The Deadly Gender Gap
Fighting AIDS in Africa means convincing men to take responsibility for what is often thought of as a woman's disease
December 30, 1998
Dakar, Senegal -- "I really trusted my husband," says Brigitte Syamaleuwe, a 40-year-old Zambian woman. She knew she hadn't had sex with anyone else, so when she tested HIV-positive she felt "totally shattered."
She's hardly an exception. A study from nearby Uganda found that 60 percent of HIV-positive women were married and monogamous. Yet in a way, Syamaleuwe is lucky.
While her husband at first refused to believe her diagnosis -- and turned hostile -- he eventually came around, and the couple now works together educating others about HIV.
No such reconciliation happened for a woman from Togo, who told her story on condition of anonymity. Her boyfriend didn't use condoms even though, as she later found out, he had known he was infected for several years. When she told him she had tested HIV-positive, he left her -- and later tried to run her over with his car.
Many such stories emerged as about 500 AIDS workers from 40 nations gathered in this vibrant West African city earlier this month for the seventh international conference of the Society of Women Against AIDS in Africa (SWAA). As if to underscore the stigma against women with AIDS, just last week a South African activist, Gugu Dlamini, was stoned and beaten to death by her neighbors, furious that she had spoken out about her life with HIV.
But rather than using such tales to define AIDS as it has come to be understood in the developing world -- as a woman's disease -- this conference cast AIDS as a man's disease. "Without men there would be no AIDS epidemic," declares AIDS and Men, a new book published by the highly regarded Panos Institute and widely discussed at the conference. Men account for 80 percent of all injection-drug users, and virtually every sexual case of HIV involves a man (in many cases only men).
Moreover, notes AIDS and Men editor Martin Foreman, it is usually men "who determine whether sex takes place and whether a condom is used." The vagina is biologically more susceptible to HIV than the penis, and men generally have more partners than women. So, Foreman explains, "women are more liable to contract HIV without passing it on, men more liable both to contract and transmit the virus to others." Even prostitution, clearly a vector of transmission, is driven by male desire.
Foreman cautions that perhaps "no more than a quarter of men endanger themselves and their female or male partners," and conference participants stressed that castigating men would only backfire. In particular, African men have often been stereotyped as hypersexual, and no one wants to inflame such bigotry. Yet a problem clearly exists: As AIDS and Men notes, hundreds of millions of men from every continent seem to "regularly act without thought and leave women to deal with the consequences."
That's a major reason why the conference theme was "Enhancing Men's Participation." Noerine Kaleeba, one of the architects of Uganda's world-renowned educational response to AIDS, notes that "boys are supposed to chase girls, and girls are supposed to run," so countless AIDS prevention programs have tried to help girls keep running. But it's at least as important to persuade boys to ease up on the chase or act responsibly if they catch up. As Foreman puts it, "Persuading 10 men with several partners to use condoms, sterilize needles, or have fewer partners has a far greater impact on the epidemic than enabling 1000 women to protect themselves from their only partner. The 10 men are at the beginning of a chain of infection; the 1000 women are its last link."
No one is suggesting abandoning the struggle to empower women, especially not in sub-Saharan Africa, where AIDS is running rampant. Two-thirds of people with HIV -- which killed 2.3 million people this year -- live in sub-Saharan Africa, where the virus has infected more than a fifth of the adult population of some countries. Peter Piot, director of the Joint United Nations Programme on AIDS, says the epidemic will surpass every African catastrophe "since the slave drive."
Boosting women's power provides a proven bulwark against the virus. A Zambian study, for example, found that women who finish school are four times more likely to avoid HIV than women who drop out. But women's rights are inseparable from economics, and the poverty that envelops much of the continent was made poignantly clear by Emilia Mwange, a woman from rural Zambia who organizes home care for people with AIDS and other diseases in her village. Her volunteers spare food when they can, but often they have only enough for their families. "So you just go to do what you can -- sweep, draw water, bring firewood," she says. "Sometimes the patient needs aspirin, but you don't have money for that."
Such dire circumstances magnify the consequences of women's powerlessness. Poor hygiene and limited health care foment sexually transmitted diseases, which strike women more than men and make HIV transmission more likely. "How can we say to a woman, 'Don't have sex for money,' when she has to eat?" says SWAA cofounder Fathia Mahmoud of Sudan. "Poverty is still killing us."
Westernization often makes matters worse, at least in the short term. During a freewheeling plenary discussion, a woman from Burkina Faso lamented urbanization, noting that social cohesion was tighter in traditional villages. "But in the city," she said, "a man can do anything he wants against women, even beat them." In Zambia, notes Syamaleuwe, privatization of the copper mines is leading to layoffs of many miners, thrusting families into deeper destitution and aggravating male frustration and rage.
Many laws and customs keep women second-class citizens. "Men are allowed to divorce on account of infidelity, but in many countries women don't have this right," said Kaleeba. Several participants noted that while polygamy is accepted in many countries for men, it is universally condemned for women. In some cultures, women cannot own property; when a woman's husband dies, she can lose everything to his relatives.
Finally, there is the personal power men wield, and discussions on this topic were often wrenching. "In sexual relations," said a woman from Niger, "maybe we shouldn't call men our partners, but rather our bosses." Another woman told how her boyfriend, who had infected her, was sleeping around. "How can you protect these other women?" demanded a member of the audience, but no one offered an answer. And another woman said, "When I go back home to Nigeria, my husband will say, 'What is this about a condom?' And I cannot force him to do what he doesn't want to do."
That's why news about the female condom sparked so much excitement and debate: Women need something to protect them -- now -- before the transformation of society is finished. A pouch that fits in the vagina, the female condom has not taken off in the United States, where it is more expensive than the male condom, makes noise during sex, and sometimes causes discomfort.
But at the conference, a study from Senegal documented "high demand" for the female condom, and that apparently mirrors the experience of women in other African countries. "In Zimbabwe, it's enormously popular," says Helen Jackson, director of SAfAIDS, an HIV information service for southern Africa headquartered in Zimbabwe. She says that country's initial shipment of female condoms sold out much more quickly than expected, and that it sold well in both rural and urban areas. When they weren't available, she says, a few women "were even found experimenting with plastic bags," trying to fashion homemade versions of the female condom.
Why would African women seize on something American women have rejected? "They're desperate to have something," answers SWAA president Eka Esu-Williams. "Women want something they control."
Still, there is some skepticism over the cost, acceptability, and proper use of the female condom, along with fear that subsidizing it would drain money from other prevention programs. There is even concern about men "misrouting" their penises to go under the pouch instead of in it. "This gadget," says Kaleeba, "is difficult to use without the cooperation of men."
But such arguments miss the point, says Jackson: "The female condom is for use when male condoms won't be used," leaving the woman with no protection at all. "It's so much better than nothing, so for God's sake why are we hesitating?"
Whatever its virtues, the female condom is a technological fix to what might be called the problem of masculinity. In many parts of Africa, says Jackson, "Men call STDs 'battle scars.' They're an honor for men, but they're stigmatizing for women." As the only incurable and fatal STD, says Mwange, AIDS stacks death on top of sexual shame to create an even more frightening stigma.
To avoid it, some women even risk harming their children. Researchers in the Ivory Coast studied whether a short regimen of AZT can prevent mother-to-child transmission. Women took their pills religiously -- until they went into labor, when suddenly less than half took the drug as directed. Part of the reason was certainly the trauma of giving birth, but researchers believe another reason was fear of exposure. African women give birth surrounded by relatives, and taking AZT would reveal the mother's HIV status, exposing her and her baby to abandonment or violence by her husband.
There is certainly hope for change. In some Zambian cultures, when a husband dies, his wife used to be ritually cleansed through having sex with one of the dead man's brothers. Now, because of AIDS, that cleansing almost always takes place through another, nonsexual ritual. But at the conference, speaker after speaker called for men to make an inner transformation, a change not just in rituals but in values and attitudes, in what it means to be a man.
But how? Men are caught in a catch-22. They "run the national AIDS programs," says Esu-Williams, "but they don't do the work on the ground." This means much more than just a heavier burden for women. It means "there isn't that platform to mobilize men, to bring them together. There's a vacuum."
MacDonald Maswabi is trying to change that in Botswana, which has the world's second-highest HIV-infection rate. He's the coordinator of a pilot program called "Men, Sex and AIDS," which convenes small groups where men discuss their sexuality -- not merely HIV. "The image a man has of himself as a man, sexual object, lover, etc.," explains the program's description, "might influence sexual behaviour just as much as the fear of an unwanted STD."
Surprisingly, Maswabi adapted the program from one targeting gay men in Norway -- and not surprisingly, it wasn't a perfect fit. The Norwegian version required Maswabi to discuss his fantasies -- something that would never happen in the traditional culture of his southern African country. "I was thinking, 'These white men are crazy!"' he recalls. But he overcame his "hell no" reaction and modified the program for sensibilities in Botswana.
"Even though cultures differ," Maswabi says, "men are alike in so many ways." Indeed, he could be talking about almost any country when he says that sex for men is "all about pleasing the male ego; a man needs to make his mark. So if sex hasn't been going well, the easiest way out is to blame the woman and say, 'Hell, there's something wrong with her, I'll go elsewhere.' And that's a link to HIV."
There are many others. Most conceptions of masculinity encourage men to start sex at an early age, to have many partners, and sometimes even to coerce women into having intercourse. Failing to appear masculine, notes Foreman, can bring down a rain of ridicule, and it is fear of this shame that leads many men to take sexual risks. But masculinity also calls for protecting one's family from danger and staring down one's own fears. If cultures can promote these images of masculinity, and create new ones, then more men might start doing what they desperately need to do: shoulder responsibility for AIDS.
More articles by Mark Schoofs.
More articles by Mark Schoofs.
It is a part of the publication The Village Voice.