that "States Parties shall take all appropriate measures to:
a) provide adequate, affordable and accessible health services, including information,
education and communication programmes to women especially those in rural areas;
b) establish and strengthen existing pre-natal, delivery and post-natal health and nutritional
services for women during pregnancy and while they are breast-feeding;
c) protect the reproductive rights of women by authorising medical abortion in cases of sexual
assault, rape, incest, and where the continued pregnancy endangers the mental and physical
health of the mother or the life of the mother or the foetus."

For the first time in international law, the Protocol guarantees the right to abortion in case,
inter alia, of sexual assault, rape and when the pregnancy endangers the mental or physical
health of the mother. The Protocol also guarantees the rights of widows, including the right to
be free from inhuman, humiliating or degrading treatment, to automatically become the guardian
of her children after the death of her husband, and to have an equitable share in the
inheritance. States are directed to reduce their military expenditures "significantly" and to
use the funds instead for social development, especially with regards to women.

Under the International Covenant on Civil and Political Rights (ICCPR), to which Rwanda is a
state party, states parties are required to refrain from human rights violations against women
and to protect women from abuses by other actors, whether in peacetime or war. The Human Rights
Committee has specifically mentioned the risk posed to women in times of conflict and informed
states that they must report to the Committee "all the measures taken to protect women from
rape, abduction and other gender-based forms of violence". Children are additionally protected
by provisions of the UN Convention on the Rights of the Child, to which Rwanda is a state
party, which sets forth standards for the protection of girls from sexual violence and
exploitation. State parties must undertake to protect children "from all forms of sexual
exploitation and sexual abuse," and in particular take all appropriate measures to prevent "the
inducement or coercion of a child to engage in any unlawful sexual activity" and "the
exploitative use of children in prostitution or other unlawful sexual practices".(18) States
must take all appropriate measures to promote physical and psychological recovery and social
integration of a child victim of any form of neglect, exploitation, or abuse; torture of any
other form of cruel, inhuman, or degrading treatment or punishment; or armed conflicts.(19)

The International Covenant on Economic, Social and Cultural Rights (ICESCR), to which Rwanda is
also a state party, guarantees enjoyment of its substantive rights without discrimination of
any kind. Women, on an equal basis to men, therefore have the right to the highest attainable
standard of health and to education.

VI. Domestic legal framework

Rape and attacks on decency are the subject of articles 358 to 362 in the Rwandese Penal Code,
which prohibit rape. Under Rwandese law, rape requires sexual penetration of the sexual organs,
anus or mouth, by a male sexual organ or in some cases by another object. Under article 360,
rape can be perpetrated by violent means or by means of threats, deception or by taking
advantage of a person who is not in full possession of their faculties due to illness or any
other cause, making the individual incapable of giving consent. Article 33 describes child
rape, and articles 47 to 50 relate to the forced or early marriage of children under the age of
18. Article 360 states that rapes that result in the death of the victim are subject to capital
punishment, and Article 361 states that if the act causes grave health problems to the victim,
the sentence will double. Similarly, child rape resulting in the death of the child or
infection with an incurable illness carries the death sentence. Amnesty International is
opposed to the death penalty under all circumstances, as it constitutes a violation to the
right to life, and considers it the ultimate form of cruel and inhuman punishment. Under
article 361, circumstances are aggravated and the sentence doubled if religious ministers,
public sector employees, doctors and other healthcare workers, teachers, and individuals in
positions of authority commit the assault.

Organic Law No. 08/96 of August 30, 1996 on the Organization of Prosecutions for Offences
constituting the Crime of Genocide or Crimes against Humanity committed since October 1, 1990
("the Genocide Law") categorizes crimes according to their severity. Those in "category 1", for
the most serious offences, include "persons who committed acts of sexual torture", for which
they may be sentenced to capital punishment and which do not carry the option of reduced
sentences. Domestic law inflicts capital punishment for sexual violence only when victims die
as a result (art. 359 al.3 and art.360 al.4 of the Penal Code, cfr. n° 25); in order not to
violate the principle of retroactivity, sexual violence perpetrated during the genocide is
generally classed in Category 1 only if it constituted grave sexual torture, which can include
repeated rape or mutilation. This interpretation harmonizes with Article 316 of the Penal Code,
which likens the use of torture for the execution of a crime to assassination.(20)

Provisions have been made for women to testify in special courtrooms and to maintain their
privacy. The Genocide Law stipulates that victims are entitled to the payment of damages or
compensation. Article 30 requires that "convicted persons whose acts place them within Category
1 under Article 2 shall be held jointly [sic] and severally liable for all damages caused in
the country by their acts of criminal participation, regardless of where the offences were
committed", and those in Categories 2, 3 and 4 shall likewise be held liable for damages.
Article 32 states that "damages awarded to victims who have not yet been identified shall be
deposited in a victims Compensation Fund, whose creation and operation shall be determined by a
separate law. Prior to the adoption of the law creating the fund, damages awarded shall be
deposited in an account at the National Bank of Rwanda opened for this purpose by the Minster
responsible for Social Affairs and the Fund shall be used only after the adoption of the law."

Organic Law N. 40/2000 of 26/01/2001 Setting Up "Gacaca Jurisdictions" And Organizing
Prosecutions For Offences Constituting The Crime Of Genocide Or Crimes Against Humanity
Committed Between October 1, 1990 And December 31, 1994 contains provisions for damages to be
paid. Article 90 stipulates that the gacaca judgments are to be forwarded to the Compensation
Fund for Victims of the Genocide and Crimes Against Humanity, which will then fix "the
modalities for granting compensation". Article 91 notes that "any civil action lodged against
the State before the ordinary jurisdictions or before 'Gacaca jurisdictions' shall be declared
inadmissible on account of its having acknowledged its role in the genocide and that in
compensation it pays each year a percentage of its annual budget to the Compensation Fund. This
percentage is set by financial law."

Paragraph 9 of the preamble to the 2003 Constitution reaffirm Rwanda's "adherence to the
principles of human rights enshrined in the United Nations Charter of 26 June 1945, the
Convention on the Prevention and Punishment of the crime of Genocide of 9 December 1948, the
Universal Declaration of Human Rights of 10 December 1948, the International Convention on the
Elimination of All Forms of Racial Discrimination of 21 December 1965, the International
Covenant on Civil and Political Rights of 19 December 1966, the International Covenant on
Economic, Social and Cultural Rights of 19 December 1966, the Convention on the Elimination of
All Forms of Discrimination against Women of 1 May 1980, the African Charter of Human and
Peoples' Rights of 27 June 1981 and the Convention on the Rights of the Child of 20 November
1989". Paragraph 10 of the preamble records Rwanda's commitment "to ensuring equal rights
between Rwandese and between women and men without prejudice to the principles of gender
equality and complementarity in national development".

Article 11 of the Constitution affirms that "discrimination of whatever kind based on, inter
alia, ethnic origin, tribe, clan, colour, sex, region, social origin, religion or faith,
opinion, economic status, culture, language, social status, physical or mental disability or
any other form of discrimination is prohibited and punishable by law."

VII. Justice, impunity and redress

Ten years after the genocide, justice is slow in coming for many women. The women's rights
organization Haguruka, in an interview with Amnesty International in March 2004, estimated that
significantly less than one hundred women have seen rape cases from 1994 through the ordinary
courts. According to Haguruka, of the twenty or so defendants who were found guilty, most were
sentenced to death, but appealed their sentences. The organization notes that women have little
interest in bringing such cases, as testifying-even behind closed doors-is traumatic and
increases the chances that community members will find out about the rape. Cases of grave
sexual violence are all meant to be transferred to the ordinary jurisdictions. If such cases
were being discussed in the gacaca (or community-based) jurisdictions, no perpetrator would yet
have been sentenced, as gacaca has yet to try a single case.(21) Gacaca is still in the phases
of categorizing suspects according to the severity of the crime, a process that is expected to
take until the end of 2005, before the trial phase can begin countrywide. The Rwandese
government, according to some representatives of bilateral cooperations working on gacaca and
members of Rwandese civil society, seems to have lost interest in the process. The gacaca
process was frozen during the months leading up to the presidential and parliamentary elections
of August and September 2003, and had, at the time of writing in 2004, not yet recommenced.

Women who suffered at the hands of RPA or RPF soldiers face an even more difficult struggle for
justice. Survivors of sexual violence who accuse soldiers face reprisals and are unlikely to
see the case advance. Journalists note that discussion of crimes committed by the RPA and RPF
are still taboo in Rwanda. Only a few isolated cases have been brought to court, though the
Rwandese government maintains that all RPA soldiers suspected of having committed rape have
been brought to justice. Amnesty International has repeatedly asked for statistical evidence
and names regarding RPA/RPF perpetrators brought to justice; the Rwandese government has on
several occasions promised to produce figures, but these have never been forthcoming.

VII.1. Compensation fund

One of the recurrent requests of rape survivors from the 1994 period with whom Amnesty
International delegates spoke was the establishment of a compensation fund for victims,
particularly victims of the genocide. It is very difficult for victims to recover effective
remedies from suspected perpetrators, as they are usually very poor, particularly if they have
spent most of the past decade in prison. There is a high risk of persons sentenced to be made
bankrupt, and no decision on damages has reportedly been enforced through court action.
Although an old version of the compensation law for victims of the genocide was drafted and
discussed by the Council of Ministers in August 2002, it has yet to be put to a vote in the
National Assembly. A new version of the bill putting into place the Fonds d'Indemnisation
(FIND), or Indemnity Funds, is apparently being circulated. The new version will reportedly
limit the total funds distributed by compensating a fixed amount to genocide survivors.(22) Up
until this point, the Rwandese government has been providing services via the Fonds des
Rescapés du Génocide (FARG) or Genocide Survivors Fund, in the form of approximately 5% of the
state's internal revenue spent on housing, medical and educational assistance, which may be
increased under the new draft bill. Many genocide survivors complain that the funds are
insufficient and can be difficult to access. In theory, FARG is meant to assist both Hutu and
Tutsi victims of the genocide. However, some Hutu survivors with whom Amnesty International
spoke said they been denied assistance and suspect their ethnicity to be the cause of the
denial.

VIII. Access to healthcare

"The truly indigent are luckier than the mid-level poor, as they are likely to get some
medicine for free, while the moderately poor can neither afford medicine themselves nor benefit
from government assistance".

Olive Gatesi, President of the national network of people living with HIV/AIDS

VIII.1. Poverty and access to healthcare

The majority of the population in Rwanda faces difficulty in accessing basic healthcare, much
less coping with the extremely high costs of AIDS treatments, tests and hospitalisations.
According to UNAIDS, only an estimated 28% of Rwandese households affected by HIV are able to
afford even basic health care; many families borrow money, sell assets, including land, or
decide to forego healthcare.(23) The Rwandese healthcare system operates on a cost recovery
policy, which was re-instituted soon after the genocide, though the government and
international donors are trying to encourage people to participate in community health
insurance schemes. The World Health Organization Commission on Macroeconomics and Health noted
in 2001, "Experience has taught repeatedly that user fees end up excluding the poor from
essential health services, while at the same time recovering only a tiny fraction of
costs."(24)

Rwandese living in extreme poverty are sometimes able to procure cards that attest to their
indigence and allow them to access free services, including medical care and education for
their children. However, the beneficiaries of this program are sometimes too poor even to
afford the transportation to the appropriate medical centre. The process for procuring the
indigence card is tedious, and some destitute people with whom Amnesty International delegates
spoke had not pursued the option. Other women accessed free medical services thanks to the FARG
assistance for genocide survivors, though these did not cover some HIV-related services,
including ARV treatments. Human rights activists also noted that the FARG and indigence system
were open to corruption, and that high political officials, including members of parliament,
benefited from FARG assistance, which is supposed to be directed to the most vulnerable people
in Rwanda.

Individuals who do not find assistance under these categories find the burden of living with
HIV/AIDS onerous. Transportation fees, consultation fees, medicines and tests are well beyond
the means of most Rwandese. Those few who do access free ARVs are still required to pay for
hospitalisation and consultation fees. Many find themselves deciding between paying for medical
expenses or buying food and wondering how to apportion the little food there is between family
members. The majority of Rwandese who are not eligible for free medical care are often unable
to afford basic treatments; women have reportedly been held prisoner in health centres after
giving birth and being unable to pay for medical expenses. Their families sometimes sell a
piece of their land in order to find the money to secure her release. Women are now reportedly
required by some healthcare providers to bring a guarantee from a government authority at the
cell-level (smallest administrative unit in Rwanda) reassuring the healthcare provider that she
will pay for services rendered.

"Services are increasing, but we can't help everyone...Sometimes women are afraid of having
their children tested because it is simply too painful for them to know, when they don't have
the means to care for the child".
Dr. Fabienne Shumbuso, HIV/AIDS specialist, Gitarama hospital

VIII.2. Prevalence of HIV/AIDS

HIV prevalence in Rwanda is itself a contentious issue. UNAIDS estimated adult prevalence at
8.9% in 2002, or 495,000 people living with HIV/AIDS, including 65,000 babies and children, out
of a population of 8,162,715.(25) Rwandese government figures describe a national prevalence of
between 11 and 13%(26). All parties do agree that prevalence is rising and that it is far
higher in the capital, Kigali-with the most commonly cited figure being 17%¯than elsewhere in
the country. A 2002 sentinel surveillance of women visiting antenatal clinics around the
country showed urban HIV prevalence varying between 3.7% and 13.0% in sites tested with a
median site-specific prevalence of 6.9%, and rural prevalence between 1.2% and 5.1%, with a
median site-specific prevalence of 3.0%(27). Based on this survey, the United States Centre for
Disease Control estimates prevalence at 4.9%.

VIII.3. Availability of ARVs and the international response

The availability of medical care for PLWHA has increased significantly in the past few years,
but does not begin to meet the needs of the population, including survivors of sexual violence.
Voluntary counselling and testing (VCT) programs are expanding and administered free of charge.
Experts in Rwanda estimate the number of patients clinically in need of life-prolonging
anti-retroviral (ARV) therapy at between 50,000 and 100,000. Rwanda is currently in a period of
rapid scale-up of ARV delivery, but as of January 2004, only about 2,000 Rwandese were being
treated with ARVs, including approximately 800 who paid for their own supply of medicine. A
month of ARV treatment, without additional tests, cost about 33,000 Rwandese francs, about 59
US dollars, in January 2004. 3,000 to 5,000 patients are projected to be receiving treatment by
the end of 2004, depending on arrival of funds, logistical considerations and capacity of
overburdened healthcare workers to follow their patients. Many more patients are benefiting
from antibiotics and treatment of opportunistic infections (such as tuberculosis) to stave off
serious illness and death. Donors such as the Global Fund to Fight AIDS, Tuberculosis and
Malaria, The World Bank and bilateral donations pay for these initiatives.

Some doctors and policy advisors expressed concerns to Amnesty International that treatment
programs in Rwanda have during the past year received as much money as they can absorb. They
cite the limited capacity within the health sector for adequate medical follow-up of large
numbers of HIV/AIDS patients. Other doctors hotly contested this notion and believe that it
would be possible to scale up ARV delivery significantly. These medical professionals do
concede that ARV scale-up poses logistical problems, for instance that hospital and clinic
management needs to be reconfigured with every new influx of money and services that is made
available. In either case, many gaps remain in ameliorating the daily living conditions and
addressing basic needs of PLWHA, such as food assistance and nutritional programs, school fees,
housing and psychosocial support.

VIII.4. Government-coordinated responses to HIV/AIDS

The National Commission to Fight Against AIDS (CNLS) was established in 1986, and a first plan
for monitoring and preventing HIV/AIDS put in place in 1988. Since then, the government of
Rwanda, multilateral and bilateral donors and non-governmental organizations (NGOs) have made
strides to expand prevention, care and treatment services available in the country. President
Kagame and First Lady Janet Kagame have both committed considerable effort to domestic advocacy
and international lobbying. Donors are generally satisfied with the Rwandese government
response, planning and implementation and note progress in coordination and procurement
procedures.(28) However, the same sources acknowledge that a weak healthcare system, management
problems, stigma surrounding HIV/AIDS (exacerbated by some healthcare personnel), difficulties
in changing behaviours and capacity limitations all pose substantial challenges to combating
the disease. Donor contributions of money and technical support have sometimes been
uncoordinated, resulting in glaring gaps in services, occasional duplication of efforts and a
high concentration of service provision in urban areas.

The Rwandese government has developed a national strategic framework and multi-sectoral plan
for the 2002-2006 period that continue prevention, monitoring and VCT efforts, prepare for
scale-up of treatment programs and step up the presently rather weak community and home-based
care systems to support PLWHA. Government ministries, private businesses, NGOs, religious
groups and other civil society organizations are all requested to participate in curbing the
spread of the virus and mitigating its consequences. Some private businesses in Rwanda have
particularly strong programs to offer ARV treatment to employees and have acknowledged that it
makes business sense to do so.

VIII.5. Access to ARVs for survivors of sexual violence

Most women survivors of sexual violence who do benefit from free ARVs at government or private
clinics entered treatment programs following their participation in prevention of
mother-to-child transmission (PMTCT) programs. Survivors of rape are not accorded special
privileges in government ARV treatment plans, though there are very limited privately
implemented programs that offer free treatment, in particular for genocide widows with HIV/AIDS
and their children. The government does acknowledge that rape, including child rape, is a
significant factor in HIV transmission in addition to constituting a grave violation of the
individual's rights. In March 2003, the Minister of Health and State Minister for HIV/AIDS both
confirmed to Amnesty International delegates their intention to put in place post-exposure
prophylaxis (PEP) for survivors of violence to reduce the likelihood of HIV transmission(29).
However, no implementing partner, government official or donor with whom Amnesty International
spoke in 2004 had seen any concrete plans to realize this stated government intention.

Genocide survivors living with HIV often complain publicly that defendants awaiting or
undergoing trial at the International Criminal Tribunal in Tanzania, accused of high-level
participation in the genocide, receive ARVs and high quality medical treatment while in prison.
Meanwhile, women who were survivors of atrocities lack access to medical treatment and a basic
standard of well-being. Many women have expressed a sense of profound injustice at this
differential treatment.

VIII.6. Privileged access to ARVs

Some of the people whom the Rwandese government sponsors for free ARV treatment are reportedly
military officers. The Ministry of Defence pays for their ARV treatment, but not for the
treatment of ordinary soldiers who, like many others in the population, cannot afford to pay
for ARV therapy. High-level civilian authorities also reportedly benefit from free ARV
treatment, in spite of their relatively high incomes. Human rights sources have told Amnesty
International that the RPF government have sometimes used ARV treatment as a bargaining chip
and have threatened these civilian authorities with revoking treatment if they did not support
RPF policies.

IX. Eligibility and access to ARVs

Some donors and implementing partners are worried that the phase of selecting patients for
limited ARV treatments will prove problematic and open to manipulation, in spite of agreed
protocols for deciding on patient eligibility. The World Bank assessment paper warns of "(i)
pressures to select participants, as the number of people requiring treatment will exceed
financial and institutional capacities; (ii) risk of leaving behind the most needy who have
limited negotiating skills and low levels of education; and (iii) concerns over financial
sustainability, particularly in light of the large pool of infected persons and the high cost
of drugs for this chronic illness".(30)

A Ministerial Instruction was issued in 2003 "determining the conditions and modalities for
health care delivery to persons living with HIV/AIDS". This instruction makes provisions for
Technical Committees for Patient Selection, which includes representatives from the health care
provider, heads of psychosocial teams designated by the head of the health care delivery
institution and "two representatives of associations of PLWHA located within the geographical
area served by the health institution designated by the network of persons living with HIV".
The ministerial instruction has been hailed as a fair document that sets out logical criteria
for eligibility for access to treatment and financial requirements based on medical
considerations, proximity to treatment site and acceptance of behaviour that minimizes risk of
further HIV transmission. Refugees living in Rwanda are not explicitly excluded from receiving
treatment. However, the requirement that patients must have a fixed address for six months
prior to treatment - a requirement intended to facilitate delivery and encourage continuity -
means that refugees (and others without a fixed address) are less likely to be eligible for
treatment.

IX.1. Access to HIV/AIDS-related services and the critical role of associations of PLWHA

The rationale of grouping as many people living with HIV/AIDS into associations as possible is
to have a clear means of organizing and delivering services to the population, for associations
to provide moral and psychological support to PLWHA and to educate and assist people who have
just learned their HIV status following voluntary testing. The associations typically have
weekly meetings and serve as focal points for HIV/AIDS education, any delivery of aid or
assistance, and distribution of information about healthcare opportunities. For most PLWHA,
particularly in rural areas, associations will be their point of contact for whatever
information and assistance is made available. Membership in an association of PLWHA is not a
precondition or requirement for people to access ARVs. However, local authorities have sent
strong signals that people with HIV/AIDS had to join associations if they were to have a chance
of receiving ARVs and other treatments and services. Some people with whom Amnesty
International delegates spoke acknowledged that they recently joined associations in hopes of
benefiting from projected ARV scale-ups and other services. Those who are perceived to be, or
regard themselves as being, in opposition to the government are afraid that they will face
discrimination within the association when services are made available-or indeed, can already
attest to such discrimination. Some NGOs fear that government statements transmitted via
associations might raise expectations of access to healthcare and other services that are
impossible to fulfil, further frustrating the hopes of suffering individuals.

In some cases, association leadership appears to be working against the best interests of
PLWHA. Even high-profile associations of genocide survivors or PLWHA with international
reputations are routinely criticized for diverting funds and for being highly politicised.
Several journalists and PLWHA cited associations that were run by individuals who did not have
HIV, but were using the associations as a means of collecting money for themselves personally.
Other PLWHA spoke of their exclusion from associations because of conflicts they may have had
with local politicians. In other cases, the president and vice-president of an association
might have benefited from services, while the membership was left with little or nothing. Often
the management issues highlighted the gap in education and money between leadership and
members. Some association members said they did not dare to speak out publicly against the poor
leadership for fear they would be entirely denied access to services. One activist for PLWHA
said, "Here, farmers aren't free to ask for what they want, even to make suggestions. They are
afraid of prison or maltreatment, so they say nothing." In one case, the HIV-negative
leadership of an association excluded some PLWHA from the association because they had asked
about opaque financial transactions of the association. Because the association president was
politically well-connected, she was able to prevent the excluded individuals from registering a
new association.

"Sometimes people who are HIV-positive are excluded from associations because they have
problems with politicians; sometimes you find associations whose president doesn't even have
HIV". Woman living with HIV/AIDS, Kigali

"In many associations, you find that the only people receiving ARV treatment are the president
and vice-president. Sometimes this may be because they are educated and so are the only ones
wealthy enough to afford to buy drugs every month. But it may be that they are using the
association to ensure that they will have access to medicine. There are many problems with
transparency in the association, but people may not speak out because they are afraid to lose
any hope of accessing medicine". Journalist, Kigali

The leaders of these organizations are literally being given the power of life and death over
membership, as they are often empowered to accord or deny services or donations to membership.
Adequate measures should be put in place to ensure that they are operating transparently, that
members have a means of filing grievances without suffering retribution and that PLWHA have
access to services through means other than associations. Additionally, associations tend to
cease functioning if members of leadership become sick; efforts to democratise associations
would help ensure that they represent the best interests of their constituents and help to
prevent associations from being rendered dysfunctional by the illness of leaders.

IX.2. Access to HIV/AIDS-related services and national associations of PLWHA

At higher levels, the National Network of PLWHA (Réseau National), a network of some 250
associations of PLWHA, has been criticized for being a government mouthpiece rather than
representing the interests of its membership. Information reportedly tends to flow from the top
down rather than from the grassroots up to the policy makers.

The National Association to Support People Living with AIDS (ANSP), under the Ministry of Local
Government (MINALOC), has itself been twice sanctioned for embezzlement and mismanagement. More
seriously, some PLWHA say they or people they know have been manipulated by ANSP. They cited
instances when individuals were called upon to declare their HIV status publicly, sometimes in
a crowded stadium, with the promise of being given ARV treatments. Reportedly, the individuals
who declared their serological status publicly received nothing in exchange, in spite of the
promises ANSP had made, but did suffer the predictable stigma that followed the event. At least
one young man who testified has since died of an AIDS-related illness. One journalist told
Amnesty International, "There are Rwandese government officials whom everyone suspects of
having HIV, and yet they do not speak out about their situation to help destigmatise the
disease, because they already can pay for ARVs; and yet the government expects the poor people
to do just that."

X. Freedom of expression and access to HIV/AIDS-related services

Articles 19 and 20 of the Universal Declaration of Human Rights protect the rights to freedom
of expression and assembly respectively. Article 19 protects the "freedom to hold opinions
without interference and to seek, receive and impart information and ideas through any media
and regardless of frontiers". PLWHA should have the right to receive information regarding
their disease as well as to participate in representative mechanisms to advocate for provisions
that ameliorate their access to health(31). Amnesty International is concerned that a climate
of fear exists that curtails people's willingness to exercise their right to freedom of
expression. PLWHA with whom Amnesty International delegates spoke reported problems expressing
themselves within the context of their associations, particularly if they commented on the
financial management or equitable distribution of services to association members. The
Government of Rwanda should give meaningful assurances that PLWHA who do peacefully exercise
their right to freedom of expression will not be subject to expulsion, denial of services or
discrimination in receiving services or treatments, and other forms of intimidation. One
association head commented, "You never see demonstrations in Rwanda. People living with HIV are
very frustrated when they see their health deteriorate and there are many promises but no
services, but they are too scared to demonstrate."

One exiled journalist cited the case of the former president of the ANSP who was the subject of
a 2002 newspaper article in Umuseso, an independent newspaper. The article pointed out that she
did not have HIV and accused her of embezzling mo