Gender and HIV/AIDS: Taking stock of research and ... - UNAIDS

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Gender and HIV/AIDS:Taking stock of researchand programmes

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© Joint United Nations Programme on HIV/AIDS (UNAIDS)1999. All rights reserved. This document, which is not a formalpublication of UNAIDS, may be freely reviewed, quoted, re-produced or translated, in part or in full, provided the source isacknowledged. The document may not be sold or used in con-junction with commercial purposes without prior written ap-proval from UNAIDS (Contact: UNAIDS Information Centre).

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Acknowledgements

The text of this document was written by Daniel Whelan ofthe International Centre for Research on Women (ICRW),USA, and reviewed by Marina Mahathir and Hilary Homans.

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UNAIDS/99.16E (English original, March 1999)

Gender and HIV/AIDS:Taking stock of researchand programmes

B E S T P R A C T I C E C O L L E C T I O NU N A I D S

Contents

Executive summary ................................................................... 3

I. Introduction ........................................................................ 5Historical perspective ............................................................... 5Individual risk and societal vulnerability .................................. 6Purpose and scope of this review .............................................. 7

II. Taking stock of research on gender and HIV/AIDS....... 8Individual risk .......................................................................... 8

Cognitive factors .................................................................. 8Attitudinal and behavioural factors ..................................... 9

Societal vulnerability .............................................................. 14Economic factors, gender and vulnerability ....................... 14

Migration ...................................................................... 14Forced migration ........................................................... 15Economic dependency ................................................... 15Economic impact........................................................... 16

Political factors .................................................................. 19

III. Taking stock of programmatic responsesto address gender, vulnerability and impact alleviation ..... 21Efforts to reduce individual risk ............................................. 21

Information, education and skills for prevention ............... 22Appropriate services and technologies ............................... 23

Efforts to reduce societal vulnerability ................................... 25Addressing gender-related determinants of vulnerabilityto HIV infection ................................................................. 26Addressing gender-related determinants of the impactof HIV/AIDS ..................................................................... 28

IV. Conclusions and challenges for the future.................. 30

V. References................................................................... 32

Gender and HIV/AIDS: Taking stock of research and programmes

UNAIDS

Individual risk of HIV/AIDS is influenced by cognitive, attitudinal and behavioural factors - what people know

and how they understand it, what people feel about situations and about others, andwhat people do. Societal vulnerability to HIV/AIDS stems from sociocultural, eco-nomic and political factors that limit individuals’ options to reduce their risk.

In most societies, gender determines how and what men and women are expected toknow about sexual matters and sexual behaviour. As a result, girls and women areoften poorly informed about reproduction and sex, while men are often expected toknow much more.

Gender norms that interfere with women’s and men’s knowledge about sexual riskand HIV/STD prevention are linked to attitudes and behaviours that contribute toindividual risk of HIV. For example, the high value place on virginity in some cul-tures may encourage older men to pursue younger women, or it may encourageunmarried women to indulge in high-risk behaviours such as anal sex. High-riskbehaviours may also be more likely in situations where women are socialized to pleasemen and defer to male authority. In addition, nonconsensual sex and violence againstwomen are growing gender-related concerns that have consequences for HIV prevention.

Most efforts to understand individual risk of HIV from a gender perspective havefocused on women. Fewer data are available on how gender roles and societal pres-sure put men at risk. Men generally have higher reported rates of partner changethan women do, and the condoning of this often begins during adolescence. The useof drugs and alcohol has been identified as contributing substantially to men’svulnerability to HIV, as has injecting drug use.

The migration of men to find employment, for instance, adds to their vulnerability. Itmay disrupt marital and family ties and lead to risky sexual behaviour. In addition, asmore women enter manufacturing sectors of the economy without the protectivefeatures of their families and home communities, young women are becoming sexu-ally active at an earlier age and are often unaware of the risk of HIV and sexuallytransmitted diseases. Migration fostered by economic conditions has also contrib-uted to an increase in the number of female-headed households, while economicnecessity is often linked to migration for the sex trade in south-east Asia.

Many women in monogamous relationships who are vulnerable to HIV through theirpartner perceive the negative economic consequences of leaving the high-risk relation-ship to be far more serious than the health risks of staying. Low-income girls may facean added risk of HIV because of vulnerability to the enticements of older men.

Women are likely to be disproportionately affected by HIV/AIDS when a male headof household falls ill. The burden of caring for children orphaned as a result of thepandemic is borne chiefly by women. Loss of income from a male income-earnermay compel women and children to seek other sources of income, putting them atrisk of sexual exploitation.

Executive summaryGender norms ascribe distinct

roles–both productive and

reproductive–to women

and men. By doing so, gender

norms also influence women’s

and men’s access to key

resources. In this way, gender

norms affect both individual

risk and societal vulnerability

to HIV/AIDS.

Social and economic factors

foster conditions for risky

behaviour

Sociocultural norms often

prevent women from

participating fully in, and

benefiting from, the productive

economy, thus keeping them

dependent on a male partner.

3


Gender-related discrimination is often supported by laws and policies that prevent womenfrom owning land, property and other productive resources. This promotes women’s eco-nomic vulnerability to HIV infection, limiting their ability to seek and receive care and support.

Prevention programmes have tended to aim at reducing individual risk in three ways: sexualabstinence or reduction in the number of sexual partners; non-penetrative sex or the use ofmale condoms; and the diagnosis and treatment of sexually transmitted diseases. However,two specific programmatic and policy recommendations to reduce individual risk have emergedfrom the research on gender and HIV/AIDS — firstly to improve access to information,education and skills regarding HIV/AIDS, sexuality and reproduction, and secondly to pro-vide appropriate services and technologies to reduce women’s individual risk and to improvewomen’s access to them.

Nor should it be seen as an insurmountable barrier to reducing individual risk of HIV.However, many risk reduction efforts have been tested only on a small scale. As they areexpanded, it is essential to complement them with efforts to reduce societal vulnerability too.

Only a limited number of programmes have so far addressed gender and societal vulnerabil-ity but the number is growing. There have been targeted interventions, for instance, aimed atreducing the vulnerability of female sex workers by providing them with other income-generating skills and opportunities. Some programmes have aimed to improve women’ssocial and economic status, while others have aimed to develop education and services sothat women can share knowledge, responsibility and decision-making about reproductivehealth and even help design health policies and projects. Yet other programmes have aimedto improve women’s access to economic resources, though not necessarily with the primarypurpose of reducing the spread of HIV or alleviating the impact of AIDS. Many programmesaround the world provide various kinds of care and support. Some of the most successfulhave adopted a gender-sensitive approach, recognizing the burdens women bear as a resultof economic and social influences.

We know more about what needs to be done than we know about how to do it. Hence thenext generation of HIV/AIDS researchers and programmers face a number of challenges.One such challenge is to improve our understanding of how gender influences men’s knowl-edge, attitudes and sexual behaviour. This is needed in order to design prevention programmesthat more effectively address gender-related factors that influence personal and societalvulnerability to HIV. Another challenge is to advocate for and provide more resourcesfor gender-sensitive care and support. A third challenge is to develop indicators that willenable interventions to measure reduction in gender inequalities relating to vulnerability toHIV/AIDS.

A broader understanding of gender is also needed within institutions. There must be a publiccommitment to gender, a participatory approach to developing mechanisms for addressinggender, and the incorporation of gender across programmes. Front-line workers also need tobe provided the tools to undertake gender analysis.

Gender is not

an abstract concept.

There is no one solution

to the question of gender

and HIV/AIDS.

However, the

empowerment of women

is essential to eliminating

present gender

imbalances.

4

UNAIDS

Since the development of a global response to the HIV/AIDS pan-

demic began more than a decade ago, re-markable strides have been made in ourunderstanding of the nature, scope andimpact of HIV/AIDS on individuals, com-munities and societies around the world.The most striking development is the rec-ognition of the role that gender plays infuelling the pandemic and influencing itsimpact. “Gender” is defined as the widelyshared expectations and norms within asociety about appropriate male and fe-male behaviour, characteristics and roles,which ascribe to men and women differ-ential access to power, including produc-tive resources and decision-makingauthority. Gender roles vary over timeand by class, caste, religion, ethnicity andage [1]*. This review examines researchon gender as it relates to women’s andmen’s different vulnerabilities to HIVinfection, and their different abilities toaccess resources for care and support inorder to cope with the impact of the epi-

demic. The paper also reviews program-matic responses that have sought to ad-dress gender-specific concerns andconstraints in an attempt to contain thepandemic and alleviate its impact.

There are also biological differencesbetween men and women, which have animpact on their vulnerability and accessto care. For example, young women areparticularly vulnerable to HIV due tofragile vaginal and anal epithelia. HIV-positive women face a particular set ofproblems associated with pregnancy,delivery and breast-feeding. They may suf-fer undue discrimination through beingcounselled not to proceed with their preg-nancy, or because their HIV status isdiagnosed through a sick child. These aresome of the biological factors that do notaffect men and adversely impact women.Although they are not explicitly the sub-ject of this paper, some of them may beaddressed implicitly in discussion of the vul-nerabilities caused by gender differences.

Since the early years of the HIV/ AIDS epidemic, the public health

model of disease prevention has remainedcentral to efforts to reduce the spread ofinfection. Epidemiological models haveidentified routes of transmission (sexual,perinatal, parenteral) and patterns ofspread. By and large, the public healthresponse to epidemiological data has re-

Historical perspective

I. Introduction

lied on individual behaviour change in-terventions to control the transmissionof HIV, given the lack of a vaccine orcure. From the mid-1980s until the early1990s, the risk reduction model becamecentral to these efforts, as evidenced bythe creation of a three-tiered approachwithin national AIDS programmes sup-ported through the Global Programme

*–For this review, care is definedas a comprehensive, integratedprocess which recognizes therange of needs for well-being; itincludes services and activities,providing counselling and psycho-social support, nursing and medi-cal care, and legal, financial andpractical services. Support refersto the resources men and womenneed to alleviate the economic andsocial consequences of the impact,including the interacting struc-tures, of social relations that pro-mote or prevent men and womenfrom accessing those resources.

5


on AIDS of the World Health Organization(WHO/GPA). This approach involved theprovision of information and education;programmes to deliver services (HIV test-ing and counselling, needle exchanges,condoms, drug treatment, provision ofsafe blood and blood products); and pro-motion of non-discrimination regardingpeople with HIV/AIDS. This last featurewas new to public health, but there wassufficient evidence to prove that HIV/AIDS-related stigmatization and discriminationwere instrumental in thwarting efforts toreduce risk through education and servicedelivery. Throughout this period, preven-tion of HIV/AIDS and provision of care/treatment for those already infected weretreated as separate goals [2].

Since the early 1990s, HIV preventionhas been concerned with two main ob-jectives: implementation of the risk re-

duction model to ever-wider sectors ofsociety and improvement of the deliveryof services to those at risk; and the de-velopment of more strategic approachesto HIV/AIDS through consideration ofthe contextual factors that foster vulner-ability, including integrating care andsupport with prevention. The first ofthese objectives focuses primarily onthe individual and on promotion ofchanges in behaviour to reduce risk ofHIV transmission. The second stemsfrom the development of the concept ofvulnerability to HIV/AIDS, which is in-fluenced by sociocultural, economic andpolitical factors that constitute the con-text of individual behaviour. These con-textual factors also create barriers orotherwise constrain a person’s ability toprotect him/herself from HIV infectionand to cope with the consequences ofHIV/AIDS.

The concepts of individual risk and societal vulnerability are inextri-

cably intertwined. The societal contextof vulnerability includes the individual—whose behaviours, experience, knowl-edge and attitudes have often beenthe primary concern of HIV/AIDSprogrammes—since groups of individu-als make up societies and define theirnorms regarding gender. In order tofacilitate a clear presentation and discus-sion of the body of research and program-matic activity on gender and HIV/AIDS,this paper discusses individual and soci-etal aspects of risk and vulnerability—the first referring to individualcharacteristics, and the second to the so-cietal context.

At least three types of factors influ-ence individual risk: cognitive, attitudi-nal and behavioural. Cognitive factors

Individual risk and societal vulnerability

are those that relate to how and what in-dividuals know about sex and sexuality,and their ability to identify risk and un-derstand information vital to risk reduc-tion. Attitudinal factors include people'sfeelings about situations, others andthemselves. Behavioural factors are thosethat emerge from the cognitive and atti-tudinal-how people act and what they doin light of what they know and feel. Thebehavioural aspect of individual risk alsoincludes the skills of individuals regard-ing HIV risk and risk reduction, such asthe ability to use condoms consistentlyand correctly and/or to negotiate their usewith a sexual partner.

Societal vulnerability stems from theconfluence of sociocultural, economicand political factors and realities thatcompound individual risk by significantlylimiting individuals’ choices and options

6

UNAIDS

for risk reduction. These include discrimi-nation and marginalization of certaingroups of people, illiteracy and lack ofeducational opportunity, poverty and in-come disparity, lack of work or economicopportunities, law and the legal environ-ment, political will to mount effectiveresponses to the epidemic, and the state'swillingness to protect and promote thefull range of political, economic and so-cial human rights.

Gender norms significantly affect anindividual’s risk and societal vulnerabil-

ity to HIV/AIDS because they ascribe dis-tinct productive and reproductive rolesto women and men, and because theydifferentially influence women’s andmen’s access to such key resources asinformation, education, employment,income, land, property and credit. Inso-far as gender permeates all aspects ofsociety and social relations, any accurateanalysis of personal and societal vulner-ability to HIV/AIDS must examine thesefactors from a gender perspective.

Using the vulnerability framework described above, this paper has

two sections. The first describes publichealth and social science research on per-sonal and societal vulnerability to HIV/AIDS in terms of prevention, care andsupport as they relate to gender. The sec-ond reviews programme efforts withinpublic health and development initiativesto address gender issues and concerns asa key component of reducing personaland societal vulnerability to HIV/AIDSand its impact.

This review is based on more than 200published and unpublished documents,personal interviews with over 40 indi-viduals, and more than 20 programmecontent questionnaires completed byprogramme managers and other key per-sonnel working in HIV/AIDS and otherareas of economic and social develop-ment. Nevertheless, the review of re-search is not meant to be exhaustive. Ithighlights key trends, themes and issuesthat have emerged from the recent litera-ture on the relationship between genderand the HIV/AIDS epidemic. Similarly,the review of interventions provides asnapshot of the types of programmes thathave begun to address gender and vul-

Purpose and scope of this review

nerability in a more systematic manner,rather than a full descriptive analysis ofevery programme undertaken. Thereview of both research and program-matic responses highlights the gaps thatexist and the challenges that need to bemet for programmes to adequately ad-dress gender as this critical process of dis-covery and response continues.

7


As described earlier, three key factors influence individual risk of

contracting HIV. Cognitive factors in-clude men’s and women’s knowledge andbeliefs regarding sex and sexuality, HIVrisk and risk-taking, and HIV/AIDS-re-lated care. They include women’s andmen’s ability to understand HIV risk andthe information that would allow themto reduce their risk. Attitudinal factorsare those linked more closely to people’sevaluation of situations, themselves andothers. They include feelings about HIVand AIDS, attitudes towards those in-fected, and views about the culpability(or otherwise) of social groups. They alsoinclude attitudes regarding gender rolesand relations, including the role and func-tion of virginity, motherhood, and powerover sexual interactions. They cantrigger support, companionship and un-derstanding or lead to discrimina-tion, stigmatization and denial. Thebehavioural component of individual riskis defined by the practices, behavioursand skills that are related to HIV risk andrisk reduction, care and support. Theseinclude sexual behaviours and practicesand skills to use preventative options ornegotiate their use, and behaviours andpractices in the realm of care and of alle-viating the impact of the epidemic.

Research has shown that gender de-fines the differences between women andmen in terms of what they know, whatthey believe, how they feel, and how theybehave. Gender determinants are deeplyrooted in social norms that ascribe towomen and men a distinct set of produc-

tive and reproductive roles and respon-sibilities. Gender, therefore, influences howwomen and men seek out and understandinformation about reproduction, sexualityand HIV risk; the sexual behaviours andpractices that foster HIV risk; and how menand women cope with HIV/AIDS-relatedillness once infected or affected.

Cognitive factors

In most societies, gender determineshow and what men and women are ex-pected to know about sexual matters, in-cluding behaviours, pregnancy andsexually transmitted diseases (STDs).Research has revealed that societal con-structions of ideal feminine attributes androles typically emphasize sexual inno-cence, virginity and motherhood, andthat many cultures consider female igno-rance of sexual matters a sign of purityand, conversely, knowledge of sexualmatters and reproductive physiology asign of easy virtue [3-5]. Data also showthat a remarkably different set of culturaldefinitions are applied to men, who areoften expected to be more knowledgeableand experienced and therefore take thelead as sexual decision-makers [6-12].Research has also shown how these gen-der ideals are part and parcel of children’ssocialization process, and how perva-sively entrenched these expectationsabout sexual knowledge are among ado-lescent boys and girls [13]. For example,young women’s ability to seek informa-tion or talk about sex is greatly con-strained by strong cultural norms that

II. Taking stock of researchon gender and HIV/AIDS

Individual risk

8

UNAIDS

emphasize the value of virginity [9]. Datafrom Brazil, Mauritius and Thailand re-veal that young women fear that seekinginformation on sex or condoms will la-bel them as sexually active regardless ofthe true extent of their sexual activity [14-16]. Low income young people fromRecife, Brazil, for example, feared that iftheir families should find out that theysought sexual health services, their vir-ginity would come into question [14].

As a result of these gender norms, girlsand women are poorly informed aboutreproduction and sex. For example, re-cent studies carried out in Brazil, India,Mauritius and Thailand found thatyoung women knew little about theirbodies, pregnancy, contraception andSTDs [14-18]. Poor married women fromBombay, India, said they had received noinformation about sex prior to their ownexperience [19]. This lack of informationlimits women’s ability to protect them-selves from HIV, contributing, for ex-ample, to fears among women aboutcondom use. In studies conducted in Bra-zil, India, Jamaica and South Africa, somewomen reported not liking condoms be-cause they feared that if the condom felloff inside the vagina it could get lost ortravel to the throat, or that a woman’sreproductive organs would come outwhen the condom was removed [6, 19-21]. Other studies show that lack of in-formation about their bodies limitswomen’s ability to identify abnormalgynaecological symptoms that could sig-nify an STD [19, 22, 23].

On the other hand, gender norms dictatethat males should know more about sexthan females. For example, studies inLatin America among youth who had notundergone formal sex education showedthat adolescent boys were more likelythan adolescent girls to know how to usea condom properly, and to recognize the

symptoms of STDs [7, 24-26]. However,despite these expectations, other researchshows that many men are ill-informed. Be-cause ignorance is construed as a sign ofweakness, male gender norms often preventmen from admitting their lack of knowledgeand seeking out correct information regard-ing HIV/STD prevention [8, 10, 12].

Although there are no data on howgender influences differences in men’s andwomen’s knowledge of HIV/AIDS careand treatment, there are data that sug-gest gender differences in attitudes to-ward ill-health in general. For example,a study in India demonstrated that manywomen accept the itching, burning, dis-charge, discomfort, and abdominal andback pain associated with STDs as aninevitable part of their womanhood [19].Research also shows a generalized gen-der-based attitude toward health care thatseems to favour boys over girls. For ex-ample, a recent review of the literatureon gender differences in health and nu-trition among children under five yearsof age revealed that girls tend not to betaken for health care as often or as earlyin their illness as boys [26].

Attitudinal andbehavioural factors

In order to facilitate a more compre-hensive understanding of how gender in-fluences women’s and men’s risk of HIV,this section departs from traditionalanalyses which treat attitudes andbehaviours separately. It is precisely ananalysis of gender-related attitudes abouta wide range of issues—including virgin-ity, sexuality, STDs, motherhood andpower—that brings the issue of risk-related behaviours into much clearer fo-cus in terms of interventions necessaryto reduce individual risk. The followingsection is based on the premise that

9


behaviour change cannot be achievedwithout a concerted effort to changewomen’s and men’s attitudes about gen-der roles as they relate to sexuality andsexual risk of HIV.

Gender norms and expectations thatinterfere with women’s and men’s knowl-edge about sexual risk and HIV/STD pre-vention are inextricably linked toattitudes and behaviours that contributeto their individual risk to HIV and inter-fere with their ability to alleviate the im-pact of the disease. For example, incultures where virginity is highly valued,research has shown that some youngwomen practice alternative sexualbehaviours in order to preserve their vir-ginity, although these behaviours mayplace them at risk for HIV. Anecdotalreports from Latin America suggest thatanal sex is practised among unmarriedcouples to prevent pregnancy and safe-guard virginity [7, 14, 27]. In anotherstudy, young, unmarried women work-ing in export processing zones inMauritius report a practice referred to as“light sex”, which is not construed asbeing sexual intercourse. However, in-depth questioning revealed that “light sex”involved rubbing the penis against thevagina and penetration up to the point ofpain. Women who practised “light sex”felt they were protecting their virginity,and did not perceive themselves to be atrisk for pregnancy nor HIV infection [18].

The literature also suggests that someyoung girls who are virgins are placed athigh risk due to the notion that femalevirginity symbolizes an innocence andpassivity that some men find erotic [6].In the age of HIV/AIDS, virginity alsosignifies cleanliness and purity, and thusfreedom from disease. In areas of highseroprevalence, it has been reported thatolder men are seeking out ever youngergirls in the belief that, as virgins, they are

free from HIV, and may offer themmoney or gifts in exchange for sex. Forexample, one study in the DemocraticRepublic of Congo (formerly Zaire) re-ported that men choose young and/orplump girls for sex, assuming they areHIV-negative [28]. Other studies haveshown that some men believe that theycan rid themselves of HIV or STDs byhaving sex with a virgin [7, 27, 29].

The phenomenon of older men’s pur-suit of younger women is borne out inepidemiological evidence on HIV infec-tion, when disaggregated for age. Cur-rently, seroprevalence among women ishighest in the 15-25 age group, whereasmost men are infected 10 years later, be-tween the ages of 25 and 35 [30]. In manysocieties urban young women begin sexualintercourse before they are 14 years of age[13], and marriages at a young age arecommon in rural areas [31, 32].

In cultures where women are social-ized to please men and defer to maleauthority—particularlyin sexual interac-tions—research has shown that womensometimes engage in high-risk sexualbehaviour which they believe is pleasur-able for their male partners [12]. For ex-ample, in parts of west, central andsouthern Africa, many women insert ex-ternal agents into the vagina to tightentheir vaginal passages, which is seen toenhance male pleasure during inter-course. These agents include herbs androots as well as scouring powders whichmay cause inflammation, lacerations andabrasions that could significantly increasethe efficiency of HIV transmission [20,33, 34]. In South Africa, women report-edly used such external agents not onlyto increase their partners’ pleasure, butto dry out their vaginal secretions thatthey believed could be construed by theirpartners as a sign of an STD, whichwould indicate previous infidelity [20].

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UNAIDS

Anal sex is another example of asexual behaviour in which women areplaced at risk of infection in an effort toplease their male partners [9]. Survey dataindicate that anal sex is practised to vary-ing degrees on women around the world[27]. Once again, women often engagein this practice not for their own plea-sure but to satisfy their male sexual part-ners or, in the case of unmarried couples,to protect the virginity of the woman.In individual interviews with female fac-tory workers in Rio de Janeiro and SãoPaulo, women reported that their part-ners pressure them to engage in anal sexdespite their reluctance [6]. The samestudy showed that, for some Brazilianmen, anal sex implies the conquering ofa second virginity and symbolizes theirpower and control over women [6].

Another manifestation of male powerand control is nonconsensual sex, whichresearch has shown to be a pervasivereality of adolescent girls’ and women’slives and which is increasingly beingrecognized as a barrier to reducing theirrisk of HIV infection. Elias and Heisehighlight the growing body of evidencewhich shows that many woman arefrequently denied the freedom to con-trol their sexual behaviour and areforced to have intercourse againsttheir will both within and outside of con-sensual unions [35]. In these circum-stances, partner reduction and condomuse are unrealistic preventive options forwomen. For adolescent women, sexualcoercion is highly correlated with teenpregnancy. For adult women, it is asso-ciated in general with chronic pelvic painand unspecific gynaecological and psy-chological problems. In a study offemale youth in South Africa, it wasfound that 30% of girls’ first intercoursewas forced, 71% had experienced sexagainst their will, and 11% had beenraped [36].

In recent years, a concerted focus onthe incidence and consequences of vio-lence against women has emerged as agender-related concern in women’s health[37]. Research on this topic has revealedthat, in some cultures, violence againstwomen is central to maintaining politi-cal relations at home, at work and inpublic spheres [38]. Analyses of the de-terminants of gender-related violencehave concluded that the situational fac-tors that provoke violence against womenare vast. They include: male dominanceand histories of family violence; malecontrol of family wealth; divorce restric-tions on women; verbal marital conflict;heavy alcohol consumption; economicstress and unemployment; isolation ofwomen and the family from communitysupport; delinquent peer associations;notions of masculinity linked to tough-ness and honour; rigid gender roles; asense of male entitlement and ownershipof women; approval of physical chastise-ment of women; and a cultural ethos thatviolence is a valid means of solving inter-personal disputes [39, 40].

The pervasiveness of violence has con-sequences for HIV prevention. Researchconducted in countries as diverse as Gua-temala, India, Jamaica and Papua NewGuinea yielded similar findings: womenoften avoid bringing up condom use forfear of triggering a violent male response[7, 19, 21, 41]. Furthermore, threats orfears of violence control women’s mindsas much as do acts of violence, “makingwomen their own jailers” [37]. Violenceis also a reality of women living withHIV/AIDS. In one study among womendrug users living with HIV/AIDS, 96%had experienced violent contacts [42].

In many cultures, motherhood, likevirginity, is considered to be a feminineideal. Data from around the world pointto the economic realities and social pres-

11


sures which reinforce the value of moth-erhood for women and contribute to highfertility rates [5,43]. Children are viewedas sources of labour for the family andof security for the parents in their old age.In polygamous societies, they maintainthe balance among co-wives, bring in sta-tus via schooling and employment, buildstable ties to men and maintain a resourcenetwork of money, clothes and medicalexpenses. For men, there is an accumu-lation of resource networks in the num-ber of children they father [44]. Otherstudies have shown that children repre-sent a definition of self-worth and socialidentity for many women around theworld [5, 43].

It is in this context that behaviouraloptions to prevent HIV infection, suchas non-penetrative sex and use of barriermethods, present difficult and often in-surmountable challenges for women andmen in balancing fertility against HIVprevention. Research has shown how thevalue of fertility can contribute towomen’s vulnerability to HIV in twoways. First, although condoms may beeffective in preventing STD/HIV infec-tion, they also prevent conception which,for many, interferes with familial sourcesof economic security and support, andwomen’s social value [45]. Second, infer-tility in many societies is sanctioned as areason for a man to divorce his wife, orto acquire a subsequent wife. If she is notremarried, she may be compelled to engagein high-risk sexual transactions for eco-nomic security or protection [23, 46, 47].

Although gender analyses have beenemployed in the past to describe women’svulnerability to HIV, gender norms alsocontribute substantially to men’s vulner-ability. Results from sexual behaviourstudies around the world indicate thatheterosexual men, both single and mar-ried, as well as homosexual and bisexual

men, have higher reported rates ofpartner change than women [41, 48, 49].Multiple sexual partnerships for men arecondoned implicitly or explicitly inperhaps the majority of societies [42, 43,48, 50]. This finding is supported by re-search that reveals how both men andwomen believe that variety in sexual part-ners and sexual variation is essential tomen’s nature, and that “real men takerisks” [6, 7, 23, 43, 48]. For example,men from rural and peri-urban commu-nities in South Africa felt they needed tomaintain the tradition of their fathers andgrandfathers by having more than onesexual partner; for young men in particu-lar, having many relationships wasequated with being popular and impor-tant in the community [20].

Recognition and condoning of mul-tiple partner relationships for men butnot for women begin during adolescence.This is illustrated by the observations ofmale Zimbabwean high school studentsin focus group discussions; they pointedout that boys can have many girlfriendsbut girls should stick to one boy [51]. Insuch cultures, therefore, expectingwomen to discuss mutual monogamywith their partners directly conflicts withthe very definition of masculinity. Focusgroup discussions with Jamaican workingwomen revealed that they were very con-cerned about infidelity on the part of theirmale partners, but felt that the notion ofmale monogamy was “pie in the sky” [21].

Another gender-related factor thatcontributes to men’s vulnerability to HIVis the stigma associated with men whohave sex with men. A recent review ofprogrammes addressing sexual behaviourand sexuality in developing countriesconcludes that sex between men occursin all countries and societies but that so-cial and cultural norms and epidemiologi-cal categorizations of sexuality can hide

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the true extent to which it occurs [52].As a gender issue, the fact that sex be-tween men is socially stigmatizing (and,in many cases, illegal) contributes to in-ability to reach those men with informa-tion and services to reduce theirindividual risk of infection. Furthermore,research shows that in many societiesmany men who have sex with men alsohave sex with women, and that manybisexual behaviours are often accompa-nied by a wide range of sexual identities,homosexuality being one of them [53].For example, a study in India revealedthat 90% of male clients of male sexworkers reportedly were married [52].Sexual behaviours that are not recognizedas a valid form of sexuality, therefore,contribute to both men’s and women’svulnerability to HIV.

The use of drugs and alcohol havebeen identified as contributing substan-tially to men’s vulnerability to HIV, in-sofar as they impair judgement and canlead to high-risk behaviour and unpro-tected sex. Although research shows thatsubstance use is typically a male prob-lem, the gender determinants have onlyrecently begun to be explored. Neverthe-less, men are often expected to use alco-hol more than women, and even toexcess. The role of alcohol has often beencited in reference to violence againstwomen, although recent research into therole of alcohol in domestic violence pointsout that alcohol is a contributing factor andnot the actual cause of violence [54, 55].

Beyond the well-documented risk towomen and men who are injecting drugusers (IDUs), gender factors further in-crease female IDUs’ risk of infection, in-cluding unprotected sex with male sexualpartners who also inject drugs and gen-eral sexual networking within IDUcircles. One study carried out in NewYork, USA, among 326 women in a

methadone maintenance programme re-vealed that 35% had had unprotectedvaginal sex within the preceding 30 days,and the data suggest that most of thosesexual acts were with male IDUs. Fur-thermore, 28% of those women had hadsex with more than one partner, and 18%had sex with a partner who was HIV-positive [56]. Further evidence comesfrom a study in Canada among womenIDUs, where 56% of the women enrolledin the study reported never usingcondoms with their regular sex partner,81% of whom were reported to be maleIDUs. Furthermore, the study revealedthat 31% of the women shared needles,and 70% obtained those needles fromtheir regular sex partner [57]. In addi-tion, both female and male substanceusers may resort to selling sex in orderto finance their habit.

These data show how men’s andwomen’s knowledge, attitudes and re-lated sexual behaviour are highly influ-enced by gender norms and expectations,and how gender roles contribute to anindividual’s risk of HIV infection. Despiteefforts to understand individual risk ofHIV from a gender perspective, most ofthe focus has been on women. There arefar fewer data available on how genderroles and societal pressure fosterbehaviours that place men at risk, andthwart their ability to seek information,services and technologies to protect them-selves from HIV. According to Mane,even though sexuality education forwomen in many societies is generally ig-nored, they often receive at least someinformation in order to prepare them fortheir reproductive role. For men, how-ever, there is an almost total absence ofreliable information on sex [58]. Theseare among the many gender-related gapsthat will need to be filled as the next gen-eration of HIV prevention programmes isdesigned and implemented.

13


In recent years, social science research has sought to enrich the lit-

erature on gender and sexual behaviourby exploring the context in which sexualbehaviour take place. Social, economicand political factors foster the conditionsthat facilitate risk behaviour and furthercreate obstacles to women’s and men’sability to protect themselves from HIVand effectively cope with the impact ofthe epidemic. Many of the socioculturalnorms and expectations that define gen-der roles and relations have been exam-ined in terms of influencing individualrisk. The following section reviews andanalyses broader economic and political re-alities as part and parcel of an analysis ofvulnerability to HIV and the impact of AIDS.

Economic factors, genderand vulnerability to HIV

Research has shown that economic fac-tors contribute to vulnerability to HIVin two ways: first, macroeconomic pres-sures can contribute to men’s andwomen’s vulnerability to infection by dis-rupting stable social relationships, thusincreasing the likelihood that unprotectedsexual behaviour will take place. Second,gender-related sociocultural norms cre-ate barriers to women’s full participationin, and ability to benefit from, the pro-ductive economy, thereby increasing thelikelihood that women will be dependenton a male partner. In an economicallyand socially dependent relationship, awoman’s ability to leave a high-risksexual relationship is limited, as is herability to successfully negotiate safer sexwith a non-monogamous sexual partner.In both instances, economic factorscontextualize the gender-related factorsthat contribute to individual risk thathave been previously discussed.

Societal vulnerability

MigrationResearch has shown how rural-to-ur-

ban labour migration of men contributesto their vulnerability. It appears to dis-rupt marital and familial ties and leadsto sexual networks in urban areas wherethere is an unequal ratio of men towomen and seroprevalence is likely to behigh [51, 59-61]. Women’s vulnerabilityis also influenced by male labour migra-tion as a result of men returning to theirrural households where they re-establishsexual relationships and increase the pos-sibility that HIV/AIDS will be transmit-ted to rural women [31, 51, 62-65].

As for women who seek employment,a growing body of data on labour mar-ket segmentation shows that women areentering manufacturing sectors of theeconomy due to macroeconomic policiesthat drive export promotion in develop-ing countries [66, 67]. For example, inBangladesh, Mauritius and Thailand,where women now make up a large ma-jority of workers in the manufacturingsector [67], migration is pervasive andvillage families rely on the remittancessent back by adolescent daughters [68].Here new peer networks, includingsexual networks, are formed. Researchamong these populations has shown thatwithout the protective features of theirfamilies and villages, young women arebecoming sexually active at an earlier ageand are often unaware of the risk of HIVand STDs [15, 16].

Patterns of migration fostered by eco-nomic conditions have also contributedto a dramatic increase in the number offemale-headed households throughoutthe world. Research has shown that, inup to one-third of these households,women are the sole income earners [27,69]. Female heads of households must

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balance the twin demands of family andeconomic survival in a context where theyhave less access to agricultural support,have smaller land holdings, lower in-come, fewer assets and less access totraining and support for agriculturalwork than do men [69-73]. For many ofthese women, transactional sex* has becomea rational means of making ends meet [19,64, 74]. For example, in order to meet im-mediate economic needs, women in theDemocratic Republic of Congo seek occa-sional sexual partners known as pneus deréchange or “spare tyres” [75-77].

Forced migrationAnother form of migration that has

been well documented is the sex trade insouth-east Asia. A report issued by Hu-man Rights Watch-Asia revealed howeconomic necessity compels Burmesefamilies to send daughters to work inThailand through a broker or agent, of-ten not realizing they are essentiallybeing “sold” into sexual slavery. Further-more, though Thailand has laws and is asignatory to several international andregional treaties which outlaw the prac-tice, the report described in great detailhow public officials at many levels areinvolved in the practice by acceptingmoney and favours in return for theirnon-interference [78]. Women and girlsare trafficked for the sex trade not onlythrough abductions and false promisesof good jobs or marriages but alsothrough the argument that women canearn more through prostitution [79].Nowadays there is also an increasingdemand for younger sex workers due toclients’ fear of HIV infection [80].

Economic dependencyWomen who are not otherwise affected

by economically-motivated migration arealso vulnerable to HIV, but in a differentway. Despite the fact that women areproductively engaged in both the formal

and informal sectors of the economy, re-search from around the world shows thatthere are gender-related differentials inwomen’s and men’s access to productiveresources, such as land, property, credit,employment, training and education.This is a consequence not only of laws andpolicies that, for example, prohibit womenfrom owning land or inheriting property,but also of the reality that these laws andpolicies fail to provide women with theopportunities to realize the full benefitsof economic and social development.

Evidence reveals that different income-levels of families do not seem to reducewomen’s vulnerability to HIV. Researchfrom Uganda, for example, revealed thatseroprevalence among women with high-income partners was almost twice thatamong women with low-income partners[81]. Although this data may seem to beincongruent with other research whichhas highlighted the relationship betweenpoverty and vulnerability to HIV, the re-search from Uganda reinforces the over-all conclusion that women’s vulnerabilityis associated with factors that are not nec-essarily within their control.

Given the fact that sociocultural normscondone multiple sexual partnerships formen and place an emphasis on male plea-sure and control in sexual interactions-both of which have been shown toinfluence men’s and women’s individualrisk of HIV-many monogamous, marriedwomen find themselves vulnerable toHIV despite the seemingly protective fea-tures of marriage or a steady sexual rela-tionship. One study in Senegal, forexample, revealed that 50% of womenliving with HIV/AIDS had no risk fac-tors other than being in a monogamousunion [82].

Furthermore, young girls may face anadded risk of being vulnerable to HIV

15

*Transactional sex is defined asthe exchange of sex for comfort,goods or money, not necessarilyon a professional basis.


because of economic factors. In Uganda,it is has been reported that girls from low-income families are particularly vulner-able to the enticements of older men or“sugar daddies” who offer money or giftsin exchange for sex [44, 83]. In a studyconducted in Zimbabwe, high schoolgirls acknowledged the “sugar daddy”phenomenon in their communities andreported that having sex with these menwas largely motivated by economic fac-tors, including paying for school fees andbooks [44, 84].

Research has also explored the circum-stances under which some women areable to reduce their individual risk in avariety of ways. An analysis of researchconducted by Elias and Heise found thatin instances where women are financiallyindependent, they are more like to be ina position to reduce their risk of infec-tion [35]. For example, Orubuloye et al.found that Yoruba women from south-westNigeria were able to refuse sex without vio-lent consequences if their partner had asexually transmitted infection [48]. A studyof African-American and Hispanic womenfrom New Jersey (USA) reported that thewomen were able to exert considerablepower by withholding sex if their partnerdid not agree to use a condom [85].

For most other women in monogamousrelationships who are vulnerable to HIV,research shows that they perceive the nega-tive economic consequences of leavinghigh-risk relationships to be far more se-rious than the health risks of staying inthe relationship [19,24,74,86]. For ex-ample, despite the fact that 97% of femalerespondents in an STD study in Zimba-bwe cited their husband as the sourceof their infection, only 7% considered di-vorce or separation as an option [87].

For women who lack economic inde-pendence and therefore are not able to

leave or avoid situations in which theyare at risk, the only other option avail-able is to attempt to negotiate changes inthe behaviour of their male partners.However, data from research projectsconducted in Brazil, Guatemala, India,Papua New Guinea and South Africa re-veal that many women who are aware oftheir partner’s sexual behaviour feel help-less about their inability to change it, andhave cited their fear that trying to do socould result in disruption of the partner-ship and even jeopardize the physicalsafety of the woman [6, 7, 19, 20, 41].Other research has demonstrated thatwomen who raise the issue of condomuse run the risk of conflict, loss of sup-port, and violence [75, 84, 88]. Studiesconducted in Rio de Janeiro and SãoPaulo, Brazil, found that women fromlow-income communities perceived thatthey would incriminate themselves as un-faithful and have to suffer the conse-quences of a male partner’s anger andviolence if they were to ask their part-ners to use a condom [6]. Additionally,research has shown that, in many in-stances, sex takes place under conditionsof poverty and overcrowding which makeit difficult for women to communicatefreely with their partners, let alone nego-tiate [19]. Moreover, low-income womenfrom situations as diverse as Bombay,Guatemala City and the highlands ofPapua New Guinea report that men of-ten demand sex under the influence ofalcohol, making negotiation an unrealis-tic option [7, 19, 41]. In addition, formany couples negotiation is not the usualstyle of communication. In many in-stances women are not able to determinewhen or whether to have sex.

Economic impact

Gender also plays a significant role indetermining how men and women are

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able to cope with the impact of the epi-demic in terms of economic effects, ac-cess to care and support, and as a resultof gender-related discrimination. Theterm “impact” refers to both the macro-economic and microeconomic effects oflost productivity and income (such asselling off assets), as well as household-level impact in terms of household labourdistribution, family and social structures,and support systems. In a 1992 study ofthe economic impact of AIDS, Ainsworthand Over concluded that “at themicroeconomic level, researchers havedone a much better job of characterizingthe nature of the impact of AIDS ratherthan of measuring it” [89]. Whereas datacollected on the impact of HIV/AIDS atthe household level has improved to meetthis need, few studies have examined gen-der as a variable in measuring the house-hold and community-level effects of theepidemic. For example, a recent reviewof socioeconomic impact studies fromZambia exemplifies the extent to whichgender analysis of the impact of HIV/AIDS is lacking. Although the reviewexamined the macroeconomic impact ofHIV/AIDS vis-à-vis the agriculture, edu-cation, health, public and informal sec-tors, and the microeconomic impact atthe level of the household, the only spe-cific references to gender-related impactdata in this analysis are passing referencesto girls and women resorting to sex work,and widows who find it difficult to re-marry and establish new family networksfor the care of their paternally orphanedchildren [90].

Similarly, a study of the household-leveleconomic impact of HIV/AIDS-relatedmortality in the Rakai District ofUganda—undoubtedly one of the mostaffected areas in the world in terms ofHIV/AIDS—concludes that householdsthat have experienced an adult death dueto HIV/AIDS cope by altering in size and

composition, and incur economic lossesthrough a depletion of durable goods[91]. The data were not analysed from agender perspective to determine the ex-tent to which the effects of these copingstrategies differently affect men andwomen. Household coping studies inKagera, Tanzania, reveal that householdsare likely to spend more on funeral ex-penses than medical expenses for bothmen and women whether the cause isAIDS-related or not, though for men whohad AIDS the funeral expenses were over-shadowed by medical expenses. In gen-eral, the households tended to spendmore on both medical and funeral ex-penses for men than for women [92].

Despite the lack of solid, gender-disag-gregated data on impact, there is ampleevidence from research conducted in thefield of development to suggest thatwomen are likely to be affected dispro-portionately by HIV/AIDS. For example,if a woman living in an agricultural com-munity where women are responsible forsubsistence farming becomes infected andfalls ill, the cultivation of subsistencecrops will fall, resulting in an overall re-duction in food availability in the house-hold [93,94]. Given the availableevidence from the field of educationwhich shows that girls are often pulledout of school before boys to fulfil house-hold duties when the need arises [95], girlchildren are likely to be pulled out ofschool to fill the gaps in food productionin instances where outside workers can-not be hired due to the depletion ofhousehold economic resources [94].

Women are also likely to be dispropor-tionately affected by the impact of HIV/AIDS when a male head of householdfalls ill. As a result of the loss of incomefrom a male income-earner, women andchildren may be required to seek othersources of income. Research has shown

17


that adolescent girls may be particularlyvulnerable as a result of bartering sex forcash or other resources [84, 96]. Otherevidence suggests that the epidemic iscontributing to a downward trend in theage of marriage for young women as menseek younger wives to protect themselvesfrom infection, and families seek the eco-nomic security of marrying off theirdaughters to economically stable adultmen [97]. This phenomenon has far-reaching consequences in terms of youngwomen’s education, the health conse-quences of early childbearing, diminishedaccess to productive resources, and eco-nomic dependency on a male partner-allof which have been identified as factorscontributing to vulnerability to HIV [97].

Since traditional gender norms supportthe primary role of women in child wel-fare, the burden of caring for childrenorphaned as a result of the epidemic isborne disproportionately by women inmany parts of the world. UNAIDS/WHOestimates show that at the end of 1997the cumulative number of childrenunder 15 years of age orphaned by AIDSsince the beginning of the pandemic was8.2 million [98]. In high-prevalence set-tings, research has shown that if relativestake in orphans this creates stresses onhousehold economic and food security,especially for families that are alreadycaring for more than one ill or dying fam-ily member [94]. Moreover, as the num-ber of persons with HIV/AIDS within ahousehold grows, women are required tospend ever-increasing amounts of timeon care-giving. The combined physicaland emotional burdens of caring for sickfamily members (including orphans andmembers of extended families who havebeen affected by the disease), ensuringan adequate food supply, and replacinglost income inevitably forces womento neglect their own health and well-being [93].

Research has begun to document howgender-related discrimination, coupledwith coping with the burdens of the im-pact of the epidemic, have conspired tofurther contribute to women’s and ado-lescent girls’ overall vulnerability to HIVand the consequences of AIDS. In in-stances where a male head of householdhas died, studies show how some womenface a tragic set of circumstances in termsof loss of social support from familymembers, ostracism by the community,and lack of legal protection to inherit landand property [93, 95, 99]. Furthermore,in many areas of Africa a woman is in-herited by the husband’s brother whenthe husband dies. Instances have beencited where a husband’s family mayblame a widow for the death, and refuseto accept her or her children into theirfamily support system [94]. In regionssuch as Africa, where orphaned childrengo to the paternal family, one study re-vealed that the paternal family typicallymaintains control over the inheritedproperty of the orphaned children. Insocieties where children lack propertyrights, ostracism within the family canlead to exploitation, deprivation of theirrights, abuse and neglect [94, 100]. Fur-thermore, girl children who are orphansof the epidemic are often less welcomedinto the extended family than boys, es-pecially if no dowry has been providedfor a future marriage. As a result, theymay be used by the family as economicobjects, and may be coerced into sexwork [94].

Finally, in interaction with broader eco-nomic conditions, gender plays a signifi-cant role in determining women’s andmen’s relative access to care and socialsupport, often exacerbating the alreadydesperate and dire consequences of HIV/AIDS. Research has shown that womenface proportionally more barriers thanmen in seeking and accessing care and

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support due to: overall economic con-straints in accessing formal health careservices [101], lack of infrastructure suchas roads and transportation, lack ofmoney to pay for treatment, religious andcultural norms, and the perception bywomen that the care they receive is inap-propriate [102]. Another constraint thathas been identified is the vertical arrange-ment of care services, whereby womenare exposed to stigmatization in seekingout treatment and care at separate facili-ties [102]. Additionally, women who can-not afford to seek care at private facilitiesresort to public services which often havepoorly trained staff and lack treatmentregimes [103]. Men may also face barri-ers in seeking care if they perceive theservices to be directed at women only.

Political factors

Since the early years of the HIV/AIDSpandemic, researchers (and especiallyactivists and proponents of human rights)have pointed out the political and gov-ernmental factors that play a role inperpetuating the pandemic, includingpolitical and policy responses (or non-responses) directly dealing with the pan-demic, those indirectly related to thepandemic, and broader policy areasnot typically associated with thepandemic but which play a role in creat-ing a context of societal vulnerability toHIV/AIDS.

The broadest set of analyses are thoseexamining fear-driven policy responses tothe epidemic itself, such as mandatoryand compulsory testing, quarantine, dis-crimination in the areas of employment,housing, and health care, and limitationson the mobility of people living with HIV/AIDS, including immigration and othertravel-related restrictions [104]. Not onlyhave such policies been criticized for their

ineffectiveness in slowing the epidemic,but they have also been examined as po-tential violations of international humanrights standards and law [104]. As a re-sult of gender roles and social norms, theimpact of these political factors is borneunequally by men and women. For ex-ample, men and women who are HIV-positive often face severe discriminationin the household and the community, yetwomen living with HIV/AIDS face“double jeopardy” as a result of gender-and health-related discrimination. In-stances have been cited where familymembers encourage a husband who isasymptomatically HIV-positive to leavehis wife with AIDS and find another one.Often her children are forced out of thehome as well [82]. This is the first step ina cycle of abandonment by family mem-bers, friends and neighbours that is com-pounded by economic powerlessness andlack of legal rights to property and otherproductive resources. The result is pov-erty in addition to lack of access to careand treatment [93]. In communities thathave been particularly devastated byHIV/AIDS, such as those in Tanzania,there is anecdotal evidence that stigmaleading to abandonment of women liv-ing with HIV/AIDS is on the decline[102]. In other situations where the im-pact of HIV/AIDS has not yet been felt,the opposite may be the case. In India,Mane suggests that women with HIV arelikely to be viewed as vectors of infec-tion and therefore “guilty” of havingtransgressed “goodness” and deservingof their fate [105].

Although they are fewer in number,other analyses have examined policies in-directly related to the epidemic, includ-ing the criminalization of certainbehaviours and activities (such as homo-sexuality, injecting drug use, and sexwork), legal restrictions and other barri-ers to the free flow of information about

19


sexuality, and restrictions on the provi-sion of services, such as access to clinicsand the provision of condoms [106]. Themost obvious area where women can bedisproportionately affected by these poli-cies is in the area of sex work, where itsillegality may make information and ser-vice provision to women sex workers dif-ficult. Similarly, women and adolescentsare disproportionately affected by gov-ernments’ efforts to curb information andservices relating to sexuality and HIV pre-vention for reasons of protecting “socialmores” and public morality. For example,many countries do not allow the distri-bution of condoms to adolescents. Inthose instances, there is a critical break-down in prevention efforts, given that acritical option for HIV prevention hasbeen eliminated from the choices thatsexually active adolescents have [106].

A newer body of research and analysishas begun to examine even broader po-litical and policy realities that create acontext of societal vulnerability to HIV/AIDS. These include gender- and age-re-lated discrimination and the role thatstate-sanctioned violence plays in fuellingthe epidemic. Gender-related discrimina-tion is often supported by laws and poli-cies that prevent women from owningland, property and other productive re-sources; research has shown that thiscontributes to the feminization of pov-erty, promotes women’s economic vulner-ability to HIV infection, and createsparticularly significant barriers towomen’s ability to seek and receive careand support when they themselves areinfected [107]. Gender-based sexual vio-lence in often condoned through lightsentences or the absence of prosecution.Other forms of discrimination in the ar-eas of employment, education and accessto health care services and information fur-ther exacerbate women’s vulnerability [108].

Research has also demonstrated the im-pact of war on women and young girls.For example, research carried out inBosnia, Croatia and Rwanda revealed thehorror that many women faced as a re-sult of policies whereby rape and otherforms of sexual abuse were utilized asweapons of war. There were brutal re-ports of gang rapes and of subsequentestablishment of brothel networks forwomen who had suffered this atrocity.Although seroprevalence data are limited(especially in the former Yugoslavia), itis likely that many women were exposedto HIV as a result of rape and their sub-sequent exile into what has been calledsexual slavery [109, 110].

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III. Taking stock ofprogrammatic responsesto address gender, vulnerabilityand impact alleviation

Efforts to reduce individual risk

Reducing individual risk to HIV infection has been the central fo-

cus of most HIV/AIDS programmes theworld over. As was highlighted in theprevious section on research, efforts toreduce the impact of the epidemic havetypically been separate from preventionefforts, which have remained the domi-nant focus given limited resources to ad-dress the epidemic. Most preventionprogrammes have delivered messages andservices to reduce individual risk in threeways: sexual abstinence or sexual part-ner reduction; non-penetrative sex or theuse of male condoms; and the diagnosisand treatment of STDs. There is ampleevidence to demonstrate how individualrisk reduction initiatives have indeed beensuccessful in reducing the incidence ofHIV infection. The majority of these suc-cess stories come from programmes thathave focused their efforts on reachingpopulations considered to be most at risk,such as IDUs, sex workers, men who havesex with men, and clients of STD clinics.Given limited resources and the alarm-ing rapidity with which HIV oftenspreads among these most vulnerablegroups, priority typically has been givento designing individual risk reductionprogrammes for these groups. Yet re-search shows that wider segments of so-ciety that are not epidemiologicallyidentified as high risk have become increas-

ingly vulnerable, and risk reduction mes-sages should be designed for them as well.

Where those messages have reachedbroader segments of the population, re-search has shown that the materials andmethods often support misconceptionsabout who is at risk and thus create afalse sense of security for those who areunaware of their own risk [62, 111]. Interms of gender, for many years the term“women and AIDS” was often and is stillin some parts of the world used in refer-ence to female sex workers. As the re-search described in the previous sectionsuggests, many behaviour changeprogrammes that were specifically de-signed for female sex workers failed tomeet the needs of other women in con-sensual sexual relationships [11, 12, 59,60, 64, 112, 113].

Broadly speaking, in addition to thebroader framework of improving genderequality there are two specific program-matic and policy recommendations toreduce individual risk that have emergedfrom the research on gender and HIV/AIDS. The first is to improve access toinformation, education and skills regard-ing HIV/AIDS, sexuality, and reproduc-tion for women and girls, and for menand boys; the second is to provide ap-propriate services and technologies to

21


reduce women’s individual risk, and toimprove women’s access to them.

Information, educationand skills for prevention

Improving access to information, edu-cation and skills for prevention takes intoaccount the gender-related barriers toinformation and knowledge, and to theavoidance of sexual risk behaviours be-tween men and women. It also recognizesthe need to provide a comprehensive ba-sis of knowledge about sexuality and re-production in concert with informationon HIV and STDs. Finally, it acknowl-edges that women and girls have need fordifferent gender-related information andskills than men and boys, but that ad-dressing gender roles and relationshipsand building skills for improved partnercommunication must also be addressedin order to improve individual risk re-duction programmes.

Programmes have responded by ac-knowledging that face-to-face communi-cation is the most effective means ofinfluencing individual behaviour. Further-more, many programmes have adoptedpeer education as a method of face-to-face communication, insofar as thismethod has been shown to challengenormative beliefs and behaviour throughdialogue and personal interactions [114].Those peer education programmes thathave addressed gender-related variables,such as lack of information, services, andtechnologies for risk reduction, have mostoften been programmes for female sexworkers. Evaluation data indicate thatmany peer education programmes withsex workers worldwide have improvedthe sex workers’ knowledge of HIV/AIDSand that they have also adopted risk re-duction behaviour [113]. Despite thesesuccesses, peer education remains an

underutilized method of community-wideHIV prevention among women and menin the general population.

Nevertheless, there are lessons to belearned from those peer educationprogrammes that have sought to promotevulnerability reduction among womenwho are not sex workers. For example,projects conducted among migratory fac-tory workers in Mauritius and Thailandhave demonstrated that, given targetedmaterials and small group dialogueamong peers, young women’s awarenessof HIV/AIDS and competencies to nego-tiate and communicate safe sex with apartner, family and friends will improve[15, 16]. As with interventions among sexworkers, peer education interventions infactories demonstrate that risk reductionprogrammes for hard-to-reach popula-tions (e.g. migrant women and youth)need an institutional base to promotesustained and consistent small group in-teraction and support. Furthermore,project design and materials used mustbe creative enough to allow young womento overcome the barriers they face in dis-cussing sexuality and condom use [16].

Recent intervention studies that haveexpanded the content of information andeducation programmes to include thebuilding of skills and discussions aboutgender roles and relationships haveyielded useful results. A project in Thai-land among never-married adolescentfactory workers showed that an empha-sis on partner communication, negotia-tion and relational aspects of HIV/AIDSprevention can be successful if the ses-sions are supported by appropriate edu-cational materials that recognize the factthat the workers are out-of-school youthwith few years of schooling, yet who areincreasingly exposed to new lifestyles andvalues [115]. Another recent study suggeststhat school-based programmes can success-

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UNAIDS

fully address broader, gender-related issuesby going beyond a didactic, information-only approach to HIV prevention [116].

Additionally, a recent peer interventionstudy among low-income adolescent girlsin Brazil focused on six broad gender-re-lated issue areas in addition to traditionalinformation on HIV/STD prevention,namely: communication and sexuality,virginity, self-esteem, autonomy, fidelity,and adolescent sexuality. Among the keyresults from the study was the conclu-sion that including STD/HIV preventionin a broader discussion of sexuality andlocal social norms had a significant im-pact on the target group. Furthermore,the programme contributed to a greaterunderstanding of the need to become in-volved in community mobilization effortsto challenge wider social inequalities andproblems [117].

As a sub-set of these efforts, programmesto address partner communication haveemerged as a result of a more gender-sen-sitive approach to HIV prevention [118].One study among adult women and mendemonstrated how belief in one’s vulner-ability to HIV or STDs was not signifi-cantly associated with frequency ofcondom use, whereas verbal interactionswith a sexual partner about safer sex andsexual history were [119]. Similarly, astudy with Thai migratory youth empha-sized how gender-related communicationincreased couples’ ability to practice “ne-gotiated safety” [120]. Another studyfound that training women and men inpartner communication via role-playsand interactive methods led to womenfeeling more comfortable with discuss-ing their partner’s sexual history, and menwere more comfortable requesting con-dom use [120]. Similar interventions inBrazil, Indonesia and Tanzania demon-strated how an emphasis on female-initi-ated and mediated communication with

one’s husband can result in reduced riskof STDs and HIV for women, and showedthat women are likely to express less fearof a husband’s refusal and anger [121].

Another programme that has testedcommunication skills-building ap-proaches for adult women is in fa-mily planning clinics operated by theSociedade Civil Bem-estar Familiar doBrasil (BEMFAM) in Brazil. In thatprogramme, more than 3000 women haveparticipated in group discussions that al-lowed them to share concerns with otherwomen about sexual issues such as STDhistory, risk and condom use, and to“practise” conversation with their part-ners. BEMFAM staff say that these ses-sions have had positive results [122, 123].

Appropriate servicesand technologies

Some innovative condom social mar-keting programmes have addressed thebarriers women face in accessing malecondoms and insisting on their use withmale partners. For example, women inCameroon and Côte d’Ivoire can pur-chase condoms in self-service shops,where anonymity is preferred over directinteraction with salespeople. In BurkinaFaso and Haiti, organized groups ofwomen are involved in the delivery ofHIV prevention information and condomdistribution to other women. Peer edu-cation programmes in Bangladesh,Burkina Faso, Haiti and India also pro-vide women with effective responses tocommon male objections to condom use[124, 125].

Another response to the need to pro-vide women with more prevention op-tions is the female condom. A recentreview of over 40 acceptability studiesconducted around the world concluded

23


that, by and large, women and men havehad favourable reactions to the introduc-tion of the female condom as a methodof STD/HIV prevention [11]. Further-more, research suggests that whenwomen are given an expanded range ofprevention options, including the femalecondom, it is likely that the number ofunprotected sexual episodes will decrease[126, 127]. For example, a UNAIDSstudy carried out in Thailand in 1995measured consistent condom use andSTD incidence between two groups of sexworkers: one that used only the male con-dom, and one that used the female con-dom when male condoms were notavailable. The sex workers that had ac-cess to both male and female condomsreported fewer acts of unprotected sex andone-third fewer STDs that those whohad access to the male condom only [128].

Nevertheless, the literature has pointedout that, in the absence of a supportiveintervention, the simple introduction ofthe female condom is unlikely to changethe balance of power between men andwomen in sexual relationships. A recentstudy initially supported by WHO/GPAsought to investigate the nuances of howthe female condom influences sexual re-lations between men and women and thecircumstances under which the femalecondom can be considered not only a toolfor prevention but also a vehicle to chal-lenge other relational factors that con-tribute to women’s vulnerability to HIVinfection, such as improving sexual com-munication and fostering women’s em-powerment. According to the study, thesebenefits were realized to a greater extentby sex workers who already had some ne-gotiation skills, among couples where menwere already supportive of family plan-ning, where community and peer accep-tance of the female condom was high, ininstances where the female condom wasconsidered a welcome alternative to the

male condom, and where the female con-dom was able to be eroticized [129].

Finally, research data on women’svulnerability to HIV infection has beenthe impetus for the development of avaginal microbicide [126, 130]. Cur-rently, there are seven products in earlyclinical evaluation, but only one inadvanced efficacy testing [131]. Theseproducts can potentially be used in sev-eral ways, such as a barrier to HIV/STDinfection during intercourse, a vaginalwash during delivery (to reduce perina-tal transmission), a postcoital prophy-laxis, or a protection from secondary HIVinfection for women already living withHIV [132]. Although a clinical study onthe effectiveness of nonoxynol-9 as anagent to reduce the transmission of HIVamong women met with disappointingresults [133], other efforts are under way.For example, UNAIDS launched amultisite study in 1996 to test the effec-tiveness of a microbicidal compoundamong female sex workers in Benin, Côted’Ivoire, South Africa and Thailand. Theresults of this study are forthcoming.UNAIDS is also sponsoring a study inMombasa, Kenya, by the University ofWashington with some products. Finally,many sites sponsored by UNAIDS forvaccine research have recently expressedinterest in evaluating microbicides [131].As for the future of microbicides, advo-cates maintain that the most challengingbarriers to the development of an effec-tive microbicidal agent or agents is finan-cial and political rather than scientific[132]. The key issue is still to identify asafe compound and to find a pharmaceu-tical company that is prepared to manu-facture it for retail at low cost. Otherissues relate to whether the microbicideis only virucidal (i.e. it will protect againstHIV and other sexually transmitted in-fections) or is also able to protect againstpregnancy.

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UNAIDS

These examples show that gender is nei-ther an abstract concept nor an insur-mountable barrier to the creation ofeffective programmes to reduce indi-vidual risk of HIV. However, many ofthese efforts have been tested only on asmall scale. In order for them to be ex-panded, evaluations need to allow

programme impacts to be disaggregatedby gender. Nevertheless, even the bestdesigned gender-sensitive individual riskreduction programme will not be enoughto fully address vulnerability to HIV andAIDS without complementary efforts toreduce societal vulnerability to HIV andthe impact of AIDS.

An expanded response to the epidemic in terms of prevention and

impact alleviation must include the rec-ognition that other sectors of society out-side the field of health need to be activelyengaged in reducing the barriers peopleface in effectively protecting themselvesand alleviating the impact of HIV/AIDS-related morbidity and mortality. Giventhat public health is ill-equipped to ad-dress wider contextual determinants ofvulnerability and impact, those workingin the field (most of whom are health re-searchers and practitioners), must lookelsewhere for solutions to reduce gender-related economic and social vulnerability.

Although the body of evidence thathas revealed broader gender-related de-terminants of vulnerability has grownsubstantially since the late 1980s, pro-grammatic responses to those factorshave evolved slowly. First, the processthrough which research is transformedinto an intervention is a slow one. Re-search must be conducted, then a pilotintervention must be designed, imple-mented and evaluated. Unfortunately,many research findings never get to thepilot phase due to lack of resources orchanging donor priorities. For thoseprojects that do make it to the pilot phase,there is a severe lack of useful evaluationdata on outcomes that would allow most

Efforts to reduce societal vulnerability

pilot interventions to be expanded. Eventhose that are found to be successful arerarely expanded or scaled up to servelarger populations.

Second, public health, with its primaryfocus on epidemiology and disease con-trol models, lacks the tools to mount so-cial and economic interventions toaddress the contextual issues that re-search has shown contribute to vulner-ability to HIV/AIDS. Similarly, thevertical nature of most economic andsocial development programmes hasmade evaluation of their outcomes interms of reducing societal vulnerabilityto HIV and the impact of AIDS particu-larly difficult. As a result, the creation ofprogrammes to address HIV/AIDS withina comprehensive and expanded responseframework has remained largely withinthe realm of theory.

Finally, a lack of understanding of thecomplexities and challenges of gender asa variable in vulnerability to HIV andAIDS limits the extent to whichprogrammes have been able to addressgender within their interventions to re-duce vulnerability.

25


Addressing gender-relateddeterminants ofvulnerability to HIV infection

Although only a limited number ofprogrammes have so far addressed gen-der and societal vulnerability, their num-bers are growing along with a widerrecognition of the link between the so-ciocultural and economic contexts ofmen’s and women’ differential vulnerabil-ity to HIV and the impact of AIDS. Therehave been targeted interventions, for ex-ample, that have sought to reduce the vul-nerability of female sex workers byproviding them with alternate income-generating skills and opportunities [52,134, 135, 136].

A few programmes have sought to im-prove women’s social and economic sta-tus, and thereby improve the sexualhealth of communities. Two suchprogrammes in Bolivia are Casa de laMujer and CIDEM/Kumar Warmi Clinic.Casa de la Mujer approaches women’sreproductive health from a holistic per-spective; its work is guided by the phi-losophy that women’s health is notmerely a medical issue but is affected andoften determined by the wider contextof home, relationships, politics, econom-ics and culture [137]. Besides offering re-productive health services, Casa de laMujer tries to respond to the other needsof the community with legal services(dealing mostly with domestic violenceand child support cases), psychologicalcare, education (including basic literacytraining and educating women abouttheir legal rights and the meaning of citi-zenship), potable water, nutrition, pre-ventive health, healthy environment,citizenship training, and labour training[137]. Although Casa de la Mujer wasconceived as a woman’s place with ac-tivities involving only women, theprogrammes now seek to involve hus-

bands and partners of their clients wher-ever possible, and to direct special effortsat youth of both sexes.

Similarly, the Centro de Información yDesarrollo de la Mujer (CIDEM)/KumarWarmi Clinic provides education and ser-vices that allow women to share knowl-edge, responsibility and decision-makingabout reproductive health and also par-ticipate in the design of health policiesand projects. CIDEM’s approach is basedon a gender perspective that permeatesthe project’s concepts, goals, methods andthe doctor-patient relationships. KumarWarmi provides not only accessible ser-vices in terms of low-cost and free ser-vices for very poor families, but also hasa family-friendly atmosphere as well ashumane and respectful treatment of poorand indigenous women. Its emphasis oncontinued patient/client education andgrowth, based on respect for differences,allows patients/clients to become activeparticipants in their own health care andmaintenance. This represents a shift awayfrom the more common situation wheremedical knowledge is the monopoly ofthe doctor. The clinic offers integrated ser-vices addressing biological, legal, psycho-logical and sociocultural aspects ofwomen’s health, with a complementaryfocus on traditional medicine, designedto recognize and reinforce the positivepractices of women participants [137].

Among the many programmes designedto improve women’s status, few havebeen evaluated. One exception is theParipurna Mahila (A Complete Woman)course designed by the New Delhi-basedAsian Centre for Organization Researchand Development (ACORD) in collabo-ration with local nongovernmental orga-nizations. The nine-month, nine-moduletraining course is designed to sensitizeboth men and women working withgrassroots organizations in low-income

26

UNAIDS

rural and urban areas to the significantcontributions made by women in the de-velopment process [138]. It aims to raisegender awareness among the participantsand to provide educational inputs forwomen so as to raise their self-esteem,increase their self-confidence and makethem aware of the factors responsiblefor women’s low status in society. Themodules include topics such as “womenand family”, “the woman as a person”,“women’s contribution to the economy”,and “women and the law” [138].

An evaluation of the first 500 partici-pants to enrol in the course quantitativelymeasured changes in perceptions relatingto prevalent myths, social expectations(gender roles), factual information andlegal awareness, some of which werefound to be statistically significant. Thequantitative data was supplemented byqualitative data which revealed signifi-cant gains in knowledge, as well as im-proved confidence and self-esteem. Theparticipants reported that of the ninemodules, the one on legal rights had themost impact in bringing about changesin perceptions and attitudes [138].

These examples provide a glimpse intothe overarching relationships that existbetween contextual realities and health.They share features such as mobilizingwomen for community health, a respectfor women’s autonomy and dignity, anda respect for women’s basic human rights.Furthermore, they recognize the impor-tance of bringing women into the pro-cess of programme development. Formany programme planners, however, thelink between improving women’s socialand economic status as a way to reducetheir vulnerability is not evident and, asa result, such projects have not beenevaluated specifically in terms of vulner-ability reduction. This reality poses achallenge to HIV/AIDS programmers to

assist those working in development toharness such projects and further dem-onstrate that improving women’s socialand economic status can have a signifi-cant impact in reducing vulnerability toHIV and the impact of AIDS.

Many other interventions andprogrammes have sought to improvewomen’s access to economic resourcesbut have fallen outside the purview ofHIV/AIDS prevention due in part to thefact that such programmes do not seekto reduce the spread of HIV or alleviatethe impact of AIDS as established goalsand objectives. In this category are vari-ous micro-finance projects for women(i.e. credit schemes and economic coop-eratives), initiatives to provide womenwith training to improve their skills andaccess to other economic resources, andlegal reform efforts to improve women’saccess to the legal and justice systems orto promote their economic and socialrights [102, 139]. It also includes empow-erment and leadership projects that seekto improve women’s self-esteem, confi-dence and political participation; projectsto address the incidence and causes of do-mestic violence; and programmes to im-prove women’s literacy and promotewomen’s access to formal and nonformaleducation. Even though the objectives ofthese programmes and initiatives neitherinclude HIV risk reduction nor seek nec-essarily to improve women’s sexual andreproductive health and rights, it is pos-sible that they may actually do so. Thelack of evaluation indicators designed tomeasure HIV-related outcomes makessuch a determination difficult.

There are exceptions, however. Recentevaluations of the Grameen Bank and theBangladesh Rural Advancement Com-mittee (BRAC) credit programmes forwomen indicate that these programmes’income generation activities can lead to

27


contraceptive acceptance and use amongpoor families. This suggests that womenwho control money and participate infamily decisions have more control overreproductive health decisions [140-143].Furthermore, these programmes havebeen shown to contribute to a decreasein the incidence of domestic violence, al-though the programme evaluators suggestthat expanding employment and incomegeneration to women is only one strategyfor alleviating domestic violence [39].

Similarly, a recent study conducted inNigeria explored correlates of women’sparticipation in household decision-mak-ing in the areas of their children’s educa-tion, reproductive and child health, andthe household economy. The study re-vealed that women whose preferenceswere achieved in these areas typically hadmore economic power, considerable mo-bility, better access to information, andindependent social and economic activi-ties outside the household [144]. Thefindings of the studies in both Bangladeshand Nigeria suggest that interventions toimprove women’s social and economicstatus can have a significant effect on re-ducing some of the key gender-relatedbarriers they face in protecting themselvesfrom HIV infection.

These examples of how programmeshave sought to address sociocultural andeconomic determinants of gender-relatedvulnerability to HIV infection reveal theneed for expanded evaluations of exist-ing interventions that include HIV-relatedoutcomes, as well as a need for moreHIV/AIDS programmes that seek to ad-dress gender-related sociocultural andeconomic inequalities as part of an ex-panded response to the epidemic.

Addressing gender-relateddeterminants of the impactof HIV/AIDS

In regions of the world where the epi-demic is well established, there are manyprogrammes that provide care and sup-port in a variety of ways. Some of themost successful programmes are thosethat have adopted a gender-sensitive ap-proach and recognize the burdens placedon women as a result of the economicand social impact of the epidemic. Addi-tionally, literature on impact alleviationshows that many local organizations thatprovide support are, in fact, run bywomen [145].

Communities have responded to theimpact of HIV/AIDS in their lives by de-veloping ad-hoc mechanisms that havebecome more formalized in recent years,such as The AIDS Support Organization(TASO) which provides counselling andcare to the extended family and betterways to serve the extended family that isoverburdened with care and support ofthe infected [146, 147]. This approachsupports prevention in that the goal is tolessen the burden of care for households,many of which are headed by women.The Society for Women and AIDS inAfrica (SWAA), which has branches in26 countries, works with governments,nongovernmental organizations andother groups from the international to thegrass-roots level in order to reduce eco-nomic and sociocultural conditions thatincrease women’s vulnerability. SWAAalso provides care and support servicesfor women living with HIV/AIDS, theirchildren and families, and provides train-ing and research on women and AIDS[146, 147]. In Zimbabwe, members ofthe Women and AIDS Support Network(WASN) work with women’s groups invarious sectors to support HIV-positivewomen and each other in prevention ac-

28

UNAIDS

tivities for women. WASN has alsofocused on risk reduction for women care-givers of family members living with HIV/AIDS, and has research in three commu-nities in Zimbabwe to improve its abilityto support and empower women to re-spond effectively to the epidemic. Resultsfrom WASN’s study were used to supportcommunity-based counterparts in theirefforts to raise awareness among womenabout prevention, care and support [148].

Recognizing the increasing burdens andresponsibilities placed on women to pro-vide for their HIV/AIDS-affected families,a number of community-based organiza-tions are implementing programmes thatincorporate both economic developmentand HIV/AIDS-focused activities. Forexample, in Uganda, ACORD runs anintegrated rural development programmefocusing on income-generating activities.In 1988, ACORD added an HIV/AIDSprogramme which offers counselling,support for people living with HIV/AIDS,education and training, and makes refer-rals to TASO for HIV testing. ACORDhas specifically addressed gender-relatedproblems confronting women whosepartners or family members die fromAIDS, such as the issue of inheritance andland rights, by working with the UgandaWomen Lawyers Association. This collabo-ration has resulted in an increasing num-ber of women being able to retain propertyafter the death of their spouse [149].

These programme examples reveal thatthe success of community-based interven-tions designed to address gender-relatedimpact depends on the involvement ofwomen and communities, and that theprocess of community mobilization of-ten supersedes the content of theprogrammes they develop [150, 151]. Ineach case, the process of engaging par-ticipants, listening to their stories, facili-tating the diagnosis of their problems and

working through potential solutionstakes precedence over the simple dissemi-nation of HIV/AIDS-related information.Unfortunately, the impact of the processof community mobilization exemplifiedin many of these programmes has notbeen evaluated.

Furthermore, although many gender-sensitive initiatives have begun to addresswomen’s vulnerability to HIV and theimpact of AIDS, gender-sensitive ap-proaches to male vulnerability are stilllacking. Campbell argues that only bytargeting both women and men canwe more comprehensively address gen-der relations in an effort to reduce riskand vulnerability to HIV/AIDS [9].Projects such as those supported throughthe Women’s Initiative of the AIDSCAPproject found that a “dialogue” approachto communication between men andwomen holds great promise for stimulat-ing and supporting sustained behaviourchange to reduce women’s and men’s riskand vulnerability to HIV. These assump-tions have been tested through an opera-tions research project conducted withtruck drivers and their spouses in Jaipur,India, in 1997. The results have since fa-cilitated the funding of a two-year pilotintervention that will expand the projectto more sites in India [152].

29


Three main conclusions can be drawn from this review of re-

search and programmatic activities toaddress gender and vulnerability to HIVand the impact of AIDS. First, there re-mains a substantial gap in our under-standing of male sexuality and the socialand economic forces that sustain formsof male sexuality that foster risky sexualbehaviour. Second, much more researchand programmatic is effort devotedstrictly to HIV prevention than to care,support and impact alleviation, especiallyas they relate to gender. Thirdly, whileresearch clearly suggests a need for con-textual interventions, there are very fewexamples from which to draw conclu-sions regarding the appropriate structureand content of programmes to addressgender within an expanded response toHIV and the impact of AIDS. In short,our understanding of what needs to bedone is substantially more evolved thanour understanding of how to do it.The challenges for the next generation ofHIV/AIDS research and programmingclosely match these conclusions.

From a research standpoint, one keychallenge is to improve our understand-ing of how gender influences men’sknowledge, attitudes and sexualbehaviour in order to fill critical gaps inthe design of prevention programmes thatcan more effectively address gender-re-lated factors that influence personal andsocietal vulnerability to HIV [50, 153]. Aswith the examination of women’s vulner-ability to HIV, male sexuality also needsto be examined within its social context

IV. Conclusionsand challenges for the future

and not just in terms of individual riskreduction [9, 36]. Equally as importantfor research is to gain a clearer under-standing of how gender influences men’sroles in alleviating the impact of AIDSand of how providing care and supportwill promote the development of responsesin which men and women share the bur-dens of the epidemic more equitably.

A second key challenge is for HIV/AIDS and development programmes toadvocate for and provide more resourcesfor gender-sensitive care and support ini-tiatives, particularly now that manycountries have experienced the epidemicfor more than a decade. The modellingof expanded interventions that recognizethe importance of a prevention-care-support continuum will be critical asother regions begin to experience wide-spread HIV/AIDS-related morbidity andmortality in the coming decade.

A third key challenge for the future isthe development of very specific indica-tors that will enable interventions to mea-sure reduction in gender inequalities asthey relate to vulnerability to HIV/AIDS.In an age of proliferating indicators, how-ever, there is a need for “process solu-tions” that respond to local circumstancesin a more meaningful manner. There canbe no ready-made formula for measur-ing the overall effectiveness of a widerange of programmes, especially thosedesigned to reduce economic and socialvulnerability to HIV/AIDS [154]. Inter-vention research supported through newinitiatives (such as HORIZONS, a five-

30

UNAIDS

year operations research programme sup-ported by USAID) can provide appropri-ate and cost-effective strategies to test andevaluate the potential effectiveness of in-terventions and document internationalbest practices in HIV/AIDS prevention,care, support, and alleviation of impact.

Furthermore, there is a need for amuch broader understanding of genderwithin institutions. The institutionaliza-tion of gender has long been problem-atic, although programme experiencesuggests that it can be successfully accom-plished over time. A review of evaluationresults from a number of internationalagencies, such as the Canadian Interna-tional Development Agency (CIDA), theInternational Labour Organisation(ILO), the United Nations DevelopmentProgramme (UNDP) and the World Bankhave yielded valuable lessons on success-ful models of gender institutionalization[155]. First, there must be a political com-mitment to gender, publicly stated by theorganization’s leadership. Second, a par-ticipatory approach to developing insti-tutional mechanisms for addressinggender has been found to be mosteffective in promoting ownership at dif-ferent levels within institutions. Third,gender must be incorporated acrossprogrammes, rather than placed withina separate unit or individual, ifmarginalization of gender issues is to beavoided. At the same time, the successfulinstitutionalization of gender must in-clude accountability and must rely onprogramme efficiency rationales, ratherthan simply on changing the attitudes ofindividuals within an institution, if suc-cessful integration is to be achieved [156].

Other gender institutionalization ex-amples include the government of SouthAfrica, where an institutional frameworkon gender has been created, including anOffice of State for Women, located in the

President’s office. Gender units have beenestablished in various sector ministries(e.g. Trade and Industry, Finance, LandAffairs) and gender policies instituted.In addition, an independent gender com-mission has been set up to monitor howwell the national gender framework isworking [157]. Similar institutionaliza-tion of gender has been central to themultisectoral approach of the UgandaAIDS Commission since the early 1990s[158, 159]. More recently, the UN Gen-der Working Group issued a UN JointGender Policy Statement for Malawi, inresponse to that government’s call fordonor organizations to support the Na-tional Policy Framework for PovertyAlleviation programme. The policy state-ment is an effort to ensure coordinationamong the various UN agencies workingtowards “the empowerment and ad-vancement of women, which are neces-sary in the process of eliminating theexisting gender imbalances” [160].

Finally, programme experiences sup-port the need to continue providing front-line workers with the tools to undertakegender analysis, whether this be throughresource kits, training programmes,workshops, seminars or technical sup-port. Within communities, some of therespondents provided examples of howcommunity capacity-building is beingapproached. The general feeling was thatthere is no one solution, thus supportingthe need for process-oriented solutionsthat are informed by experiences at thegrass roots [154, 161-163].

31


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