Gender and the HIV/AIDS Pandemic.

HIV/AIDS has appeared in many guises since the first cases of the devastating illness emerged in the early 1980s, but its explosive growth can only be explained by a combination of factors that transcend the merely biological. The social, cultural, economic and even political aspects which comprise the HIV/AIDS pandemic make it one of humanity's greatest challenges at the beginning of the 21st century. At the same time, HIV transmission has exposed yet again the persistent inequality which dominates gender relations, the unequal access of women to resources and social participation in comparison with men and the imbalance of power and control over decisions regarding sexuality and reproduction. This historical inequality encourages HIV infection among females, especially although not exclusively among poor, marginalized and unprotected women who cannot adopt preventive measures.

Dealing with HIV/AIDS must necessarily include a gender perspective because "gender inequality is evident at all stages of the prevention-care continuum. Gender inequalities affect, amongst other things, the possibilities of prevention, access to appropriate materials, information and resources, the quality of care received, and survival chances." (Tallis, 2000)

Because of the need fully to protect the fundamental human rights of those infected and affected, a transversal rights focus must inform any and all policies, programs or interventions related to HIV/AIDS. But in addition to this perspective, a parallel analysis from a gender perspective is also required because the original concept of basic human rights suffers from a clear masculine bias, despite the more inclusive view which emerged in the second and third generations of human rights advocacy. Traditional human rights approaches are based on a male norm, and women's rights are not always seen as human rights. Some human rights as currently defined may not have significance in the lives of women. For example, freedom of expression has little impact on women who have been denied education, are illiterate or are silenced in other ways" (Tallis, 2000).

Evolution of the Pandemic

Although at first AIDS became known as the 'pink plague" when only homosexuals seemed to be vulnerable to the infection, public health evidence soon proved that the sense of safety enjoyed by heterosexual males and the female population was an illusion. Men and women of all ages, with different lifestyles and different sexual practices, slowly and then explosively began to appear in the epidemiological statistics on HIV/AIDS. especially in the 1990s when the virus began to spread principally by heterosexual transmission. Only then did the many sectors involved - governments, health professionals, the scientific community, international agencies and NGOs working in the area - admit that HIV did not recognize boundaries of sex, age, race, social status or sexual preference. Nor did it confine itself to the so-called "risk groups" - homosexuals, sex workers, injecting drug users - which for years gave those far removed from these categories of human behavior a false sense of security.

But even more than heterosexual men, it was women who were truly made invisible during the debut of the pandemic. Not only were women left out of the early prevention education campaigns, even worse, they themselves were convinced that they were not at risk. Medical research aimed at probing the mysteries of AIDS also ignored women. As a result, research into the characteristics of the infection in women, the diagnosis and evolution of the disease in the female body, the differential impact in their biological processes, the efficacy of the therapies, survival rates, etc., were addressed by the scientific community somewhat reluctantly and much later in the development of the pandemic. This attitude failed to take into account what the statistics were saying: that in Africa and the Caribbean, infection rates among females were very high, a phenomenon which was likely to be repeated in other regions. In fact, this is precisely what has occurred.

However, when the necessary focus on women finally emerged, it was linked to the urgent need to diminish perinatal infection, that is, transmission from the mother to the child during pregnancy, birth or breastfeeding. But the attention failed to include a real concern for women beyond their reproductive role, as sexual beings with rights, needs and demands transcending the historical mandate of biological and social reproduction. In fact, this focus stigmatized women as "vectors", as potential transmitters of the virus to "others", i.e., their children or sexual partners, a paradigm which remains current to some extent even today, despite the work of HIV-positive women internationally.

Nor can we forget that prevention strategies designed after the means of transmission were identified were in large part irrelevant to the reality of women's lives. These strategies, based on sexual abstinence, the reduction in the number of sexual partners, the correct and consistent use of condoms, the practice of mutual monogamy by non-infected partners and the prompt diagnosis and treatment of sexually transmitted infections (STIs) have been shown to be particularly difficult for women to carry out as they lack the power to demand or enforce these options.

"The most marginalized members of a society may be hard put to gain access to the information, services and supplies of even well-designed and funded AIDS prevention programs. More limiting still, however, is the kind of pervasive societal discrimination, the sexual status quo,' that denies women sufficient power to safeguard their own health. Indeed, given that those communities in which HIV is predominantly transmitted heterosexually are characterized by a severely disadvantaged economic and social status of women, heterosexual transmission of HIV can be viewed as a direct reflection of gender inequality" (Mann, J., in Rao Gupta and Weiss, 1993).

The Pandemic Today

At the onset of the third decade of the pandemic, the face of HIV/AIDS is increasingly younger, poorer and more feminine. In recent years, AIDS has experienced a marked feminization, especially though not exclusively in Africa. Around the world, 18.5 million of the 37.1 million adults now living with HIV/AIDS are women, and 2 million of the 4.2 million adults newly infected in 2001, or 47.6%, are females (UNAIDS, 2001). The means of transmission in approximately 90% of the cases of HIV positive women is heterosexual relations, and 90% of all infected people live in the developing world. Similarly, youth of both sexes between 15 and 24 constitute the most affected age group at the global level, representing half of all new infections. Every minute, an estimated six young women and men under 25 acquire HIV infection (UNAIDS, 2001,1999).

In addition, while infection rates in some more developed countries are beginning to stabilize and mortality among those with AIDS is decreasing thanks to prompter diagnoses and the effect of anti-retroviral treatments, the infection seems unstoppable in the poorest parts of the developing world and even in the more marginalized sectors of the rich countries. For example, in the United States, infection rates among black women u those with the least economic power u have increased faster than in any other racial/gender group in recent years while the rates among white gay men are decreasing (Gender-aids, 2000).

More Women Than Men

In the evolution of the AIDS pandemic, the case of Africa is emblematic, especially that of sub-Saharan Africa, considered the 'global epicenter." This region is home to only one-tenth of the world's population, but 28.5 million of the people infected with HIV or ill with AIDS live there, more than 70% of the world total. More than 55% of these 28.5 million people are women. This means that there are six women infected for every five men (UNAIDS, 2002).

Unlike the rest of the world, in Africa the rates of infection for women and men were always similar. Today, in a number of countries south of the Sahara, HIV-positive women already far outnumber infected men, especially among adolescents. For example, girls from 15 to 19 are an estimated five to six times more likely to be HIV-infected than boys of their age (WHO, July 1999). This phenomenon is explained by a number of factors: early sexual initiation; sexual violence; poverty; the gap between knowledge and preventive practices; the persistence of traditions which damage women physically; etc.

Furthermore, given the persistence of military conflicts among different ethnic groups, as well as natural disasters, famines and the like, a great mass of displaced people survive in subhuman conditions on the African continent, either in refugee camps or migrating from one zone to another. Most of them are women, children and elderly people. Women and girls living in refugee camps are an estimated six times more likely to acquire HIV than those living in normal conditions, as a result of the sexual violence to which they are subjected in these places (Pawe News, 2000).

In general, wherever conflicts or crises cause large numbers of people to move about, in situations where numbers of refugees and military personnel increase, the probability of HIV dissemination also increases. The social and economic chaos common in these situations deepens poverty and increases the incidence of rape and prostitution. Similarly, military personnel constitute one of the sectors most susceptible to the infection due to the very characteristics of their labor: long absences from the home and the family which induce sexual risk behaviors. This has been documented not only in Africa but in several other regions of the world, as well.

In addition to Africa, some Caribbean island states exhibit similar patterns of the evolution of the illness, that is, primarily heterosexual transmission, with a significant and increasing impact in the female population. The most serious case is Haiti where approximately 5.1% of the adult population between the ages of 15 and 49 is Hiv-positive, followed by 4.1% in the Bahamas and 2.8% in the Dominican Republic (CIMAC, 2000). Another country where the female population has felt a heavy impact is in Brazil, where AIDS now constitutes the number one cause of death in women from 15 to 49 years of age in the major cities (Villela, 1998).

Another example is the recent report of a rapid spread of AIDS among women homemakers with stable partners, mostly of reproductive age, in the northern Chilean city of Calama. This city of only 140,000 inhabitants has registered some 100 cases, and for each one an estimated five to seven other individuals are HIV-positive. The explosion of cases among women occurred within a period of two years. In 1999, there were 17 men with the virus and no women, but the following year two cases out of 16 were women. Suddenly in 2001, the number of cases rose to 29: 19 men and 10 women, a ratio of just under 2:1. At the national level, by contrast the ratio is one infected woman for every seven men.

What distinguishes this city from others is its social, economic, environmental and cultural conditions. Calama is a large mining center with many nightclubs and an ample supply of commercial sex. Although some 500 topless workers are registered and regularly checked, others avoid these controls, including many transvestites (El Mercurio, July 26, 2002).

Vulnerabilities

Taking into account the complexity of the evolution of the pandemic, a number of analytical approaches have been suggested, including some which borrow from the social sciences. One popular focus uses the concept of vulnerability, applied to AIDS epidemiology by the late Jonathan Mann and other researchers from Harvard University. This concept attempts to determine the degree of likelihood of infection of a given group of people through observing the intersection of individual, social, economic and political factors in a given society, rather than focusing exclusively on individual behavior. Starting from this framework, Mann argued that certain groups or communities are especially vulnerable to HIV and require greater protection, including: children, minorities, indigenous populations, migrants, refugees and internally-displaced persons, people with physical limitations, men who have sex with men, injecting drug users, prisoners and, especially, women (ICASO, 1997).

Nonetheless, as empirical evidence shows that every person is potentially at risk of infection, others question the emphasis on the vulnerability of particular groups, calling instead for a more holistic approach. In this view, both women and men are vulnerable to infection to different degrees and involving different factors; to gender vulnerability must be added those which arise from race, ethnicity, age, social condition, place of residence, sexual preference, etc.

In this article, we will concentrate on how women are especially vulnerable to HIV infection due to a broad range of factors related to their subordinate position in society, their "second- or third-class citizenship." This historical subordination of the female sex underpins the explosive growth in the numbers of women with HIV/AIDS that we see today all over the world. "While both women and men are vulnerable to HIV infection, the context of gender inequality places women at greater risk of being infected and affected by HIVIAIDS. Although physiology affects women's greater risk of HIV transmission, it is women's and girls' relative lack of power over their bodies and their sexual lives, supported and reinforced by their social and economic inequality, that make them such a vulnerable group in contracting, and living with, HIV/AIDS At the same time, if women as a group are more vulnerable to HIV/AIDS than men, women's vulnerability in relation to each other is further fragmented by a combination of factors such as race, class, age, ethnicity, urban/rural location, sexual orientation, religion and culture" (Expert Group Meeting, 2000).

Economic and Social Vulnerability 

All over the world, poverty has been "feminized"; an estimated 70% of the 1.2-1.3 billion of the world's poor are now female. They suffer the consequences of two of the most persistent inequalities that characterize modern society: poverty and gender. While women's entry into the workforce has increased steadily in recent decades, it occurs mostly in precarious conditions, either in the informal, less protected sector or in formal "female" occupations, generally the worst paid and the least prestigious, and often involving the service role judged from time immemorial to be the proper function of the female sex, Likewise, their salaries are consistently less than those of men, even when performing the same work or with better qualifications.

In addition, women's incorporation into the labor force has been not accompanied by a reordering of the responsibilities for domestic work and child-rearing, resulting in an exhausting triple workday for women: external paid work, unpaid and unrecognized domestic labor, plus biological reproduction.

Another characteristic phenomenon of our times is the steady increase of femaleheaded households on every continent. Research has shown that these households are vastly overrepresented in the statistics for extreme poverty. Forced to shoulder alone the responsibility to sustain the family, women are always disposed to work in precarious jobs which barely enable them to survive (G 1997).

Underemployment, unemployment and the lack of training to obtain better work opportunities also affect women and youth more. Thus the commercial sex trade becomes a ready incomeproducing alternative, and increasing numbers of women and adolescents resort to it. An estimated 2 million girls between the ages of 5 and 15 enter the sex trade worldwide every year (UNFPA, 2000), many sold into traffickers' networks by their own parents to support other children while others prostitute themselves by their own decision. In India, for example, UNICEF has estimated that more than 400,000 girls and boys in the streets of the main cities sell sexual favors or are exploited by pimps. Equally dramatic are the situations in other Asian paradises for pedophiles and sexual tourists such as Thailand and Cambodia. A study by Human Rights Watch of Cambodia found that girls between 12 and 17 account for 31% of the sex workers in several provinces there where HIV infection is rapidly rising. In Latin American cities such as Bogota , Rio de Janeiro, Santiago, Guatemala City, etc., child and youth prostitution is also common. Another increasingly frequent phenomenon is the occasional trading of sexual favors by poor women, housewives and even high school and college students to increase their meager family incomes or pay for their studies. In all these cases, the exposure to HIV is very high.

At the same time, millions of migrants -- mostly male but also some female -- face a hostile and alien world without social support services as they search for work opportunities. The mere fact of living far from the family and community increases the migrant's vulnerability and the probability of sexual risk-taking. In addition, the migratory flows themselves constitute a potential risk of dissemination of HIV and for the intermingling of viral subtypes.

Similarly, to the extent that women do not obtain paid, stable work with protections and benefits, their access to services such as education, housing, social security and especially health is more difficult. Furthermore, as the neo-liberal economic models currently in effect erode the government's role in providing basic welfare services to the population, the privatization of public services has accelerated.

As public health services are no exception to this rule, health is not conceived today as a human right but rather as a product that can be "acquired" by those with the means to pay private health premiums. This has a disproportionate impact on women, traditionally the majority of users of public health services (Matamala, 1997). For example, recent studies show that women in Latin America are at a great disadvantage in obtaining the health resources they need and have more problems in accessing those services in comparison with men due to the conditions of their insertion into the labor market (CEPAL, 1997). In addition, obstacles to education also have a negative impact on personal life projects and the chances of reaching a satisfactory standard of living, which in turn affects self-esteem, autonomy and decision-making power. Many societies do not send girls to school, limiting them to the domestic sphere, marriage and child-rearing. As a result, all over the world, there are more illiterate women than men . Although female school attendance at different levels has grown steadily in recent years, especially in primary education, this has not yet borne fruit in reversing women's social and cultural disadvantages.

Other factors which strongly reinforce women's social and therefore sexual vulnerability and increase their risk of HIV/AI DS infection include: inadequate legal frameworks, such as obsolete and discriminatory laws with regard to the economic, political, sexual and reproductive rights of women or the lack of legislature on these rights; stereotyped and denigrating images of women and girls transmitted by the communications media which place them in the role of subordinate sexual objects; the influence of obscurantist religious concepts which impede advances in equality of opportunities and equity between women and men; damaging practices falsely dressed up as "tradition"; the "naturalization" of certain expressions of violence against women, etc.

A dramatic example is the widespread "tradition" of female genital mutilation, the supreme, brutal act of control over the sexuality of women, which carries a very high risk of HIV due to the use of non-sterile instruments, frequently by inexpert practitioners in unhygienic conditions. Another dangerous practice is "dry sex," common in many African communities. It consists of inserting diverse astringent products into the vagina before coitus (soaps, stones, plants, newsprint, cotton, leaves, etc.) or practicing "vaginal douches" to dry the vaginal walls. Its objective: greater sexual pleasure for men. Studies undertaken in Zambia showed that 86% of the women in different socioeconomic and ethnic groups had utilized this "technique," while in Zimbabwe the percentage was 93%. Groups of women interviewed in Zaire identified some 30 different substances utilized for this purpose, which seriously irritate the vaginal mucous membranes, increasing the danger of transmission of HIV or other STIs (Halperin, 2000). Al though this custom is most common in Africa, women in other regions also practice it, as has been found by research in Seattle (USA), Haiti and the Dominican Republic.

Biological Vulnerability

Women also clearly have a biologically vulnerability to HIV infection. Various studies have shown that male-to-female transmission of the virus and other STIs is two to four times more efficient than female-to-male. This is explained by the greater exposed surface of the female genitalia which can suffer lacerations during the sexual act, thus facilitating the entry of the virus. In addition, there is a higher concentration of HIV in the semen in comparison with the vaginal fluids. This risk increases in the case of girls and adolescents, given that their defenses are weaker and their vaginal tissues and cervical mucous membranes less mature. Women's risk of acquiring HIV infection increases as the age at first coitus drops and/or the difference of age between the girl and her partner increases (Elias and Heise, 1993).

Likewise, undiagnosed STIs in women increase the chance of HIV infection. In part, this reflects the difficulty women have in accessing health services, information and orientation, especially those involving STI diagnosis and treatment because of the stigma associated with them. This situation is aggravated in the case of adolescents who rarely can rely on specialized, confidential services. In addition, their ignorance of the symptoms leads them to believe that certain irritations such as pelvic pain, extremely heavy menstrual flow, smelly discharge, etc., are just a normal part of being a woman. However, each year 333 million new STIs occur in the world, affecting most often the population from 15 to 24 years of age; the consequences are always much more severe for women than for men (UNFPA, 1999). Epidemiological studies on different continents have demonstrated that an STI increases risk of HIV transmission between three to five times and possibly more.

Sexual Vulnerability

As women have been denied the capacity to make autonomous decisions over their bodies, their sexuality and their reproduction, they obviously face sexual vulnerability as all too often they are obliged to engage in sexual relations against their will; many times, maternity is more of an obligation than a choice. In fact, non-consensual sexual relations are a frequent reality for girls and adolescents who may experience sexual relations for the first time through forced sexual initiation, rape. In other cases, they are pressured into having sexual relations by either boyfriends or peers. In short, although young women may want to opt for abstinence or postpone their sexual activity, it is not always in their power to do so. Lamentably, coercive, non-consensual sex, abuse, incest, forced marriage, exchange of sex for money or goods from older men (in Africa, the "sugar daddies") are everyday events in our societies.

The issue of sexual violence and its close link to HIV/AIDS transmission received due attention at the World Conference on AIDS in Durban, South Africa in 2000 and also in the recently concluded conference in Barcelona. An estimated 50,000 cases of rape are reported every year in South Africa, in comparison with only 1,200 two decades ago. However, researchers estimate that only one out of every 24 rapes is reported, which suggests that the real total is 1.6 million cases per year. Given the extent of HIV seropositivity in the population, the health services are instructed to provide anti-retroviral therapy to rape victims to avoid potential infections.

A variety of reasons are offered to explain this extraordinary increase in sexual attacks. First, victims are now more likely to denounce this type of aggression compared with previous decades. In addition, "studies done in the country have demonstrated that violence is such an endemic phenomenon that men and women have come to accept that coercive and even violent sex is normal." (Expert Group Meeting, 2000) During the Durban conference, a Declaration on Women and HIV/AIDS drew hundreds of adherents, both organizations and individuals. The Declaration sustains that "the unacceptable level of gender-based violence in South Africa, which places women at a greater risk of HIV infection, is a political issue" and emphasized that women in South Africa face greater levels of poverty, marginalization and social exclusion due to the AIDS pandemic.

According to Gender-aids (1999), the estimated risk of transmission of HIV for a single episode of penile/vaginal intercourse is estimated to be only 0.1% and that for a single act of receptive anal intercourse 0.5%-3%. "However, the risk associated with rape may be much higher as there often is genital and rectal trauma and bleeding, exposure to multiple assailants, or exposure through multiple receptive sites."

Studies from the United States and Kenya have found that around one-fifth of the HIV-positive women surveyed had suffered a high degree of violence from their regular partner, relatives or members of the community when their status as HIV carriers became known (WHO, June 2000).

In addition, sexual abuse of girls and adolescent women has enormous repercussions in their future lives, aside from the immediate risk of contagion and/or pregnancy. In fact, "early sexual victimization also can leave women with fewer skills with which to protect themselves, less confidence in their own worth and their personal limits and a greater inclination to accept victimization as part of their female persona" (Heise, Pitanguy and Germain, 1994).

In other words, a history of sexual abuse or domestic violence is correlated with future risk behaviors with respect to HIV. Even when adolescents freely choose to have sexual relations at an early age, they rarely have access to appropriate reproductive health services for their specific contraceptive and prevention needs, much less sex education or orientation to prevent undesirable consequences.

Sexual subordination of women places them at risk of infection not just during adolescence but throughout their lives. As deeply-entrenched, gender-based power differences persist in the culture, women remain unable to resolve issues related to their sexual lives, maternity and their very bodies. To negotiate when or how to have sex or to demand condom use are very difficult for most women because of the threat of violence, mistrust, recrimination, abandonment or loss of sustenance for them and their children. Women's role in sexual relations continues to be generally passive and unassertive while men's is active and determinant, concordant with the socially-accepted models of femininity and masculinity.

In surveys undertaken in Latin American, women acknowledge that their awareness of the ways HIV is transmitted is not a relevant factor in their sexual lives, except among those with a higher educational level (CEPAL, 1998). Another frequent phenomenon observed both in men and women is the denial of risk, especially among youth.

However, in the case of women, denial is intermingled with other elements. For instance, the fear of pregnancy is much greater than the fear of HIV. In addition, there is an interpersonal factor for women, who are particularly resistant to perceiving potential risk on the part of a trusted, intimate partner. Therefore, it remains almost impossible for a woman with a stable partner to demand condom use or suggest sexual alternatives to penetration.

Unfortunately, figures show that increasing numbers of women acquiring HIV infection maintain monogamous relationships while their partners in fact do not. An example: the number of women who have died of AIDS in Sao Paulo, Brazil, has increased exponentially in recent years: while in 1992 there were five men living with HIV for every women, now the proportion is two to one. One quarter of the women infected acknowledge only one sexual partner, and the age range most affected is women from 25 to 30 years old. All this demonstrates the absolute irrelevance of the use of the sole partner as a prevention strategy: marriage is a risk factor rather than a protective one.

Vulnerability and Seropositivity

The vulnerability of HIV-positive women is manifest on a number of levels, from their difficulty in obtaining early diagnoses which would improve their chances of survival, to receiving timely and adequate treatment, exploring alternative health strategies and enjoying the freedom to adopt sexual and reproductive decisions without coercion or violence, etc. The obligatory testing of pregnant women, without adequate protection of the privacy of the results, also foments the violation of their rights and generates discrimination.

In fact, health professionals have a hard time viewing women's health demands and complaints in an unprejudiced way, thus retarding the therapeutic responses women urgently need. On other occasions, women themselves delay seeking health services out of reluctance to acknowledge that they are sick or their habit of placing the health of family members before their own.

This behavior "is probably due to complex psycho-social determinants related to the role of women as family caretakers, their relative poverty, and the paternalism and even hostility with which the medical system handles women's problems. Inadequate research and diagnosis of HIV/AIDS in women reflects the uncomfortable relationship between medicine and the female population" (Denenberg, 1997).

Meanwhile, right from the start of the epidemic, women were seen as "potential transmitters" of the virus to children, leading to pressure for them not to reproduce, either through sterilization or abortion. In other cases, they have been denied safe abortions when they sought them.

HIV-positive mothers have to resolve another complex issue, breastfeeding, usually discouraged because it increases the risk of transmission of the virus to the newborn. However, a number of variables have to be taken into account, such as the possibility of obtaining artificial nutrients and preparing them in hygienic conditions, as well as the cultural factors in those countries where social pressure to breastfeed is intense and where those who fail to practice it immediately attract suspicion among their peers.

Another area where discrimination and stigma is practiced against HI V-positive women is sexuality. From the moment they receive the HIV diagnosis, they are completely denied the possibility of sexual expression and do not receive prevention resources that would help them avoid potentially dangerous reinfection.

One option that has been explored by UNAIDS for a number of years as a prevention strategy is the distribution of female condoms at discounted prices, not only for HI V-positive women but for all women. In 2000, some 45 countries distributed more than 4.5 million female condoms, which means that more than 35 million have been sold in the last eight years. However, the availability of this method in the developing world is still closely linked to special health programs. Similarly, many of the distribution programs have been pilot projects. For example, in Ghana the program began in 1999 with 75,000 female condoms to be distributed, rising to 420,000 in 2000 and 1 million in 2001. But other countries have gone beyond the experimental phase to large-scale programs, such is the case of Brazil, Namibia, South Africa, Uganda and Zimbabwe (Female Condom electronic newsletter, 2001).

South Africa, with the greatest number of women and men living with HIV/AIDS in the world -4.7 million, or one of every nine South Africans - now has one of the largest female condom distribution programs. The National Health Department acquired 1.4 million units in March 2001, making a total of more than 5 million female condoms distributed since the program began in 1997.

In Brazil, distribution of the female condom also has been positive. In 2000 the Health Ministry acquired 2 million female condoms, the first public health experience in distributing the female condom directly to the population. However, access to the method was not universal. In addition, its relatively high cost means investment in the female condom cannot keep pace with its male counterpart. However, the initiative was important as it coincided with the urgent need to improve and broaden prevention methods for women in the face of the increase in AIDS among the female population. In 2001, the Ministry acquired another 2 million units and distributed them to women with special vulnerabilities, such as HIV-positive women, wives of HIV-positive men, partners of drug users, etc.

Another option of extraordinary importance is microbicides, products which prevent HIV infection when applied in the vaginal or anal area. Women have control over these products and can use them even without their partners' knowledge. At the Durban and Barcelona conferences, there was great interest in developing a safe and effective microbicide, and there are currently more than 30 types under study. Some suggest that a method of this sort may be ready before an anti-HIV vaccine.

The Global Campaign for Microbicides and Preventive Options for Women, a broad effort by women's groups, STI/HIV activists and defenders of reproductive health around the world, is actively working to increase access and demand for alternative HIV-prevention technologies to the male condom. This educational initiative is designed to generate greater consciousness about the needs for new technologies that women and men can utilize to protect themselves from infection. As campaign coordinator Lori Heise has pointed out, women-controlled methods are important because:

* current prevention methods - condoms - depend mainly on the cooperation of men;

* most HIV-positive women acquire the virus in the context of monogamous relationships; and

* many women do not want or cannot risk prejudicing their partner relationships by introducing negotiations on condom use: they fear that beginning this discussion in the context of a "stable" relationship could provoke economic abandonment, accusations of infidelity, violence and, above all, the loss of trust.

As a result of the Microbicides Conference 2002 held in Belgium in May, a new initiative emerged to promote this woman-controlled prevention method. The International Partnership for Microbicides (IPM) will undertake a global effort to accelerate the development of and access to safe and effective microbicides for people at risk of HIV infection, especially in underresourced regions. To this end, the IPM encourages funding agencies to invest in this area, constructs alliances and sensitizes public opinion about the importance of this type of prevention method. Initially, IPM will operate out of Family Health International in the United States.

Conclusion

The Programme of Action of the International Conference on Population and Development (Cairo, 1994) and the Platform for Action of the Fourth World Conference on Women (Beijing, 1995), as well as their five-year revisions known as Cairo+5 and Beijing+5, address the problem of HIV/AIDS and its impact in the general population and among women and youth in particular. They draw attention to the shared responsibility of all social sectors to reverse this trend.

Likewise, the "Declaration of Commitments on HIV/AIDS: Global Crisis, Global Action," which emerged from the United Nations General Assembly Special Session on HIV/AIDS (UNGASS, New York, June 25-27, 2001) drew attention to the importance of prevention in the fight against the advance of AIDS, demanding broad access to methods such as female and male condoms, better access to information, education and communications in the area for people of all ages, with emphasis on youth.

But for women, it is essential that their vulnerabilities be confronted through the construction of more secure, equitable and egalitarian social norms which favor their economic autonomy, improve their access to education and training, and empower them. Similarly, men and boys must be educated in a culture of respect between the genders and to recognize the full human rights of all individuals.

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WHO (2000). "Women and HIV/AIDS." Fact Sheet 242, June.

RELATED ARTICLE: Increasing Access to Anti-Retro viral Therapy

In response to the urgent need to scale up access to HIV/AIDS treatment, the World Health Organization (WHO) and the International AIDS Society at the 14th International AIDS Conference formally launched new international guidelines for a public health response to the treatment of AIDS in resource-poor settings.

For the first time, complex antiretroviral (ARV) therapy has been simplified so that it can be used in settings that lack highly-trained medical staff or sophisticated laboratories to initiate and supervise treatment.

WHO estimates that today nearly six million people living with HIV/AIDS need equitable access to care and support, including anti-retrovirals (ARVs). Currently, fewer than 5% of those who require treatment in developing countries have access to these medicines while an estimated 230,000 people currently receive ARV therapy in the developing world.

Half of these people live in only one country, Brazil. In Africa, the continent hardest hit by the HIV/A/DS pandemic, fewer than 50,000 people are estimated to be currently receiving ARV therapy. This coverage represents less than 2% of the people that need access to this life-saving therapy.

WHO believes that at least three million people needing care could get ARVs by 2005- a more than ten-fold increase in the developing world.

Source: WHO. Press Release WHO/58. July 9, 2002.

Microbicides: Making All the Difference

This woman-controlled method could make all the difference in preventing transmission of HIV/AIDDDDS and other sexually transmitted infections. A microbicide that is even 60% effective could prevent 2.5 million new HIV infections.

In addition, if microbicides were used by 30% of the population easily reached through the currently existing health services, 3.7 million new infections could be prevented.

Source: The Microbicide Initiative. Mobilization for Microbicides. The Decisive Decade. New York, 2001.

HIV/AIDS in Latin America and the Caribbean UNAIDS FACTSHEET 2002

* Approximately 1.9 million adults and children in Latin America and the Caribbean were living with HIV/AIDS at the end of 2001 (1.5 million people in Latin America and 420,000 in the Caribbean). The total figure includes the 200,000 people who acquired the virus in 2001.

* The estimated 100,000 AIDS deaths in 2001 have further increased the ranks of children orphaned by the epidemic. Some 330,000 of the orphans are living in Latin America (130,000 of them in Brazil) and 250,000 in the Caribbean (200,000 of them in Haiti).

* Twelve countries in this region (including the Dominican Republic and Haiti and several Central American countries) have an estimated HIV prevalence of 1% or more. In these areas, the epidemic is firmly rooted in the wider population and is driven primarily by transmission through heterosexual intercourse.

Leading Cause of Death

HIV/AIDS is now the leading cause of death in some countries of the Caribbean Basin, where adult prevalence rates are surpassed only by the rates experienced in sub-Saharan Africa. Haiti's life expectancy in 2000-2005 is nearly six years below what it would have been in the absence of the AIDS epidemic. In the Bahamas and Guyana, the number of deaths among 15 to 34-year-olds is about 2.5 times higher than it would have been in the absence of AIDS.

* Worst affected are Haiti and the Bahamas, where adult HIV prevalence rates are over more than 6% and 3.5%, respectively. Recent surveillance data indicate a relatively stable HIV prevalence rate of 2.5% among the adult population of the Dominican Republic, following the increases seen there in the 1990s.

* Among the factors that help drive the spread of HIV is the combination of unequal socioeconomic development and high population mobility, as Central America shows. There, the epidemic is worsening and is concentrated chiefly among socially margin-alized populations.

Vulnerable Populations

* Population mobility (spurred by high rates of unemployment and poverty) is emerging as a significant factor in the epidemic's growth. Central America's geographic position also makes it an important transit zone for people moving between the rest of the region and North American countries. Appropriately, protecting vulnerable populations on the move, including adolescent girls and young women, is now the focus of a regional initiative in Central America.

* In Mexico, adult HIV prevalence in the wider population is still well under 1%, but prevalence rates are much higher in specific population groups in some parts of the country - up to 6% among injecting drug users and 15% among men who have sex with men. The epidemic has been spreading mainly through these modes of transmission.

* Relatively low national HIV prevalence rates in most South and Central American countries mask the fact that the epidemic is already firmly lodged among specific population groups. There is significant overlap between injecting drug users and men who have sex with men, especially in Brazil and the southern cone countries, where injecting drug use is a growing social phenomenon. Injecting drug use is also a major route of HIV transmission in Argentina and Uruguay.

* Brazil's prevention programs for injecting drug users have resulted in a substantial decline of HIV prevalence among this population group in several large metropolitan areas. In addition, a national survey showed that condom use among injecting drug users rose from 42% in 1999 to 65% in 2000 -- another indication that Brazil's sustained education and prevention efforts are bearing fruit.

Treatment and Care Success

* Latin American and Caribbean countries have made significant advances in access to treatment and care. Of 24 countries in the region surveyed in 2001,11 have policies, regulations or laws that guarantee access to anti-retroviral therapy.

* At the end of 2001, approximately 170,000 people across the region were receiving anti-retroviral treatment - including 105,000 in Brazil, where prevention efforts are complemented with an extensive treatment and care program that guarantees state-funded anti-retroviral therapy for those living with HIV/AIDS.

* By reducing HIV/AIDS-related morbidity, Brazil's treatment and care program is estimated to have avoided 234,000 hospitalizations in 1996 2000.

The author is the editor of the Latin American and Caribbean Women's Health Network's Revista Mujer Salud.