Women and AIDS / by Elizabeth Reid

Women and AIDS by Elizabeth Reid Consultant with the Health Advancement Division, Austral ian Department of Community Services and Health, Canberra Men and women alike are at risk of infection from the HIV virus, yet in many ways women are particularly vul- nerable. The chronology of the epi- demic in the developed world has lulled many women into a false sense of security, since it emerged historically as a disease of men. Women continued with their daily lives of working, caring for their children, maintaining the home , unaware that in many important ways they were at risk of infection. This is not true of women in sub- Saharan Africa or parts of Latin America , who can read the chro- nology of this disease on the faces of their women friends as they waste away and die. They watch men and women die in equal num- bers . The modes of transmission of the virus are the same for women as for men: through blood , invas- ive instruments or sexually. Thus women's susceptibility arises large- ly from their reproductive role and their place in society. For men , both homosexual and heterosexual, self-identity is , to a significant extent, bound up with male sexuality, and this places men at particular risk of sexual transmis- sion. Women's self-identity is not based , to the same extent as men , on their sexuality , but there are other factors which put them at 28 risk. One is their social and sexual passivity; in particular, a lack of assertiveness in interpersonal rela- tions. Women, even when they are aware of the risk of transmission , find it difficult to insist on safe or protected sexual intercourse , just as they find it difficult to insist on the act being a pleasurable one for them. This socialised passivity is linked to a form of conformity by default which arises when women are not taught the skills required for saying no: saying no to experimenting with or taking drugs ; saying no to alcohol; saying no to sexual propo- sitions. These are all social situ- ations in which women must now be able to refuse to participate in order to protect themselve. In the 1970s this was acknowledged on a badge which read: " I have just said no and I don 't feel guilty." Today , however, for many women, the as- sertion must be: either a condom or not at all. Bargaining within casual or longer lasting sexual rela- tions is not consonant with the non- assertive or peacemaker roles in- stilled into women. Another critical factor, in " West- ern" societies at least, is the incul- cated belief in the myth of romantic love. True love or falling in love are assumed to be beyond the reach of reason. One is caught up and swept along. Orderliness , it is assumed, will happen later on. Data on prostitutes show how pervasive and how dangerous these myths are . A number of studies show a high level of awareness in prostitutes of the way the disease is transmitted , and they often require clients to use condoms. But in their private lives , prostitutes often do not use condoms, on the grounds that this is a way of distinguishing love relationships from work rela- tionships , that it would not be ro- mantic to use them, and that the husband or sexual partner would not allow it. Men with multiple sexual part- ners , whether heterosexual or bi- sexual, place women at high risk of infection. Often the wives or sexual partners of these men are not aware of the existence of other sexual partners and so are at risk without their knowledge. In these cases , women are vulnerable to infection , not through their own behaviour but through the behaviour of their sexual partners , and without the ability to protect themselves from infection. There are also socio-economic factors which put women at risk, in particular those factors which force women to work in the sex industry. In many developing coun- tries , for instance, there is an WORLD HEALTH, March 1988 increasing displacement of women to urban slum areas. There , because of what is considered acceptable or appropriate behaviour for men and women, and because of discrimina- tion in access to education, training and land ownership, many women drift into prostitution and become vulnerable to infection with the virus. A number of social customs re- lating to women must now be re- considered for risk factors. One of these is the use of blades or other instruments in female circumcision . There is no evidence as yet of trans- mission of the virus by this means , but the practice puts women poten- tially at risk. Childbirth places mid- wives and traditional birth atten- dants at risk in areas of high female infection. In rural areas , these women are called from their fields to attend a birth. Their hands are marked by their work , and usually neither gloves nor other means of protecting themselves are available or routinely used. Women who are infected or whose partners are infected are at present faced either by a life with- out any, or any more, children or by the possibility of giving birth to an infected child. Women are still choosing to have children in these circumstances. Studies of wives of infected men with haemophilia W ORLD HEALTH, March 1988 indicate that this choice is being made despite a great deal of knowl- edge about the risk of infection to themselves and to their child. Is it that life without childbirth , child- bearing, and children is unaccept- . able? We must look at the nexus between conception and child rais- ing. Is this link essential or can the desire for children be satisfied by raising children other than one's own? Is this socially acceptable or normal? Is it legally possible? If this nexus cannot be broken , the choices for women are stark: child- lessness or the possibility of death for themselves and their children. However, there are also ways in which the existence of this terrible disease may even help women , and certainly ways in which women can help to prevent its spread. Commu- nities are being forced to face many issues which previously had been ignored or denied: extramarital sexuality , adolescent sexuality , prostitution, homosexuality and in- travenous drug use . One positive outcome for women may be the need to take a more ac- tive role in social and interpersonal relations. Their self-confidence and assurance will be essential to com- bat this epidemic, not only to pre- vent sexual transmission but also transmission through intravenous drug use and even through medical Facing page : AIDS is a double tragedy when both mother and child are infected. Left: Health education for two girls in an African capital. Above : Red light area in a European city. Women impelled by social factors into the sex industry are inevitably among the high-risk groups. Photos WHO/E. Hoope r, M . Goldwater/Network and (above) L. Sirman © treatment. In developing these skills , individual women will be bet- ter able to protect themselves and to limit the spread of the virus. The role of women 's organiz- ations in containing this epidemic will be crucial. Firstly , they have the potential to assume a direct pre- ventive role. This has already oc- curred in many countries where women have organised themselves , for example, in Mexico and India against rape , in India and Kenya against alcoholism in men . Secondly , women's organizations have an important educational role and are a means of reaching not only into each community and vil- lage but into each household. The message that must go out about the means of containing the epidemic will strike a chord with women. One common source of distress to women , illiterate or literate , in villages or towns , is the disintegration of relationships be- tween men and women , the grow- ing lack of trust, responsibility and communication. To survive unin- fected , particularly from sexual or intravenous transmission , women must learn not only to be assertive but to choose or create relation- ships based on mutual concern and respect. This in itself should lead to an improvement in the quality of their relationships. • 29