HIV Among Women in Developing Countries
By Pamela DeCarlo
During her pregnancy, Mercy Maklehema, a South African woman with HIV, followed a zidovudine (ZDV) regimen to prevent transmission of the virus to the child she was carrying. After her daughter was born HIV-negative, Maklehema discontinued taking the ZDV. No one warned her that her newborn daughter could become infected with HIV through breastfeeding. Tragically, the infant did become infected and later died. Lack of information is just one of the many problems with life-threatening consequences that confront women with HIV in resource-scarce countries. Another, the high rate of HIV infection, confronts all women.
Women account for nearly half of all new HIV infections worldwide, and the number of women becoming infected is increasing each year. Last year, more than 2 million women were infected with the virus. Moreover, young women are especially vulnerable. Half of all new HIV infections occur in young people between the ages of 15 and 24, and two-thirds of these infections are among girls and young women.
Eighty percent of the world’s women with HIV live in Africa. The statistics on HIV infection among women in Asia attest to the virus’s grim presence in that part of the world as well. In Cambodia, 1 in 30 pregnant women is infected. In Latin America, where the spread of HIV has followed the patterns seen in industrialized countries, women in some areas have been particularly hard hit. In Brazil, for example, women with HIV make up one-quarter of the country’s infected adult population, and AIDS is the leading cause of death among women between the ages of 15 and 45.
In several ways, women are more vulnerable than men to HIV infection. Male-to-female HIV transmission is about eight times more likely to occur than female-to-male transmission, often for a strictly biologic reason: During intercourse, the exposed mucosal surface of the female genital tract is much greater than the exposed surface of the male genital tract, and this facilitates infections by the virus. Women are also more vulnerable to coercion and sexual abuse, situations that increase their risk for contracting HIV. In general, gender, social, and economic inequalities usually result in women being less able to negotiate for safer sex or to choose their sexual partners.
Availability of Treatment and Care
In industrialized nations in the past few years, combination therapy - that is, therapy that involves the simultaneous use of several antiviral drugs - has helped increase health and prolong life among many people infected with HIV. However, in resource-scarce countries, most people with HIV find it nearly impossible to receive the latest treatments. These treatments not only involve drugs that are expensive and complicated to administer, but they also require frequent visits to a health-care provider.
In many developing countries, women have access to ZDV only when they participate in clinical trials investigating perinatal transmission. Once their babies are born and the trials end, women may lose access to ZDV and to specialized care. At the international AIDS conference held in Geneva in the summer of 1998, perinatal transmission of HIV was the most frequently discussed topic relating to women. According to Robin Gorna, chair of the conference’s Community Planning Committee, the emphasis on preventing perinatal transmission is "good news for the babies, but not good for the women." She believes programs should "not just focus on women who are giving birth" but should instead address the multitude of prevention and care needs that confront all women.
Maklehema echoes Gorna’s concerns. "These trials set out to save the lives of babies," she says. "How do they support and prolong the lives of women?"
Proper treatment of HIV can only be adequately addressed in the context of the overall need for affordable health care. For women, gender-related issues must also be an integral part of the discussion.
"There needs to be a genuine recognition that you can’t offer women HIV education or give them condoms without also dealing with the gender-related issues that are involved in HIV," says Sofia Gruskin, director of the Human Rights Program at the François-Xavier Bagnoud Center for Health and Human Rights at the Harvard School of Public Health. "We need to ensure women’s equal access in all areas - political participation, education, and health care. Women need access to reproductive health care that is not dependent on their husbands or fathers."
Access to Information Is Critical
Health care for women with HIV also needs to include up-to-date and accurate information on treatment options and on the effects of treatment. For example, in developing countries, it is vitally important that pregnant women with HIV who participate in clinical trials of drugs such as ZDV understand what may occur to them or to the children they are carrying as a result of their participation in a study. This kind of information usually is contained in informed consent statements. Ensuring that these women receive statements that are complete and easily understood is an important issue - and an important concern among those who serve their interests.
"Doctors think that because we’re women and mothers that we’re ignorant," says Maklehema. "They don’t explain the side effects of the drugs, so we can’t recognize them and know when there might be a problem."
Once women with HIV have access to information, they also need to have access to professionals who can help them make meaningful choices. Key to filling this need is providing women with caring and well-informed counselors. However, this need often goes unfilled in developing countries because there is usually little funding available for counselor training or similar efforts. "In South Africa," says Maklehema, "the doctors are all elite men and they only speak English. Do you think they can provide adequate counseling?" Makelehema believes that HIV-infected women need to be included in counselor training and support programs.
Breastfeeding
If breastfeeding is to be eliminated as an avenue for HIV infection, alternatives such as bottle feeding must be made safe and available. One cannot safely clean bottles and prepare formula in an area that is without adequate supplies of clean water. In some rural areas in Uganda for example, 85 percent of the infants who are fed formula die because it has been made using water contaminated with deadly bacteria. In the same areas, the death rate among infants who become infected with HIV through breastfeeding is 27 percent.
Even when clean water is available, the money to buy formula often is not. In Uganda, the cost of feeding one child adequately with formula is about one and a half times the annual earnings of an average village family.
Cultural issues also are factors in women’s decisions on whether to feed their infants by breast or by bottle. For many years the United Nations and public health organizations have been promoting breastfeeding as the healthiest way to feed and the best way to nurture a child. In many countries, the idea that the "breast is best" is still very strong, and the cultural view is that a good mother is one who breastfeeds.
Women’s Sex and Sexuality
In many countries, sex and sexuality are taboo subjects for women and men alike. Yet with vaginal intercourse the most common source of HIV transmission in developing countries, women must be educated in order to make informed decisions about their sexual health. Communities as a whole also need to break down the barriers to discussing sex and sexuality.
A related concern is women’s control over their own sexual relations. Young women - the population with the fastest-growing rate of HIV infection in the world - are particularly vulnerable to sexual exploitation. In many countries, education and job training are not available to young women. Economic hardship and lack of alternatives force many into sex work.
"In India, because AIDS first showed up in female commercial sex workers, it was easy for the government to sweep it under the rug," says Radhika Ramasubban, professor at the Centre for Social and Technological Studies in Bombay. Although India currently has the highest number of people infected with HIV of any country in Asia, the topics of sex and sexuality are excluded from public discourse.
"It is assumed in India that all people get married and are monogamous," Ramasubban says. "So topics like condom use, homosexuality, and multiple sexual partners are very difficult to address."
Successful Programs Meet Basic Needs
While the overall situation for women with HIV in developing countries is sobering, some regions have shown success in slowing the spread of the virus. In parts of Tanzania, for example, HIV-infection rates among young women have been halved as a result of strong prevention programs.
In Senegal, the government responded to increases in HIV-infection rates by encouraging open discussion of HIV, providing sex education in schools, promoting the use of condoms, and providing treatment to people with sexually transmitted diseases (STDs). As a result, HIV incidence among pregnant women in Dakar has remained at 2 percent since 1989. Many young people are using condoms regularly, and STD rates have fallen among female sex workers in Dakar.
In Thailand and Nepal, programs have been developed to address the needs of young female sex workers. Some of these programs provide health care; others provide these young women with access to education. Thai government officials quickly responded to the dramatic spread of HIV in their country by promoting a policy that advocated condom use among all Thai sex workers. The 100-percent condom-use policy, along with an effective and widespread media campaign, resulted in drops in the rates of infection for STDs and HIV. In Nepal, an aggressive campaign to provide HIV-prevention education and condoms to sex workers and truck drivers succeeded in doubling their use of condoms between 1994 and 1996.
In Brazil, efforts by workers at a center that seeks to protect the rights of children living on the streets of Rio de Janeiro led to progress on a very basic level. The workers procured birth certificates for girls and boys so that the children could apply for health care and get jobs. Providing for these basic needs may help prevent the children from becoming infected with HIV.
In the Democratic Republic of Congo’s capital, Kinshasa, programs aimed at facilitating discussions of sex and sexuality between mothers and daughters also helped to build community support for those who made safe choices about their health and sexuality.
To be effective, programs aimed at women must address education, equal rights, and access to full and comprehensive information. "AIDS is a social issue," says Maklehema. "We need to help women deal with their own social problems before we can deal with HIV-related problems."
- Pamela DeCarlo is communications specialist at the Center for AIDS Prevention Studies, University of California, San Francisco.
