Special AIDS threat to women

26 World Health • November-December 1990 Special AIDS threat to women Rosmarie Erben Men can protect them- selves against the sexual transmis- sion of HIV. Women find it more problem- atic. This is the difficult issue that challenges health promotion. Negative influences The condom is seen at present as the only effec- tive preventive measure against sexual transmis- sion of HIV. Yet, "Only as we move into the 1990s hos the world started to recognize the special threat that AIDS poses to women." The ability of women either to protect them- selves from infection or, in case they are infected, protect others, is nega- tively influenced by several fac- tors: psychoso- cial, cultural, and legal barriers to women's deci- sion-making or 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 abandoned. In cultures where the married woman is traditionally expected to bear many children, insisting on safer sex or refusing to engage in sexual rela- tions 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 mortality rates to increase by 36 per cent; about three million women are currently HIV-infected; and finally, over 100 million cases of sexually transmitted diseases are reported each year, pointing to the enormous potential for sexual trans- mission of HIV. With the AIDS pandemic, as with many other health problems, women have often been viewed as "reser- voirs of infection," posing a threat to men, and also to their babies, since vertical transmission has been recog- nized. 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 injec- tion equipment used either in the medical environment 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 our- selves 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 dependent on the living and working conditions common to our society. 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, husbands or partners and parents; women's gener- ally lower literacy, limited mobility, and limited access to iriformation; 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 recognized. Confronted 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 realized that behaviour- individual and collective- can dictate a sen- tence of death. In recent years, health promotion has helped gay men in the industrialized world to effect major changes in individual and group sexual practices. But only as we move into the 1990s has the world started to recognize the special threat that AIDS poses to women. World Health • November-December 1990 Health promotion uses five key areas as its framework for interven- tion: they refer to public policy, supportive environments, community action, individual skills and health services. In the public domain it goes beyond health care. It aims to combine complementary approaches, including legislation, fiscal measures and organizational changes leading to health and social policy that in tum foster greater equity. Present approaches vary widely. In one country, for example, HlV- infected professional blood donors (virtually all men) are not isolated or punished. Prostitutes who test posi- tive, on the other hand, are quaran- tined and held in prison long after their legally imposed sentences. Thirteen states in the USA have passed Jaws making compulsory the testing of individuals convicted of prostitution (85 per cent of those convicted are women). Proposals to test men have not been enacted into law. Not really powerless The need for supportive environ- ments arises because fear and preju- dice are the primary attitudes towards women who are HlV- 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 orga- nizations and women's groups. Women are not really powerless. It is a question of identifying our strength," says an organizer of the Zimbabwe 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 atti - tudes towards women who are HIV- infected or have AIDS, and to promote a more positive environ- ment, is high on the list of health promotion priorities. Indeed one main objective is to establish closer communication between those affected by the virus and that part of society that defines itself as healthy. An important aspect of supportive environments is "to make the health- ier choice the easier choice" and facilitate non-risk behaviour. In the case of AIDS, this means easy access to condoms. Programmes of free distribution 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 27 Philippines, the Republic of Korea and Thailand have worked for better information, education and treatment of women with HIV infection. They have campaigned to have HIV- 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. Women's community action groups can play a crucial role in pressuring governments to change The concept of women as "reseNoirs of infection " denies the reality that women get infected through sexual contact with men, as well as by drug abuse. 28 laws or reorient budgets to ensure that funds are allocated for AIDS prevention and care. Increasing the involvement of nongovernmental organizations, particularly at the community level, is a must. What about the individual ? The process of "enabling people to increase control over their health" is at the heart of health promotion. Hence the focus on providing infor- mation and enhancing life-skills. Most studies carried out in various cultural and economic contexts reflect misconceptions and consider- able confusion about HIV transmis- sion and AIDS. So it is important to study the knowledge, attitudes, beliefs and behaviour of women and link the results to information and education activities. How to reach women in certain cultural settings and how to communicate with them are also major questions for health promotion research. "Safer sex" workshops are an important component of health promotion, 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 prevention and control of HIV infection must be closely tied with existing services for women, moth- ers and children. All services pro- viding maternal and child health care, family planning and treatment of sexually transmitted diseases must ensure that HIV/AIDS activi- ties 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 trans- fusions are given to women and young children in connection with childbirth and its complications. On the broader level, health services need to be more sensitive to cultural needs and client expecta- tions. Too often, health care is given from the perspective of the health care providers 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 organizations, by local authorities, industries and the media. It offers opportunities for new, broad-based health-oriented action. In the case of World Health • November-December 1990 women and AIDS, it is directed against the stigmatization and social disadvantage experienced 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. • Dr Rosemarie Erben is the Health Promotion focal point for the Global Programme on AIDS, World Health Organization, 121 I Geneva 27, Switzerland. How AIDS is A IllS !S >prewl mainly through SEX UAl. INTERCOURSE .vith an mfccted ~rson AIDS is spread through INfE TEO Llt.OO[) TH i\NSfUSION. A I US is spread through INFECTIW WOMAN DURING PREGNANCY to her unborn child. ~======~====~==~~~ ~ro,, .,.. ,., .,., AIDS! Have sexual intercourse with a faithful partner for life. ~ Accept medical treatment only from trained health workers i~ health ~ tres where equipment is kept sterile and blood is checked agmnst AIDS! J Uglndl ~hool HeJll.h lit Oft AI{IS Control (ltoll 1) UNIC(f Killll>lll i A poster from Uganda explains the transmission of HIV infection.