Women and children: increasingly targeted by HIV.

A young woman sat in a crowded clinic with a small baby, waiting patiently to see a nurse. The child, resting limply in his mother's arms, had not eaten for days and suffered from persistent diarrhoea. While anxious over her baby's health, the mother assumed these were normal, early childhood illnesses.

Instead, she soon discovered that both she and the child were infected by HIV Many women, especially in Africa, find out that they are HIV-positive in this way, said Dr. Sandra Anderson of the Health Care Support Unit of WHO's Global Programme on AIDS (GPA).

"They may test the baby for HIV without asking for consent, and then they test the mother--and the results come back", explained Dr. Anderson. "Women often find out that they're HIV-positive in a very shocking way."

Increasingly targeted by HIV, women may suffer the consequences of the disease more than most. An HIV-positive woman not only lives under her own death sentence, but has to endure damage to her childbearing and nurturing role. She has a 25 to 40 per cent chance of passing HIV to a child in the womb or at birth.

"I think women with AIDS are much more likely to be rejected than men", added Dr. Anderson. "They often end up being blamed."

WHO estimates that by the year 2000, more than 13 million women will have been infected by HIV, the virus leading to AIDS, and about 4 million will have died. In sub-Saharan Africa, women infected with HIV now outnumber men by six to five. In Malawi, infection rates among women attending prenatal clinics increased from about 3 per cent in 1985 to more than 30 per cent in 1993.

Even in industrialized countries, where transmission is most often through homosexual contact or by injecting drugs, there has been an ominous rise in heterosexual transmission, WHO reports. In the United States, AIDS cases in women were 10 per cent higher in 1993 than in 1992.

"A decade ago, women and children seemed to be on the periphery of the AIDS epidemic", Dr. Michael Merson, Executive Director of the GPA told the Second International Conference on HIV in Children and Mothers (7-10 September 1993, Edinburgh, Scotland). "Today, . . . women and children are at the centre of our concern."

What makes women susceptible to HIV?

There are three main reasons, according to WHO, for the growing rate of HIV infections in women:

* Women are biologically more vulnerable, since they have a larger mucosal surface exposed during sexual intercourse. Also, semen contains far higher concentrations of HIV than vaginal fluid.

* Women are epidemiologically vulnerable. For instance, they tend to marry or have sex with older men, who may have had more sexual partners and are, therefore, more likely to be infected. Also, in the developing world, women frequently require blood transfusions during pregnancy or child birth, exposing them once again to HIV.

* Women are socially vulnerable, since they are often expected to be passive in their sexual relationships. In some cultures, men expect sex from women receiving their financial support. Women also face difficulties protecting themselves from transmission through mutual fidelity or condom use.

"In our society, a woman is educated to be in total submission to her husband", explained Aimee Muadi, who works in Zaire for the Society for Women and AIDS in Africa (SWAA). "She has no right to resist his demands even if he is a doubtful partner. The use of a rubber is the man's initiative, not hers."

The youngest victims

In the mid-1980s, HIV infection started to appear in very young children. Specialists soon determined that infected mothers could pass on the virus during pregnancy, possibly at delivery and, in a very few rare cases, in breastmilk.

In most children, the course of AIDS is swift, because the small body has not yet had time to build its defences. In Cite Soleil, a poor urban neighbourhood in Haiti, 13 per cent of children of HIV-infected women die before three months of age, and 2 3 per cent before their first birthday, UNICEF reports. It is currently assumed that, on average, nearly half of HIV-infected children die before age two, and that by the age of five, 80 per cent will have perished.

Whether or not an HIV-infected woman transmits the virus to one or more of her children, her early death from AIDS will have a profound impact on all of them. Who will care for those she leaves behind?

"It is felt that it is against African culture to foster or adopt a child whose totem you do not know. This is said to bring misfortune to the adopting family", said Elizabeth Matenga, who works for the Family AIDS Counselling Trust in Zimbabwe.

By the year 2000, WHO estimates there will be some 5 million to 10 million AIDS orphans less than 10 years of age worldwide--90 per cent of them in Africa. As the traditional extended family loses its ability to provide for them, many may take to the streets, where they, too, will become prime targets for HIV infection.

The lack of capacity within government services to cope with the problem has been compensated somewhat by the response of non-governmental organizations, such as the AIDS Support Network in Uganda and the SWAA. Mission hospitals are also pioneering home-based care programmes supported by mobile teams.

"If, with patient care, I can keep an AIDS-infected parent alive for six months, I prevent the children being orphaned sooner than necessary", said Ursula Sharpe of St. Joseph's Hospital in Uganda. "Let them see their parents die in dignity. That will help them."

Living with AIDS

It is hard to imagine how AIDS destroy the day-to-day lives of millions of people around the world. One of them--Jeff Quinlivan, a 34-year-old New York City dancer--describes his fight to maintain his sense of worth:

"I think of those concepts that people don't understand about me and living life with AIDS. Fatigue, tired, no energy, in paid, dizzy, weak, fragile. That same feeling after you work a 15-hour day, except you have only taken your morning shower.

"Sickness and prolonged sickness is the constant dreaded fear. To adjust ceaselessly ad nauseum to medical wearing and tearing; drugs, needles and side effects; doctor visits and tests; and unending reduction and acceptance of quality of life."