DRUGS OF NO CHOICE

Today, antiretroviral (ARV) drugs are prolonging the lives of people with HIV. But access to those drugs depends on how much money a person and where she lives.
In the US, for example, the death rate for AIDS dropped by 40 percent over the last decade as a result of ARV medicines. And even though the price is now down to about $1 a day in many regions, that’s still out of reach in many poorer nations where most people earn only about $400 a year.

When she attends meetings, Antigone Hodgins of the International Community of Women Living with HIV/AIDS says it’s difficult to see other women sitting around the table from developing countries who don’t have medicines. “Some of these women are really sick. I went to a meeting in South Africa, and shortly after, one of the participants died.”

Brazil and Argentina have made progress with prevention programs and better access to drugs, but the majority of developing nations haven’t. In 2003, the World Health Organization called the failure to deliver ARV medicines to millions of people in need a “global health emergency” and said that “urgent action is needed.” To that end, the organization teamed with UNAIDS to meet what they termed an “ambitious target” of providing ARV drugs to three million people by the end of 2005, or the “3by5” target. However, while the undertaking provided drugs to many who desperately needed them, some organizations deemed it a failure, as only about one in every six HIV-infected people received the drugs. To date, approximately five million people are still without ARV drugs, according to the International Community.            
Another option for women are microbicides. These gels and ointments are applied topically, allowing women to prevent HIV and other sexually transmitted diseases without asking their partner to wear a condom. But further trials are needed, all costing money. And the largest demands for the products are from poor women in Africa and Asia, which is not a targeted market for pharmaceutical companies. Thus far, nonprofits and government spending have financed research and early testing.

DECLARATION GOALS NOT BEING MET

When the Declaration of Commitment at the UN Special Session of HIV/AIDS included issues of gender inequality and women’s lack of empowerment, women worldwide were hopeful. In June 2001, 189 countries signed that declaration, focusing on action steps and providing a range of specific and time-bound goals and targets.

But after six years, those goals have still not been met. “We have come a long way, but not far enough,” said UN Secretary-General Kofi Annan. Outlining a litany of shortcomings, he noted that a third of all countries still had no policies to ensure that women had access to prevention and care and fully two-thirds of all countries failed to provide legal protection against discrimination for groups most vulnerable to HIV.

The Declaration is a wonderful document, says Stephanie Urdang, UNIFEM’s advisor on Gender and HIV/AIDS, but the first step is to look at policies. “If policies aren’t in place, how can programs be in place?” she asks.

“Governments have policies they’ve signed, which acknowledge the role of gender and women’s lack of empowerment, but when they go home, political will is really, really critical.”
           
Dr. Geeta Rao Gupta, president of the International Center for Research on Women in Washington, DC, agrees that what’s needed is an “infusion of resources as well as leadership and political will” to get back on track with goals.

It is estimated that supporting and funding prevention strategies in 125 low- and middle-income countries would avert about 28 million new HIV infections between 2005 and 2015, and would save the U.S. $24 billion in associated treatment costs, according to the UN 2006 Report on the Global AIDS Epidemic. The report also acknowledges, however, that effective prevention strategies for women should contain several components, including easy access to HIV services, policy reforms to reduce women’s vulnerability to HIV, and helping to change the gender norms and attitudes of men and boys. As mentioned earlier, gender equality continues to be a major deterrent to women getting the resources they need to help fight HIV.

In 2001, U.N. Secretary-General Kofi Annan created the Global Fund to Fight AIDS, Tuberculosis and Malaria, with a goal of $10 billion annually needed to fight these diseases. The fund has already contributed $8.4 billion to 136 countries throughout the world.
           
In addition, the (U.S.) President’s Emergency Plan for AIDS Relief commits $15 billion from 2003-2008 for HIV/AIDS prevention, treatment and care in 14 countries in sub-Saharan Africa and the Caribbean. While this plan contributes $1 billion as a multi-year pledge to the Global Fund, critics contend that monies and programs need to focus more specifically on empowering women to halt the spread of the epidemic.

TAKING ACTION

• Women typically have less access to educational and preventive resources in developing and Third World countries. Urge national governments to provide effective prevention programs targeted at young women, with regard to the transmission of HIV through sexual contact and intravenous drug use.
  
  
• In conjunction with World AIDS Day (December 1), sponsor annual HIV/AIDS awareness event encouraging AIDS prevention and testing, and partnering with local clinics, health care and community health centers to offer low-cost AIDS testing and education programs.
   
  
• In 2006, the UN conducted a review of the past five years, and acknowledged that many of the targets contained in the Declaration of Commitment have not been met. The document called on governmental organizations across the world to continue the fight against this “unprecedented human catastrophe.”  The UN will meet again in 2008 and 2011 to review the Declaration. Write to your senator and ask them to support the Declaration of Commitment.
  
  
• As the AIDS epidemic continues to affect women at increasing rates, it is important that research and medications are created that keep the specific health needs of women in mind. More women are now taking part in AIDS clinical trials in the U.S. and studies are looking at the signs of HIV/AIDS in women and how HIV/AIDS is passed to babies. Doctors are also testing creams and gels that women can use to protect themselves against HIV/AIDS. Encourage pharmaceutical companies and research centers through e-mail and letter-writing campaigns to continue to research the specific impact of AIDS on women.

The Feminization of AIDS
As the epidemic shifts gender roles, more women are dying today than ever before
By Marielena Zuniga

She is from Mexico. Poverty forces her into domestic labor at age 13. One night she is raped by her employer’s drug-addicted son. But she is blamed for the attack and fired. Her family will not take her back and she is forced into commercial sex work. Today, at 14, she is HIV-positive.

She is from India. She is 18 years old when she is raped by an older man. Forced to marry him, she lives with his family as is the custom in her country. She soon discovers he is HIV-positive and that he has infected her. But her husband’s family blames her, not him. He dies. They throw her out of the house. With no money, job or education, she is forced to survive in any way she can.

She is from Ethiopia. Drought and famine hit her rural village and her husband leaves to find work in one of the larger cities. He is not monogamous. During his visits home, he brings HIV with him. He dies. A widow after one year of marriage, she is in denial that she might be infected. She delays treatment. She, too, dies.

These women, and countless others like them, are the face of AIDS in today’s world. Far from the “gay white men’s disease of the ‘80s,” HIV/AIDS is infecting and affecting women more than ever before. As the epidemic enters its third decade, though important progress has been made, the numbers of people living with AIDS has risen to 40 million worldwide. Now, 62 percent of young people ages 15-25 living with AIDS are female, according to the International Women’s Health Coalition (IWHC), a New York City-based group promoting the health and rights of girls and women worldwide <www.iwhc.org>. Specifically, in sub-Saharan Africa, women ages 15-24 constitute 77 percent of all new HIV infections.

Of the estimated 2.8 million people who died of AIDS in 2005, 1.3 million were women, according to a United Nations and World Health Organization 2006 Report on the Global AIDS Epidemic.

What’s fueling the “feminization of AIDS?” Gender inequality, says experts. A host of cultural, legal and economic factors limit the control women have over their lives, their sexual relationships and the power to protect themselves from infection. Sadly, the majority of women are being infected by their husbands, making marriage one of the most dangerous places for women today.
In Brazil, for example, even though the country has been credited with developing a successful and internationally known program to fight HIV/AIDS, it still leaves much to be desired for women. There, the epidemic is rising nine times faster for women than men.

Because relationships between men and women are based on power, women have a hard time saying ‘no’ to unwanted or unsafe sex, says Stephanie Urdang, United Nations Development Fund for Women (UNIFEM) advisor on Gender and HIV/AIDS. (www.unifem.org) “From teens in America to teens in Africa, to women throughout different age groups … even when women know their partners have had sex with others and are in a high-risk category, women can’t assert or protect themselves.”

A married woman in Zaire told researchers, “If you have AIDS, society rejects you. When you die you will not be missed, because you have died of a shameful disease. They will say that this woman has strayed. They will not see that maybe she has remained faithful while her husband has strayed.”

AIDS, gender and poverty 
While many factors make women vulnerable to HIV/AIDS, poverty is a driving engine. And the mix of poverty, gender and AIDS is lethal. In many cultures women depend on their husbands for economic security or live with their husbands’ families. When women do not have independent income, they are often forced to stay in abusive relationships.

“If the people who are the supporting actors in your life—the labor resources, your social world—are all tied into your husband’s family, you don’t have that kind of option to leave,” says Corinne Whitaker, senior program officer for the Africa program of the IWHC.

Without bargaining power, women can’t talk about whether they want sex, when they want sex or how they want to have sex, says Antigone Hodgins, North American representative of the International Community of Women Living With HIV/AIDS. (www.icw.org)  “All the power is with the husband, and if they [the women] bring up a condom, they’re at risk for violence. They get blamed,” she says.
Blame, violence and discrimination – all are the cost for speaking up. A much-publicized story was that of Gugu Diamini, a young woman from Durban, South Africa, who was murdered by her neighbors after publicly disclosing her HIV status. And in Kenya, a group of HIV-positive women admitted hiding the news from their partners because they were afraid of being beaten or abandoned.

If a woman is abandoned, or is denied the right to own or inherit land or property, she spirals into destitution. This has enormous consequences says Dr. Geeta Rao Gupta, president of the International Center for Research on Women (ICRW), a Washington, DC-based nonprofit working to improve the lives of women in poverty and advance their equality and human rights. (www.icrw.org). “If a woman is left with no access to economic resources, employment or income, she is more likely to sell sex for money,” Dr. Rao Gupta says.

Sex work is often the only option for a woman who must feed her children. “Toward the end of the month, if there is no money to buy food [for her family], a woman will be involved in what is called ‘transactional sex work’ or ‘survival sex work,’” says Urdang of UNIFEM.

At a World AIDS briefing, a woman from Manila, the Philippines, summed up the dilemma of “survival sex” faced by so many women like herself. “AIDS might make me sick one day,” she said. “But if I don’t work my family would not eat and we would all be sick and die anyway.”

Young girls at higher risk
In addition to poverty, women also must fight cultural customs that put them at risk. In many villages in Africa, some men are known as “cleansers,” paid to have sexual relations with women after their husbands have died to dispel what villagers believe to be evil spirits.

Says Whitaker, “The issues around sex cleansing are decisions not being made by a woman herself. It’s not a path she would choose … and part of the reason with HIV/AIDS we have to address the broader issues of women’s rights and status.”

In other parts of Africa, men believe that if they have sexual relations with a virgin they will be cured of AIDS. So infected men actively seek out young girls who are especially at risk. Today, the majority of new infections are among adolescent women, who have the least power, fewer rights and who often “do not have access to information and services to protect themselves,” says Whitaker.
Girls are vulnerable for a variety of reasons. For one, older men who have had multiple partners prefer sex with teenage girls, who are especially vulnerable because the walls of their vagina are more prone to tearing (which provides an entry point for the virus). Young girls also exchange sex to get through school and because they lack assertiveness skills, they don’t negotiate safe sex.
In South Asia, as in many other patriarchal societies, when girls marry they have little knowledge of sexuality, HIV or condoms. Their first task is to produce a son, so even if they had access to condoms, using them would be impossible. “Many are physically immature and malnourished,” according to the IWHC, and “too often, especially if a husband drinks or is a violent person, sex is forced and injures the girl’s delicate tissues, making HIV even easier to transmit.”            

In addition, HIV/AIDS heavily impacts girls when they must drop out of school to help their infected mothers or care for another ailing family member. Urdang of UNIFEM says, “If a girl is taken out of school to support the work in the home, then she loses the opportunity for learning how HIV is transmitted and getting the courage to say ‘no.’ And, she loses the opportunity for more sound economic employment in the future.”

Solutions amid suffering
As women and their children continue to die in record numbers, the social and economic consequences are decimating communities and continents. Women are the backbone of agricultural countries, says Whitaker, and are also the generational links and information sharers.  Women also bear the added burden of caring for those suffering with AIDS – spouses, siblings, children – whether or not they have the disease themselves.

“They are responsible for keeping their children safe,” she says, “and when they are ill and unable to do that, it has a significant impact on the outcomes of their children.”
Facing a bleak future, AIDS orphans are likely to be malnourished and unschooled and at greater risk themselves for HIV-infection. Today, 14 million children have lost parents to AIDS.

In the midst of such overwhelming suffering, what is being done to help women? Some say a critical turning point was the U.N. General Assembly Special Session (UNGASS) on AIDS in June 2001 when 189 countries signed a Declaration of Commitment acknowledging that “gender equality and the empowerment of women are fundamental elements in the reduction of the vulnerability of women and girls to HIV/AIDS.” (See sidebar.)

Currently, governments, international agencies, NGOS, religious organizations and women themselves are taking action. One of the strongest efforts is toward education because “strong data” shows that secondary education for girls is negatively correlated with HIV. “The more education girls have, the less likely they are to be infected,” says Dr. Rao Gupta.

The education component is part of seven actions that ICRW calls “essential to empowering women.” These include, among others, increasing women’s access to economic assets; promoting zero tolerance for violence against women; intensifying the development and distribution of women-controlled prevention options; and supporting the needs of women caregivers.

Of the latter, Dr. Rao Gupta says, “Women are the caregivers, the nurses, the ones at home on the frontlines of providing support and care for those who are ill and infected with this disease. But they have absolutely no support. They don’t have full information of the risks they face, no gloves, no syringes, no clean water, not to mention no relief from the burden of care … what are the government-led systems doing that could help them?”

Whitaker of the IWHC says her organization works with “women to help them realize they have options in their lives.” They teach women that they have the right to make decisions and that they have “international agreements and movements within their own countries to support them in that … and to give them skills to negotiate encounters or get the resources they need,” she says.

Part of the IWHC’s efforts are through the Girls Power Initiative in Nigeria, which provides girls with factual information about sex, risk and use of clinical services, and teaches them healthy body image and self-esteem.

Finally, women themselves are organizing. The International Community of Women Living With HIV/AIDS was started at an international AIDS conference by a group of women who realized they were “outside of any dialogues happening,” says Hodgins. “There were very few voices of women at conferences,” she says.

Today, the group serves in an advocacy role at policy-making tables and government meetings, pushing the implemention of AIDS strategies that help women. “It’s important to remember that women have the solutions,” she explains. “We’re not just victims. I know women who are very brave and faced the stigma in their communities and in their lives and made a difference.”

Action needed now
Most advocacy groups agree: Until a commitment is made to eradicate gender inequalities, governments and nations cannot move forward against the epidemic. Asia is of paramount concern to leaders. Dr. Peter Piot, executive director of UNAID, said, “The question is no longer whether Asia will have a major epidemic, but rather how massive it will be.”

And yet, when Dr. Rao Gupta of the ICRW attended a recent UN General Assembly meeting marking the progress of positive actions in various countries, she noticed the decided absence of Asian leaders.

“African leaders pointed it out,” she recalls, “and actually said to their peers. ‘Pay attention. We have paid a huge price for responding too late.’ What’s frightening is the amount of work that needs to be done with countries like India, to openly talk about this as a gender issue and getting mobilized into strong action.”