Combating Gender Inequality Needs to be at the Heart of HIV Prevention Strategies in Developing Countries
Introduction
HIV/AIDS is one of the most fatal diseases know to man today. Globally, not less than 200,000 people lived with HIV/AIDS was recorded in 1980, and this number soared to 3 million by mid 1980s, and further rose to 8 million by the end of the decade. However, the increase with the rate of infected individuals rose in the 1990s enormously, bringing it to 40 million people living with HIV/AIDS in 2001. In Sub-Saharan Africa, it has been reported that it has less than 11% of the world population infected with the disease, thus, containing more than 70% of all HIV infected people in the world. In addition, more than 28 million infected people live in Sub-Saharan Africa, 7 million in Asia, 2 million in Latin America and the Caribbean, and 3 million in other regions of the world (2007). From the figures given above, it can be perceived that the African continent serves to have the most number of HIV/AIDS infected individuals. Given such figures, its relevance and incidence would be emphasized in relation to gender inequality in the continent.
The question of why a disease like HIV/AIDS follows a different epidemiological pattern in Africa compared to Western counties lies on the historical, political, economic, and sociocutlural environments of the continent. It has been reported that the African continent had been exposed to the increasing rate of infection of the disease due to the disruption of the traditional family, social, and environmental structures by European hegemonic adventures (2005). In the early stages of the pandemic, HIV infection was predominantly among men in many industrialized and some developing countries. However, as of the end of 2002, almost 50% or 19.2 million of the 38.6 million adults living with HIV/AIDS globally are women. In Sub-Saharan Africa, 58% of HIV-positive adults are now women. The differences in the rates of HIV/AIDS infection in Africa leads to the determination and evaluation of important differences between men and women in terms of biology, sexual behavior, and socially constructed ‘gender’ differences in roles and responsibilities, access to resources, and decision-making power ( 2003).
The increase in the infection rates in Africa may stem from the economic and patriarchal structure in its society. Among sub-Saharan Africans, women have become a particular class of victims of the HIV/AIDS pandemic. Since African societies are patriarchal, girls are socialized from very young ages to play subordinate roles, making them desirable women for marriage. They could be rewarded for enhancing family honor and image, and thus, years of “hand-me-down” conditioning of women have accounted for gender inequality. In this generation, the generation of HIV/AIDS, this power imbalance between the sexes in Africa is particularly significant, as women have become especially susceptible to the disease due to their limited power in sexual encounters. In one estimate, 6-11% of young women aged 15-24 years old were HIV positive compared to 3-6% of their male counterparts (2005). Such figures are related to the early initiation of sexual activity among girls, which is directly related to the practice of early marriage in African societies. Early marriage exposes girls to an increased risk of HIV/AIDS infection, especially if their partners are older and have had more sexual exposure. In Sub-Saharan African societies, the sexual partners of young women are often much older than the women themselves, indicating that in 16 countries, husbands of 15-19 year old girls are on average ten years older than their wives ( 2003). Thus, this situation suggests that women may be more susceptible to HIV/AIDS infection due to gender inequality, subordination, and powerlessness.
In addition, the dependence and subordination of women in a patriarchal society account for African women’s vulnerability to the disease. The desire of African men to have many children and to commit polygamous relationships contributes to the spread of the disease. In fact, in rural Tanzania, 40% of married men were reported to have non-marital sexual partners, thus, infecting their spouses in the process. In Zimbabwe, women may be under pressure from their spouses or sexual partners not only to reproduce, but also to achieve a desired number of children. Thus, in this sense, it can be observed that the women in traditional African societies lack the power to deny sexual intercourse from their partners even when marital infidelity can be proven (2005). Moreover, the patriarchal society that Africa has produces high risks for both young and adult women to become victims of rape and sexual coercion, thus, exposing them to threats in acquiring the disease. This is most evident during conflict situations, such as the Balkan conflict. In Rwanda, 3% of all women were raped during the genocide, and during HIV testing, it was found out that 17% of the women tested for HIV were positive, compared to 11% who were not raped ( 2003).
Aside from sexual subordination of women in African societies, their dependence and lack of bargaining power can also be attributed to their poverty, low economic status, and lack of education. In South Africa, women make only 70% of what men earn, which already puts them at a disadvantage for attaining self-sufficiency. Women’s vulnerability often forces them into engaging in sexual relationships outside marriage, thus, giving men more leverage for taking multiple wives. Inequality being experienced by women in Africa also leads to unequal environments in academic institutions. There have been reports that girls are being forced by their teachers to engage in sexual activity as a punishment for being late or in exchange for food at lunchtime ( 2006).
From such facts and figures, it can be perceived that the African society, more particularly its women are burdened with grave issues in relation to their health and welfare in relation to acquiring HIV/AIDS infection. Primarily, many countries in Africa have no effective access to relevant information regarding HIV/AIDS prevention. In terms of access to treatment or availability of care, it has been stressed that in many countries in Africa, HIV/AIDS information and services are provided primarily through family planning, prenatal and child health clinics, which are basically not designed to reach men or meet their needs. Consequently, men may be less likely than women to receive HIV/AIDS information, counseling, and treatment services (2003). Second, the male condom is often not a realistic option for women who live in patriarchal families and communities, such as in South Africa. This is because the use of condoms is a contentious issue ( 2006), and may practically lead for them to experience threat or physical violence when attempting to negotiate safer sex through the use of condoms ( 2003). In relation to this, another dilemma being faced by women is the fact that female condoms are not available in South African clinics, and microbicides, a clear gel that a woman can use before sexual intercourse are still undergoing testing in Africa and have not been properly or effectively distributed. In addition, as primary care givers, uninfected women in Africa faces the burden of taking care of orphaned children of HIV/AIDS victims. In South Africa alone, there are 1.1 million AIDS orphans and by 2010, the number is estimated to increase to approximately 3 million (Suich 2006). Moreover, another issue to be taken note of is that the huge statistics of individuals who need treatment from the disease pose not only a huge challenge to medical care, social resources, and state finances and policies, but also in confronting the present ethics and human rights debate with a serious moral dilemma. Such issues include the stigmatization of HIV infected individuals and their discrimination (2003). These issues then decreases the chances for HIV/AIDS infected individuals, especially of women to seek help and treatment. Given such issues, it can be distinguished and emphasized that the status of women in the African society presents grave threats to their increased risk of acquiring the HIV/AIDS infection. This statement can be deduced from the different facts and figures presented above, which aim to describe the present situation of African women in the African society. As such, this paper would be discussing the view that gender inequality in the African society must be surmounted in order to make HIV prevention strategies effective and efficient in different developing countries, such as the many African countries.
Issues of Gender and HIV Treatment
HIV/AIDS is now said to be the leading cause of death in Sub-Saharan Africa and has drastically reduced life expectancy. Life expectancy in Botswana, one of Southern Africa’s wealthiest countries, plunged to 50 years. South African life expectancy is now 48 years, and Zimbabwe’s life expectancy is now 37 years. Thus, the pandemic in Africa is limiting the economic growth and eroding social and political structures, depriving children of parents, schools of teachers, and governments of personnel ( 2002). Based on the above discussion, it can be understood that the gender of women in African societies in itself largely contribute to their increased risk in acquiring the HIV/AIDS infection. Thus, in this sense, the issue of gender inequality in most African societies participates in the increased risk of acquiring the disease and the decrease of life expectancies of the region’s peoples.
HIV/AIDS is considered a gender issue in African societies based on their own sexual behaviors and socially constructed gender practices and beliefs that are innate to their ways of life. In addition, the issue of disease acquisition is also a gender-related issue given their social structure that is far from different with the social structure being observed in other societies in other parts of the world. In this sense, their own beliefs and practices may contribute in jeopardizing their present situation and their future. The increase in the risk of HIV/AIDS acquisition in the African continent remains and would remain a gender-related issue, if the following number of factors would not be addressed by the African government (2007):
1) Unequal power relationship in sexual interaction – In Nigeria, it has been reported that adolescents’ sexual interaction is usually characterized by unequal power relationship between the male and female, which is due to the fact that girls are usually socialized in early life to defer to the boys, even when they are in a relationship. This in turn led the boys to learn that as boys, they most be more aggressive, and the girls more receptive with its attendant implications for spreading the disease.
2) Gender inequality in terms of decision-making – Many African societies have cultures that show women having less power than men in terms of decision-making, thus, preventing them from using preventive measures and even discussing it with their sex partners. In most African cultures, women are expected and taught to subordinate their own interests to those of their partners, thus, often making them feel powerless to protect themselves against the disease and intended pregnancies.
3) Sexual behavior and motives – A certain study in Nigeria indicates that women were more likely to have relationship with older partners, for monetary gains, maturity, understanding, and security.
4) Age and Gender-related behavior – Young people are vulnerable because they are likely to engage in high-risk behavior, by having multiple sex partners, unprotected sexual intercourse among others.
5) Level of awareness and education – In Nigeria, it was found out that males have a higher level of awareness than the females. The amount of education, information, and awareness of women in Africa depends upon the level of their education. However, most African women are not educated, based upon their socioeconomic status.
6) Social status of women – From birth, women are seen as helping mates to men, thus, in certain parts of Nigeria, women are made to be subject to men, such that during their marriage, a woman will be informed of her husband’s and his family’s right over her.
7) Socioeconomic status of women – It has been reported that economic needs and dependency put women at further risk of HIV. Sex in many places is widely viewed as a resource for women. Economic vulnerability reduces women’s ability to influence the terms of this exchange and to leave relationships that they perceive to be risky. Students are vulnerable to sexual harassment and exploitation by their teachers, especially in situations where the cost of fees is prohibitive for their parents (2003).
8) Unequal share of resources – Upon entering marriage, a Nigerian woman has no share from the belongings of the man, and has to undergo dehumanizing experiences, for example after the death of her husband. This intensifies the risks of acquiring the disease, as women are left with nothing, thus, in order to make ends meet, the situation could aggravate multiple sex partners.
9) Discriminatory practices in religion – Several religions and traditions teach women to be subordinate over men, emphasizing the fact that women are mere sexual objects of men. This perception instills in men that they have power over women, thus, giving them the “right” to abuse them.
10) Pressures of childbearing – The African society places pressures on women, who must be able to bear children for the survival of the household. Given the polygamous nature of African women, Nigerian women are more exposed to the variables that transmit HIV/AIDS.
11) Violence – (2005) indicates that gender disparities and patriarchal institutions circumscribe the extent of men’s license to use violence against their partners. Patriarchy also limits women’s agency to abandon an abusive husband. Thus, gender inequality in Tanzanian marriages or relationships may create a kind of “sexual contract” that places women at a distinct disadvantage, setting the stage for intimate partner violence.
12) Burden of increased orphans – Studies made in Zimbabwe, Cote d’Ivoire, and Zambia indicate that HIV-positive women are most unaware that they should cease childbearing because of the risk of vertical transmission to the prospective child and of adding to the number of future orphans (2002).
13) Contraceptive behavior – Knowledge of HIV-positive status in Kenya, Rwanda, Cote d’Ivoire, and Uganda of both men and women does not lead to increased condom use (2002). The powerlessness of women and their neglect in acquiring the disease in such countries in Africa contribute to their increased risk in becoming infected.
Given the fact that HIV/AIDS acquisition in African societies is a gender-related issue, the accessibility of treatment and healthcare of the victims, most especially the victims of the disease must be analyzed. It can be assumed that today’s generation and advancement in science and technology would have provided HIV/AIDS infected persons with an increase access for treatment and healthcare, due to increased awareness of the issue. However, if such treatments and healthcare strategies were visible, then the number of HIV/AIDS victims would have decreased. In this sense, accessibility to treatment and healthcare would be discussed.
It has been reported by the UN Population Division that about 40% of Africa’s population currently live in towns and cities, and although presently, Africa is the least urbanized region in the world, by 2030, its urban population is expected to exceed the total population of Europe. Typically, average urban incomes are no doubt higher than average rural incomes, wherein the proportion of people living in poverty is smaller and the standards of service provision per person are higher. However, evidence indicates that income and consumption inequality is generally greater within urban areas. While economic growth has picked up some African countries since the 1990s and national trends show some decrease in the incidence of poverty, many urban dwellers continue to live in extreme poverty. The presence of services does not mean that the poor can access them. Poor urban people have incomes insufficient to meet basic needs, lack assets and secure tenure, live in poor and overcrowded housing conditions, have inadequate access to infrastructure and services, have no social safety net, and are powerless to influence decision-making. Such issues worsen the HIV/AIDS epidemic, the prevalence of which is invariably higher in urban than in rural areas. In high prevalence locations, the increase in the risk for acquiring the disease affects every family directly or indirectly through illness, death, or an increased burden of care for orphans and the sick. In addition, the desolate conditions being experienced by urban residents in Africa reinforce the acquisition of HIV/AIDS of women, through their risky sexual behavior. In Nairobi, it has been found out that the poor women living in slums engage in sexual activity at an earlier age, and with a larger number of partners due to high unemployment and low and unstable incomes (2006). With such conditions, it must be assumed that the society should be concerned with providing effective healthcare, treatment, and awareness to infected persons, most especially with women. However, it has been stated that gender inequality in healthcare remains a significant factor in the disproportionate burden of HIV/AIDS among women in Sub-Saharan Africa. Women are less likely to seek healthcare or be cared for in healthcare settings compared to men. Socioeconomic status and low literacy are major factors influencing this outcome. Low literacy rates tend to hamper the knowledge of women about prevention strategies. In addition, many women are less likely to benefit from anti-HIV/AIDS campaigns channeled through the print media. Men mostly own radios and televisions, while women in rural settings are worse off in this regard. Furthermore, women are more likely to delay seeking healthcare either because symptoms were not considered severe, had disappeared or for lack of money. Even when women sought care, they were more likely to turn to public healthcare facilities wherein marginal care is the norm. To worsen the situation, most Africans believe in the power of traditional healers, who initiate the reuse of unsterilized needles and cross contamination with the body fluids of patients. It has been reported that 60% of Nigerians believe the powers of traditional healers, which must be considered a public concern, as such, patronage delays prompt appropriate medical interventions for HIV/AIDS patients (2005). Another factor to consider in terms of the delay of treatment for HIV/AIDS infected individuals is the stigma of having the disease. Stigma due to AIDS is a reality in many African countries, but it is made particularly bitter in South Africa due to the country’s conflicted history with the illness (2006). It has been emphasized that HIV-positive individuals are still stigmatized in the modern-day society, and they are the victims of all forms of discrimination in work places, educational institutions, and even in religious communities. The main reason for this reality is that the disease is perceived to be the result of unacceptable sexual and moral behavior and other bad habits. Thus, in this regard, the stigmatization and discrimination of HIV-infected persons are the most inhibiting factor in the prevention and treatment of the disease (2003). From this, it can be perceived that poverty, ignorance, discrimination and stigmatization, and risky sexual behavior contributes to the delay and decreased access of HIV/AIDS infected individuals with treatment and healthcare.
The decreased access to treatment and healthcare must prompt the design and implementation of strategies for the prevention of HIV/AIDS. This is because better prevention without better treatment would leave millions of HIV-infected adults and children without the alleviation of their suffering and prolongation of their lives made possible by modern medicine, and unless prevention efforts improve, the pandemic will continue to worsen (2002). The most important strategy for the prevention of HIV/AIDS in the African region includes strategies that would emphasize equality between men and women in African societies. Equality between men and women does not only mean equality in terms of decision-making in the family, sexual matters, and marriage, but also involves equal opportunity in terms of work and social status. The “Conscientizing Male Adolescents” program in Nigeria participated in this strategy, by allowing adolescent males to empathize with women’s experiences of patriarchy and by understanding how women are oppressed (2003). In addition, the national Constitution in Cote d’Ivoire has now improved the situation of women, as it stipulates on the equality of both genders (2001). Another useful strategy includes rights to contraception and abortion, which can be employed to protect one’s self, one’s partner, and one’s future children. Recent studies provide a more encouraging picture in terms of women’s ability to influence men’s sense of sexual risk and condom use. One study has shown that married women play an important role in condom use, which depended on the woman’s subjective sense of HIV risk. Some authors have concluded that men’s resistance to condom use can be overcome more easily than has been presumed. This is confirmed by a recent qualitative study in Uganda, among married couples who used condoms consistently for gender-specific reasons, implying that differentiated strategies targeting men and women when promoting dual protection ( 2007).
From this, it can be perceived that the education of both men and women regarding HIV/AIDS is needed. Therefore, strategies in providing sexuality education to many African societies must be evoked in order to allow persons to become aware of the risks in HIV/AIDS acquisition. This must not be focused only with women, but with men as well, as they are said to be one of the factors why women have high risks in acquiring the disease. This also involves combating the issue of violence, which puts women at higher risks. In Senegal, it has been stated that approximately 78% of women are illiterate. This is why it has been proposed that the best way to assist them would be to include functional literacy components in development projects (2001), which would not only empower them as individuals, but also provide them the necessary means to earn money for their families. Most importantly, equity in the health system, regardless of gender or class, must be done in order to provide more preventive measures in the African society. As a response, several African countries like Cameroon, South Africa and Malawi opted to implement medical rationing, which involves policies or practices that balance medical supply and demand by causing patients to forgo medically beneficial treatment within a system of healthcare provision that is collectively financed. This was done by comparing the targets of current national treatment initiatives in Sub-Saharan Africa with the estimated numbers of people in those countries who need AIDS treatment (2006).
However, despite the number of strategies and opportunities open for further increasing HIV/AIDS-related casualties in the African region, a number of obstacles can also be distinguished, being hindrance to implementing such strategies. The primary obstacle is that the implementation of such strategies highly depends on international funding. For example, the U.S. PEPFAR program aims to distribute billion for AIDS prevention, care, and treatment, but it does so unilaterally to only 15 countries, and the choice of countries seems either arbitrary or politically motivated. Another obstacle is the halting in the distribution of antiretroviral drugs, due to patent and approval issues, thus, limiting the number of individuals to be treated in the African region. The third obstacle involves the implementation of policies by the IMF, which hinders the smooth provision of healthcare to HIV/AIDS victims, as economic issues are being raised, thus, complicating the process ( 2006). Obstacles also include an unfair process of considering and providing treatment and care for victims, due to racial, gender, and class discrimination. In this sense, the gender of women, their ignorance, poverty, social status, and traditional beliefs may serve to be significant obstacles for their own treatment and improved welfare.
Conclusion
From the discussion, it can be understood that several factors contribute to the increased risk of African women for acquiring HIV/AIDS. From pointing out the different factors, it can be perceived that gender inequality must be the most important aspect in terms of designing and implementing HIV prevention strategies in developing countries, most especially in the African continent. This is because gender inequality seems to be the root of the many problems that African women face in the African society. Being women, they have the increased opportunity for becoming oppressed due to their low socioeconomic status, ignorance, lack of education, and irrational traditional beliefs, which were handed down to them through their tradition and culture. In this regard, their increased risk of acquiring HIV/AIDS can be blamed for belonging to the female gender. However, blaming a person for becoming a female is sign of idiosyncrasy, which places a certain society or community in danger. This is because they blame a particular effect with the wrong cause. Thus, in this sense, the society would not be able to determine the real causes of problems. Therefore, the essence of this paper is to point out and emphasize that the upsurge of HIV/AIDS cases in African countries indicates the gender inequality that women suffers from. Thus, gender inequality must be initially and primarily be scratched from the list of behaviors of the African society in order to survive.
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