Introduction

AIDS no longer is an affliction of any particular group. Estimates reveal that women are being increasingly affected, and the infection rate among women is equal to that among men.

Further, the World Health Organisation estimates a cumulative total of 30-40 million HIV infectious in men, women and children by the year 2000, of which 90% shall be in the developing world.

On an overview, the issue of HIV infection in women needs the following considerations.

• The current scenario and areas where we need women
• Specialised areas of concern
• HIV prevention strategies tend to focus on women and children
• Certain questions of ethics that require clarifications.

The current scenario

Looking hitherto at the known possibilities of HIV transmission, one gets an idea of the importance of the issue of ‘Women and HIV’.

HIV transmission can be caused by way of (i) horizontal transmission (through sexual contact, blood transfusion or sharing or syringes among drug-addicts.) and (ii) vertical transmission, i. e., from mother to child (perinatal transmission).

The two areas principally involving women are heterosexual transmission and perinatal routes of transmission.

Women and heterosexual transmission

Heterosexual transmission (i. e. man to woman and vice versa) is on the increase throughout the world. This implies in turn, that the involvement of women is on the increase. Transmission here is bi-directional, meaning it can be from man to woman and/or from woman to man. Any one who is sexually active can acquire or transmit HIV through sexual contact. A normal sexual relationship with someone who has been infected with HIV is sufficient to acquire the infection.

There was a time in the history of AIDS, when homosexuality amongst men was implicated an important cause in the spread of HIV infection. However, today, since heterosexual intercourse is becoming the predominant mode of HIV transmission in most parts of the world, infections among women of child-bearing age are rising steeply.

The involvement of women is not exclusive. When more men are infected, more women are at high risk of being infected, since these men pass it on to their wives and female sex partners. This element of risk is especially high when the men are asymptomatic.

Increased incidence amongst prostitutes (female sex workers) acts in two ways. On one hand, their involvement adds to the direct increase of an affected female population; and on the other, they are the source for a secondary chain of transmission to yet another group of women (mostly innocent and ‘caught unaware’ wives and other female partners) through their male clientele.

The subordinate status of women in the family and in society almost throughout the world makes them more vulnerable to infection. Women, especially, wives, are frequently in the dark about the sexual practices of their male sex partners and find it difficult to insist on safer sex practices like use of condoms. In a country like India, where the woman’s opinion is often ignored, neither her knowledge nor her awareness can offer her protection. Not many wives can demand safe sex practices from their husbands.

Some important facts about heterosexual transmission:

• Multiple sex partner relations increase risk of infection.
• Repeated relations with prostitutes increase woman-to-man transmission of infection

The above mentioned facts should remind us that the role of women in HIV transmission cannot be under-estimated.

Because HIV is primarily transmitted through sexual relations, AIDS selectively hits young and middle aged women, with consequent disruption of families and orphaned children. The work force is also depleted.

Women and perinatal transmission

In perinatal transmission the mother passes on her infection to her children. The transmission can be when the foetus is developing in the mother’s womb, during delivery and/or while breast feeding.

While the number of children infected with HIV is not reported routinely, World Health Organisation (WHO) estimates that world-wide, HIV infected women have borne close to 1 million infected children and about 2 million non-infected children. The latter have already been orphaned due to the death of one or both the parents or will soon be becoming so.

Special area of concern

One of the most important risk situations of HIV transmission is the ‘sex-work situation’.

‘Sex-work situation’ popularly called prostitution, is a potential risk setting for HIV transmission and the transmission could be:

• from female sex worker to clients;
• from clients to the female sex worker;
• from either of them to their other sex partners.

The extent of this transmission varies according to the cultural, social, economic and ethico-social contexts of the situation and society.

Certain factors serve as determinants of the rate of sex-work related transmission of HIV:

• prevalence of HIV infection among client and/or sex workers; frequency of unprotected sex;
• use and acceptability of condoms;
• prevalence of other behaviours, such as the sharing of un-sterilised drug, injection equipment;
• economic status of both sex workers and clients; and
• working conditions including the legal constraints under which prostitutes operate.

In a sex-work-related transmission, a client-focus component needs to be remembered. Whatever prevention or safety measure is proposed in such a situation, members of clientele tend to offer resistance to the measure. They are not usually prepared to undergo the prevention method. Most sex workers repeatedly report client refusal to use condoms. These sex workers, who depend on their clientele for survival, are not in a position to demand condom use for safer sex from their clients, for fear of being left unsupported.

Another constraint in this regard is lack of support from the management of the sex-work establishment. Those involved in the provision of commercial sex (owner and managers of bars, brothels, red light houses, taxi- drivers, pimps) often discourage any such practice, again for fear of losing business.

Thus the female sex-worker is exposed to a high risk situation of being both a target of HIV transmission and a source. Society does nothing to safeguard her and help her prevent spread of the disease.

Preventive strategies

Let us glance at the strategies that are being currently employed to nullify at least some of the problems.

Several AIDS prevention and control programmes currently in vogue tend to place greater emphasis on issues concerning ‘Women and AIDS’. The programmes necessarily need to focus on:

• A prevention of HIV transmission from and to women;
• lessening the impact of the AIDS pandemic on women by making them educators, counsellors and family caregivers; and
• ensuring whole-hearted participation of women in AIDS control programmes.

A gender-specific approach aimed at benefiting women is being incorporated into almost all AIDS strategies now.

The World Health Organisation and other international agencies are developing specific action plans on women and AIDS. They acknowledge the subordinate status of women in society and recognise their susceptibility to infection and transmission. They attempt to tailor prevention programmes to the particular needs of women in order to interrupt transmission. An important aspect of these plans is the support and testing of preventive methods directly controllable and usable by women. One such product, the ‘female condom’ (or fendom) hit the European market in 1992. Efficacy of vaginally applied virucides (drugs that kill or destroy the virus) is also being tested.

Studies that targeted sex-workers showed several obstacles to the success of any preventive or control project in sex work areas. These include client refusal of condoms, non-use of condoms in other sex relationships of the male clients, lack of supply and availability of condoms, lack of awareness, non-acceptance or suppression by clients of already present HIV infection (even if they know of it) and higher incidence of other sexually transmitted diseases.

Though awareness and requisite knowledge can be provided through health education, the rest of the obstacles need specialised solutions. These, if left unsolved, would endanger the female population further.

Client co-operation is essential in any of these projects. Particularly dangerous is the client who does not reveal his ailment, especially if he has an STD, as according to him the female sex worker after all gets her ‘fee’ for her services and does not enjoy the right of questioning or knowing.

The global programme of the WHO and other integrated AIDS strategies target female sex-workers but they also incorporate parallel programmes for the clientele, managers, and others involved (the police, health and social welfare agencies that monitor commercial sex-work).

Problems that need emphasis

It cannot be over- stressed that most of the strategies which claim to benefit women are yet to gain momentum. Developing countries, including India, have not overcome the difficulties that arise on social, psycho-social and moral grounds, to ensure that women, as the subordinate class, will not have to undergo ‘stigmatised’ suffering.

It is mandatory of any AIDS prevention or control strategy to relate to the definitive and specific problems of women and ensure break of transmission.

Apart from empowering women with information on the prevention of disease, they should also be given adequate training to act as peers and educators to the risk groups. Women counsellors, attending on target populations school and college students, pre-marital youth, housewives, working and non-working women, women of low socio-economic status and media- watchers, should be encouraged and provided sufficient back-up.

Women should also be imparted necessary and adequate knowledge to render their roles as wholesome care-givers in the family and society. A situation with an HIV-infected AIDS-afflicted patient requires sensitive and sensible handling – for which a woman could best fitted with requisite awareness and training.

Questions that need answers

Certain ‘sayings’ have repeatedly been affirmed on women’s role in halting the AIDS pandemic.

• female sex-workers make up a chief source of HIV infection;
• the chain of transmission primarily begins with them;
• unethical and unhygienic practices amongst them leads to greater affliction of their male clientele.

How far these are true, is uncertain.

A woman, who has been declared HIV-infected or AIDS-afflicted, is looked upon with contempt. She is regarded as a personification of immorality and disloyalty.

Nevertheless, the question that remains unanswered is: who was responsible primarily, for bringing HIV infection into the female population?

If a female sex-worker is implicated, which of her male clients gave it to her? When a wife gets infected, how much of her husband’s sexual practice, was/is she able to control?

The chain of transmission towards and from a female sex worker could only be through her clients. Is she given a right, in the first place, to know of her client’s relationship with other partners (some of whom might be infected and the start of the chain) and ask for protection against any sexually transmitted disease, leave alone AIDS? Will her clientele approve of safety measures implemented by her and still continue to patronise her?

What about the innocent, flawless, loyal and sincere wife? Though sincere and loyal to her marriage and husband, she remains a subordinate to her husband. She has no access to information on him. She cannot control his sexual and other practices. On the other hand, she will almost certainly be ostracised if found suffering from AIDS or HIV infection.

These aspects require urgent action.

To ensure complete success, strategies to counter AIDS should necessarily raise these questions and provide answers.