InterPress News Service (IPS); Thursday, 17 October 1996.
Judith Perera

Writing in the current issue of the prestigious British medical weekly The Lancet, she points out that most programmes in developing countries target so-called high risk groups such as sex workers.

"But most women in need of prevention are not sex-workers but women with one partner -- their husband," she points out. "For them monogamy is an irrelevant strategy."

This applies to 50-80 percent of all infected women. And even those women who do have multiple partners may have little choice in the matter. "For a large subset of women who are not monogamous, having multiple partners is a means of survival.

With few marketable skills women hay have to use sex as a means of earning a living for themselves and their children."

She argues that most women in developing countries lack the social, political and economic power to refuse unsafe sex with their partners." Her conclusions are based on many years of experience working with NGOs and government organisations throughout the world.

"When a women is economically powerless to negotiate her basic needs or is subject to domestic violence and abuse, encouraging her to negotiate safer sex is unrealistic," she says in her Lancet article, published Friday (Oct. 18).

The HIV epidemic is spreading at a rate of 6,000 new infections a day, mostly in southern and central Africa and south Asia. Up to half of these new infections are in women aged between 14 and 24. By 2000 WHO forecasts up to 40 million new cases, 90 percent in developing countries. Both heterosexual and mother-to-child transmission are increasing.

At present programmes against heterosexual transmission comprise mass awareness campaigns for the general public and interventions with supportive services for specific groups. while they are quite successful within these groups, they have failed to prevent the general spread of HIV.

"Most prevention programmes concentrate on influencing individual behaviour and do not take into consideration the social, economic and structural determinants of risk that act as barriers to the adoption of preventive behaviour."

Women are not he only vulnerable groups. Adolescents and young people living in economically and socially underprivileged conditions are also at risk. "For them selling sexual services is a means of survival not only for themselves but also often for the whole family," D'Cruz-Grote notes.

"Without a supporting network and access to education and to health services, even when they know the preventive measures they should take, they are in no position to regulate their behaviour."

Efforts to promote more extensive condom use have not been as successful as hoped because of their high cost, poor quality, limited availability and lack of accessibility in some countries.

"Even when condoms are available, men's decision to use them may be hampered by cultural misconceptions and social inhibitions," she points out.

"Women cannot control the use of male condoms when they cannot discuss sex freely and they also fear being labelled 'promiscuous'.

Socially, women are under pressure to engage in sex without condoms because of the importance of fertility and of having children for the stability of marital union and the social and economic security this supposedly brings."

For HIV prevention to succeed the social and economic status of women and other vulnerable groups must be improved, she insists.

"For both men and women, the evidence emphasises the singular importance of education as a means of gaining access to work and of improving family welfare and health status and hence of enhancing their capacity to protect themselves."

A major problem for developing countries continues to be complacency and denial of the existence of AIDS, she says, as well as a growing tendency to regard AIDS as a problem of others.

"Meanwhile for those working in AIDS it has become clear that HIV- AIDS is no longer an emergency but a fact of life. However, there is still a tremendous opportunity for prevention, if only wee confront the issues that have been known for decades and which AIDS has forced to the forefront. (END/IPS/JMP/MOM/RJ/96)

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