AIDS Alert International

World health community focuses on problems of women, HIV, and violence for 2005

Women comprise nearly half of epidemic

World health officials are focusing in 2005 on improving intervention and prevention programs that target women, particularly young women, who appear to be shouldering some of the heaviest burdens of the epidemic in sub-Saharan Africa.

By the end of 2004, the number of women infected with HIV amounted to about 45% of the total HIV cases worldwide. In the epidemic’s epicenter of sub-Saharan Africa, women represent almost 57% of the total HIV cases; and 76% of people ages 15-24 years who are infected with HIV are female.1

"In a nutshell, women are making up 50% of the people living with HIV, but the main new finding is that in every single region, the percentage of women among people living with HIV is going up," says Peter Piot, MD, executive director of UNAIDS of Geneva.

Piot spoke in preparation of World AIDS Day on Dec. 1, 2004, addressing the current state of the world’s AIDS epidemic.

"This is an emerging pattern that we had seen first in Africa, in sub-Saharan Africa, but it’s now confirmed in about every region . . . , and we’re also [seeing] trends over fairly long periods, over basically two decades in this report," he says.

The trend has profound implications for the future of the epidemic, Piot adds.

"One, we’ve got to really put women at the heart of the response to AIDS if we’re going to stop this epidemic," he says. "And secondly, we need to go beyond ABC in terms of HIV prevention."

Violence prevention needed

HIV interventions targeting women need to include violence prevention and access to basic education and employment opportunities, says Karen Stanecki, MPH, senior advisor on demographics and related data in the department of social mobilization and information for UNAIDS.

She also is the chairwoman of the Monitoring the AIDS Pandemic (MAP) Network. Stanecki spoke with Piot as part of UNAIDS’ World AIDS Day activities.

Microbicide research also needs to be a chief focus in the search for ways to reduce the rate of HIV infection among women, she adds.

"Infection rates among young women are especially high," Stanecki points out. "Millions of young people are becoming sexually active each day with no access to prevention services, and young women are about three times more vulnerable to HIV infections than their male counterparts."

HIV/AIDS researchers and world health officials cite the lack of empowerment as a main reason for the high infection rate among young women in sub-Saharan Africa and other developing nations.

"The empowerment of women is an essential step," says Allan Rosenfield, MD, dean of the Mailman School of Public Health at Columbia University in New York City.

"Many women, particularly those in their teens, have little ability to refuse sexual activity in some [regions] or to insist on condom use," he explains. "Women’s groups in these countries will play an increasingly effective role in this regard."

This is why the development of a microbicide would be a major step forward in allowing women to protect themselves when their partner refuses to use a condom, Rosenfield adds.

"Unfortunately, an effective microbicide is at least five years away," he notes.

"In the interim, much more attention needs to be given to the use of female condoms, when the partner refuses to use condoms," Rosenfield points out.

Another issue is that women often lack access to existing HIV/AIDS prevention and treatment programs in developing nations, Piot continues.

The World Health Organization (WHO) is collecting data on who has access to antiretroviral therapy, but anecdotal evidence suggest that women are shortchanged, he adds.

"Just one example: I was, a month ago, in Addis Ababa in Ethiopia; and I visited . . . a hospital [that is] one of the few centers [that is] providing antiretroviral therapy," Piot says. "And I asked, Out of about 1,500 [patients], how many are women?’ And the answer was about one-third, 30%."

However, in Ethiopia, women comprise about half of the HIV epidemic; so at least in that area, there was inequity in how treatment was dispersed, he notes.

Since the treatment at the hospital in Addis Ababa was not free, it would mean that either women lack the money to pay for their HIV treatment or their husbands are not willing to pay for it, Piot adds.

Treatment access a key factor

When clinics in sub-Saharan Africa offer free access to treatment, then they have better success in getting more women to receive care, Stanecki says.

"But when we look at any of these centers that do have some kind of fee for service, even if it’s just minimal, then right away, the majority of the people who are getting treatment are men," she explains.

Even in Uganda, world health officials investigating HIV treatment access found that less than 30% of the people receiving treatment were women, Stanecki adds.

There are several infrastructure improvements that need to be made in sub-Saharan African to reduce the HIV risk young women face, Piot and Stanecki say.

"One is a legal framework that doesn’t exist in most countries," Piot explains.

For example, rape is against the law when it’s outside marriage, but it’s not against the law when it’s the husband raping the wife, and data suggest marital/partner rape is a major factor in the epidemic, he says.

"Secondly, we really have to link up with programs to keep girls in school," Piot says. "That’s obviously necessary even without an AIDS epidemic, but in the case of AIDS, that is becoming key."

Third, the world health community now is getting into the issue of alleviating the consequences of the AIDS epidemic as it pertains to property and inheritance rights for women, he says.

"When a woman loses her husband because he died from AIDS, and she may be infected, she also often loses everything — her house, etc., and all the property," Piot explains. "This really is not only pushing her into extreme poverty, but puts her at risk for HIV because she often has only her body to sell."

With more funding for free HIV treatment and prevention, women’s access would likely improve, officials say.

AIDS funding for developing countries is about $4 billion short of what is needed, but another challenge is to put the available money to the most efficient use, he says.

"The key challenge now is to make that money work and to make sure that it’s used for evidence-based prevention and treatment programs and that it’s getting to the communities," Piot continues. "So in other words, we need still to increase the funding."

One size does not fit all

An example of how a one-size-fits-all attitude toward HIV prevention is not efficient or successful for all populations is the ABC prevention program, which stands for Abstinence, Be Faithful, Use Condoms.

While it may be working in some areas and with some populations, it’s not an adequate prevention strategy for young women and girls because of their lack of power, says Desmond Johns, MD, director of the UNAIDS New York Office in New York City.

"No. 1, given the social dynamics of relationships, it’s not within the control of young women or girls to abstain — that decision is taken by her partner," he explains.

"She cannot be faithful all on her own when it’s the male partners who are unfaithful or have other high-risk behavior."

Likewise, women have no control over their partners’ use of condoms, Johns adds.

"Young girls and women cannot insist their partner uses a condom if the women have reason to think he’s being unfaithful," he says. "So the ABC approach is not sufficient for girls."

The classic prevention approaches have to be expanded, Piot says.

"These interventions cannot happen in a vacuum and ignoring social context, the context of gender and equality," he says.

"The [AIDS epidemic] report highlights the need to address sexual violence, which is particularly affecting women, and where we see a direct link between this violence and death through AIDS, education opportunities, and inheritance laws."

Addressing societal issues

One obstacle is that it’s difficult to address the issue of male violence and sexual violence, Piot says.

"So what it really shows is that in addition to the AIDS-specific interventions, we’ll have to add some quite serious action to change societal norms," he explains.

"And in this case, it should be not acceptable that there is sexual violence against women, that it is not acceptable that as a societal norm that you have older men who can just exploit girls and that the girls need that or do that because they need a school uniform."

While no one expects that the solution to AIDS is to first solve the problem of poverty, there are steps that need to be taken, Piot says.

"I think all of these examples show that AIDS is a disease, but it cannot be solved by approaching it only as a public health issue," he adds. "It really requires a quite broad development approach and societal approach, but it will be more difficult."

Reference

1. UNAIDS/World Health Organization. AIDS Epidemic Update: December 2004. Annual report released Dec. 1, 2004; 1-30.