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.
Invisible Hope: HIV/AIDS and Women 8 Katherine EllingtonIntroductionI-llV/ AIDS persists throughout the world, causing well-foundedpanic ~nd fear. According to the current epidemiologicalsurveillance data, there are 36.1 million adults and children living • -twith HIV/ AIDS. (CDC/UNAIDS/WHO, 2000). Media coverageand the internet have made news and information about theimpact of HIV / AIDS globally accessible both inside and outsidethe medical and scientific community. In February 2001, TIMEmagazine devoted the cover story on the human devastation of thismodern day plague. This extensive article also confirmed the rapidlethal rate of increase in HIV / AIDS over the last three decadesleaving men, women and children dead; families desolate; andcommunities destroyed across the world. News reports have ledto public response as well asprecipitated social and political actionby governments, non-governmental organisations, internationalagenciesand 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 overwhelmingcomplexity and tragedy of HIV / AIDS makes it difficult andchallengingto focusspecificallyon HIV/ AIDS in women, especiallythe proportion of suffering babies and children. Women are moreoften recognised as potential transmitters of HIV / AIDS or as themoral guardians of their male partners (Kurth, 1993), but areinvisible as its victims. 102 :;:s:: ~¥ • = ~- _u .---
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. Inaddition, we shall examine, the political will and some of the socialinequalities that arise from policies regarding the prevent;ion andtreatment of HIV/ AIDS in women with specific reference to theUnited States (US), the Caribbean and sub-Saharan Africa.A global view of HIV / AIDSThe HIV / AIDS pandemic has affected everybody, leaving nogeographic region unscathed. According to the report, "Trendsin HIV Incidence and Prevalence: Natural course of the epidemicor results of change?" Sub-Saharan Africa, where 25.3 million adultsand children are living with HIV? AIDS, is the most affected regionof the world (UNAIDS, June 2000). See Figure 1.1.Figure 1.1 Regional HIV / AIDS Statistics at the end of 1999 per cent ofAdults and Children living with HIV / AIDS Caribbean North America 1% 3% Other 10% South & South East Asia 16%Source: Modified UNAIDS/WHOAccording to the World Health Organization (WHO), there are 16countries where the rate of HIV infection affects more than 10 percent 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-SaharanAfrica. There are 12 HIV infected women for every 10 HIV infectedmen. In the late 19805, as South Africa put an end to apartheid,
104., Womens Health: African and Global PerspectivesHIV / AIDS emerged as the most serious challenge facing thecountry. South Africa has 4.2 million HIV / AIDS cases, the largestnumber in the world. While in Africa as a whole pproximately200,000 Africans have died in war, more than 2 million have diedof AlDS. Worldwide 18.8 million people have died of AIDS andmore 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 andother developing nations. In the US, there are 920,000 cases of HIVinfection, and although treatment using combination antiretroviraldrug therapy has slowed AIDS progress and prolonged the livesof many, at 0.8 per cent the US rate of prevalence is the highestof any developed nation. (MAP, November 2000). WhereasAfrican-Americans and the Hispanics represent about 20 per centof Americans, they constitute more than half of the HIV / AIDScases. Xhile HIV / AIDS in the US is most transmitted throughhomosexual relations and injection drug use, the heterosexual HIVtransmission rate is also rising. However, there is a perception thatthe HIV / AIDS epidemic has been contained in North America.HIV / AIDS and WomenWhat is HIV / AIDS?The human immunodeficiency virus (HIV) is a relatively largeretrovirus with a short half-life in vitro, which can only live inmammals. HIV cannot be transmitted from person to person ,---,---,...".,.,~--~----------------- - -- ---
, Invisible Hope: HIV/AIDS and Women 105through casual or surface contact (e.g. shaking hands, toilet seats).While blood, semen, vaginal secretions, breast milk, and otherbody fluids can spread HIV, epidemiological studies indicate thatvirtually all HIV infection is the result of three primary routes oftransmission: sexual, blood to blood, and parental (blood-born)and perinatal (CDC, 1999). The predominant mode of HIV transmission occurs throughsexual intercourse (Quinn, 1996). Blood to blood producttransfusions, which contain HIV -infected blood, and has anestimated 95 per cent risk of infection and also includes injectiondrug users who share needles as well as share a very high risk ofHIV infection. Mother to child HIV (MTCT) occurs when HIVinfected pregnant women pass HIV to their babies either duringpregnancy, delivery or breastfeeding (CDC, 1998). HIV has the same plan of attack in infecting people. It penetrates, Iinfects and induces cell death throughout their immune system. T-lymphocytes, which are blood cells also known as CD4 cells, arethe main HIV target. CD4 cells are steadily depleted and peopleinfected 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 testAIDS. Most HIV infected people carry the virus for many yearsprior to the onset of AIDS. However, infections combined with HIV weaken the humanimmune system to the point that it has difficulty fighting off certainillnesses. Such "opportunistic" infections seize the opportunity ofweakened immune system to cause illness. HIV progression leads to AIDS. Physicians, on the basis ofCD4 blood counts and clinical manifestations of specific illnesses,diagnose AIDS. Classification and staging systems have beendeveloped by various agencies and institutions to assist withHIV / AIDS diagnoses. In 1993, the Center for Disease Controlpublished a revised classification system of HIV / AlDS-relatedillnesses. The new revision includes illnesses specific to women assuch as vulvovaginal candidasis, cervical intraepithal neoplasia and
106 Womens Health: African and Global Perspectivespelvic inflammatory disease, particularly if complicated by tubo-ovarian abscess. These gender specific clinical manifestations werenot recognised in their prior version and, as such, AIDS cases inwomen often went undiagnosed until the onset of late stages andthe advanced progression of the disease. Furthermore, in the earlydays ofHIV / AIDS, women were not seen as affected in comparisonto homosexual men in the United States. The CDC classification and staging system is widely usedthroughout North America, but in the developing world high-techmedicine and financial resources do not exist. The WHO developeda more broadly defined system, which requires less diagnostic dataand fewer laboratory resources. In the WHO system, HIV / AIDSstages are defined by peripheral blood counts, CD4 cell counts(optional) and clinical observations. The category range is fromasymptotic to severe disease and some classifications vary by region.For example, endemic mycoses are common in AIDS in SouthEast Asia, but not in the United States or Europe, therefore thisclassification is specific to this region. HIV / AIDS classifications systems are crucial tools in helpingclinicians to evaluate illness, plan therapeutic intervention,determine the level of disease progression and provide prognosticinformation. In addition, such systems facilitate HIV / AIDSsurveillance and monitoring worldwide, making epidemiologicaldata accessible. There is comprehensive data specific to HIV / AIDSin women available in part because of the utilisation of such systemsworldwide. International and regional institutions, including theWHO, the United Nations Programme onHIV / AIDS (UNAIDS),the Pan-American Health Organization and other agencies provideand 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
Invisible Hope: HIV/AIDS and Women 107factors, women are also challenged by cultural, socioeconomic andpolitical 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 / AIDSIII women.Table 1.1: Regional estimate of number of people living with HIV and AIDSat 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/WHOWomen are biologically more vulnerable to HlVBiologically, women are more vulnerable to HIV infection as withother STls. Women have larger mucosal surface area that providesgreater risk of mv permeability. For women, sexual intercoursemay result 1) in microlesions (especially increased in coerced sex)that maybe points of virus entry; and 2) in the passing of semenfluid where there is a higher concentration of the virus than in
108 Women 5 Health: African and Global Perspectives ."fvaginal secretions. Women are at least four times more vulnerable Ifto HIV infection (CDC, 1998).I1ldividual behaviour a1ld cultural practices make women morevul1lerable 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, HIVinfection in women occurs most often through heterosexualcontact. In these regions and in similar communities, women arevulnerable to HIV infection as they depend on men who demand fand 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). Womenin 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 aboutl-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 leftwith no viable options for survival outside of their communities ..Governments, community leaders, and international agencies mustaddress cultural practices that lead to harm in women. Prevention .programmes must continue to promote the use of condoms. Theseefforts have worked effectively in some places like Uganda where
Invisible Hope: HIV /AIDS and Women 109there has been an actual decline in the rate of HIV / AIDS over thelast few years. In the 1990s, efforts to control HIV / AIDS throughprevention programmes have focused on personal lifestyle choicesof individuals, but there has been renewed focus on the social andeconomic context of peoples lives that shape their risk behavioursand contributes to the spread of HIV / AIDS. Leadership along with government interventions can make adifference in changing social norms and reducing HIV / AIDS. Forexample, Ugandas President Yoweri Museveni was the first leaderin sub-Saharan Africa to officially discuss HIV / AIDS. His decisionto reverse a long-standing opposition to condom use strengthenedeffective prevention campaigns and has significantly reduced theHIV / AIDS prevalence rate in Uganda. Silence, fear and denial oftenfurther deepen the plight of illV / AIDS, while committed effortsmake 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 incomewith a lower socioeconomic status; 2) inadequate health carecoverage; and 3) a personal or partner history of injection drugand/ 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 lackeconomic independence. (US Department of Health & HumanServices, 2000). Leaders more diligently should work together toacknowledge and identify solutions to address the socioeconomicchallenges women encounter regardless of geographical setting. Itis no secret that economic opportunity and educational trainingmake it possible for women to have and to make different choices.
" ~ 110 Womens 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 Anderson, Jean M.D., 2000. A Guide to Clinical Care of Women With HIV US Dept. of Health and Human Services, HRSA - HN IAIDS Bureau. Preliminary Edition. Doyal, Lesley 1995. What Makes Women Sick: Gender and the Political Economy of Health. New Jersey: Rutgers University Press. Kurth, A. (ed.) 1993. Until the Cure: Caringfor Women with HIV New Haven: Yale University Press. McGeary, Johanna 2001. Death Strikes a Continent," Time February 18: 25+. MAP IUNAIDSIP AHO 2000. "HIV and AIDS in the Americas: an epidemic with many faces," Monitoring the AIDS Pandemic. Quinn, T.C 1996. "Global Burden of the HN Pandemic," Lancet, September 20: 99-106. Root -Bernstein, Robert 1993. Rethinking AIDS: The Tragic Cost of Premature Consensus. New York: Free Press. UNAIDS 1999 "Trends in HIV Incidence and Prevalence: natural cause of the epidemic or results of behavioral change" 1999. Joint United Nations Programme on HIV/AIDS. Geneva, Switzerland. UNAIDS 2000. "Report on the global HIV/AIDS epidemic." Joint UnitedNations Programme on HIV/AIDS. Geneva, Switzerland. U.S. Center for Disease Control & Prevention 1998. What is HN?" Divisions ofHIV/AIDSPrevention (November). YIorld Health Organization 2000. Women and HN I AIDS". WHO Infonnation Fact Sheet No. 242. (June).