Gender not condoms: Refocusing strategies and popular conversations in HIV prevention
by Jossi Tinga
In Kenya the strategies and popular conversation on the spread of the Human Immunodeficiency Virus have focused on men and gender-neutral prevention strategies. However, infection trends indicate gender is a far more important issue in the spread of HIV than commonly acknowledged. Gender issues impact heavily on the consummation of sex in heterosexual relationships. Hence gender affects the possibility of HIV transmission in far more confounding ways than the popular conversation acknowledges. Gender is the overriding factor in the spread of HIV in Kenya.
Perhaps the most confounding aspect of the HIV pandemic is how it has affected women. Leolin Katsidzira and James G. Hakim of the Department of Medicine at University of Zimbabwe state, “More than two-thirds of people living with HIV globally are in sub-Saharan Africa, the majority in southern Africa (UNAIDS 2008). The HIV epidemic in the sub-region is generalised, hyperendemic and mature. Close to 60% of infected individuals are women, and even more women are indirectly affected. These gender differences are particularly stark in young people aged 15–24 years, where women are up to three times more likely to be infected.” In their paper published in the journal Tropical Medicine and International Health volume 16 no 9 of September 2011, they urge a reassessment of HIV prevention strategies. The paper titled is “HIV prevention in southern Africa: why we must reassess our strategies.
The finding that the HIV pandemic is increasingly being feminised is corroborated by Monica Akinyi Magadi writing in Sociology of Health & Illness 4 May 2011. She observes in her study, “The findings suggest that women in sub-Saharan Africa have on average a 60% higher risk of HIV infection than their male counterparts. The risk for women is 70% higher than their male counterparts of similar sexual behaviour, suggesting that the observed gender disparity cannot be attributed to sexual behaviour. The results suggest that the risk of HIV infection among women (compared to men) across countries in sub-Saharan Africa is further aggravated among those who are younger, in female-headed households, not in stable unions or marital partnerships or had an earlier sexual debut.” Women are being infected at higher rates yet they do not exhibit far more risky behaviour than men. On the contrary they are less adventurous but still more at risk.
Laura Lee of the Liu Institute for Global Issues at the University of British Columbia researches on public health, social medicine, anthropology and gender with a focus on marginalized children and youth. She cites data from The Kenya Demographic Health Survey 2010 in her paper Reducing HIV Rates Among Young Kenyan Women. It is published in the African Initiative an online portal supported by the South African Institute of International Affairs. The paper reveals that “despite the significantly higher prevalence rate among women in Kenya, however, the data also show that more men are sexually active than women. This trend is particularly pronounced for 15 to 19 year girls, 37 percent of which have had sex and carry an HIV prevalence of 2.7 percent, compared with 44 percent of boys who have had sex with a rate of less than one percent.”
The United Nations Programme on HIV/Aids in its AIDS Epidemic Update 2004 noted that “Many HIV strategies assume an idealized world in which everyone is equal and free to make empowered choices, and can opt to abstain from sex, stay faithful to one's partner or use condoms consistently. In reality, women and girls face a range of HIV-related risk factors and vulnerabilities that men and boys do not-many of which are embedded in the social relations and economic realities of their societies. These factors are not easily dislodged or altered, but until they are, efforts to contain and reverse the AIDS epidemic are unlikely to achieve sustained success.” Yet, the existing strategies still focus on prevention especially by mechanical means or abstinence as the cornerstone of HIV control.
Which way for woman?
Even in far more advanced societies which have achieved gender parity in many areas the unique challenges women face in negotiating safe sex has been observed. Gina M. Wingood and Ralph J. DiClemente of the Department of Health Behaviour, School of Public Health, University of Alabama, Birmingham writing in the American Journal of Public Health noted that “Gender-neutral interventions or interventions that do not (differentiate) between sexes, implicitly assume static "sex roles" while obscuring potentially modifiable social processes that influence women's risk of HIV infection. This approach to risk reduction fails to recognize the importance of social sexual relationships between women and men and how these relationships may adversely affect a woman's ability to adopt and maintain HIV-preventive behaviours. Relational factors, such as having the self-efficacy to communicate condom use, having a long-term relationship, and having a history of sexual abuse, have been repeatedly cited as major determinants of women's high-risk sexual behaviour. Effective HIV prevention efforts will need to change gender-based relational norms to support women's role in practicing safer sex.” In their well-researched letter published in April 1995 they sought to discount the thinking challenging the “compatibility of Acquired Immunodeficiency Syndrome (AIDS) prevention efforts and cultural sensitivity.” It is instructive that they too entered the conversation via the Letters to the Editor page. Clearly, the conversation on the prevention of the spread of HIV has been steeped against those advocating for far reaching changes in approaches.
Viewpoints and strategies on HIV prevention have relied heavily on existing medical techniques and approaches. Thus, the condom, invented for use by men has been portrayed as the silver bullet in the fight against HIV. It is possible that the condom has served men well. It found new relevance after its contraceptive and previous prophylactic uses were largely nullified by pharmaceutical means. Antibiotics rendered its early prophylactic uses somewhat redundant. Prior to the advent of pharmaceutical contraception, men routinely neglected to use it. Contraception only became practical when women got overriding control of the issue.
Prevalence rates among men in Kenya have fallen to a low of 4.3 percent. This compares with a rate of 8 percent for women. The national average is 7.1 percent. The national average has fallen from a high of 14 percent in 1999. Girls and young women between the ages of 15 and 24 have a prevalence rate of 4.6 percent. That is more than four times that of boys of similar age according to data published in Kenya Demographic Health Survey of 2010. The Survey is widely quoted by the National Gender and Equality Commission in its report titled, Gender, HIV and Acess to Health Care in Kenya. As much as the condom is effective in preventing infection, Kenyan women have little say over its usage.
The Gender and Equality Commission notes in its report that, “the subordinate status of women in Kenyan society means that many face substantial barriers to accessing education and paid employment. Furthermore, many women have limited control over productive resources such as land, and low decision making power concerning household resources. Their socioeconomic disadvantage and dependency affects their ability to make free and informed choices concerning their sexual and reproductive health and their access to relevant health services and information. Furthermore, it limits their negotiation power in sexual matters and makes them vulnerable to domestic violence and abuse. Lack of financial security and employment opportunities may also lead women and girls to engage in sex work or other forms of transactional sex, which enhance their risk of HIV infection.”
From the foregoing it is not a wonder that women continue to bear the brunt of the HIV/AIDS infection even as the epidemic stabilises. The recent introduction of the female condom and gels or microbicides promises women better tools in the fight against the pandemic. Katsidzira and Hakim acknowledge the promise of microbicides thus, “New female–controlled methods such as microbicides remain a priority,as they can potentially disrupt transmission to young women, altering the epidemic trajectory. Even though testing and treating is unproven, the theory is appealing, and this should sustain research efforts.” They believe the microbicides applied in the vagina prior to sex to help prevent infection can defeat the pandemic. They assume women will have information, ready access and the final say on whether to use the substances. Experience with the female condom suggests otherwise.
Monica Akinyi Magadi of the University of Hull’s Department of Social Sciences observed, “Although use of female condoms can substantially reduce the risk of acquiring HIV the price of the female condom (4–10 times that of male condom) makes it inaccessible to most women.” As Wingwood and DiClemente observed the decision to use any prevention method is negotiated. Where the woman has low negotiating power or cannot access the intervention, as demonstrated by the report by the Gender Commission, it is probably futile to give her new tools.
Katsidzira and Hakim while apparently pandering to the popular view that a medical solution is the best, acknowledge that “single-strategy preventive methods” have failed. They advocate a composite effort even though they give pre-eminence to biomedical approaches. Experience with existing medical solutions has shown them ineffective in protecting women from infection. “The ABC of AIDS” which preached Abstinence, Being faithful to one uninfected partner or Condom use has seen off the worst of the epidemic. That is, if you are a man. For Kenyan women, socioeconomic and cultural factors still predispose them to infection. They have little power to negotiate the use of preventive strategies. The only ways to make HIV prevention woman-friendly is to invent a vaccine or tackle the age-old issue of gender equality.
Katsidzira and Hakim, being men and doctors, enthusiastically embrace the vaccine option. Their partiality towards a pharmaceutical solution is evident despite their acknowledgement of technical barriers in the quest for a vaccine or effective microbicides. They declare “The ultimate HIV prevention weapon would be a vaccine.” They should have added a rider to the statement. It should read, “Everything being the same, the ultimate prevention weapon would be a vaccine.” The presumption is the underlying gender issues propagating the epidemic cannot be addressed easily. Indeed the AIDS Epidemic Update 2004 notes as much.
As the Epidemic Update emphasises, unless the underlying issues are addressed the threat remains. A newer, more virulent strain of the virus can exploit the underlying weakness to spark a resurgence of the epidemic. We remain vulnerable to similar pandemics due to the gender imbalance. The accruing benefits from addressing the imbalance will have multisectoral and cross-cutting benefits. The one good thing that the HIV/AIDS pandemic has done is to reveal the inter-connections between various cultural factors and socioeconomic indicators. Principally the pandemic has demonstrated that gender is the Achilles’ heel of our society. Heal the gender imbalance, and you heal the society of many ills and weaknesses- including HIV vulnerability. It may be the harder way but is certainly the sure way.
Even in far more advanced societies which have achieved gender parity in many areas the unique challenges women face in negotiating safe sex has been observed. Gina M. Wingood and Ralph J. DiClemente of the Department of Health Behaviour, School of Public Health, University of Alabama, Birmingham writing in the American Journal of Public Health noted that “Gender-neutral interventions or interventions that do not (differentiate) between sexes, implicitly assume static "sex roles" while obscuring potentially modifiable social processes that influence women's risk of HIV infection. This approach to risk reduction fails to recognize the importance of social sexual relationships between women and men and how these relationships may adversely affect a woman's ability to adopt and maintain HIV-preventive behaviours. Relational factors, such as having the self-efficacy to communicate condom use, having a long-term relationship, and having a history of sexual abuse, have been repeatedly cited as major determinants of women's high-risk sexual behaviour. Effective HIV prevention efforts will need to change gender-based relational norms to support women's role in practicing safer sex.” In their well-researched letter published in April 1995 they sought to discount the thinking challenging the “compatibility of Acquired Immunodeficiency Syndrome (AIDS) prevention efforts and cultural sensitivity.” It is instructive that they too entered the conversation via the Letters to the Editor page. Clearly, the conversation on the prevention of the spread of HIV has been steeped against those advocating for far reaching changes in approaches.
Viewpoints and strategies on HIV prevention have relied heavily on existing medical techniques and approaches. Thus, the condom, invented for use by men has been portrayed as the silver bullet in the fight against HIV. It is possible that the condom has served men well. It found new relevance after its contraceptive and previous prophylactic uses were largely nullified by pharmaceutical means. Antibiotics rendered its early prophylactic uses somewhat redundant. Prior to the advent of pharmaceutical contraception, men routinely neglected to use it. Contraception only became practical when women got overriding control of the issue.
Prevalence rates among men in Kenya have fallen to a low of 4.3 percent. This compares with a rate of 8 percent for women. The national average is 7.1 percent. The national average has fallen from a high of 14 percent in 1999. Girls and young women between the ages of 15 and 24 have a prevalence rate of 4.6 percent. That is more than four times that of boys of similar age according to data published in Kenya Demographic Health Survey of 2010. The Survey is widely quoted by the National Gender and Equality Commission in its report titled, Gender, HIV and Acess to Health Care in Kenya. As much as the condom is effective in preventing infection, Kenyan women have little say over its usage.
The Gender and Equality Commission notes in its report that, “the subordinate status of women in Kenyan society means that many face substantial barriers to accessing education and paid employment. Furthermore, many women have limited control over productive resources such as land, and low decision making power concerning household resources. Their socioeconomic disadvantage and dependency affects their ability to make free and informed choices concerning their sexual and reproductive health and their access to relevant health services and information. Furthermore, it limits their negotiation power in sexual matters and makes them vulnerable to domestic violence and abuse. Lack of financial security and employment opportunities may also lead women and girls to engage in sex work or other forms of transactional sex, which enhance their risk of HIV infection.”
From the foregoing it is not a wonder that women continue to bear the brunt of the HIV/AIDS infection even as the epidemic stabilises. The recent introduction of the female condom and gels or microbicides promises women better tools in the fight against the pandemic. Katsidzira and Hakim acknowledge the promise of microbicides thus, “New female–controlled methods such as microbicides remain a priority,as they can potentially disrupt transmission to young women, altering the epidemic trajectory. Even though testing and treating is unproven, the theory is appealing, and this should sustain research efforts.” They believe the microbicides applied in the vagina prior to sex to help prevent infection can defeat the pandemic. They assume women will have information, ready access and the final say on whether to use the substances. Experience with the female condom suggests otherwise.
Monica Akinyi Magadi of the University of Hull’s Department of Social Sciences observed, “Although use of female condoms can substantially reduce the risk of acquiring HIV the price of the female condom (4–10 times that of male condom) makes it inaccessible to most women.” As Wingwood and DiClemente observed the decision to use any prevention method is negotiated. Where the woman has low negotiating power or cannot access the intervention, as demonstrated by the report by the Gender Commission, it is probably futile to give her new tools.
Katsidzira and Hakim while apparently pandering to the popular view that a medical solution is the best, acknowledge that “single-strategy preventive methods” have failed. They advocate a composite effort even though they give pre-eminence to biomedical approaches. Experience with existing medical solutions has shown them ineffective in protecting women from infection. “The ABC of AIDS” which preached Abstinence, Being faithful to one uninfected partner or Condom use has seen off the worst of the epidemic. That is, if you are a man. For Kenyan women, socioeconomic and cultural factors still predispose them to infection. They have little power to negotiate the use of preventive strategies. The only ways to make HIV prevention woman-friendly is to invent a vaccine or tackle the age-old issue of gender equality.
Katsidzira and Hakim, being men and doctors, enthusiastically embrace the vaccine option. Their partiality towards a pharmaceutical solution is evident despite their acknowledgement of technical barriers in the quest for a vaccine or effective microbicides. They declare “The ultimate HIV prevention weapon would be a vaccine.” They should have added a rider to the statement. It should read, “Everything being the same, the ultimate prevention weapon would be a vaccine.” The presumption is the underlying gender issues propagating the epidemic cannot be addressed easily. Indeed the AIDS Epidemic Update 2004 notes as much.
As the Epidemic Update emphasises, unless the underlying issues are addressed the threat remains. A newer, more virulent strain of the virus can exploit the underlying weakness to spark a resurgence of the epidemic. We remain vulnerable to similar pandemics due to the gender imbalance. The accruing benefits from addressing the imbalance will have multisectoral and cross-cutting benefits. The one good thing that the HIV/AIDS pandemic has done is to reveal the inter-connections between various cultural factors and socioeconomic indicators. Principally the pandemic has demonstrated that gender is the Achilles’ heel of our society. Heal the gender imbalance, and you heal the society of many ills and weaknesses- including HIV vulnerability. It may be the harder way but is certainly the sure way.
Comments