Gender and HIV

In recent times, the term "gender" has somehow become synonymous with "women". In all our discussions around gender, we tend to focus on women as if to say that gender is exclusive to women. All of us know that gender impacts women. Most of us here are women and we have experienced the impact of gender on our lives. However, we should be aware of and acknowledge the fact that gender impacts men as well. In order to make an appreciable and sustainable difference to the quality of lives of women, to protect them from HIV and its impact, we need to involve men, both in our discourse and our actions in this regard.

Sex, Sexuality and Gender

Many variables influence the spread of HIV in any society. However the three most important ones are Sex, Sexuality and Gender. These three terms are often used interchangeably and can seem confusing. For purposes of this paper, I will broadly distinguish them as follows:

• Sex is a biological phenomenon, determined by the arrangement and number of the x and y chromosomes in a human body. This is mediated by biology alone and is innate to an individual. Sex can usually be seen as a binary configuration as in, the female sex and the male sex.

• Sexuality is a conglomerate of sexual needs, sexual desires, sexual orientations, sexual expressions, sexual actions and interactions. Though the needs, desires and orientations may spring from within the individual, the expression of her/his sexuality is mediated by a variety of factors including gender.

• Gender generally refers to widely shared ideas and expectations about women and men; ideas about "typically" feminine and masculine characteristics and abilities; and expectations about how women and men should behave in various situations. These ideas and expectations usually reflect and influence the different roles that women and men play through their lives, their social status, and the economic and political power they wield in society.

Characteristics of HIV

Like many viruses, HIV has certain specific characteristics. Though it is present in all body fluids, only blood, semen, and vaginal fluids contain the virus in quantities sufficient enough to cause infection. HIV infection can only occur when the virus has direct entry into the blood stream. Hence, for an individual to acquire HIV infection, blood, semen, or vaginal secretions from a person with HIV has to find direct entry into her or his blood stream.

In Tamil Nadu, like in many other parts of India, the most common route of HIV transmission is unprotected sex between men and women. In addition, there is a smaller, though significant percentage of spread through sex between men having sex with other men.

How Sex Affects HIV

The physiology of women, makes them more vulnerable to HIV infection than men. A woman is three times more likely to acquire HIV infection through unprotected sex with an infected man than a man is from an HIV positive woman. This is because of the following factors:

• The surface area of the vagina is far greater than the surface area of the penile head. This increases a woman's exposure to the virus as compared to a man.

• Reproductive Tract Infections (RTIs) are very common among women. Many RTIs and STIs (Sexually Transmitted Infections) are asymptotic in women. Because of this, and because women are unable to look into their own vaginas, they are often unaware of the many minute cuts and bruises that the vaginal area may harbour. If these are not adequately treated, they will provide an easy entry point for HIV.

• The concentration of HIV is very high in semen as compared to vaginal fluids. Thus "viral load" and "infectivity" is correspondingly higher.

Sexuality and HIV

In our society, as in many other in the world, overt expressions of sexual needs and desires are discouraged both in men and women. However, the control over a women's sexuality is far more heavily enforced. It is not acknowledged within the family, community, or even among policy makers that women experience sexual needs and desires soon after puberty. These are confusing to the adolescent girl child who cannot access a place or service that can allow her to discuss her feelings, seek appropriate information, or access resources that can help, if she finds herself in a situation where sexual activity is either possible or present.

Premarital sex is more common than one would imagine. A survey conducted among women in prostitution in Tamil Nadu in 1997 by the National Commission for Women revealed that a significant percentage of the women had been sexually abused within the family and cited it as the principle reason for leaving home and entering prostitution.

The practice of men having sex with other men is another area most people would find difficult to acknowledge. Yet, this is widespread in Tamil Nadu. Usually the men also marry due to pressure from their families. The families themselves are unaware that their sons / brothers / husbands / fathers have sexual relationships with other men.

This leads to the interesting situation, where the men would see themselves as "homosexual" (based on their desires), society would classify them as 'heterosexuals', while their behaviours would be termed as 'bisexual'.

This need to keep the behaviour secret so as to avoid stigma and discrimination has more serious implications than the one of classifications. It leads men to have sex with men on the sly, where they can't be noticed and where they can get it over and done with quickly before getting back home to their wives and kids. Since homosexual sex is considered a criminal act under Indian law, it invites a great deal of violence and harassment from the police. All these factors come in the way of the man using a condom. Besides, the condoms currently available in the country are suited only for vaginal sex and not anal sex, which is the common practice among men having sex with men. This makes the men highly vulnerable to HIV infection. This automatically means that their wives are vulnerable as well: Our inability and unwillingness to understand, acknowledge and accept sexuality as part of human reality is a primary co-factor in the spread of HIV.

How Gender Impacts HIV

Physiological differences between men and women cause the virus to spread more easily from men to women than from women to men. But, women's biological disadvantage is also compounded by social factors. While male and female condoms can effectively prevent the transmission of HIV/AIDS, social and cultural factors can often prevent women from using them. Where women are denied reproductive health and sexual education because social doctrines hold that this knowledge encourages promiscuity, women are ill equipped to make use of condoms even where they are available. Further, in many cultures women lack power vis-à-vis their sexual partner to negotiate condom use. This applies to married women, women and girls in coerced sexual liaisons, victims of rape, single women, and sex workers.

The male orientation of the understanding of the epidemic to date is evident also in the way HIV-related illnesses and AIDS have been defined. The case definition of AIDS issued by the United States Centres for Disease Control and used worldwide, focuses on the marker diseases that are characteristic of HIV-related illness in men and omits conditions that often signify the onset of HIV-related conditions and AIDS in women, including pelvic inflammatory disease, cervical cancer, vaginal candidiasis and conjunctivitis. This has had serious consequences for women, leaving many women undiagnosed or wrongly diagnosed, delaying diagnosis and treatment, and denying women access to disability and other benefits and services because they have not been diagnosed with AIDS.

Although most of the people who have contracted HIV since the start of the epidemic have been men, of the 17.5 million adults who have died from the disease, nine million have been women. These statistics reflect, among other issues, fundamental gender inequality in access to and utilization of HIV/AIDS prevention, treatment and hospital or home-based care.

Gender and Women in Prostitution

Women's access to the cash economy other than through prostitution, is often limited by land ownership or usage regulations, by their limited access to education, training, credit or employment, and through their culturally restricted mobility. The sale of sex is also something that women may engage in from time to time in order to support themselves and their families. For these women, sex work is not an occupation or even a chosen lifestyle, but a pragmatic measure to overcome transitory economic hardship. The risk of HIV transmission to which they are exposed has to be tragically balanced by them against need.

Prostitution is often the only means of support for deserted, separated, divorced, or unmarried older women, highlighting once again the close link between economic need and exposure to HIV infection.

The impact of HIV epidemic on women is not confined to their own risk of being infected with HIV. As the primary care givers, women bear the burden of caring for the sick, of holding the family unit together in the face of sickness and death and coping with the emotional trauma of dying. They must often forego productive activities or employment opportunities in order to fulfil their duties as care givers. The psychological burdens and responsibilities carried by women in these circumstances are great and will be exacerbated where the women herself is infected with HIV and experiences anxiety about her own health and the future care of her children.

Preventing Transmission of HIV to Infants

More recently, interventions have been initiated in India that is attempting to reduce the transmission of HIV to babies in the womb. If a woman was to be infected with HIV before she conceives or during pregnancy there is a 30% chance that the virus will be transmitted to the foetus. Though the woman acquires the infection from her male partner in the first place, she is still seen as the primary vector of HIV infection to her baby. In fact, these interventions are even termed Prevention of Mother-to-Child Transmission of HIV (PMCT). This not only increases the guilt of women, it also refuses to acknowledge the fact of the father's responsibility.

In a continuation of the policy that favours anything or anybody over women, all interventions are designed to prevent transmission to baby while doing nothing to the women. In addition, women invariably find out their HIV status when they are tested during a visit to the antenatal clinic. Testing is almost always coercive. Though the women may be told that they tested positive for HIV, sign the consent form, they rarely understands what the implications of the test are. Worse, she finds out her HIV status before her husband does, this leads to his suspecting her fidelity.

Since breast milk can also transit the virus to infants, women are advised not to breast feed. However such advice is also questionable from more than just a biological point of view. Because most women can't afford artificial feeds in adequate quantity the children are usually under nourished and may die of malnutrition and poor hygiene-related diarrhea before HIV can claim them.

In addition, women not breast feeding their infants are suspected of having AIDS by their family and community leading to isolation and discrimination.

We now know that exclusive breast feeding that is giving the infant nothing but breast milk, protects the child from HIV even where the mother is positive. We now need to encourage women to exclusively breast feed if they feel they are unable to afford alternate feeds for their infants.

Sustainable Initiatives

We have now learnt that interventions have to go beyond the information, education, communication, and condoms model if we are to effectively address HIV prevention and care. We've also realized that we need to involve men in order to protect women better. Some key areas that have to be addressed include:

• Violence against women.

• Protecting human rights of both women and men.

• Addressing discrimination of sexual minorities and positive people in the family, community, institutions and society.

• Opening up discussions in the family and community with regard to both sexuality and gender.

• Involving men as part of the intervention.

• Ensuring access to affordable, good quality services for prevention and care.

• Strengthening community organizations and encouraging community-managed interventions.

• Increasing economic self-reliance of women through thrift cooperatives.

• Increasing access of children to education.

• Increasing capacity and skills of affected communities to work in HIV-related interventions.

Recommendations for Policy

• Addressing primary determinants of vulnerability of HIV infection as a concrete component of HIV interventions.

• Expanding the scope of reproductive health to include sexual health.

• Including interventions for men and/or men in the interventions planned for women.

• Community-level interventions to support young women and men through adolescence.

Violence

• Campaign to protect girl children from domestic sexual abuse.

• Stringent punishment for traffickers.

• Dismissal from service of police personnel using violence upon women in prostitution.

• Re-examination and revision of Section. 377 that defines homosexuality as a criminal act.

Services

• Ensuring availability of services for sexual health for all women.

• Ensuring adequate and free supply of condoms to women and men to encourage use.

• Promoting manufacture and distribution of female condoms

Counseling

• Ensuring community-level availability of counselling services.

• Discouraging coercive HIV testing and unethical follow up.

• Promoting couple counselling at antenatal clinics.

Preventing Parent-to-Child Transmission of HIV (PPTCT)

• Discouraging episiotomy procedures during delivery.

• Promoting exclusive breast feeding.

In conservative societies, as in much of Tamil Nadu, women's sexual needs and desires are derived from their capacity to bear children. Any woman who expresses sexual desire as a part of her personality without relating it to the family, is considered a "bad woman". Thus women who do not stay within the social expectations of their sexuality are often persecuted by society and the State. A striking example is the issue of women in prostitution. The law is more supportive of the women than the law enforcers are. According to the Immoral Traffic Prevention Act, (Sec. 8 b), a woman may be prosecuted only when she is caught soliciting in a public place. The police on the other hand do not make such distinctions. A survey among nearly 200 women in 13 districts of Tamil Nadu in the period July - Sep. 2000, exposed the brutality of the police towards women in prostitution.

On the other hand, both the law and the State appear to consider the behavior of men seeking paid sex as perfectly normal.

Because women are discouraged from expressing their own sexuality they are naturally discouraged from accessing resources that can protect them against the possible negative consequences that such expressions might throw up. For example, most women we know find it embarrassing to insist on the use of condoms though they know unprotected sex might expose them to sexually transmitted infections.

Most interventions in HIV in this region have concentrated on addressing women in prostitution. There have been very few attempts made to intervene in other circumstances. Thus, any overt expression of a woman's sexuality delinked from her husband or her children can be the basis for violence and discrimination.