Achieving gender equality in HIV prevention: a case study of South Africa
Jonathan Currie, Laura Mason, Eleanor Southgate, Yolande Squire
Intercalating Medical Students International Health BSc, Centre for Child & Adolescent Health, University of Bristol, Bristol BS6 6JL, UK
The current HIV epidemic in South Africa stands as one of the most severe in the world. In 2005, 5.5 million people were living with HIV and 320 000 people died from HIV/AIDS, more than 875 lives per day 1. Moreover, there are no signs of the epidemic reaching a plateau. Stark differences exist in the proportion of men and women affected; young women (aged 15-25 years) are approximately four times more likely to be infected than men.1
Whilst it is recognised that females are more biologically susceptible, the inequitable gender relations that exist within South Africa are central to the augmented vulnerability of women to HIV 2. These inequities compromise a woman’s ability to initiate, implement and negotiate preventative measures for HIV. The ‘culture of silence’ surrounding sexuality, combined with the powerlessness of many women in sexual relationships, makes many women vulnerable to HIV. Economic vulnerability often becomes a trigger for exploitative and transactional relationships; increasing women’s likelihood of contracting HIV and impedes their ability to protect themselves.
The South African government has stressed that in the absence of a cure for AIDS, prevention measures should be central to their HIV strategy 3. Historically the programme has focussed on promoting public awareness; aiming to promote sexual behavioural change messages through campaigns such as “ABC” (Abstinence, Be Faithful and use Condoms) and mass distribution of condoms to ensure availability. In 2002 the government freely distributed 350 million condoms, rising to 386 million for the period 2005-2006 4.
HIV infections in South Africa can be largely attributed to heterosexual transmission, yet condom usage nationally remains poor, particularly among young people. A survey in 2003 found an uptake rate of only 52% among 15-24 year olds; those residing in rural areas faired worse with only 36% reporting having used a condom during the last time they had sex 5. This same survey found lower consistency among those in longer term relationships, along with a lower rate of condom use among females.
For South African women there are obstacles to every aspect of condom use. Condoms may be easily obtainable; however research has highlighted incidents of negative and abusive attitudes from nursing staff when requesting contraception. Widespread poverty makes purchasing condoms all the more difficult. On top of this, carrying condoms can invite stigma from the community. In a study undertaken in 2003 women suggested they would be labelled as promiscuous if they carried condoms, whilst males divulged a lack of trust for females who carry condoms, since it displays their “lack of sexual innocence”6.
Insisting on condom use can imply a lack of respect or trust. This is particularly evident in marital sex: a wife’s request that her husband uses a condom may be interpreted as an accusation of infidelity or may result in the husband accusing the wife of promiscuity, infidelity or being HIV positive.
Men may refuse to use condoms on the basis that they reduce sexual pleasure or insult masculinity. This attitude, in combination with the commonly seen gender power imbalance, makes it nigh on impossible for a woman to insist on condom use. Furthermore, in a country where sexual violence is rife, where a high proportion of women have experienced sex against their will and there is one rape every 35 seconds 7, women have minimal power to employ condoms as a means of protecting themselves from contracting HIV.
The above highlights the difficulties with the ABC campaign in a society where there is a stark imbalance in gender empowerment. ABC is made not so simple if women are unable to abstain as a result of being coerced or forced to have sex, or even if they are being faithful but their husbands are not. Women have minimal ability to protect themselves from HIV during intercourse where condoms are the only available method of protection to them. The gender limitation cries out for an urgent alternative preventative method that can be widely distributed and is easily accessible, thus enabling women to take control of their HIV status.
An abundance of research is being undertaken to develop preventive methods which could enable women to take the initiative in preventing HIV infection. However, attempts to capitalise on female-controlled preventions have had little success so far. The only viable method for females currently is the female condom, which, despite having a high efficacy and acceptability among women, is thwarted by issues such as a high cost and negative attitudes from males 8. Moreover, use of a female condom still requires negotiation with the man, therefore failing to overcome many of the barriers inherent in the use of the male condom.
With these issues in mind, women are clearly in dire need of a method whereby they can protect themselves from contracting HIV. Intra-vaginal microbicides may represent just such a method. Research in this area remains is limited, although the product has received wide support, particularly in South Africa. Before the product becomes a reality several issues must first be addressed.
There have been concerns about the partial effectiveness of microbicide protection. Current research has shown its expected effectiveness to be between 50-60%, which gives rise to concerns about promoting their use in the place of condoms 9. There is a great need for further research into both the efficacy and acceptability of microbicides within the population, especially considering the diverse needs of a population such as South Africa. However the encouraging results of recent studies, especially when introduced in conjunction with education programs have made promising groundwork for future development 10.
Prevention of HIV among women in South Africa and indeed across the entire globe will require not one single strategy, but a comprehensive package of interventions including condom distribution, awareness building and gender empowerment. Should research into microbicide gels prove fruitful, their distribution and use should by no means be construed as a panacea; tackling the HIV epidemic will ultimately require the root social determinants of its spread to be addressed.
References
1. UNAIDS. AIDS Epidemic Update. Geneva. UNAIDS. 2006
2. Shisana O et al. South African national HIV prevalence, HIV incidence, behaviour and communication survey. Pretoria, Human Sciences Research Council 2005. http://www.hsrc.ac.za/media/2005/11/20051130_1.html
3. Pettifor, A.E., Measham, D.M., Rees. H.V and Padian, N.S Sexual Power and HIV Risk, South Africa. Emerging Infectious Diseases 2004;10:11
4. Department of Health South Africa. HIV/AIDS Fact Sheet. 2006. http://www.info.gov.za/faq/aids.htm
5. Pettifor A.E, Rees H.V, Steffenson A, Hlongwa-Madikizela L, MacPhail C, Vermaak, K and Kleinschmidt I. HIV and Sexual Behaviour Among Young South Africans: A national survey of 15-24 year olds. Johannesburg: Reproductive Health Research Unit, University of the Witwatersrand 2004.
6. MacPhail C, Campbell C. ‘I think condoms are good but, aai, I hate those things’: condom use among adolescents and young people in a Southern African township. Soc Sci Med 2001;52:1613-2.
7. Robertson M, An overview of rape in South Africa. Continuing Medical Education Journal 1998; 16: 139-42. http://www.csvr.org.za/articles/artrapem.htm
8. Mantell JE, Scheepesr E, Abdool Karim Q. 2000. Introducing the female condom through the public health sector: experiences from South Africa. AIDS CARE 2000; 12:589-601.
9. Orner P, Harries J, Cooper D, et al. Challenges to micro-biocide introduction in South Africa. Social Science and Medicine 2006; 63: 968-978.
10. Van de Wijgert, Coggins C. Microbicides to prevent heterosexual transmission of HIV: ten years down the road. AIDScience 2002;1.
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