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.