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Research |
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Haitian Women's Role in Sexual Decision-Making: The Gap Between AIDS Knowledge and Behavior ChangeIII. Conclusions and Recommendations |
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1. Implications for Intervention: Translating Research to Action The final objective of this research was to identify possible intervention points for strengthening the role of women in the prevention of AIDS. Since the start of the epidemic, HIV surveillance has documented the relentless spread of the disease through urban and rural populations; AIDS prevention activities have disseminated information and education widely; and condom promotion and distribution programs have increased the availability and to a limited extent the demand for protection. Efforts to alert the Haitian people to the danger of HIV transmission have succeeded to the point that most know what AIDS is and associate condom use with prevention. Clearly the HIV/AIDS surveillance, education and condom distribution programs must continue with even greater support and determination, but, alone, they are not sufficient to change culturally rooted expectations of behavior which this study suggests are the real obstacles to change. The AIDS prevention campaign in Haiti must simultaneously address a fourth component, namely normative change. This approach would infuse current AIDS prevention activities with empowerment-oriented strategies which place AIDS in the context of women's sexuality and social status. The blueprint for action now must include not only informing, educating, motivating, but also enabling. HIV/AIDS prevention can be realized only if men and women together come to grips with the need for change in norms which control sexual relationships and deny women the right to determine their own lives. Normative change calls for radical intervention inasmuch as it takes the problem of HIV/AIDS prevention beyond individual behavior to a societal level, where it requires basic change in cultural definitions of sexuality and gender relations. This component of HIV/AIDS prevention is difficult to actualize, but the findings of this study suggest that people in Haiti are ready to act if they have the means. Focus group participants have demonstrated that it is not so much lack of information and motivation that is fueling the AIDS epidemic in Haiti, but old patterns of sexual behavior, including the subordination of women to male sexual freedom, which contradict the messages they receive from AIDS prevention programs. We have seen a common determination on the part of men and women to survive in the AIDS epidemic, but until they are able to resolve behavioral conflict through redefinition and negotiation, neither men nor women will have the power to prevent HIV transmission. Following are six substantive areas in which the focus group transcripts give particularly clear direction for HIV/AIDS intervention. They reinforce the value of continued preventive education while making empowerment the driving force to slow the spread of the epidemic. Although most people are aware of the disease and know that it is sexually transmitted, many focus group participants were confused about other modes of transmission, particularly casual contact. There also seemed to be little awareness - or perhaps concern - about perinatal transmission, and some were confused as to whether infection was passed to the fetus by an infected father, infected mother, or both. Belief that the sperm carries the virus directly to the fetus might lead an HIV+ woman to think that her baby would not be at risk if the father were seronegative However, because so few participants commented on risk to the unborn child, it is possible that many participants simply did not know, or did not take seriously, the danger of vertical transmission. HIV/AIDS education must also continue to help people understand the major channels of transmission and recognize false or distorted information which may lead to unnecessary concern and unwarranted discrimination against infected individuals. As cases of AIDS increase, the epidemic is becoming more visible in Haiti, and efforts to promote a realistic understanding of HIV infectiousness will be critical in preventing stigmatization and isolation of AIDS patients and their families. Recommendations
Most women seemed to know that condoms are their best and most practical defense against HIV in an infected partner, but many were negatively disposed to using them. They feared breakage and contact with the lubricating gel (referred to as "grease"), which they believed were the causes of disease and possibly death. They also claimed that condoms have an unpleasant odor and that they decrease their sexual pleasure. Many believed that for similar reasons men would not use them. However, in addition to their objections to the physical properties of condoms, women complained that use of condoms threatens a stable relationship by suggesting that one partner is either diseased or unfaithful. It is inappropriate, many participants felt, for a woman in a long-term relationship to suggest condoms, although they believed that promiscuous young girls, prostitutes, and others who wish to avoid pregnancy have the right to do so. Therefore, fear of rejection or retaliation was a strong deterrent to raising the issue of condom use with a stable sexual partner. The quality of the latex in condoms is obviously critical to an intervention strategy, but so is education to teach their appropriate use and dispel myths about condoms as a cause of disease. Moreover, AIDS prevention programs must deal with the perception of condoms as a threat to the stability of a relationship and, in many cases, to a woman's economic support. These are complex and difficult issues, but if they are not directly addressed and resolved, suspicion and fear will continue to deny many women the right to protect themselves from HIV infection. Recommendations
As suggested above, the prevailing standard of sexual behavior in Haiti makes it difficult for women to take the initiative to change sexual practices that affect their partners. The findings of this study indicate that for many Haitian men and women, conjugal harmony is more highly valued than fidelity. The code of behavior which supports long-term relationships discourages women from interfering in their partners' extra-conjugal affairs or, in fact, from acknowledging that they even exist. Questioning or rejecting a man's sexual advances, the participants said, is likely to anger him, and an angry man may react by leaving the house to find a "loose woman" who will be more compliant and less demanding. Women in the AIDS epidemic are therefore in a double bind: They can attempt to control a man's sexual behavior to reduce HIV risk but only at the peril of even greater risk when he goes off to sleep with other women. Or, they can continue to play the traditionally compliant, nurturing role, accepting him as he is in exchange for material support and affection - along with continued exposure to HIV. The complex issue of women's rights in the conjugal union needs to be a focal point for intervention. Both male and female focus group participants agreed on the right of women to protect themselves from a deadly disease, but it was evident that this position ran counter to traditional expectations of behavior in a sexual relationship. HIV/AIDS prevention messages must be explicit about women's rights, sensitizing women as well as men to the actions that women have a right, even a duty, to take in order to protect themselves and their families. This strategy will require AIDS prevention programs to incorporate opportunities for people to resolve the clash of values between old norms and the threat of a deadly new disease. Cross-gender discussion of sexual practices among adults has seldom been a component of AIDS prevention programs, but the present study has demonstrated that many men and women may be ready to work together to explore solutions to this common problem. Recommendations
D. Protecting Children and Adolescents Although focus group participants were emphatic that sexually active adolescents are at risk of acquiring HIV and that parents have a responsibility to counsel children about prevention, most doubted that children would listen. Comments on how parents might help their children tended to be vague and inconsistent, indicating that it is not an easy issue. Some participants suggested that a mother's only recourse is to provide her daughter whatever she wants so that she will not be tempted to accept the gifts that older men may offer in exchange for sexual favors. The participants in this study seemed to be open to discussing sexuality with their children, but the risk of HIV imposes demands too urgent for many to deal with alone. Findings suggest that parents are ready for counsel and support in identifying and dealing with this critical issue. Recommendations
E. Communicating with Other Women about HIV/AIDS Prevention Women in this study expressed a strong sense of obligation to help other women avoid contracting AIDS. However, they warned that while many women are now talking among themselves about AIDS, they still find it a difficult topic to discuss because of the anxiety it raises. A woman who tries to counsel another woman runs the risk that her intentions will be misinterpreted either as slander or as an attempt to separate her friend from her partner. Nevertheless, focus group discussions indicated that some women have at least a rudimentary sense of collective responsibility, although for most of them it did not extend beyond family and close friends. The study also offers evidence of the need to provide women with basic communication and leadership skills, as well as techniques and materials for AIDS education, to encourage them to expand and act on their sense of responsibility to other women. Recommendations
F. HIV/AIDS Prevention Messages in Family Planning Although contraceptive behavior was not a specific focus of this research, participants frequently alluded to family planning in the context of AIDS prevention. They sometimes seemed more comfortable promoting disease protection under the guise of family planning than confronting AIDS risk directly. They used the Creole term, "planin", to mean condom and occasionally advised women to take uncooperative partners to a family planning clinic for an explanation of AIDS risk and prevention. On the other hand, few participants in the study said they currently used, or had ever used, a contraceptive method. Despite this apparent contradiction, the HIV/AIDS prevention campaign in Haiti needs to consider ways of exploiting the relative neutrality of family planning to promote responsible sexual relationships and the use of condoms for protection against HIV and other sexually transmitted diseases. Recommendations
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