Sunday, December 28, 2008

Gender and HIV

There are numerous factors involved in the spread of HIV in Kenya. For example, high levels of disease and bad health, especially sexual and reproductive health, under funded health systems, poor nutrition, low levels of food security and sanitation, crumbling education systems, high levels of urbanisation, high population density and demographic imbalances, high levels of circular migration and dangerous labour practices.

A lot is known about curing some diseases but, more importantly, it is well known that many diseases are avoided by good nutrition, sanitation and healthy lifestyles. Again, it doesn't take a genius to work out that large groups of men working in cities and around mines will eventually be followed by small groups of commercial sex workers. It's not difficult to provide transport for the men to return home regularly or even to provide accommodation for wives, families and partners. It's not difficult, just rare. The point is, we know what would alleviate some of these factors, even if we don't necessarily know how to implement these measures or are not in a position to do so at present.

However, all these factors have played a part in the transmission of HIV because, for various reasons, they have been given very little attention (unless lip service counts as attention). The reasons for this could include poor leadership and governance or greed and selfishness on the part of a powerful few. The powerful few are not just leaders and other people in Kenya; one must include interested parties who neither come from nor live in Kenya, nation states, economic partnerships, multinationals and even international organisations that usually represent the wealthy, despite a pretence of representing everyone equally.

But one of the less tractable factors in the spread of HIV is gender, a factor operating at many levels. From the top down, slightly more than half of all Kenyans are female. Yet only around 7% of Kenya's MPs are female. Females are also more likely to be poor, have less access to education and health services, are less likely to be employed in the formal sector and are more likely to be dependent, economically and in other ways (usually on men).

At a guess, 100% of Kenyan MPs are in the wealthiest 20% of the population. In contrast, nearly 50% of Kenyans live on less than 2 dollars a day. Put all this together and most Kenyans are not particularly well represented by their elected leaders, this being especially true of Kenyan women.

From the bottom up, around half of Kenyan women have experienced violence as adults, around one quarter in the 12 months preceding the interview (Kenya Demographic and Health Survey, 2003). There are high levels of gender violence across income brackets, employment status, educational levels, rural or urban residence and province, although levels do vary somewhat. This violence is most likely to be perpetrated by a partner, though teachers and mothers are second and third, respectively, in the list of most likely perpetrators.

A specific form of violence that most affects females is Female Genital Mutilation (FGM), sometimes referred to as 'female circumcision'. This is thought to affect more than 30% of females. It is still practiced in some areas, despite being prohibited by law for some years. As well as violating human rights, FGM renders women more susceptible to infection with HIV and other sexually transmitted infections (STI). FGM also contributes to maternal deaths and many serious reproductive health problems. The operation is usually carried out by women but the demand for it is said to come from men.

The practice of FGM is declining but it is far higher in Kenya than neighbouring Uganda or Tanzania. Another practice, which is also said to be declining, is violence against children. It, too, is prohibited by law but still practiced and defended on the grounds that children need to be disciplined. Of course, violence against children is not gender based but it is odd that what is seen as justified on the grounds of discipline in the case of children is also seen as justified on the grounds of discipline in the case of women, but not in the case of men.

But perhaps the most worrying thing about gender violence is the percentage of people, including women, who think it is acceptable for husbands to beat their wives, either as punishment or to assert authority. It is not hard to find people who defend violence against women (and children) or who see it as a normal part of life and not, therefore, a problem.

Nor are these the only gender issues. Women often have little or no right to inherit land or property from their husband. In some places, when a woman is widowed, she herself is 'inherited' by a member of her husband's family. Girls are often encouraged to marry early, sometimes to save their family the cost of their upkeep. They often marry older men who are more likely to be sexually experienced and even infected with HIV or other STIs. In fact, despite the popularity of 'abstinence only until marriage' HIV prevention programmes, married women in Kenya are more likely to be infected by their husbands than unmarried, sexually active women.

Despite being more likely to be responsible for the health and education of children and dependents (including those infected with HIV), women have less access to education, health and other health services and they are, partly for those very reasons, more vulnerable to HIV and other STIs.

So the issue of gender and how it relates to the spread of HIV is not just intractable, it is also multifaceted. I am not able to do it full justice in such a short space. I hope to return to it, often. But I don't want to end with the impression that 'gender' only refers to the female gender.

For several years after HIV was identified, more men were found to be infected than women. In some areas, that is probably still the case. If a small number of commercial sex workers gather round a mining town where the population is predominantly male, more men than women may end up infected. However, if those men return home and infect their partners, it is likely that there will eventually be more HIV positive women.

In Kenya, the ratio of infections was 1 female to 1.2 males in 1986. In 2006 that ratio was 2 females to 1 male. However, in 2007, the ratio had moved in the opposite direction again and now stands at 1.6 females to 1 male.

This may have happened because men are taking more risks and/or fewer precautions, because women are taking fewer risks and/or more precautions or some other reason. I admit, this analysis is fairly speculative. But if a higher proportion of males are infected now, the potential for them going on to infect other women, perhaps several women each, is very high. (In Kenya, most women are infected by men, as opposed to intravenous drug use, blood transfusion, etc). In addition to reversing the ratio of females to males infected, this could also result in a substantial increase in national prevalence.

Now, men, generally, are less likely to become infected with HIV, are likely to become infected later in life than women, are often in a better position to protect themselves (and, therefore, their partners) against HIV and other STIs and they have often received more education.

Therefore, it may be possible to intervene with measures that specifically target men. Men may need to be targeted with different HIV messages than women and, for various reasons, there may be more time and opportunity for effecting such interventions.

For example:

- men who work away from home for long periods, in tea, sugar or cut flower industries, need to be able to return home regularly (using affordable transport); or their family needs to be able to visit or live with them (in decent, affordable accommodation)
- delays at borders that give rise to men visiting commercial sex workers need to be reduced, presumably by those interested in reducing the costs of, and barriers to, trade
- men need to be engaged in dialogue with women and other men to identify and influence attitudes that result in women’s lower status in commerce, politics, marriage, sexual relations and many other areas

There are others (and I must make it clear, I adapted these examples from Eileen Stillwaggon’s AIDS and the Ecology of Poverty), but most intervention efforts at present seem to emphasize a ‘one size fits all’ approach. There are many problems involved in HIV prevention but also, many approaches.



Claire said...

Hmm. Men as high transmitters. So does a relatively high proportion of men infected mean incidence is on the increase; whereas if HIV is languishing in more dead-end females, the epidemic is on the wane?

Right, so, men stand to benefit much more, relative to women, from campaigns that address risk behavious directly, whereas women benefit from increases in sexual equality.

Simon said...

I realise I'm sticking my neck out here but I mean that a high proportion (or perhaps a high number?) of men who are engaging in high risk sex, possibly with multiple partners, could give rise to a large number of new infections because of the greater probability of women becoming infected. If 10 commercial sex workers infect 50 men, those men could infect 100 or even more women, in other words, their partner plus a casual partner or partners. The reason I'm suggesting there is a particular increase in the proportion of men is because the figures for some provinces are suggesting that. So as well as being a possible increase in the number infected, it is men who infect women in Kenya, men who are likely to have more partners, sometimes less likely to use condoms, etc.

As for HIV languishing in dead end females, I'm just suggesting the next step, if the figures we have so far are correct. Not that women don't cause new infections, just that the many not cause so many new infections so quickly.

Men and women stand to benefit from campaigns that address risk behaviours but influencing men may have more effect, given the relative lack of power in certain types of relationship, such as CSW/client, husband/wife, teacher/pupil, older male partner/younger female partner, etc.

Women and men will benefit from increases in sexual equality but men need to take part in those changes, not just women. But women have most to lose where sexual inequalities remain.

I hope that makes things clearer rather than the opposite!

Simon said...

The sentence

"Not that women don't cause new infections, just that the many not cause so many new infections so quickly"

should read

"not that women don't cause new infections, just that they may not cause so many new infections so quickly."

Claire said...
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Claire said...
This comment has been removed by the author.
Claire said...

Hey Simon, made a mistake in the previous graph. I looked at this with the model outputs I have, and found a weak, non-significant positive relationship between the ratio of males to females infected and the 5-year future incidence:

There are other factors which affect future incidence. I was wondering whether male:female ratio would be a strong enough predictor of future incidence that it could be a warning sign. If you can isolate its effect from those of other factors, e.g. epidemic stage, i'm sure it would be a predictor, but on its own, i think it is swamped by these other factors, so it does not come out as a clear herald of increasing prevalence.

Simon said...

Thanks for that, well I'm just guessing! I have no doubt UNAIDS wouldn't resort to guessing, of course.

Stephanie said...

Hi Simon,

I really enjoyed your last three bullet-points, as I think they would be effective. Your analysis of the reasons behind the spread of the disease I think are also accurate.I found your conclusion interesting: that men should be (more) targeted, as opposed to women, and should be educated about the dangers of HIV. So, all in all, I really enjoyed your article (so thank you).

But what about female education? I'm currently interning at the Campaign for Female Education (Camfed), which focuses on tackling HIV/AIDS in Tanzania (so not too far from where you are :P), Ghana, Zimbabwe, and Zambia, by giving girls an education. I was really impressed by the studies that I read when I started working. For example, women with post-primary education are five times more likely than illiterate women to know the basic facts about HIV/AIDS. Girls’ education ranks among the most powerful tools for reducing girls’ vulnerability. It slows and reduces the spread of HIV/AIDS by contributing to female economic independence, delayed marriage, family planning, and work outside the home, as well as conveying greater information about the disease and how to prevent it.When girls get educated, they are three times less likely to contract HIV/AIDS. And the data goes on and on!

All of this to say: would it actually not be wiser to focus on women? What do you think?

Simon said...

Hi Stephanie. Thank you for your thoughtful comments. I agree, the data for the efficacy of making sure that females have equal access to education are overwhelming. But despite this, in many countries females are denied their right to equal treatment in many spheres.

However I think it would be a big mistake to exclude men from gender based interventions. As well as the possibility of alienating them when you really need their cooperation, it doesn't make sense to address something to women and girls while ignoring men and boys. Would you advocate peace talks with only one side in a war?

Would it be sensible to tell girls not to marry or have relationships with older men (a significant risk factor in transmission of HIV) without also bringing up boys to become men who know the risks that their daughters face?

Boys also need to grow up to be able to raise daughters who are safe from various risks and that their sons, over time, become sensitive to the needs of girls and women. Otherwise you'll end up with a lot of disappointed females and arrogant, frustrated males.

'Gender based' so often relates to women. One of the points I would like to stress is that there are many types of intervention, educational, health related, infrastructural, etc. There is no one type that is the best or the only one, none!

Even education is pointless if there are no opportunities after that education, whether it includes females or not. Many educated women resort to survival, some while they are at university. In some countries, girls with primary education are less likely to have HIV than those who have no education, yet those with secondary education are more likely to have HIV than those with no education.

In addition, some interventions must target men. Giving commercial sex workers an alternative way of making money does not stop men from trying to buy sex, at best it will just put up the price. I hope this is clearer. You won't get rid of commercial sex completely, but you can reduce the risks by increasing knowledge and access to condoms, etc.

Also, be careful citing mere statistics to defend targeting women. Over the course of the epidemic, at times better educated and wealthier quintiles have had higher rates of HIV and this effect was stronger for females than for males, in Tanzania! The issue is not straightforward.

This is not to say education and economic interventions are not good, only that they are good things in themselves. They should not be seen as having only instrumental value, value only in reducing HIV. If you are ever overwhelmed by evidence, that evidence may be a bit biased.

BTW, I'll be in Tz in a few weeks. What part are you in? I'd love to visit your project.