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UNFPA - United Nations Population Fund

State of World Population 2005

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CHAPTER 4

Reproductive Health: A Measure of Equity

Reproductive Health:
A Measure of Equity

-Maternal Death and Disability

-The Feminization of HIV/AIDS

-Reaping the Rewards of Family Planning

The Feminization of HIV/AIDS


Increasingly, "the face of HIV/AIDS is a woman's face".(39) Women have greater susceptibility than men to infection due to social, cultural and physiological reasons, and are now being infected at a higher rate than men. Though the epidemic initially affected mostly men, today approximately half of the 40 million people living with HIV are women. The highest female infection rates are in countries where the epidemic has become generalized and where transmission is primarily heterosexual, often in the context of marriage. (40) Fifty-seven per cent of all people living with HIV in sub-Saharan Africa and 49 per cent in the Caribbean are women, with young women facing the highest risks (see Chapter 5).(41) Seventy-seven per cent of all HIV-positive women in the world are African.(42)


"The toll on women and girls. presents Africa and the world with a practical and moral challenge, which places gender at the centre of the human condition. The practice of ignoring gender analysis has turned out to be lethal."

- Stephen Lewis, UN Secretary-General's Envoy to Africa, Barcelona International AIDS Conference


AT THE EPIDEMIC'S CORE: POVERTY, VIOLENCE AND GENDER DISCRIMINATION. Gender discrimination, poverty and violence lie at the centre of the AIDS epidemic (see Box 13). Physiologically, women are at least twice as likely as men to become infected with HIV during sex.(43) Women and girls are often illinformed about sexual and reproductive matters and are more likely than men to be illiterate. They often lack negotiating power and social support for insisting on safer sex or rejecting sexual advances. Genderbased violence is a major risk factor for contracting HIV (see Chapter 7). In addition, poverty forces many women into subsistence sex work or transactional relationships that preclude negotiating condom use. Often these women are unable for economic reasons to leave a relationship, even if they know their partner has been infected or exposed to HIV.(44) Some harmful practices-such as female genital mutilation/ cutting, child marriage, and "widow inheritance" (the union of the widow to a relative of the deceased husband)-compound women's risks.

Many people are still unaware of how to protect themselves from HIV. Only about 8 per cent of pregnant women and 16 per cent of sex workers worldwide were reached by prevention efforts in 2003.(45) Though most countries, including those in sub-Saharan Africa, have adopted national strategies to combat the epidemic, millions of women and men-indeed, the vast majority-are still without services or treatment.

GENDER MATTERS. Gender-sensitive approaches to preventing HIV are central to halting the epidemic. They can also catalyse broader social transformation. Women can gain more control in decisions affecting their lives with the support and cooperation of male partners, providers, communities and governments. Young men who learn to respect women and understand their responsibilities in halting HIV/AIDS are more likely to use a condom. Husbands can be enlisted to protect their wives and future children against HIV and other sexually transmitted infections.

Preventing HIV among women of childbearing age is crucial. Voluntary family planning should be integral to any and all strategies to halt the epidemic: Ethics and human rights demand that women who are HIV-positive can make informed family planning choices, including to prevent unwanted pregnancy. Access to antiretroviral treatment can help safeguard a woman's well-being and prevent the tragedy of HIV transmission to her children.

Prevention, care and treatment programmes have gradually opened up discussions on gender, sexuality and reproductive issues. In 2004, UNAIDS launched the Global Coalition on Women and AIDS, a worldwide alliance of civil society groups, networks of women living with HIV/AIDS, governments and UN organizations. Its platform calls for education, literacy and economic rights for women; equal access to antiretroviral treatment; access to sexual and reproductive health services; changes in harmful gender stereotypes; and zero tolerance for genderbased violence.(46)

13    |    HIV/AIDS: WHAT DOES GENDER HAVE TO DO WITH IT?

About three quarters of all new HIV infections are sexually transmitted between men and women. The attitudes and behaviours of men are critical to prevention efforts: Men hold overwhelming power in decisions on sexual matters, including whether to use condoms. In many societies, women are expected to know little about such matters, and those who raise the issue of condom use risk charges of being unfaithful or promiscuous. Violence against women and adolescent girls, and the fear of it, further erode women's negotiating position.

  • AIDS emerged in the 1980s as a disease that primarily affected men; but the proportion of infected women compared to men has risen steadily, from 35 per cent in 1990 and 41 per cent in 1997, to 48 per cent in 2004.


  • Among HIV-positive women, many are married and have had only one partner-their husbands.


  • In parts of Africa and the Caribbean, the two regions with the highest HIV prevalence, young women (ages 15 to 24) are up to six times more likely to be infected than young men their age.


  • Young women are the most affected group in the world: They represent 67 per cent of all new cases of HIV among people aged 15 to 24 in developing countries. In sub-Saharan Africa, young women represent 76 per cent of young people living with HIV. Up to 38 per cent of unmarried adolescents ages 15 to 19 years have engaged in sex for money or goods in some sub-Saharan African countries where AIDS is rampant.

Marriage: Safety or Risk for HIV?

Most people think marriage is "safe", but in many places it poses significant risks of HIV infection for women. The following figures, from both national studies and smaller-scale surveys of women, are indicative:

  • More than four fifths of new HIV infections in women occur in marriage or long-term relationships with primary partners.


  • In sub-Saharan Africa, an estimated 60 to 80 per cent of HIV-positive women have been infected by their husbands-their sole partner.


  • At least 50 per cent of Senegalese women living with HIV reported only one risk factor-living in a "monogamous" union.


  • In Mexico, more than 30 per cent of women diagnosed with HIV discover their status after their husbands are diagnosed.


  • In India, some 90 per cent of women with HIV said they were virgins when they married and had remained faithful to their husbands.


  • In Cambodia, 42 per cent of all new HIV infections occur from transmission by husbands to their wives. One third of new infections are to the babies of these women.


  • In Thailand, 75 per cent of women living with HIV were likely to have been infected by their husbands.


  • In Morocco, up to 55 per cent of HIV-positive women were infected by their husbands.


  • Studies show that married women would often rather risk HIV infection than ask their husbands to use a condom, thereby confronting them over infidelity. In two districts of Uganda, only 26 per cent of women said it was acceptable for a married woman to ask a husband to use a condom.

"I didn't understand how I, as a submissive woman, could be infected, having been faithful to the one man in my life."
- HIV-positive woman from Burkina Faso


It's Not as Simple as "ABC"

The "ABC" approach to HIV prevention counsels people to Abstain from sex, Be faithful to one partner, or use Condoms. ABC programmes have indeed expanded awareness. However, unless both women and men can make free and informed decisions, "ABC" messages may overlook critical factors that millions of women must confront:

  • Can an adolescent girl insist that her older husband use a condom or be faithful?


  • Can a battered woman who depends on her partner or husband to support her and her children raise the subject of fidelity or condom use?


  • Can a young wife insist on condom use when she is pressured to produce a child in order to be accepted by her new husband and in-laws?


  • Can a sex worker struggling to feed her children refuse a client who does not want to use a condom, especially if he pays twice or more the usual rate?


  • Can an adolescent girl who is sexually coerced or raped protect herself from infection?


  • Does counselling abstinence until marriage keep young people safe when most are sexually active before they turn 20?

Disproportionate Vulnerabilities, Disproportionate Burdens

Women and adolescent girls face high risks of HIV infection. They also provide much of the care for others who have acquired or are affected by the disease, including husbands and orphaned children. Women and girls represent 75 per cent of those caring for people living with AIDS. Taking care of the sick erodes the ability of women to generate income, thus limiting their opportunities for economic participation. The impact is especially severe in countries where women comprise the majority of farmers and produce most of the food. In the United Republic of Tanzania, women caring for sick husbands spent half as much time farming as they had previously. The loss of a husband's income, the costs of health care for ill relatives, and additional responsibilities can plunge women and their children deeper into poverty.

Women with AIDS are also the last and least likely to seek or receive care. By the time a husband dies, family resources have usually dwindled to the point where women are either unable or unwilling to seek medical care. Inheritance laws and customs that favour the husband's relatives may leave widows and their children impoverished. The additional financial pressure may force women and girls into exploitative and risky sex work or relationships, further fuelling the epidemic. See Sources


REPRODUCTIVE HEALTH AND RIGHTS OF HIV-POSITIVE WOMEN. Most HIV-positive women in developing countries have no access to antiretroviral treatment, neither for themselves nor to prevent transmission to their children. In addition, many assume that HIV-positive women will not have sexual relations and should not have children.(47) As a result, these women are often denied information and services to prevent pregnancy and mother-to-child HIV transmission, as well as access to quality prenatal and obstetric care. In societies where women are expected to produce children, HIV-positive women who opt to have none must contend with both the social disapproval of being childless and the suspicions and prejudice surrounding their status. Protecting the reproductive rights of HIV-positive women, including preventing coerced abortions or sterilization, is a critical human rights issue.

The International Community of Women Living with HIV/AIDS, created to address the lack of support provided to HIV-positive women, has led a Voices and Choices initiative in Central America, West Africa, Thailand and Zimbabwe that promotes women's rights to sexual and reproductive health.(48) In Argentina, FEIM, a leading women's NGO, disseminates the women's Bill of Rights developed at the 2002 International AIDS Conference and trains health personnel on human rights and contraception for HIV-positive women.(49)

In Kenya and South Africa, the "Mothers 2 Mothers 2 Be" project links HIV-positive new mothers with HIV-positive pregnant women for advice on issues from family planning to income generation.(50) Such "peer-led" counselling has helped HIV-positive women understand their reproductive health options and to cope with the challenges they face.

14    |    TRANSFORMING LIVES IN SWAZILAND

In the drought-stricken Lumombo region of Swaziland, women's active role in food distribution has led to benefits for the whole community. Non-governmental organizations supported by UNFPA and the World Food Programme trained women who led food distribution projects to address issues affecting the rural poor: sexual abuse, exploitation, AIDS and family planning. Community Relief Committees, which were 80 per cent women, reached out to men through discussion on these issues in community meetings, on food distribution days, at church, during home visits and when visiting the sick.

The project resulted in increased reporting to police by women and children of sexual abuse, a surge in requests for HIV testing, and a ten-fold increase within a year in the number of people receiving antiretroviral treatment. One major success is that rural leaders now give women authority to speak in community meetings-which is unprecedented- because women are seen not only as food distributors but also as sources of knowledge.

"I have never felt so important in my community. Before I was chosen to be a member of the food distribution committee, I was a nobody, and now people come to me for advice and help," said a woman who is now a recognized community leader.


WOMEN'S ACCESS TO HIV/AIDS TREATMENT. Programmes to prevent mother-to-child HIV transmission provide the only access to antiretroviral drugs for many HIV-positive women. In developing countries, most programmes focus on preventing transmission to the child and offer no benefits to the mother. In 2003, only 2 per cent of pregnant women testing HIV-positive worldwide received antiretroviral drugs to improve their own health.(51) In Africa, only 5 per cent of pregnant women are offered HIV prevention services.(52) Some emerging programmes emphasize the health and well-being of both child and mother.(53)

For wealthy people living in wealthy countries, antiretroviral drugs have largely transformed HIV into a manageable, chronic disease. But only 12 per cent of people in low and middle-income countries had access to treatment by the end of 2004.(54) Concerned that women, especially those not pregnant, might be denied access to treatment as it becomes available, women's groups, WHO and UNAIDS have called on governments to set national targets for equal access.(55)

SHAME, BLAME AND AIDS. Stigma kills. The shame associated with AIDS is a major obstacle to its prevention, and the stigma that surrounds people living with HIV is compounded by discrimination against women. Hundreds of thousands of HIV-positive women avoid testing and treatment services for fear of abandonment and other repercussions from husbands, families, communities and health providers.(56) Lack of confidentiality in testing services is a well-grounded concern. Women sometimes discover their HIV status last-after their husbands or in-laws.(57) Only 5 per cent of HIV-positive people are aware of their status,(58) and testing during pregnancy is often the only way that a family learns of HIV in its midst. Even if they contracted HIV from their husbands, women are sometimes blamed for "bringing AIDS home" and may face violence or ostracism as a result.(59) Health care providers sometimes deny HIV-positive women proper care during and following delivery. Women may refuse or discontinue treatment after negative interactions with staff.(60)

Many developing countries are combating stigma by opening up discussions about the disease, a key step in encouraging people to seek testing and treatment. One such programme supported by UNFPA is a regional initiative in seven Arab States on HIV awareness-raising. In Uzbekistan, a popular television soap opera airing since 2003 focuses on issues encountered in daily life, including substance abuse, HIV prevention and discrimination against people living with HIV/AIDS. In eight African and six Asian countries, UNFPA supports partnerships between radio networks and communitybased health organizations to produce dramas on HIV and AIDS.(61) Multiple partners are supporting many similar initiatives across the developed and developing world, using the mass media and community-based dialogue to overcome the shame and discrimination that perpetuates the epidemic.

THE OTHER EPIDEMIC-SEXUALLY TRANSMITTED INFECTIONS. Sexually transmitted infections (STIs) and reproductive tract infections are among the most common causes of illness worldwide. An estimated 340 million new cases of curable STIs are reported every year.(62) When incurable infections (including HIV) are taken into account that number effectively triples. Women are more susceptible than men to these infections, for sociocultural and physiological reasons, and disproportionately suffer severe consequences, including cervical cancer and infertility. About 70 per cent of women with STIs present no symptoms (compared to 10 per cent of men),(63) making diagnosis in women more difficult. When symptoms do appear, women tend to accept them as unimportant.(64) The presence of STIs can also increase the risk of HIV infection two to nine times.(65) Yet only 14 per cent of people with STIs in sub- Saharan Africa had access to treatment in 2003.(66) In addition, because sexually transmitted infections, including HIV, are most prevalent among young people, preventing these infections can have long-term benefits for the labour force and lead to higher productivity.(67)

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