Fighting for Women: HIV Prevention in Sub-Saharan Africa
June 23, 2014
Love, hope, and care are expectations among married women and those in relationships. Marriage and childbearing are highly valued in African cultures, and girls are expected to be married by age 16. When that age comes and goes and no suitors are making marriage proposals, she becomes the talk of the village and faces ridicule and name-calling.
In our parents' day, married women were safe in their homes, and their key threat was domestic violence. Childbearing was required to protect their marriages -- if they chose not to have many children, they could lose their husband as he might marry a second wife who was willing to have more children. Women who refused birth control did so not because they wanted more children, but because their husbands demanded it.
The tide of AIDS has changed the African journey for women and now young girls as well. Up until the '90s married women had few fears of contracting HIV -- that was a song for sex workers or single people. They never considered that their husbands were sleeping with people who are vulnerable to HIV. But recently, there has been a call for women to wake up and see that they have no bargaining power to protect themselves from the virus by demanding condoms as singles are able to.
According to the World Health Organization, 50% of all people living with HIV are women. In sub-Saharan Africa, that number rises to 61%. Young women (15-24 years) are three to six times more likely to be infected than men in the same age group. Worldwide, HIV rates are high among sex workers (the great majority of whom are young women), ranging from 6% in Vietnam to 73% in urban parts of Ethiopia. In some Asian countries such as Cambodia and India, women are increasingly infected with HIV within the context of marriage.
Eastern and Southern Africa continue to be the epicenter of the HIV epidemic. Southern Africa in particular experiences the most severe HIV epidemics in the world, with 34% of all people with HIV globally residing in its 10 countries.
Surveys in several countries show that more men than women have multiple partners. But the number of women using condoms with their partners is lower -- only 38% use them regularly. Testing rates are low too. In 2007, only 18% of pregnant women in low- and middle-income countries received HIV tests.
While only 33% of pregnant women living with HIV received meds to prevent transmission to their children, this was a substantial increase compared with only 10% in 2004. Fortunately, access to HIV meds is increasing, from 7% in 2003 to 37% in 2010. In some countries, women have access to treatment in proportion to the expected need. But though women live longer than men in most parts of the world, WHO estimates that AIDS has driven women's life expectancy below that of men in Kenya, Malawi, Zambia, and Zimbabwe.
My country, Malawi, has a population of over 13 million, and nearly a million are living with HIV -- as many as in the U.S. More women (13%) than men (10%) have the virus, and women get infected at a younger age -- 4% of women aged 15-19 have HIV compared with less than 1% of men that age. The number of women with HIV remains higher than men until age 30 and again outpaces that of men after age 40.
In 2011, 9% of Malawi women who had never married were HIV positive, 12% of married women, 19% of those who were divorced, and 41% of widows. While 71% of sex workers are positive, it may be surprising to learn that 56% of all new infections in Malawi occur in people in stable sexual relationships -- people who were previously considered to be at low risk.
About 88% of all new HIV infections in Malawi and other sub- Saharan countries, including Zimbabwe, South Africa, Uganda, and Zambia, are acquired heterosexually. Several factors account for this, but one significant driver is that more people are having sex with multiple partners: in Malawi, 26% among men and 8% among women. The root causes for this are poverty among women and girls and a lack of information on the dangers of this practice.
Surveys in Malawi show that only 47% of men and 30% of women have ever used a condom. Among those aged 15-24, that drops to 13% and 2%. There is limited education on condoms and limited availability, especially in rural areas. This has serious implications for women and girls, since disempowerment, along with the traditional feminine and masculine roles, makes them unable to negotiate safer sex.
The situation in South Africa and other African countries is also very much the same, with young women being at greater risk. In 2005, 17% of women aged 15-24 had HIV, compared with 4% of men. This results from a number of factors: poverty, violence against women, cultural traditions that promote intergenerational sex, a preference for "dry sex" (without using a lube), and a high prevalence of sexually transmitted infections (STIs). In addition, an aggressive government response against HIV began only recently in that country.
Labour migration has played a major role in the spread of HIV in Southern Africa. During the era of apartheid, South Africa was a major recipient of migrant labour from neighboring countries like Zimbabwe, Botswana, and Swaziland, and even from countries farther away, like Zambia and Malawi. Some authors have described "circular migration", where individuals cycle through urban and rural areas in search of jobs. The number of men and women migrating is very different -- over 90% of migrant workers are men, who often have other partners while away from home and then infect their spouses.
This has at least three important implications. First, the men transmit HIV and other STIs to their wives back home during their holidays or upon their return. Second, they also bring infections acquired in their homeland to the migrant labour camps in the host countries and infect women there. Finally, since there are more men than women, female sex workers have multiple partners, and 70% of their clients are married men. Some men have multiple partners to prove they are "real men".
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