Stopping HIV before it begins: issues faced by women in India
Suniti Solomon1, Jessica Buck2, Sreekanth K Chaguturu2, A K Ganesh1
& N Kumarasamy1
1 Suniti Solomon, A. K. Ganesh & N. Kumarasamy are at the YRG Centre for AIDS Research and Education, Voluntary Health Services, Tharamani, Chennai 600113, India
2 Jessica Buck and Sreekanth Chaguturu are at Brown Medical School, Providence, Rhode Island 02912, USA.
Despite advances in understanding HIV pathogenesis, the economic, social and legal constraints in India continue to make women particularly vulnerable to HIV infection.
Indian women attending HIV education classes.
More than 40% of new human immunodeficiency virus (HIV) infections occur among women globally, mostly through sexual transmission1. Despite prevention efforts during the first 20 years of the HIV epidemic, women continue to be vulnerable to HIV. This is nowhere more apparent than in India, where approximately four million HIV-infected individuals live and up to 46% of these are women2.
Nearly 90% of the HIV-infected women in a study from south India reported a history of monogamy and marriage as their only risk factor for HIV3. However, many of the women seen in south India test positive for HIV early in infection, when they are still asymptomatic. They were tested as part of prenatal care or because their husbands were presenting for care4.
How are women vulnerable to infection? A woman's reproductive tract is more biologically vulnerable than a man's reproductive tract to HIV and other sexually transmitted infections5. However, other forms of vulnerability less often discussed—economic, social, cultural and legal discrimination—also drive this epidemic in women.
In India, the social construct of gender, which has evolved over several hundred years, makes women highly vulnerable to HIV and other sexually transmitted infections. Gender imbalance curtails women's independence and offers expanded sexual freedom for men by enforcing differing rules of conduct.
Cultural vulnerability from birth In India, different values are placed on the births of female and male children. Male children are celebrated and pampered, whereas the birth of a girl is treated with disappointment or indifference. Boys are provided with many educational, career and marriage opportunities not available to girls. Boys have fewer obligations than girls in the home, allowing them to pursue educational opportunities and interests further. Instead of investing in a daughter's education, families save for her dowry and marriage.
Silence and virginity As a woman matures, she is expected to maintain a culture of silence when confronted with issues of her own sexuality. A woman who speaks about sex is considered to be promiscuous. This suppresses a women's ability to access information about her sexual health for fear that her reputation will be damaged.
The pressure for women to maintain virginity until marriage heightens this fear. Many women engage in alternative and even risky sexual behaviors such as anal sex in an effort to maintain their virginity6. When women do engage in sex, their ignorance and the continued culture of silence make them unable to negotiate safer sex practices.
Men also have difficulty accessing information about their sexual health because admitting ignorance about sexual matters is an affront to their masculinity. Ideas of masculinity that promote promiscuity and even sexual violence cause many men to experiment with unsafe sex practices. Lack of knowledge regarding sex and sexual health lead men to believe in myths, such as the idea that having sex with a virgin may cure them of their sexually transmitted infections (STI; S.S., unpublished observations, abstract 114, 10th Conference on Retroviruses and Opportunistic Infections, Boston, 2003).
Motherhood and violence As with virginity, motherhood is also a virtue in India. A woman's value often resides in the number of children, especially males, that she can produce. The woman is always blamed in a childless couple, and barren women are considered bad luck. Using barrier methods or nonpenetrative sex as safer sex options are seen as affronts to this conception of motherhood.
The pressure for children is even greater among HIV-serodiscordant couples. In one study from an HIV care center in south India, 44% of couples were serodiscordant for HIV, but many women are willing to risk acquiring HIV to conceive a child. However, there are cases in which a woman will know her husband is HIV positive, but the mother-in-law, oblivious to her son's HIV status, threatens a second marriage for her son because a child has not been produced for the family. The woman must now decide between saving her marriage or saving herself.
In addition to reproductive pressures, a woman has the pressure of pleasing her husband. If a woman refuses intercourse with her husband, she is seen as an unaccommodating wife. She risks violence, abuse and abandonment. These risks impede a woman's ability to negotiate safer sex practices.
The relationship between violence, risky behavior and reproductive health is clear; individuals who have been abused multiple times are likely to engage in riskier sexual practices. In India, a woman is raped every 34 minutes. A woman is burned to death over dowry issues every 93 minutes7. In one study in India, men who reported extramarital sex or STI symptoms were 6.2 and 2.4 times, respectively, more likely to report wife abuse than those who had not8.
Many women remain in these relationships for fear of abandonment. They tolerate the infidelity and abuse of their husbands and submit to their demands to avoid further abuse. The culture of silence is maintained, and many view this violent relationship as 'normal'.
Empowerment of women It is depressing that it takes a ruthless epidemic to awaken the world to the needs and condition of women. What are the next steps? Addressing the gender inequities that lie at the root of the pandemic requires a multipronged response that increases women's access to productive resources and protects girls and boys from the corrosive effects of gender stereotyping.
HIV prevention program for rural women.
Empowerment begins with education. Girls must be provided with the same educational opportunities as boys. Key organizations like the World Health Organization, the United States Agency for International Development, the United Nations Programme on HIV/AIDS and the United Nations Children's Fund are now starting to realize the importance of educating girls in stemming the HIV pandemic. These organizations, in collaboration with governments and nongovernmental organizations, have begun promoting education of girls in India and throughout Africa and Asia. They provide scholarships, supplies and flexible education hours that allow girls to complete chores and attend classes. They also help relieve girls' obligations within the home by providing support for families, and work with community leaders to emphasize the importance of educating girls. Collaborations and programs such as these need to be expanded.
Another important source of power is access to economic resources and assets. Educational programs such as those described above, along with skilled training programs and 'micro-credit' loan schemes, can help women to achieve economic independence. Such programs have demonstrated that women feel more confident in negotiating and protecting their sexual autonomy and health as well as their rights in general once they have acquired economic resources. In addition, society must also ensure that laws against gender discrimination in hiring and salary practices are enforced and that property and inheritance rights of women are protected.
Women in sex work have historically been disempowered and are at risk for exploitation, violence and infection. Programs that organize and mobilize sex workers have been successful in increasing the power of these women and their communities. Organizations from all over India have combined into The National Network of Sex Workers to improve the social, economic and health conditions of these women. Such programs must be strengthened and expanded.
Further empowerment comes with political representation. Despite the fact that the population of India is more than 48% female, women represent only 7% of the parliament, 4% of the state high courts and supreme courts, and 3% of civil service administrators9. The Women's Reservation Bill, introduced 5 years ago in the Indian Parliament, which reserves 33% of all elected bodies for women, has yet to be passed9. Globally, the Cairo Agenda and the Beijing Platform for Action call for specific reforms to address female representation and empowerment. These initiatives need to be implemented as soon as possible.
Involvement of men Empowerment will not be effective until women enjoy the same rights as men. Gender inequities and power dynamics inherently involve both genders, so it is important that men are not excluded when issues affecting women are addressed. Sensitizing females and males to these issues at a young age may reduce risky behaviors and violence while enhancing information-seeking behavior and female autonomy. The United Nations Population Fund, The Population Council, the United Nations Development Fund for Women and other organizations have started several programs in India and throughout the world to promote constructive and healthy relationships. These programs encourage men to be supportive partners and take responsibility in issues of sexual and reproductive health.
In India, these programs must promote the value of women as people and reverse the concept of women as property transferred along with dowry from fathers to husbands. More must be done to examine the effect of placing responsibility and blame for sexual activity, marriage and reproduction solely on the shoulders of women, while relieving men of responsibility of sexual risk behaviors and violence.
Couples' counseling, family planning, and medical testing and care provide another outlet to promote open communication between genders. Such programs can help reduce the practice of blaming women for infections, infertility and other sexual and family issues, while encouraging both partners' involvement in decision-making.
Information, healthcare and prevention While addressing the overall, long-term goals of empowerment and gender dynamics, we must also take more immediate steps to stem the epidemic and allow women the ability to protect themselves. Lack of access to information, skills and healthcare prevents women from having control over their lives. As it is often difficult for women to access services without the permission or monetary support of their husbands, steps must be taken to provide services to women in convenient, low-cost and discreet environments. In a south Indian voluntary counseling and testing center, women represent a growing proportion of attendees, and increasing access to voluntary counseling and testing centers may provide a concurrent opportunity to increase access to sexual health information10.
In addition to lacking information, women often have no choice in whether or not typical male-controlled HIV and STI prevention methods are used. Research in south India found that only 23% of women felt comfortable encouraging condom use with their primary partner and only 5% would refuse sex without a condom (A. K. Srikrishnan et al., reported in abstract O777, Sixth International Conference on AIDS in Asia and the Pacific, Melbourne, 2001). Research and development of female-controlled methods of HIV and STI prevention, such as vaginal microbicides, needs to continue. In the same study from south India, 83% of women reported that they would be willing to use a microbicide to prevent HIV and STI transmission. The willingness of men to allow sexual partners to use microbicides to prevent HIV and STI transmission varied; 89% would allow nonprimary sexual partners to use microbicides, whereas only 42% would allow their primary partners to use them. This emphasizes the need for female-controlled prevention strategies that do not require permission from men (A.K. Srikrishnan et al., reported in abstract O777, Sixth International Conference on AIDS in Asia and the Pacific, Melbourne, 2001).
Conclusions Empowering women ultimately empowers communities, countries and the world at large. Until policy makers, healthcare providers, mass media, development assistance agencies and others concerned with stemming this HIV pandemic take into account strategic gender interests and power dynamics, it will be impossible to devise effective solutions. We absolutely must make the impossible possible, and with proper planning and execution, we firmly believe that it can be done.
Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO). AIDS Epidemic Update: 2001 (UNAIDS/WHO, Geneva, 2001).
National AIDS Control Organization. Surveillance for HIV Infection/AIDS Cases in India (Ministry of Health and Family Welfare, Government of India, New Delhi (2001).
Weiss, E., Whelan, D. & Rao Gupta, G. Sex. Relat. Ther.15, 233–245 (2000). | Article |
Progress of South Asian Women, 2000 (United Nations Development Fund for Women, New Delhi, India, 2000).
Martin, S.L. et al. JAMA287, 1967–1972 (1999).
Rao Gupta, G., Whelan, D. & Allendorf, K. 2002 Expert Consultation on Integrating Gender into HIV/AIDS Programmes (International Center for Research on Women, Washington, DC, USA, 2002).
Solomon, S. et al. AIDS Behav.4, 71–81 (2000). | Article |
