Markkula Center of Applied Ethics

Awareness Is Not Enough:
Gender in the HIV/AIDS Pandemic in Africa

By Charlotte Vallaeys

Charlotte Vallaeys was awarded the Markkula Prize in 2002 for this paper and the background research and service project that led to it. Charlotte graduated from SCU with majors in Religious Studies, German and Psychology, and a minor in Gender Studies. Here is her description of how her project originated and developed:

"In the summer of 2001, I went to Africa and lived in a town in eastern Ghana for three weeks with a non-profit organization called Cross-Cultural Solutions. I was there to learn more about traditional healers and traditional religion, and I spent my mornings interviewing and observing priests and healers. While I was there, however, I became very interested in HIV/AIDS. A friend and I made a survey to get a sense of how much people know about the virus, where they get their information, and how much their behavior has changed as a result of that information. We managed to get 244 surveys completed, and were surprised to find that while people were very knowledgeable about the disease and how it is transmitted, that knowledge did not necessarily translate into behavioral changes. Later at SCU, I took a Health Psychology class, and learned that few informational campaigns alone are successful at changing people's behavior. My paper tries to explore some of the reasons why, by looking at the deeper ideological and economic factors that prevent or discourage people in Africa from appropriately changing their behavior to protect themselves from HIV."


Introduction

AIDS is now the leading cause of death in Africa.1 Twenty-five million people in Sub-Saharan Africa are HIV-positive, with adult infection rates ranging from 1.35% in Niger to 35.8% in Botswana.2 Already, 22 million people, of whom 18 million were Africans, have died from the disease. Twelve million children have lost one or both parents to AIDS, and a half a million babies are born HIV-positive every year in Africa. In Zimbabwe, life expectancy has dropped by 22.2 years to 39 years, and a young person between the ages of 15 and 24 is infected every five minutes.3 Furthermore, only 25,000 Africans currently have access to anti-retroviral care, meaning that only one out of every 10,000 HIV-positive Africans receives the appropriate medical care.4

The virus has devastated the African continent, and will continue to do so unless serious awareness campaigns, ideological changes, economic stability and educational opportunities for all are securely implemented. Kofi Annan, the Secretary-General of the United Nations, commented that large-scale awareness campaigns are needed to prevent the further spread of the pandemic.5 While educating people about the ways in which the virus is transmitted is absolutely necessary and invaluable, it is by no means adequate. Although people need to know how to protect themselves, they also need a favorable cultural and economic environment that allows them to make these necessary changes in behavior. For men, this means that the cultural concept of masculinity needs to correspond with the messages of the awareness campaigns. Women, on the other hand, need the economic and social independence necessary to have control over their bodies and their sexual relations.

Messages of Awareness Campaigns and Concepts of Masculinity

Campaigns that seek to prevent the spread of HIV/AIDS generally center on educating people about the ways in which the disease is transmitted. Specifically, the campaigns tend to focus on urging people to use condoms while decreasing the number of sexual partners and sexual encounters. However, what does it mean for an African man or woman to learn that using condoms and decreasing the number of sexual partners will decrease his or her risk of contracting the deadly disease? For men, this information directly challenges traditional concepts of masculinity. For women, the information is relatively useless unless they are able to ensure that their sexual partners use condoms with them and their other partners. Too often, women are unable to protect themselves from the virus because they lack the power and economic independence to either refuse sex or force their partners to wear a condom. Noting these challenges for women, UNAIDS launched a campaign in 2001 specifically and directly targeting men.6 Although a campaign that seeks to change the underlying attitudes regarding masculinity may seem quixotic, it is time that one of the major roots of the problem be targeted.

A 1998 UNAIDS report conveyed that "researchers and prevention workers are coming to the firm conclusion that the global epidemic is driven by men."7 The nearly universal concept of masculinity as being sexually active is greatly hindering the effectiveness of awareness campaigns that urge men to decrease their number of sexual partners. Congruent with the almost universal hegemonic concept of masculinity, African men are expected to have frequent sexual intercourse, have many sexual partners, and take risks. Changing these behaviors, however, may be extremely difficult considering the cultural and economic situation of many African men. Perhaps the greatest factor for the spread of a sexually transmitted disease like AIDS is migration. Migrant men in urban areas are more likely to seek new sexual partners than when at home8 due to loneliness, sexual frustration and the stress of the city. The lack of social controls when away from home may also be a factor, although some anthropologists and researchers have noted that these sexual practices are often considered socially acceptable.9

Furthermore, in certain tribes, women may not have sex during pregnancy or for two years following birth, as it is believed that this will contaminate the breast milk and give the child diarrhea. These beliefs in turn lead to extramarital affairs by the husband, who puts himself, the wife and all subsequent children at risk.10 One study found that the longer the duration of the post-partum abstinence in Ibadan, Nigeria, the more STDs were present.11 A study in Guinea-Buissau found that men who did not have sex with their wives during lactation were more likely to have other "casual" relationships than men who did continue to have sex with their wives.12

For men who have extramarital affairs either due to migration or post-partum abstinence, awareness of the risks of contracting HIV/AIDS would be the first step in preventing further spread of the virus. However, the prevalent assumptions regarding masculinity must be targeted as well. For example, the belief that a man's need for sex is beyond his control explains and legitimates the social expectation for having many sexual partners. Sexual excesses by urban men are often hallowed and viewed as prestigious.13 Men are also much more likely than women to see themselves as being invulnerable to illness or risk, which may contribute to the ineffectiveness of awareness messages. Condoms are often viewed as "unmasculine," and sex without a condom also adds to the sense of danger that traditional concepts of masculinity encourage. Clearly, the awareness campaigns will have little effect unless a deeper ideological change occurs as well.

First, AIDS educators need to work with men to change the traditional concepts of masculinity that directly counter the messages of decreasing sexual partners and increasing condom use. Overall social and cultural changes need to take place to convince men that sexual restraint instead of sexual excess is masculine. Making such changes is feasible with the help of the media and religious leaders. Already, Islam and the Christian churches are substituting the idea that a "real man" has many sexual partners with the idea that a good Muslim or Christian man is faithful to his wife. UNAIDS has also suggested the widespread and affordable availability of condoms may not be enough, but that condoms should be marketed as being masculine in order to encourage more men to actually use a condom.

Women and "Biological Sexism"

HIV has been called a "biologically sexist" virus by scientists, because women are in much greater danger of contracting the disease during sexual intercourse than the man. In the absence of sexually transmitted infections, a man with HIV/AIDS has an average chance of one in 500 of passing the virus to a woman in a single act of unprotected vaginal intercourse. The odds of woman-to-man transmission in the same situation are about one in 1000.14 Women under the age of twenty are more likely to contract HIV because an immature genital tract has fewer layers of mucous membrane, increasing the chances that the virus enters the bloodstream. In the presence of lesions in the genital tract, the risk of contracting HIV increases up to sevenfold.15 An additional reason for women's increased vulnerability is that the concentration of the virus is higher in seminal secretions than in vaginal secretions.16 An additional cultural factor is female genital mutilation, which greatly increases a woman's chances of contracting HIV if she bleeds or damages her vaginal membrane during sexual intercourse.17

The Need for Social Change to Empower Women in Sexual Relations

Women are not only at a biological disadvantage, but at a social disadvantage as well. When Human Rights Watch released a report on AIDS and human rights in June 2001, it mentioned that "the second-class status of women in economic, social and civic life has fueled the pandemic in much of the world."18 Lesley Doyal, a Health Studies expert of Africa, pointed out that "women cannot use condoms in the way most government programs recommend. Instead they must persuade men to do so, and this can be an extremely difficult task."19 In traditional African relations, women are not expected to discuss or make decisions about sexuality.20 In a study by Brooke Grundfest Schoepf in Tanzania in 1991, a group of women from a church all asked their husbands to use a condom. One-third of the women reported that their husbands refused, some even physically beating their wives for asserting their own wishes. Another third convinced their wives that (perhaps rightfully) there was no danger of contracting HIV/AIDS because they had no other sexual partners other their wives. The other third agreed to use a condom. While every man engaging in heterosexual intercourse can decide whether or not to use a condom, this study shows that women are at a disadvantage and do not have the same freedom as men. While not all women are powerless, this study does confirm that many women are victims of a patriarchal system that robs them of the freedom over their own bodies.21

The danger of being raped is another way in which women are disadvantaged in protecting themselves from the virus. In South Africa, there are an estimated 1.3 million rapes per year.22 Considering that violent sexual acts are more likely to lead to lesions and infection for the female victim, it is once again painfully clear how women are clearly disadvantaged in protecting themselves.

Just as women do not have control over condom use, they also have little control over their husband's sexual practices. A woman may learn that decreasing her number of sexual partners will decrease her risk of becoming HIV-positive, but researchers have estimated that "between 50 and 80 percent of all HIV-infected women in Africa have had no sexual partners other than their husbands."23 Another study in Kigali, Rwanda, found that women with no other risk factor except their long-term partner formed the largest proportion of women with HIV/AIDS.24 Once again, women are placed at a high risk of contracting the virus, not from their own behavior, but from the behavior of men over whom they have little control.

However, even in situations where the husband respects the wishes of his wife, it may still be in the family's best economic interest not to use condoms. The reasons are simple: conception cannot be combined with safe sex, and most Africans want large families. Not only is the joy of having children enough reason to disregard the advice of using a condom, but there are other cultural and economic factors as well. In a culture that places such high value on family life, and in which family size is an issue of gaining status and respect in the community, it may very well be futile to urge married couples to use condoms. In this case, not using a condom is in the best interest of the woman as well, because "in many societies, motherhood represents the only route to status, identity and personhood, and ultimately security and support in old age."25 Even if a woman suspects her husband's infidelity and HIV-positive status, it may still be in her best interest not to request a condom.

Economic Dependence as Endangering Women

In addition to biological and social factors, the economic situation of women in Africa also contributes to their increased endangerment of contracting HIV. In Africa, as in the West, many women are economically dependent on their husbands: the man works to support the family financially, while the woman stays at home to care for the family and the household. Unless a woman is steadily and adequately employed, her economic security is dependent on the support of her husband. For the majority of women, therefore, survival depends on a relationship with a man. Doyal points out that "sexual intercourse in the way that he desires may well be the price that [women] pay for [financial] support."26 Therefore, while women may ask their husbands to use a condom during sexual intercourse, they are at the mercy of his wishes and preferences. While a financially independent woman may threaten to leave her husband if he doesn't comply with her wish that he use a condom, a financially dependent woman does not have this freedom. She knows that her only choices are to either comply with his wishes, which could lead to her contracting the disease and dying young, or leave her husband, which would most likely lead to financial ruination, powerlessness and misery. As Bassett and Mhloyi reported: "the choice becomes one of 'social death' or 'biological death.'"27

While the advice of using condoms is most likely to be ineffective with married women due to their financial dependence on their husbands, the advice of having only one or no sexual partner is unlikely to have much impact on many unmarried women unless they also gain financial independence. For many divorced, widowed or abandoned women who live in countries with soaring unemployment rates and low levels of education for girls, the chances of finding a secure job and therefore gaining financial independence are slim. While the path to exchanging sex for money may differ, the overwhelming majority, if not all, women who resort to sex work do so in order to survive financially. The June 2001 report by Human Rights Watch also stated that "the disease most deeply affects those least able to enjoy their rights: the poorest, the weakest, the least educated, the most stigmatized."28 Women who exchange sex for financial security are, for the most part, poor women with low education who have no other means of ensuring that money will be available to feed and house themselves and their children.

Brooke Grundfest Schoepf, who has done extensive research on women and health in Kinshasa, Zaire, explains that most sex workers in Kinshasa do not consider themselves to be "prostitutes." The word "prostitute" connotes women who solicit strange men for sex-for-payment, and then never see the man again. For many women in African cities, the situation is very different. Schoepf explains that, in the most common scenario, a divorced, abandoned or widowed woman will quickly find herself without a job and therefore without the money needed to pay for rent, food and her children's education. Her only option is to become a man's "deuxieme bureau" (a term used in Kinshasa, meaning "second office"), meaning that she has an affair with a man who, in return for sex, pays her rent and provides her with financial support that usually a husband would provide. However, many women soon find themselves neglected by their sexual partner, who either loses interest or the financial capability to support her. For these women, the only option is then to either start a "relationship" with another man, or turn to several lower-paying sexual partners. While this is the typical path into prostitution that Schoepf observed from her fieldwork with poor women in Kinshasa,29 other researchers explain different scenarios, but all with the common motivation of financial survival.

In South African mining towns, a group of researchers found that women would take sexual partners as a way to supplement salaries that were simply too meager to support a family.30 Bassett and Mhloyi found that women in Zimbabwe often funded their education by having long-term "boyfriends" who helped them financially.31 These women, many of whom probably could not imagine going to bars or street corners to solicit strange men into sex-for-payment, do not consider themselves to be "prostitutes." Most of these women know their partners, the relationships tend to be longer than simply one-time encounters, and payment comes in the form of paying the woman's rent or giving her a monthly payment for her household. These women, then, would consider it an insult to be called "prostitutes," and awareness campaigns that have linked the use of condoms with prostitution have in fact exacerbated the problem of low condom use.

Even if sex workers do want to use a condom, they might again find themselves in an unfavorable economic situation. These women are at the mercy of their "partners" during the sexual relationship. As with married women who are unable to make their partner use a condom, unmarried sex workers are also mostly unable to practice safe sex. It would be financially dangerous for a woman to ask her partner to use a condom, because the man could simply walk away and find another woman who does not insist on the use of a condom. Again, the fear of financial loss results in the lack of women's freedom to protect their own health.

The failure of the awareness campaigns to result in behavior change among financially insecure women is again clear with regard to women who are forced to exchange sex for money. While the awareness campaigns can tell people to decrease the number of sexual partners and sexual encounters, these messages will not elicit behavior change from women who must choose between short-term financial survival and long-term biological survival. In order to pay rent and put food on the table, these single women, many of whom are single mothers, have only their body as a means of generating income. Unless the social and economic status of women is changed to allow them financial independence and financial security, these pleas for sexual abstinence are unlikely to result in behavior changes that prevent the spread of HIV/AIDS.

Conclusion: Awareness Campaigns are not Enough

Education and awareness of HIV alone will not suffice in curbing the spread of this tragic disease that continues to ravage the Sub-Saharan African continent. The challenge may seem insurmountable, but ideological, economic and social changes are needed to control the virus. AIDS educators, governments, doctors, religious leaders and the media need to work with men to gradually change the dominant concept of masculinity. For example, making condoms widely available and affordable is necessary, but not enough. The use of condoms must also be marketed as being "masculine." As long as men are expected and encouraged by society's dominant concept of masculinity to be sexually active and engaged in risky behavior, the messages from the awareness campaigns will fail to produce serious behavior changes.

While men need to be convinced and enticed into using their freedom to protect themselves from the virus, women need to be given the freedom that they now lack. Girls need to be educated and women need economic independence and security. In the words of the World Health Organization: "they must be empowered so that they are able to control their own lives and in particular their sexual relations."32 This will require a profound shift in social and economic power relations between men and women, through increased educational and employment opportunities for girls and women, as well as public education campaigns on the harmful effects of unequal gender relations. Awareness of the risks and transmission of the virus is a necessary first step, but the pandemic is unlikely to be brought under control unless the underlying cultural and economic factors that put both men and women at risk are changed as well.

Endnotes

1. World Health Organization (WHO) and Joint United Nations Programme on HIV/AIDS (UNAIDS), "AIDS Epidemic Update," December 2001. Back

2. UNAIDS and WHO, "Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections," 2000. Back

3. "Total Control of the Epidemic," Ministry on Health and Child Care, Zimbabwe, 2000, available at www.drh-movement.org Back

4. Annabel Ferriman, "UN Calls for $10 billion to Wage War on AIDS," British Medical Journal 322 (5 May 2001), p. 1082. Back

5. Ibid. Back

6. UNAIDS, "I care… Do you?" 2001. Back

7. UNAIDS, "Men: Taking Risks or Taking Responsibility?" 1 December 1998. Back

8. John Caldwell et al., "Mobility, Migration, Sex, STDs and AIDS: An Essay on Sub-Saharan Africa with Other Parallels," in Sexual Cultures and Migration in the Era of AIDS, ed. by Gilbert Herdt (Clarendon Press, 1997), p. 51. Back

9. Joyce Hickson and Dawn Mokhobo. "Combating AIDS in Africa: Cultural Barriers to Effective Prevention and Treatment," Journal of Multicultural Counseling and Development 20 (January 1992), pp. 11-22. Back

10. Ibid Back

11. Pat Caldwell and John Caldwell. "The Function of Child-Spacing in Traditional Societies, and the Direction of Change," in Child Spacing in Tropical Africa: Tradition and Change, ed. by H. J. Page and R. Lesthaeghe (Academic Press, 1981). Back

12. M. Hogsborg and P. Aaby. "Sexual Relations, Use of Condoms and Perception of AIDS in an Urban Area of Guinea-Bissau with a High Prevalence of HIV-2," in Sexual Behavior and Networking: Anthropological and Socio-cultural studies on the Transmission of HIV, ed. by Tim Dyson (Ordina Press, 1992). Back

13. Hickson and Mokhobo. "Combating AIDS in Africa." Back

14. Rachel Royce et al., "Sexual Transmission of HIV," New England Journal of Medicine. 10 April 1997, pp. 1072-1078. Back

15. Antonio Gerbase, "Global Epidemiology of Sexually Transmitted Diseases," The Lancet, June 1998. Back

16. World Health Organization (WHO), "Fact Sheet No. 242," June 2000. Back

17. Ibid. Back

18. Human Rights Watch (HRW), AIDS and Human Rights: A Call for Action, 27 June 2001. Back

19. Lesley Doyal, "HIV and AIDS: Putting Women on the Global Agenda," in AIDS: Setting a Feminist Agenda, ed. by Lesley Doyal et al. (Taylor and Francis, 1994), p 17. Back

20. WHO, "Fact Sheet No 242." Back

21. Brooke Grundfest Schoepf et al., "Gender, Power, and Risk of AIDS in Zaire," in M. Turshen, ed., Women and Health in Africa (Africa World Press, 1991). Back

22. K. Wood and R. Jewkes. "Violence, Rape and Sexual Coercion: Everyday Love in a South African Township," in Men and Masculinity, ed. by C. Sweetman (Oxfam, 1997). Back

23. E. Reid. "Gender, Knowledge and Responsibility," in AIDS in the World: A Global Report, ed. by Jonathan Mann and Daniel Tarantola (Harvard University Press, 1992), p. 659. Back

24. Jonathan Mann and Daniel Tarantola. AIDS and the World II (Oxford University Press, 1996) p. 465. Back

25. Doyal, "HIV and AIDS," p. 20. Back

26. Doyal, "HIV and AIDS," p. 17. Back

27. M. Bassett and M. Mhloyi. "Women and AIDS in Zimbabwe: The Making of an Epidemic," International Journal of Health Services 21/1, p. 146. Back

28. HRW, AIDS and Human Rights. Back

29. Brooke Grundfest Schoepf, "Health, Gender Relations, and Poverty in the AIDS Era," in Courtyards, Markets, City Streets, ed. By Kathleen Sheldon (Westview Press, 1996), p. 159. Back

30. K. Jochelson et al., "Human Immunodeficiency Virus and Migrant Labor in South Africa," International Journal of Health Services 21/1, p. 167. Back

31. Bassett and Mhloyi p. 150. Back

32. WHO, "Fact Sheet No. 242." Back

Copyright for this paper is held by the author, Charlotte Vallaeys.

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