GENDER AND HIV/AIDS

1. Vulnerability

It is widely accepted that women and girls are disproportionately affected by HIV/AIDS. According to the UNAIDS Africa Factsheet, nearly 50% of the 38-million people living with HIV/AIDS globally are female, up from 41% in 1997. In Sub-Saharan Africa 57% of those infected with the virus are female, or approximately 17-million women and girls. For more statistics on gender and HIV/AIDS see the International Women's Health Coalition website.

Across the region, women are disproportionately affected by HIV. Women and girls make up almost 57% of adults living with HIV in sub-Saharan Africa, according to UNAIDS. Overall, three quarters of all women with HIV worldwide live in this region. On average, there are 13 women living with HIV for every 10 infected men and the gap continues to grow. In most countries, women are being infected with HIV at earlier ages than men. Young women (aged 15-24) are bearing the brunt of new infections in sub-Saharan Africa. Recent population-based studies suggest that there are on average 36 young women living with HIV, for every 10 young men.

What makes women more vulnerable to HIV infection?

1.1 Biological Vulnerability

Heterosexual women can far more easily become infected through penetrative sex than heterosexual men, and vaginal and/or anal sex is much riskier than other modes of transmission because:

• The vagina and anus have larger areas of exposed and sensitive skin
• The virus can survive for longer in the vagina and the anus than on the surface of the penis
• There is a higher viral load of HIV in semen than there is in the fluids of the vagina or anus
• The vaginal and anal walls are much more likely to be ruptured during vaginal or anal sex, especially if the sex is violent or coercive or when a woman is very young and her cervix is not yet fully developed. Cuts, scrapes and bruises allow easy access for the HI virus into the blood stream

1.2 Socio-Economic Vulnerability

Socio-economic vulnerability is based on gender inequality:

• Women may be unable to negotiate safer sex or the use of condoms in relationships. Marriage does not protect women from HIV infection. In South Africa married women are identified as the group most at risk for HIV infection and more than four-fifths of new infections in women result from sex with their husbands or primary partners (source)
• Women are often economically dependent on their husbands or partners and fear rejection and/or violence if they insist on condom use or disclose their HIV status
• Poverty undermines women's opportunities to seek the knowledge, power or time to be concerned about safer sex
• Practices such as "dry sex", "widow cleansing" and female circumcision add to women's vulnerability
• Unequal property and inheritance rights also exacerbate women's vulnerability
• Often women are expected to bear children to demonstrate their fertility and fulfill their roles as mothers
• Because women are traditionally perceived as care-givers the "burden of care" that the HIV epidemic has created more frequently falls to women than men
• Women and young girls may use sex as a commodity in exchange for goods, services, money, accommodation or even status. This transactional sex — more often than not with older men — is especially prevalent in sub-Saharan and South Africa

2. Gender-Based Violence and HIV/AIDS

Gender-based violence is also rooted in socio-economic inequality. It can take many forms, and can include physical, emotional and/or sexual abuse. While both men and women can suffer from gender-based violence, it is predominantly women and children of both sexes that fall victim to it. Gender-based violence can include rape and sexual assault, violence between "intimate" partners (including marital rape) and violence associated with war. The most pervasive form of gender-based violence is violence committed against a woman by her partner.

How can gender-based violence increase a woman's vulnerability to HIV infection?

2.1 Violence between Intimate Partners

• Violence can cause women to suffer from a host of reproductive health disorders, increasing her biological vulnerability to HIV
• Sex can be violent, coerced or take the form of marital rape, which can allow easy access for the virus (see "biological vulnerability" above )
• In such cases women are unlikely to be able to discuss sex or negotiate safer sex and/or condom use with her partner
• Gender-based violence can lead to excessive alcohol and/or drug abuse, depression, low self-esteem and post-traumatic stress which can, in turn, lead to multiple partners, unprotected sex or increased risk taking

2.2 Rape

Rape is a crime of violence and power, not of sex, as is commonly believed. According to Rape Crisis, the definition of rape used by our courts is: "Intentional, unlawful sexual intercourse with a woman or girl-child without her consent (sexual intercourse means the penetration of the vagina by the penis)."

This includes rape within marriage ("marital rape") and the rape of a woman by the man she is going out with or a friend ("date" or "acquaintance" rape).

Rape therefore means sex without consent. Our law limits the definition of rape to penetration of the vagina by the penis. When a woman or girl is forced into sex that does not include sexual intercourse, the law describes this as indecent assault. Organisations like Rape Crisis believe that any sex without consent should be viewed as rape, including:

• Rape of men and male children;
• Oral rape; and
• Rape with objects

Other terms used around sexual violence are:

• gang rape: where a woman is raped by more than one man at the same time
• statutory rape: when any male person has, or attempts to have, unlawful sexual intercourse with a girl under the age of consent (16 years of age). Sexual intercourse with a child under the age of 12, whether or not she consents, is regarded as rape by our common law and is a punishable offence

Rape statistics in South Africa is a very complex issue. In 1997, 52,160 rape cases were reported to the South African Police Service (source). That year, the SAPS estimated that 1 in 36 rape cases are reported, meaning the total number of actual rapes exceeded 1.8-million that year. This figure has been disputed.

According to Rape Crisis:

• "South Africa has the highest per capita rate of reported rape in the world (115.6 for every 100,000 of the population in 1998)
• For various reasons, rape is both a very under-reported and sometimes an inappropriately reported crime
• In attempting to asses the real incidence, we use a figure of 1 in 20 as a conservative estimate
• In the end, the issue of whether the real figures are 20 times higher or 35 times higher than the reported figures is irrelevant. Our figures are high — too high — and that is the real issue"

South African Police (SAPS) statistics on reported rapes. (Under the current definition of rape)
Period	Reported rapes
1994/1995	44 751
1995/1996	49 813
1996/1997	51 435
1997/1998	51 959
1998/1999	49 679
1999/2000	52 891
2000/2001	52 872
2001/2002	54 293
2002/2003	52 450
2003/2004	52 733
Percentage increase from 1994 – 2004: 17.8%. Source: Rape Crisis, 2005

How can rape increase a woman's vulnerability to HIV infection?

• The violent nature of rape leads to cuts, scrapes and bruises which allows easy access for the HI virus
• It is highly unlikely that a woman would be able to negotiate safer sex in situations of rape or coerced (forced) sex
• In a rape situation, is quite possible that there would be a presence of a sexually transmitted infection (STI). STIs increase the possibility of HIV infection by 90%, because lesions and sores also allow easy access for the virus into the bloodstream
• Rape is under- and inappropriately reported in South Africa: often incidences of ongoing marital rape, "date" rape and other forms of rape can inhibit a women from seeking health care and treatment

Post-exposure prophylaxis is available in the public health sector for rape survivors. (see Prevention Factsheet: Post-Exposure Prophylaxis)

3. Sexuality and Desire

While it cannot be denied that women are disproportionately affected by HIV/AIDS for the reasons outlined above, a "discourse of vulnerability" can advance dangerous and disempowering gender stereotypes about women and HIV/AIDS.

Jonathan Berger warns that using women's vulnerability as the sole consideration for what drives the epidemic is "telling part of the story as if it were the whole story" (2004:p46). Finding a single theory to explain a complex phenomenon tends to overplay vulnerability — this kind of analysis must be complemented with a focus on the ways in which sexuality and desire also impact on people's behaviour and practices. We must recognise that:

• Sexuality is fluid, changes and doesn't always fit into the strict binaries of heterosexual and homosexual practices
• There is great variation in our sexual practices — women too enjoy sex, can also be unfaithful to their partners and also can engage in various sexual practices that are normatively seen as "deviant" or "dirty"

In order to have a full understanding of the epidemic we should acknowledge that sex, sexuality and desire drive the epidemic as well as issues of vulnerability. There is no doubt that the HIV pandemic is one driven by poverty and gender inequality, yet is it also "an epidemic of desire" (Berer in Berger: p48).

4. The Role of Men

Men are not as biologically susceptible to HIV/AIDS as women, but they are still at risk.

Yet men, too, are constrained by gender constructions that determine what is seen as appropriate male behaviour. Cultural and societal expectations and norms create an environment where risk is acceptable, even "encouraged" for real men. Prevailing norms of "masculinity" include:

• Expectations that men are more informed and experienced in sexual matters, which can prevent them from seeking information or admitting lack of knowledge
• Socialisation into being self-reliant and not seeking help in times of need — seemingly this creates a sense of invulnerability, yet in fact renders men more vulnerable to risky behaviour
• Thus, men are less likely to seek health care than women and are more likely to engage in behaviour that puts their health at risk, such as alcohol abuse
• Migrant labour disrupts marital and family ties and contributes to unsafe sexual behaviour (for an interesting study on masculinity on the mines in South Africa see Campbell , C. (2004). Migrancy, Masculine Identities and AIDS: The Psychosocial Context of HIV Transmission on the South African Gold Mines. In HIV/AIDS in Africa: Beyond Epidemiology
• Socially "acceptable" and rewarded behaviour: flesh-on-flesh sex, cross-generational partners and multiple partners, for example

Dominant discourse on men's role and responsibility is often focused on "blame". Men are seen as fuelling the epidemic by engaging in unsafe sex with multiple partners and other irresponsible and risky behaviour, resistance to condom use and alcohol abuse.

However, "men" are not a homogenous, monolithic whole and should not be addressed in a way which overlooks the differences between men. The existence of dominant and subordinate masculinities, or of alternative or oppositional ways of being a man, is often unacknowledged. Studies show that some men are attempting to transform their attitudes and behaviour (see Garson, 2005). In addition, gender roles and expectations are not entirely created by men but instead are created by both men and women. The "tone of blame" has little value in building the kinds of partnerships which are needed to address gender relations. Purnima Mane and Peter Aggleton (2001) argue that efforts that encourage and support positive behaviours and responses and which challenge both male and female gender stereotypes should be encouraged. These are not to replace programmes that empower women and girls, but should work alongside and with these efforts. Programmes do exist: the Men as Partners initiative and couples counselling at Chris Hani Baragwanath hospital in Soweto, Johannesburg, are just two examples.

Mane and Aggleton point to two ways we can begin to understand and address notions of masculinity: changing the ways boys are raised and working with younger and older men on HIV/AIDS prevention and care.