Wall Street Journal - Tuesday, July 9, 2002
Mark Schoofs and Rachel Zimmerman, Staff Reporters

BARCELONA, Spain -- Along with a lack of money, one of the most intractable obstacles to slowing the spread of HIV is the emotionally charged, culturally entrenched ways that men and women interact sexually, researchers at the XIV International AIDS Conference said.

"The gender issue is the key driving force of the epidemic," said Milly Katana, an HIV-positive Ugandan activist who delivered a major address to the 14,000 conference delegates. Young women are especially vulnerable: More than two-thirds of infected 15- to 24-year-olds in sub-Saharan Africa are female, according to a report by Unicef. In some cities in eastern and southern Africa, for every boy infected, there are five infected girls.

Women are infected more easily and more often than men, but men drive the spread of the virus.

Men generally have more sexual partners, and "it is usually men, not women, who determine when and how often to have sex, and whether a condom is used," explains a report from the London-based Panos Institute, which is working with the United Nations AIDS program, UNAIDS, on how to encourage men to change their behavior.

Among the findings presented Monday: A study from Bangladesh of 160 women and 72 men found that more than a quarter of women reported having received absolutely no information about sex before they got married. An additional 21% received their first sex education on their wedding days, most often from a sister-in-law or a grandmother. Half the women in the Bangladesh study said that when they tried to refuse sex, their partners coerced them to have it, usually through physical force.

In Angolan refugee camps, where many people displaced by the long civil war live in crowded and squalid conditions, more than half the men said they either don't know about or won't use contraceptive methods, including condoms. The researchers also documented widespread reports of rape by police and military personnel at the camps.

Other research has documented higher rates of HIV among soldiers, such as Nigerian forces on United Nations peacekeeping missions.

In California, a study funded in part by the federal Centers for Disease Control and Prevention found that women who forgo condoms usually do so because they want to feel closer to their partners. The women said condoms undermined intimacy, demonstrating the deeply personal complexities of AIDS education. "Counseling the HIV-negative partners does not seem to significantly enhance the effectiveness" of prevention efforts, said Cynthia Gomez, the scientist who presented the study.

Geeta Rao Gupta, who heads the International Center for Research on Women, Washington, D.C., said in an interview that her organization had recently published a study of 10,000 randomly selected women in India.

Forty percent of the women reported physical abuse from an intimate partner, and half of those said the assault occurred during pregnancy. "With that level of violence a reality in women's lives, it's hard for them to negotiate" the use of a condom or other sexual-prevention methods, Dr. Gupta said.

To try to stanch the spread of HIV, a new prevention working group, comprising a virtual who's who of AIDS prevention experts, is advocating that an additional $4.8 billion a year be spent to launch an array of proven prevention methods.

The group is co-headed by Helene Gayle, of the Bill and Melinda Gates Foundation, and Drew Altman, of the Henry J. Kaiser Family Foundation. The group estimates that basic methods such as condom distribution and school-based sex education reach fewer than one in five people at risk -- a deadly failure that could be rectified with more money.

More broadly, Dr. Gayle says in order to shift behavior, a range of new approaches are necessary, among them, empowering women economically through "micro-credit" lending programs, which are accessible to the poor, and through education.

Research from 14 African countries shows that men with more education are more likely to use condoms. She also said that strengthening laws such as those on rape could make it easier for women to say no.

Specifically to help women, the group is also calling for a $1 billion increase in public-sector funding for microbicides, gels which a woman can insert in the vagina before sex that would block HIV infection. Women could use this without their partner's knowledge or consent, giving them power they currently lack.

But such a product is years away, so in the meantime prevention efforts must combat entrenched cultural traditions.

Princess Kasune Zulu, an HIV-positive mother of two from Zambia attending the conference, went to get tested for HIV in 1997, but her doctor refused to perform the test until she had obtained the consent of her husband, a copper miner. When the results came back positive, she was excommunicated from her local church after her husband reported that she wasn't being submissive. Even her aunts, traditional counselors in many African societies, told her to stop making trouble and obey the man she married.

"The traditions are killing us," Ms. Zulu says. "It's the older women educating the younger women to be submissive.

Write to Mark Schoofs at and Rachel Zimmerman at

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