SPEAK OUT

HIV
South African WOMEN DON'T BELIEVE THEY HAVE THE RIGHT TO SAY "no"
AND PROTECT THEMSELVES FROM HIV INFECTION

J Am Med Womens Assoc 2001 Fall;56(4):193-6

Barriers to preventing human immunodeficiency virus in women: experiences from KwaZulu-Natal, South Africa.

Abdool Q, Karim.

Department of Community Health, Nelson R. Mandela School of Medicine at the University of Natal in South Africa.

OBJECTIVE: to determine barriers to the adoption of safer sex practices in women in KwaZulu-Natal, South Africa. METHODS: This cross-sectional survey was conducted in a peri-urban and a rural community in 1991 to 1993. A structured, pretested questionnaire was administered to consenting women age 15 to 44 years who had been drawn randomly from a 10% systematic sample of households. The questionnaire included the following items: demographic characteristics, sexual relationships, knowledge of human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS), perception of risk, knowledge of and skills with respect to safer sex practices, and perceptions of rights to safer sex practices. RESULTS: A total of 219 interviews were conducted. Most respondents had an average of 8 years of schooling and were seeking employment. The majority of the respondents were sexually active (88.1%) and had extensive knowledge of modes of transmission and methods of preventing HIV/AIDS. Although most respondents underestimated their risk of HIV infection, a key reason for women not acting on their knowledge and perception of risk was that many did not believe they had a right to refuse sex with their partners (48.8%) or insist on condom use (46.1%). Most women thought their partners had a right to multiple partners (62.2%). Only 35.2% of respondents had the skills to object to their partners' having multiple partners, and 82.4% lacked the skills to use condoms. CONCLUSION: Women in these communities are at high risk of HIV infection. Their perceived lack of a right to safer sex, lack of skills to adopt safer sex practices, financial dependence on their sex partners, and the threat of violence influenced their ability to reduce their risk of HIV infection.

-------------------------------------------------------------------------------- Public Health and Prevention

Laurie Garrett,[7] medical and science writer at Newsday in New York, New York, and the Pulitzer prize-winning author of The Coming Plague and Betrayal of Trust, provided the opening keynote address for the meeting. She described the potential threat of shifting resources from HIV/AIDS efforts to the newly actualized threats of bioterrorism. She pointed out that the 2002-2003 congressional allocation for the Global Fund for AIDS, Tuberculosis and Malaria has been slashed from $1 billion to $190 million, noting that mandates for expenditures on vaginal microbicides and vaccines were rolled into requirements to address other infectious diseases as well as issues of HIV/AIDS treatment.

Garrett also described reports of increases in unsafe sexual practices and noted that an estimated 40% of new primary HIV infections are with drug-resistant virus, 10% being resistant to multiple drugs. She discussed a recent report of the Harvard Center for Risk Analysis describing delays in Medicaid payment for HIV treatment, leading to increased annual costs of treatment. She stated that there were an estimated 5.3 million new cases of HIV infection worldwide last year, and noted that the CDC estimates of 40,000 new infections per year in this country have been the same since 1986, suggesting either false numbers or a massive failure of prevention efforts. The numbers of infections and deaths have eclipsed those of the Great Influenza Pandemic of 1918, and are approaching that of the Black Plague of the 14th century. For countries such as South Africa, where 55% of the adult population is HIV-infected, or Zimbabwe and Botswana, where an estimated 80% of adults are infected, the comparison is apt.

Garrett described the rapid growth of HIV infection in China, India, and South Asia, which is influenced by particular cultural and religious practices. HIV infection in the states of the former Soviet Union is driven by massive corruption supporting the narcotic and sex trades, as well as poor infection control practices. The Ukraine particularly demonstrates the relationship between corruption and HIV. Syphilis rates in 16-year-old girls in the Ukraine are 1550-2000 per 100,000, largely the result of teenage prostitution.[8] Coepidemics of hepatitis C, tuberculosis, and especially multidrug-resistant tuberculosis, are a background to HIV, contributing to the rising disease and death rate. In the global village, the increase of communicable disease threatens not only the region but also the world.

The dark picture that Garrett's talk paints gives direction for future prevention efforts. She noted that making sterile syringes available in the Ukraine will help to prevent what is currently an injection drug use-driven epidemic from becoming a sex-driven epidemic there. Efforts to reform injection practices of vaccine programs as well as to improve the blood supply system will also be of benefit. In Africa, social and political reforms that educate and empower girls and women will help to reduce transmission. As treatment efforts improve, studies linking availability of treatment with prevention efforts may help to stave off the complacency around prevention and false assurances of treatment seen in the United States and Western Europe. In closing, she reminded us of the successes of injection drug users in New York City, decreasing HIV seroprevalence from 60% in 1985 to about 1% today through the combined efforts of needle and syringe exchange, counseling, methadone treatment, and social support.[7]