AIDS and the single girl

BANGKOK -- Ennita Manyumwa could be a poster woman for the Bush administration in the fight against AIDS. She's African, 26, HIV-free, and for years she has resisted older men who bring her gifts in exchange for an implicit promise of sex later. She races through boyfriends. Many leave because she said no to sex. After one man made a particularly strong plea for sex with a condom, she told him, "What if it breaks? Who would be carrying the burden? Me."

But Manyumwa, who is from Zimbabwe, where an estimated one-quarter of adults aged 15 to 49 are HIV-positive, also wants no part of the US administration's prevention policy against HIV and AIDS, called the "ABCs" -- for abstinence, being faithful to one's partner, and failing that, using a condom.

"It never worked for me," she said during a break in the 15th International AIDS Conference last week in Bangkok, where she was a delegate. "And it hasn't worked for most of my friends. How can I abstain from sex if I have a sugar daddy?" she asked, using the term for an older man who showers gifts on a mistress. "How can I be faithful if my boyfriend is not faithful? What helped me was my behavior. I set my goals. I decided what I want to do in life."

At this AIDS conference, unlike past ones, the old political divisions over the competing priorities of prevention and treatment of HIV had largely faded away. Instead, battles between leaders of global AIDS groups and the Bush administration centered almost entirely on the best ways to prevent the further spread of the deadly pandemic. And as new data underscores the vulnerability of women in contracting the virus, a new term in the global fight against AIDS -- "cross-generational sex," or older men having sex with girls and young women -- became a major topic of conversation in seminars and in hallways at the conference.

"Older men having sex with girls and younger women is what's really driving the epidemic," said Peter Piot, the executive director of UNAIDS, in an interview. And according to Piot, there is widespread belief that the current ABC approach is "irrelevant" in protecting young women in such situations. To many of the delegates in Bangkok, the "ABCs" of fighting AIDS seemed outmoded and simplistic.

Underlying the new focus on women is a series of alarming numbers: Among 15- to 24-year-olds in sub-Saharan Africa, an estimated 75 percent of those infected with HIV were girls and young women; of the estimated 4.8 million new infections in 2003, more than 85 percent were in persons who acquired it heterosexually; and 25 percent of women in South Africa are infected with HIV by the time they are 22 years old.

According to UN epidemiologists, older men typically have much higher rates of HIV infection than young women, and women are three to seven times more biologically susceptible to contracting the virus than men, making cross-generational sex one of the most efficient ways of spreading the disease. Some studies suggest that young women face even more risks if they marry an older man. In Kenya and Zambia, adolescents who are married are contracting HIV at a faster rate than sexually active unmarried teens; researchers said this was due to the high rate of extramarital sex among men in cross-generational couples.

"The three currently available prevention approaches . . . are just not enough," Dr. Zeda Rosenberg, CEO of the International Partnership for Microbocides, said during a plenary session, referring to the ABC approach. "Married women, or women who do not have control over if they have sex, cannot choose abstinence. And many women who have contracted HIV infections from their husbands or long-term partners were faithful."

According to AIDS specialists, large numbers of African and Asian women are having sex with older men for a variety of reasons -- rape, coercion, poverty, lack of family support, and a tacit societal acceptance of the practice. For men, according to behavioral studies, the primary incentive is simple: sexual gratification. For experts like Piot, an emphasis is needed not only on women's behavior but on men.

"Since, many times, a young women's first intercourse is violent or coerced, forget about using condoms," Piot said. "Since many men are having affairs, forget about being faithful. . .. The key is sex behavioral change for men. . .. We can empower women, and that is necessary, but if men do not change their behavior, we will have a limited effect."

Manyumwa, from Zimbabwe, knows this well. She has several friends who agreed to the advances of older men. "They became mistresses," she said. "Their sugar daddies bought them a flat. They are going to be mistresses forever."

She said she avoided that route because of a strong family and several community organizations, including the YWCA and a church group.

"I had exposure. When all that pressure came to me, from the older men, I had enough information and strength to be able to say no," she said. "I blame my peers. We have to seek more information." But, she said, "You can't inform old men."

At the conference in Bangkok, several AIDS experts called on political leaders, both on national and local levels, to speak out against cross-generational sex -- as has Ugandan President Yoweri Museveni, who has been held up by the Bush administration as the best example of an African leader who has delivered effective prevention messages. In his speeches, Museveni has repeatedly invoked the image of a goat tied to a stake as a way of telling older men not to stray from their relationships.

In the meantime, those working on new prevention techniques and behavioral studies believe that while progress in protecting young women will be slow, there are specific steps that can be taken in the near term. One is to purchase and distribute many more female condoms. Some have worried that making more female condoms available will result in displacing male condoms and not lead to an increase in overall condom use, but a recent study in Brazil contradicted those fears and found that the addition of female condoms substantially increased protection.

Another is to increase awareness of the risk of HIV to heterosexual couples. A behavioral study in Kenya in 2001, which included interviews with older men and younger women, found that both sexes perceived that they had little risk in contracting HIV in their relationship. One obvious strategy, aimed at both men and women, would be to publicize the high risks, as well as to develop peer groups for men and women to discourage both sexes from entering into cross-generational relationships.

The researchers say they will turn to people such as Manyumwa to influence her peers.

"I do talk with my friends," she said. "You have to say to people, `What can you do to improve the situation?'"

She encourages other young women to set goals for their lives. "Say I have a goal of five years of being the Minister of Gender in Zimbabwe, and say I have four or five boyfriends a year. Well, that's 20 boyfriends. With HIV rates so high in my country, what about the risk to myself? It means I have to change my behavior. That's what we have to do."

John Donnelly, the Globe's Africa bureau chief, is based on Pretoria, South Africa. He can be reached at donnelly@globe.com.