Our understanding of the HIV/AIDS epidemic has evolved over the past decade, from the misguided belief that the virus is only a problem for sex workers and other "risk groups" to the recognition that all women are vulnerable to HIV. The epidemic is finally being cast within a much broader reproductive health framework, and the power imbalance in gender relations is seen to be at the root of all vulnerability. Yet despite the growing sophistication of the discourse, an appropriate programmatic response seems elusive.
The Women and AIDS Research Program--17 studies in 13 countries conducted by the International Center for Research on Women with funding from the U.S. Agency for International Development--identified many obstacles to preventing HIV infection among women. They include sexual norms that limit women's access to information by dictating that they must be ignorant about sexual matters, women's economic dependence on men, violence against women and widespread acceptance of male promiscuity. Somehow, despite the fact that we also identified opportunities for intervention, what people heard were the barriers and constraints.
One response to these seemingly overwhelming barriers has been to conclude that women are powerless and to revert to a focus on men. But programs aimed at changing men's behavior do not attempt to challenge any of the contextual determinants of that behavior. Instead, the emphasis is still on condom use and education.
A second response has been the search for an alternative technology for prevention--a much-needed female-controlled technology to give women an alternative to male condoms. Thus arose the movement to develop a microbicide, test the acceptability of the female condom, and examine more closely the possibility of offering the diaphragm with nonoxynol-9 as one alternative in a hierarchy of prevention options.
Although these responses are pragmatic, they implicitly convey a passive acceptance of the unchangeable nature of social roles in general and male sexuality in particular. The belief that "men will be men" and will seek multiple partners for sexual release and that women will remain powerless to modify sexual interactions acts as a strong deterrent to change. Recommendations to economically empower women or to improve their access to education are characterized as long-term measures outside the domain of AIDS prevention. So while the discourse accepts the wider context of women's vulnerability to HIV, the programmatic response remains restricted to the margins.
What can and should AIDS programs do to address gender concerns? To proceed, we first need to clarify certain basic assumptions. The first assumption is that all women are not alike. There is an undeniable commonality of experience because of gender, but many variables--class being one--intervene to create complex differences. Women are at different points on the empowerment continuum; therefore, there can be no single blueprint for action.
The second assumption is that social systems are not immutable; they can and often do change to meet different needs. There are many examples of the definition of the norms governing male and female roles changing due to critical events, such as World War II. Such changes also can be brought about through concerted effort--especially when the lack of change has the potential to destroy the entire social system or subsystem. One example is changes in the social norms that dictated the sexual behavior of gay men.
Bringing about such change requires multiple, mutually reinforcing interventions and a focus that goes beyond one behavioral act. But we have to believe that it can be done. We can push the envelope on social norms that discriminate and compromise the rights of individuals. Together, we can begin to question the definitions of masculinity and femininity--definitions that now threaten the well-being of communities.
And the final assumption is that empowering women is not a zero-sum game. Power is not a finite commodity: more power to one ultimately means more power to all. Interventions within the women in development field have shown that poor men support women's empowerment when it enables women to bring much-needed resources into the family or community or when it challenges power structures that have oppressed and exploited the poor of both sexes. Empowering women to protect themselves, to speak up and to access technologies also frees men from the stereotypical role of oppressor and exploiter. That message must be communicated without any caveats.
Given these assumptions, what can AIDS programs do to tackle the gender issues that stand in the way of effective prevention? First, we must ensure that traditional AIDS programs are gender sensitive. And being gender sensitive requires that we know what women need and that our programs respond to their needs.
So, for example, we found that without sex education and basic information about reproductive anatomy and physiology, women can do very little to protect themselves. Such information is easily provided, and there should be no excuse for not providing it. We also know that women need to have access to a technology they can control and use. Efforts to provide access to a female-controlled prevention method are all steps in the right direction that should have occurred long ago.
Second, the information we provide must not reinforce gender stereotypes for short-term gains. Many past education efforts have perpetuated a predatory, violent, irresponsible image of male sexuality. This must stop. No amount of data on the increase in condom sales as a result of such campaigns is going to convince me that they are not damaging in the long term. Any gains achieved by such efforts are unlikely to be sustained because they erode the very foundation on which AIDS prevention is based: responsible and respectful sexual behavior. We know now that women suffer from the consequences of such an image of male sexuality and masculinity. And men rarely benefit. We have learned that the macho image of masculinity as the man who is always in control puts a lot of pressure on adolescent boys and limits their ability to speak up about their need for more information or about their doubts and fears.
Third, we must not presume that the availability of a service, commodity or information ensures its accessibility equally to women and men. Women's access to services is greatly constrained by a range of factors, including restrictions on their mobility, which make distance an insurmountable barrier, and competing demands on their time, which increase the cost of waiting for care or traveling long distances.
The way to tackle such barriers is to design services that are women-friendly as much as they are men-friendly. This means providing services at times that are convenient for women; integrating services to reduce the time spent waiting for or traveling to multiple services; making condoms and STD diagnosis and treatment available in places where women can access them without fear of social censure; and, whenever possible, providing community outreach services so that distance does not become a barrier to women's use of a service.
In sum, we must do what is in our immediate control--modify existing programs to ensure they are gender sensitive. To encourage widespread analysis of programs from a gender perspective, there is an urgent need for practical training tools that can highlight different ways to increase the gender sensitivity of a program and its staff.
These modifications in existing programs are essential but not sufficient to bring about sustained social change because they do not, for the most part, deal with the larger contextual issues that lie at the root of women's vulnerability to HIV. I am referring to two very important components of power: economic resources and social support.
The standard recommendation for dealing with these barriers is to improve women's socioeconomic status. But what can AIDS programs do about women's economic and social status? First, they can and should explore the possibility of linking up with economic interventions that are already in place, such as credit programs, agricultural extension services for women farmers, women's cooperatives or savings schemes. Linking up means providing AIDS information and services through those channels rather than setting up parallel, vertical programs just for HIV/AIDS. Such linkages ensure the most efficient use of financial resources and of skills. They require collaboration with other non-AIDS groups, including women's groups, and a strong conviction that economic empowerment is essential for sustained, effective prevention.
This is not an impossible dream. People are already experimenting with such expanded AIDS programming. The Zambian National AIDS Program (NAP), with support from the Global Programme on AIDS's Prevention Research Unit, is working in collaboration with a women's group called Women for Change, the YWCA and the Zambian Cooperative Federation to give women fish traders the opportunity to form a cooperative that will provide them with interest-free loans. These loans will ensure that the women have fish to trade without having to provide sexual favors to the fishermen who control their access to fish or the truck drivers who transport them from the urban areas to the fishing depots.
In the Zambian program, the women's group has the institutional expertise to identify gender issues for the design of the program, the cooperative federation has the technical know-how on setting up successful cooperatives, and the NAP has the expertise in AIDS programming. We desperately need more such alliances.
Although the results of this particular experiment are not yet available, we know that forming cooperatives is also a way for women to gain access to a social support network. From the Women and AIDS program we learned that giving women the opportunity to meet regularly in groups, away from home, gave them much-needed social support from their peers. AIDS programs can enable women to meet regularly for group educational sessions or counseling and in that way offer them a legitimate social support group.
A second way for AIDS program practitioners to influence women's socioeconomic status is to advocate for improvements in women's access to education and productive resources. Because AIDS has fatal consequences for women and entire communities, it tragically provides an opportunity, like never before, to push for policy changes to improve women's social and economic status. And who better than AIDS service organizations and program experts to undertake such advocacy--because improvements in women's social and economic status are essential for the success of all HIV prevention.
-- Geeta Rao Gupta, International Center for Research on Women
Dr. Geeta Rao Gupta is vice president of the International Center for Research on Women (ICRW) in Washington, D.C., where she works on reproductive health projects. This opinion piece is adapted from a speech she gave at the 3rd USAID HIV/AIDS Prevention Conference in Washington on August 7, 1995. Entitled "Gender and Sexuality: Implications for HIV Prevention," the speech will be published in full by ICRW.
