The theme of today’s International Women's Day is Inspiring change. One area the world desperately needs an effective reversal of fortunes is in the fight against HIV. HILARY BAINEMIGISHA looks at the world scourge that has devastated women and why there is hope for them on their international day
According to UNAIDS 2013 worldwide statistics, more women are living with HIV than men. In sub-Saharan Africa, 57% of all people living with HIV are women. In Uganda, of the approximate 1,400,000 people living with HIV, about 780,000 (56%) are women.
The risk of acquiring HIV from sex is two to three times greater for woman than for a man. But most women in Uganda have no direct control of the available HIV prevention technologies like ABC, circumcision and ARVs.
The female condom failed to gain popularity. The only technology they can use without the permission of partners is Pre-Exposure Prophylaxis (PrEP) where you take ARVs before exposure to unprotected sex. Did the world ignore the women? Do Governments concentrate on men? Does Uganda have anything special for the women?
Women are the hardest hit because of biological and behavioural factors. The vagina’s surface area offers a large exposure risk to HIV-infected seminal fluid. Sometimes the vagina small tears especially in cultures that value dry sex like the Sabiny (Sebei), Pokot and Tepeth as well as in situations of rape, sex under duress and lack of adequate preparation, which abounds in many parts of Uganda.
Rape is common especially where legal redress is too expensive or embarrassing for women. Thus HIV laden semen has more time of exposure over a wide area to infect the woman.
Sexually transmitted infections, which increase the risk of infection due to inflammation, also occur in women without being recognised.
Behavioural factors include gender inequities where many women are not free to refuse sex or insist on safer sex using condoms.
Many women are not empowered, have less access to and control of resources, employment and education often resorting to sex (formally or informally) to earn money to support themselves and their children.
Many girls have sex with older men (sugar daddies) for financial reasons. UNICEF 2013 data show that while UPE has given most girls an opportunity to study, their survival rate up to P7 is about 64%. Others drop out to get married, due to pregnancies and lack of parental assistance.
Dependence doesn’t allow women to question or challenge their male partners’ risky behaviours. Many cannot risk losing their partners by denying them sex, even if it is unsafe.
Violence (physical, sexual and emotional) affects 10 - 60% of women worldwide, according to UNAIDS statistics. Forced sex contributes to HIV transmission due to tears and lacerations.
Women who have been sexually abused are more likely to risk unsafe sex, have multiple partners, and trade sex for money or drugs. Men who are violent to their partners are also more likely to have STDs.
Dr Fiona Kouyoumdjian and colleagues carried out a study in Rakai on the intimate partner violence last year and discovered that women who have been subject to violence from a sexual partner are more likely than other women to go on to acquire HIV.
The findings were published in the May 15 issue of AIDS. The more severe, frequently or sustained the violence, the greater risks of HIV infection, the study revealed.
As a way forward, authors proposed that women attending health services for HIV testing and counselling should be asked about partner violence and referred to appropriate services.
In Uganda, some women are married to men who have sex with men, who end up bringing HIV to the home because the anus is one of the most risky transmission routes. Sex workers too are most at risk because the system doesn’t favour Government programmes aimed at helping them.
Many women also lack access to accurate, relevant information on HIV and sexuality. They may be unaware of risks because they have limited links with the outside world. Sometimes their migratory husbands frequently bring home HIV or leave them exposed to risky temptation.
The role of women
Yet women assume the major share of care-giving in the family. They produce wealth, food, tend the sick, look after orphans better and contribute greatly to family stability.
A mother’s death often begins an unfortunate process of family disintegration where children are distributed to various relatives. The widower often marries again and ignores his responsibilities.
But when AIDS claims the head of the household, widows are blamed for ‘having brought death’ into the family. A 2008 study in Rakai district revealed that many HIV widows lost their homes, inheritance, possessions, livelihoods and even their children, especially because they were deemed to be too dangerous to be ‘inherited’.
This forced many to adopt survival strategies that included sex work which, in turn, increased the spread of HIV.
At many HIV research centres, women volunteers are hard to get because of the family resistance. While men can offer themselves without consulting, women often find that they need to ask for permission from either their fathers or husbands.
Planning for women
Women’s Day should call us to mind the kinds of interventions that are focused on women. While the disparities between men and women need to be addressed, new emphasis in women-focused HIV research, funding and sponsoring of easy-to-use products are needed to allow women to assume more control over safer sex.
There is a fear that, if the recent international alarm over the homosexuality law in Uganda brings financial costs, it is the women who will face the brunt of the consequences. The latest World Bank blocking of the $144m loan was intended for maternal health, newborn care and family planning.
At least three other European countries are withholding millions in aid and the US, UK, and Canada are warning of similar action. Yet 16 women are still dying in childbirth daily in this country that depends on donors for about 20% of its budget and 90% of all HIV response.
The female condom failed to gain popularity and, according to Dr. Shaban Mugeruwa of Ministry of Health, the ministry procured only 2.4 million female condoms for all the 8.5 million sexually active women. Issues of acceptability should be investigated and the female condoms remarketed to women and their partners.
Right now, women can use PrEP which proved that taking ARVs before unprotected sex with an infected partner can prevent HIV infection by up to 73%.). Trials among discordant couples (one person HIV-positive, one negative) were done in Uganda, Kenya and Botswana.
However, the ministry has refused to include it in the strategy due to limited funds and fear of misuse. The ministry has also forced private pharmacies to remove Tenofovir, the main drug used in PrEP, from the shelves. Adocacy groups are still engaging policy makers over this development.
The good news is the Option B+, which is funded by PEPFAR, and is availing testing opportunities to pregnant women, free life-long treatment, family planning and follow up.
According to ministry of health, it has reduced the number of babies born with HIV/AIDS to 8,000 from 15,000 in 2012. The Health performance report for 2013 shows that there are health facilities that have not recorded any HIV+ babies for the last consecutive years.
The director general of health services, Dr. Jane Aceng, is now optimistic that Uganda will achieve the ambitious target of zero HIV infections or 3% of babies born with HIV by 2015.
“We have taken these services to as far as health centre II’s. We call upon all Ugandans to take advantage of these services so that the country can realized its objective,” she said.
The science world is busy searching for interventions that women can control without fear or need for permission. Trials of HIV drug-based vaginal microbicides (a gel, women can apply into the vagina, to kill off HIV in the semen) may have failed to yield an effective microbicide but more trials are going on.
According to the regional HIV prevention research expert, Dr Patrick Ndase, women should have hope in the ongoing studies in the HIV prevention technologies they can control. He gives the FACTS 001 study as an example.
This will find out if tenofovir gel (an ARV), when used before and after sex, is safe and effective at preventing HIV and human simplex virus (HSV-2), the virus that causes genital herpes. It was launched in October 2011, and will study 2,900 HIV-uninfected women.
It is a follow up of the CAPRISA 004 study which found that tenofovir gel reduces women’s risk of HIV infection by 39% when women inserted the gel into the vagina before and after sex. Women who adhered to the prescribed use at least 80% of the time, showed a 54% reduction in HIV infection.
Another study, according to Ndase is the Dapivirine microbicide ring. The study is testing if the long-acting vaginal rings prevent HIV if inserted in the vagina to stay for a month.
Researchers want to see if the ring, which slowly releases the ARV drug dapivirine over time, can provide women with monthly protection. It is works, there is hope for formats that can last up to 60 or 90 days.
Government needs to promote programmes that can empower women with economic opportunities (microfinance and micro-credit, vocational and skills training and other income generation activities), protect and promote their inheritance rights, and expand efforts to keep girls in school.
Women need a fair share of treatment, starting at the grassroots and addressing their rights, empowerment, life skills and opportunities.
Governments should institute legislation to protect women’s rights, access to resources, fair allocation of treatment, address violence and abuse against women, enforce legislation against Female Genital Mutilation and other actions to address the low status of women. The Domestic Relations Bill should be revisited and restructured to address these concerns.
HIV/AIDS programmes should monitor and evaluate impact of programmes on women, build capacity of key stakeholders to address gender inequalities, facilitate meaningful participation of women's groups and women living with HIV, and allocate resources for programme elements that address gender inequalities.
Prostitution is illegal in Uganda but, according to UNAIDS report, the sex workers, their clients and partners of clients contribute 10% of new infections in Uganda. Robert Kanwagi, the coordinator of the Breaking the Ice Project, says HIV prevalence among sex workers is as high as 47.2%, compared to the national prevalence of 7.3%.
There are NGOs trying to assist sex workers with access to HIV services but they still complain that the illegal nature of the trade makes sex workers difficult to reach with HIV-prevention services.
"They plead with us, saying, 'please doctor, is there some way we can get services and not go to the clinic? When we go to the clinics we meet our clients and that spoils our business'," said Henry Kibira, who works with the NGO, InterAid Uganda, Rakai.
Catherine Nandago of the Uganda chapter of the Alliance of Mayors and Municipal Leaders' Initiative for Community Action on AIDS at the Local Level (AMICALL) said there is no clear framework to deal with the commercial sex workers.
“When you approach them they think you are bringing police, who harass them all the time,” she said, adding that sex workers complain to her of rape by law-enforcement officers.
UNAIDS report adds that Uganda AIDS Commission lacks special and comprehensive programmes for commercial sex workers and their clients.