Ellington, Katherine. ‘Invisible Hope: HIV/AIDS and Women’ in ed. Grace Bantebya-Kyomuhendo. Women’s Health: African and Global Perspectives. Kampala: Women and Gender Studies, Makerere University, 2005.

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2. Invisible Hope: HIV/AIDS and Women
8
Katherine Ellington
Introduction
I-llV/ AIDS persists throughout the world, causing well-founded
panic ~nd fear. According to the current epidemiological
surveillance data, there are 36.1 million adults and children living •
-t
with HIV/ AIDS. (CDC/UNAIDS/WHO, 2000). Media coverage
and the internet have made news and information about the
impact of HIV / AIDS globally accessible both inside and outside
the medical and scientific community. In February 2001, TIME
magazine devoted the cover story on the human devastation of this
modern day plague. This extensive article also confirmed the rapid
lethal rate of increase in HIV / AIDS over the last three decades
leaving men, women and children dead; families desolate; and
communities destroyed across the world. News reports have led
to public response as well asprecipitated social and political action
by governments, non-governmental organisations, international
agenciesand similar institutions.
A gender-based view of HIV / AIDS reveals that worldwide,
women now represent 47 per cent of all adults living with HIV /
AIDS and this proportion isincreasingsteadily. The overwhelming
complexity and tragedy of HIV / AIDS makes it difficult and
challengingto focusspecificallyon HIV/ AIDS in women, especially
the proportion of suffering babies and children. Women are more
often recognised as potential transmitters of HIV / AIDS or as the
moral guardians of their male partners (Kurth, 1993), but are
invisible as its victims.
102
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3. Invisible Hope: HIV /AIDS and Women 103
Let us look at HIV / AIDS with respect to individual behaviour,
treatment and control and in relation to women worldwide. In
addition, we shall examine, the political will and some of the social
inequalities that arise from policies regarding the prevent;ion and
treatment of HIV/ AIDS in women with specific reference to the
United States (US), the Caribbean and sub-Saharan Africa.
A global view of HIV / AIDS
The HIV / AIDS pandemic has affected everybody, leaving no
geographic region unscathed. According to the report, "Trends
in HIV Incidence and Prevalence: Natural course of the epidemic
or results of change?" Sub-Saharan Africa, where 25.3 million adults
and children are living with HIV? AIDS, is the most affected region
of the world (UNAIDS, June 2000). See Figure 1.1.
Figure 1.1 Regional HIV / AIDS Statistics at the end of 1999 per cent of
Adults and Children living with HIV / AIDS
Caribbean
North America 1%
3% Other
10%
South & South
East Asia
16%
Source: Modified UNAIDS/WHO
According to the World Health Organization (WHO), there are 16
countries where the rate of HIV infection affects more than 10 per
cent of the total population. In parts of the Southern Hemisphere,
one in five people are living with HIV infection.
Heterosexual HIV transmission predominates in Sub-Saharan
Africa. There are 12 HIV infected women for every 10 HIV infected
men. In the late 19805, as South Africa put an end to apartheid,

4. '104., Women's Health: African and Global Perspectives
HIV / AIDS emerged as the most serious challenge facing the
country. South Africa has 4.2 million HIV / AIDS cases, the largest
number in the world. While in Africa as a whole pproximately
200,000 Africans have died in war, more than 2 million have died
of AlDS. Worldwide 18.8 million people have died of AIDS and
more than 13 million children have been orphaned.
AIDS has become a full-blown development crisis. Its social and
economic consequences are felt widely not only in health but in
education, industry, agriculture, transport, human resources and
the economy in general. This wildly destabilizing effect is also
affecting already fragile and complex geopolitical systems ...[and
is] rapidly becoming the key issue for human security in sub-
Saharan Africa. AIDS in Africa was chosen as the theme for the
United Nations Security Council meeting on 10 January 2000
- the first time that body had dealt with a development issue.
(UNAlDS, June 2000)
The AlDS epidemic in the US is different from that in Africa and
other developing nations. In the US, there are 920,000 cases of HIV
infection, and although treatment using combination antiretroviral
drug therapy has slowed AIDS progress and prolonged the lives
of many, at 0.8 per cent the US rate of prevalence is the highest
of any developed nation. (MAP, November 2000). Whereas
African-Americans and the Hispanics represent about 20 per cent
of Americans, they constitute more than half of the HIV / AIDS
cases. X'hile HIV / AIDS in the US is most transmitted through
homosexual relations and injection drug use, the heterosexual HIV
transmission rate is also rising. However, there is a perception that
the HIV / AIDS epidemic has been contained in North America.
HIV / AIDS and Women
What is HIV / AIDS?
The human immunodeficiency virus (HIV) is a relatively large
retrovirus with a short half-life in vitro, which can only live in
mammals. HIV cannot be transmitted from person to person
,---,---,...".,.,~--~----------------- - -- ---

5. , Invisible Hope: HIV/AIDS and Women 105
through casual or surface contact (e.g. shaking hands, toilet seats).
While blood, semen, vaginal secretions, breast milk, and other
body fluids can spread HIV, epidemiological studies indicate that
virtually all HIV infection is the result of three primary routes of
transmission: sexual, blood to blood, and parental (blood-born)
and perinatal (CDC, 1999).
The predominant mode of HIV transmission occurs through
sexual intercourse (Quinn, 1996). Blood to blood product
transfusions, which contain HIV -infected blood, and has an
estimated 95 per cent risk of infection and also includes injection
drug users who share needles as well as share a very high risk of
HIV infection. Mother to child HIV (MTCT) occurs when HIV
infected pregnant women pass HIV to their babies either during
pregnancy, delivery or breastfeeding (CDC, 1998).
HIV has the same plan of attack in infecting people. It penetrates,
I
infects and induces cell death throughout their immune system. T-
lymphocytes, which are blood cells also known as CD4 cells, are
the main HIV target. CD4 cells are steadily depleted and people
infected with HIV will have CD4 cells counts below 500 cells/ mm3•
HIV is the agent that induces acquired immunodeficiency syndrome
(AIDS). A positive I--ITV result does not mean that a person has
test
AIDS. Most HIV infected people carry the virus for many years
prior to the onset of AIDS.
However, infections combined with HIV weaken the human
immune system to the point that it has difficulty fighting off certain
illnesses. Such "opportunistic" infections seize the opportunity of
weakened immune system to cause illness.
HIV progression leads to AIDS. Physicians, on the basis of
CD4 blood counts and clinical manifestations of specific illnesses,
diagnose AIDS. Classification and staging systems have been
developed by various agencies and institutions to assist with
HIV / AIDS diagnoses. In 1993, the Center for Disease Control
published a revised classification system of HIV / AlDS-related
illnesses. The new revision includes illnesses specific to women as
such as vulvovaginal candidasis, cervical intraepithal neoplasia and

6. '106 Women's Health: African and Global Perspectives
pelvic inflammatory disease, particularly if complicated by tubo-
ovarian abscess. These gender specific clinical manifestations were
not recognised in their prior version and, as such, AIDS cases in
women often went undiagnosed until the onset of late stages and
the advanced progression of the disease. Furthermore, in the early
days ofHIV / AIDS, women were not seen as affected in comparison
to homosexual men in the United States.
The CDC classification and staging system is widely used
throughout North America, but in the developing world high-tech
medicine and financial resources do not exist. The WHO developed
a more broadly defined system, which requires less diagnostic data
and fewer laboratory resources. In the WHO system, HIV / AIDS
stages are defined by peripheral blood counts, CD4 cell counts
(optional) and clinical observations. The category range is from
asymptotic to severe disease and some classifications vary by region.
For example, endemic mycoses are common in AIDS in South
East Asia, but not in the United States or Europe, therefore this
classification is specific to this region.
HIV / AIDS classifications systems are crucial tools in helping
clinicians to evaluate illness, plan therapeutic intervention,
determine the level of disease progression and provide prognostic
information. In addition, such systems facilitate HIV / AIDS
surveillance and monitoring worldwide, making epidemiological
data accessible. There is comprehensive data specific to HIV / AIDS
in women available in part because of the utilisation of such systems
worldwide. International and regional institutions, including the
WHO, the United Nations Programme onHIV / AIDS (UNAIDS),
the Pan-American Health Organization and other agencies provide
and rely on consistent surveillance data that is available because
knowledge and information systems, despite their shortcomings,
help progress.
Why women are at risk HIV / AIDS?
In women, the risk ofHIV / AIDS is more significant when gender-
based disparities are considered. In addition to unique biological

7. Invisible Hope: HIV/AIDS and Women 107
factors, women are also challenged by cultural, socioeconomic and
political factors, which further widen their risk of getting HIV /
AIDS. The regional HIV / AIDS statistics in Table 1.1 confirm
?ender disparities and echo the need for a closer look at HIV / AIDS
III women.
Table 1.1: Regional estimate of number of people living with HIV and AIDS
at the end of 1999
Region Epidemic Number of Prevalence Per cent Main
started adults and among ofHIV mode of
children adults infected transmISSIOn
living 0/0 adults for adults
with HIV who are
infection women
Sub-Saharan Late 1970s 25.3million 8.8 55 Heterosexual
Africa contact
South, Late 1980s 5.8 million 0.56 35 Heterosexual
South Ea5t contact
Asia
Caribbean Late 1970s 390,000 2.3 35 Heterosexual
contact,
male/male
sex
North Late 1970s 920,000 0.6 20 Male/male
America sex, injection
drug use,
heterosexual
contact
Total 36.1million 1.1% 47%
Source: Modified from UNAIDS/WHO
Women are biologically more vulnerable to HlV
Biologically, women are more vulnerable to HIV infection as with
other STls. Women have larger mucosal surface area that provides
greater risk of mv permeability. For women, sexual intercourse
may result 1) in microlesions (especially increased in coerced sex)
that maybe points of virus entry; and 2) in the passing of semen
fluid where there is a higher concentration of the virus than in

8. 108 Women '5 Health: African and Global Perspectives ."f'
vaginal secretions. Women are at least four times more vulnerable If
to HIV infection (CDC, 1998).
I1ldividual behaviour a1ld cultural practices make women more
vul1lerable to HIV r·
Behaviouraldata in several countries show that sex with a single,
regular partner is the norm in most countries, at least among
women. However, a significant proportion of adults in many
countries have casualpartnerships, and multiple panners are not
uncommon. In almoSt every country where data is available, .
men are far more likely to have casual partners than women.
Since it is not sex but unprotected sex that exposes people to
HIV and STI infections, condom use is extremely important
in determining how likely an infection is to spread through a
population (UNAIDS, 1999).
In sub-Saharan Africa, South East Asia and the Caribbean, HIV
infection in women occurs most often through heterosexual
contact. In these regions and in similar communities, women are
vulnerable to HIV infection as they depend on men who demand f
and often coerce them into unprotected sex. An African woman, ..
whose husband works 200 miles away and comes home twice a .
year, acknowledges other casual sex partners and admits, ('You risk ~
your life in every act of sexual intercourse." (Time, 2001). Women
in developing nations living in the depths of poverty have no sexual,
freedom as they are pressured to exchange sex for daily sustenance .
and depend on men for survival. "
Regardless of geography, communities are often silent about
l-llV / AIDS. Denial is real and lethal in places like sub-Saharan ;'
Africa where women risk violence, abandonmenr, neglect,
destitution and ostracism in relation to HIV / AIDS. Cultural beliefs -
demonise HIV/ AIDS as an immoral disease and women are left
with no viable options for survival outside of their communities ..
Governments, community leaders, and international agencies must
address cultural practices that lead to harm in women. Prevention .
programmes must continue to promote the use of condoms. These
efforts have worked effectively in some places like Uganda where

9. Invisible Hope: HIV /AIDS and Women 109
there has been an actual decline in the rate of HIV / AIDS over the
last few years. In the 1990s, efforts to control HIV / AIDS through
prevention programmes have focused on personal lifestyle choices
of individuals, but there has been renewed focus on the social and
economic context of peoples lives that shape their risk behaviours
and contributes to the spread of HIV / AIDS.
Leadership along with government interventions can make a
difference in changing social norms and reducing HIV / AIDS. For
example, Uganda's President Yoweri Museveni was the first leader
in sub-Saharan Africa to officially discuss HIV / AIDS. His decision
to reverse a long-standing opposition to condom use strengthened
effective prevention campaigns and has significantly reduced the
HIV / AIDS prevalence rate in Uganda. Silence, fear and denial often
further deepen the plight of illV / AIDS, while committed efforts
make a difference and offer a glimpse of hope.
Socioeconomic and political patbogens
HIV has a tendency to spread along the fault-lines of our
societies,highlighting neglectedpopulations and confronting us
with inequity and hypocrisy. Over one half of drug injectors in a
study in the Eastern US city of Baltimore never graduated from
secondary school, for example, and 97 per cent were African-
Americans...the concentration of HIV in ethnic populations is
usually politically sensitive (UNAIDS, June 1999).
In the US, women with HIV / AIDS have 1) lower income
with a lower socioeconomic status; 2) inadequate health care
coverage; and 3) a personal or partner history of injection drug
and/ or cocaine use. They are also primarily Black and Latina.
Not unlike their impoverished sisters in sub-Saharan Africa,
South East Asia and the Caribbean, many American women lack
economic independence. (US Department of Health & Human
Services, 2000). Leaders more diligently should work together to
acknowledge and identify solutions to address the socioeconomic
challenges women encounter regardless of geographical setting. It
is no secret that economic opportunity and educational training
make it possible for women to have and to make different choices.

10. " ~ 110 Women's Health: African and Global Perspectives
Beyond HIV/ AIDS, socioeconomic disparities affect the health of
the society, worldwide.
Conclusion
In conclusion, the HIV / AIDS pandemic offers challenges to
individuals, communities and governments. As individuals consider
their risky behavioural practices, communities face harmful cultural
beliefs and governments confront socioeconomic disparities, a
visible opportunity to control HIV / AIDS emerges. Solutions to
these challenges present an opportunity that is no less powerful
than the miracle of a medical cure.
References
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