FHI - Making Prevention Work Global Lessons Learned from the AIDS Control and Prevention (AIDSCAP) Project 1991-1997 Making Prevention Work 7. Women, Men and HIV/AIDS: Building Gender-Sensitive Programs

Table of Contents

7. Women, Men and HIV/AIDS: Building Gender-Sensitive Programs (See Below)

8. Managing HIV/AIDS Programs and Building Capacity to Sustain Prevention Efforts

9. Prevention and Care: Mutually Reinforcing Approaches

10. Crossing Borders: Reaching Mobile Populations at Risk

7. Women, Men and HIV/AIDS: Building Gender-Sensitive Programs

One of the most significant changes in HIV/AIDS prevention during the second decade of the epidemic has been a growing appreciation of the need to reduce women's vulnerability to the virus. Once considered a disease of homosexuals, injecting drug users, sex workers and other "high-risk" groups, HIV/AIDS is now recognized as a serious threat to most sexually active women -- including those who are monogamous.

Rising rates of HIV/AIDS among women and young girls throughout the world confirm that they are at increasing risk of infection. Worldwide, the proportion of adults living with HIV/AIDS who are women rose from about 25 percent in 1990 to 42 percent in 1995. By the year 2000, the annual number of AIDS cases among women will equal or exceed those among men. Today six out of ten new infections worldwide occur in women 15 to 24 years of age, and in that age group, twice as many young women are infected as young men.

Biology plays an important role in women's heightened susceptibility to HIV. In fact, sexual transmission of the virus is at least four times more efficient from men to women than from women to men. But research and experience have shown that the imbalance of power between men and women is at the root of women's vulnerability to HIV. Women's economic dependence on men and society's acceptance of different standards of sexual behavior for men and women put women at risk and make it difficult, if not impossible, for many of them to negotiate safer sex with their partners.

During the past six years, AIDSCAP and other international organizations have begun to define a more gender-sensitive approach to prevention that addresses some of the root causes of HIV's rapid spread among women. Based on a deeper understanding of the economic, legal and social factors that fuel the epidemic, this approach aims to educate policymakers about the deadly consequences of gender inequities, empower women to protect themselves from unwanted and unprotected sex, develop and test prevention methods that women can initiate and control, improve communication between the sexes, and give boys and girls positive models of mutually supportive relationships between women and men.

Gender Initiatives

AIDSCAP advanced a gender-sensitive approach to HIV/AIDS prevention through pilot interventions, training of policymakers and grassroots leaders, research and information dissemination. Millions of women and girls acquired knowledge and skills to help them reduce their risk of HIV infection, and hundreds of policymakers, health care providers, educators and grassroots leaders -- both men and women -- were sensitized to the gender aspects of the epidemic.

The reach and scope of the activities and interventions described in this chapter and in previous chapters reflect the success of AIDSCAP's efforts to institutionalize a gender perspective in its own programs and those of its partners. Through its Women's Initiative, established in 1994 with support from USAID's Office of Women in Development and HIV/AIDS Division, AIDSCAP integrated a gender focus into many existing projects, expanded a number of interventions to address broader issues of gender inequality and women's social and economic empowerment, and developed dozens of new projects and activities.

With the creation of the Women's Initiative, AIDSCAP staff and their partners were challenged to take a critical look at their projects and programs to ensure that they addressed the needs of women. The results ranged from the development of regional and national gender and HIV/AIDS strategies, such as the one developed for the Latin America and Caribbean region (Box 7.1), to incorporation of seemingly small but critical design features.

In India, for example, AIDSCAP-supported NGOs found innovative ways to reach Indian housewives who would not have been able to attend other public HIV/AIDS education events, combining outreach efforts with competitions in traditional household arts.¹ Worldwide, AIDSCAP was successful in gaining widespread acceptance among its partners of the importance of collecting and analyzing separate evaluation data on men, women, young women and young men in order to understand the true impact of their interventions on these populations.

7.1 LAC Regional Gender and HIV/AIDS Strategy: A Catalyst for Change
Throughout much of Latin America and the Caribbean (LAC), many people still believe that HIV/AIDS strikes only those who live at the margins of society. Yet three out of every four HIV infections in the region result from heterosexual transmission, and in many countries, HIV rates are rising faster among women than in any other group.

In this decade alone, the male-to-female ratio of reported AIDS cases throughout LAC shifted from 4.9 to 1 in 1991 to 2.8 to 1 in 1996. In the Dominican Republic, the male-to-female ratio of HIV infections went from 7 to 1 to 1.5 to 1 in eight years. And in Haiti, equal numbers of men and women are infected with the virus.

AIDSCAP responded to these alarming trends in HIV among women with a concerted effort to strengthen the capacity of HIV/AIDS programs in LAC to address the gender issues that make women so vulnerable to infection. Meetings with AIDSCAP resident advisors and their colleagues from the region led to the development of a strategy that encompassed training in gender analysis, research and pilot projects and sharing of lessons learned.

Under the regional strategy, each AIDSCAP program in the region carried out a study, training program or pilot intervention. For example, AIDSCAP's program in Brazil trained 100 government and NGO health care providers from three states to ensure that they were sensitive to gender issues that affect service delivery and to promote integration of HIV/AIDS prevention into other reproductive health services. In Honduras an AIDSCAP-supported project enhanced the leadership skills of 50 women in two municipalities, enabling them to become advocates for the reproductive health needs of women in their communities. These and other projects strengthened HIV/AIDS prevention efforts and offered models for designing gender-sensitive interventions in the future.

But the impact of the effort to develop and implement a regional gender strategy was more far-reaching than the results of the pilot projects. After AIDSCAP established its Women's Initiative in 1994, project staff reviewed all their activities in the region to determine how to reach a broader range of women and to address the needs of both women and men. This new emphasis on gender sensitivity was soon reflected in the strategies, plans and activities of AIDSCAP programs in the region -- and even in the language staff used to describe them.

In Haiti, AIDSCAP worked with HIV/AIDS and women's organizations to ensure that gender concerns would be addressed in the country's future prevention strategies. In May1995, a "Day of Reflection on Women" brought together 30 representatives from 18 organizations to develop consensus on goals and strategies for preventing the spread of HIV/AIDS among Haitian women. This dialogue was continued during the final year of AIDSCAP's program in Haiti through a series of forums in four regions of the country organized by a coalition of 34 women's organizations. The recommendations of forum participants were reported to the new Haitian National AIDS Commission for incorporation into its five-year National Plan of Action.

AIDSCAP's program in Honduras, which was launched in 1995, addressed gender issues from the beginning. Baseline survey results were analyzed to identify gender-based constraints to prevention for both men and women, and educational materials were revised to ensure they were gender-sensitive. The project also made special efforts to reach women at all levels of society. One project, designed in collaboration with the Honduran Women's Government Office, trained peer educators to lead discussions about HIV/STD prevention in their communities. Another project linked education and discussions about HIV/AIDS, sexuality, domestic violence and women's rights with credit programs for women in rural areas. And interventions in factories with large numbers of female employees worked to prevent sexual harassment as well as HIV transmission.

In Brazil, a total of 16 new "rapid-response" grants for gender-sensitive interventions were awarded during 1996 and early 1997. One NGO distributed targeted HIV/AIDS educational materials to more than 500 newly elected councilwomen throughout the state of S�o Paulo to encourage them to strengthen the legislative response to the epidemic. Another NGO trained women radio broadcasters from four states in ways to present HIV/AIDS prevention on the air and helped them produce two radio spots on prevention for women. In Rio de Janeiro, a project designed to generate dialogue about HIV and STDs among women in the waiting room of a busy gynecological clinic was expanded to reach men attending other clinics at the same health care center.

And in the Dominican Republic, AIDSCAP worked with the government's department of women's affairs, the national STD control program and local NGOs to develop a strategy for preventing HIV and other STDs among young women. This strategy included a mass media campaign modeled after the program's successful campaign for adolescents. Local and cable television stations began airing the public service announcements created for the campaign in May 1997 and continued to broadcast them after AIDSCAP activities in the country ended three months later.

AIDSCAP also sponsored numerous studies, training workshops, interventions and policy initiatives to address gender and HIV/AIDS in the Dominican Republic. Most notably, a women and HIV/AIDS plan created by AIDSCAP and the Dominican public health association, in collaboration with other governmental and nongovernmental organizations, was incorporated into the National AIDS Control Plan.

Gender training conducted in January 1997 reinforced the commitment of AIDSCAP program managers to gender-sensitive programming. It also strengthened their capacity to plan, implement and evaluate such programs as they began to make the transition from managing AIDSCAP programs to running their own indigenous HIV/AIDS NGOs.

AIDSCAP staff had an opportunity to share what they had learned about integrating a gender perspective into HIV/AIDS programs with colleagues from other countries in the region at a workshop in April 1997. Twenty-five participants from six LAC countries met to discuss strategies for addressing gender issues in HIV/AIDS prevention and to develop mechanisms for sharing their experiences in the future. The resulting partnerships between HIV/AIDS organizations in Brazil and Bolivia and in Honduras and Nicaragua will ensure that AIDSCAP's strategy for gender and HIV/AIDS continues to influence prevention efforts throughout the LAC region.

Many of the most innovative gender initiatives were additions to projects already underway. A South African prevention project targeting sex workers and their clients and partners was broadened to address the harassment and violence that the women often face from law enforcement officers and clients (Box 7.2).² An Ethiopian NGO gave its young peer educators gender training and created a drop-in center where facilitators encouraged discussions between young men and women about sex and sexual risk.³ And a Senegalese project built on an earlier intervention with market women to use their credit associations to help a particularly vulnerable group of market women and their daughters learn to access credit and protect themselves from HIV/AIDS.

7.2 Gender Training Produces Results
In Pietermaritzburg, South Africa, as in many parts of the world, women who trade in sex often face harassment, violence and sexual assault, not only from clients and brothel owners, but also from the police. The South African NGO Lawyers for Human Rights has collected the stories of many women who were raped by those entrusted with enforcing the laws against sexual abuse.

One woman, only 19 years old, reported being forced to have oral sex with five police officers, who left her naked on a remote road outside of town. On her way home she was raped by a drifter who demanded sex in return for a ride. Another woman was arrested for soliciting and locked in a cell for several hours by two policemen, who released her only after she agreed to have unprotected sex with each of them in the back of a police van.

In both cases -- and many others -- no charges were filed. Considered criminals under South African law, sex workers are easily intimidated by threats of police retaliation.

The AIDS Training, Information and Counseling Centre had been working with sex workers and their clients in Pietermaritzburg, educating them about HIV/AIDS and condom use. But in an environment where sex workers had almost no protection against physical abuse and sexual assault, "negotiating" condom use seemed a remote possibility.

Such power imbalances between women and men are often overlooked in the design of HIV/AIDS prevention projects. Driven by the urgent need for prevention education and methods and constrained by the difficulty and cost of addressing more complex issues, many projects ignore the long-term social, economic and legal problems that make people vulnerable to HIV infection.

In Pietermaritzburg, however, Lawyers for Human Rights recognized the problem early on. As participants in a regional gender training workshop organized by AIDSCAP's Women's Initiative with support from USAID's Regional Economic and Development Services Office for Eastern and Southern Africa, representatives of the NGO identified the widespread disregard for sex workers' human and legal rights as a major obstacle to HIV/AIDS prevention. The pilot project they developed during the workshop and launched in January 1996 with support from AIDSCAP included interventions to educate both sex workers and law enforcement officers about the women's legal rights, as well as national advocacy efforts to decriminalize sex work.

By April 1997, some 24 women had received training to help them understand and assert their rights and to empower their peers with this information. Lawyers for Human Rights reports that sex workers are beginning to use their new knowledge and the support they received from the NGO to do what few had dared to do before -- to bring charges of rape and assault against their attackers.

Some progress was also made in sensitizing police officers, as evidenced by a decline in the number of reported incidents of police harassment and intimidation of sex workers. The project developed a training package designed to help law enforcement officers and others who work with the public confront negative and potentially dangerous attitudes toward marginalized members of society. And on the national level, it established a network of advocates to work toward the long-term goal of decriminalization.

The Pietermaritzburg project was one of five initiated as a result of AIDSCAP's gender training workshop held in Mombasa, Kenya, in October 1995. The structure of the training, which included a follow-up workshop to assess project results, and the provision of seed money made it possible for participants to put their new knowledge and skills into immediate practice.

Forty-one senior program managers from government agencies, NGOs, AIDSCAP offices and USAID Missions in Ethiopia, Kenya, South Africa, Tanzania and Zimbabwe participated in the five-day workshop, which was designed to give them the skills needed to incorporate a gender perspective into HIV/AIDS programs. Their enthusiastic response led to plans to hold similar workshops elsewhere in Africa.

In fact, workshop participants from the AIDSCAP-supported Tanzania AIDS Project (TAP) developed their own plan to train NGO personnel in leadership skills for identifying gender issues and modifying interventions. Forty-two NGO representatives from the nine regions covered by TAP participated in a training-of-trainers workshop, then went back to their districts to hold similar workshops for a total of 239 NGO staff throughout the country. AIDSCAP's resident advisor in Tanzania reported that the impact of this gender training was reflected in the design of new projects and in the new roles men and women had assumed in prevention and care efforts.

A manual produced by AIDSCAP, A Transformation Process: Gender Training for Top-Level Management of HIV/AIDS, will facilitate further replication of such workshops. The first gender training manual for senior HIV/AIDS program managers, it is available in English and French and includes conceptual frameworks for gender analysis, guidance on developing gender-sensitive projects, case studies and facilitators' guidelines.

In July 1997, facilitators used the manual to conduct a regional training workshop for 26 senior program managers from five West African countries. Early reports on follow-up by the participants were encouraging. Less than two months after the workshop, for example, the executive director of the national AIDS control program in C�te d'Ivoire had already scheduled six gender and AIDS workshops for local AIDS and reproductive health coordinators, NGO personnel and private sector managers.

AIDSCAP's experience suggests that targeting senior program managers for gender training is an effective strategy, noted E. Maxine Ankrah, associate director of AIDSCAP's Women's Initiative. "Those who make or influence policy, plan and monitor programs, and provide resources are ultimately the ones who determine whether gender concerns are addressed as an integral part of HIV/AIDS programs," she concluded.

AIDSCAP programs also designed new projects to address the expanding epidemic among women. Examples include training and supporting HIV-positive women to serve as outreach educators in Thailand,⁴ integrating STD treatment and prevention into family planning services in Nepal (Box 7.3), creating a dynamic mass media campaign in the Dominican Republic emphasizing women's right to protect themselves from HIV infection, and training women community leaders in Honduras as advocates for better sexual health education and HIV/STD prevention services.

7.3 Integrated Services Improve Women's Access to STD Treatment in Nepal
A woman comes to the Chitwan State Clinic in the Nepalese city of Bharatpur seeking contraceptives. While discussing her family planning needs with a provider, she mentions that she has been experiencing pain in her lower abdomen. The provider carefully explains that this symptom could be a sign of a sexually transmitted disease, and suggests that the woman see the clinic's physician.

The doctor talks to the woman about her symptoms, does a pelvic examination and asks her some questions to assess her risk of sexually transmitted infection. Then he tells the woman that she probably has an STD and explains the importance of taking all the prescribed medicine, even if she feels better after a few days. He advises the woman on how to prevent further infection, and the assisting staff nurse gives her a wallet of condoms and a referral card for her husband. The nurse also provides tips on how to convince the husband to seek treatment.

The nurse asks the woman to stop in the clinics' health education room on her way out. There she meets with a woman health educator who demonstrates how to use a condom and gives her a simple brochure about STDs and HIV/AIDS. Before leaving the clinic, the woman sits for a few minutes to watch a short, entertaining videodrama about condom use and HIV/AIDS prevention.

This woman and hundreds like her received STD treatment from a trusted source -- the providers at their local family planning and maternal-child health clinics -- as a result of an AIDSCAP-supported pilot project implemented by the Family Planning Association of Nepal (FPAN). Although the goal of integrated reproductive health services remains elusive in much of the world, it has become a reality in the FPAN clinics in the Central Region districts of Chitwan, Makawanpur and Dhanusha.

The clinics offer prompt, effective STD diagnosis and treatment and HIV/STD prevention counseling and education along with family planning and maternal-child health services. Prevention of STDs, including HIV, has also been integrated into the work of the clinics' outreach staff and volunteers, who distribute condoms, talk to community members about STDs, and refer people to the clinic for STD services.

Just a few years ago, FPAN provided no STD services, and most providers were reluctant to talk to their clients about STD prevention. Outreach workers distributed condoms, but only for family planning.

That all changed when Dr. Bijaya Neupane, the physician at the FPAN clinic in Chitwan, attended an AIDSCAP-sponsored training session on STD case management conducted by the Nepal Medical Association. Believing that FPAN had an important role to play in improving women's access to STD treatment, he proposed that AIDSCAP support a pilot project to test an integrated reproductive health model in Chitwan district.

Beginning in January 1996, FPAN's Chitwan branch recruited additional nursing and health education staff, upgraded the clinic's facilities and extended its hours. All staff received an orientation in the basics of HIV/STD prevention. Then targeted training sessions in STD syndromic management, risk assessment, prevention counseling and laboratory support prepared medical, counseling and laboratory staff to provide quality STD services.

Outreach staff and volunteers also received training to help them make the shift from family planning alone to integrated reproductive health. They learned to promote condoms for disease prevention as well as contraception, and to help people assess their risk of contracting an STD. Outreach workers not only referred women whom they believed to be at risk for STDs, but accompanied them to the FPAN clinic to ensure proper follow-up.

A revolving drug fund begun with U.S.$1,700 in seed money from FPAN enabled the clinic to supply STD drugs to clients at a cost about 15 percent below the retail price. When patients cannot afford to buy the prescribed drugs even at discounted prices, FPAN staff tries to supply them free from sources such as physicians' samples or contributions from drug wholesalers.

Impressed with what FPAN had accomplished in Chitwan, AIDSCAP provided funding in December 1996 to expand STD services to the FPAN clinics in the cities of Hetauda and Janakpur. During the first four months, more than 100 people sought STD diagnosis and treatment at each of these clinics.

FPAN's experience in the three clinics represents one of a few successful attempts to integrate STD diagnosis, prevention and treatment into family planning and maternal-child health services. In just 15 months, 1,275 patients -- both men and women -- were treated for STDs at FPAN clinics and outreach sites in the three districts. More than 87 percent of those patients were women, evidence that the project had achieved its goal of improving women's access to STD services.

Much to the surprise of the family planning workers who had feared any association with the stigma of STDs, the new STD services actually enhanced FPAN's reputation for providing high-quality, client-centered services. For Chitwan, offering STD services had a dramatic impact on the demand for all reproductive health services. For example, the number of clients requesting sterilization services climbed by 65 percent from 1995 to 1996.

These results impressed Nepali family planning managers and policymakers attending a lessons learned workshop in April 1997, and they recommended further integration of STD services into family planning and maternal-child health programs. FPAN and Family Health International plan to begin this expansion in Nepal's Eastern and Western regions.

Financial and technical support from the project encouraged governments and other groups working in HIV/AIDS prevention to devote more resources and attention to gender-sensitive activities. In Haiti, for example, AIDSCAP sponsored a series of forums to encourage collaboration between governmental and nongovernmental organizations and to reach consensus on recommendations about women and HIV/AIDS for the National Plan of Action on HIV/AIDS. The Honduran Women's Government Office worked with AIDSCAP's office in that country to develop strategies for reaching rural women with prevention messages and activities. And in India's Tamil Nadu State, an AIDSCAP grant supported the creation of a network of influential women, including policymakers, health care providers, lawyers, journalists, educators and film stars, to advocate for legal, economic and social change to reduce women's risk of HIV infection.

Collaboration with other development organizations, particularly women's groups and networks, was a key strategy. One of the most successful collaborations, a coalition of ten organizations spearheaded by AIDSCAP, raised awareness about HIV/AIDS in women at the United Nations Fourth World Conference on Women in Beijing in 1995 by organizing 14 panel discussions, two film festivals and three press conferences and distributing over 50,000 printed materials. In 1996, AIDSCAP and UNAIDS cosponsored a journalists' contest to encourage accurate reporting on HIV/AIDS and women that attracted almost 200 entries from 50 countries.⁵ And in 1997, AIDSCAP brought together 130 scientists, policymakers, women's advocates and program managers from 19 countries to develop recommendations for increasing access to and use of the female condom.

AIDSCAP-sponsored studies on the female condom featured an innovative research design to explore introduction of the device through women's organizations. Conducted in Brazil and Kenya in 1996, the research gave women from all levels of society an opportunity to try female condoms and demonstrated the potential for women's peer support groups to sustain the use of this woman-initiated device.⁶ Other AIDSCAP studies identified ways to improve communication between Kenyan mothers and their daughters, Senegalese market women and their male suppliers and partners, and young Dominican men and women.

Research results and tools developed by AIDSCAP's Women's Initiative (AWI) will continue to help other organizations and programs carry out more gender-sensitive HIV/AIDS interventions. The initiative created the first training manual developed specifically for integrating a gender perspective into HIV/AIDS policies and programs, based on training workshops held for policymakers and NGO leaders from five countries. (Box 8.2).⁷ And a resource guide on the use of dialogue as an HIV/AIDS prevention strategy will promote more constructive communication between men and women about sex, sexuality and HIV/AIDS prevention.⁸

The Women's Initiative's most important legacy, however, may be its contribution to raising awareness about the need for a gender-focused approach to HIV/AIDS prevention. Working in close collaboration with members of its Women's Council and with other HIV/AIDS and women's organizations, AIDSCAP sought to educate policymakers and programs managers through information dissemination and advocacy. These efforts helped put women and HIV/AIDS on the agendas of international organizations, national governments and local organizations, contributing to the growing recognition that slowing the spread of the epidemic requires fundamental changes in gender power relations between women and men.

Lessons Learned

Gender Sensitivity

Although gender is a cross-cutting issue, organizations need specific mechanisms for strengthening and sustaining a focus on gender concerns.

AIDSCAP's experience confirms that policy and resource support are essential for institutionalizing a gender perspective. By providing an explicit focus on gender and the resources needed to carry out training, research and interventions, the project's Women's Initiative made it possible to achieve a broader integration of gender concerns into AIDSCAP policies and programs. A core staff of four professionals at headquarters and designation of an AWI "point person" in each of AIDSCAP's three regional offices and many of its country offices ensured that analysis and monitoring of gender concerns occurred throughout the project. Support from USAID's Women in Development Office, USAID Missions and AIDSCAP core funding enabled resident advisors to devote more resources to identifying and addressing gender issues, empowering women, involving men in efforts to protect women and girls from HIV/AIDS, and improving communication between the sexes.

Training is an effective tool for making HIV/AIDS prevention programs and projects more gender-sensitive.

Gender training workshops sponsored by AWI for project staff, implementing partners and policymakers inspired participants to initiate gender-focused programs and activities. For example, participants in a 1995 gender and AIDS training workshop AIDSCAP conducted for 41 policymakers and program managers in five eastern and southern African countries agreed that it had improved their understanding of how to recognize and analyze gender issues and integrate them into HIV/AIDS prevention policies and programs. Projects with a gender perspective were launched in each of the participating countries (Box 7.2) And in the Latin America and the Caribbean region, AIDSCAP resident advisors and their implementing partners used the gender analysis skills they had acquired at an AIDSCAP regional workshop to develop pilot intervention and research projects to improve HIV/STD prevention services for women across the region (Box 7.1).

Dialogue

The dialogue approach to communication between men and women holds great promise for stimulating and supporting sustained behavior change to prevent transmission of HIV and other sexually transmitted infections.

AIDSCAP promoted the use of dialogue, designed to give men and women the gender awareness and skills they need to communicate openly and honestly about sex and other issues that affect their sexual health, at the interpersonal, community and policy levels. Representatives from 27 countries who helped field test the methodology in a satellite meeting at the XIth International Conference on AIDS in Vancouver responded enthusiastically, calling this initiative "long overdue." One woman noted that dialogue is "the only way that women can approach men in my culture. We cannot 'negotiate' with our men." After the meeting, groups from around the world requested assistance in replicating the dialogue among policymakers, communities and couples.

Most participants in the first operations research project to test the dialogue process -- a series of facilitated sessions with truck drivers and their spouses conducted in Jaipur, India, in 1997 -- reported that the experience made them feel comfortable discussing sexual matters with spouses and friends. Many of the truck drivers said they had started to use condoms with their spouses for the first time. These encouraging results convinced the John D. and Catherine T. MacArthur Foundation to fund a two-year pilot intervention using the dialogue process with Indian truck drivers and their wives.

Although the ultimate goal of dialogue for HIV/AIDS prevention is to improve communication between men and women, it may be necessary to first build sexual communication skills in single-sex groups.

In Zimbabwe, for example, the Women and AIDS Support Network found that initially it was better to separate boys and girls for school-based HIV/AIDS education sessions, giving the girls opportunities to ask questions without feeling inhibited. Once the girls gained confidence in their ability to discuss sexual issues, they asked that the boys be included in future sessions. And in the operational study of the dialogue process with Indian truck drivers and their spouses, only one of the five facilitated sessions involved a mixed-sex group. The researchers found that they had to convene single-sex groups for the other rounds of dialogue because of cultural constraints against unacquainted women and men discussing sexual issues. Nevertheless, participation in these groups helped truck drivers and their wives talk to each other about sex and sexual health. Policymakers and policy influencers meeting at a national conference organized by AIDSCAP in New Delhi in May 1997 recommended same-sex approaches as a means of initiating dialogue between women and men on HIV/AIDS programs and policies as well as personal protection.

Men as Prevention Partners

Although it is critical to empower women so that they are better able to protect themselves from HIV, prevention interventions for women must also address men's behavior and communication between the sexes.

Research data from around the world consistently demonstrate that many women's risk of HIV stems from their partners' unsafe behavior, not their own. In most societies, men still have greater control over sexual decision making than their female partners, and are in a better position to act on messages that focus on individual behavior change.

Moreover, AIDSCAP found that strategies for empowering women were most successful when they involved men as well. In Nigeria, for example, several AWI projects reached out to include men after the women they were working with said that it would be easier to use their new skills if their male partners were also aware of the importance of prevention. In Brazil, the NGO Grupo Pela Vida expanded a project that offered education and facilitated discussion about HIV/STD risk reduction in the waiting room of a large gynecological clinic to reach the primarily male clientele of a tuberculosis and pneumonia clinic at the same health center and to encourage discussion about HIV/AIDS among male and female clients.

HIV/AIDS prevention programs should address men not only as sexual beings, but in their roles as fathers, husbands, workers and community members.

For example, gender-sensitivity training for drivers of Kenyan matatus (vans that serve as informal public transport) succeeded in convincing the young men to be more courteous to female passengers by appealing to them to treat all women as they would like their mothers, sisters, wives and daughters to be treated. They were also encouraged to extend the same courtesy to their partners. A study at two Haitian clinics revealed that the most important motivations for men to seek STD treatment were preserving fertility and ensuring healthy offspring.

Woman-Initiated Methods

Peer support can help women who are vulnerable to HIV/AIDS and other STDs convince their partners to use female condoms.

AIDSCAP's research in Kenya and Brazil, as well as UNAIDS-sponsored studies in Costa Rica, Indonesia, Mexico and Senegal, found that group discussions with peers helped women overcome obstacles to using the female condom, including unfamiliarity with the device and the need to communicate with one's partner about its use. During the sessions, women encouraged each other and shared strategies for introducing female condoms into a relationship.

The female condom is an acceptable alternative to male condoms for some couples.

In AIDSCAP's studies in Brazil and Kenya, 70 percent of the Kenyan women and 97 percent of the Brazilian women said that they would like to continue using female condoms after the research ended. The majority of their male partners also wanted to continue using the new condoms. While none of the women were able or willing to buy male condoms regularly, most said they would be willing to pay for female condoms if they were available.

Results from acceptability and intervention research discussed at a conference on the female condom AIDSCAP convened in suburban Washington, D.C., in May 1997 support these findings. For example, successful pilot projects in Bolivia, Guinea, Haiti, South Africa and Zambia demonstrated that women and men will buy female condoms at prices about twice as high as male condoms.

Women's Organizations

Women's organizations are effective partners for empowering women to protect themselves from HIV/AIDS and integrating HIV/AIDS prevention into other health and development programs.

More than 70 percent of the projects funded under AWI were carried out by women's groups, which provided the access and structure needed to reach women and built on the formal and informal support networks women themselves had established. Through these groups, AIDSCAP helped influential women become spokespeople and advocates for HIV/AIDS prevention and other women's health and development issues in their communities.

In Nigeria, for example, working with five established women's organizations enabled AIDSCAP to institutionalize discussion of HIV/AIDS prevention and other health issues among groups that reached hundreds of women and girls and their families and friends. Now these issues are on the agenda for each regular meeting of the Federation of Muslim Women's Associations Nigeria (FOMWAN) in Jigawa State and of several branches of the NGO Women in Nigeria (WIN). Women trained by WIN/Cross River State started grassroots women's health clubs to continue to disseminate information and promote health-seeking behavior, while the market women's daughters trained by WIN/Lagos formed peer leader groups to help them continue educating other youth in the market.

Working with women's organizations that addressed other health and development issues also encouraged a more integrated approach to HIV/AIDS prevention. In Senegal, for example, HIV/AIDS interventions for market women were carried out by an organization that also provides credit and literacy programs, establishing a link between prevention education and practical measures to empower the women. And in Honduras, the Association for the Development of Youth and Rural Women integrated HIV/AIDS and STD prevention with credit programs and other efforts to improve the lives of rural women by training 20 women leaders from communal banks and solidarity groups. These women became facilitators for discussions about HIV/AIDS, sexuality, domestic violence and women's rights in their communities.

Some women's groups may be reluctant to become involved in HIV/AIDS prevention work.

Although AIDSCAP found many women's organizations that were eager to implement prevention interventions and others that had already begun to do so, some groups did not want to address HIV/AIDS. Leaders of some development and family planning organizations thought that such work would dilute their mission, while others feared it would stigmatize their organizations. Fear of stigma was most common in countries or regions with less advanced epidemics. Education and advocacy are needed to sensitize women's leaders to the threat HIV/AIDS poses to all women and to promote an understanding of how HIV/AIDS organizations and women's groups can work together to achieve shared goals.

Recommendations

Gender orientation of policies and programs should be an explicit policy of an organization from its inception. HIV/AIDS prevention programs should build in specific structures and mechanisms, such as gender training of staff, point people in field offices and earmarked funding, to integrate a gender perspective into projects and monitor all activities for gender sensitivity.
Additional operations research should be conducted to explore the use of dialogue as a strategy and tool for improving sexual communication between men and women and promoting HIV risk reduction.
HIV/AIDS interventions should not target just women or men, but should focus on improving understanding and communication between them. Men should be addressed in their roles as fathers, husbands, workers and community members, and not merely as sexual beings.
HIV/AIDS programs should work together to make the female condom more available and affordable to women and men in developing countries. Efforts to increase availability should begin with large-scale introduction in a few countries; efforts to improve affordability should include expediting research on whether the female condom can be used more than once and providing incentives for alternative, less expensive product designs.
HIV/AIDS organizations should collaborate with women's groups, particularly those that address other health and development issues, to empower women and promote a more integrated approach to prevention. They should also continue to promote a better understanding among these organizations of the threat that HIV poses to health and development efforts and of the need to work together for women's empowerment and gender equity.

Future Challenges

Understanding Stable Relationships

Few studies have explored the dynamics of sexual communication and control between couples. More research is needed to understand how to help couples develop safe, respectful, mutually satisfactory sexual relationships.

Increasing Women's Options

The enthusiastic response to the female condom in studies and pilot projects throughout the developing world confirms the urgent need for HIV/STD methods that women can initiate and control. Female condoms are a promising option, but their cost has limited their availability to all but a handful of countries. Research to develop microbicides that protect women against HIV and other STDs and simultaneous efforts to improve access to affordable female condoms must be a top priority for prevention programs.

Integrating Reproductive Health

The promise of integrating family planning, HIV and STD prevention, and STD treatment services to reach millions of women through family planning, maternal-child health and primary health care clinics has yet to be realized. Obstacles include inadequate resources, providers' reluctance, a lack of clear technical guidance on how to provide integrated services in different settings, and an emphasis on treating and counseling women rather than couples. Operations research is needed to address these constraints to achieving a truly integrated approach to reproductive health.

Empowering Women

In many developing countries, women's vulnerability to HIV/AIDS will continue without fundamental changes in their social, economic and legal status. Income-generating activities linked with HIV/AIDS prevention can empower some women to protect themselves from infection, but the scope of such activities is far too small to have a significant impact on the status of women in society as a whole or on the spread of the epidemic among women. Political commitment, human and financial resources, and true collaboration among health and development agencies and organizations are required to empower women through legal reform, education and greater access to employment and credit.

References

Dadian MJ (1997). Inclusive Prevention Efforts Fight Stigma in Rural India. AIDScaptions 4(1):48-51.
AIDSCAP Women's Initiative (1997). A Transformation Process: Gender Training for Top-Level Management of HIV/AIDS Prevention (report). AIDSCAP/FHI, Arlington, Virginia.
Henry K (1997). Saving a Generation: Ethiopian Youth Rally to Prevent HIV/AIDS. AIDScaptions 4(1):32-35.
Chomsookprakit C. Life with Hope: HIV-Positive Support Group Helps Others Avoid Infection. AIDScaptions 3(3):39-41.
AIDSCAP Women's Initiative (1996). One Strong Voice: Writings on Women and HIV/AIDS. AIDSCAP/FHI, Arlington, Virginia.
The Female Condom: From Research to Marketplace (conference proceedings). AIDSCAP/FHI, Arlington, Virginia.
AIDSCAP Women's Initiative (1997). A Transformation Process: Gender Training for Top-Level Management of HIV/AIDS Prevention (manual). AIDSCAP/FHI, Arlington, Virginia.
AIDSCAP Women's Initiative (1997). Dialogue: Expanding the Response to HIV/AIDS. A Resource Guide. AIDSCAP/FHI, Arlington, Virginia.

Making Prevention WorkGlobal Lessons Learned from the AIDS Control and Prevention (AIDSCAP) Project 1991-1997

7. Women, Men and HIV/AIDS: Building Gender-Sensitive Programs

Making Prevention Work
Global Lessons Learned from the AIDS Control and Prevention (AIDSCAP) Project 1991-1997