Aids Alert International: Global concerns focus on the powerless women who are living with AIDS in the developing world

Microbicides might work where ABCs don’t

UNAIDS and other international organizations have been drawing attention in recent months to the plight of women in nations where HIV infection is pandemic and likely to continue the trend of disproportionately affecting women.

Half of the people living with HIV/AIDS worldwide are women, and in sub-Saharan Africa, women comprised 58% of all people infected with HIV by the end of 2003, according to the latest statistics from UNAIDS of Geneva.

Growing challenges

As women’s stake in the epidemic rises, so do the challenges facing groups that desire to improve HIV prevention among women.

What’s lacking is strong women’s leadership on the issue of women and HIV, says Mary Robinson, executive director of the Ethical Globalization Initiative in New York City.

"At the grass-roots level, women’s organizations are dealing with this problem and are aware of it, but it hasn’t been sufficiently handled at the leadership level," she says.

For example, women’s leadership is needed to tackle the patriarchal traditions, such as property, marriage, and inheritance laws, that contribute to the overall powerlessness of women in many developing nations, she notes.

"You cannot come in from the outside and point a finger," Robinson points out. "You have to empower women in the village, and it’s they who will stop these practices, but that takes time and effort."

One result of traditions and governmental policies that discriminate against women is that young women report high rates of sexual violence both in and outside of marriage.

Between 20% and 50% of all girls and young women across the world report that their first sexual encounter was forced, a reality that makes it difficult to envision that the currently popular ABC prevention policy ("Abstinence, Be wise, and use Condoms) could be effective in the lives of most at risk women.

Women infected by their husbands

The ABC policy also ignores the plight of married women who are faithful to their husbands, but are powerless to ask that he wear a condom even when he is known to have acquired HIV infection.

"When we look at the ABC strategy, it’s not going to empower women to prevent HIV infection because many women do abstain, and they say their sole sexual experience was with their husband," says Bella Matambanadzo, executive director at the Zimbabwe Resource Center and Network in Harare.

"These women say, I was a virgin when I got married, and now I’m HIV-positive,’" she says. "They say, I was wise. I waited, got married, so are you telling me that I was unwise?’"

Other problems that contribute to HIV risk are unreported cases of rape and sexual violence within families and the social coercion that exists in societies where men have all of the money and power and women have little or none.

"What we publicly know exists is the sugar daddy phenomenon," Matambanadzo says. "It’s something that happens in our society where older men have the three C’s: cell phone, car, and cash."

These men attract young women, including teenagers, into relationships in which they have too little power to negotiate about sex, she explains.

"The vast majority of infections of HIV within the 18 to 24 age group are among women, so we can extrapolate that this is from relationships with much older men," Matambanadzo notes. "Boys in the same age bracket have rates of four to five times less HIV infection."

Another cultural trend is rape within families, including marital rape, she says.

Risky traditions

For instance, in some places in Zimbabwe, there is a tradition in which the father of a son who has just married will have sex with his son’s new wife to ensure that she came to the marriage a virgin, Matambanadzo adds.

"So if the father is HIV-positive then it exposes his daughter in law and son to HIV infection," she says. "This happens in pockets of the country — it’s not common and it doesn’t happen in the city, but I know it happens in certain areas of the country."

Essentially, what it all boils down to is that there are very few women of any age or stature who can claim that they have autonomy over their bodies and over their sexual experiences, Matambanadzo points out.

This fact makes microbicides an attractive potential HIV intervention.

"Microbicide [gels] are very much like lubricated sex," she says. "It can be a secret; you don’t have to show it to your partner or negotiate its use."

The key to microbicides is that they’re women controlled, says Nancy Padian, PhD, a professor of obstetrics, gynecology, and reproductive sciences and the director of international research for AIDS Research Institute at the University of California, San Francisco.

"Condom use works, but there are many instances where women can’t negotiate condom use with a male partner," she says. "So we absolutely need tools that women use themselves to protect themselves against HIV."

The only other women-controlled alternative is the female condom, but that has had a number of drawbacks that seem to have kept it from being a major factor in HIV prevention in the developing world.

For one thing, the female condom’s ability to attract investment and attention has been hampered, Robinson says. "Because it’s directed to women, it seems to be a poor market and there’s not the investment in pricing and marketing to make it accessible, and that’s why we need an effective microbicide," she adds.

Using a microbicide is easier and more clandestine than a female condom, Padian notes.

And, at least in Zimbabwe, the female condom is 10 times more expensive than male condoms, and it has a stigma that, ironically, was acquired during the clinical studies in the early 1990s, Matambanadzo says.

"In the studies, they used sex workers as research subjects, so the female condom gained a lot of stigma," she explains.

However, inexpensive and marketable microbicides for women in developing countries probably are five to 10 years away and several hundred million dollars from being a reality, according to UNAIDS and microbicide experts.

This is why the Ethical Globalization Initiative (EGI) and UNAIDS are pushing for greater women’s leadership in the fight against HIV.

In February 2004, UNAIDS launched the Global Coalition on Women and AIDS to address the impact of AIDS on women and girls worldwide.

EGI also has been working to bring together a council of women leaders that includes women prime ministers and presidents, as well as women who head various governmental agencies, Robinson says.

Finding common ground

Women leaders from various cultures and countries can find common ground in the realities of HIV, women, and women’s lack of interpersonal and political power.

For example, women might agree that the ABC intervention strategy works on principle, but not if a woman lacks a willing partner or if she is raped, Robinson says.

Robinson, who has attended conferences with women across the globe, including sub-Saharan Africa, India, China, Eastern Europe, and Central Asia, says the cultural challenges are very similar worldwide.

For instance, in the Mideast, which often is overlooked in the international AIDS community, more women are infected than men, and the epidemic still is seen as a minority issue rather than a health problem that could impact the general population, she says.

"The issues are extremely grave, and it requires women’s leadership," Robinson says. "And I’m glad there’s a global coalition, and I’ll do everything I can as part of it."