Transcript Women and HIV/AIDS

GENDER ISSUES IN
CLINICAL TRIALS
Jessie Mbwambo,
MUHIMBILI UNIVERSITY COLLEGE
OF HEALTH SCIENCES(MUCHS)
DAR ES SALAAM, TANZANIA
Presented at the HPTN Africa Community Regional
Working Group-Lusaka Zambia
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DISPOSITION
o
Definition of gender and “gender roles”
o
Gender roles and the AIDS epidemic
o
Focus specifically on women and the
HIV/AIDS epidemic
o

Women’s specific vulnerability to HIV infection

Contexts facilitating women’s increased
vulnerability to HIV

Women’s vulnerability in VCT, pMTCT and other
clinical trials settings
Summary and challenges in including Men
as partners
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GENDER ROLES AND
STEREOTYPES
o
Gender and gender role are widely
shared ideas and expectations


o
about men and women
about masculine and feminine
characteristics
Knowledge imparted through
socialization and through

families, friends

religious institutions

cultural institutions
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Traditionally men
o
o
o
Go to towns to work; women stay in
villages
Men have other sexual relationships
and go back to wives
In this background men expose
women to infection as:
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men expected to have poor control
women can not question men’s
infidelity
when women jealous it is shameful
provided men provides for women
should tolerate
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Traditionally women
o
o
o
Need to be sexually attractive to men
Should be adept at sex
Should pleasure men sexually
o
o
o
Should bear children for men
o
o
Wet sex
Dry sex
Other wise should be returned home to her
parents as she is “filling the husbands
toilet” and not doing what is expected of
her
Should remain virgins until they marry
versus men who are expected to take
multiple premarital partners to get
the requisite experience
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GENDER ROLES AND THE
AIDS EPIDEMIC
o
o
Interaction and mobility

Urban worse versus rural; epidemic picking up in rural
communities.

interaction between local population and migrant
workers fuelling epidemic

More young women affected
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Blame of the epidemic to young marginalized women
makes men not appropriately assess their risk as they
do not want to be associated with sex workers
Expectations of men’s behaviours

Traditional structures place women in inferior positions
thus they can not question men furthermore female
controlled methods looked upon as immoral --will make
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women have sex with other men
Gender roles and AIDS
epidemic #2
o
Women blamed for STDs and HIV
infections
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o
Men blame women for infecting them
Men can become drunk and have risky sex
Men can have natural urges makes them “real
men”
Women should remain “pure”?

hide previous relationships therefore do not
acknowledge their previous risk

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After all they can not even show they had any
sexual education as means they were
promiscuous otherwise how did they know?
women have relationships (some tribes
encourage these but one has to be discreet)
Women lack adequate education to have relevant
information and assess risk
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WHY WOMEN AND
HIV/AIDS
o
o
The AIDS epidemic is progressing and is
especially worse among women
Preventive strategies not working and
only selective towards few aspects of
epidemic

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o
o
o
Abstain
Be faithful
Condomising
Impact not felt among especially women
Epidemic on young women enormous
Women specific vulnerability to HIV due
to:
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
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social
physiological
economic
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Prevention strategies
limited?
o
Do not address women’s
 traditional gender roles and stereotypes
 roles interfere with her risk assessment
 dis-inheritance when partner dies
 failure to control their risk of infection
o
o
social status
o
economic status
o
political power
Do not asses whether methods male
or female controlled
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WOMEN SPECIFIC
VULNERABILITY
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Age differences in partnerships
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o
Women may have STDs which may go
unrecognised thus untreated
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o
o
exposure of young women to more sexually
experienced male partners
risk of traumatic first sexual experience to
an immature genital tract
need financial support
even when recognised women may have no
money to get treatment for STDs
Men encouraged to get more
experience even within permanent
partnerships
Questioning men means “you do not
trust me” and may result in violence
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Facilitation of women’s
vulnerability
o
Difficult economic situation
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migration
sex for subsistence i.e. money or favours
cannot negotiate safe sex practices
treatment including of STDs
shift of government funding from social
services and prevention
Lack of adequate knowledge on exact
mechanisms of transmission results in
creative misdiagnosis
 shopping for health care therefore deplete
meagre resources

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WOMENS VULNERABILITY IN
VCT SETTINGS
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Experiences of testing for HIV
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Experiences of disclosure of HIV sero-
status
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Association of HIV and Violence
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Experiences of testing
o
Factors influencing women’s
decision to test for HIV
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Perceptions of benefit
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Perceptions of risk
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Decision making patterns
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Fear of partners reaction
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Couple communication
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Experiences of disclosure of
HIV-1 sero-status
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Disclosure of HIV-1 sero-status
Overall
 HIV+ women
 HIV- women
 No one

o
79%
69%
83%
9.8%
Effects on disclosure of serostatus
Overall understanding and supportive
 Few have untoward negative effects

o
Easier to disclose and good
outcome indicators if had initially
communicated to primary partner
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The reality: Associations
between HIV & Violence
o
Lifetime experiences with
violence, common among all
women but significantly more
common among HIV+ women
o
The odds of physical violence among
young HIV+ women 10 times higher
than among young HIV- women
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WOMENS VULNERABILITY IN
pMTCT SETTINGS
o
Difficult choices between not fulfilling
child bearing obligations and being HIV+
with attendant consequences

…Then my in law came “what type of woman are
you?” Your peers now have three children you only
have the one. They told my husband come home to
marry. I told him you could go but remember we
have a Christian marriage. Almost immediately I had
another pregnancy and then child. Though the
dialogue continued, the tension was reduced. But
then my sister in law told my husband, your wife is
on OCP. Then he comes asks me are you on
OCP?...Woman HIV+ age 34
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Informed decisions to continue child
bearing irrespective of HIV+ serostatus
o
…I knew all these and I also knew our home situation,
if you go back to your parental home you should
explain yourself. How will they receive this news, some
will hear about this and will just isolate you, they will
not drink water in your house, others will just be
accepting but then others will say “she is a prostitute
you know”…Woman HIV+34
o
…the truth is when they saw us come back pregnant
for a second time they were unhappy. It was then
necessary for us to tell them about our home situation.
We are indeed ready to stop having children but when
you think I am already HIV infected, if this man returns
me back home to my parents what will I have done? …
Woman HIV+ age 38
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Women decide not to follow through
interventions as fear inadvertent
disclosure of HIV+ status
o
o
…nowadays all is know completely [interventions],
they know there are these medicines, which
increase longevity for those who are HIV infected.
They know they are medicines given to pregnant
women to help women not give their unborn
children infection, this information they have. They
also know if one is HIV infected they should not
breast feed their new born…
…Mama X how dare you feed your child formula at
the cost of Tshs 3000 per tin. If you have all that
money why do you not out of this pit to a better
room in a better house? Why give this child Tshs
3000. Why do you like to give this child bottled milk
all the time? Or what is the problem? This made me
do my feeding inside my room…
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Consequences of disclosure of
HIV+ sero-status
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o
o
o
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Decreased assistance from family and other
community members in accessing care and
continued support if known to be infected
Denial of services or receive less aggressive
treatment
Experience caregivers’ shaming and
judgmental attitudes
Fear may be turned away by health workers
Prefer to go to places of care where they think
they will be well treated --research sites--:


Travel further, wait longer, & incur greater costs
to seek non-stigmatizing care
Delay seeking care until health problems are
severe
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WOMENS VULNERABILITY IN
OTHER SETTINGS-MICROBICIDES
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Microbicides are biological or chemical
substances capable of killing or neutralizing
viruses present in ejaculate or cervical or
vaginal secretions
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Maybe gel, cream film or suppository (for rectal
applications)
o
Hoped that would give women power to protect
women from STDs and HIV
o
Newer developments may also give women
choice to regulate child bearing
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Aim to develop substances that would not
disrupt the outer membranes of cells thus
facilitating transmission of STD/HIV
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Good products but maybe
barriers to their use
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Still under development and the
pharmaceutical industries still not very
interested in their production due to
presumed low financial returns and/or fear
of liabilities
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Women may use products by themselves
without partner involvement but partners
maybe aware of their use during
intercourse
o
Women may not hide the use of
microbicide to their partners as they may
consider it to be risky
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Good products but….
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Use of microbicides may not be optimal in
settings where dry sex is practiced
o
Men say they will be angry if women used any
products without their consent
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Though men may prefer microbicides as
appear to be more appealing than condoms,
women’s use of microbicides without consent
of the partner (especially if has spermicidal
properties) will be viewed very suspiciously
o
Successes in microbicide trials will depend on
explanation of use to couples and not women
only

Inclusion of partners will minimize partner
conflict
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SUMMARY
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Women are more at risk to HIV-1 infection by
right of their social, physical and economic
vulnerability
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Women’s choices in prevention from HIV-1
infection are limited by their “inferior positions”
in society
o
Women’s fear of violence limits their attempt to
take preventive measures
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Women who have history of violence are more
likely
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to be positive for HIV

experience negative outcomes on disclosure of
sero-status
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Summary#2
o
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Women make informed choices as to what
interventions to take and this is guided by
their risk perception and fear of negative
outcomes
Partners of women in clinical trials need to
be involved in the research process—lest
they become angry and suspicious of
women’s intention
o
o
Calls for more comprehensive role in HIV
interventions where both voices need to be heard
Infrastructure seem to further compound failure
to include Men as Partners (MAP) in integrated
STD/HIV prevention and family planning services
Time men can visit
o Predominantly children and women domains
o
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Summary #3
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Infrastructure for inclusion of MAP#2
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Staff--both research and non research--a main barrier
in inclusion of MAP as do not have requisite skills level
to confidently work with men
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May need to revisit the socio-cultural
expectations and norms in sexuality related
issues among the genders better addressed
through working with young men e.g.
Profamilia
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Community involvement right at the offset
to allow for support for women who access
Clinical Trials
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“the community has eyes with microscopes”
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CONCLUSION
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In dealing with the HIV-1 epidemic
more comprehensive strategies
involving both the genders right from
community level through to the
research and national levels are the
mainstay to adoption and
sustainability of interventions
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FINALLY
Thank you for
listening
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