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RHO archives : Topics : HIV/AIDS

Special Focus: Gender and HIV/AIDS

Of the 38.6 million adults living with HIV/AIDS at the end of 2002, 19.2 million—or nearly 50 percent—were women (UNAIDS 2002). Rather than representing equity between the sexes, the one-to-one ratio of male-to-female HIV infections demonstrates the way in which gender inequalities affect HIV/AIDS incidence rates. Since the HIV/AIDS pandemic began more than 20 years ago, infection rates among women have accelerated. Traditional gender roles held by many of the worlds societies are largely responsible for the continued spread of HIV, particularly from men to women. In most societies, women also carry a disproportionate amount of the burden of caring for family members living with HIV/AIDS, and experience the brunt of the stigma associated with HIV infection. Correcting the gender imbalance that contributes to and is exacerbated by the HIV/AIDS pandemic will depend upon improving womens social and economic status, and increasing men's responsibility for HIV prevention and care.

One reason for womens vulnerability to contracting HIV is biological: the large mucosal structure of the vagina and the high concentration of the virus in semen put women at a much higher risk of acquiring HIV during unprotected sexual intercourse (NIAID 2001). In addition, women often have difficulty negotiating safer sex with their partners because of their lower social status, economic dependence on men, and fear of violence. Young women and girls are often the target of older men in search of "safe" sexual partners, including men who believe the myth that sex with a virgin will cure their HIV infection (Matlin and Spence 2001). Unequal social roles and vulnerability to mens demands also mean that women are more likely to become infected with HIV at an earlier age than young men: in some of the most affected countries, infections rates in girls are five to six times higher than infection rates in adolescent boys (Walsh 2001).

When HIV infection occurs within a couple or a family, women often assume a disproportionately large role in caring for those living with the virus. Once they have contracted HIV, however, many women lack access to health care and social support, due in part to their disadvantaged socioeconomic status. Cultural and language barriers also impede womens access to prevention information and other services. Regardless of which partner first became infected, women are often blamed by their partners and society when HIV surfaces in a family, especially when a child is infected with the virus at birth. Fear of isolation, rejection, and social stigma, in addition to the threat of partner violence, often discourages women from revealing their HIV status to their partners, or even from being tested for the virus. The same violence and the resulting inability to discuss safer sex or partner infidelity cause many women to believe that they cannot protect themselves from possible HIV transmission (National Womens Health Information Center).

Given that male behavior is one of the main determinants of HIV infection in women, the participation of men in prevention activities is clearly essential. The 2000 World AIDS Campaign—"Men and AIDS: A Gendered Approach"—helped to broadcast the message that men can be part of the solution, and that cultural beliefs and expectations also increase mens own vulnerability to HIV/AIDS. As a result of many cultural expectations, men have more sexual partners than women and are more likely to engage in such risky behaviors as drinking, reckless driving, and injecting drugs. In many countries, married men or those in long-term relationships with female partners also engage in unprotected sex with other men. Men are also less likely to seek health care or focus on their sexual health or safety (UNAIDS 2000). As discussed above, all of these factors impact directly on mens female partners.

To address the gender imbalance fueling the HIV/AIDS pandemic, a number of approaches are available to programs working with men and women on prevention and care. For example, programs can:

  • highlight how gender stereotypes and expectations affect both women and men, and support work to improve gender equality and equity;
  • challenge damaging notions of masculinity and other gender stereotypes;
  • encourage men and boys to explore the ways in which they were raised and how they are expected to behave;
  • encouraging men to discuss sex, drug use, and HIV/AIDS;
  • strengthen women's ability to decide when, where, and whether sex occurs;
  • improve men's access to information, counseling, and support;
  • advocate for wider understanding and acceptance of men who have sex with men;
  • support efforts to reduce male violence and sexual violence (UNAIDS 2000).

Policies that promote healthy behavior and HIV prevention must incorporate some fundamental changes. Depicting women as givers but never receivers of care perpetuates dangerous gender stereotypes. Ensuring that sexual health is understood to be the business of men as well as women is also critical. Educational messages that simply tell people to "use a condom" do not address the power imbalance between men and women that make this recommendation impossible in many cases (Doyal 2002). Instead, HIV/AIDS programs should simultaneously focus on men and acknowledge womens need for support and resources. Effective HIV/AIDS programs should recognize that all sexually active men may be risking HIV infection, not just those who appear to be sexually promiscuous. Programs also need to encourage men to talk about sexuality and safety, while also promoting the fundamental link to the safety and well-being of their partners and children. Finally, high-profile men, such as politicians, sports figures, and other celebrities, must accept and advocate for mens responsibility in promoting and safeguarding sexual health (Bujra and Baylies 2001).

Some programs have begun to address mens responsibility for HIV/AIDS prevention and care. For example, the Mathare Youth Sports Association in Kenya helped develop a list of priority issues for policy makers to address to promote male responsibility, protect young people from HIV/AIDS, and increase the involvement of young people in prevention activities. In Zambia, World Vision, an international nongovernmental organization (NGO), has created teams of young people who serve as peer counselors to young men (and women) in bars and nightclubs, where mens alcohol consumption, in particular, can lead to risky sexual behavior. ACORD, an African NGO, runs peer-educations programs for in-school and out-of-school young men in Tanzania and Uganda. And in India, the Mumbai Municipal Corporation and the Mumbai District AIDS Control Society established the AIDS Prevention and Education Programme. In 2001, the program reached 125,000 secondary school students in 600 schools, focusing on such issues as reproductive health, anatomy, contraception, conception, and HIV/AIDS knowledge, in addition to organizing discussions and role plays on attitudes, values, life skills, relationships, and pressures (Scalway 2001). Despite the success of these and other innovative programs, a great deal of work remains to be done if men are to assume their full responsibility for sexual health and HIV/AIDS prevention and care.

RHO's HIV/AIDS section provides more information on issues and resources relevant to this topic. In addition, be sure to visit the Men and Reproductive Health, Gender and Sexual Health, and Adolescent Reproductive Health sections for additional discussion and exploration.

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Annotated bibliography

Please note that PDF files require Adobe Acrobat Reader software, which can be downloaded for free at www.adobe.com/products/acrobat/readstep.html.

Bujra, J. and Baylies, C. Targeting men for a change. ID21 Research Highlights (2001). Available at: www.id21.org/static/insights35art2.htm.
This submission to the ID21 Research Highlights points out that women cannot protect themselves against HIV infection without the cooperation of men. Two key challenges include (1) creating programs that treat men as individuals, and (2) being aware that the relations between men and women—not men and women themselves—are in need of change. Men continue to make important family decisions, control the benefits of womens labor, consider it their right to marry younger women and have extramarital relationships, and run the risk of contracting HIV through unprotected sex with multiple partners. At the same time, men are beginning to re-evaluate traditional gender roles and discuss issues of sexual health and condom use. Prevention programs need to focus on men in general rather than only such groups as long-distance truck drivers and army personnel. HIV/AIDS programs should target men but also acknowledge womens need for support and resources. Creative approaches should encourage men to take responsibility for their wives, partners, and children. Effective programs must also appeal to all sexually active men, not just those who appear promiscuous. Finally, politicians and other high-profile men need to advocate for men to assume their responsibility in HIV/AIDS prevention and care.

Doyal, L. Sex, Gender and Health: Need for New Approach [post to the Gender-AIDS website]. http://archives.hst.org.za/gender-aids/msg00032.html. Accessed November 2002.
This Gender-AIDS submission by a professor of health and social care at the University of Bristols School for Policy Studies calls for a clearer understanding of the impact of sex and gender on health. High-quality reproductive health services are necessary to address the biological risks to womens sexual health. Gender differences in levels of income and wealth render women vulnerable to poverty, which in turn constitutes a risk to womens health and their access to basic services. The perceived need for men to maintain a strong heterosexual male identity leads to a high level of risk taking, including dangerous jobs, reckless driving, hazardous sporting activities, drinking, smoking, and unsafe sex. A number of measures could help improve the health of both women and men. For example, women may need better transport and child-care services, while both men and women need more services in the workplace or in community locations. Maximum impact of health-promotion policies requires gender-sensitive messages. Social and economic policies also have a role in improving gender relations and sexual health—for example, by increasing the flexibility of working hours or providing more parental leave so that men can spend more time with their families. Through these and other strategies, addressing gender inequalities could lead to improved health for both women and men.

Matlin, S. and Spence, N. "The Gender Aspects of the HIV/AIDS Epidemic." Presentation at the Expert Group Meeting on the HIV/AIDS Pandemic and Its Gender Implications, Windhoek, Namibia (2001). Available at: www.un.org/womenwatch/daw/csw/hivaids/matlinspence.html.
The authors of this paper indicate that more women than men are now dying of HIV-related causes. The changing patterns of HIV transmission mirror divergences linked to biology, sexual behavior, social attitudes and pressures, and economic power and vulnerability. Women and girls are more vulnerable to HIV infection because of their lower social status and disadvantages related to health-care access, education, and employment. The authors go on to examine HIV/AIDS as it pertains to a number of gender-related factors, including mothers and children, education, youth, the labor market, health services, the law, and situations of conflict and population displacement. They then advocate for the mainstreaming of gender into multisectoral responses to HIV/AIDS. Womens groups are also instrumental in strengthening the response to HIV/AIDS and protecting womens interests. Among other things, they can advocate for the protection of legal, civil, and human rights and ensure that women have the same access as men to treatment, counseling, and support. They can also lobby for better health education and public awareness and the adoption of preventive strategies such as safer sex, monogamy, abstinence, and the use of safe blood products.

National Institute of Allergies and Infectious Diseases (NIAID). HIV infection in women [fact sheet]. Bethesda, Maryland: NIAID (2001). Available at: www.niaid.nih.gov/factsheets/womenhiv.htm.
This electronic report provides an overview of the issue of women and HIV/AIDS. The document asserts that women around the world "face the greatest risk of acquiring HIV due to substantial mucosal exposure to seminal fluids, high prevalence of non-consensual sex, sex without condom use, and unknown, high-risk behaviors of their partners." A section on current research highlights a number of relevant studies. One study concluded that "women with high viral loads were more likely to have detectable levels of HIV in their genital tract" and "reductions in HIV levels in the genital tract of women could have a significant impact on HIV transmission." Another study demonstrated that the presence of a baseline level of serum albumin, the principal protein found in blood, was a strong indicator of the probability of survival for HIV-infected women over the following three years. Additional research has taken place on the issue of microbicides. One study found BufferGel, a chemical agent that "helps maintain the healthy acidic environment of the vagina in the presence of semen," to be safe and generally accepted. Research is now underway to determine the effectiveness of BufferGel in preventing HIV infection. Other research areas covered by the report include mother-to-child transmission and HIV transmission to women. Further sections list the signs and symptoms of HIV, symptoms specific to women, gynecologic screenings, early diagnosis, and survival among HIV-infected women.

The National Womens Health Information Center, U.S. Department of Health and Human Services. Sociocultural Issues Related to HIV/AIDS. Available at: www.4woman.gov/owh/pub/womenhiv/wasocio.htm.
This online document provides a brief summary of such sociocultural issues as women and violence, womens care-giving role, and access to health care and other services. The summary maintains that "[p]hysical and sexual assaults and histories of childhood abuse are disturbingly common among women with or at high risk for HIV/AIDS." Studies have shown that women may be unwilling to discuss fidelity and condom use for fear of a violent reaction from their partners. As the principal caregivers in a family, women may be burdened with the care of family members with HIV-related illnesses, but lack the support necessary to minister to their own health care needs. Womens lack of access to health care is often linked to their disadvantageous socioeconomic status, as well as to cultural and language obstacles. Women living with HIV/AIDS may need child care, respite care, mental health services, and substance-abuse treatment.

Scalway, Thomas. Young Men and HIV: Culture, Poverty and Sexual Risk. London: The Panos Institute/UNAIDS (2001). Available at: www.panos.org.uk/aids/Panos_Aids_Pages.qxd.pdf.
This thoughtful and comprehensive report focuses on the role of young men within the HIV/AIDS pandemic. The report points out that young men aged 15 to 24 engage in the riskiest behavior of any age or gender group, and as a result account for 25 percent of all people living with HIV/AIDS. They inject drugs, have multiple sex partners, and often engage in unprotected sex with other men. In a section on masculinity, poverty, and risk, the report also discusses typical ideas of masculinity, multiple partners, poverty and sex, drugs and alcohol, and perceptions and knowledge. The following section on young men at special risk highlights the issues of men who have sex with men, migrants and refugees, prisoners, sex workers, and members of the uniformed forces. Section four discusses ways to bring about change, including strategies for reaching young men, peer education, school-based programs, the media, sports, health clinics, youth clubs, and traditional rituals. The report also contains several useful examples of current efforts to work with young men on HIV/AIDS prevention.

UNAIDS. Men and AIDS: A Gendered Approach. Geneva: UNAIDS (2000). Available at: www.thebody.com/unaids/men/contents.html.
Produced for the 2000 World AIDS Campaign, this thorough document maintains that women are at particular risk of HIV infection due to their "lack of power to determine where, when and whether sex takes place." At the same time, the report underscores the need to establish a balance between acknowledging how the behavior of some men fuels the HIV/AIDS pandemic and inculcating—thereby perhaps alienating—all men. Men and AIDS also discusses in detail such topics as the impact on women, the roots of masculinity, reaching adolescent boys, mens relations with women, sex between men, preventing sexual transmission of HIV, violence and HIV, substance use, special settings (such as prisons, mines, the military, areas of migrant workers and long-distance truck drivers, and zones frequented by sex workers and people who live on the street), mens health needs and health-seeking behavior, and how men interact with their families. The document concludes with a series of points for action aimed at increasing gender awareness, improving sexual communication and negotiations, reducing violence and sexual violence, and promoting support and care.

Walsh, J. Fact Sheet on Gender and HIV/AIDS. Geneva: United Nations (2001). Available at: www.hivnet.ch:8000/topics/gender-aids/viewR?912.
This fact sheet, produced for the United Nations Special Session on HIV/AIDS in June 2001, outlines the ways in which gender determines the vulnerability of women, men, girls, and boys to HIV infection. The document maintains, among other things, that inequalities linked to gender are also tied to inequities in social, cultural, economic, and political areas. In terms of the impact on women, the fact sheet asserts that the percentage of women living with HIV/AIDS has been on the rise for many years, that women are often infected at an earlier age than men, and that gender-based violence accounts for a large proportion of HIV infections in women. Women in stable relationships are often vulnerable to HIV infection through their partners who use drugs or have multiple sexual partners. Women then often face discrimination when they seek care and support to deal with their HIV infection. Women and girls also bear the burden of care for family members with HIV-related illnesses. The document lists a number of ways to meet the challenges posed by gender and HIV/AIDS, including actions taken at the community and family levels, legal and human-rights reform, prevention and care programs that incorporate gender into their approach, and activities for girls and for boys and girls that encourage more equitable and mutually respectful attitudes, particularly within sexual relationships.

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Links to resources

Listed below are some useful resources on gender and HIV/AIDS.

EngenderHealth
www.engenderhealth.org/
The website of EngenderHealth, a U.S.-based organization that works to improve reproductive health in developing countries, offers a wide range of information and resources on family planning, maternal/child health, mens health, HIV and other sexually transmitted infections, and sexuality and gender. Special "in-action" sections discuss topics such as "ensuring womens health" and "working with men." EngenderHealth also provides web-based and CD-ROM self-instructional courses for health care providers, supervisors, students, and trainers all over the world. The courses are designed particularly for those in low-resource settings, and cover such topics as sexuality and sexual health, sexually transmitted infections, HIV and AIDS, and infection prevention. Also available are a number of professional materials, including a training package on mens reproductive health.

Gender-AIDS
www.hivnet.ch:8000/topics/gender-aids/viewR?909
Part of Health Development, "a global health information exchange platform supporting partnerships between people and organisations working on HIV and AIDS in developing countries," Gender-AIDS is an interactive forum that lists substantial messages related to gender and HIV/AIDS. Where full texts are not posted, links to relevant documents are usually available.

Gender and AIDS
www.genderandaids.org
The United Nations Development Fund for Women (UNIFEM) and UNAIDS recently created "the first comprehensive gender and HIV/AIDS web portal." This site is committed to providing users with cutting-edge research, studies and surveys, training materials, multi-media advocacy tools, speeches and presentations, press releases and current news, best practices, email updates and newsletters, online discussion forums, and links to websites and databases.

The HIV/Gender Continuum
www.ippfwhr.org/resources/gender_continuum.html
Available to download as a PDF file (in English, French, Portuguese, or Spanish) from the website of the International Planned Parenthood Federation, Western Hemisphere Region (IPPF/WHR), the HIV/Gender Continuum is a succinct, user-friendly tool designed to help service providers evaluate how responsive their programs are to the related issues of gender and HIV prevention. The continuum provides readers with a series of questions that help locate a program or organization on a spectrum of gender-sensitivity ranging from "non-gender-sensitive program" to "somewhat gender-sensitive program" to "ideal gender-sensitive program." A final gender-sensitive score, based on answers to the questions, delineates an organizations placement on the spectrum. The continuum ultimately helps organizations answer larger about their ability to fully examine HIV risk factors, support women's negotiation and decision-making skills, provide effective counseling on HIV and gender-based violence, and link related services.

KIT (Gender and AIDS)
www.kit.nl/specials/html/ga_gender_and_aids.asp
The Royal Tropical Institute (Koninklijk Institut voor de Tropen) of the Netherlands offers a wide range of information on gender and HIV/AIDS, including an overview of the Institutes own work on the topic. KITs Gender and AIDS section also features a useful link to electronic publications on gender and HIV/AIDS, listed in reverse chronological order. The publications are available through links to other websites or as PDF files to download. Other links connect viewers with related KIT information sources, statistics, fact sheets, gender-analysis tools, news and events, electronic discussion lists, and additional websites.

Living for Tomorrow
www.nikk.uio.no/forskningsprojekt/livingfortomorrow/
Living for Tomorrow was a three-year development and research project (1998-2000) sponsored by the Nordic Institute for Women's Studies and Research in collaboration with the Tallinn AIDS Prevention Center in Estonia. The project's goal was to develop sexual health awareness and safer sexual behavior among young people, while highlighting the issues of gender, youth perspectives, and active learning processes. The project yielded several noteworthy reports available as PDF files, including Challenging Gender Issues: Report on Findings from the Living for Tomorrow Project About Young Men's and Young Women's Attitudes to Men, Women and Sex and Mobilising Gender Issues: Report from the Living for Tomorrow Project on Youth, Gender and HIV/AIDS Prevention (www.nikk.uio.no/forskningsprojekt/livingfortomorrow/lft_pubtext.html).

Panos Books
www.panos.org.uk/books/books.htm
The Panos Institute website lists several relevant publications for sale, including four booklets on men and HIV in Malawi, Swaziland, Zambia, and Zimbabwe. AIDS and Men: Taking Risk or Taking Responsibility examines "the impact of mens actions and attitudes on women, children and other men," as well as exploring programs that aim to help men protect themselves and their partners. The book also includes reports written by journalists from 11 countries in Asia, Africa, the Americas, and Eastern Europe on how HIV/AIDS affects different types of men. Also available is On the Margins: Men Who Have Sex With Men and HIV in the Developing World, which "looks at the many different types of men who have sex with men, the extent of male-to-male sex, and the frequency of risky sexual practices which can lead to the spread of HIV" in developing countries.

Women, Gender and HIV/AIDS in East and Southeast Asia
www.unifem-eseasia.org/Resources/GenderAids/genderaids13a.htm
The United Nations Womens Fund (UNIFEM) East and South East Asia division has developed an information kit available in several formats to view or download (including Microsoft Word and PDF versions). The kit includes sections on why HIV is a gender issue; basic facts; facts specific to several countries in the region (including Cambodia, China, Myanmar, Papua New Guinea, Thailand and Vietnam); how HIV is a human rights issue for women; vulnerability to HIV; mobility, gender, and HIV; mother-to-child transmission; the role of men; HIV, women, and peace; what is being done in the area of gender and HIV/AIDS; and a list of resources for information on women, gender, and HIV/AIDS.

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