HIV and Intimate Partner Transmission: A Call to Action
Fri, 2009-07-10 14:20 — admin
An estimated 50 million women in Asia are at risk of contracting HIV from their intimate partners and approximately 90 percent of the 1.7 million women living with HIV in Asia became infected from their husbands or partners while in long term relationship, said researchers and policy makers who spoke today at the Symposium on
The HIV epidemic in Asia is largely fuelled by unprotected paid sex, the sharing of contaminated needles by injecting drug users, and unprotected sex among men who have sex with men. Many of these men, who are at high risk of contracting HIV, are married or in intimate partner relation with women. “This puts a significant number of monogamous women at high risk of contracting HIV,” they said.
Quoting from the 2008 Report on the Commission of AIDS in Asia, Caitlin Wiesen, Regional HIV Practice Leader, Asia Pacific, UNDP, said that the single most important contributor to Asia’s HIV epidemic is men who pay for sex. An estimated 75 million men in Asia visit sex workers and 10 million women cater to them. Nearly 50 million women, who are long term sexual partners of these men, are at risk. Add to these figures the injecting drug users (IDUs) and men who have sex with men (MSM) and we have a very large number of people who are at great risk of getting infected and in turn, infecting their partners.
The UNAIDS report on HIV Transmission in Intimate Partner Relationships in Asia, released today, confirms that the largest number of new infections occur among married women. The report also shows that injecting drug users are contributing to increase in the epidemic, and spousal violence is widespread across social and economic strata. All these lead to increase in intimate partner transmission of HIV.
According to Prasada Rao, Director, UNAIDS Regional Support Team for Asia and the Pacific, “understanding transmission among intimate partners is one of the most difficult and sensitive areas but it is key to understanding the epidemic and may even be the key to turning the epidemic around”.
Dr. Nafis Sadik, UN Secretary General’s special envoy on HIV/AIDS in Asia and the Pacific, said that with the discussion of intimate partner transmission of HIV, we enter the most sensitive and difficult area, and one that is key to understanding and addressing the pandemic. According to Dr. Sadik, “three quarters of HIV infections occur through sexual contact and many of these occur within marriage, raising issues of trust, confidentiality and gender power relations.” She further added that the root causes of HIV transmission through intimate partners are still to be addressed and pointed out that the national legal frameworks are poorly enforced in the region and there is a need for “a slew of activities to address the problem”.
Geeta Rao Gupta, President, ICRW, said that the prevalent sexual norms and the culture of silence that surrounds sex in the region are contributory factors to a rise in the HIV transmission among intimate partners. She emphasized the need to break the taboo on speaking about sex and sexuality to address women’s vulnerability to HIV.
Urging concerted action to address the transmission of HIV through intimate partners, a significant contributor to the epidemic, the speakers at the Symposium highlighted the increasing vulnerability of monogamous women married to men with high-risk behaviours, the links between violence and intimate partner transmission, and challenges in addressing these issues.
The speakers also emphasized that the issue had not yet gained entry into the strategies and policies of national governments despite evidences from the field showing its growing importance in contributing to the rise in HIV infection among women.
Growing Proportion of Women among People Living with HIV
In Asia, 3 out of every 4 adults living with HIV are men, yet the proportion of women living with HIV has risen from 19% in 2000 to 24% in 2007. According to the Commission on AIDS in Asia (2008), it is 35 percent in Thailand, 47 percent in Cambodia and 37 percent in India. Almost all new infections in many countries of the region are through marriage.
According to Dr. Nafsiah Mboi, Secretary, National AIDS Commission, Indonesia, women in Indonesia are at high risk of contracting HIV. She noted that the 2020 projections for Indonesia indicated a growing proportion of women among PLWHIV.
Mobile Men at High Risk
According to Caitlin Wiesen, “mobile” men, who travel from home in the course of their work, are exposed to very high risks of contracting HIV, as a large number of them seek paid sex. According to data from Family Health International (2006), in China, the percentage of men in mobile occupations who seek paid sex is nearly four times higher (33%) than the proportion of men in the general population who pay for sex (9%). In Vietnam, it is 16 times higher at 32%, compared to 2% of men from the general population who seek paid sex.
Reasons for HIV Transmission among Married Partners
According to Dr. Sadik, the problem of intimate partner transmission of HIV is rooted in gender inequality, violence and discrimination that is so pervasive in the Asian region.
Men are more likely to hide or delay the disclosure of their HIV status to partners, compared to women. Non disclosure prevents regular condom use and hence higher transmission of HIV. The subjugation of women, their low status in society, and their exclusion from decision making render them highly vulnerable to contracting HIV from their spouses. The prevalence of women as receivers of anal sex also put them at increased risk of HIV infection.
According to Geeta Rao Gupta, there are three fundamental gender-related structural factors that interact to fuel intimate partner transmission. The first is gender inequality in access to productive resources, an inequality that favours men and creates an unequal balance of power in heterosexual relationships. The second is the prevalent sexual norms that stigmatizes homosexuality and bisexuality and upholds a double standard of appropriate sexual behaviour in which “good” women are expected to be sexually naïve and faithful, while excusing men’s infidelity and sexual adventures. The third is the culture of silence in the region that shrouds sex and sexuality.
Link between Intimate Partner Violence and HIV Transmission
According to Mr. Prasada Rao, research from several Asian countries indicate that between 15% and 65% of women experience physical and/or sexual violence in intimate partner relationships, placing them at increased risk of HIV infection. Studies from India, Bangladesh and Nepal show that women who were exposed to intimate partner violence from husbands infected with HIV through unprotected sex with multiple partners were seven times more likely to acquire HIV compared to women not exposed to violence and whose husband did not have sex with multiple partners.
Framework to Address HIV and Intimate Partner Transmission
The UNAIDS report outlines the need to integrate protection of women into all HIV prevention programmes. Important is to scale up prevention interventions for MSM, IDU and clients of sex workers; HIV prevention among mobile populations and migrant workers with focus on protecting intimate partners; structural interventions for vulnerable women and their male sexual partners; and operational research to deepen the understanding of the dynamics of HIV transmission among intimate partners.
Definition and Terminology
While HIV transmission through intimate partners is not new (it was known as spousal transmission), its definition is now broadened with more epidemiological studies from the field to include MSM who also have sex with women and IDUs. However, Geeta Rao Gupta warned that if definitions are general, it will lead to ineffective solutions. “If we are not careful, overgeneralized terms will define problems, and then will lead to ineffective solutions. We need to be clear about exactly what we are grappling with in different contexts, and then develop solutions to address them specifically,” she said.
Key Challenges
At present, there is no effective strategy to protect women within marriage. There still exists a huge gap in the understanding of characteristics of sexual behaviour among intimate partners that render the designing of effective prevention programmes difficult. The strong patriarchal culture in Asian countries severely limits a woman’s ability to negotiate sex in intimate partner relationships. HIV prevention programmes focused on female partners of men with high risk behaviours still have not found a place in national HIV plans and priorities.
Excerpts from an E-Discussion Leading up to the Symposium on www.hivapcop.org
Highlighting the feedback received from participants in an on-line discussion held by UNDP as a lead up to the symposium, Dr. Sadik said that it was important to understand why men seek paid sex. While there is no research on this, it could be speculated that it gives men a sense of control, which they lack in their daily lives. This, she explained, brings to the fore issues of gender violence – spousal violence in particular. In this context, she said, it is important to understand the sexual behaviour of migrant workers as well.
Effective protection of women, the e-discussion pointed out, calls for programmes far beyond the current efforts, which have focussed on remedial approaches.
Most participants felt that countries must eventually address the underlying power structures that effectively keep women in subjugation. As part of this effort, women need wider social and economic measures which would empower them to take their lives in their own hands. In this context Dr. Sadik said that educational outreach on sexual and reproductive health must also include men and boys.
Lastly, the e-discussion pointed out that infected women and children need much more than care and treatment. Importantly, they need protection from stigma and discrimination. For this, Dr. Sadik emphasized, there is a need to have an open, frank and value-free discussion that reaches every village as well as informs policy and enforcement agencies.
Way Forward
According to Caroline Thomas, Women’s Asia Pacific Network of Positive People (WAPN+), Indonesia, there is an urgent need to enhance awareness and gender responsive action by all stakeholders including the UN, donors, local and international organisations, government agencies, enforcement agencies and decision makers.Important is to provide women easy access to comprehensive sexual and reproductive health services.
Dr. Nafsiah Mboi, Secretary National AIDS Commission, Indonesia said: “The call for action includes the need to integrate gender and reproductive rights into HIV programmes.” She called for an explicit policy response on gender-based violence.
According to Caitlin Wiesen, gender and human rights concerns are found in national AIDS strategies but are not often budgeted and therefore not translated into action. There is thus a need for new ‘resource needs’ estimation tools.
Raffy Martinez, Migrant Health Advocate, ACHIEVE, Philippines stressed the need for a reintegration programme for migrant workers who are sent back from the host country after being infected with HIV. “This will go a long way in addressing intimate partner transmission of HIV,” he said.
According to Geeta Rao Gupta, it is important to address the underlying structural causes that put women at risk and increase their vulnerability in long-term and stable sexual partnerships. This, she says, will greatly increase the effectiveness of our efforts to reduce the risk of sex workers, MSM, and IDUs and would help break the link between their risk and that of their regular partners. According to her, we cannot hope to address this problem only through public health measures. “We need to shift the dynamic of gender relations.”
While continuing to create conditions for decreased vulnerability of most-at-risk populations, including the decriminalization of sex work and same-sex sexual practices, we must continue to push for age-appropriate sex education for children and adolescents, and facilitate open, community led discussions on sexuality. With all of these measures, we will be able to dismantle the foundation of inequality, fight the stigma, and break the silence on which intimate partner transmission thrives.
According to Dr. Sadik, mainstreaming all these issues and having a holistic approach is important.
When the floor was open to the public, the participants highlighted the importance of providing safe and secure spaces for women and girls to discuss issues related to sexuality and the need to invest in younger people so that they have youth friendly spaces to discuss issues concerning them.
Geeta Rao Gupta said that there was a lot of rhetoric, but none of it has been integrated in national programmes and policy. She said: “We know a lot more now, but this has to be translated into actionable strategies.”
Summing up the symposium, Dr. Sadik said that gender inequality and pervasive harmful gender norms are major barriers to achieving universal access to HIV prevention, treatment, care and support. She added that more concerted, committed and comprehensive actions to address these root causes of intimate partner transmission of HIV in the region are urgently needed.
Chairs:
Dr. Nafis Sadik, UN Secretary General’s Special Envoy for HIV/AIDS in Asia and the Pacific
Prasada Rao, Director, UNAIDS Regional Support Team for Asia and the Pacific
Panelists:
Dr. Nafsiah Mboi, Secretary, National AIDS Commission, Indonesia – The Challenges of engendering National AIDS Programmes including low risk women
Caitlin Wiesen, Regional HIV Practice Leader, Asia Pacific, UNDP - Introduction to intimate partner transmission in the Asian Region
Caroline Thomas, WAPN+, Indonesia - How do positive women see intimate partner transmission?
Geeta Rao Gupta, President, ICRW- The gender dimensions of HIV transmission in intimate partner relationships
Raffy Martinez, Migrant Health Advocate, ACHIEVE Inc – Mobility, families and HIV vulnerability
Discussant:
Anandi Yuvaraj, Coordinator, International Community of Women living with HIV/AIDS
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Date and Venue:
Tuesday 11 August, 14:00-15:30, Nusa Indah, Westin Hotel
Organizers:
UNDP, WAPN+, UNAIDS, UNIFEM,UNFPA,ICW
| Attachment | Size |
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| Symposium Report- Intimate Partner Transmission.pdf | 23.15 KB |
