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close this bookEffective Approaches for the Prevention of HIV/Aids in Woman (PAHO, WHO; 1995; 62 pages)
View the documentExecutive summary
View the document1. Introduction
View the document2. Opening of the meeting
close this folder3. Women and HIV/AIDS
View the document3.1 The global epidemiological situation
View the document3.2 Current state of vaccine development
View the document3.3 Current research on female-controlled methods
View the document3.4 An overview of key social and economic factors contributing to women’s vulnerability to HIV/AIDS
View the document3.5 Consultation for policy-makers on women and AIDS in preparation for the Fourth World Conference on Women
Open this folder and view contents4. Effective approaches to prevention of HIV/AIDS in women
Open this folder and view contents5. Experiences from other fields: implications for HIV/AIDS prevention
Open this folder and view contents6. Future directions: national policies and large-scale programmes
View the document7. Overall conclusions
View the documentAppendix 1 - Agenda
View the documentAppendix 2 - List of participants
View the documentAppendix 3 - List of background papers
View the documentAppendix 4 - Selected reading list

3.4 An overview of key social and economic factors contributing to women’s vulnerability to HIV/AIDS

As the proceeding sections have shown, women are becoming infected with HIV at increasing and alarming rates. The prospects for developing vaccines in the short term are! poor and research on microbicides has a long way to go. Clearly, for years if not decades to come, we will have to continue relying on both individual behaviour change as well as on the eventual adoption of safe practices by those not yet sexually active, to reduce HIV transmission among women. But individual options and actions are influenced by broader forces. Ms S. Cherney outlined the social, cultural and economic factors which determine women’s vulnerability to HIV.

There are enormous differences in social, cultural and economic contexts which constrain or enhance acquisition of knowledge about AIDS, understanding of HIV transmission, motivation for self-protection, and ability to take preventive action. Many cultures do not grant “social permission” to talk about sexuality to children, and in particular to girls. This limits what girls can learn not only at home but also at school. However, even in situations where HIV/AIDS prevention education is provided at school, girls are at a disadvantage compared to boys because their schooling is often curtailed by pregnancy, domestic responsibilities, or lack of financial resources.

Even assuming that she knows about HIV transmission, a girl will need the motivation to take action. She needs to be convinced that she can take action. But what does it do to a girl’s self-esteem and confidence when her culture tells her that males take the lead in sexuality and are aggressive in pursuing sex, while females are meant to be passive? There are many countervailing pressures to a girl’s assertiveness in sexual decision-making and yet for girls in most cultures, sex is supposed to be their bargaining chip, the currency in which they are expected to pay for life opportunities. For example, while boys who need to find their own school fees may engage in petty trade, girls, who are brought up to see their attractiveness to men as their main asset, frequently exchange sex with older men for this purpose. Furthermore, girls are more often confronted by the problem of having to find school fees as parents are more willing to invest in boys’ than in girls’ education.

Assuming that a girl does have the necessary information and motivation to protect herself through condom use, where is she going to get the money to buy them? In general, adolescents are the group for which condom social marketing is least effective because they find even subsidized condoms unaffordable.

Perhaps a girl wishes to protect herself through abstinence. Here too, social and cultural factors may make this impossible. Forced sex, like child abuse, is a hidden social phenomenon, but we are beginning to learn more about the extent of it among girls. Rape is common in school settings, and sex may be forced even in the home. Two recent studies from Latin America of teenage mothers under 16 showed that the majority of them had been raped and many were victims of incest. Tragically, in the AIDS era rape has consequences even more “final” than pregnancy.

Some girls are forced into sex work from an early age, starting prior to puberty. In some cases, the parents themselves sell their girl children. There are areas in the world where this has become a lucrative trade. Even when there is no outright sale, girls themselves must sometimes turn to prostitution to survive - for example, street kids. Youngsters in such circumstances are often illiterate, their knowledge of AIDS is rudimentary or absent and their negotiating possibilities nil.

Grown women too may turn to sex work as their only real alternative to dire poverty -women whose choice of livelihood is limited, young women prior to marriage who often migrate in search of work in order to support their families in the villages, women whose lives have been disrupted by war or natural disaster, once-married women who have lost their partner to death or divorce (such women also commonly lose access to land and property, owing to discriminatory inheritance laws). Sex tourism is another aspect of the sexual exploitation of poor women, for example, by men from the industrialized world seeking sex without emotional demands, at extremely low prices. In addition, once infected with HIV, women are often abandoned by their husbands and may be forced into sex work to survive, thereby fueling the epidemic.

Like their younger sisters in prostitution, adult sex workers are often ignorant of HIV and its mode of transmission. Sex workers could turn to more experienced prostitutes for advice on working safely. However, many women exchange sex for money, food or shelter, with one or several partners, regularly or occasionally, in order to survive. They do not see themselves as prostitutes, may never discuss these issues with others and do not have access to advice from “formal” sex workers.

But even if they know about HIV, what then? The virus is just one of a host of threats to their well-being and survival, and by no means the most immediate. But the main factors in their vulnerability are their fear of asking clients to use a condom, lest they go elsewhere, and their inability to obtain consistent condom use. A prostitute is exposed so often, so repeatedly, that even an increase in client condom use from 30% to 50% may not save her life.

Between women who sell sex to survive and those who rely for their survival on a husband or another regular partner, there are innumerable intermediate forms of existence. But a vast and increasing number of women who are currently being infected with HIV are in stable relationships. Still the main AIDS prevention message for couples is that monogamy protects you. But monogamy for whom? While there are some cultures where extramarital affairs are tolerated for both sexes and some cultures where they are discouraged for both (with varying success), most cultures have a double sexual standard: women should be virgins or have had very limited sexual experience on marriage and monogamous thereafter, while for men both premarital and extramarital sex is tolerated or even expected.

AIDS has not changed the rules of the game. Not only is the woman supposed to leave the initiative in sex to her partner, but there is often no “social permission” for a discussion of sex between them. Worse still, she is not supposed to acknowledge knowing he has affairs, let alone mention them, because they conflict with the prevailing moral code. The same “conspiracy of silence” stops women from acting on the other major AIDS prevention message - use a condom. Suggesting that her partner should use a condom with her implies that she knows he has sex elsewhere (or, even worse, that she has transgressed) - and suggesting that he use them for extramarital affairs runs into the same problem.

Complicating the issues further, condoms - the only technology now available for HIV prevention - are not compatible with procreation. Childbearing brings fulfilment and, in many places, is women’s only path to social status. Condom use in a stable relationship, where the couple has not completed childbearing, is a nonsensical suggestion.

Finally, most women with a regular partner cannot escape the HIV risk by simply leaving the relationship. Divorce laws may deprive them of their possessions and children, and in any case they cannot afford to leave unless they have resources or income-generating potential of their own to support themselves and their children.

In summary, to the extent that women are educated about HIV/AIDS, they can protect themselves. To the extent that they have or can generate financial resources, they can survive without selling sex and without risking their life because of a husband’s extramarital affairs. To the extent that they live in a culture with some semblance of egalitarian ideology and openness about sexuality, they are not forced into a killing conspiracy of silence about sex, extramarital relationships, and condom use.

A survey in a developing country community once showed that 30% of the women interviewed believed they had no control over their relationship with their partner. This is frightening - but the other side of the coin is that more than two-thirds of the women felt they had at least some control. The challenge is to find out what makes the difference - and use those insights to help women empower themselves.

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