In Brief
Bridge Bulletin. Issue 11. September 2002
Gender and HIV/AIDS
In this Issue:
 Gender, development and HIV/AIDS
 Positive women: Voices and Choices
 Can men change? And can we measure it?
-------------------------------------------------------------------------------------------------------------Why, after 20 years of international responses to the HIV/AIDS epidemic, are infection
rates still on the increase? Why are the numbers of women living with HIV increasing
faster than the number of men? Gender inequality is a major dynamic explored in this
bulletin. What can be done to address a problem entrenched in inequality, denial and
stigma? Starting from the everyday realities of people’s lives and with the priorities of
positive women is how the International Community of Women living with HIV/AIDS
(ICW), an international network run for and by HIV-positive women, approaches these
problems. Working with young men to reflect on and re-evaluate their attitudes and
behaviour towards women is the aim of the Brazilian organisation Instituto PROMUNDO.
-------------------------------------------------------------------------------------------------------------Gender and HIV/AIDS: spotlighting inequality
Emma Bell
(based on Tallis, Vicci, 2002, ‘Gender and HIV/AIDS: Overview Report’, BRIDGE Cutting
Edge Pack, Brighton: Institute of Development Studies)
HIV/AIDS is not only driven by gender inequality – it entrenches gender inequality, putting
women, men and children further at risk. Defining and stigmatising those ‘at risk’ as men
who have sex with men, sex workers and drug users has until recently obscured the
increasing infection rate among people generally thought to be ‘safe’, including married
and older women. The dominant risk factor is now heterosexual sex. It is estimated that
almost 50 per cent of those living with HIV and AIDS are now women (UNAIDS, 2002).
As individuals and in their social roles as mothers and carers, women are now
disproportionately affected by HIV/AIDS.
Gender Inequality
HIV/AIDS
Traditional health-based approaches have been, and continue to be inadequate, ignoring the
social, cultural, economic and human rights dimensions. A focus on sexual and
reproductive rights for women and men is an important corrective measure. Yet a broader
human rights framework is needed to address the range of inequalities that drive HIV/AIDS
– including poverty and that recognises the rights of those that contracted HIV through
ways other than sex. The Convention on the Elimination on All Forms of Discrimination
Against Women (CEDAW) is one such framework. Another useful tool is ‘Women and
HIV/AIDS: The Barcelona Bill of Rights’ (July 2002) which includes, among others, the
right to equality, economic independence, and education.
The denial, blame and stigma surrounding HIV has silenced open discussions, delayed
effective responses, and added to the burden of those living with HIV and AIDS. Women’s
sexuality is particularly subject to stigma and control. Indeed, the social construction of
sexuality – who should or should not express one – including men who have sex with men,
young people, people with disabilities, and those beyond reproductive age, means they are
often denied appropriate sexual health information and services.
When it comes to decision making in relationships, men are expected to dominate and
women to be passive. Unequal parties are not in a position to negotiate when they have sex,
how often and how they can protect themselves from sexually transmitted infections (STIs)
and HIV. The double standard of condoning multiple sexual partners for men, and the
expectation that men should know more about sex, puts them and their partners at risk as
well as preventing them seeking sexual health advice.
The relationship between HIV, gender and poverty is complex. Pressing concerns for shortterm survival may lead poor women to engage in survival sex which paradoxically can
expose them to the long-term risk of illness and death through HIV infection. Poverty also
limits people’s access to sexual health information, prevention technologies and treatment.
Whilst this is true for women and men, gender inequality shapes different experiences of
poverty and impacts on women and men’s ability to move out of poverty. Social spending
cuts often lead to increased pressure on women and girls to take on the role of social safety
net, caring for sick relatives and securing a livelihood as earning family members become
sick and die. This is one of the invisible impacts of HIV/AIDS.
Unfortunately, many approaches to combat the spread and impact of HIV/AIDS have failed
to take gender differences and inequality into account. Some have reaffirmed ideas of
female passivity and male dominance in decisions on sex and reproduction. Others have
responded to the different needs and constraints of women and men, but failed to challenge
the gender status quo. Interventions should both seek to empower women and transform
gender relations.
Starting from the everyday realities of people’s lives and with their priorities is a must.
ICW addresses the question ‘What do HIV-positive women want?’ and the Sonagachi
project in India supports the self-defined priorities of sex workers including negotiating
safer sex with their clients. Both programmes are led by the women themselves. Genuine
participation in defining both problems and solutions is fundamental to achieving
empowerment.
Women and men living with HIV can lead lives of dignity and enrichment when they are
supported by the societies and communities they live in, rather than stigmatised. As one
HIV-positive woman in Mexico said ‘I know I am a woman of worth’. Such positive
reinforcements are the result of concerted efforts by individuals, communities, and
organisations, such as ICW (see ‘Positive Women: Voices and Choices’ article).
However, ‘empowerment’ is in danger of remaining just rhetoric if the unequal power in
gender relations at a personal, collective, institutional and broader societal level is
neglected. Transformation of the unequal power in gender relations is at the heart of the
Stepping Stones participatory approach to HIV, which works with both women and men in
developing their communications and relationship skills. Impacts have included a decline in
domestic violence and better communication between women and men on sexual matters.
The power imbalance between development institutions and those they seek to support have
to be contested if approaches are to be empowering and transforming. Development
practitioners need to question their prejudices around HIV and their vulnerability to
HIV. So breaking down the artificial division between the ‘experts’ and those ‘at risk’.
Likewise, recent trends towards working solely with men need to be challenged if they are
at the expense of programmes for women, or target men but do not address gender
inequality. Instituto PROMUNDO successfully works with young male peer-promoters in
Brazil to challenge the acceptance of gender-based violence (see ‘Can Men Change?’
article).
The complex nature and magnitude of the HIV/AIDS epidemics requires a co-ordinated
response that occurs at all levels, encompasses different approaches, such as service
delivery, capacity building, research and advocacy, and is incorporated into all sectors. In
South Africa the Joint Oxfam HIV/AIDS Programme (JOHAP) has, through dialogue and
funding, supported partner organisations in mainstreaming an approach to gender and
HIV/AIDS in all their work.
The effectiveness of responses to HIV/AIDS depends on our ability to deal with the
inequalities that both drive and are entrenched by the epidemic. We must open up debates
around issues of sexuality and address gender equality in sexual relationships, and
challenge the stigmatisation and discrimination faced by those living with HIV and AIDS.
Those most affected should both define the problem and identify the solutions. Through
collective action at all levels, from local to international, we can harness the energy to
translate this challenge into a co-ordinated action.
‘Openness about my HIV status has changed many people's perception that HIV is a result
of prostitution, promiscuity, and punishment from God. It has helped other HIV-positive
people come to terms with their status. Now they now look at me as a whole person. They
now accept that I can have sex as an HIV-positive person, the same as eating, drinking,
going to work.’
(narrated by Tarisai to Sunanda Ray of SAfAIDS)
-------------------------------------------------------------------------------------------------------------Positive women: Voices and Choices
By Joanne Manchester and Promise Mthembu, International Community of Women Living
with HIV/AIDS (ICW)
What do HIV-positive women want? ICW, an international network run for and by HIVpositive women, identified a gaping lack of sensitive and relevant research into the
experiences of positive women. This led ICW to develop the project Voices and Choices, a
gendered response to HIV-positive women’s sexual and reproductive rights and well being.
Because positive women feel more able to discuss difficult, sensitive issues with other
positive women, the principle ethos governing the project was that it should be led by
positive women and involve them in all stages of planning and implementation.
At first when I heard that ICW wanted to do a research on reproductive health and sexual
issues, my first reaction was that they come again with the research which we are tired of
and that we were not going to benefit again. Just coming to us as positive women taking the
data they want and vanish in the air. But when they told us that this project was going to be
owned and managed by positive women I was very happy.
Otilia, Zimbabwe
In this collaboration between researchers and HIV-positive women over 600 women were
interviewed in Zimbabwe and Thailand (1998–2001). In both countries positive women
were elected from HIV support groups to be interviewers/team leaders and received
training from researchers in interviewing, data analysis and counselling skills. This lengthy
training was an empowering process for many of the women involved.
‘I feel different from before because I was always the target of interviews but now I was
part of the planning and interviewing other people. I gained self-confidence from doing the
interviews, made new friends and learned about the many problems which positive women
face, so many things that I had never thought of’.
Prairat, Thailand
‘I learnt a lot about solving problems, especially finding solutions for positive women like
getting to know the real needs of positive women. When I was doing the interviews I also
reflected on my own situation and found the solutions to some problems within that
process. Before the project I had sometimes felt alienated from other positive women and
didn’t understand why they felt the way that they did. After the interviews I understood
more about them and myself.
Junsuda, Thailand
Data collection was not simply data extraction but provided emotional support and
information.
‘Outreach leaders went to the HIV-positive women whom we live with, we learned from the
women and loved them.’
Etta, Zimbabwe
In both Thailand and Zimbabwe most women had little or no knowledge of HIV
transmission or risk before they were diagnosed HIV positive. Married women particularly
did not consider themselves to be at risk of infection, revealing a fundamental failure of
HIV prevention efforts. The study affirmed that positive women continue to have sexual
feelings and want sexual relationships after their HIV diagnosis. Many women rarely
receive support or advice around sex after their diagnosis and experience difficulty in
negotiating condom use.
In Thailand 32 per cent of the women in the study were diagnosed when pregnant.
Unfortunately the provision of free antenatal testing is not coupled with counselling or
support before or after the test.
‘When I was pregnant and went for antenatal care, I was told to have a blood test. They did
not tell me what the test was for. Every woman who came to the clinic had to have her
blood tested. They did not explain at all what kind of test they were doing. I realised it was
the AIDS test when I received the result’
Thai woman aged 29 [name unknown]
Many Thai women reported judgmental and hostile attitudes from service providers,
including testing without consent and refusal of services.
The positive Zimbabwean women without children expressed a strong desire to have
children. They felt that they had to have children or risk rejection and abandonment by their
partners and communities. Many Zimbabwean women felt under pressure from their
families to conceive and under pressure from health care workers to avoid conception.
None of the Zimbabwean women reported having been given information to help them
conceive safely or to reduce the risk of mother to child transmission. Women who already
had children and wanted to avoid pregnancy for health and economic reasons experienced
great difficulty in accessing contraceptives and negotiating safer sex with their partners.
As a result of their training and experience of working on the project, the team leaders in
Zimbabwe increased their public profile both locally and at a national level. Team leaders
in Birchenough Bridge were elected to serve on their local Constitutional Reform
Committee. Three team leaders have taken up positions in community working groups on
health and one has been appointed to her local hospital board to represent people living
with HIV.
The project findings have formed the basis of a national HIV/AIDS and gender advocacy in
Zimbabwe strategy involving people living with HIV, HIV service organisations,
community-based groups, academics and policymakers. In Thailand there are plans to
develop advocacy strategies, extend counselling to women diagnosed in ante-natal clinics,
and to implement the Voices and Choices study in the southern region of Thailand, an area
with few support services.
Positive women rarely have the opportunity to express their opinions and feelings but
without them any response to the HIV pandemic is flawed. Voices and Choices makes a
unique and important contribution to our understanding of the impact of HIV at a personal
level and highlights the need to develop a gendered response to the needs and dreams of
women with HIV.
Recommendations:
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Undertake further research of this kind which supports the active participation of people
living with HIV and which links research to advocacy and promoting change.
Build positive women’s capacity to enable them to work with researchers and policymakers at all levels of research, policy and programmes planning, implementation and
evaluation.
Incorporate positive women’s sexual and reproductive health issues in the mainstream
sexual and reproductive health/rights research and advocacy agenda.
Recognise the Twelve Statements from the International Community of Women Living
with HIV/AIDS (see box).
Twelve Statements from the International Community of Women Living with
HIV/AIDS - www.icw.org
To improve the situation of women living with HIV and AIDS throughout the world, we
need:
1. Encouragement and support for the development of self-help groups and networks.
2. The media to realistically portray us, not to stigmatise us.
3. Accessible and affordable health care (conventional and complementary) and research
into how the virus affects women.
4. Funding for services to lessen our isolation and meet our basic needs. All funds directed
to us need to be supervised to make sure we receive them.
5. The right to be respected and supported in our choices about reproduction, including the
right to have, or not to have, children.
6. Recognition of the right of our children and orphans to be cared for and of the
importance of our role as parents.
7. Education and training of health care providers and the community about women's risk
and our needs. Up-to-date and accurate information about all the issues for women living
with HIV/AIDS should be easily and freely available.
8. Recognition of the fundamental human rights of all women living with HIV/AIDS,
particularly women in prison, drug users and sex workers. These fundamental rights should
include employment, travel without restriction and housing.
9. Research into female infectivity, including woman-to-woman transmission, and
recognition of and support for lesbians living with HIV/AIDS.
10. Decision-making power and consultation at all levels of policy and programmes
affecting us.
11. Economic support for women living with HIV/AIDS in developing countries to help
them to be self-sufficient and independent.
12. Any definition of AIDS to include symptoms and clinical manifestations specific to
women.
For further details about ICW programmes contact:
2C Leroy House, 436 Essex Rd., London, N1 3QP, UK, Tel: +44 (0) 20 7704 0606
Fax: +44 (0) 20 7704 8070, email: info@icw.org, website: www.icw.org
Can men change? And can we measure it?
An example from Brazil
By Gary Barker, Instituto PROMUNDO
What do we know about young men?
Men’s behaviours are a driving force behind the HIV/AIDS epidemic. In heterosexual
relationships, it is generally men who determine how and when sex takes place. Men’s use
of violence against women, men’s reluctance to pay attention to their health needs, and
men’s resistance to using condoms are among the biggest challenges to reducing HIV risk
worldwide. Can commonly held attitudes be changed such as: sexual health matters are
women’s concerns; violence against women is acceptable; men need sex more than women,
and that quantity in sexual relationships is more important than quality? Can men change
their sexual behaviours? Can we convince men to treat women with more respect, to
negotiate sexual matters with them and to pay attention to their own and their partners’
health?
Instituto PROMUNDO, a non-governmental organisation (NGO) based in Rio de Janeiro,
Brazil, engages young men (ages 15–24) in the promotion of health and gender equity.
Evidence suggests that attitudes and behaviours are formed during adolescence. We started
this process with research that identified young men in low-income communities who were
’more gender-equitable’ than others.
....’ there’s this guy who’s a friend of mine and he had a girlfriend and she got pregnant
and he abandoned her when she was pregnant, and he never liked to work, and he doesn’t
do anything, just takes from his mother. My point of view is different. I believe in working
because I want to have a family, a really good family. I want to be there when they need
me, accepting my responsibilities […] They can think I’m square, so I’ll be square then’.
João (teenage father, 19)
Contributing factors to this were interaction with male role models or mentors with more
progressive ideas, and belonging to groups that modelled and supported more genderequitable attitudes. Reflecting on the cost of traditional ideas of male behaviour – for
example a father or stepfather who used violence against the mother, or a father who
abandoned the family – was also found to be key to the young men developing more
gender-equitable attitudes.
These research findings were incorporated into training manuals for community
interventions on sexual and reproductive health, mental health, violence prevention,
fatherhood and caregiving, and HIV/AIDS by PROMUNDO working with three other
NGOs (ECOS in São Paulo, Brazil, PAPAI in Recife, Brazil, and Salud y Genero, in
Mexico). The manuals are used in group activities facilitated by young men that
demonstrate more gender equitable attitudes and behaviour. The activities include
discussions of male ‘honour’, condom negotiation, and role plays in which young men act
out coercive and non-coercive relationships. These help young men reflect on how
traditional and negative male behaviours affect their own lives and how they can construct
alternative ways of interacting in their intimate relationships. As peer groups strongly
influence individual attitudes, the creation of these potential alternative peer groups for
young men should strengthen the impact of the manuals.
Working towards measuring impact
So can these kinds of group activities change young men’s attitudes and behaviours? Initial
field testing of the materials in five countries with 170 young men found that many who
participated in the group activities began to question what some called ‘their machista
attitudes’. Others were able to see how violence they had experienced themselves led them
to use violence against partners.
To further test the impact of these activities combined with a condom social marketing
programme, a two-year study has been initiated with support from the Horizons Project
(Population Council). Attitudes are measured immediately following the intervention and
once six months later to see whether they have changed. The assessment is also designed to
determine how many interventions young men should participate in to achieve optimum
change.
Initial research for this two-year study, with a random sample of young men from the
community, found that self-assessed attitudes were related to their behaviours. Specifically,
young men who had more gender-equitable attitudes were less likely to use violence
and more likely to use condoms. Attitude change will therefore serve as a proxy by which
we will know if our activities are moving the young men in the right direction towards
changing their behaviour. Behaviour change is a more long-term challenge and difficult to
measure.
As men usually hold the power in society, working with men is essential as long as it does
not reinforce male dominance over women. By creating an alternative peer group that
encourages relationships based on mutual respect, PROMUNDO has worked towards
changing young men’s attitudes and behaviours. Over the next two years we will continue
to improve the effectiveness of our programme in achieving true change in men.
For more information about Instituto PROMUNDO contact:
Rua Francisco Serrador, 2/702 – Brasil, CEP 20031-060, Rio de Janeiro, RJ Brasil
Tel: 55 21 2544 – 3114, 2544 – 3115, Fax: 55 21 2220 – 3511, email:
promundo@promundo.org.br, website: www.promundo.org.br
References
Barker, G., 2001, ‘Gender Equitable Boys in a Gender Inequitable World: Reflections from
Qualitative Research and Program Development with Young Men in Rio de Janeiro,
Brazil’, Sexual and Relationship Therapy, Vol 15 No 3: 263–282
Instituto PROMUNDO, 2002, Working with Young Men, Rio de Janeiro: Instituto
PROMUNDO. A series of 5 manuals, ‘Sexuality and reproductive health’, ‘Paternity and
care giving’, ‘Reasons and emotions’, ‘From violence to peaceful co-existence’,
‘Preventing and living with HIV/AIDS’
ICW, 2002, ‘Positive Women, Voices and Choices: A project led by positive women to
explore the impact of HIV on their sexual well-being and reproductive rights and to
promote improvements in policy and practice’, London: ICW
ICW, forthcoming 2002, ‘Thai report on the Voices and Choices programme’, London:
ICW
Tarisai, 2002, ‘Tarisai's Story’, SAfAIDS "Positive Voices" Series, Victoria: The
Communication Initiative
www.comminit.com/Commentary/sld-4989.html
UNAIDS, 2002, Report on the Global HIV/AIDS Epidemic, Geneva: UNAIDS
www.unaids.org/barcelona/presskit/barcelona%20report/contents.html
-------------------------------------------------------------------------------------------------------------Also available – Cutting Edge Pack on Gender and HIV/AIDS
As well as this bulletin the pack includes:
 an Overview Report outlining the main issues, examples of good practice and
recommendations
 a Supporting Resources Collection including contact details of relevant organisations
and summaries of key texts, case studies, tools, and online resources.
In Brief is also available in French and Spanish. For copies contact BRIDGE.
BRIDGE supports gender mainstreaming efforts by bridging the gaps between theory,
policy and practice with accessible gender information. Based at the Institute of
Development Studies in the UK, BRIDGE was set up with financial assistance from the
OECD-DAC agencies. BRIDGE is grateful for the financial support of the following
agencies: The Canadian International Development Agency (CIDA), The Commonwealth
Secretariat, The Danish Ministry of Foreign Affairs, The Department for International
Development, UK (DFID), The New Zealand Ministry of Foreign Affairs and Trade, The
Norwegian Agency for Development Cooperation (NORAD), The Norwegian Ministry of
Foreign Affairs, The Swedish International Development Cooperation Agency (Sida), The
Swiss Agency for Development and Cooperation (SDC).
© Copyright: Institute of Development Studies 2002 ISSN: 1358-0612
Editor: Emma Bell
Special thanks to Alice Welbourn and Vicci Tallis for their advice, and to BRIDGE
colleagues for their editorial support.
For further information on BRIDGE please contact:
Emma Bell, BRIDGE, Institute of Development Studies, University of Sussex, Brighton
BN1 9RE, UK
Tel: +44 (0) 1273 877747 fax: +44 (0) 1273 678491
email: bridge@ids.ac.uk
www.ids.ac.uk/bridge
www.siyanda.org/
www.genie.ids.ac.uk