By Assoc. Prof. Dr. Mary Huang Soo Lee
Department of Nutrition and Health Sciences
Faculty of Medicine and Health Sciences
Universiti Putra Malaysia
Serdang Selangor

Introduction
In the early stages of the epidemic HIV/AIDS was perceived as a gay men’s disease. However with time it began to make its appearance in heterosexual men but because of it’s association with sex, it became apparent that the women would not be spared. In fact as we step into the new millennium, reports of women being infected in a year has outstripped their male counterparts. For example, while women made up 41% of total infections worldwide in 1997 in 2000 women made up 47% of total infection (UNAIDS various years). In fact in sub-Saharan Africa women form 55% of the HIV+ adults in 2001 and teenage girls were infected at a rate of five or six times greater than their male counterparts (UNIFEM, 2001).

In Malaysia the number of infected women has also risen. In 1990, nine women were identified as being infected with HIV. Five years later the number of infected women reported increased 17.8 times to 161 and by the end of 2000 it had tripled to almost 500. There were also concurrent increases in the number of women with AIDS as well as those who had died of AIDS. It against this scenario that the issue of gender has been examined more closely in order that more realistic programs can be implemented to arrest the epidemic.

Reasons for the increase in the number of infections in women are varied. They include biological make-up, socio-economic factors including economics, culture, gender, sexuality and the role of men. To tease out each of these factors would be impossible because they are all inter-related and in some cases one is part of another, but it would be safe to say that all of them contribute directly or indirectly to the vulnerability of women to infection. Thus as the epidemic matures we find it reflected in the increase in total number of women infected each year.

Biological vulnerability
Biologically semen contains more viral load than vaginal fluid and because in sexual intercourse semen is deposited in the vaginal and can remain in the vagina for long periods of time, the virus has ample time to infect a woman. Secondly, the mucosal surface in the vagina that is exposed to abrasions during sexual intercourse is much larger than that of the penis of a man, allowing for greater chances of entry of the virus. On the other hand younger women whose vaginas are not fully developed frequently experience tears and abrasions allowing for the entry of the virus. Thirdly, more women than men receive blood because of their reproductive functions (as in childbirth) that consequently predisposes them to the virus. It is also known that women often contract sexually transmitted diseases (STDs), especially genital ulcers that predispose them to the virus. Furthermore when infected with STDs women because of various socio-economic factors are slower of in some cases do not even have access to medical care.

Gender, Sexuality and Vulnerability
Perceived generally as part of culture, gender refers to women’s and men’s roles and responsibilities that are socially determined. Gender relates to how we are perceived and expected to think and act as women and men because of the way society is organized, not because of our biological differences (WHO, 2000). Gupta (2000) on the other hand reminds us that gender is a culture-specific construct and that there are significant differences in what women and men can or cannot do in the culture compared to another. Therefore the terms “masculinity” (associated with dominance) and “Feminity” (associated with passitivity) with its socially constructed ideals exist in all societies. However the general assumption across cultures is that distinct roles of men and women in are seen in the access to resources and decision-making authority. While men take on the productive roles, women are responsible for the reproductive and productive activities around the home.

Sexuality on the other hand is defined as the social construction of a biological drive. Gupta (2000:pg 2) reiterates that an individual’s sexuality is defined by whom one has sex with, in what ways, why and under what circumstances and with what outcomes. She goes on to say that the components of sexuality are:
1) Practices
2) Partners
3) Pleasures/pressure/pain
4) Procreation and
5) Power

To her it is power, underlying any sexual interaction, heterosexual or homosexual that determines how all the other Ps of sexuality are expressed and experienced. Power determines whose pleasure is given priority and when, how and with whom sex takes place. Wilton (1997) postulated that it is unequal power in sexual relations that leads to sexual double standards, which in turn has alarming implications for both men and women’s ability to prevent the sexual transmission of HIV/AIDS.

In the area of HIV/AIDS, such cultural constructs that predispose women to infection include the inability of women to negotiate safe sex, lack of information about her own health including about HIV/AIDS, various forms of violence against women, unavailability of services for positive women and gender expectations of men.

Inability of Women to Negotiate for Safe Sex
In most cultures of the world it is assumed that men should play the dominant role of initiating sex and that women should never be seen as aggressor but more importantly they should be ever ready to consent to having sex with their husbands. Women grow up believing that sex happens to them and men are taught that sex is something that they do. Negotiations (for whatever reason) for safe sex are not a right of women. The condoning of multiple partners relationships of men indirectly increases the vulnerability of women and more men than women visit sex workers (positive sex worker can pass on the infection to more that forty people in a year). This phenomenon is even more widespread in situations where husbands because of work are separated from their spouses for long periods at a time. On the other hand negotiation is perhaps not even an option considering the fact that women are less educated and therefore do not have access to health information which can save her life (studies have shown that some positive women had never heard of a condom until they were diagnosed as being positive). She may also be economically dependent on her husband and this makes her even less able to challenge the demands of her husband even if her life could be in danger. UNAIDS fact sheet on Gender and HIV/AIDS (2002) pointed out that research has found that up to 80% of cases where women in long-term relationships are positive had in fact acquired the virus from their husbands who had been infected through their sexual activities outside the relationship or drug use. Furthermore because HIV/AIDS is also spread through sex, negotiations for safe sex (including prevention of pregnancy) initiated by the woman herself could also be misconstrued that she herself had been unfaithful to her husband.

Lack of Access to Information About HIV/AIDS
More women than men do not have access to basic education. This lack of basic education has far fetching results. This lack of education is a disadvantage when it comes to seeking economical independence. More than that it prevents the women from being able to find any information, including those information that can save lives. Women due to lack of education are ignorant about reproductive health information including sexually transmitted diseases including HIV/AIDS. Furthermore femininity means that women’s sexuality should be invisible and that it needs to be controlled. Talking about sex by way of gathering information could be misconstrued as being “loose” in some cultures. Under such situations no wonder some women had never even hear of HIV/AIDS nor condoms until they were diagnosed with the infection.

Violence Against women
Generally violent and coerced sex increases women’s biological vulnerability to HIV because of the possibly damage to the genital area. Men who abuse their wives were also more apt to have visited sex workers (Gupta (2002). Therefore in such extreme situations (often accompanied by economic and social insecurity) it is perhaps not inconceivable that women prefer to risk unsafe sex rather than face the more immediate threats to their well-being. Zierler and Keieger (1997) in WHO (2003) pointed out that it is the outcome of complex interpersonal negotiations in which social constraints of gender inequality play a key role. It is often the poorest women who have the fewest choices, run the most frequent risks and are most likely to become infected.

War and conflict situations increase the risk and incidence of gender based violence against women. In such instances a combination of factors including a breakdown in law and order and population movements all result in higher incidence of rape of women and girls thus exposing them to infection by military forces, who generally also have higher HIV rates, and emergency personnel. As women have to cope with lost of family property and support of family members they can also be forced into survival sex (in order to generate income for food).

Young girls are particularly vulnerable. In poverty situations ignorant parents sometimes “sell” their daughters to middlemen who promise to find legitimate work for them in the cities. These young girls are often sold to pimps in cities where they do not know anybody. Sometimes young girls are themselves attracted to the promise of luxuries from boyfriends who befriend them in order to live off them. Virgins in fact fetch high prices due to traditional beliefs. In Asia older men believe that their sex life can be revived by as much as ten years by having sex with a virgin. In some parts of Africa, positive men believe that they can be cured from HIV/AIDS if they had sex with a virgin.

Positive Women
Meanwhile positive women find themselves faced with double whammies. While carrying the virus they continue to play her roles as wife and mother having to physically care for their positive husbands and children. Women also find themselves discriminated against when trying to access care and support. Some of them have to face the wroth of in-laws and the community. In resource poor countries access to medical care for secondary infections often favor men because of their breadwinner role. It is also the case when it comes to anti retroviral that are very costly in developing countries. Wives themselves often give up the luxury of purchasing such drugs to prolong their lives in favor of their working husbands. The exclusion of positive women from clinical trials has also worked in favor of men because science has only been able to study the disease on men without giving due consideration to gender difference to response to intervention.

Gender and Men
It would be unfair to talk about gender and HIV without the mention that men are equally burdened by gender roles expected of them. In some cultures it is an acceptable that men have a variety of partners for after all they should be well versed in the art of love making in order to play their role as the aggressors. This predisposes them to the infection because some resort to sex workers for their first experience. Therefore it is sometimes not unusual to find that a man is already positive at the time of marriage and if he is not aware of his status can infect his new bride.

On the other hand the gender expectations of men and their manhood also prevent the acceptance of homosexuality. This has lead to stigma and discrimination that altogether forces those men who have sex with men keep secret their tendencies and therefore increase the risk to themselves and their partners including wives they had married in order to satisfy the expectations of their family and culture.

Conclusion
There is a lot of comfort for each of us to live up to the expectations of a society or culture. In fact any effort to challenge any of these expectations will be met with resistance. However we have to recognize that the HIV/AIDS epidemic is already more that twenty years old and yet we have not seen the any obvious reversal in trend except in situations when gender issues are addressed. Unless we do this, the epidemic will continue to bring sorrow and pain to the families affected, and destroy or nullify the economic and development gains countries fight so hard to attain. Gender roles and sexuality are based on perceptions of individuals in a society. They can be changed and if the adults’ perceptions are too difficult to change surely we must begin with the young because any time loss means lives and in this case girls’, women’s, wives’, mothers’ or grandmothers’ lives.

References:
Gupta G.R. (2002) “Gender, Sexuality and HIV/AIDS: the What, the Why, and the How” paper presented at the XIIth International AIDS Conference, July 12th 2002, Durban, South Africa.

http://www.eldis.org/gender/dossiers/Genderviolence.htm

Ministry of Health (2003). “HIV Infection, AIDS Cases and AIDS Death” Ministry of Health. Kuala Lumpur

UNAIDS and WHO (2002) “AIDS epidemic update” UNAIDS, Geneva.

UNAIDS (2001) “Special Session Fact Sheet: Gender and HIV/AIDS” given out at the United Nations Special Session on HIV/AIDS Global Crisis-Global Action. 25-27 June 2001 New York.

UNIFEM (2001) “Gender and HIV/AIDS” - Article for CSW, UNIFEM.

WHO (2000) “Gender and Health: Technical Paper”, WHO, Geneva.