Documento(s) 7 de 13

As we move forward through the second decade of AIDS infections, we must ask ourselves: "Have we really learned from this disease?"

-- Arletty Pinel, genos International, São Paulo, Brazil

AIDS -- acquired immune deficiency syndrome -- is a major public health issue in most regions of the world. AIDS is a disease defined by a set of signs and symptoms, caused by HIV (human immunodeficiency virus), and characterized by a compromised immune response. HIV, which is transmitted through body fluids (semen and blood), produces a defect in the body's immune system by invading and then multiplying within white blood cells.

Since the identification of the HIV virus over 14 years ago, there has been a substantial growth in the number of people affected by this disease. An average of 6 000 people per day -- over half of them women -- are infected with HIV (World Bank 1993). The World Health Organization's Global Programme on AIDS estimates that more than 17 million people have been infected with HIV since the beginning of the pandemic. Of those, there are an estimated 4 million AIDS cases (who and UNDP 1994). The World Health Organization has predicted that by the year 2000 there could be as many as 26 million people affected by HIV and AIDS worldwide (World Bank 1993). However, it emphasizes that "given the short time it takes infection rates to double in many developing countries and the rapid spread of the disease to countries that previously had low numbers of infections," the total figure in 2000 may be two to three times higher than the above projection (World Bank 1993, p. 99).

Although the AIDS epidemic is a major concern in many regions of the world, some areas have been more profoundly affected than others (Figure 2). In 1990, more than 80% of those infected lived in developing countries, and this figure is expected to increase to about 95% by 2000 (World Bank 1993).

Sub-Saharan Africa has been hardest hit by the AIDS pandemic and accounts for over two-thirds of the total worldwide number of people infected with HIV. As of mid-1994, who estimated that over 10 million HIV infections had occurred in Africa. In certain cities in Africa, the prevalence of infections is as high as one in three. Northern Africa, however, is an area that currently has a relatively low level of HIV infection.

AIDS was not recognized as a serious health issue in Asia until the late 1980s. However, the progression of HIV infection is now faster in Asia than in other regions of the world. As of mid-1994, who estimated that there was a cumulative total of over 2.5 million HIV infections in this region. India and Thailand account for the majority of infections.

Figure 2.Estimated distribution of total adult HIV infections (source: WHO and UNDP 1994).

In Latin America and the Caribbean, 1.5-2 million people are believed to be infected. Brazil and Honduras are the worst affected. HIV infections in this region are largely concentrated in urban areas.

With regard to HIV and AIDS statistics, it is tremendously difficult to assess the true extent of the epidemic because of the high levels of under-reporting. For example, according to epidemiologists, the rate of undernotification in São Paulo, Brazil, may be as high as 100%, and the number of HIV positive people may be as many as five times the number of officially reported cases (Goldstein 1994).

Infection levels among women

Since 1981, the pattern of transmission of HIV has shifted considerably. In certain regions of the world, AIDS was originally thought to affect mainly homosexual males, prostitutes, and drug users who shared needles. Married women, or those with steady partners, were believed to be at a relatively low risk of HIV infection through sexual transmission.

In recent years, however, the number of women infected with HIV throughout the world has increased dramatically. In 1994, the number of women infected with HIV exceeded 6 million worldwide. The World Health Organization estimates that there are currently 115 000 HIV-infected women in North America, 425 000 in Latin America and the Caribbean, more than 4 million in Africa, and about 1.8 million in Asia and the Pacific (Figure 3). By 2000, it is expected that the number of infected women will equal that of men (Panos Institute 1990).

In North America and Europe, women have remained a relatively small percentage of the total number of HIV-infected people. However, the rate of infection among women is on the rise. In 1994, 18% of all AIDS cases in the United States were women (up from 7% in 1985) (Cohen 1995). The Centers for Disease Control in the United States said that cases among women are increasing by roughly 17% a year, and growing numbers are contracting AIDS through heterosexual contact (New York Times 1995, p. 11). In the United States, minority women are consistently affected more often. Blacks and Hispanics account for over 75% of reported cases among infected women (Campbell 1990; Carpenter et al. 1991).

In sub-Saharan Africa, more than one-half of newly infected adults are women, and over 1 in every 40 adult women is now infected. Between 60 and 80% of infected women are monogamous and have been infected by their husbands (Hatcher Roberts and Law 1994). In Uganda, more than 60% of infected persons are women, and in Kampala, more than 30% of all pregnant women are infected (World Bank 1993). The HIV status among prostitutes in Kenya has reportedly risen from zero in 1980 to 88% in 1988 (Ngugi 1991, cited in Koblinsky, Timyan et al. 1993).

Figure 3. Projected distribution of HIV-infected women (excluding AIDS cases) in 1995 (source: who and UNDP 1994).

In Asia, as in Africa, almost half of all newly infected adults are women. The commercial sex industry in many Asian countries (such as Thailand and India) is closely related to the heterosexual transmission of HIV from female sex workers to male clients and vice versa.

In Latin America, initially, the most profoundly affected by AIDS were homosexual men, bisexual men, and injecting drug users. However, heterosexual contact now accounts for 75% of all new infections. One-quarter of all HIV infections are among women. In Brazil, the percentage of reported AIDS cases attributable to heterosexual transmission increased from 7.5% in 1987 to 26% in 1993-94. In Peru in 1987, the ratio of AIDS cases among men and women was approximately 15 to 1. In 1993, the male to female ratio was 7 to 1 (Chauvin 1993).

Transmission and effects of HIV and AIDS

The main mode of transmission for AIDS in developing countries is through heterosexual intercourse, which accounts for more than 85% of infections (World Bank 1993). As well as through sexual intercourse, an individual can be exposed to HIV by contact with contaminated blood.⁴AIDS can also be transmitted from mother to child during the perinatal period. Approximately 30% of babies born to HIV-positive mothers are infected with the virus (who and UNDP 1994). Babies can also contract HIV through breast milk (World Bank 1993).

Casual transmission from person to person does not occur. AIDS is not transmitted by kissing, embracing, coughing or sneezing, or by sharing dishes or clothing. HIV may live in the human body for years before actual symptoms of AIDS appear. It takes 6-10 years, on average, for an HIV-infected adult to develop AIDS (World Bank 1993).

AIDS is a syndrome in which "the body's immunity goes berserk" (Usher 1992). AIDS weakens the natural defence system that usually regulates the body. It causes disease primarily by lowering the resistance of the body to fight other infections that can be fatal. The body eventually dies because, vulnerable to the slightest infection, it can no longer protect itself. As described by Usher (1992, p. 26):

For women, the chief mode of transmission of HIV is heterosexual contact.

-- Anna Strebel, University of the Cape, Belleville, South Africa

People infected with the human immune deficiency virus fall prey to ailments that a normal healthy person might barely notice. People with AIDS die of tuberculosis, they die of cancers and pneumonia, they die of internal haemorrhaging, they die because wounds inflicted from a bump or a fall never heal but just get worse .... A person with AIDS can die from the common cold.

Treatment and prevention

There is no effective treatment, and no cure. Although numerous efforts are currently under way in the search for a cure, the prospects of success are far on the horizon. Studies are being done with antiviral drugs such as azidothymidine (AZT), but these drugs are prohibitively expensive for most people in developing countries.⁵ Antiviral drugs also have severe side effects, and may, at best, slow down the progress of infection and marginally prolong life (do Prado 1994). Most treatment focuses on the alleviation of pain and the management of opportunistic infections that afflict HIV-infected persons, such as tuberculosis, diarrhoea, and candidiasis.

In the search for a cure, researchers must be cognizant that any vaccine must be appropriate for use in developing countries. A vaccine based on HIV strains commonly found in Europe and the United States would be of limited use in developing countries. Furthermore, an effective vaccine would have to be easy to distribute and affordable to all.

With no definitive cure or treatment for AIDS, prevention is the only way to fight the spread of HIV transmission. Currently, the main prevention methods are as follows:

• Providing information on how to avoid infection (such as reducing the number of sexual partners and modifying high-risk sexual behaviour);

• Promoting the use of the male latex condom, which is effective in preventing the transmission of HIV when it is used in a consistent and correct fashion;

• Treating other sexually transmitted diseases; and

• Reducing blood-borne ransmission.

STDs HIV transmission

With the recent worldwide focus on HIV and AIDS, other diseases that are transmitted primarily by sexual contact have received less attention. Sexually transmitted diseases (stds) are extremely common infections. According to a 1990 estimate by who, there are more than 250 million new cases each year worldwide. An increased risk of acquiring an STD is related to the following factors: young age of first sexual intercourse (which increases the number of years of sexual activity and the probability of exposure to a number of partners), multiple partners, a relationship with a partner who has a history of multiple partners, and lack of appropriate protective contraception (rcnrt 1993).

The female reproductive tract appears to be particularly vulnerable to organisms transmitted during sexual intercourse. Male-to-female transmission of some stds is at least 15% more efficient than female-to-male transmission (who and UNDP 1994).

stds have severe and often irreversible consequences that disproportionately affect women. Untreated stds in women can lead to pelvic inflammatory disease, infertility, increased risk of ectopic pregnancy, spontaneous abortions and stillbirth, premature delivery, and acute or chronic infections in infants born to infected mothers (rcnrt 1993).

The presence of stds also greatly increases the probability of HIV transmission. Individuals with an STD are two to nine times more likely to become HIV-infected through intercourse with an infected partner, than those who do not have an STD (Population Reports 1990). In 1991, 54% of all STD patients at an STD clinic at Zambia's University Teaching Hospital and 60% of STD patients at an urban health centre in Kariba, Zimbabwe, tested positive for HIV. Nearly one-third of the patients in an STD clinic in Bombay, India, were HIV positive in 1991 (Panos Institute 1992).

HIV transmission is facilitated by the genital lesions and inflammation associated with stds. The probability of HIV transmission is most pronounced with the presence of a genital ulcerative condition (Germain 1991; Bassett and Mhloyi 1993), although there is growing evidence that nonulcerative cases can also increase the probability of HIV transmission.

With regard to vaginal discharge, women often receive little or no information regarding its genesis, how it is transmitted, how it can be treated, or how it can be prevented. Most affected women are convinced that vaginal discharge is a natural part of being a woman, and that they are condemned to suffer from it for life, particularly if they maintain an active sexual life.

-- Leda Pesce, Paulina Luisi Movement, Melo-Cerro Largo, Uruguay

Because of the role of stds in AIDS transmission, many experts and international organizations have emphasized the importance of controlling STD infections (World Bank 1993; Lwihula 1994). However, the importance of stds as cofactors for HIV transmission, especially for women, continues to be overlooked (Dixon-Mueller and Wasserheit 1991). From the perspective of the woman, chronic vaginal discharge is often seen as a "normal female complaint" related to her intimate life, one of the many "natural" discomforts associated with being a woman (Guimarães 1994; Pesce 1994; Vlassoff 1994).

stds in women often go undetected and therefore untreated (Mhloyi and Mhloyi 1994; Ngwenya 1994). Sometimes physicians fail to distinguish an abnormal discharge from normal secretions. Although most stds cause painful symptoms in men, women are more likely to harbour asymptomatic infections for prolonged periods -- indeed, 50% of STD-infected women have no external symptoms whatsoever (Nowak 1995). This has serious consequences for the health and well-being of women and also results in an increased vulnerability to HIV infection (Standing and Kisekka 1989).

The current emphasis on AIDS should not let us marginalize or ignore other stds. A sizable proportion of the population, particularly young girls and boys, still lack adequate information about stds. Educational programs need to focus on the link between HIV infection and stds and educate women and men, and young girls and boys, about how to prevent stds, recognize symptoms, and how and where to seek appropriate health care related to stds. Restrictions that exist in some societies and prevent adolescents, particularly young women, from having access to information on sexuality, contraception, and disease prevention must be overcome (Pino et al. 1994).

The presence of sexually transmitted diseases has been shown to increase the risk of HIV infection. In women, symptoms of a STD are often less apparent than in men. stds in women often go undetected, and therefore untreated, which results in an increased vulnerability to HIV infection.

-- Anna Strebel, University of the Cape, Belleville, South Africa

The AIDS epidemic and women

The AIDS epidemic has had particularly harsh consequences for women in developing countries. Because women are usually the primary caretakers of family members, household illness often means that greater demands are placed on women (Wilson 1993). Women must care for infected family members and continue their already substantial duties in the home and in the formal employment sphere. Danziger (1994, p. 913) points out:

As the number of people with AIDS within a given household rises, and growing numbers of orphans and other dependents are taken in, so the female head together with other women in the household are required to spend more and more time on care provision.

Women may also have to take up the activities of sick household members, which means that their working days become longer, their work loads heavier, and some of their own activities may have to be deferred (Durana 1994). "The enormous burden of care placed upon women by the AIDS epidemic ... will eventually force many women to neglect some of their other responsibilities, including their own health and well-being" (Danziger 1994, p. 913). Support and resources for those involved formally or informally in the care of sick and dying HIV-infected individuals are urgently required.

Many AIDS victims are heads of households, which has disastrous implications for families. In Uganda, for example, the highest incidence of AIDS cases occurs among adults between the ages of 16 and 42 (Wawer 1991), the most productive members of society. The illness of a wage earner in the household, who is often male, means that the household loses the person's labour, as well as the income deriving from their job (Adeokun 1994; Tsikata 1994).

When a woman develops a HIV-related illness, fulfilling her responsibilities becomes difficult or impossible. The implications for the family are particularly acute in cases where women are heads of their households and responsible for the day-to-day problems of securing support. Families that depend on women for the maintenance of subsistence crops, for example, often face a radical reduction in the availability of food within the household (Danziger 1994). In some cases, a woman's role on the farm may be replaced by the labour of older children, particularly girls, who are removed from school for this purpose.

When a household member develops AIDS, extended family members may interfere to the detriment of the woman. She may be accused of being the cause of the infection and treated in a cruel fashion by meddling relatives, even if she is not responsible for the illness. An HIV-positive women is often assumed to have had multiple partners or to have engaged in prostitution, and she is therefore considered a "bad woman" (who and UNDP 1994). She may be relocated to her parental home as a way of reducing her burden on the marital household and denied the custody of her children. The repercussions can be particularly devastating if her illness is, in fact, traceable to previous sex work (Agyeman 1992; Anarfi 1992).

HIV-positive women may suffer violence or abandonment often at the hands of their husbands (Danziger 1994). Hamblin and Reid (1991) reported that "[o]ften relatives will encourage a man who appears fit and well to leave his wife with AIDS and find another, with no understanding that he may pass the infection on to another woman."

In a few cases of HIV-positive women [in relationships with noninfected men], males have received direct pressure from their own families to abandon their partners.

-- Rafael Garcia, Autonomous University of Santo Domingo, Dominican Republic

In areas of the world that have been worst affected by AIDS, the rapid sequence of deaths of adult household members has resulted in the total collapse of households. Tragically, high levels of orphanhood and child destitution have resulted (Adeokun 1994), and the older generation has been left with the burden of raising orphans. Gender inequality could result in the differential treatment of female and male orphans: "When caretakers can only afford to send a few children to school, female orphans will probably be disadvantaged; grandparents may also keep older girls at home to help even if funds are available" (De Bruyn 1992, p. 255).

Certain cultural traditions can further exacerbate the terrible effects of the AIDS epidemic. In some patriarchal societies, for example, when a husband dies, in addition to the emotional suffering created by the loss, women have no traditional rights of ownership to their husbands' property. This creates enormous hardship for surviving family members (Adeokun 1994).⁶ Moreover, "even when inheritance laws upholds women's rights to their husband's property, customs which surround inheritance practices may be such that widows are coerced into conceding their inheritance to the families of their deceased husbands" (Danziger 1994, p. 913).

Appropriate policy initiatives are needed to change deleterious social and legal traditions [such as the] unfairness of inheritance systems. Governments need to move beyond the rhetoric of gender equality and make the necessary legal modifications to traditional practices that so patently deny equality to women.

-- Lawrence A. Adeokun, Makerere University, Kampala, Uganda

The transmission of AIDS among women Biological factors

There is increasing evidence that women are biologically more likely to acquire HIV infection through heterosexual intercourse than men (Mantell et al. 1988; Rodin and Ickovics 1990; UNDP 1992; Adeokun 1994). who and UNDP (1994) reported that studies in many countries have found that male to female transmission of HIV appears to be two to four times as efficient as female to male transmission.

There are a number of dimensions of the female reproductive system that make it more conducive than the male anatomy to HIV transmission: the concentration of HIV is greater in semen than in vaginal secretions; the vagina is more susceptible to infections than the penis; and, anatomically, with unprotected intercourse, women are the depositories of seminal fluids (do Prado 1994; Pesce 1994). The fact that prevalence of HIV infection is highest in women aged 15-25 years⁷ has led to the suggestion that the intact but immature genital-tract surface in young women is less efficient as a barrier to HIV than the mature genital tract of older women (UNDP 1992). Furthermore, decreased mucous secretion among young and postmenopausal women provides less assistance in minimizing irritation and tearing of the genital membranes and can facilitate viral entry among these women (UNDP 1992; do Prado 1994; Pesce 1994; who and UNDP 1994). Sexually transmitted diseases and gynaecological infections also leave the female vulnerable to AIDS (do Prado 1994).

HIV does not seem to progress more rapidly in pregnant women than in nonpregnant women, at least in the early stages of infection (Strebel 1994). Pregnancy, in the absence of HIV-associated symptoms, does not strongly influence disease progression (Carpenter et al. 1991; Hankins and Handley 1992). However, because of their childbearing role (involving pregnancies, abortions, and births), women run a significant risk of receiving blood transfusions and other blood products that, without adequate blood-screening procedures, may be contaminated with HIV (Pesce 1994).

Women frequently have a poorer prognosis once infected and die sooner than men (Jones and Catalan 1989; Berer and Ray 1993). This may be related to the fact that the progression of AIDS is associated with the basic health and immune status of the individual prior to infection, and women tend to have poor general health and nutrition (Adeokun 1994). Inadequate nutrition not only slows the healing process and depresses the immune system, it can also inhibit the production of mucous (UNDP 1992).

It is difficult to discern whether the poor prognosis of women, compared with men, is related to biological differences or is connected to the fact that women tend to be diagnosed later than men and usually present for medical help later than men (Hankins and Handley 1992). A recent American study, which followed 768 women and 3 779 men over a 15-month period from 17 health centres around the United States, reported that women suffering from AIDS had shorter survival rates than men and were particularly susceptible to pneumonia, a main killer of infected victims. The researchers stated that the increased risk of AIDS-related pneumonia among women might have been associated with their relative lack of access to health care, their lower socioeconomic status, and their limited access to the social support available to infected men (Melnick et al. 1994).

Urgent research is needed to explore the possibility of a physiological basis to the susceptibility of infection in women. For example, research should examine whether the shorter period between diagnosis and death for women, in comparison with men, reflects factors such as delayed diagnosis in women, a lack of knowledge about the early symptoms of HIV infection in women, or more rapid progression of the disease (Paolisso and Leslie 1995).

Misconceptions about AIDS

Lack of complete information and understanding about AIDS

Many researchers have pointed out that although there appears to be a widespread general awareness about the basic messages surrounding AIDS, in many instances, there is a lack of detailed or thorough understanding about the disease (Adeokun 1994; Guimarães 1994; Mhloyi and Mhloyi 1994; Pinel 1994; Kuyyakonond 1995). Adeokun (1994) and Mhloyi and Mhloyi (1994) reported that, in their respective countries (Uganda and Zimbabwe), nearly 100% of people were aware of AIDS and understood the central role of the condom as a method of preventing the transmission of the virus. Mhloyi and Mhloyi reported that there were no marked sociocultural differences in AIDS awareness and that a basic comprehension could be found across all age, sex, and marital groups. However, both researchers found that, despite the fact that people had been bombarded with basic information, they continued to be ill-informed. For example, Mhloyi and Mhloyi found that approximately 36% of the respondents reported that they did not know the difference between HIV seropositivity and AIDS, and 32% reported that there was no difference. Only 13% said that a HIV positive person was healthier than one who was suffering from AIDS (Table 1).

Data from Mhloyi and Mhloyi's study also revealed that there were a number of misconceptions about the causes of AIDS. Only 19% of the respondents understood that AIDS was caused by HIV, and only 11% reported multiple sex partners as a determinant of HIV infection. Consistent with the frequent belief that sexually transmitted diseases are a "woman's disease" and that women are "reservoirs of infection" or "vectors of transmission," whereas men are victims, the majority of respondents thought that AIDS was caused by women, prostitutes, and soldiers (Table 2).

A survey in Tanzania revealed that 15% of respondents believed AIDS was an unpreventable punishment from God, 10-12% thought AIDS could be contracted by touching the body or wearing the clothes of a person who died of AIDS, 25% believed AIDS could be transmitted through mosquitos and other insect bites, and 20% said the disease only affected prostitutes, barmaids, and long-distance truckers (Ndejembi 1993).

Table 1. Survey results: "What is the difference between someone who is HIV positive and someone who is suffering from AIDS?"

Response	Frequency (%)
Don't know the difference	35.9
There is no difference	32.1
HIV-positive victim is healthier	13.1
Not sure	03.4
HIV-positive victim can be cured	00.9
Other	02.1

        Source: Mhloyi and Mhloyi (1994).

Table 2. Survey results: "What causes AIDS?"

Response	Frequency (%)
HIV	18.9
Women	21.4
Men	05.9
Prostitutes	16.8
Soldiers	11.6
Truck drivers	03.8
Many sexual partners	11.0
Other	10.5

        Source: Mhloyi and Mhloyi (1994).

In Mhloyi and Mhloyi's study, there was a greater understanding of AIDS symptoms. Weight loss was identified as a symptom of AIDS by 53% of respondents, 38% recognized continuous illness, and 2% had no awareness of the symptoms of AIDS.

Some people may act on insufficient and incomplete information, much to their detriment. In the words of one 30-year-old man who purported to know a great deal about AIDS, "Since I got to understand more about AIDS, I only go out with younger girls, or even married women if I can; no more prostitutes" (Mhloyi and Mhloyi 1994, p. 18). Some men had a lack of comprehension concerning the latency period of HIV infection. They believed that "these days you have to be careful with the choice of partners" and said that they took precautions "by picking a woman you see is AIDS-free" (Mhloyi and Mhloyi 1994, pp. 13, 18).

A study of rural women in Northeast Thailand also found that women did not understand that there was a latency period between the time of infection and a positive HIV test. Some women felt that their husbands were safe because they had been tested before they returned home after an extended absence. Other women stated that they used condoms "for a period following a husband's engagement with prostitutes" (Kuyyakonond 1995, p. 65). In the same study, some women said that they knew that they or their husbands were free of infection because they had been tested at some time in the past, indicating that they did not appreciate that the results from an old blood test may no longer be valid.

The results are consistent with the cultural belief that sexually transmitted diseases are a "woman's disease," and that women are vectors whereas men are victims. The association of AIDS with "high-risk" sexual groups is a belief that serves to distance HIV infection from the mainstream population.

-- Gilford D. Mhloyi and Marvellous M. Mhloyi, University of Zimbabwe, Harare, Zimbabwe

Women who used condoms with their husbands reported that they used them only for brief periods directly following visits by their husbands to prostitutes -- "until the danger has passed." Discussions revealed that these women did not see the risk of HIV-transmission as something continuous, but rather as something short lived and restricted to specific periods -- following a husband's visit to a prostitute, and when symptoms become "especially bad."

-- Thicumporn Kuyyakanond, Northeast Centre for AIDS Prevention and Care, Khon Kaen University, Thailand

A study conducted in the Dominican Republic found that some men, believing that the risk of AIDS was related to commercial sex workers, avoided sexual relations with them, or "use[d] condoms when they believe[d] they [were] dealing with street-women"; however, with other women, such as less professional barmaids, they were less cautious (Garcia et al. 1994). Morris et al. (1994) reported that condom use was significantly less consistent with regular (multivisit) commercial sex partners than with casual (single-visit) partners. These are perfect examples of the extent to which "a little knowledge can be a dangerous thing." Men and women clearly need better quality education to dispel the myths and lack of depth of understanding about AIDS.

The association of AIDS with "high risk" groups

The association of AIDS with "high risk" groups, reinforced by educational and media campaigns, has served to distance HIV infection from the mainstream population (Usher 1992). Originally, AIDS was thought to affect mainly homosexual males, prostitutes, and drug users who shared needles. Despite the fact that the pattern of AIDS transmission has shifted considerably, in many societies there continues to be the misperception that AIDS is a "gay plague" (Guimarães 1994), a "peste gay" (gay pest) (Pinel 1994), the "pink plague" (Chauvin 1993), or the long-awaited divine punishment (Pinel 1994) meant to eradicate drug addicts, prostitutes, and homosexuals. In Brazil, for example, the archetypal AIDS patient is considered to be the prosperous white, male homosexual, working in the world of fashion, entertainment, or the arts. Language reflects this perception: the word aidético, which is used to refer to a person living with AIDS, implies homosexual behaviour (Guimarães 1994). Tragically, many people, struggling daily to lead "normal" lives, do not identify with media campaigns directed to "deviant" or "high risk" groups, and believe that they are not at risk (Guimarães 1994; Pinel 1994).

When asked who was at risk for AIDS, women most frequently responded that prostitutes and men who have sex with prostitutes were at risk. It is notable that very few women identified the wives of these men as a group at risk.

-- Thicumporn Kuyyakanond, Northeast Centre for AIDS Prevention and Care, Khon Kaen University, Thailand

Given the perception that AIDS is largely a male disease, women who are not prostitutes may not acknowledge that they are at risk of AIDS infection. According to Guimarães (1994), women interviewed in her study in Brazil often believed that their main risk of AIDS came from exposure to HIV-infected blood or objects that have had contact with blood (such as dental drills and syringes). Guimarães argued that because of the undue focus on the "scapegoats" of AIDS, the gender dimensions of AIDS among "normal" people have been overlooked. She said that, if we seriously want to conquer the AIDS epidemic, we must work toward a fuller understanding of the gender relations of "normal" people, rather than just focusing on certain "deviant" groups.

"Not my man!": The inability of women to accept that partners may be unfaithful

One of the recurring and highly troubling issues raised by many researchers concerned the fact that, despite evidence to the contrary, married women, or those in steady relationships, often do not think of themselves at risk of HIV infection. Many women have trouble accepting that their husbands or partners could have intercourse outside of their steady relationships, and expose them to the risk of HIV (do Prado 1994; Guimarães 1994; Mhloyi and Mhloyi 1994; Pesce 1994). This inability to view partners as possible infectors greatly reduces the possibility of preventive steps being taken by women (Pesce 1994).

One 35-year-old woman from Zimbabwe reported that, "the AIDS problem is for the men who spend time with prostitutes, this is not our problem" (Mhloyi and Mhloyi 1994, p. 18). Similarly, in a study conducted in rural Northeast Thailand, 77% of women, when asked who was at risk from the disease, reported that men having sex with prostitutes were at risk. It is notable that very few women (14.8%) identified the wives of these men as a group at risk (Kuyyakonond 1995). In the same study in Thailand, women who said that their husbands "did not travel" felt that they were not at risk. It was generally believed that travelling away from home was a time when men frequented prostitutes.

In Pesce's research study (1994) of poor women in Uruguay and Argentina, almost all the women interviewed submitted to the nonadoption of safer sex. Most women tended to believe that it was other women, and not themselves, who were exposed to the risk of AIDS, and they were unable to link their husbands or partners to "the men who fool around." One of the common HIV prevention methods cited by women in a Brazilian study related to the subjective choice and evaluation of partners. One woman at a family planning clinic in Brazil, when questioned about the risk of AIDS from her steady partner, replied, "but I know him!" (Guimarães 1994). Meanwhile, female AIDS patients at the Gaffrée University Hospital stated how misled they had been by their partners, what little knowledge they had about their partner's sexual life outside the home, and how they felt betrayed (Guimãraes 1994).

Some women apparently assume that marriage, or the state of being in love, protects them from this deadly disease (Pesce 1994). Women need to be educated to understand that, despite love and marriage, many men have intercourse outside of their steady relationships, and may expose their partners to the risk of HIV (do Prado 1994).

Brazilian culture nourishes a romantic fantasy where two individuals meet, fall in love, and become immune to all dangers. Love is almighty, and both men and women are seen as incomplete beings without the complement of each other. Sex is validated through love where there is no room for an infected prince or princess or the need to interrupt spontaneity with the latex of a condom. After all, everything can be justified for love, even death.

-- Arletty Pinel, genos International, São Paulo, Brazil

Economic factors

Poverty of women's lives

Depending on various socioeconomic factors, some women are more likely to be exposed to HIV infection than others. There is a growing recognition that class variables, as well as race variables, intersect with gender to compound the complexity of power relations (Ramazanoglu 1989; Stamp 1989). In the United States, almost half the people who have been diagnosed as having AIDS are African-Americans and Latinos from impoverished urban neighbourhoods, and poor minority women are consistently most affected by AIDS. "In the U.S. especially, AIDS is disproportionately a disease of the dispossessed, a disease of the socially condemned and denigrated, a disease of social outcasts and a disease of the poor" (Singer 1994, p. 944).

Likewise, in Brazil, a large number of young, poor women, classified as either black or mulatto and largely illiterate, have become infected through HIV-infected partners (Guimarães 1994). In Ontario, Canada, sexually active teenagers from low-income families are much less likely to use condoms than teens from households with higher family incomes (Canadian Institute for Child Health 1994). Generally, evidence over the last two decades "points to the fact that powerless and poor groups of people (no matter where in the globe they exist) are ... more susceptible to the ravages of HIV" (Kambon 1995).

Poor women are likely to have reduced access to educational opportunities and decreased exposure to health-related information. Poverty contributes to poor nutrition and susceptibility to infection. Poor nutrition, chronic stress, and prior disease may lead to a compromised immune system and increased susceptibility to AIDS (Singer 1994). Women living in poverty are also less likely to receive an early diagnosis of HIV infection, and they frequently have limited access to health care and adequate treatment (Strebel 1992; Guimarães 1994).

Strebel pointed out that women often lack power and social status in society and, therefore, access to economic resources. As a result of their differential positioning in society, women are usually poorer than men, and are often economically dependent on men (Campbell 1990; Ankrah 1991; Ulin 1992). This lack of economic independence affects their ability to demand safer sex. In contrast, women with economic independence are more likely to be able to control the events of their sexual and reproductive health. According to a recent who document, "It is not coincidental that the countries in which the virus is now spreading fastest heterosexually are generally those in which women's status is low. Wherever sex discrimination leaves women undereducated, unskilled, unable to gain title to land or other vital resources in their own names and low self-esteem, it also leaves them especially vulnerable to HIV infection" (who 1994a, p. 59).

A higher degree of female autonomy may result in wives being able to refuse sex from husbands who are HIV-infected.

-- Lawrence A. Adeokun, Makerere University, Kampala, Uganda

Poor women, concerned with economic survival, may not change their behavioral patterns, despite messages to adopt safer sex. AIDS statistics do not directly impinge on their lives. "Statistically, and in her own subjective view of the world, she is more likely to die of hunger, of a poorly done abortion, or other health complications before dying of AIDS" (Goldstein 1994, p. 919).

Over the past 15 to 20 years, Brazil has been facing a social, economic, and political crisis. This has resulted in several deleterious consequences including high rates of inflation, critical unemployment, constant lay-offs, low salaries, poor health care, chronic endemic diseases, and rising urban violence. These are immediate survival issues that are usually considered more pressing than the remote risk of HIV infection.

-- Carmen Dora Guimarães, Universidade Federal do Rio de Janeiro, Brazil

Living and employment patterns

Living and employment patterns, as the result of economic imperatives, may have an impact on HIV transmission rates. In Zimbabwe, for example, there is a dual economy that is characterized by urbanized industrial centres and expansive agricultural communities that are connected by a well-developed communication infrastructure (Mhloyi and Mhloyi 1994). Family members are often separated for economic reasons as men go to urban areas to find work while women remain in rural areas. Couples can therefore spend a large proportion of their sexually active and reproductive years away from each other. Away from their partners, men often take a second wife or a girlfriend, or seek the services of a prostitute. A vicious cycle arises when migrants return home, bringing infections with them (Jacobson 1992b).

There have also been high levels of female migration from some countries as women search for work. For example, there has been widespread migration of women from the Philippines to surrounding Asian countries, the Middle East, and North America, to work as domestic labourers. These women may experience domestic violence and sexual abuse, and therefore be exposed to stds, including HIV (Osteria 1995).

Prostitution

Despite the risks, women continue to engage in multiple sexual relations, often for economic reasons (Adeokun 1994; Lwihula 1994; Strebel 1994). As a result of the subordinated position of women in society, and their limited access to economic resources, commercial sex is an important source of income for many women struggling to survive with limited resources (Standing and Kisekka 1989; Pauw 1993). According to who (1994a, p. 59), "in hard times, some [women] find it necessary to trade sex for money, food, or shelter." Poor women who are under pressure not to refuse client demands for unprotected sex may be less able to insist on the use of condoms, thus increasing the risks of HIV infection (Schoepf 1988; Larson 1990; Strebel 1994).

In Brazil, for example, with growing inflation and poverty, an increasing number of young women in large urban areas, as well as men, have been drawn into the commercial sex market in search of an alterative source of income (Guimarães 1994). The epidemic is expanding rapidly in parts of Asia (such as Thailand and India), especially in countries known for their history of prostitution and for being affected by the impacts of international sex tourism (Ford and Koetswanang 1991; Rana 1991; Seraprespamni 1991). Random HIV testing of prostitutes in Bombay showed an increase from next to zero in 1986 to more than 25% in 1990 (Basnet Dixit 1990). A recent study conducted with prostitutes on Bombay's Falkland Road found that about 50% of the tested women were HIV positive (Manneschmidt, see footnote 6).

Feeding children and keeping a roof over their heads is high on [women's] agenda; even if it means sleeping with a new partner, for whatever support he gives during the period of time he spends with her.

-- Asha Kambon, Economic Commission for Latin America and the Caribbean, Port of Spain, Trinidad (see Kambon 1995)

Economically destitute women and single-parent mothers who have entire economic responsibility for the members of their household, and less household income than male-headed homes (Schoepf 1988; Ulin 1992), may turn to sex work or prostitution (Anarfi 1992). According to one commercial sex worker, "the reason why I do this is because I have two children, no husband, and what else is there for me to do? I don't enjoy it, but I got no alternative" (Bledsoe 1990).

It should also be remembered that at least 100 million children live and work in the streets of cities across the world. Young girls from various parts of Nepal, for example, are sold by their parents and brought to urban centres, such as Bombay, India, to work as prostitutes (Manneschmidt, see footnote 6). These children live in extreme poverty, suffer from malnutrition and poor health, are often victims of exploitation, violence, and sexual abuse, and are at great risk of HIV and other sexually transmitted diseases (Panos Institute 1994a).

A few caveats

Strebel (1994) noted that some writers have warned against taking a simplistic analysis of the link between economic factors and AIDS. The complexity of the interrelationship between economics and AIDS can be seen in a number of ways. To begin with, some studies have found that women of higher economic status, who may have affluent, mobile husbands who are likely to pay for sex, also are vulnerable to HIV-infection (Larson 1990; Gwede and McDermott 1992).

Although some women are in single-headed households as a result of male abandonment, an increasing number of women are deciding to stay single because they believe that this strengthens their economic situation (Ramphele and Boonzaier 1988; Stamp 1989). According to Strebel (1994), these women may be in a better position to insist on condom use.

Sociocultural factors

Extramarital sexual relations

There are a number of traditions, contexts, and situations that involve the interchange of sexual partners, and which may increase the risk of STD or HIV infection. In many cultures, it is generally acceptable, even expected, for men to have sexual partners outside of marriage. In Thailand, for example, extramarital sex by husbands is a key factor in the transmission of HIV to wives (Pramualratana 1995).

In a survey conducted in Tanzania, four out of five men believed that it was a sign of manhood for a man to have extramarital sex (Ndejembi 1993). According to Guimarães (1994), the husband or steady partner who has extramarital relations may reason that what he does away from home is his own business, as long as he fulfills his prescribed role as protector of the home and provider of family needs. A man's sexual activity with other women is often seen as an expression of his virility.

Us men, we take AIDS as a joke. We are more happy-go-lucky. This is a man's nature; male chauvinism. When a man sees a woman, he forgets about AIDS. No matter what problem arises, the man says: "I can bear it." Many men feel that if the solution is not to have several women, they would rather die of AIDS. If you are a man and get AIDS, people support you and say: "He is a macho," because he got the disease by doing men's thing -- sex with women. I myself used to believe AIDS was a tale, until I got a positive HIV test.

-- HIV-positive man from the Dominican Republic, reported by Rafael Garcia, Institute of Human Sexuality, Universidad Autónoma de Santo Domingo, Dominican Republic

It has been estimated that between 50 and 80% of all infected women in Africa have no partners other than their husbands (Hatcher Roberts and Law 1994). In formally polygynous societies, males can justify extramarital relations, explaining that they might evolve into additional marriages (Adeokun 1994; Mhloyi and Mhloyi 1994). In societies where polygynous marriage practices do not exist or are on the decline, extramarital liaisons on the part of men are not uncommon (Mhloyi and Mhloyi 1994). One survey has shown that 75% of Thai men have had sex with a prostitute (Economist 1994). Other surveys in Thailand have shown that about six million Thai men use prostitutes each week and that condom use in brothels is inconsistent (Pradubmook 1994).

The cultural practice of postpartum sexual abstinence may also lead to multiple sexual partnerships on the part of the male. In some societies, although sexual abstinence after the birth of a child is proscribed for females, male are allowed to "graze around" (Mhloyi and Mhloyi 1994). Social and religious taboos that discourage intercourse between husband and wife while the women is menstruating or breastfeeding may also encourage men to seek extramarital partners (Jacobson 1992b). As well, throughout sub-Saharan Africa, traditional healers promote the idea that men infected with stds should have sex with virgins to cure themselves (Jacobson 1992b).

Socially sanctioned practices that are used by men to justify oppressive practices toward women need to receive urgent but sensitive attention (Ramphele and Boonzaier 1988; Stamp 1989; Strebel 1994). As Ankrah (1991, p. 972) argues:

The unassailable facet of African culture, the customary and legal right of males to unlimited numbers of partners, according to his wishes, should now be questioned as a value, because the heterosexual pattern of transmission puts all African men who have multiple partner sexual encounters at risk of HIV. Where culture and tradition, including polygamy, no longer advance a people, they should be jettisoned.

Although in some societies it is socially sanctioned for men to have sexual relations outside of marriage, this is generally not the case for women. However, in many societies, traditional practices and rituals exist that call for women to have extramarital sexual contacts. In parts of sub-Saharan Africa, for example, following the death of a man, one of the deceased man's brothers may "inherit" his widow. Intrafamilial sex may be sanctioned if the husband fails to impregnate his wife. Furthermore, a customary practice concerning the "sexual cleansing of widows" requires a widow to have sexual intercourse with a stranger. This is traditionally done immediately after the death of the husband to fend off haunting spirits of the dead husband (Lwihula 1994). Other situations where extramarital sexual contacts are reported to occur include the birth of twins and at weddings, where the bride's paternal aunt might have intercourse with the groom before the bride does (Balmer 1994). In areas where stds and AIDS are endemic, these traditional practices, involving extended sexual networks, carry the risk of STD or HIV transmission (Lwihula 1994). Many societies are now faced with the dilemma of balancing the demands of traditions with acceptance of medical advice and technologies recommended by STD- and AIDS-prevention programs.

The Uganda Women Lawyers Association has been working to restrict, through the formal legal system, the cultural practice of a widow marrying her husband's brother. At issue is the perpetual marginalization of women, their inability to own property, and their right to be the primary guardians of their children.

-- Seble Dawit, Independent Consultant on International Human Rights Law, New York, NY, USA (see Dawit 1994)

The implications of male bisexual relations

Male bisexuality, which exists throughout the world, poses particular difficulties for the prevention and control of HIV transmission: "There are married men who do not identify themselves as homosexual ... or bisexuals, but who have a fling with a ... gay man and then infect their wives" (Thomson 1994, p. 26). "It's the bisexual community that poses a greater problem [than the homosexual community], partly because those men are in denial of being at risk, and in denial of having homosexual relations with other men" (C. Jones, quoted in Ortiz 1994, p. 2).

In much of Latin America, a distinction is made between activos, men who insert during anal intercourse, and pasivos, men who receive (Singer 1994). Activos, although they engage in bisexual behaviour, view themselves to be heterosexual, while pasivos are considered to be homosexual (Carrier 1989; Singer 1994). Goldstein (1994) reported that, in Brazil, a large proportion of men are sexually active with both men and women but define themselves publicly (including to their female partners) as exclusively heterosexual. As a result, women are unaware of, or do not acknowledge, the bisexual sexual practices of their male partners.

Guimarães (1994) explored the issue of male bisexuality in Brazil and its implications for HIV transmission in women. Official statistics since 1982 have indicated that male bisexuality is related to a significant percentage of all AIDS cases. As of January 1994, 32.7% (13 084) of the reported cases of AIDS in men were the result of homosexual transmission; whereas, bisexual transmission contributed to 16.9% (6 773) of reported cases (Guimarães 1994).

In the past few years, a rise in the prevalence of HIV transmission in "low-risk" women⁸ led to epidemiological investigations. These inquiries revealed that many women unknowingly had bisexual partners who were HIV-infected (Guimarães 1994). Despite statistics that have existed since the onset of the epidemic, the implications of male bisexuality for women have been grossly ignored by AIDS medical specialists, AIDS researchers, as well as those responsible for AIDS interventions (Guimarães 1994).

In the study conducted by Guimarães, women who were interviewed rarely suspected or mentioned that their partners might engage in bisexual behaviour. Many women, believing that their men were "macho" and "macho" men only wanted women, reported that their risk of AIDS rested solely with their partners' involvement with other women.

Since 1982, official statistics [in Brazil] have indicated that male bisexuality accounts for [a significant percentage] of all reported AIDS cases. Why was the female dimension of male bisexual relations so grossly ignored by AIDS medical specialists?

-- Carmen Dora Guimarães, Universidade Federal do Rio de Janeiro, Brazil

Early sexual activity and early marriage

Early sexual activity plays an important role in the transmission of stds. In many countries, over half of all HIV infections to date have been among 15-24 year olds, with a female to male infection ratio of 2 to 1. Indeed, the prevalence of HIV infection is highest in young women aged 15-25 years, and peaks in men 5 to 10 years later in the 25-35 year age group (UNDP 1992). High rates of infection in young females may be a result of early entry into marriage and early sexual relations.

Adolescents tend to believe that they are immortal and invincible and this poses a challenge to HIV-prevention strategies (Gray and House 1989). Recent studies suggest a trend toward increased sexual experimentation, by more adolescents, at a younger age, with more sexual partners (Cochran and Peplau 1991; Pino et al. 1994), and without the benefit of effective or regular contraception (Lema and Kabeberi-Macharia 1992).

The fact that women become infected at a significantly younger age than men has sparked a growing interest in discovering the reasons for this discrepancy. In addition to the possibility of a physiological basis, circumstances and situations in which young women have sexual intercourse are also relevant. For example, nonconsensual or hurried intercourse may inhibit mucous production and the relaxation of the vaginal musculature, both of which would increase the likelihood of vaginal trauma (UNDP 1992). As well, women often have sex with older men, who are more likely to be infected because they have been sexually active for a longer time. An increasing number of girls and young women are being encouraged or coerced to engage in sexual activities, as men select ever-younger partners in an attempt to reduce their risk of HIV infection. "There have been anecdotal reports of 'sugar daddies' waiting outside schools to offer money in exchange for sex to schoolgirls who may welcome the case so as to be able to buy supplies and other essential items" (Danziger 1994, p. 913). "Some exchange sex for stylish clothes and accessories which neither their poor parents, low wages nor petty trade provide" (Schoepf 1993, p. 1402). Men are also seeking out younger women for marriage with a view to protecting themselves from infection (Danziger 1994).

There is a need for further research concerning the relationship between onset of sexual relations and the pattern of HIV transmission. Strategies aimed at delaying the entry of females into sexual activity are clearly important, as are measures that increase the ability of young girls to control the situations in which they are sexually active. Neither young women nor young men should be pressured into early marriages or early pregnancies.

Successful marriage bonds in African settings are cemented by the bearing and rearing of children. A childless couple is often shunned and ridiculed. More often than not, the woman is blamed for the failure to have children, and is assumed to be infertile.

-- George K. Lwihula, Faculty of Medicine, Dar es Salaam, Tanzania

Cultural importance of children

After marriage, there is considerable pressure for women to have children in all societies (rcnrt 1993; Garcia et al. 1994). Condoms, the main way to prevent HIV transmission, also control fertility, which presents a particular difficulty for women of child-bearing age. As Kathryn Carovano (1991, p. 136) noted, "To provide women exclusively with HIV prevention methods that contradict most societies' fertility norms is to provide many women with no options at all."

The grandmothers believed that the more children one has, the more helping hands you will have. Women believed that "children are treasures," and if you have no children, people would remark that you are a "barren and useless woman."

-- Daw Win May, Institute of Nursing, Yangon, Myanmar

The main avenue for social legitimization for women in many societies is their role as mothers. Motherhood can provide women with their only "personal project," their only source of identity, and their only personal "possession" (Bonino 1994). Given the fundamental role that motherhood plays for many women, women who are aware of their HIV-positive status may become pregnant (Lwihula 1994), and they may also see this as a way to retain partners (Garcia et al. 1994). Furthermore, women with HIV-positive partners may risk infection to try to conceive (Garcia et al. 1994). One woman's strong desire for a child, despite her HIV status, was reported by Hamblin and Reid (1991):

I am still hoping to have a child .... I have been told that it is totally selfish, that I have no right to inflict the potential for suffering on an as yet unborn child. Who says I have no right? If I am lucky enough to fall pregnant, my child will be loved and wanted. Will that be further reason for my rejection by society?

Finally, cultural practices in some African countries that restrict certain funeral rights to those who have a child may provide further understanding as to why some HIV-infected women try to become pregnant.

The "right" of husbands to sex and sexual violence

In some societies, men dominate all decision-making in the household, and their dominance may include the "right" to sexual intercourse. In some African cultures, for example, it may be nearly impossible for a woman to refuse sex from her husband, even if she suspects that he has engaged in promiscuous sexual behaviour and that there may be a serious risk of HIV transmission (Bledsoe 1990; Lwihula 1993). A wife's refusal of her husband's "conjugal right" can be a legitimate ground for divorce (Adeokun 1994). In Zimbabwe, because a groom must pay money for his wife upon marriage ("bride price"), the woman is made to feel like a piece of property and often believes that she must give him "his money's worth" in terms of her sexual and reproductive capacity.⁹

Women, as a result of the "[s]ocial construction of traditional sex roles, together with women's limited control over their lives," (Strebel 1993, p. 39) are also exposed to the potential threat of sexual violence and the associated risk of HIV infection. Women who are raped face the possibility of contracting stds, including AIDS, from an infected assailant (Berer and Ray 1993). A rape crisis centre in Bangkok reported that 10% of its clients contracted stds as a result of rape (World Bank 1993). Young girls may also be victims of incest and sexual abuse by respected elders (teachers, for example). Societies should develop and enforce laws against rape and other forms of sexual violence.

Mutilation of female genitals

The practice of female-genital mutilation, popularly known as female circumcision, is widespread in 27 African countries, 7 Middle-Eastern countries, parts of Malaysia, India, and Indonesia, and among some immigrant populations in Western countries. An estimated 85 million to 114 million women in the world today have experienced genital mutilation. If current trends continue, more than 2 million girls will be at risk of genital mutilation every year (World Bank 1993).

Female-genital mutilation poses a plethora of health risks to girls and women: hemorrhage, tetanus, infection, urine retention, shock, and occasionally death (World Bank 1993). Possible transmission of HIV and other viral infections may occur when unsterilized instruments are used. For example, in rural areas, crude instruments such as dull knives, rusty razor blades, or shards of unwashed glass may be used (Omer Haski and Silver 1994). Moreover, infibulated women may be at greater risks of contracting stds because tears are more likely during vaginal intercourse, and partners may practice anal sex if vaginal intercourse is impossible (De Bruyn 1992; van der Kwaak 1992). Because of the severe consequences that female-genital mutilation pose to women's health, women's groups in Africa have been working to end the practice (World Bank 1993). Other ritual practices, such as scarification, tattooing, and blood letting may also lead to HIV infection if performed with unsterilized equipment (who and UNDP 1994).

Vaginal drying

Vaginal drying or "dry sex" is a cultural practice that may contribute to significantly higher risks of infection among the women involved. To have "dry sex," women insert into their vaginas a variety of different agents (powders, herbs, cloth, aluminum hydroxide, rock salt, or stones) that are designed to tighten the vagina and dry up its natural secretions before sexual intercourse. Dry sex is based on the idea that the woman's vagina should be dry, tight, and hot to enhance sexual pleasure (Panos Institute 1994b).

The use of vaginal drying methods has been reported in Cameroon, Costa Rica, the Dominican Republic, Ghana, Haiti, Kenya, Malawi, Saudi Arabia, Zaire, Zambia, and Zimbabwe (Panos Institute 1994b). In rural areas of Zimbabwe, young women may be informed about dry sex by an aunt who is acting as a traditional educator at puberty or before marriage.

Dry sex probably increases the risk of contracting HIV during intercourse. The agents that are inserted into the vagina may cause irritation and damage. Increased friction augments the risk of genital ulcerations to both partners. Because condoms require some lubrication, and because they are likely to tear with excessive friction, the practice of dry sex makes it nearly impossible to use condoms (Panos Institute 1994b). More research about this sexual practice is urgently needed.

Unequal power relations between men and women

The subordination of women affects their decision-making in all areas of life, including sexuality (Pesce 1994), and plays an important role in HIV transmission. Gendered power relations influence the ability of women to take health-enhancing knowledge and translate it into preventive action. Men and women occupy different positions in society, and masculine and feminine gender roles are sharply differentiated. According to gender-role expectations, men should be active and dominant in sexual relations; whereas, women should take the passive and subordinate role. Women are socialized to believe that the "ideal woman" suppresses her desires to please her partner (do Prado 1994), that her body is an object meant to satisfy men (Pesce 1994), and that she is valued for her sexually passive role. Many women do not control how, when, with whom, and how often they have sexual intercourse, but instead must submit to the judgements, opinions, decisions, and feelings of men (do Prado 1994).

To avoid infection, women are advised to abstain from sex, practice monogamy, or negotiate the use of condoms with their male partners. However, many women have a limited ability to influence the sexual activity of their spouses or partners (Strebel 1994). According to one woman from Zimbabwe, "what can we do, men will always graze around" (Mhloyi and Mhloyi 1994, p. 18). Women are asked to exert control and make choices in a domain where they have little control and few options (Hollis 1992; Strebel 1994).

These issues emerged in a study conducted in Cape Town, South Africa (Strebel 1994). Focus-group discussions were held with almost 100 black women (and a few men) from antenatal and STD clinics and community political organizations, and with domestic workers, teachers, and students. Gender issues were a dominant theme, particularly notions of power and responsibility. Many women stated that men had the power to determine the nature of sexual relationships. This meant that men had multiple sexual partners and women were not entitled to protest or to expect men to admit to this behaviour. It was recognized, however, that women did have some power and might also have multiple partners. Some women said that women could be more assertive and challenging regarding safer sexual practices. However, women saw many obstacles to challenging entrenched gender positions (Strebel 1994). Practicing safer sex was not an easy task because men largely did not take responsibility for prevention in the same way that they did not take responsibility for contraception. Because women generally took control of health issues, it was emphasized that a woman-controlled HIV-prevention method, which does not require male partner awareness, compliance, or action, was essential.

Difficulty negotiating condom use

Numerous researchers have addressed the various barriers that prevent the usage of condoms (Adeokun 1994; do Prado 1994; Garcia et al. 1994; Guimarães 1994; Lwihula 1994; Mhloyi and Mhloyi 1994). The inequality of power between men and women makes it difficult for women to suggest the use of condoms (Garcia et al. 1994; Guimarães 1994). According to Maria De Bruyn (1993), "prevailing power dynamics make self-protection by women problematic at best and very difficult or impossible at worst." AIDS-education programs need to acknowledge and find strategies to deal with the fact that women invariably have little or no say in sexual relationships and yet they suffer more severe consequences from reproductive health infections than men do (Germain 1991). Prevention strategies will continue to fail unless programs deal directly with these realities.

First and foremost, women and men need to be able to communicate effectively with one another. Most prevention and control measure require understanding and cooperation from both parties. However, there is often minimal or complete lack of communication between partners on everyday subjects, and there is even less dialogue on matters related to HIV prevention (Lwihula 1994). Furthermore, in many societies, there may be cultural restrictions preventing the discussion of issues surrounding sexuality (Ngwenya 1994; Manneschmidt, see footnote 6). In a study conducted in Thailand, little talk of condom use was reported among married couples, and half of the women said they would be embarrassed to ask for condoms (Kuyyakonond 1995). What talk did occur appeared to have been very limited and perfunctory. For example, women reported that their husbands had told them not to worry about AIDS because they had used condoms when they "went out."

In a study of poor women from Uruguay and Argentina, Pesce (1994) reported that almost three-quarters of the women interviewed had talked to their partners about AIDS. However, because almost all of these women engaged in unprotected sex, Pesce suggested that the conversations were not very effective in encouraging the use of prevention measures. This raises the question of what exactly takes place when couples talk about AIDS. A greater understanding of communication patterns between women and men with regard to HIV transmission, as well as strategies to encourage more effective communication between partners, are essential. The lack of dialogue between partners on sexual matters suggests that there is an immediate need for interventions that bring women and men together to work on creating greater understanding of other points of view, reducing communication barriers, and initiating and sustaining behaviour change (Balmer 1994).

To be effective as an AIDS-prevention measure, condoms must be used correctly and consistency. However, men continue to resist condoms. As one women in a study by Mhloyi and Mhloyi (1994, p. 18) remarked: "If you want to get divorced, try asking your husband to use a condom."

Condoms may be unacceptable to men for a variety of reasons. To begin with, condoms interfere with reproduction, and children are very important to both women and men in most cultures (Adeokun 1994; Lwihula 1994). In some sub-Saharan African countries, the average man wants to have more than 10 children, in part because large families serve as cultural symbols of a man's virility and wealth (Sachs 1994). Men also resist condoms because they are concerned about reduced sensitivity, and because they fear that using it will permanently interfere with fertility (who and UNDP 1994). Family-planning workers commonly report that suggestions of condom use are greeted with sayings such as "you can't wash your feet with your socks on," or "that would be like eating a sweet with the wrapper still on it" (Sachs 1994, p. 16). Also, because family-planning units tend to be women-oriented and accessible only to women, some men are reportedly upset when their wives bring home condoms because they have not participated in the decision-making process (Lwihula 1994).

Women encounter numerous difficulties when they attempt to introduce safer sex practices (Balmer 1994; do Prado 1994; Garcia et al. 1994; Guimarães 1994). Use of a condom clearly depends on the cooperation of the man because he is the one who "wears the condom." In many cultures, women depend on men to provide condoms because it may be socially inappropriate for a woman to carry condoms (Sacco et al. 1993; Garcia et al. 1994), and women may be reluctant to buy, carry, or keep condoms at home (Garcia et al. 1994).

To justify their request for condom usage, a woman may explain that the condom is necessary for contraceptive purposes. However, if a woman is married or in a stable relationship, she has other contraceptive options that can be used with no discomfort to her partner, such as the oral contraceptive, the intrauterine device (IUD), or sterilization. A woman may have difficulty justifying condom usage for anal sex because contraception is obviously not a consideration for this practice.

Although a woman can also explain that a condom is necessary to protect against STD (or HIV) transmission, this poses a challenge to the concepts of romantic love and fidelity (Strebel 1994), particularly if the woman is married or in a steady relationship. Permanent relationships usually operate on the assumption of monogamy, fidelity, and mutual trust. Suggesting the use of a condom, the "unwelcome symbol of extra-marital sexual activity" (Byron 1991, p. 29), implies that she suspects that her partner has been unfaithful. If her partner agrees to use a condom, her suspicion of infidelity is confirmed. A woman's suggestion to use a condom may also lead her partner to suspect that she has been disloyal, which may provoke a strong reaction from her partner, possibly involving physical punishment or desertion (Garcia et al. 1994; Guimarães 1994; Strebel 1994). According to a woman from Buwunga, Uganda, "If you advise your husband to use a condom, he may beat you and send you away. Where will you go then?" (Perlez 1990, p. A4).

Condom usage is also an issue for single women without regular partners. If a single women requests the use of a condom, her partner may believe that she is promiscuous or has a sexually transmitted disease, which may prevent the relationship from continuing. As one woman explained, "a good man is hard to find these days" (Guimarães 1994, p. 29). Single women, therefore, may be willing to take a chance by not using condoms and hope that love or luck will protect them against infection.

One highly disturbing fact is that condoms, the most commonly suggested prevention method, appear to be widely unavailable, particularly in remote areas (Lwihula 1994). Researchers from Africa, Asia, and Latin America have noted that limited family-planning services, lack of condom availability, or the high cost of condoms may make it impossible for those who wish to take preventive measures to do so (Adeokun 1994; Mhloyi and Mhloyi 1994; Ngwenya 1994; who 1995) This resource problem, which may be related to poor management and distribution, must be properly addressed.

Fatalism and the irrational nature of love and sex

Individuals living in communities where AIDS is widespread can become complacent and fatalistic about AIDS. As people observe more and more people dying of AIDS, some may assume that they are also infected and decide that there is no use in altering sexual behaviour. According to individuals from Zimbabwe, "Death is with us, we can't run away from it" and "Well, we are all HIV positive, no one will remain, it is just a question of time" (Mhloyi and Mhloyi 1994, p. 18).

Finally, it must be remembered that people do not always deal with matters of sex and love in a rational fashion, and this may dramatically affect HIV transmission. AIDS interventions, however, have been devised based on the supposition that people will act in a logical manner if they are just given the right information. In the words of Keeling (1993, p. 307): "Our benign and hopeful assumption that reasonable people given reasonable information in a reasonable way would be reasonably likely to make reasonable changes in their behaviour to reasonably reduce their risks of acquiring HIV turned out to be unreasonable."

Individuals often take excessive risks when it comes to love and sex. Even when a woman is aware that her partner is HIV-infected, for example, she may not protect herself as a demonstration of her total, symbiotic link with her partner.

Interventions

Health education

Health education and prevention programs have been one of the main strategies used worldwide in the attempt to prevent the spread of stds, including AIDS, and to increase awareness and understanding of these diseases. Initially, most programs focused on "high-risk groups," such as homosexual men, prostitutes, drug users, and truck drivers (Sekimpi 1988; Balmer 1994). In recent years, however, programs to spread information and change behaviour patterns have been increasingly directed to general populations, particularly young people who are starting to be sexually active (Balmer 1994; Manneschmidt, see footnote 6). The particular concerns of women have also started to receive more attention and service providers are currently struggling to develop and deliver gender-appropriate programs (Panos Institute 1990; Pearlberg 1991; Guimarães 1994).

Prevention programs aim to distribute information on how the virus is spread, and to inform people about the steps they can take to protect themselves against HIV infection.¹⁰ These programs are based on the hope that education will lead to changes in behaviour patterns, and therefore to a reduction in STD transmission (Balmer 1994; Manneschmidt, see footnote 6).

Attempts to controls sexual behaviour through education, however, have not always proven successful. Even with correct, properly understood information, people may not change their actions. In a study of male truck drivers in East Africa with a 25% prevalence of HIV, 90% had sufficient knowledge of stds and HIV, including knowledge of condoms and lower-risk behaviours (Bwayo 1991). Despite this knowledge, two-thirds of the men continued to engage in risky sexual practices.

Programs designed to increase adolescents' knowledge about HIV have also not eliminated high-risk behaviour (Baldwin et al. 1990). Available evidence suggests that adolescents continue to engage in high-risk sexual behaviour, even after participating in education programs (Thurman and Franklin 1990; DiClemente et al. 1992). Programs that attempt to promote the use of condoms as a preventive measure have only increased awareness, not usage (Jay et al. 1988).

Media strategies

Although health beliefs can be influenced by media messages, the use of media to transmit complex information may be of limited effectiveness. Knowledge gained through the mass media is often incomplete, and it is of limited value because people do not have the opportunity to ask questions (Mhloyi and Mhloyi 1994). First-hand experience often has better success in promoting behaviour change (Mhloyi and Mhloyi 1994; Pesce 1994). Furthermore, many women may not benefit from information gained through educational campaigns in the media because the language used is not tailored to their level of education or cultural background (Pesce 1994). If media strategies hope to reach women, messages need to be appropriately targeted and tailored to the particular characteristics of women.

Poorly thought out media messages can create false impressions and be counterproductive. For example, many women do not believe that their partners could be possible infectors. This misperception can be reinforced by unclear media messages that promote monogamy as a way to prevent AIDS, and thereby lead some women to think they are not at risk of HIV transmission because they are only having sexual intercourse with one person. Health promoters need to exercise caution with these types of messages (Pesce 1994).

Some media methods may be better than others. Mhloyi and Mhloyi (1994) reported that exposure to radio was more likely to reduce the likelihood of STD infection than exposure to newspapers. Kuyyakonand (1995) also reported that women whose primary source of information was the radio tended to have more accurate information. This may be because live radio presentations, which often include question-and-answer sessions, may be more realistic to listeners (Mhloyi and Mhloyi 1994). Also, because of low levels of literacy, some women may not benefit from newspapers.

Creative educational approaches

Given the lack of success of traditional educational campaigns, creative educational approaches are needed and information needs to be packaged in ways that make it interesting and relevant (Garcia et al. 1994; Manneschmidt, see footnote 6). More and more countries are using entertainment media, including soap operas, radio shows, and songs to encourage AIDS awareness (Heise 1993). Mhloyi and Mhloyi's study (1994), for example, experimented with different educational approaches including drama, the use of role models, songs, and discussions. These types of innovative approaches reduced communication barriers and informed people about key issues. The plays and songs were filled with conversation-provoking lines. For example, one line from the play read, "Theresa, don't you know that when you are in the middle of that business, you can barely think of a condom?" which encouraged the group to discuss obstacles to condom usage (Mhloyi and Mhloyi 1994). According to Asha Kambon (1995):

New techniques need to be given greater prominence .... Popular theatre, [for example], can empower as it imparts new information and ... by its very meaning must be rooted in the culture of the people.

To educate and change risky behaviour in northeastern Thailand, IDRC-supported researchers, Thicumporn Kuyyakanond and Eleanor Maticka-Tyndale, pioneered an AIDS-awareness program that involved regular radio dramas on the subject of AIDS (Conway 1995). The radio scripts were based on stories taken directly from focus-group discussions and reflected real-life situations. The dramas, a mixture of soap opera and improvisational theatre, were styled after a traditional form of Thai theatre called Maw Lum. The project generated much interest and enthusiasm, and Thai health officials, in collaboration with local ngos, expanded the pilot project to province-wide programs.

Empowering women

Gender-power dynamics limit women's ability to determine the conditions under which sexual intercourse occurs. Many researchers have emphasized that the solution to AIDS "involves something much more profound than instruction in the use of condoms" (Usher 1992, p. 17), and one of the most important strategies to deal with AIDS is to increase the power and autonomy of women. Women need to be educated about their subordinate position in society, and encouraged to care for themselves: "The notions of self-care, and control over one's life, need to be felt at every emotional level, and not just rationally or intellectually imposed" (Pinel 1994, p. 57). As Usher (1992, p. 46) observes:

Women in the age of AIDS, especially young women, must know her body well and understand her sexuality before she can be expected to discuss it with her future partner. AIDS requires women to make conscious, active decisions about the most intimate areas of their lives.

The difficulties encountered by women when they demand safer sex need to be explored with women , and strategies must be developed. Women need to be trained in how to use condoms and how to include them in sexual foreplay (Pesce 1994). It is also crucial that false beliefs be corrected through awareness-raising, such as the widespread misperception that husbands and partners are not infectors. At the Paulina Lousi Movement training program in Uruguay, for example, when women asserted that "men play around," program leaders probed this statement by asking "which men play around" to encourage women to consider the personal risk they may be exposed to (Pesce 1994).

Group counselling and training can be an effective format for helping women to deal with these issues. In a group, women are able to share common experiences and perceptions, examine values, gain support and validation for each other, and practice new behaviour skills in a safe environment (Moore 1981; Burden and Gottlieb 1987). Group training has been shown to improve the self-esteem of women, and may lead to a sense of empowerment (Weitz 1982). Jacobson (1992b) reported that several countries are now trying to bring women together to discuss taboos that may be harmful to their health. This empowers women because it breaks their silence and enables them to focus on the what is in their own best interest.

Throughout the world, women have always found strength in informal organizations, mobilizing themselves around specific activities, using kinship ties, neighbourhood groups, and other informal networks to accomplish their aims (March and Taqqu 1982; Ulin 1992). AIDS-prevention programs need to make the most of women's capacity for collective action. Heise and Elias (1995) argued that women who organize for change can help build group consensus and create a unified sense of purpose and possibility. In community organization projects, women can learn to analyze their situation and seek individual and collective solutions to their problems.

Female-controlled prevention measures

Given the incredible difficulty that women face in convincing men to use condoms, research is increasingly focusing on developing HIV-prevention methods that women can control. The recently available female condom, a polyurethane sheet with two rubber rings that secure it inside the vagina, still requires partner cooperation, and many women find it bulky and awkward to use (Panos Institute 1994b; Cohen 1995).

Although the spermicide nonoxynol-9 has been known to kill HIV in the laboratory for many years, there has been limited research on its protective effect against the sexual transmission of HIV. The first large-scale trial on American women is just beginning, and it will be several years before results are available.

The possibility of developing a virucide, a vaginally inserted microbicide that would protect against HIV transmission, while letting sperm pass unharmed, is currently being investigated. Such a product would allow women to protect themselves from HIV without their partner's knowledge or cooperation. However, this research is still in its very early stages (Panos Institute 1994b).

Interventions targeted to men

Most gender-based programs to prevent HIV transmission have focused exclusively on women. Although many AIDS interventions have targeted homosexual men, there has been limited attention placed on heterosexual men (Strebel 1994). However, because men have so much decision-making power in all areas of life, including sexuality, men need to be encouraged to take the initiative for prevention and be taught the importance of consistent and correct use of condoms.

In this regard, a recent study in Lima, Peru, suggested it may be important to use males as workers in the distribution of contraceptives, including condoms, to effectively reach men (Foreit et al. 1992). With the use of men in a community-based distribution program, the sales of condoms increased dramatically, as did the number of new male clients. Male distributers may have been particularly successful when working with male clients because they shared common characteristics with the population they served.

Likewise, the National Family Planning Council of Zimbabwe reported success with a 1989 intensive media campaign designed specifically to increase men's responsibility in family planning and to encourage joint decision-making among couples. The campaign included a series of informational and motivational talks by male educators. In addition, an entertaining serial drama about the consequences of irresponsible sexual behaviour was broadcast over the radio twice a week for 6 months and reached 40% of the male population in the country. At the end of the campaign, 40% of the men said that family-planning decisions ought to be made jointly by husband and wife, and 17% of the men who had attended at least one talk reported that they had started using a family-planning method (Sachs 1994).

Early and complete treatment of stds

Promotion of the early and complete treatment of stds is one of the key strategies to prevent HIV transmission. However, many STD-control programs have had little success (O'Connor et al. 1992; Lwihula 1994). There are a number of barriers that prevent women from obtaining adequate STD care. Women in many cultures have little knowledge about their reproductive health and, therefore, few skills in diagnosing possible STD symptoms (Manneschmidt, see footnote 6). Pesce (1994) reported that several women in her study in Uruguay, especially poor women, had a complete lack of knowledge about their bodies and their sexuality.

As a result of shame, embarrassment, and the stigma associated with stds, women are often reluctant to report to health services for the diagnosis and treatment of stds. In many cultures, women have been socialized to feel shy about expressing anything in relation to their body that could be regarded as sexual (Tin Tin Saw 1995; Manneschmidt, see footnote 6). Also, many physicians are men, and there can be cultural barriers that prevent women from being seen by men who are not their husbands (Manneschmidt, see footnote 6).

Furthermore, because stds are associated with "female deviance" and sexual immorality, some women may be highly concerned about the possibility of being ostracized by their family and their community (Guimarães 1994; Lwihula 1994). In contrast, stds in males have become "a proud proof of manhood and virility" (Pinel 1994); consequently, there may be a higher level of reporting of stds among men (Pinel 1994).

Care for stds is generally restricted to STD clinics and women have reported that they were reluctant to use STD services because they felt uncomfortable attending clinics primarily frequented by prostitutes and men (Guimarães 1994). If they recognized the stigma associated with stds, health services could improve the prospects that women would seek care by offering STD services in conjunction with primary health care and family-planning services. If the consultations were in privacy, it would not be obvious why the person was visiting the centre (Elias 1991; World Bank 1993).

Many health professionals reportedly lack knowledge about the symptoms of stds, including AIDS (Guimarães 1994; Manneschmidt, see footnote 6). Furthermore, Guimarães (1994) pointed out that medical staff at a family-planning clinic in Brazil often ignored "minor" symptoms of stds in female patients. Pesce (1994) reported that health-clinic professionals in Uruguay provided women with little or no information regarding the genesis of vaginal discharge, how it is transmitted, how it can be treated, or how it can be prevented. These findings suggest that more instruction on stds, particularly from a gender perspective, is needed in the professional training of health providers.

Finally, in some cases there can be a requirement that infected individuals bring their partner as a condition for treatment, which may greatly affect compliance. Such stipulations should be eliminated. Individuals who are married or in permanent relationships and also have casual sexual partners may be unwilling to meet this condition (O'Connor et al. 1992; Lwihula 1994).

⁴ Such as from blood transfusions or through exposure to HIV-infected blood products, such as syringes and infected medical instruments.

⁵ According to the World Bank (1993), 1 year of AZT costs more than us $3000.

⁶ See Manneschmidt, S., "AIDS programs in Uganda: what lessons can be learned for Nepali women?" Unpublished paper submitted to the 1994-95 tdr/IDRC competition.

⁷ In men, HIV infection peaks 5 to 10 years later in the 25-35 year age group.

⁸ "Low-risk" women are those who are married women or those with steady partners, between 20 and 40 years of age.

⁹ See Mhunga, R., "AIDS and violence against women." Unpublished paper presented at a seminar on the impact of HIV and AIDS on development, held 1 december 1994 at the International Development Research Centre, Ottawa, ON, Canada

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