Thousands of miles from advanced medical facilities in the United States and Europe, Dr. Ignace Bingi carries on a somber fight to treat patients infected with HIV and/or suffering from AIDS. Nearly every day, he walks a mile from his family’s modest home in the war-ravaged Democratic Republic of Congo (DRC), in central Africa, to the makeshift clinic that employs him.

Ten years ago, a continent-wide scramble began for the DRC’s vast resources of gold, diamonds and copper. A guerrilla movement led by Laurent-Desire Kabila overthrew the longtime dictatorship of Mobutu Sese Seko, sparking a gross litany of wartime abuses, including widespread rape. Although a truce ended most of the hostilities in 2005, fighting and sexual violence persist in the eastern part of the country, where Dr. Bingi lives and works. The United Nations humanitarian group UNAIDS estimates that in the conflict’s aftermath, 3 to 4 percent of the DRC’s total population of 64 million has HIV; for women who have suffered sexual violence in the country’s still-volatile regions, that figure now hovers at 20 percent.

The DRC government had established a system for monitoring domestic HIV/AIDS infection patterns in 1995, before the civil war. But the country has only sporadically conducted further research, due to the breakdown of health services, massive displacement of the population and prolonged instability from militia activity in the bush. Indeed, the DRC has the highest wartime death toll since World War II: Four million people have perished from direct combat or related factors, including disease, malnutrition and poverty. On average, 40 women are raped per day in South Kivu, according to the refugee-advocacy journal Forced Migration Review; UNAIDS and UNICEF report that the country has more than 680,000 AIDS orphans.

Dr. Bingi lives in the Ituri province, just outside the town of Bunia. His hospital there, the Centre Medical Evangelique, is funded and operated by the Church of Christ. Evangelique can hold no more than 300 patients; every week it admits, on average, ten new people living with AIDS. On one cloudy afternoon, Dr. Bingi points from his office to an empty pharmacy building where a handful of young men sit on a stoop. “It’s a beautiful structure,” he says. “Too bad it’s empty.”

He talks about the realities of being a local doctor fighting AIDS in a war-affected country—without any antiretroviral (ARV) drugs. “It’s very rare that patients come in and say they’ve been infected with HIV through rape,” Dr. Bingi says. “They’ll say that they’re very poor and have to take money for sex, but it’s not often violence is presented as a reason.” Dr. Bingi is one of many clinicians and observers to point out that survivors of sexual violence in lands like the DRC suffer under a double stigma: first, contracting HIV and, second, contracting it through rape, a deadly shame that keeps many from coming forward to get lifesaving treatment.

According to “Women’s Bodies as a Battleground,” a report by the advocacy group International Alert, most survivors of conflict-driven sexual violence experience some form of fistula—a condition where the wall separating the uterus from the vagina is ruptured—as well as the threat of HIV. But only a third receive any medical care. If treatment is sought at all, it typically involves traditional local medicines.

What’s more, Dr. Bingi says, “there are many places in the [DRC] where people do not know that sexual activity can lead to the disease. And the war has had a huge impact. The soldiers are armed and the women have no means to resist them. When the Ugandan [invaders] were here, women would present themselves at their camp for food and money. The main problems are poverty and [lack of] education.”

Later in the afternoon, Dr. Bingi sits with a patient in the AIDS ward. Florien—who, like most DRC war and rape survivors interviewed for this story, asked that her last name not be mentioned—is a 47-year-old housewife from Bambou, a mining territory some 90 minutes’ drive from Bunia. In a musty, sweat-stained bed, Florien lies on her side, staring at the opposite wall.

When speaking with her and other patients, Dr. Bingi rarely uses the words “HIV,” “AIDS” or “SIDA” (the French acronym for “AIDS”). “It frightens people too much,” he explains. Florien says that since her husband doesn’t have the disease, she likely got it from an outside relationship. The doctor adds, out of her earshot, “It may or may not have been forced,” alluding to the possibility of rape. Due to stigma and poor testing resources, most patients whom Dr. Bingi diagnoses as HIV positive have already developed AIDS and are near the end of their lives. Florien is no different.

There is no lack of global historical precedent linking conflict, sexual violence and sexually transmitted disease. During the Bangladeshi war for independence in the early 1970s, upwards of 250,000 women were raped. More recently, rape camps in Bosnia and Herzegovina were places of severe abuse and degradation for thousands of women. Following the three-month genocide in Rwanda in 1994, several hundred thousand women reported having been sexually assaulted, and a high percentage of those contracted HIV and/or bore children from their attacks. The pattern continues today in the embattled Darfur region of Sudan.

But even by these standards, “the level of gender violence in the [DRC] is horrific,” says Nigel Fisher, president of UNICEF-Canada. At last year’s international HIV/AIDS conference in Toronto, Fisher—who had traveled to the eastern DRC, specifically North and South Kivu, in the summer of 2006—helped lead a groundbreaking workshop focused on HIV/AIDS in emergency situations.

“Sexual violence has broken down community standards,” he continues. “That’s applicable to many situations, not just the DRC. You can always make excuses about excess, but political will and whether leaders are interested in putting resources into combating the violence and disease are what matter. We know what to do, but it’s a matter of getting the resources. UNICEF could provide the testing, the ARV administration and the counseling, but we need the budget. To test somebody so that they know whether or not they’re positive and then not provide drugs is cruelty.”

In the DRC, sexual violence is also used to intimidate or oppress women, girls and even boys. A 35-year-old mother of four, Mandosi lives in a camp for displaced civilians in Bunia. Many similar refuges tend to the people who were forced to flee their homes during the war. But displacement is hardly Mandosi’s only challenge. A survivor of sexually inflicted military violence, she is uncertain about her HIV status. For those who have been raped by the military fighting in the region, there are even fewer places of recovery or materials available to them than there are for other civilians who left their homes and communities because of the war.

In December 2005, Mandosi was at home with her husband and children when a rebel militia came to their village of Bavu, and began looting. After destroying their home, the invaders turned to Mandosi, forcing her to have sex with all three of them—in front of her family. Several days later, the soldiers returned to the home and started shooting. Mandosi’s husband tried to flee and escaped out a window to climb onto the roof, but he was soon forced down and shot to death. Again, Mandosi was raped, and she fled the region with her children to the camp where she now lives.

“Life has been difficult for me,” she says, while sitting in a house operated by the Mother’s Union, a safe haven for women who’ve been raped during the course of the fighting. “I didn’t get any medical assistance or treatment. I didn’t have the money for food, let alone treatment. I always go to work for local people in order to feed my children. At the hospital, they gave me some tablets and sent me back home.” She’s not sure what the tablets were. “Nothing about exams or medicine,” she continues. “They just sent me back home.” Cases such as Mandosi’s are typical, as many local hospitals lack the drugs or medical personnel to fully respond to the disease.

The silence of women—not only in coming forward to receive medical treatment and psychosocial counseling but also in seeking legal remedy—has created a culture of impunity, where few prosecutions are able to occur. While rebel militias were responsible for tragic incidences of sexual violence, all sides and armies have been implicated, including the Congolese army, which became more aggressive in its investigations following support from the European Union.
 
“Even if perpetrators are known, the women don’t talk about it,” says Diane Sarawayo, a researcher with the Norwegian Refugee Council in Goma, a DRC city on the Rwandan border. “The family often abandons the rape survivor who has a child, and the women who are taken away and raped are not accepted when they go back. People are not informed about HIV, and some still believe that they can be healed from AIDS by raping a child.”

At the Orphants Mudzipela, an orphanage in Bunia with about 64 children at the moment, the specters of sexual violence and AIDS prevail. Sister Maculin is a nun who runs the facility with the help of a small staff.

“We’ve found children next to the dead bodies of their parents, as well as those abandoned by their parents,” she says. “Malaria, diarrhea and, of course, HIV are concerns. In regard to sexual violence, we have three cases of children who are victims of rape and have AIDS—one was 5 months, one was 2 months and one was 6 months. Medical treatment is difficult.”

One success story: Ajedi-Ka, a local organization formed in 1988 to serve the needs of survivors of sexual violence. Based in the South Kivu community of Uvira, the group addresses the issues of poverty, the environment and children, all of which have a connection to the spread of HIV and AIDS. The organization also helps care for thousands of child soldiers, both boys and girls, many of whom were also infected during the fighting. As in other countries where child soldiers have been used, such as Sri Lanka, Liberia and Chechnya, demobilized youth are not typically tested for STDs nor given specific rape counseling.

Ajedi-Ka’s executive director, Bukeni Beck, is helping to reshape his country’s attitudes toward sexual violence and sexual health. “When someone [in the DRC] suspects that they might be infected, they ask themselves, ‘Why get tested?’” he says from his present home in New York City, where he has sought asylum after testifying against warlords in the DRC. “That’s because they can’t even afford the test. And if they can afford it, the knowledge of having the disease or not wouldn’t do any good because the [drug prices] are too high, if any are even available.”

The average cost of so-called “first-line treatment” in the DRC is US$1 per day; less than 0.3 percent of the infected are receiving regular treatment. A monthly regimen of ARVs costs $22 a month, far beyond the salary of most Congolese. What’s more, the challenges of underfunding, conflict-forced displacement and organizational instability can inhibit effective ARV programs in a war zone. When patients begin a regimen and are then forced to flee because of fighting, the breaks in treatment can lead to drug resistance.

Riziki is a former child soldier with the Congolese national army who served for four years. Joining because of problems at home with her family, she ended up being approached by an adult commander who wanted to sleep with her. When she refused, the officer ordered other soldiers to beat her.

“I was afraid to sleep with him because I was scared of STDs,” she told Bukeni Beck from Ajedi-Ka. Eventually, she met another soldier who wanted to take her sexually, and the two ended up living together in the bush as husband and wife. When they were demobilized and sent back home, Riziki learned she’d contracted HIV. Her husband left the family, and today she barely subsists living alone with her infant daughter. Too poor to buy drugs in the DRC, she traveled to a camp in neighboring Burundi, only to learn the center had no more drugs.

Added Mauwa, another mother in Uvira who has AIDS and spoke with Beck, “Many of the sick hide. They don’t want to be singled out by people saying, ‘This one has AIDS.’”

On the occasion of this year’s International Women’s Day, March 8, women’s rights groups from around the world lobbied donors for more money focused on HIV and AIDS among women—especially women who are victims of violence. A report prepared for the event, “Show Us the Money: Is Violence Against Women on the HIV and AIDS Funding Agenda?” highlights the increasing link between violence against women and HIV in the absence of matching funds to address the issue.

In January, the United Nations High Commission for Refugees began a new policy of encouraging access to ARVs for HIV-positive refugees and displaced populations. The agency estimates that between 25,000 to 35,000 refugees around the world need the medicines.

Four years ago, Médecins Sans Frontières (Doctors Without Borders) began providing patients in Bukavu with ARVs. What began with a dozen individuals has now expanded to more than 1,000, a fraction of the overall need but marked progress. The Geneva-based, Nobel Prize–winning group provides low-cost generic drugs other African nations had rejected. Rape survivors willing to brave the stigma and come into an MSF-supported facility within 72 hours of their attack are given prophylactic medicines for HIV/AIDS, but treating those confirmed to have AIDS was significantly more challenging. It was the first time a non-governmental organization had attempted to give ARV treatment while the war was still being fought, at a cost of $29 to $40 per month per patient. A recent loan of $102 million from the World Bank in Washington, DC, to the elected government of the DRC, led by President Joseph Kabila (Laurent’s son and successor), will give 25,000 more people access to ARVs by 2009, while 15,000 more could be assisted through a Global Fund grant of $35 million.

The DRC does have a local drug production facility in Bukavu, Pharmakina, which has the potential to produce enough ARVs for all HIV/AIDS-infected Congolese. Since the spring of 2005, it has produced the drugs, making Congo the first central African nation to do so. Able to ship out 180,000 pills per month, Pharmakina has been awaiting approval from the World Health Organization. The company’s ARV is called “Afri-Vir.” Even when ARVs are available, access is still limited. For example, most of those with HIV in the northeast section of the country are not coming to get free pills offered by the government through a program that started in early 2007. Stigma, a suspicion of Western medicines and restricted freedom of movement have hampered the initiative. In the first five months, only 28 people in the entire province of Ituri came for medicine.

Some private corporations are making headway, even if it’s not with direct support through drugs. In December 2005, Johnson & Johnson partnered with UNIFEM, the United Nations Development Fund for Women, and the Joint U.N. Programme on HIV/AIDS to create a trust fund for locally based groups around the world dealing with the relationship between gender violence, HIV and AIDS.

“One of the things we recognized is that the growing epidemic of AIDS is linked to the growing violence against women,” says Anu Gupta, J&J’s director of corporate contributions. “The timing [in the Congo] was good because the war was ending. The trust fund grants are one to two years and given at the discretion of UNIFEM. Our partnership is really to give a large part of funding in total. UNIFEM determines the amount.”

The trust fund was created to support groups in ten countries, although the Congo is the only one affected by conflict. Others include Haiti, India and Vietnam.

Over the last six years, UNIFEM has been working with various women’s groups in the Congo to assist in the effort to put women’s rights on the national political agenda permanently. Since the war began, the agency has worked to promote women as peace builders in the conflict-negotiation process.

Last year, UNIFEM began a “Multipurpose Centre” in the community of Kindu in partnership with a local women’s organization, Collective des Femmes du Maniema (COFEMA). The center not only provides mental health support for female survivors of violence but also works to build wide strategies for dealing with the HIV/AIDS pandemic.

But other humanitarian leaders say that only a fundamental shift in gender attitudes can prompt sexual violence survivors to seek the care they need and deserve. “Gender equality can work to reverse the spread of HIV and AIDS,” argues Noeleen Heyzer, executive director of UNIFEM, in her New York office overlooking the Secretariat building. “There are a lot of things that need to happen if we are going to end violence in women’s lives. There needs to be a worldwide mobilization to end impunity. As long as these are taken as minor crimes, we are not going to be able to reverse these trends. Violence, especially in war, is not just a devastation of women’s lives but of the community. It makes it extremely difficult for communities to revitalize themselves.” She pauses. “You cannot have peace unless you have justice.”

Meanwhile, back in his Bunia office, Dr. Bingi stares at his rickety wooden desk, piled high with medical books. How can he possibly expect to offer any lasting care—or remain even remotely optimistic about his contributions—without the benefit of ARVs? He says he tries to provide whatever comfort and encouragement he can. When asked to name his most potent tool, he says “music.” And then he motions toward his desk. There, behind the books, sits a red-and-white accordion.