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Indian Journal of Community Medicine

Vol. 31, No. 3 (2006-07 - 2006-09)

Editorial

Operationalizing Gender in Context of HIV/AIDS

S Garg*, P Sharma*

The global pandemic of HIV/AIDS has now entered its third decade and now-a-days women and girls are bearing its heavier burden than men. Research conducted over the past decade has revealed that gender roles and relations directly and indirectly influence the level of an individual’s risk and vulnerability to HIV infection. Gender norms often dictate that women and girls should be ignorant and passive about sex, which greatly constrains their ability to negotiate safer sex or access appropriate services. In terms of HIV/ AIDS, this ideology often assigns to women particular roles that substantially influence the design of HIV/AIDS interventions that are ultimately harmful and counterproductive. A recent analysis of levels of knowledge about HIV/AIDS prevention in 23 developing countries found that levels of knowledge are almost always higher among men than among women with 75 % of men on an average having accurate knowledge about HIV/AIDS transmission and prevention as compared to 65 % of women1. Few societies define sexual practices linked to reproduction as moral and those linked to pleasure as immoral. In sharp contrast, in many societies it is believed that variety in sexual partners is essential to men’s nature as men and that man will inevitably seek multiple partners for sexual release2. Results from sexual behavior studies from around the world indicate that heterosexual men, both married and single, as well as homosexual and bisexual men, have higher reported rates of partner change than women. This underscores the need for HIV/AIDS prevention efforts to change the gendered norms of sexuality, if interventions are to be effective.

Epidemiological and biomedical research has long established a link between an individual’s sex and his or her risk of contracting HIV infection. It is well known, for example, that physiological factors account for more efficient transmission of infection from an infected man to a woman than from an infected woman to a man. Sociocultural norms about masculinity and feminity conspire with biological and physiological factors to compound individuals’ risk of infection, resulting in epidemics of significant size and proportion in different parts of the world.

Stigma and Discrimination

In a number of societies, women are mistakenly perceived as the main transmitters of sexually transmitted diseases (STD’s). Together with traditional beliefs about sex, blood and the transmission of other diseases, these beliefs provide a basis for the further stigma of women within the context of HIV and AIDS. HIV- positive women are treated very differently from men in many developing countries. Men are likely to be 'excused’ for their behavior that resulted in their infection, whereas women are not.

“My mother-in-law tells everybody. Because of her, my son got this disease. My son is a simple as good as gold but she brought him this disease”. – HIV-positive woman aged 26, India.

In India, for example, the husbands who infected their partners may abandon women living with HIV or AIDS.

Economy and Gender vulnerability

Women’s economic and social dependency on men greatly affects their use of services and ability to treatments and other medical regimens. Economic constraints such as the lack of money to pay for services or transportation or the high opportunity costs of time, create significant barriers for women’s use of health services. In families where income and resources are pooled from multiple individuals, women are still at a disadvantage in accessing funds for health services because families typically allocate resources for men and boys first and women and girls later or not at all. For men, gender related norms and economic needs force them to migrate without their families in search of work, creating situations that foster multiple sexual relationships that may lead to HIV infection. Overall, poverty greatly exacerbates both women’ and men’s vulnerability by restricting access to information and services and making it more difficult to cope with the impact of the epidemic. Women’s economic dependence also makes it impossible for women to negotiate safe sex or it forces them to exchange sex for survival or to resort to be self reliant, not to show their emotions and not to seek assistance even in times of need or stress. It is therefore not surprising that men are less likely to seek unsafe sexual practices. Studies from across the developing world indicate that poverty is overwhelmingly the root cause of women bartering sex for economic gain or survival. Women and men who are economically disadvantaged are less likely to have information about HIV/AIDS than those from higher income levels and therefore are more vulnerable to infection.

By curtailing women’s sexual rights and autonomy, encouraging irresponsible and risky sexual behavior among men, restricting women’s access to and use of economic resources and fostering homophobia, gender norms have contributed to creating a culture of silence and shame that surrounds sexuality and an unequal balance of power between women and men. Together these pose a significant challenge for policies and programmes that seek to contain the spread of the HIV/AIDS epidemic. To meet this challenge, WHO is committed to integrating gender considerations into all HIV/AIDS programming.

Violence as Predictor of HIV/AIDS

The experience of violence against women has also been found to be a strong predictor of HIV. Research conducted in a wide range of countries, including India found that violence against women contributes both directly and indirectly to women’s vulnerability to HIV. Most obviously, violent sexual acts such as rape are likely to result in vaginal tearing or lacerations, thus dramatically increasing the risk of contacting an STI or HIV. Additionally, fear of violence or abandonment often prevents women from discussing fidelity with their partners or asking their partners to wear a condom. Fear of violence has also been found to be a barrier to the success of efforts that seek to reduce the perinatal transmission of HIV. In a study of Mother to Child transmission prevention programmes in six African countries, fear of ostracism and domestic violence were important reasons for which pregnant women refused HIV testing or did not return for their test results. HIV positive women who have been advised to bottle feed their babies to avoid risk of HIV transmission have also voiced similar concerns.3

Gender and Access to Health care services

Socio cultural norms that define male and female roles and responsibilities also affect women’s and men’s access to and use of health services, including HIV/AIDS services. In countries where son preference is a norm women and girls are further constrained from using services because of gender norms restricting their mobility. For example, women feel uncomfortable interacting with male health care providers. The barriers that men face in using services are often related to socio cultural norms that ascribe reproductive responsibilities entirely to women and shun men out of parenting or nurturing roles. This has significant implications for men’s ability to protect themselves from the epidemic. Gender and HIV/AIDS consequences

Women are generally more vulnerable to the consequences of AIDS morbidity and mortality, whether they themselves are HIV positive or they are living with and caring for others who are HIV Positive within the family or both- a situation whose prevalence is on the rise. Women are more likely to wait longer periods of time before seeking services and treatments during the course of an illness, they are more likely to be at an advanced stage of HIV infection and present related opportunistic infections before they actually seek out treatment and services.3

Implementing Gender perspective

World health Organization (WHO) has identified the need to develop a set of guidelines to help national level HIV/AIDS programme planners and managers integrate gender based issues and needs comprehensively within HIV/AIDS policies and programmes. Keeping this in view along with WHO’s overall goal of integrating gender into all aspects of its broad mandate to assure health for all4.This goal includes analyzing and addressing gender issues in planning, implementation, monitoring and evaluation of policies, programmes, projects and research. WHO recognizes that integrating gender considerations is essential for:

i) Increasing coverage, effectiveness and efficiency of interventions

ii) The promotion of equity and equality between women and men, throughout the life and ensuring that interventions do not promote inequitable gender roles and relations

iii) The provision of qualitative and quantitative information on the influence of gender on health and health care, and

iv) Supporting Member States in undertaking gender responsive planning implementation and evaluation of policies, programmes and projects.

Structural Aspects:

i) There is need to foster and develop the political will and leadership at the level of state institutions.

ii) Initiatives to integrate gender should rely on equity based on human rights, appeals to justice, or other fairness-related argument. Gender integration maximizes the effectiveness of programmes by reaching more people and reducing constraints to accessing and using information, technologies and services for all.

iii) Funding for all the programme areas be increased to match the overall programmatic goals of an HIV prevention, care and support or treatment programme with gender-disaggregated goals and indicators for evaluation woven in throughout.

iv) Gender must be seen as a core element to be addressed in order to maximize the effectiveness of the programme. Integration must extend outward to ensure that all programme staff understand the gender differentials related to risk factors of HIV infection, access to information, education, services and technologies, differences in progression of HIV infection and distinctions between men and women as to the type and severity of opportunistic infections, the different roles that men and women play as formal and informal care providers, and the differential social and economic burdens of AIDS morbidity and mortality.

v) Sex-disaggregated data on a host of other socioeconomic indicators of women’s status that are essential to understand the direction, scope and impact of the epidemic in different parts of the world.

vi) Sound monitoring and evaluation criteria and tools need to be integrated into programme design from the outset

vii) There should be an institutional incentive system that rewards employees who pay attention to gender issues to ensure that gender is integrated comprehensively throughout the programme.

Technical Aspects

i) Thus in order to be gender sensitive health programmes must offer different services for women as compared to men when their needs differ but must ensure that services do not treat men and women differently when their needs are the same. Another important observation in HIV/AIDS programming that seeks to be gender sensitive is that women and men are provided with different interventions or informations when in fact their needs and responsibilities are the same. A common example is when basic information about the prevention of perinatal transmission of HIV is provided only to women. Family planning, prenatal and child health clinics are typically not designed to reach men or meet men’s needs because in many settings HIV/AIDS information and services are provided primarily in such clinics, men are less likely to benefit from those services and are thus less likely to be fully informed about HIV/AIDS prevention, care and support and treatment options.5

ii) Programmes that seek to transform gender roles and create more gender equitable relationships are more advanced than gender sensitive approaches because they seek to change the underlying conditions that cause gender inequalities.

Programmes that seek to transform gender relations include efforts to work with couples as the unit of intervention, rather than with individual men and women. Couple counseling in HIV testing clinics to help couples deal with the results of their tests and in family planning programmes to promote dual protection against both unwanted pregnancy and infection are recent examples of efforts that seek to reduce the negative impacts of the gender power imbalances by including both partners in the intervention.

At the other end of the continuum from damaging policies and programmes are those that empower women and girls.

1) The first source of power for individuals in society is access to information, education and skills. We must give women and men basic information about their bodies, sexuality, disease and reproduction.

2) Another important source of power for women is access to economic resources and assets. Ensuring the implementation and protection of women’s property and inheritance rights, ensuring their access to sources of credit, ensuring equal pay for equal work, fostering the provision of business, financial and marketing skills necessary for the success of their enterprises, providing access to agricultural extension services to ensure the highest yield from their land, promoting access to formal sector employment and ensuring their right to be free of abuse and exploitation in the informal employment sector are all ways by which women’s access to economic resources can be facilitated.

3) Increasing social support for women who are struggling to change existing gender norms and helping them to expand their social networks by providing them opportunities.

Policies that aim to decrease the gender gap in education, improve women’s access to economic resources, increase women’s civic and political participation and protect women from violence are key steps in empowering women.

However, to date the majority of initiatives to integrate gender into effective programming have been small and experimental. Where pilot initiatives seemed to show promise, navigating the uncharted waters of scaling up remains a significant challenge to overcome. The realities of gender inequalities within the social and economic context of any given country can prevent or negate even the best HIV/AIDS interventions. Ultimately, to address economic and social gender inequalities that lie at the root of the pandemic requires a multisectoral response that must increase women’s and girl’s access to productive resources such as education, employment, land and credit, end the culture of silence and shame that surrounds sexuality, and protect girls and boys from the corrosive effects of gender stereotyping.

Thus recognition that HIV/AIDS is more than a health matter is a critical step forward in addressing the pandemic. The role of men and changes in gender relations has been considered a key element in fighting the pandemic. The governments, international organizations and NGOs are required to significantly upscale their work with men to challenge gender inequalities in relation to HIV/AIDS and to encourage men’s fuller participation in prevention, impact alleviation and care.

References

  1. Gwatkin DR, Deveshwar-Bahl G. “Inequalities in Knowledge of HIV/AIDS Prevention: An overview of socio-economic and gender differentials in developing countries” Unpublished draft 2001.
  2. Rao Gupta G. The Best of Times and the Worst of Times: Implications of Scientific Advances in HIV Prevention in the Developing World’. Annals of the New York Academy Of Sciences 2000:918,16-21.
  3. Nyblade, Laura, Field-Nguer ML “Women, Communities and Prevention of Mother-to Child Transmission of HIV/AIDS: Issues and findings from Community Research in Botswana and Zambia.”International Centre for Research on Women. Washington DC; 2000.
  4. World Health Organization (WHO). “WHO’s Gender Policy: Integrating Gender Perspectives in the Work of WHO”, Geneva 2002.
  5. Mane, Purnima and Aggleton P. “Gender and HIV/AIDS; What do men have to do with it?” Current Sociology 2001:49(6), 23-37.

*Deptt. of Community Medicine, Maulana Azad Medical College,
New Delhi.
Email: [email protected]

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