Annex 2
DFID'S NOTE ON GENDER AND HIV/AIDS
HIV/AIDS
There is evidence to suggest that gender roles
and relations influence:
— risk of infection;
— the burden of HIV/AIDS;
— diagnosis and treatment;
— state and health system responses.
Gender and risk of infection
Individual risks of HIV/AIDS infection are influenced
by knowledge, attitudes and practices and socio-cultural, economic
and political factors which limit an individual's options for
reducing risk. Both of these aspects are strongly influenced by
gender. In all societies, gender is important in determining what
women and men are expected to know about sexual matters, how they
are expected to behave and their attitudes in relation to sex:
— women and women are often poorly
informed about reproduction and sex and therefore risk and risk
reduction;
— men, rather than women are expected
to take the initiative in sexual matters, so women may face abuse
for trying to suggest preventive measures such as condom use;
— the high value on virginity in some
contexts may encourage older men to pursue younger women or it
may encourage unmarried women to have anal rather than vaginal
sex;
— rape, coercion and violence against
women have clear consequences for women's risk of HIV infection.
Social and economic circumstances may lead to
conditions of particular risk for both women and men and women's
ability to refuse sex or insist on condom use may be severely
constrained by their socio-economic position:
— high levels of male migration often
disrupts marital ties and encourages the growth of sex work in
centres for in-migration, leading to risk for male migrants, sex
workers and the partners of male migrants who become infected
on their partner's return home;
— the "feminisation" of the
labour force in some areas such as export processing in Newly
Industrialised Countries has led to women and adolescent girls
having their first sexual experiences younger, when they may not
be aware of the potential risks;
— in some contexts, women are forced
into sex work while in others they may take it up voluntarily
through economic necessity;
— women's bargaining position to negotiate
safe sex with husbands or other partners may be limited by their
socio-economic dependence on them;
— the importance of parenthood, both
to women's and men's gender identities and the importance of motherhood
in providing women with security, status and access to resources
discourages the use of barrier methods in many contexts.
A study in Senegal found that for 50 per cent
of women living with HIV/AIDS, their only risk factor had been
their monogamous sexual relationship with their husband or partner
(UNAIDS, 1999 Gender and HIV/AIDS: Taking Stock of Research Programmes).
Gender and the impact of HIV/AIDS
Gender also plays a significant part in how
women and men are able to cope with the epidemic, in terms of
social and economic impacts, burdens of care and accessing care
and support:
— in communities where women are responsible
for subsistence farming, if a woman becomes ill, the food security
of the household is severely affected. Similarly where men are
the main earners of cash, their illness will reduce the access
of the household to cash.
— available evidence suggests that
girls are more likely to be pulled out of school to cope with
a mother's illness.
— adolescent girls may be forced into
early marriage or sex work to support families.
— women may have lower access to resources
in the household for medical treatment than men.
A study in Kagera, Tanzania, found that households
tended to spend more on both medical and funeral expenses for
men than for women:
— men may face barriers to seeking
care where services are perceived as being directed towards women.
— the burden of caring for the sick
and orphaned in the household and community usually falls on women.
— women widowed as a result of AIDS
may be particularly vulnerable. Studies show that many women face
loss of social support from their family, ostracism by the community
and lack of legal protection to inherit land and property.
— where blame for the epidemic has
explicitly or implicitly been placed on women, violence and abuse
have been reported where women disclose their HIV status to partners
or communities
Gender and Quality of Care for HIV/AIDS
— much of the early knowledge of HIV/AIDS
was based on the effect of the virus on men. Until recently the
clinical definition of AIDS was based on male symptoms, and excluded
many gynaecological and other symptoms unique to women. Women
were excluded from the clinical trials of new drugs because of
the possibility of them becoming pregnant.
— women's groups in many developing
countries have found clear gender differences in advice given
during counselling. Women are more likely to be advised not to
have sex at all unless their partner is positive, whereas men
are told to practice safe sex.
— AIDS care policies have tended to
rely on individual patients to notify their partners of their
condition, and mandatory partner notification has been suggested
in some contexts although this may have severe negative consequences
for women.
— a culture of blaming women for the
epidemic has led to particularly hostile reactions to infected
women by health care workers.
— policies regarding pregnancy and
childbirth in the light of HIV have been prescriptive and often
unsupportive to women. For example because of the fears of transmission
to the foetus HIV positive women are usually advised to avoid
or terminate pregnancies. HIV positive women have also been discouraged
from breastfeeding despite evidence that the risk of transmission
is low. These policies are problematic in circumstances where
childbearing is important for women's status and access to resources
and where it is difficult to provide safe alternatives to breast-milk.
What can be done?
Short-term strategies may focus on meeting women
and men's immediate needs in specific communities, including:
— providing basic sexual health education
and information about risk and risk prevention which is provided
in a non-judgmental way and made accessible to neglected groups
such as adolescents;
— providing HIV pre-test and post-test
counselling and care programmes which make available information
about all aspects of living positively with AIDS, including sexual
relations and recognise women's potential problems with partner
notification;
— forming and supporting self-help
groups for people living with HIV/AIDS. Many self-help groups
provide holistic care in the community, including counselling,
information, health care, legal assistance (for example for workers
who are discriminated against, or widows who need to stake a claim
to land), income generating activities and micro-credit schemes.
Gender awareness in the development of policies
and programmes for AIDS control and care:
— all prevention and care programmes
should take measures to ensure the full participation of women
and men in their design;
— programmes which develop and support
community based or home based care need to recognise that care
has a cost and that it is usually carried out by women. Programmes
should identify how they can support women as carers and encourage
men to take on a more caring role;
— policies on pregnancy, childbearing
and breastfeeding should be informed by the fundamental right
to form a family and should recognise the importance of children
for women's position in society. Awareness of women's rights and
circumstances should be raised with health care workers. Information
on risk reduction in conception and pregnancy should be made available
to women.
In the longer term, measures to address the
gender aspects of risk include general long term measures to improve
women's position. Specific empowerment strategies which have been
pursued with relation to HIV/AIDS are:
— community work with women and men
challenging gendered norms, helping women and men to redefine
their relationships in a mutually beneficial way and developing
individual negotiating skills—see Stepping Stones case study.
— measures to improve women' access
to resources—eg through credit, marketing support.
Useful sources of information:
UNAIDS, 1999 Gender and HIV/AIDS: Taking
Stock of Research Programmes Gilks, C, Floyd, K, Haran, D,
Kemp, J, Squire, B, Wilkinson, D, 1998, Sexual Health and Health
Care: Care and Support for People with HIV/AIDS in Resource Poor
Settings. Liverpool School of Tropical Medicine, DFID Health
and Population Occasional Paper. Especially Appendix 2: HIV/AIDS
and Gender.
UNAIDS/KIT (Royal Tropical Institute Amsterdam)/
SAfAIDS (South Africa AIDS Information Dissemination Service),
Facing the Challenges of HIV/AIDS/STDS: a gender based response.
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