The special threat to women / by Rosmarie Erben

The special threat to women by Or Rosmarie Erben Health Promotion focal point, WHO's Global Programme on AIDS en can protect themselves against the sexual trans- mission of HN. Women find it more problematic. This is the difficult issue that challenges health promotion. The condom is seen at present as the only effective preventive measure against sexual transmission of HN. Yet, for many women - whatever the cultural context - to suggest to their husband or partner that he use a condom is seen as evidence of the woman's infidelity or is felt by the man as defiance or insolence. This results at best in painful discussions and a breach in the relationship, or at worst in the woman being beaten and aban- doned. In cultures where the married woman is traditionally expected to bear many children, insisting on safer sex or refusing to engage in sexual relations is impossible. These "facts of life" become even more dramatic when we look at the statistics. Some 200,000 women are expected to become ill with AIDS in 1990-1991- more than the total of all those who have developed AIDS since 1980; a seroprevalence of 20 per cent in pregnant women causes infant mor- tality rates to increase by 36 per cent; about three million women are cur- rently HN-infected; and finally, over 100 million cases of sexually trans- mitted diseases are reported each year, pointing to the enormous potential for sexual transmission of HN. With the AIDS pandemic, as with many other health problems, women have often been viewed as "reservoirs of infection," posing a threat to men, and also to their babies, since vertical transmission has been recognised. This concept has denied the reality that women get infected either through sexual contact with men who, too often, refuse to use condoms, or through unsterile injection equipment "Only as we move into the 1990s has the world started to recognise the special threat that AIDS poses to women." WORLD HEALTH, November-December 1990 used either in the medical environ- ment or to inject psycho-active drugs. The way we perceive ourselves and others, the way we express ourselves with our bodies, the way we use our bodies and protect ourselves or not from health hazards are all developed in relation to the culture in which we live, within an overall framework of individual and collective ways of living. The choices we are able to make vary from culture to culture, and are depen- dent on the living and working condi- tions common to our society. Negative influences The ability of women either to protect themselves from infection or, in case they are infected, protect others, is negatively influenced by several factors: psychosocial, cultural, and legal barriers to women's decision-making or independent action; the relative lack of economic alternatives for women, and their consequent dependence on men for support; women's role as primary caretakers of children, hus- bands or partners and parents; women's generally lower literacy, limited mobility, and limited access to information; and last but not least, cultural and moral attitudes towards sexuality. The vulnerable position of most women when it comes to sexual practices has to be recognised. Con- fronted by this situation, what can health promotion hope to achieve? With the advent of AIDS, health promotion has taken on a sense of urgency. People have suddenly realised that behaviour - individual and collective - can dictate a sentence of death. In recent years, health pro- motion has helped gay men in the industrialised world to effect major changes in individual and group sexual practices. But only as we move into the 1990s has the world started to recog- nise the special threat that AIDS poses to women. Health promotion uses five key areas as its framework for intervention: they refer to public policy, supportive environments, community action, indi- vidual skills and health services. In the public domain it goes beyond health care. It aims to combine comple- mentary approaches, including legisla- tion, fiscal measures and organ- izational changes leading to health and social policy that in turn foster greater equity. Present approaches vary widely. In one country, for example, HN-infected WHO/ J. Hernandez-Claire 7 professional blood donors (virtually all men) are not isolated or punished. Prostitutes who test positive, on the other hand, are quarantined and held in prison long after their legally imposed sentences. Thirteen states in the USA have passed laws making compulsory the testing of individuals convicted of prostitution (85 per cent of those convicted are women). Propo- sals to test men have not been enacted into law. Not really powerless The need for supportive environ- ments arises because fear and pre- judice are the primary attitudes towards women who are HN-infected or have AIDS. They may be denied medical assistance, rejected by their family and friends, and forced to leave their jobs. "If women can't get support from their families, they can get it from traditional organizations and women's groups. Women are not really power- less. It is a question of identifying our strength," says an organizer of the ZimbabvJe Women's AIDS Support Network. The Network gives women the confidence to fight AIDS and suggests ways of doing so in a society where women have little control over the sexual behaviour of their menfolk. The need to change social attitudes towards women who are HN-infected or have AIDS, and to promote a more positive environment, is high on the list of health promotion priorities. Indeed one main objective is to establish closer communication between those af- fected by the virus and that part of society that defines itself as healthy. An important aspect of supportive environments is "to make the healthier choice the easier choice" and facilitate non-risk behaviour. In the case of AIDS, this means easy access to condoms. Programmes of free distribu- tion exist in some countries and are supported by WHO. Examples of community action, especially through effective self-help and support groups that women have set up, can be found in many coun- tries. Such groups in India, the Philip- pines, the Republic of Korea and Thailand have worked for better information, education and treatment of women with HN infection. They have campaigned to have HN-infected women released from detention and lobbied for the free distribution of condoms to tourists. They have fought for the rights of people with AIDS and their families. "EMPOWER" is a support group run by and for women working as bar hostesses in Bangkok. 8 WHO/J. Hemandez-Claire WORLD HEALTH, November-December 1990 Women's community action groups can play a crucial role in pressuring governments to change la\NS or re- orient budgets to ensure that funds are allocated for AIDS prevention and care. Increasing the involvement of non-governmental organizations, parti- cularly at the community level, is a must. What about the individuaR The process of "enabling people to in- crease control over their health" is at the heart of health promotion. Hence the focus on providing information and enhancing life-skills. Most studies carried out in various cultural and economic contexts reflect misconcep- tions and considerable confusion about HN transmission and AIDS. So it is important to study the knowledge, attitudes, beliefs and behaviour of women and link the results to informa- tion and education activities. How to reach women in certain cultural set- tings and how to communicate with them are also major questions for health promotion research. "Safer sex" workshops are an important component of health pro- motion, both by encouraging women to think creatively about sexuality and by providing practical information. They can be run by trained female health educators, but members of peer groups can also be trained and usually prove extremely effective . In developing personal skills, it is vital to use the language of the women themselves and to rely on interactive processes. As for the health services, the pre- vention and control of HN infection must be closely tied with existing services for women, mothers and child- ren. All services providing maternal and child health care, family planning and treatment of sexually transmitted diseases must ensure that HN /AIDS activities are integrated in their own activities. In addition, women must have access to safe blood supplies and safe medical injections. In the developing world, most blood transfu- sions are given to women and young children in connection with childbirth and its complications. On the broader level, health services Left: The concept of women as "reservoirs of infection" denies the reality that women get infected through sexual contact with men, as well as by drug abuse. Right: A poster from Uganda explains the transmission of HW infection. WORLD HEALTH, November-December 1990 need to be more sensitive to cultural needs and client expectations. Too often, health care is given from the perspective of the health care pro- viders irrespective of how appropriate this may be for the patient. What women desperately need, very often, is more attention and support. Finally, health promotion cannot be achieved by the health sector alone. It demands coordinated action by governmental and voluntary organi- zations, by local authorities, industries WHO/J. Hemandez.Ciaire The special threat to women and the media. It offers opportunities for new, broad-based health-oriented action. In the case of women and AIDS, it is directed against the stigmati- sation and social disadvantage experi- enced by those affected by the disease. It seeks to enable women to say "No" to sex risk behaviour, and this means giving them knowledge, social support and economic independence. In short, health promotion calls for concrete and efficient action, tolerance, equity and solidarity. • How AIDS is Spread \IllS,, -;>r<'a<l IIHtJili y through :.; ~: ·, UAI. 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