FHI - II. Presentation of Findings (part 7)

7. Summary and Discussion of Study Objectives 1-8

A. Knowledge and Beliefs about AIDS (Objectives 1-2)

Objective 1: To establish the knowledge base of study participants concerning AIDS transmission, modes of prevention, and sources of information.

Men and women who participated in the focus groups for this study were well acquainted with AIDS, some from firsthand experience, others as a result of AIDS education messages presented by the mass media and by health workers in clinics and community outreach programs. Informal networks are also a source of information on AIDS, which, according to study participants, has become a common topic of discussion among women.

In all focus groups, participants agreed that heterosexual contact is the principal means of transmission, particularly if either partner has other partners who may be infected. They were aware of the way that disease spreads in a sexual network and spoke of the danger to the woman at home who may not be engaged in risky behavior herself nor be aware of her husband or regular partner's other sexual activity. However, participants seldom acknowledged perinatal transmission, except when moderators asked women specifically whether they felt a responsibility to protect unborn children. A few answered in the affirmative, indicating that they knew of the risk to the fetus, but they showed some confusion over whether transmission is from the mother or the father. This topic generated little discussion, unlike the effects on children left destitute when parents become ill and die of AIDS. Concern for the welfare of such children was an important issue to many participants and a prime reason to alter sexual behavior in order to protect the mother's health.

Understanding of HIV transmission by means other than sexual contact was linked mainly with participants' perception of blood as a channel for infection. When they discussed causes of AIDS, they referred repeatedly to blood transfusion and contaminated needles in clinics and hospitals, although these were of less concern than heterosexual transmission. A minority of participants said they believed kissing was dangerous because of the transfer of saliva through dental cavities or through cuts or sores in the mouth. A few also warned that menstrual blood from an HIV-infected person may contaminate washing and drinking water, that mosquitoes may carry and inject infected blood, and that eating the meat of an AIDS-infected animal may cause the disease in humans. Casual household contact with infected people, for example sharing eating utensils, sitting in the same chair, or using the same toilet, was also believed by some to endanger other members of the family. It must be noted, however, that these distorted or incorrect notions of HIV transmission occurred with much less frequency than more accurate statements about sexual transmission and even blood transfusion. Moreover, whenever such misconceptions were voiced, at least one other group member usually contested the assertion and then provided a more accurate explanation.

In this study supernatural causation emerged as a relatively minor factor in participants' views on HIV transmission. One explanation may be that the increasing visibility of AIDS, along with a wider dissemination of HIV prevention information, is leading people to redefine the disease in a more natural context. However, this finding is contrary to other recently reported data which indicate greater popular belief in a supernatural explanation of the AIDS phenomenon. Thirty-seven per cent of respondents to the 1989 Child Health Institute KABP Survey professed belief that AIDS could be transmitted by an evil spirit (9). Researchers in the Cornell-GHESKIO Project also found strong evidence of a supernatural perspective on cause among both male and female HIV seropositive patients in an AIDS counseling unit in Port-au-Prince (6). Although fully 60 per cent of these patients directly acknowledged or "did not deny" the possibility of supernatural transmission, the authors of this report point out that the strong taboo associated with discussion of voodoo ritual in Haiti probably results in underreporting of supernatural beliefs about AIDS. In the present study, the question of supernatural transmission was never broached directly; participants were asked only the open-ended question, "As far as you know, what causes AIDS?" A few individuals in the present study alluded to voodoo ritual, but fear of disclosing personal beliefs on a taboo topic may have prevented others from offering their opinions.

The participants' generally high awareness of sexual transmission, however, was reflected in their knowledge of prevention. They displayed near unanimity on the value of monogamous relationships and condoms in blocking the spread of the virus, although some participants, both men and women, expressed doubt that condoms would be adequate protection. They also knew that condoms are available in health centers, family planning clinics, and pharmacies. None of the participants ever alluded to scarcity or difficulty obtaining condoms. Whether or not they actually made use of these sources, focus group participants believed they knew where people could find them. However, despite the frequency with which women proposed condoms as the best, and sometimes the only, effective barrier, many said that they as well as others believed condoms were harmful. Most often cited were concerns about the ill effects of the lubricating gel and the fact that a condom might break inside them, both of which possibilities they saw resulting in female genital disease and possibly death. While common in the discussions, such statements were usually countered by other participants who did not share these beliefs and were able to provide more accurate information.

Differences of opinion surfaced within groups as to whether a woman whose partner was at risk of contracting and transmitting AIDS should attempt to persuade him to change his behavior, to refuse sex, to ask him to use condoms, or to abandon him entirely. Persuasion was usually the first strategy, but participants were about evenly divided over whether a woman should then refuse sex or demand that her partner use a condom. Abandoning an uncooperative partner was generally the final solution, even though for some women the economic cost of losing a partner outweighed the gain in health protection. In any case, the focus group discussions supported the conclusions of the 1989 AIDS KABP study that Haitian men and women are relatively well informed about AIDS, its transmission, its prevention, and the availability of condoms.

Objective 2. To identify women's understanding of the seriousness of HIV infection and their attitudes concerning personal vulnerability.

Participants were acutely aware of the seriousness of AIDS and the consequences of the disease for children whose parents are infected. They saw severity in terms of the inevitable suffering and death that they associated with AIDS-infected individuals. They spoke frequently of the disruption of family life when a breadwinner can no longer support dependent members. Of particular concern to them were the needs of children for food, clothing, and school fees, as well as their moral upbringing if left alone and without parental guidance.

When asked whether "women like themselves" were at risk of getting AIDS, many participants responded candidly, confessing to being uncertain as to the sexual affairs of their own husbands and regular partners outside the home. Their feeling of vulnerability was compounded by their awareness that men may not recognize the danger of AIDS in other partners who could be infected but appear to be healthy. "Vivavek" women, the least likely to be living with stable partners, expressed particular concern, and some of their comments indicated recognition of the danger inherent in their own free lifestyle. Participants in all categories emphasized that if neither partner "fools around" ("viv deyo"), they are not in danger, but there was also general consensus that many women are at risk because their men are unwilling or unable to confine their activity to a single partner. Some of the women in "maryaj" or "plasaj" relationships testified to their own partners' fidelity, while others admitted frankly that they did not know. These observations help to explain the findings of the 1989 KABP study that, despite their knowledge of HIV prevention and low reported behavioral risk, women tend to perceive themselves as highly vulnerable.

Although virtually all participants took the attitude that women in general are at great risk of acquiring HIV and many expressed personal fear, there was a strong countervailing tendency among women in stable relationships to deny their own vulnerability. The attitude of these women was that, having only one man, they had nothing to fear. Some added that their spouses also had no other partners. Still others seemed to believe that once a man gives up his promiscuous lifestyle, it is safe to resume a normal sexual relationship with one stable partner and without considering the need for protection. There was obvious confusion among the women as to the risk they inherit from a partner's previous sexual experience. There was also a striking contradiction between the complacency of women who expressed belief in their own partners' fidelity and the equally strong assertion that men are accustomed to sexual freedom and can not be trusted to behave responsibly outside the home. These contradictory attitudes and beliefs were symptomatic of the confusion which appears to accompany the realization that the old rules of sexual behavior can no longer be taken for granted.

B. Sexual Norms as Perceived by Women: Objective 3

Objective 3: To identify women's perceptions of the norms that govern sexual decision-making and behavior associated with the risk of HIV/AIDS.

This study has examined the question of women's rights with respect to the division of authority in household matters and to sexual decisions which influence the probability of HIV transmission. Although most women claimed autonomy in certain household tasks such as food preparation and child care, they did not always agree on the locus of authority in sexual matters. Some said that both partners "decide when to make love," but most said that while women may have the right to initiate sex, they seldom had the right to refuse. Also among the decisions they believed belong to a man was the prerogative to have more than one partner. The right to have other partners was never accorded to women, although participants acknowledged that women sometimes do have affairs on the side. They made a clear distinction between "wives", or women at home, and "other women" who live freely and are expected to have multiple temporary partners. The term, wife ("madanm") was used to denote any woman in a stable relationship and sometimes in the plural when referring to the multiple steady partners of one man. Similarly, the term husbands ("mari") was used to refer to the plural partners of a woman.

According to female focus group participants, women know that men are free to engage in multiple sexual relationships, but a woman is not supposed to know about the extra-conjugal behavior of her own partner, the man with whom she shares a home and responsibility for raising children in a long-term union, whether sanctioned or not by marriage. The man's outside life is his own business. Focus group discussions revealed how women's dependency on men for subsistence has reinforced the norm of male sexual freedom. Some participants attributed subordination of women to economic disadvantage, claiming that a woman with no earned income has less bargaining power, and therefore receives less respect, than a woman who can buy what she wishes with money she earns and controls.

At the same time, they expressed the woman's domestic role in terms of the balance and harmony ("understanding") that it is her duty to maintain in her household. Participants made it clear that their material support often depended on women's success in living up to this expectation, a constraining factor that tended to reinforce compliant behavior in sexual as well as domestic activity. The more dependent a woman is, the harder she must try to compensate for the sexual excesses of her partner. Failure to comply with the behavior expected of a dutiful wife was seen by some women as justification for the husband to seek other "wives" or temporary partners "on the street." Participants who took this stand serve as guardians of the old order insofar as they believe providing sex is as much a woman's duty as preparing food; she does not let her partner go hungry, no matter what the circumstances.

Others defended women's rights in the sexual relationship, but their comments suggested that women's rights, as they defined them, were increasingly in conflict with prevailing norms. In providing new information and attempting to change risky sexual practices, AIDS prevention campaigns have increased the tension between established norms of behavior and women's perceptions of their sexual rights. Focus group discussions revealed a sense of urgency to resolve this conflict. Although women agreed in principle on their right to protect themselves from AIDS, in practice they did not always recognize their right to take the actions necessary to achieve this end.

The issue of women's rights was not new to participants. Indeed, focus group transcripts revealed numerous instances of women asserting their right to challenge old norms of sexual behavior, with no observable differences among the four female categories. Men may be the acknowledged "masters" in most sexual decisions, but many women's comments displayed their latent power in putting traditional limits to the test. In actuality, many women do claim certain rights in a sexual relationship, primarily to refuse sex when they are "not in the mood." They tended to agree among themselves that a woman can be excused from sex if she is menstruating, tired, troubled by household problems, or feeling neglected by her partner. They believed that men, "if they are not beasts," will accept temporary indisposition as an excuse and may become more attentive to the woman's needs if they recognize that sexual harmony requires "understanding on both sides." Focus group participants also pointed out that men who have other partners have other options when the primary partner is temporarily indisposed.

Participants generally acknowledged that under particular circumstances a woman has a right to ask her partner to use condoms. To wear a condom is a decision that a man ultimately controls, but in promoting mutual responsibility for children's welfare, family planning education has, in effect, relaxed the norm of male autonomy in at least one decision that affects the sexual act. Even participants who supported a conservative interpretation of women's subordinate role in other aspects of the relationship, believed that the decision to use contraception should be shared between the two partners. Women have a right, they said, to ask partners to use condoms for family planning. With no comparable terminology for a barrier against disease, some continued to use family planning terms in their rationale for granting a woman with a promiscuous partner the right to demand condoms.

The corollary also applies, that women do not have this right if the man has few or no children. When a woman insists on a condom, she says, in effect, that she is not willing to bear his children, a message that clearly contradicts basic values of procreation. Prostitutes have a right to demand condoms, the implication being that loose women should not have to bear the burden of their partners' children. Similarly, while participants did not condone sex between older men and adolescent girls, several commented that "schoolgirls" often use condoms so that pregnancy does not give away to their parents the secret of their sexual activity.

In sum, women's rights proved to be an exceedingly complex issue due at least in part to the many contradictions imposed by the AIDS epidemic on the normative structure. Belief in a woman's right to protect herself from disease ran head on into participants' views of her responsibility to play the customary role of compliant wife, to preserve harmony in a stable relationship, and to protect her own economic base. Women were clearly confused about what their rights should be, some taking the position that a woman has a right to leave a promiscuous partner, others arguing that men are justified in seeking pleasure with other women if their wives fail to live up to domestic and sexual expectations. The one common denominator across all respondent categories was that women deserve the right to protect their own welfare; how to act on that right without rejecting those values which have given positive support to the conjugal relationship in the past was a dilemma that none could resolve.

C. Women as Change Agents: Objectives 4-6

Objective 4: To assess women's beliefs in their own power to control the sexual relationship

As the above suggests, focus group participants were well aware that to claim their right to self-protection, women would have to confront men on the dangerous issue of sexual freedom. Moreover, as Bandura has pointed out, taking initiative in behavior change requires not only information and motivation but the means and resources to take action (12). For Haitian women to challenge the old normative order will require courage bolstered by strong belief in their capacity to exercise personal control. This research therefore explored women's sense of empowerment in terms of the strategies and the communication they believed might influence men's behavior and the range of responses a woman might anticipate from her sexual partner.

For the most part, women did not perceive themselves as powerless to control when and with whom they would engage in sex. Although they tended to accept the norms that protect male sexual prerogatives, they believed in their ability to manipulate the sexual act even to the extent of refusing sex when they were "not in the mood." For the most part, however, their sense of control was an illusion. Exceptions to the norm of female compliance depended on temporary or easily reversible circumstances, like menstruation and mood. Women were not expected to remain indisposed, and men could always cajole the reluctant partner with affection and gifts. With the advent of AIDS, however, the stakes have gone up; women are learning that temporary relief from their sexual responsibilities will not be enough to protect them from the risk of acquiring the disease. Old excuses have to be replaced with new and more powerful interpersonal skills which will shift the balance of power to enable women to negotiate permanent protection.

Participants debated such strategies for influencing a promiscuous partner from a variety of perspectives. Those who emphasized persuasion said they would use care and affection to convince a man to stay home and at the same explain to him the nature of AIDS and the dangers of sex with other women. Others said a woman might continue to carry out routine domestic tasks but should no longer sleep in the same bed with a man who refused to give up his "extramarital" pleasures. Still others advised women to try to convince men to use condoms, not only with their "other women," but with their wives or primary partners at home. The ultimate strategy, if all else failed, was to leave the uncooperative partner, despite the economic hardship that might follow. Several added that working as a domestic servant or a street vendor was preferable to the risk of dying from AIDS.

Acting the part of a fearful woman, participants spontaneously role-played how to gently persuade an amorous partner to use a condom or to give up other women without alienating his affection. They stressed the need to inform him about AIDS and to explain logically how it can be transmitted. The emphasis was almost always on the danger of HIV, not on the morality of the sexual behavior. Few women made direct references to the advent of AIDS as a new disease, but by implication they were saying that now there was a new reason for behavior change that had not existed before its arrival.

Although women readily suggested ways to reduce the risk of HIV transmission, not all believed their strategies would work. Some were optimistic that, if approached with tact and understanding, men would agree with the wisdom of a different lifestyle. Others believed that the same result could be achieved with an ultimatum either to change high-risk behavior or lose the primary relationship. A majority, however, were skeptical that women could actually succeed with any strategy. They based their pessimism on what they perceived to be the reluctance of men to admit to having other sexual partners, men's refusal to give up their sexual freedom, and the social and economic costs to a woman of alienating a breadwinner. Physical abuse was not a major theme in the focus group discussions, though a few women in Savanne expressed fear of violent retaliation from disaffected partners. In general, participants agreed that to question a man's sexual freedom is difficult for any Haitian woman and will require skillful communication and the courage to confront issues of power that have not had to be addressed in the past.

Objective 5: To explore women's sense of responsibility for promoting AIDS prevention among adolescent children

Whether or not women in the focus groups had adolescent children themselves, all agreed that teenagers are at risk of contracting HIV. Young people are sexually active, they said, girls have "many boyfriends," and children do not listen to the advice of their elders. Moreover, they tend to conceal their sexual activity from parents and deny sexual involvement if confronted. Furthermore, once they have experienced sex, the women believed young people would not be willing to give it up. They all advised parents to talk to children about sex, or "to tell them about life," but the transcripts reflected an undercurrent of pessimism that parental guidance would have any lasting effect. Other adults who, in their view, might be able to educate children about AIDS prevention were doctors, nurses, and other health workers or any "knowledgeable" adult. A few women raised the possibility that well-informed teenagers might be able to inform and advise others about the disease and how to prevent it.

The women believed strongly that young people should abstain from sexual contact and "mind their schoolwork," but their comments revealed a sense that abstinence is probably an unattainable ideal. Condoms, therefore, seemed to be a necessary prescription for HIV protection. Some believed that advising young people to use condoms would only promote promiscuity, but most women, sometimes reluctantly, advised that giving their children condoms might be the only way to protect them from AIDS. However, the issues of adolescent motivation and compliance remained unresolved.

Discussions of adolescent risk echoed some of the themes that emerged in discussions of adult risk. First, the common assumption that teenagers are not only sexually active but likely to have more than one partner paralleled women's accounts of similar adult behavior, including the element of secrecy that they believe shields them from disclosure. Moreover, participants often commented that they would advise a girl at least to be faithful to one boyfriend. The fact that the women focused mainly standards of behavior for girls leaves open the question of whether adults are more likely to condone or overlook the sexual exploits of boys. If so, then pressure on a girl to keep a boyfriend by pleasing him, or complying unquestioningly with his desire for sex, might only increase her risk, just as it does for adult women whose partners do not share their efforts to live within a monogamous relationship.

An even more striking analogue to the sexual and economic pressures on adult women was the implication that some young girls are already exchanging sex for material goods they could not otherwise afford. Women in Savanne were particularly conscious of this problem, complaining that if parents do not provide adequately for their daughters, they may get what they want from men who can. There is no way to judge the extent of this practice, but even as a potential threat over the heads of disadvantaged parents, it has serious implications. A few focus group participants with teenage children did, in fact, comment that to protect their daughters from the risk of contracting HIV, parents should accede to their daughters' wishes for things like clothing and jewelry. Thus, the economic implications of behavioral risk surfaced with sufficient clarity to show a glimpse of the suffering of parents caught between poverty and the risk of losing a child to AIDS. Such comments also shed light on the socialization of young women to the rules of sexual negotiation, teaching them at an early age that sexuality means bargaining.

Objective 6: To explore women's sense of responsibility for promoting sexual behavior change through interaction with other women

Very few of the women in this study reported an affiliation with a club or other organized group which might provide a forum for AIDS information and discussion. On the other hand, they said that women do talk informally together about AIDS, mostly to seek information from others, to share their anxiety, or to tell each other about a neighbor or acquaintance who has died of AIDS. At least some participants knew that information was available from health personnel and that health centers and family planning clinics provide AIDS education and distribute condoms.

When moderators asked participants how women might help each other to protect themselves from AIDS, their primary advice was to expose the promiscuous behavior of a friend's partner, to provide reasons that a promiscuous woman friend should abandon her dangerous lifestyle, and to share prescriptions for getting along with a man so that he will not be tempted to turn to other women. Participants commonly said they would offer themselves to others as role models of success in a conjugal relationship. However, most would limit their advice to friends, relatives, and people "who will listen." They warned that there are women who might need such counseling but who resent hearing it, because they distrust the counselor or because they do not want to admit to their own vulnerability.

Even women who are willing to talk about AIDS find it difficult to do so. When asked how women feel when they talk about AIDS, most participants responded with words like "scared", "uncomfortable", "sad." They explained their emotional reaction by the fact that

they did not know whether their partners were infected and by their experience of seeing people they knew die of AIDS. Yet despite the resistance of others and their own discomfort, many participants expressed an eagerness to talk among themselves and with other women about the disease, how it is spread, and how it can be prevented. They had difficulty with the concept of "collective responsibility," but their strong support for the idea of women helping other women suggested that at least those who participated in this study felt an obligation to reach out to family and friends with the ideas they encountered in the focus groups. In fact, although moderators confined themselves to asking questions and guiding discussion, many participants commented on how much they had learned, and how they looked forward to telling others what they had "learned" when they returned home.

D. Gender Differences: Objective 7

Objective 7: To determine male-female differences with respect to norms of sexual decision-making and sense of responsibility for protecting themselves and others.

The perception of sexual norms and expectations held by women were strongly validated by the views expressed in the men's groups. Female experiences and opinions were reflected in analogous accounts by men of male attitudes and behavior toward women. Many of the norms that women said made it difficult for women to protect themselves from AIDS were also documented in transcripts of men's discussions. Women expressed anxiety and uncertainty over partners' sexual behavior outside the home. Male participants spoke of the common practice of men to have other women and to guard their own sexual freedom. However knowledgeable they might be about the consequences of unprotected sex, many women were fearful that attempting behavior change might only encourage men to increase their sexual activity with women on the outside and, hence, their risk of infecting their wives or regular partners. Men repeatedly referred to the ability of a man to find what he needs elsewhere and then to blame non-sexually compliant women at home for the increased risk. Women believed that men would allow them occasionally to be non-compliant with sex; men and women both cited the same reasons for a woman's refusal, but men stressed that she should not refuse too often. Fear of retaliatory abuse emerged from the women of Savanne and was echoed in the bravado with which some of the men from the same city threatened to punish women who refused sex for unacceptable reasons.

Similarly, both men and women believed that women have at least the right to protect themselves from contracting HIV from men who have other partners, with no clear agreement on how they could do so and escape retaliation from men who were unwilling to compromise. Male participants also debated the wisdom of several alternative courses of action, including attempts on the part of the woman to force a man to give up other partners by threatening sexual abstinence, condom use, or abandonment. Although discussion of these strategies left unresolved differences among individuals within each group, there was little gender distinction.

Communication between sexual partners received considerable attention from both men and women. Spontaneous role play of situations in which women were attempting to influence partners' behavior showed men and women approaching the same problem from similar perspectives, balancing factual information, reason, tact, and the recognition that AIDS is a new disease.

Economic issues, on the other hand, were perceived differently by men and women. Many women were acutely aware of the relationship between income-generating work and decision-making power, expressing the belief that control of money is fundamental to control in other aspects of life. Men were more likely to interpret women's desire for money as manipulative. They sometimes attributed a woman's reluctance to engage in sex to her man's failure to give her money or provide for her material welfare, but at no time did men advise women to find work or did they acknowledge the effect of dependency on women's self-esteem.

Men and women also differed in their expectations of the male response to a woman's proposing the use of condoms. Women were more pessimistic. Some expressed the belief that men would never admit the need for condoms. Others feared that partners would construe the request as evidence of the woman's infidelity and either abuse or abandon her. Anxieties such as these were validated in men's harsh comments on the problems a woman causes when she refuses to agree to sex. With respect to condom use, however, male participants expected more compliance from their fellow men. Women and men set similar conditions for granting women the right to demand condoms, i.e. desire to limit or space children, evidence of male infidelity, or a promiscuous lifestyle on the part of the woman. Given these limits, male participants expected for the most part that if women use logical argument and tactful persuasion to communicate their desire to protect the family from AIDS, most men will reflect on the reason for the request and be willing to compromise. Men tended to formulate their strategy in terms of choice. Once the woman at home discovers his extramarital affairs, he must choose between giving up the other women or using condoms. If giving up women is unacceptable, or complicated by long-term obligations to more than one partner, he may decide that the only alternative is to use condoms.

That so many male participants were willing to come to grips in the focus groups with this difficult choice suggests that there is at least a latent sense of responsibility among men to protect themselves and others from contracting HIV. Women may express more overtly the urgency, and therefore the responsibility, to find a solution to the crisis that virtually all have recognized, but altering old norms of interaction is not easy. Comparison of men's and women's positions on the prospect of behavior change reveals underlying differences in gender-related coping. Comments of both women and men suggest strongly that they believe it is the woman's responsibility to set the stage for safer sexual practices. "Teaching," "explaining," "reasoning," were terms they used to describe ways that women should appeal to their men to accept disease prevention as a new way of life. Women were expected to use caresses and gentle words to communicate the harsh realities of a vicious epidemic to men who held the power to determine whether they would live or die.

This prescription preserved for men at least the illusion of their customary role as sexual decision-maker. Throughout the discussions in all participant categories there was a consensus that in the conjugal union, women possess the wisdom but men hold the power. By implication, men should weigh the merits of a woman's carefully crafted argument and decide for himself how he would respond. Men who persisted in a state of denial or disregard were defined by participants, both male and female, as deviant. They were judged in contempt of traditional cultural values that place a high premium on conjugal cooperation and harmony. The alternative choice, to accept behavior change, was positive for preventing HIV transmission and preserving "understanding" in the home but costly in terms of the man's loss of sexual freedom.

However, although both male and female participants expected women to exercise diplomacy in sexual transactions, they were not expected to be helpless. Careful inspection of the data hints at an iron female fist under the velvet glove, expressed in terms of women's ultimate recourse should reason fail. Women repeatedly threatened to leave uncooperative partners or advised other women to do so, despite the fearsome prospect of being dependent and alone. Men, too, acknowledged that women with no hope of influencing promiscuous partners to change their behavior had no choice but to leave them. This argument is flawed, however, because for many women without means of subsistence there is no middle ground between living in the shadow of HIV and destitution.

E. Opportunities and Barriers to Change: Objective 8

Objective 8: To identify factors that may promote or hinder women's ability to influence sexual behavior.

Promoting Factors

AIDS Awareness -- The fact that most of the participants had a reasonably accurate understanding of HIV is indicative of the success of AIDS awareness campaigns in their communities. It also points to the growing number of people in urban areas who are experiencing AIDS through the loss of family or friends and who are spreading the word that the disease is not a myth but a clear and present danger. Although distorted and inaccurate perceptions of AIDS arose in the discussions from time to time, there was nearly always at least one participant who argued the point with correct information. Participants were also well informed on the means of preventing transmission. They knew that risk reduction means limiting sexual contact to one person and using condoms if there was any doubt about the behavior of a partner. They were aware of the availability of condoms, and most participants believed that women as well as men should be willing to ask for them. If becoming informed is the first step to adoption of preventive health practices, then people like the participants in this study are on their way to lowering the risk of HIV.

Belief in Personal Vulnerability -- Women participants as well as men recognized the horrendous consequences of AIDS and also the vulnerability of people like themselves, despite a tendency among some women to assume that their own partners were faithful and that the AIDS prevention warnings therefore did not apply to them. Many women expressed deep personal fear that they were living with men whose sexual behavior outside the home was a mystery. A significant number of others stated frankly that they knew their husbands or regular partners had other women and were well aware that those women may have been infected yet have no signs of illness.

Fear prompted a sense of urgency as women dared propose preventive strategies that challenged the traditional woman's role in a conjugal relationship. The willingness that many women expressed to confront change, even at the risk of great economic and social sacrifice, may prove to be a critical predisposing factor in their capacity to influence behavioral norms.

Sense of Responsibility -- Another strength that the transcripts disclosed was the sense of responsibility that many women expressed, not only for protecting themselves from HIV infection, but for educating their children about the dangers of unsafe sex and cautioning other women to behave responsibly. That is not to say they necessarily believed they could be successful in influencing others; they fully recognized the difficulty in persuading adolescents to forego sexual contact, and they acknowledged that there were women who would resent their efforts. Nevertheless, the majority of women who spoke out on issues of parental and community responsibility did so with a resolve that signified courage in the face of opposition.

Men's Recognition of Women's Right to Protection -- An interesting finding of this study was the apparent willingness of men to grant women the right to violate traditional norms of sexual behavior, whenever necessary, to protect themselves from HIV infection. When AIDS was not an issue in the discussion, however, they imposed strict limits on the right of women to refuse sex and emphasized that such refusal must be short-lived and infrequent. On the other hand, in the presence of HIV and the risk of transmission through a promiscuous partner, however, men agreed that women must do what they can to avoid infection. Some men felt ambivalent about the contradiction between disease prevention and fertility, but in general, they believed that women have to educate men about AIDS and that men should be ready to compromise their behavior in order to protect themselves and their partners and preserve the integrity of the primary relationship. Although "should" is no guarantee of compliance when it comes to actual behavior, they were more optimistic than women participants that with the "right" strategy, women stood a reasonable chance of influencing men to change their behavior.

Barriers to Behavior Change

Attitudes toward Condoms -- In many different ways, focus group discussions in Savanne and in Delmas showed women ready to take responsibility for protecting themselves and others from AIDS, but several obstacles stand in their way. One is the negative association with condoms that many women still hold. According to participants, it is common for women to recognize the value of condoms in preventing HIV transmission but to reject them for their own use. Some had health concerns. They feared damage or disease if the condom should tear or come off in the vagina, or they worried about possible harmful effects of the lubricant. Others said women will not accept a condom if they believe it decreases sexual pleasure. Still others viewed condoms as a seed of discord or distrust in a relationship, capable of causing psychosocial, if not physical, damage. Women who took this position worried that for either partner to suggest condoms would raise suspicion of infidelity or HIV infection, thus destroying the relationship and the home.

Norms of Sexual Behavior -- Focus group participants alluded frequently to networks of sexual partners and the practice of men in stable unions to have periodic sexual encounters with women outside the primary relationship. Participants acknowledged that women in stable ("maryaj" or "plasaj") unions may also have other sexual partners, but a clear message comes through the transcripts that it is the extramarital affairs of men which are more frequent and more likely to be condoned or overlooked.

Sexual freedom and the double standard that supports it represent deeply rooted gender differences in sexual decision-making. As Lowenthal (11) has pointed out, women have been able to control the sexual encounter up to a point by using their sexuality to bargain for things the man can provide. Men, on the other hand, who are not expected to control their own sexual desires, dominate the physical act of intercourse. Thus, normative structure has served until recently to maintain a precarious balance of power between men and women, but the formula no longer works. For women, protection from AIDS must now include negotiating monogamy and the use of condoms, two aspects of behavior that have fallen traditionally in the domain of men. As the threat of AIDS continues to erode long-established beliefs about sexual rights and relationships, patterns of negotiation will have to change and power will have to shift, or there will be no stopping the epidemic.

Economic Dependency -- The single most important barrier to the efforts of Haitian women to effect positive behavior change is their subordinate status in the economy. The comments of several women participants highlighted directly the connection between their perceived powerlessness to influence sexual behavior and their dependence on men for subsistence. Women who have no income of their own, have no respect from their partners; their opinion does not count. The same message was heard repeatedly in the fears of women that attempts to protect themselves from HIV would lead angry partners to retaliate by withholding material support. Others asked, How can a woman refuse sex with a partner unless she has another man to support her? With little or no schooling and few opportunities for employment, most disadvantaged Haitian women have no way to earn money except as street vendors if they can find goods to sell, or as domestic servants who often work for less than a subsistence wage.

Many of the AIDS prevention measures which women proposed in focus group discussions depend ultimately on their ability to be economically self-sufficient. Although persuasion and bargaining were key elements in their self-protection strategy, their final recourse was to leave a partner who refused to change his behavior. Yet if a woman has no place to go, leaving home is unrealistic and as an empty threat only weakens her bargaining position. Self-esteem and belief in one's ability to influence others are critical tools of negotiation and decision-making. Possessing neither, an economically dependent woman runs a predictably high risk of contracting HIV. Until vocational training and income-generating opportunities become a reality for Haitian women, it is unlikely that the majority will be empowered to participate as equal partners in critical sexual decisions.

Lack of Women's Organizations -- There are few formal organizations in Haiti which foster social and economic development among disadvantaged women. With the exception of a few who participated in church activities such as prayer groups, women in the study reported no formal affiliation. Yet focus group discussions indicated that informal communication about AIDS is common. Women apparently ask questions of each other, compare notes on what they know, and gossip about acquaintances who have fallen ill or died of AIDS.

A simple question as to whether participants thought other women would benefit from opportunities to discuss AIDS prevention in small groups elicited an enthusiastic response and spontaneous offers to inform others. It also revealed that even though moderators provided no information or explanation about AIDS, many respondents believed they had been in an educational session. In point of fact, they had; but they had been instructing each other. If they are to take an effective part in AIDS prevention efforts in their families and communities, as well as in their own lives, women need to be affiliated with groups that can provide the material support and moral encouragement necessary to sustain their motivation. The concept of mutual support, whether formal or non-formal, appeared to be less familiar to Haitian women than it is to women in countries where self-help has been the basis for encouraging participation in local and national development. The lack of such support in Haiti can not help but delay efforts to empower women to gain control of their own lives and to take leadership in campaigns to stop the spread of AIDS.

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Haitian Women's Role in Sexual Decision-Making: The Gap Between AIDS Knowledge and Behavior Change

II. Presentation of Findings