Women & HIV/AIDS

Facts and figures

• 42 million people living with HIV/AIDS, 19.2 million of whom are women
• 3 and a quarter million are children under the age of 15
• 5 million adults newly infected in 2002. 2 million of them women
• 3.1 million died of AIDS in 2002. More than half were women
• 12-13 African women currently infected for every 10 African men (Year 2000 Survey)
• Half a million infections in children (under 15), most of which have been transmitted from mother to child (Year 2000 Survey)
• 55% of adult infections in sub-Saharan Africa are in women, 30% in SE Asia, 20% in Europe and USA. (Year 2000 Survey)
  

Modes of transmission

The AIDS epidemic in women is overwhelmingly heterosexual – almost entirely so in Africa and South and South East Asia.

In other areas, a proportion of women are infected through:

• sex with a bisexual or drug injecting partner
• their own injecting drug use
• heterosexual sex without these factors
• blood transfusion (in developing countries where blood is not routinely screened).
• Why are women more vulnerable to HIV infection?

Biologically

• Larger mucosal surface; microlesions which can occur during intercourse may be entry points for the virus; very young women even more vulnerable in this respect.
• More virus in sperm than in vaginal secretions.
• As with STIs, women are at least four times more vulnerable to infection; the presence of untreated STIs is a risk factor for HIV.
• Coerced sex increases risk of microlesions.

Economically

• Financial or material dependence on men means that women cannot control when, with whom and in what circumstances they have sex.
• Many women have to exchange sex for material favours, for daily survival. There is formal sex work but there is also this exchange which in many poor settings, is many women’s only way of providing for themselves and their children.
  

Socially and culturally

• Women are not expected to discuss or make decisions about sexuality.
• They cannot request, let alone insist on using a condom or any form of protection.
• If they refuse sex or request condom use, they often risk abuse, as there is a suspicion of infidelity.
• The many forms of violence against women mean that sex is often coerced which is itself a risk factor for HIV infection.
• For married and unmarried men, multiple partners (including sex workers) are culturally accepted.
• Women are expected to have relations with or marry older men, who are more experienced, and more likely to be infected. Men are seeking younger and younger partners in order to avoid infection and in the belief that sex with a virgin cures AIDS and other diseases.
  

Why must the response be gender-based?

Three main reasons:

1. Unequal gender (social, economic, and power) relations are driving the epidemic.

2. Women are disproportionately affected by the epidemic.

• They are highly vulnerable to infection.
• They bear the psychosocial and physical burden of AIDS care.
• They suffer particular discrimination; are often blamed for spreading infection.
  

3. Sex differences in pathology. Clinical management, for too long based on research undertaken on men, must be tailored to women’s particular symptomatology, disease progression, HIV related illnesses etc.

What will make a difference?

Physical and material independence and security for women which is independent of the "protection" of a man or men.

• Women must be empowered so that they are able to control their own lives and in particular their sexual relations.

This implies a profound shift in social and economic power relations between men and women. It cannot be achieved tomorrow but action must start today, through:

• Increased educational and employment opportunities for girls and women.
• Public education campaigns on the harmful - fatal, in the case of AIDS - effects of unequal gender relations.
  
  

Microbicides: our best hope

The development of a prevention method which is cheap, safe and effective and under women’s control, is essential.

• In the absence of a vaccine, this is a method likely to have an immediate and significant impact on the alarming rate of new infections in women.
• A massive investment in international research and development of a microbicide is required.
• An issue which must be dealt with is the desire for children. A microbicide for preventing both pregnancy and STIs including HIV (dual protection), and a microbicide which is not also a spermicide must be developed.

Proven effective interventions

There are a number of proven interventions (see key interventions) which together, comprise key strategies to control the spread of the epidemic. They are particularly important for women.

Treatment and prevention of sexually transmissible infections:

• Women are more vulnerable to STIs; the consequences are more serious.
• Many STIs are asymptomatic in women, so go untreated.
• Syndromic management of STI in women is more difficult than in men.
• Stigma associated with STIs is greater for women (suggests promiscuity), so they are often afraid or unwilling to seek care.
  

Safe blood

Women and children are the chief recipients of transfusions; women - during and after delivery. The following action is required:

• Antenatal care and adequate nutrition to reduce some of the need for transfusion.
• Appropriate clinical use of blood to avoid unnecessary transfusion.
• Screening of all blood as the ultimate aim.

Education for prevention including the use of condoms

Condoms, male and female, are currently the only protection methods available.

They need to be more widely accepted, available and used.

• Education to promote their use.
• Increasing access through free distribution, subsidies, or social marketing so that they are really affordable.

It has been shown that even in the most favourable circumstances, condom use (male and female) is low. The acceptability of these methods remains problematic. The female condom is if anything more cumbersome than the male condom and considerably more expensive. Furthermore, women cannot control their use. Impact will continue to be low if people’s preferences and therefore their actual use of methods, are not given due attention.

Women as carers

• Women are responsible for the health care of all family members.
• Care is only one of the many productive and reproductive activities of women which include farming, food preparation, collection of firewood and water, child care, cleaning, etc.
• Care is provided free but has a cost! During illness, women’s productive labour is lost; this has serious impact on long term wellbeing of the household.
• Care doesn’t end with death of husband/child/sister. Care of orphans lies with grandmothers and aunts.
• Women carers are often HIV positive themselves.
  

Making men more responsible

• Little attention has been paid to men’s participation in efforts to protect women.
• Men are hard to reach and educate but some are concerned about sexual health – their own and their partners.
• Raising awareness of their own risk has been shown to change certain behaviours.
• Interventions must be aimed at men (as well as at women) if women are to be protected.

Human Rights, Women & HIV/AIDS

Women's right to safe sexuality and to autonomy in all decisions relating to sexuality is respected almost nowhere.

As it is intimately related to economic independence, this right is most violated in those places where women exchange sex for survival as a way of life. And we are not talking about prostitution but rather a basic social and economic arrangement between the sexes which results on the one hand from poverty affecting men and women, and or on the other hand,from male control over women's lives in a context of poverty.

By and large,most men,however poor can choose when,with whom and with what protection if any, to have sex. Most women cannot.

As such, our basic premise has to be that unless and until the scope of human rights is fully extended to economic security ( that is the right not to live in abject poverty in a world of immense riches), women's right to safe sexuality is not going to be achieved.

Women have a right to sexuality which does not endanger their lives.

The major issues

• Lack of control over own sexuality and sexual relationships.
• Poor reproductive and sexual health, leading to serious morbidity and mortality.
  Rates of infection in young (15-19) women are between 5 and 6 times higher than in young men (recent studies in various African populations).
• Neglect of health needs,nutrition,medical care etc.Women's access to care and support for HIV/AIDS is much elayed (if it arrives at all) and limited. Family resources nearly always are devoted to caring for the man. Women, even when infected themselves, are providing all the care.
• Clinical management based on research on men. Now plans are underway to concern ourselves with the clinical management of HIV/AIDS in women.
• All forms of coerced sex - from violent rape to cultural/economic obligations to have sex when it is not really wanted, increases risk of microlesions and therefore of STI/HIV infection.
• Harmful cultural practices: from genital mutilation to practices such as "dry' sex.
• Stigma and discrimination in relation to AIDS (and all STIs); much stronger aganst women who risk violence, abandonment, neglect (of health and material needs), destitution, ostracism from family and community. Furthermore, women, are often blamed for the spread of disease, always seen as the "vector" even though the majority have been infected by only partner/husband.
• Adolescents: access to education for prevention, (in and out of school and through media campaigns), condoms, and reproductive health services before and after they are sexually active. Promotion and protection of adolescent reproductive rights (particularly girls). Obstacles in terms of laws and policies, health service provision, cultural attitudes and expectations of girls and boys' sexual behaviour, cultural practices, and educational and employment opportunities.
• Sexual abuse: there is now evidence that this is an underestimated mode of transmission of HIV infection in children (even very small children). Adult men seek ever younger female partners (younger than 15 years of age) in order to avoid HIV infction, or if already infected, in order to be "cured".
• Disclosure of status. partner notification, confidentiality. These are all more difficult issues for women than for men for the reasons discussed above - negative consequences; and the fact that women have usually been infected by their only partner/husband.
• Because disclosure is more difficult, women's access to care an support is further decreased. Protection for women when they disclose status must be assured.
  

Human rights issues relating to mother to child transmission (MTCT)

The provision of adequate pre-test counselling, pre-intervention counselling/information; infant feeding counselling; contraceptive advice especially if not breastfeeding.

Protection of confidentiality, including shared confidentiality in the interests of care and support; and the problem of not breastfeeding when this amounts to "public disclosure" of positive serostatus. Legal provisions, health service practices and community/NGO support.

Provision of family planning services, alternative infant feeding/breastmilk substitutes, material support for fuel, water etc. in addition to the intervention itself.

Involvement of partner/husband at all stages, positive and negative consequences.

Potential adverse effecrs of taking antiretrovirals (ARVs) especially in repeat pregnancies of an HIV infected woman.

Women's access to care and treatment apart from the MTCT intervention,woman as vessel for the baby.

Generations of orphans. Parents likely to die. On mother's death, baby's survival chances much reduced.