FHI - Supporting Women at Risk

Table of Contents

V. Supporting Women at Risk (See Below)

VI. Promoting Sustainable Prevention Efforts

V. Supporting Women at Risk

As AIDSCAP was getting under way in the Dominican Republic in 1992, it was clear the program needed to reach women in all sectors of Dominican society. Epidemiological data showed that HIV/AIDS was spreading from the core groups first affected by the epidemic to the population as a whole. Even monogamous women were at risk because of the behavior of their unfaithful partners. Ironically, earlier HIV/AIDS prevention campaigns that had focused on high-risk groups and linked infection with prostitution and promiscuity might have lulled some Dominican women into a false sense of security.

Evidence of the AIDS epidemic in the Dominican Republic first appeared in the 1980s, primarily among sex workers and their clients and men who have sex with men. In 1984 the ratio of men to women diagnosed with AIDS was 7 to 1. By 1991, however, that ratio had fallen to 2.2 to 1, indicating a dramatic widening of the epidemic. By 1992 some two-thirds of the country's cumulative AIDS cases had resulted from heterosexual HIV transmission.

Experience in countries around the world has shown that an HIV prevalence rate of 1.0 percent or higher among women attending prenatal clinics is an indicator of a serious epidemic impending in the general population. A Dominican government program set up to track HIV infection levels found a rate of 0.8 percent among prenatal women in one Santo Domingo hospital in 1991. In another hospital in the capital city that year, the rate was 0.7 percent for pregnant women at time of delivery. Research in the northern coastal city of Puerto Plata found a 1991 prevalence rate of 1.7 percent among prenatal women.

AIDSCAP responded to these trends with broad efforts to affect policy and social norms, as well as activities to reach specific groups of women and to ensure that its projects addressed gender issues influencing HIV transmission. In-depth research on why young women were slower than young men to embrace risk-reducing behaviors provided solid grounding for a dynamic mass media campaign that challenged the prevailing social norms governing sex and sexuality.

Broad and Targeted Responses

One route AIDSCAP took to promoting social change was to bring together government, NGO and community leaders to develop national HIV/AIDS prevention strategies and plans, including one focused on women. The first such initiative grew out of AIDSCAP's support during late 1994 and early 1995 to the Instituto Nacional de Salud (INSALUD), a national membership group for public health professionals, to build broad awareness of AIDS legislation that had been approved in the Dominican Republic in 1993. As INSALUD held a series of informational meetings around the country, it became increasingly clear that there was a need to create new approaches to dealing with women's special needs.

Out of that realization came a series of three workshops involving dozens of organizations and individuals in creating a national HIV/AIDS prevention strategy focusing on women. That new document was presented and discussed at another AIDSCAP-supported event, a September 1995 conference on women and HIV/AIDS. Organized by the Instituto APEC de Educaci�n Sexual (INSAPEC), the meeting attracted more than 400 persons to its opening night, which featured AIDSCAP's regional director for Latin America and the Caribbean speaking on the shift of the HIV/AIDS pandemic to women. Some 200 persons from 36 organizations participated in the remaining two days of the conference. AIDSCAP also assisted INSAPEC in holding a preconference workshop for groups working with women, where 22 persons from 20 different organizations received training in developing HIV/AIDS prevention programs for women.

Other AIDSCAP activities focused on equipping particular groups of women to protect themselves from HIV and STIs. One AIDSCAP project with a heavy focus on gender issues was the "Trabajo y Salud" (Work and Health) Project for employees in the industrial zones in and around Santo Domingo. Women make up half or more of the workforce in many of the zones' assembly plants and manufacturing and production facilities. The AIDSCAP partner carrying out that project, COIN, used focus group discussions to identify the issues of most concern to female employees. The group applied that new information in adapting materials on negotiation and dialogue for couples from AIDSCAP's program in Brazil.

COIN added new training sessions for its corps of volunteer health messengers on such gender issues as the social and health situation of women, sexuality, reproductive health, couple relationships, self-esteem, and sexual and reproductive rights. A number of the volunteers reported that as their knowledge grew, they also gained self-esteem and were better able to negotiate with men on issues of sexual risk. As the messengers shared that new knowledge, they saw more of their coworkers choosing to participate in the HIV/AIDS prevention activities in the industrial zone businesses and asking for copies of the COIN educational materials. The health personnel working for those businesses also reported similar increases in women workers' information inquiries on those issues.

The Acuario Project, which targeted adolescents and young adults in four low-income Santo Domingo neighborhoods, also created special educational programs focused on women's concerns. Early on in the project, 25 female health messengers were trained in gender-sensitive issues.

Despite these efforts, project surveys in 1996 revealed that young women lagged behind their male counterparts in behavior change to reduce their risk of HIV infection. The percentage of young men who reported they had used a condom in their most recent sexual intercourse rose from 29 percent in 1993 to 47 percent three years later. Reported condom use also rose among the young women surveyed, but to only 17 percent.

"Young people were changing, such as by using condoms more, but the women weren't changing as much as the men," said Bethania Betances, the director of the department of education of CASCO, one of the two Dominican NGOs that carried out the Acuario Project. "We saw we needed a new approach."

Understanding Gender Differences

Out of that realization came a CASCO research project to identify why young women still exposed themselves to sexual risk and then to create strategies that could help them better protect themselves.

CASCO conducted 24 focus group discussions with Dominican women between the ages of 15 and 24 in the four neighborhoods where Acuario was working. The CASCO investigators talked with three types of women and girls: those with no sexual experience, those with experience but no regular partner and those in a stable relationship.

Twelve of the focus groups dealt with women's sexual roles and their ability to adopt safe sex practices. In the other twelve discussions women talked about the information they needed and whom they considered reliable sources for that information.

Much of the women's behavior was tied to their economic circumstances and the level of their financial dependence on men, the CASCO research found. Dominican women have more limited economic opportunities than men and would be unable to earn an adequate living on their own if they left their parents' home. When a woman does become involved with a regular partner who is supporting her economically, she loses much of the power she had had as an unattached woman to negotiate condom use and other sexual issues. Providing women with new economic opportunities could help reduce their risk of HIV infection, the NGO investigators suggested.

Among other barriers to women's behavior changes, according to CASCO, were lack of communication between parents and their daughters, the limited educational opportunities for lower-income women and the violence, sexual aggression and harassment the women faced in their personal relationships.

"It's not just a question of what happens with your partner," said Betances. "It's self-esteem, it's economic, it's emotional. Many women think, 'To keep my relationship, I have to do what my partner wants in sexual practices.'

"Women are also pessimistic about persuading their partners to change. They think everybody's in the same situation. They say, 'If I look for someone else, he'll be just the same. And if I let go of my man, I'll be in big financial trouble.'"

To translate these study results into an action plan, CASCO convened a three-day workshop in Santo Domingo in March 1997 for some two dozen representatives from NGOs and Dominican government agencies. Meeting participants looked at the results of the CASCO study, as well as an AIDSCAP-funded investigation of the attitudes and practices of female university students and the HIV/AIDS portion of a national demographics and health survey.

The workshop representatives split into four working groups to consider four areas: broad policies and nationwide programs; mass media, such as television and radio; "small" media, including videos, brochures and posters; and such communications strategies as one-on-one and small-group counseling, telephone hot lines and peer education. Each group listed general objectives, specific actions to achieve those objectives, obstacles, messages to disseminate, needed human and material resources, and monitoring and evaluation indicators to measure their progress. AIDSCAP and CASCO compiled those ideas into a final strategy document that the two groups unveiled in July 1997.

Challenging Social Norms

The CASCO research and workshop strategizing also served as the basis for a new mass media campaign. Similar in many ways to AIDSCAP's acclaimed campaign targeting adolescents (see Reaching Youth), the new gender-focused campaign consisted of high-quality TV and radio ads supported by a number of other activities and materials.

The campaign's key message was that women have a right to protect themselves from HIV and other STIs and that men and society in general have an obligation to support that prerogative.

To get this message across, AIDSCAP enlisted the assistance of the same advertising agency that had created the award-winning adolescent public service announcements. The new ads began airing in May 1997. During the campaign's first month, Dominican broadcasters contributed more a quarter million dollars of air time for the ads. Even after the AIDSCAP office closed in the summer of 1997, radio and TV stations and cable systems continued carrying the spots. (See 5.1. Lessons and Recommendations.)

One of the TV ads was targeted mainly at women, encouraging them to change their behavior for their own sake and the sake of their daughters. The spot's opening scene shows young girls playing while a narrator talks about the things they traditionally have learned: to dance, cook, sew and iron clothes. As the ad moves to a shot of a young man grabbing and pushing a young woman, the narrator warns women, "They didn't teach you to respect yourself and to demand respect."

The spot then shows a woman and her two daughters as the narrator asks, "Will the same thing happen to your daughters?" The ad concludes by calling on women to begin exercising their right to protect themselves from HIV/AIDS and to ask their partner to understand them and not abuse them.

The second advertisement is directed at men. As a woman looks at the camera, she asks, "If God and society made men and women equal, why can't you as a man do the same thing in the home?" A narrator goes on to say that women have a right to protect themselves and that men should respect that right.

AIDSCAP created supporting printed materials that included posters, brochures, billboards and bumper stickers. Some of the NGOs working with AIDSCAP hoped to set up discussion groups that would deal with many of the issues raised in the campaign ads. Women-only discussion groups would help participants deal with their reluctance to discuss sexual issues in front of men. Mixed-sex groups could consider many of the same topics as the women's groups, as well as ways the two sexes could communicate better with each other. Both types of discussions could also provide campaign organizers an ongoing source of feedback on the effectiveness of the media messages.

"Women are in a dependent position and have less power than men," said Ceneyda Brito, the communication specialist in AIDSCAP's Dominican Republic office. "We want to create an environment so that couples will negotiate with each other."

Brito and other AIDSCAP staff members are optimistic the new advertising campaign will open up discussion on HIV/AIDS, sexuality and relationships among individual couples -- just as AIDSCAP's other women-focused activities have broken new ground for Dominican society as a whole.

5.1. Lessons and Recommendations
Lessons Learned

Addressing gender, empowerment, self-esteem and sexuality issues is fundamental to achieving sustainable behavior change for HIV/AIDS prevention.
One way to reach women in the general population who are at risk of HIV infection is to target them in the workplace, especially in industries that have a preponderance of female employees, such as in the Dominican industrial zones.
HIV/AIDS communication programs encouraging individuals to adopt safer sexual practices are more effective when they are supplemented by efforts encouraging complementary changes in social norms.

Recommendations

HIV/AIDS prevention campaigns should avoid associating HIV/AIDS and STIs only with sex work and promiscuity. Such campaigns may have lowered the perception of risk for HIV/AIDS and STIs among other women who may also be at risk, particularly monogamous women whose partners are not faithful.
Men should be included in interventions designed to reduce women's risk of HIV infection.

Meeting the Challenge of the HIV/AIDS Epidemic in the Dominican Republic: The AIDSCAP Response, 1992-1997