Gender inequality as HIV social driver

hiv sadik

According to the UNAIDS (UN programme on HIV/AIDS) 2010 report 22.5 out of around 33.3 million people globally living with HIV live in sub-Saharan Africa, where young women between 15 and 24 years old are 8 times more likely than men to be HIV positive. 80% of the women living with HIV worldwide live in the region.

Gender inequality remains one of the main HIV social drivers. According to the UNAIDS report the HIV epidemics and sex and reproductive health are intertwined. HIV related causes contribute to at least 20% of maternal deaths and countries with high HIV rates also have high teenage pregnancy and unsafe abortion rates while very few countries involve men in reproductive health programmes. Violence and HIV rates are also often associated.

Eastern Europe and Central Asia are the only regions where the number of people living with HIV has almost tripled since 2000. The proportion of women living with HIV is also growing. Female sex workers, people who inject drugs and men who have sex with men, whom remain often underserved in HIV prevention, treatment, care and support, account for most of the new infections both in these regions and worldwide.

Nafis Sadik is Special Adviser to the UN Secretary General and UN Special Envoy for HIV/AIDS in Asia and the Pacific. As former head of the United Nations Population Fund (UNFPA) she became the first woman, in the history of the United Nations, to lead one of its major voluntarily funded programmes. She is an expert on international maternal and child health, reproductive and sexual health, including family planning, on population and development and gender and development. She was born in Pakistan and lives in the United States.

In its action items on gender equality the UNAIDS 2010 report calls for the need of countries to address the needs of men who have sex with men through prevention interventions that go beyond health service provisions. What could these be and where are there positive examples that go this way?

We need to make men more responsible and educate them in the importance of women and in the need to keep them safe.

The issue has to be discussed also at policy level because even if now many governments have special programmes for men who have sex with men they haven’t changed the laws in their countries (for instance 79 countries criminalize same sex relations between consenting adults) nor they address the problems of the laws enforcement agency.

The effort is now for governments to have public advocacy programmes at national, regional and local level also by talking to religious and tribe leaders and to strengthen attention and prevention of HIV and AIDS.

HIV is socially not accepted and so are MSM (a medical and social research designation for men who have sex with men). Many of these men are also married, so they go to their male partners, get infected and then bring the infection back to their female partners. In a sense, there is a need not only to prevent HIV among them but also to protect the general population.

One of the arguments we are also using is that if you want to protect all the population and stop the spread of the epidemic you need to protect MSM, sex workers, drug users and all the most vulnerable groups.

In India we are working with governments in the change of laws that deny MSM their right to health and information. In other countries, such as Malaysia, while the laws haven’t changed, more attention is being given to the education of police officers and the courts, for instance, on the importance of promoting MSM human rights to health, information and also to protect the general population. I think we are making slow progress and the laws are changing but that is only the beginning. Our ultimate goal is to get a social change and make people understand that everyone has the right to have her or his own sexual orientation.

Since violence against women and HIV rates are often associated the UNAIDS also suggests that national HIV responses must include specific interventions to address violence. Where are there positive examples of interventions taken in this sense?

I have just been to India to see the sex workers programmes in Sonagachi (the largest red-light district in Kolkata and one of the largest in Asia). Many of them left abusive husbands and family members. They have grouped together and are now doing community educational work. I was most impressed by the fact that their children were also joining the fight against violence.

Nevertheless, to get a social change we need more actors participating in the fight, because all the time programmes are addressed to women but they are often the victims who cannot say anything. Besides, all the ministers for women’s affairs, gender equality or family planning are women but these issues need also to be addressed to men and need more of them speaking out openly and aggressively on the issue. The religious leaders are a particular issue, less easy to change, but we also need them to speak out and in some places, such as Bangladesh, this is already happening.

We are now trying to identify specific male champions in each region and let’s hope that might also help to spread the fact that gender-based violence and discrimination should be socially unacceptable and unaccepted.

Both fighting aids and achieving gender equality were objectives of the Millennium Development Goals (MDG)…

Gender equality is one the goals that was falling behind and now all the gender programmes are trying to give it all the attention, and so are governments. China for example for the last three years has been having a conference on the MDG concerning gender equality and the new UN women is developing a global strategy on this including HIV and AIDS prevention and treatment programmes.

Why are precisely central Asia and Eastern Europe the regions where HIV incidence has been increasing in the last years?

They were all on the Russian, communist and centralised model. In most of the socialist countries women’s rights were very much protected but it seems that’s not so now. People’s participation is now starting to develop but very slowly and so are civil society organizations. There are very few women in leadership positions, so women’s voices are very mute and also there we need to get male voices added to theirs.

The UNAIDS also says that Increasing evidence demonstrates that investments in the HIV response can lead to clear reductions in discrimination and stigma. One relevant example in this sense?

Just look at Cambodia or India, where sex workers rights are now being respected as a result of the HIV AIDS prevention programmes. When treatment and access started, it was only men who had access to them. Now there is a huge emphasis in avoiding mother-to-child transmission (a recent World Health Organization-led study shows how triple antiretroviral drugs during pregnancy and breastfeeding can significantly reduce mother-to-child transmission of HIV) and we expect that by 2015 this will be eliminated and that those women will also have priority in the access to treatment.

But still worldwide the great majority of pregnant women with HIV (85%) do not receive antiretroviral therapy for their own health…

This is another thing we are trying to change now through our new prevention strategy. I hope those numbers will change dramatically.

But why don’t they already receive it?

Most of the times the women themselves do not want to be identified because they fear stigma and discrimination. In Africa, many women do not even want the prevention for the child because if they do, everyone in the village would know they are HIV positive. If women were not oppressed they would not be scared, but they are. Women face discrimination in society in any case, when they have HIV they are more discriminated against, so are homosexuals and transgender.

Do you have children?

I have three children of my own and two adopted ones and 10 grandchildren.

Talking about population it is a common belief that there are too many people in the world. How much truth is there in this and what should regulate the limit?

I do think numbers matter, because if you have larger numbers you also have to provide for those larger numbers and get the resources. The solution needs to be connected to whether the women anywhere in the world want to have the children they have. In the world today there are 210 million women who get pregnant with a pregnancy that they didn’t want and that was either forced or unintended. If you want to reduce maternal mortality, protect the rights of women and their health you need to address this issue, which will also result in getting to a stable population level faster in most countries. The general premise of the International Conference on Population and Development (El Cairo, 1994) was that if you turn to individual rights, especially women’s rights, other problems will take care of themselves. So, the answer to numbers is not a population control policy from the top but to meet the needs of individuals and to have individual rights policy towards reproductive health.

By the time of the conference we did a lot of estimations and asked women in many countries how many children they wanted Overall they wanted fewer children than they had and said they had them because their surrounding expected them to but then the access to services was not easy and they often had to hide the fact that they accessed them.

If for the last 20 years the needs of women had been met, the number of people would be much less and governments wouldn’t need to have policies but just to make services available and to make it possible for women to really make their own decisions, to have more rights over their own bodies and to have a voice both in their own affairs and in the political system. Nevertheless, that is a much more difficult task to do than it is to say.

I really hope your article will make a difference in people’s understanding also because, you know, international donors give a lot of money for gender issues (the majority of funds for HIV prevention also comes from them) but then they move on to other issues, so the focus and attention keeps changing all the time. This is an issues that affects HIV, women’s health, global diseases, everything, and it affects both economic and social progress in society. Women deserve their rights because they are individuals, they don’t have to contribute to economy, they should just have them. Isn’t it?

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