|Women and AIDS (Best Practice- Point of View) (UNAIDS, 1997, 6 p.)|
UNAIDS Best Practice Collection
· UNAIDS estimates that, as of mid 1996, more than 10 million women worldwide had been infected with HIV since the start of the epidemic, out of a total of over 25 million infected adults. Women account for 42% of the over 21 million adults now living with HIV.
· Worldwide, the HIV risk for women is rising.
· In industrialized countries, practically all infections used to occur in men. No longer. While women comprised around 12% of the AIDS cases reported in France in 1985, ten years later this figure rose to around 20%. In Spain, womens share of reported AIDS cases more than doubled over the same ten-year period - from around 7% to 19%.
· Brazilian women have experienced an even more spectacular increase in risk. While only one woman was infected for every 99 men in 1984, a decade later women accounted for a quarter of all those with HIV.
· Asian women face an enormous challenge from their regions runaway HIV epidemic. Typically, one-third or more of prostitutes in cities in Cambodia, India and Thailand are infected. Even among women who are not occupationally exposed, the risk is growing. Nationwide in Thailand, in 1991, fewer than 1% of pregnant women attending antenatal clinics were found to be infected. By 1995, the figure was more than 2%.
· In Africa south of the Sahara, there are already 6 women with HIV for every 5 men. Close to four-fifths of all infected women are African.
· In the younger age brackets (15-24 years), the HIV risk for African girls is even more disproportionate. In countries where youngsters account for 60% of all new infections, young women outnumber their male peers by a ratio of 2 to 1.
· Currently, close to half of the 7500 adults worldwide who become infected daily are women. And over 9 out of 10 infected women live in a developing country.
· More than four-fifths of all infected women get the virus from a male sex partner (heterosexual transmission). The remainder become infected from a blood transfusion or from injecting drugs with a contaminated needle.
· Studies in Africa and elsewhere have shown that many married women have been infected by their one partner - their husband. Simply being married is a major risk factor for women who have little control over abstinence or condom use at home or their husbands sexual activity outside.
· Women with a sexually transmitted disease (STD) like gonorrhoea are often unaware of it because the infection is silent. Conclusive proof now exists that STDs facilitate the spread of HIV. An untreated STD in either partner increases the risk of HIV transmission during unprotected sex* up to 10-fold. The STD epidemic, with 333 million new cases a year, thus fuels the AIDS epidemic.
* Unprotected sex means intercourse without a condom.
· AIDS prevention campaigns often fail women by assuming that they are at low risk, or by urging prevention methods that women have little or no power to apply, such as condom use, abstinence and mutual fidelity.
Women continue to make strides towards equality with men. Wherever they are educated, able to generate income, and enjoy equal protection under the law, they are in a position to have some control over their economic, social and personal life.
But for millions of women, these goals are still remote. These are the women who are the most vulnerable to infection with HIV, the virus that results in AIDS.
Research shows that the risk of becoming infected with HIV during unprotected vaginal intercourse is as much as 2-4 times higher for women than men. Women are also more vulnerable to other sexually transmitted diseases.
As compared with men, women have a bigger surface area of mucosa exposed during intercourse to their partners sexual secretions. (In women, the genital mucosa is the thin lining of the vagina and cervix.) And semen infected with HIV typically contains a higher concentration of virus than a womans sexual secretions. This makes male-to-female transmission more efficient than female-to-male.
I told my husband that it was better to use condoms, the doctor said so. The doctor had also given me some to use home. My husband became very angry and asked who gave me permission to bring those condoms home.
Woman in Kenya
Younger women are at even greater biological risk. Their physiologically immature cervix and scant vaginal secretions put up less of a barrier to HIV. There is evidence that women again become more vulnerable after the menopause.
Tearing and bleeding during intercourse, whether from rough sex, rape or prior genital mutilation (female circumcision), multiplies the risk of HIV infection. Throughout the world, women run a similar risk from unprotected anal intercourse. Sometimes preferred because it preserves virginity and avoids the risk of pregnancy, this form of sex often tears the delicate tissues and affords easy entry to the virus.
A final important biological factor is an untreated STD in either partner, which multiplies the risk of HIV transmission by up to 10-fold. Between half and four-fifths of STD cases in women go unrecognized because the sores or other signs are absent or hard to see and because women, if they are monogamous, do not suspect they are at risk.
Social and economic vulnerability
Biologically vulnerable does not mean unprotectable. Experience from the past decade proves that both men and women can be helped to avoid HIV. Around the world, infection rates have been lowered by screening blood for transfusion, by frank information about how HIV can spread, by clear prevention messages urging abstinence, fidelity or safer sex, by condom promotion, by needle exchange programmes for drug users, and by encouraging and enabling people to get prompt care for STDs.
It is simplistic to think in terms of evil transmitters and innocent victims. In the AIDS game there are no winners and losers, just losers. Men must be helped to understand that by protecting others, they are protecting themselves.
Peter Piot, Executive Director of UNAIDS
However, for millions of women, many of these services are inaccessible and many of the messages irrelevant or inapplicable. Because of their socioeconomic circumstances, womens autonomy is crippled. Lacking economic resources of their own, and fearful of abandonment or violence on the part of their male partners, they have little or no control over how and when they have sex and hence over their risk of becoming infected with HIV. This is the meaning of vulnerability.
· Millions of young girls are brought up with little understanding of their reproductive system or the mechanics of HIV/STD transmission and prevention. Even when human sexuality is taught at school, girls are at a disadvantage because, especially in developing countries, they are taken out of school earlier than boys.
· At the same time, girls are taught to leave the initiative and decision-making in sex to males, whose needs and demands are expected to dominate. Male predominance often comes with a tolerance for predatory, violent sexuality. It also carries a double standard whereby women are blamed or thrown out for infidelity, real or suspected, while men are tacitly expected or allowed to have multiple sex partners.
AIDS might make me sick one day. But if I dont work my family would not eat and we would all be sick anyway.
Sex worker in the Philippines
· Failure to respect the human rights of girls and women in terms of equal access to schooling, training and employment opportunities reinforces their economic dependence on men. The reliance may be on a sugar daddy, a husband or stable partner, a few steady male partners who have fathered the children, or, for women in prostitution, a succession of clients. Indeed, for girls and women in many cultures, sex is the currency in which they are expected to pay for lifes opportunities, from a passing grade in school to a trading licence or permission to cross a border.
· A woman in a stable relationship who is economically dependent on her partner cannot afford to jeopardize his support even when she suspects he has HIV. If she refuses him sex or asks him to use condoms, she is breaking the conspiracy of silence that surrounds his extramarital activity - or, even worse, intimating or admitting that she was unfaithful. And while some men agree to use condoms, many react with anger, violence or abandonment.
· A further dilemma is that condoms are incompatible with pregnancy. Couples wanting children need to know their HIV status and, if both are uninfected, agree to remain faithful or refrain from unsafe extramarital sex. Obstacles are unwillingness to discuss these issues openly and a lack of voluntary HIV testing and counselling services.
· STDs, which augment a womans biological vulnerability to HIV, often go untreated even when symptomatic. Women are brought up to accept ill health and especially womens troubles as their lot in life, and in general have poor access to appropriate health services. Because sexually transmitted infections carry a heavy social stigma (less so for men), women tend to avoid STD clinics for fear of being recognized. And the health workers to whom women do have access, in primary health or maternal and child health clinics, are often unsympathetic, judgemental, and unprepared to diagnose and treat STDs.
· Prostitution constitutes another setting in which women have little power to protect themselves from HIV. Girls forced or sold into sex work, even before puberty, are generally unaware of the AIDS risk and unable to run away or take protective action. The sexual exploitation of girls is one of the most pernicious forms of child abuse.
Empowering women is not a zero sum game. Power is not a finite commodity: more power to one ultimately means more power to all. Interventions [in the] development field have shown that poor men support womens empowerment when it enables women to bring much-needed resources into the family or community or when it challenges power structures that have oppressed and exploited the poor of both sexes.
Geeta Rao Gupta, International Center for Research on Women
· Not all prostitution is forced. While for some women it is a choice, many turn to occasional or steady sex work as an alternative to dire poverty, exchanging sex for the basic necessities of life for themselves and their children. Often, these are women whose lives have been disrupted by war, or divorcees or widows who because of inequitable laws and customs have lost their property as well as their husbands earning power. While many sex workers risk violence or loss of income if they request condom use, in some places prostitutes have banded together to demand condoms from all clients, or work in brothels where the government has instituted a condoms-only rule. Ironically, these women may enjoy more protection than housewives who have no social permission to request or negotiate safer sex.
A vulnerable woman is one who is lacking in power or control over her risk of HIV infection. The remedy is empowerment.
Improve the access of girls to formal schooling. Ensure they have information about their own bodies, education about AIDS and the other STDs, and the skills to say no to unwanted or unsafe sex. UNAIDS is testing and comparing different approaches to skills-building and determining the best practices in this area.
Provide women-friendly services
Ensure that girls and women have access to appropriate health care and HIV/STD prevention services at places and times that are convenient for them. Expand voluntary HIV testing and counselling services. Make condoms and STD care available where women can go without embarassment. UNAIDS is helping to ensure that womens family planning options help rather than undermine their ability to avoid HIV.
Develop female-controlled prevention methods
The male condom, currently the only barrier method available for HIV prevention, urgently needs to be complemented by methods that women themselves can use, if necessary without the knowledge or cooperation of their male partner. UNAIDS is facilitating the development of and access to several such methods, including the female condom and vaginal microbicides - virus-killing creams or foams that women can insert vaginally before intercourse. A microbicide that does not kill sperm and prevent conception would be helpful to millions of couples worldwide.
Build safer norms
Support womens groups and community organizations in questioning behavioural traditions which have become deadly with the advent of AIDS, including tolerance of child abuse, rape and sexual coercion. Educate boys and men to respect girls and women, to engage in responsible sexual behaviour, and to share the responsibility for protecting themselves, their partners and their children from HIV and the conventional STDs. UNAIDS speaks out for safer, egalitarian norms and supports concrete efforts to build these in and out of school.
Reinforce womens economic independence
Multiply and strengthen existing training opportunities for women, credit programmes, saving schemes and womens cooperatives, and link them with AIDS prevention activities. For example, UNAIDS is supporting efforts to enable Zambian women fish traders to form a cooperative that will give them interest-free loans. With these, they will no longer have to exchange sex with the fishermen or truck drivers who control their access to fish and to transport.
Reduce vulnerability through policy change
UNAIDS message is that policies from community to national level must be reshaped if womens vulnerability to HIV is to be reduced. Among other things, this means protecting their human rights and fundamental freedoms and improving their economic independence and legal status. This cannot be achieved without a greater political voice for women.
[In Brazil] sterilization and the IUD are the methods that doctors and family planning services tend to offer. ... The problem for a sterilized woman is how to justify or negotiate condom use with her partner without jeopardizing her relationship, because it forces discussion of the sensitive issues of trust and fidelity.
Telma Regina Cavalheiro, GAPA (Support Croup for the Prevention of AIDS)
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Women and AIDS: UNAIDS Point of View (UNAIDS Best
Practice Collection: Point of View).
Geneva: UNAIDS, October 1997.
1. Acquired immunodeficiency syndrome - transmission
2. Womens health
3. Acquired immunodeficiency syndrome - prevention and control
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