By the year 2000, women will comprise half of the 30-40 million people infected with HIV and approximately one-third of their children will also carry the virus. Women are biologically more vulnerable to HIV infection and their lower social and economic status increases their risk of infection. An increasing number of adolescent girls and women are becoming infected with HIV and they are becoming infected at younger ages than men. WHO estimates that half of all infections to date have been in 15-24-year-olds, with a female-to-male ratio of 2 to 1 in this age range.
Despite this, little has been done to identify, analyse and document interventions and programmes that specifically target women, or that target men and young people with the aim of promoting reproductive health, including prevention of HIV/AIDS/STD. As a step in this direction, a meeting was held to look at interventions, approaches and strategies that provide examples of ways in which the transmission of HIV to women might be prevented by directly or indirectly empowering women to protect themselves.
Organized around four themes, a total of thirteen presentations were made and discussed. This report summarizes them, highlights the lessons learned from each, and draws general conclusions. The first two themes include activities that are HIV/AIDS/STD-specific and that span a range of settings (e.g. communities, workplaces, schools), particular needs of different women (e.g. young girls, women in stable partnerships, and women who are especially vulnerable to infection), and epidemiological profiles of HIV transmission (e.g. highly concentrated or diffuse). The third and fourth themes broaden the perspective by giving examples of health, social and economic interventions for women that are empowering because they are sensitive to women’s needs, and provide women with basic skills as well as opportunities to use them. The meeting closed with the presentation of a programme that reaches out to men and encourages them to share responsibility with women for contraception and disease prevention.
Theme 1: Effective approaches to HIV/AIDS prevention in women through the promotion of safer sexual behaviour. In Botswana, a community/workplace-based peer education and social support group intervention was undertaken by a women’s NGO which has members in all towns and villages in the country. Due to its success in providing information about HIV and increasing condom use among women, the intervention is now being expanded within Gabarone and to other urban areas. In Thailand, where migration of young women from urban to rural areas is common and puts them at greater risk for STD/HIV, education interventions targeted at single migratory female factory workers were implemented and evaluated, showing promising results. In Mexico, the USA and Puerto Rico, female partners of injecting drug users were reached through an intervention intended to empower and enhance their lives and led to a reduction in unsafe sex practices. Finally, reproductive health education and services for adolescents, including HIV/AIDS/STD prevention, have been offered to over 600,000 young people in Mexico by the national family planning association, through schools, in factories, on the street and through the radio.
Theme 2: Effective approaches to HIV/AIDS prevention through STD care and condom promotion. According to data on reported sexual behaviour, condom use, and declining STD incidence, outreach efforts in communities of single women in low-income areas of Bulawayo, Zimbabwe, are having an impact. Men whose behaviour contributes to rapid HIV transmission are also targeted (e.g. men with highly mobile life-styles, men who visit sex workers in bars and men who seek STD care). In India, three simultaneous approaches were adopted to reach the most vulnerable sex workers in a red-light district in Calcutta: early diagnosis and treatment of STDs; condom distribution; and IEC activities through peer educators. A key to the project’s success was the ability of peer educators and project implementors to impart a sense of self-respect and dignity to the sex workers. Making condoms accessible to all women is the aim of a new and innovative condom promotion/condom social marketing campaign in Haiti. Condoms are being made accessible and attractive through well-designed packaging and marketing through female street vendors specializing in products for women.
Theme 3: Experience from other fields: implications for HIV/AIDS prevention. There exists a wealth of information on interventions to empower women through providing basic health, social and economic opportunities. An innovative postpartum programme in Tunisia provides more convenient and holistic services to women. The programme has succeeded in increasing clinic attendance and contraceptive use (particularly of condoms and spermicides). An important initiative to promote health (including STD/HIV prevention) through a literacy programme for women is taking place in Nigeria. An evaluation showed that the participants and their children benefited significantly from the combined functional literacy, health education and economic empowerment intervention (e.g. the death rates in children under 5 fell dramatically). In another example of empowering women, the credit programme of the Grameen Bank in Bangladesh gets to the heart of the matter. Evidence shows that the financial contribution of women to the family income has strengthened their bargaining position within the household and community, and their contraceptive use rates increased as did the nutritional status of their children. The Grameen Bank, whose clientele is over 94% women, is now operating in almost half the villages of Bangladesh.
Theme 4: Future directions: policies and large-scale programmes. Social norms and the policy environment play an important role in creating a climate that is conducive (or obstructive) to safe individual sexual behaviour, as well as to efforts to reach a large number of people with HIV prevention messages and interventions. A major initiative to impart information about STD/HIV to women in Myanmar has recently begun. It consists of partnerships between a variety of NGOs (including the largest national women’s organization with local affiliates), the government and UN agencies. These partners developed a national HIV/AIDS policy with broad objectives which was subsequently translated into specific goals, operational objectives and interventions that, if successful, will be replicable throughout the country. In Thailand, a policy has recently been enacted with the aim of discouraging girls from entering sex work through increased educational opportunities, vocational training, and IEC campaigns targeting their parents. In Colombia, the National Family Planning Association took a male reproductive health approach to reach men who needed, but were not using, services. Providing a mix of services in ‘male-sensitized clinics’, the programme clearly shows that while male reproductive health needs may differ from those of women, men are intensely interested in and will amply patronize services. A key message given in the clinics is the need for partnerships between men and women in terms of sexuality, avoiding the transmission of disease, and contraception.
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