Women and HIV/AIDS: Confronting the Crisis

Ann Erb-Leoncavallo, Gillian Holmes, Stephanie Urdang, Micol Zarb, Gloria Jacobs, Joann Vanek. Geneva/New York: UNAIDS, UNFPA, UNIFEM, 2004.

“HIV/AIDS is no longer primarily striking men.”

Thus opens the new document from UNFPA/UNIFEM/UNAIDS on the issue of women and HIV entitled Confronting the Crisis. The publication has encouraging descriptions of innovative grassroots efforts to address the structural underpinnings of HIV/AIDS and to apply a gender analysis to the epidemic. It notes the “alarming trend” that women aged 15 to 24 in sub-Saharan Africa are now three times more likely than men to acquire HIV.

So AIDS, now affecting more and more women, is a “crisis”. Is it a crisis because it is affecting more and more women? The authors would probably be shocked at this interpretation, but there is a long tradition of implicitly suggesting it, as I wrote recently in these pages.¹ Despite our rhetoric about ending HIV-related stigma, there remains considerable unconscious preference for “innocent” victims such as unsexed infants or those infected through no action (or “fault”) of their own, and unfortunately Confronting the Crisis is compatible with these historical echoes. Its single-minded focus on women as casualties of gender inequality ends up boxing itself into a narrow corner where some of the useful lessons learned in creating prevention messages for sex workers, gay men and drug users fly out the window.

AIDS educators went to great lengths to explode the “risk-group” dyad that hinted that people were either guilty or innocent when it came to HIV. Nonetheless, Confronting the Crisis repeatedly contrasts “specific” or “high-risk” groups with everyone else and assumes that women are found in the latter category. Epidemics in some countries, it notes, are spreading:

“…from particular population groups – such as sex workers or injecting drug users – into the generation population, with women and girls increasingly affected.”

Some might object to the implication that sex workers are not women and girls, but in any case the document's discussion of their increased risk owes far too much to the old paradigm in which bad members of particular groups, most often male, infect good members of the general population, usually female.

And yet women do face enormous additional obstacles to the AIDS threat because of their sex, such as their lack of inheritance or land-ownership rights, the way male siblings are favoured over girl children in access to food or schooling, the pressure to exchange sex for safety or economic survival, and in a dozen other ways. Confronting the Crisis adds these important contextual elements and shows that some women are not idle witnesses to their conditions but take action to improve them. Clearly, male indifference to women's well-being is at work in these interpersonal and cultural dynamics, and projects should question them.

But what is lost in systematically ignoring the social and cultural pressures that shape men's behaviour and the suffering and ill-health that men face as a result? The authors of Confronting the Crisis acknowledge that men are central to lowering heterosexual transmission rates and easing women's unfair burden of caretaking. In fact, some of the interventions described explicitly include men. But their role is treated as merely instrumental to the aim of reducing female vulnerability and overwork.

The chapter on violence is illustrative in this regard. While women and girls undoubtedly bear the brunt of partner and domestic violence, is it possible to discuss violence related to armed conflicts without mentioning the soldiers who fight in them? To applaud men exclusively for “organising against violence against women by examining their own attitudes and behaviours” suggests a curious blind spot about what it means to be male during a war. Male involvement could be built around an entirely different question: how social norms are also detrimental to them, not just to women. But if men are only “instigators of violence” and never suffer from its effects, this approach will make no sense.

The authors might reply that their document is about women and their particular vulnerabilities, not men's. But the strategies proposed are rarely for girls or women alone; quite logically, the authors insist that men play a key role in the cultural and structural factors that affect female vulnerability. Interventions to reduce HIV infection among women inevitably must face both sides of the heterosexual equation. But Confronting the Crisis insists only that men and boys must gain awareness of gender inequity and take responsibility for their own oppressive behaviour because women and girls have “needs”. Men do not? It is hard to see how these approaches can appeal to the men who might fairly conclude that gender sensitivity is a strictly losing proposition.

There is another unintended effect of this exclusive focus on women's suffering and men's inadequate behaviour: it dovetails too neatly with the drumbeat emerging from Washington and the Vatican against sexual activity in general. Criticism of male sexual practices couched in terms of concern for women would be no great leap for the ideological sexophobes eager to push all AIDS-related work towards promotion of virginity. Those censorial and stigmatising campaigners will be quick to point out the unfairness of social standards that permit men to have sexual experience and prohibit it for women. Their solution is to prohibit it for both, and they will not hesitate to employ the gender lexicon in doing so.

A recent issue of the Horizons Report from the Population Council² takes a different approach in envisioning men as subjects who face harmful gender constructs. While this document also insists that men examine detrimental social norms and support women's autonomy, it focuses on the costs of traditional manhood to men as well, frequently including HIV infection and violence. The publication presents operations research on programmes tested in three countries that make a rare effort to view gender norms from both directions and to communicate how both men and women can gain from changing them. One study of young adults found that men sometimes mistrusted their partners' intentions and were concerned that the young women's primary motivation for the relationship was financial support and that “emotion played little role” in these relationships. This perspective is suggestive of ways prevention interventions could be shaped to provide benefit all around.

Furthermore, Confronting the Crisis is remarkably uninformed by the two decades of AIDS prevention activities oriented towards gay or homosexually-active men and the useful lessons learned there. Those interventions usually assumed that the desire for continued sexual activity would overwhelm messages that counselled abstinence or even monogamy. Condom use was the principal strategy, followed by suggestions of a modified sexual repertoire, but eventually educators realised that blanket, one-size-fits-all exhortations along the lines of “use a condom every time” had little to do with the logic of people's lives. By contrast, Confronting the Crisis celebrates an aggressive campaign that lectured eastern European youth with the question: “What's your excuse?” and answered: “There is no excuse. Wear condoms.” Do the authors of Confronting the Crisis apply this peremptory order to themselves, always and with no exceptions?

I have long believed that the women's health movement has valuable lessons to offer other types of prevention projects and vice versa, but Confronting the Crisis suggests that this dialogue is not taking place. Given the political forces set to jump at any apparent “failure” of prevention to tout their repressive alternatives, we may pay a high price for putting it off.