The dawning of each day hails HIV infection of more than 7 000 girls and women. To date, the largest numbers of Aids casualties are recorded in the women of sub-Saharan Africa and the Caribbeans.
In the mother-continent, girls and women account for almost 57% of people living with HIV. In South Africa, Zambia and Zimbabwe, young women aged 15-24 present the highest prevalence of new infections.
According to The Global Coalition on Women and Aids, some traditional HIV prevention strategies have tended to focus predominantly on “ABC”: Abstain, Be faithful, use a Condom.
While the ABC approach has undoubtedly prevented large numbers of people from becoming infected, many of the world’s women are simply not in a position to abstain from sex, rely on fidelity, or negotiate condom use. ABC can only be a viable and effective prevention option for women and girls if it is implemented as part of a multi-faceted package of interventions that seek to redress deep-rooted gender imbalances.
The Global Coalition on Women and Aids is therefore advocating for a more holistic approach to tackling HIV and Aids.
This involves advocating for the empowerment of women and the promotion of women and girls’ rights. Addressing current unequal gender norms that reduce young women and girls’ ability to make informed choices about their own sexuality is key to reversing the dramatic upward trend of HIV infection among young women and girls. At the same time, the coalition is calling for concerted action in a set of specific areas, which, if taken now, could significantly increase women’s chances of protecting themselves and ensuring that they do not pass on the infection to others.
Condom use has been presented as a feasible solution. Research reveals that condoms (male and female) are effective in preventing HIV infection. Programmes designed to promote condom use have been reported to be successful. In Mwanza, Tanzania, the distribution and promotion of condoms by youth peer educators in 1998 led to significant increases in reported condom use among young people.
In Nepal, a promotion campaign focused on sex workers and their truck-driver clients. Providing condoms and information along truck routes helped cut the risky behaviour of both sex workers and truck drivers. Between 1994 and 1996 condom use by sex workers along the routes almost doubled, to 61%.
At present, however, more than half of all people at risk of HIV infection are able to obtain condoms. Worldwide, only 4.9% of married women of reproductive age use them. That figure drops to 1.3% in Africa. There are many reasons why usage figures are so low, but one key obstacle is lack of access. Condoms may simply be unavailable (partly because of the global shortage of supplies); people may not know where to go to get them, or they may feel embarrassed about acquiring them.
The Global Coalition on Women and Aids thus suggests an urgent need to step up production, increase availability, reduce the price, and overcome the embarrassment factor via community-level awareness raising activities and life skills sessions in schools. At the same time reproductive health practitioners can play a greater role in advising patients about HIV protection, alerting them to the dual benefits the condom offers to women who want to control the number of children they have and protect themselves from HIV infection. Whether partners will be amenable to the use of condoms, especially in a marriage setting remains debatable as recent surveys have shown that nine out of 10 men in Zimbabwe are reluctant to use condoms with their wives.
The female condom remains an under-exploited option. While efforts to improve on existing models are welcome, the female condom in its current form is still the only viable option that permits women to take the prevention initiative. As evidence from reproductive health workers in developing countries indicates, demand is high. Were the female condom more readily and cheaply available, many more women would be able to protect themselves from HIV and sexually transmitted infections (STI). In sub-Saharan Africa, for example, many women are contracting HIV and STIs from their husbands and desperately need to be able to protect themselves. Again the sentiment from husbands with regards to use of the female condom points to reluctance.
In many African countries, including several with high rates of HIV infection, girls are married in their teens – often as a poverty-reduction strategy. Over the next ten years, more than 100 million girls in developing countries will be married before their 18th birthday – mostly to older men and often against their will. Today, the majority of sexually active girls aged 15-19 in developing countries are married. Ironically perhaps, these girls have significantly higher rates of infection than their sexually active, unmarried peers.
At this relatively early stage in their physical development, girls are particularly susceptible to HIV infection. When they marry older men, who are likely to have had previous sexual partners and who are also less predisposed than younger males to use condoms, the risk of infection is multiplied. In Kisumu, Kenya, 30% of male partners of married adolescent girls were infected with HIV. Unmarried but sexually active girls are more likely to have relationships with younger men, who are more inclined to favour condom use.
To help foster a climate in which girls can marry and have their first sexual relations later on in life, it will be important to raise popular awareness about the risks marriage poses to teenage girls, and encourage families to try to delay marriage for as long as possible. If families are unable to do this for economic reasons, efforts should be made to ensure that young brides have access to both reproductive and sexual health services, and stay in school. This will enable them to continue to develop skills that will help them support themselves and their families later in life, and help increase their self-esteem. An example from the multitude of studies that have found a link between level of education and safe sexual behaviour is a study carried out in four sub-Saharan African cities: Yaounde, Cameroon; Cotonou, Benin; Ndola, Zambia; and Kisumu, Kenya where a higher level of education was found to be strongly linked with condom use.
Meanwhile, there is an urgent need for guidelines to be established about the links between child marriage and HIV infection. National Aids strategies can then highlight these, and provide information to legislators that supports delaying the legal age of marriage. Even postponing a young girl’s marriage by one year could greatly reduce the likelihood of her becoming infected.
Access to sexual and reproductive health services remains a concern, especially in the developing countries, Worldwide, just one fifth of the people who need prevention services actually have access to them. This may be because there are no facilities nearby, or because they cannot travel to places where they do exist. Even if people can get to facilities, they may not be able to pay the fees charged. Moreover, girls and women may be reluctant to seek advice, for fear of stigmatization. They may also be deterred by the unhelpful and discriminatory attitude of staff in some centres. It will therefore be critical to remove some of the obstacles that keep women and girls away from sexual and reproductive health services. Sensitization programmes could help reduce stigma, for example, and training activities for health service staff could make services more user-friendly.
HIV prevention strategies must also meet the needs of women living with HIV. Positive women need to be able to access sexual and reproductive health services, without fear of stigma and discrimination. When people living with HIV can feel comfortable about being open about their status and where they can receive counselling and treatment to keep them healthy for longer and have a safe and satisfying sex life, they are far less likely to pass the virus on to others.
At the same time, it will be important to help members of vulnerable groups with specific needs to access services. These include child brides and other groups of young people: those living with HIV, people working in the sex trade, men who have sex with men and injecting drug users. (Article credit: The Global Coalition on Women and Aids).