Ministry of Health of the Republic of Moldova

Ministry of Labour, Social Protection and Family

National Centre for Health Management

Women’s Vulnerability to HIV and AIDS in the Republic of Moldova2010

Chisinau 2010

CZU

This publication has been developed within the frameowrk of the Project „Agenda for Accelerated Country Action for Women, Girls, Gender Equality and HIV ” finnaced by the Joint United Nations Programme on HIV/AIDS (UNAIDS) and imlemented by the National Centre for Health Management. The opinions expressed by authors in the present publication does not reflecte necesarily the opinion of the donor.

Authors:

Stela Bivol, Independent Consultant

Natalia Vlădicescu, CBS AXA

Study coordination team:

Otilia Scutelniciuc, Chief of the M&E Unit, National Centre for Health Management

Iuliana Stratan, independent consultant

Sociological Company CBS AXA

Alexandrina Iovita, M&E Adviser, UNAIDS Moldova

The study has been implemented by the Centre for Sociologic Investigations and Marketing “CBS AXA” SRL , Coordinator of the Quantitative Study – Nicolae Jigău, Coordinator of the Qualitative Study - Natalia Vlădicescu.

Centre for Sociologic Investigations and Marketing “CBS AXA” SRL
31 August 98 Street, office 202, MD-2012
Chişinău, Republic of Moldova
Contact phone: + 373 22203464
Fax: + 37322234987

/ National Centre for Health Management
Cosmescu 3 Street, MD-2009
Chişinău, Republic of Moldova
Contact Phone.: +373 22727386
Fax: +373727394
e-mail:

Acknowledgements

The survey report hereto constitutes the product of coordinated efforts of key stakeholders of the national AIDS response. We would like to acknowledge the outstanding support and guidance received from the Dr. Lev Zohrabyan, MD, MPH, PhD, Strategic Information Adviser, UNAIDS RST Europe and Central Asia. We also express our gratitude to Ms. Lilia Pascal and Ms. Diana Doros, Gender Equality Policies Division, Ministry of Labour, Social Protection and Family, for their gender sensitive insights. We also express our appreciation for the coordination efforts invested by UNAIDS Moldova, led by Ms. Gabriela Ionascu, UNAIDS Country Coordinator.

Graphic Design: Nicolae Ionascu

UNAIDS Moldova
Bucureşti 67 Street, MD-2012
Chisinau, Republic of Moldova
Contact Phone: + 373 22855972
Fax: + 373 22855971

Information and pictures contained in this publication may be freely reproduced, published or otherwise used for non-profit purposes without permission from UNAIDS. However, the Ministry of Health of the Republic of Moldova and the Centre for Health Management request they be cited as the source of the information.

Acronyms

AIDSAcquired Immunodeficiency Syndrome

CEDAW Committee on the Elimination of Discrimination against Women

DHSDemographic and Health Survey

EUEuropean Union

FGFocus group

FSWFemale Sex Workers

GSBGender-sensitive budgeting

HIVHuman Immunodeficiency Virus

IDUInjecting Drug Use

IOMInternational Organisation for Migration

IUDIntrauterine Device

MARPSMost-at-Risk Populations

MIMinistry of Interior

MDG Millennium Development Goals

MDLMoldovan Lei

MSMMen Having Sex with Men

NBSNational Bureau of Statistics

OECDOrganisation of the Economic Co-operation and Development

PLWHPeople Living with HIV

PhDDoctor of Philosophy

SDStandard Deviation

SIGISocial Institutions and Gender Index

STISexually Transmitted Infections

TVTelevision

UNAIDSJoint United Nations Programme on HIV/AIDS

Vsversus

WHOWorld Health Organisation

Table of contents

Executive summary

Introduction

HIV/AIDS Epidemic Overview in the Republic of Moldova

HIV/AIDS Epidemic Feminization

Gender institutional framework

Women and Men in National Statistics of the Republic of Moldova

National Bureau of Statistics

Demographic Health Survey 2005

Summary findings quantitative survey of women vulnerability to HIV

Summary findings qualitative study

Survey methods

Goal

Objectives

Target population

Sampling

Inclusion and exclusion criteria

Data collection tool

Survey implementation

Data entry and analysis

Data validation and quality control

Ethical considerations

Survey Results

Socio-demographics

Education

Employment and occupation

Income

Spending

Economic dependency

Migration

Type of labor migration

Frequency of visits home

Countries of destination

Access to health care

Care giving role

HIV knowledge and testing

HIV integrated knowledge and tolerant attitudes indicators

HIV testing

Knowledge about contraception and STIs

Opinions regarding sex education in schools

Sexual practices

Sexual onset

Number and types of sexual partners

Condom use

Reasons not to use condoms

Access to condoms

Perceptions about gender roles in marriage

Gender-based violence

General perceptions about marital gender-based violence

Experience of violence

Emotional violence

Physical violence

Sexual violence

Integrated indicators on violence experience

Seeking help

Survey of Migrant Health

Notes on methods

Migrant survey results

Sample comparison

Countries of destination

Sexual activity in migrants

HIV testing in migrants

Study limitations

Conclusions and implications for interventions

Qualitative Study

Notes on methods

Gender norms

Gender roles in families

Perceptions about gender advantages

Sexual practices

Discussions about sex: a taboo

Opinions about who is responsible for sex education

Knowledge about contraception

Access to and acceptability of condoms

Perceptions and knowledge about HIV

Associations related to HIV/AIDS

Perceptions about HIV transmission and prevention

Perceptions about vulnerability to HIV

Migration and vulnerability for HIV

The consequences of migration on couple relationships

Consequences of migration on sexual activity

Migration and HIV risk

Gender-based violence

General perceptions about violence

Sexual violence

Tolerance of violence

Preventing Violence

List of Figures

List of Tables

Bibliography

Executive summary

Globally the leading cause of death among women of reproductive age is HIV/AIDS. Women are particularly vulnerable to HIV infection due to a combination of biological factors and gender-based inequalities that make women engage involuntarily in high-risk behavior. Gender inequalities specific to HIV often arise from women's limited power of negotiation of safer sex due to gender norms of patriarchal societies.

The Republic of Moldova is no exception and since year 2002 the HIV epidemic process is characterized by an increase in heterosexual mode of transmission, feminization of the epidemic and geographical spread in all administrative units of the country, including rural areas. In order to perform an analysis of the HIV epidemic through gender-sensitive lenses, theUNAIDS Country Office Moldova, with the support of the UNAIDS Regional Office for Europe and Central Asia, commissioned a study on women's vulnerability to HIV/AIDS in the Republic of Moldova. The desk review analyzed gender policies and gender statistics in the country, while the quantitative study has explored women's vulnerability to HIV by using WHO's framework of gender inequality factors that might put women at higher vulnerability for HIV compared to men. These factors are gender norms related to masculinity and feminity; violence against women; gender-related barriers in access to services; women assuming the major share of care-giving; women lacking education and economic security.

The findings of the desk review show that the Republic of Moldova has an advanced gender legal and institutional framework and a high-level political commitment to address gender inequalities in the country. In fact, according to OECD ranking in Social Institutions and Gender Index (SIGI), the Republic of Moldova ranks 12th out of 102 countries. Yet, a watchdog non-governmental organization considers that gender equality legislation is mainly declarative, including because of patriarchal traditions and the traditional perceptions regarding women's role in the society.

This study concludes that population's gender norms show an emancipated society regarding women's rights in the society in exercising their equal role in getting education, employment and full participation to social life, but a strong patriarchal society regarding women' role in their family and private lives. The assessment of gender sexual norms show that up to half of men have extended sexual rights to extramarital relationships, thus putting married women at increased vulnerability to HIV. High-risk sex is apparently practiced by a small proportion of people, but when it does occur, effective protection is not used in about half the cases. Migrants practice high-risk and unsafe sex in higher proportions compared to the general population. The negotiation of condom use and access to condoms is reduced, especially in the case of rural women. Domestic violence is highly prevalent, about a third of women having ever experienced physical violence, thus decreasing their power of negotiation in a relationship. Women from rural areas are much more disadvantaged compared to urban population in being victims of domestic violence, experiencing patriarchal gender norms, having lower access to knowledge regarding HIV and protection means against HIV and STIs. The education level and economic dependency and access to health services are generally less important factors of vulnerability in the Republic of Moldova and in fact men access health care in lower proportions compared to women and they receive lower education levels compared to women.

The study findings call for inclusion of gender-specific priorities in the national HIV policies as relates to increasing their awareness about the factors that put them at risk for HIV transmission, increasing women's power of safer sex negotiation and increasing access to prevention means, and by addressing the modernization of social norms regarding men and women's roles in their families.

Introduction

According to a recent WHO report, globally, the leading cause of death among women of reproductive age is HIV/AIDS. Girls and women are particularly vulnerable to HIV infection due to a combination of biological factors and gender-based inequalities, particularly in cultures that limit women’s knowledge about HIV and their ability to protect themselves and negotiate safer sex. The most important risk factors for death and disability in women of reproductive age in low- and middle-income countries are lack of contraception and unsafe sex. These result in unwanted pregnancies, unsafe abortions, complications of pregnancy and childbirth, and sexually transmitted infections including HIV. Violence is an additional significant risk to women’s sexual and reproductive health and can also result in mental ill-health and other chronic health problems.[1]

While there are biological reasons why women are at greater risk of HIV infection than men and the transmission rate is 10 times higher from men to women than from women to men, the major drivers of increased risk for women are social and cultural factors. The majority of women who become infected with HIV do not voluntarily engage in high-risk behaviour. Instead, they are vulnerable as a result of the behaviour of others, or because they lack the tools, information and resources needed to protect themselves.

The concept of ‘gender’ refers to norms within a society about appropriate male and female attributes, behaviour, and roles, which in turn define how men and women interact with each other. ‘Gender inequality’ exists where men and women’s opportunities, influence, rights and responsibilities are unequal and depend on their sex.[2]Gender norms, for example, often dictate that women and girls should be ignorant and passive about sex, leaving them unable to negotiate safer sex or access appropriate services. Gender norms in many societies also reinforce a belief that men should seek multiple sexual partners, take risks and be self-reliant. These norms work against prevention messages that support fidelity and other protection measures from HIV infection. Some notions of masculinity also condone violence against women, which has a direct link to HIV vulnerability, and homophobia, which results in stigmatization of men who have sex with men, making these men more likely to hide their sexual behavior and less likely to access HIV services.[3]

The World Health Organisation sets a framework of gender inequality factors that might put women at higher vulnerability for HIV compared to men[4]. These factors are:

Gender norms related to masculinity and feminity
Violence against women (physical, sexual and emotional)
Gender-related barriers in access to services
Women assuming the major share of care-giving
Lack of education and economic security

We have used this framework to design a study of evaluation of women vulnerability to HIV infection in the Republic of Moldova. In addition to the quantitative and qualitative research, the present report also examines the current gender policies in the Republic of Moldova and the general gender situation in the country.

HIV/AIDS Epidemic Overview in the Republic of Moldova

In the Republic of Moldova the first case of HIV infection has been attested in year 1987. Since then the country embarked on building its national response to the HIV epidemic. The initial period included sporadic cases until mid 1990s and in year 1995 an HIV outbreak was registered among injecting drug users. Starting with year 2000, the proportion of heterosexual transmission was increasing gradually and in year 2005 heterosexual mode prevailed over transmission through injecting drug use. Yet, as of the end of year 2008, IDU mode of HIV transmission still accounted for 50% of cumulative cases, sexual mode for 47.3%, perinatal mode for 1.3% and undetermined mode for 1.3%. The epidemic is still considered to be concentrated in most-at-risk populations (IDUs, FSWs, MSMs, prison inmates). Significantly higher percentages are HIV-positive in these groups compared to the general population and according to sero-surveillance studies the HIV prevalence does not show signs of decrease in MARPs. Although still under 1%, some subpopulations in the general population become increasingly affected, such as migrants and youth, and increase in HIV prevalence has also been registered in pregnant women and blood donors.

Since year 2002, the HIV epidemic process is characterized by an increase in heterosexual transmission route, feminization of the epidemic and geographical spread in all administrative units of the country, including rural areas. As of January 1, 2009, the HIV prevalence constituted 94.8 on the Right Bank and 285.8 on the Left Bank, with an average total prevalence of 121.6. As of January 1, 2010, a cumulative number of 5,700 HIV cases were registered, including 1,794 in the Transdniestrian region.[5] The absolute number of newly detected HIV cases has increased from 360 cases in year 2004 to 795 new cases in year 2008, therefore the global incidence has increased more than two-fold to 19.3 in year 2008 (including 63.8 for Transdniestrian region) compared to 8.4 in year 2004.[6]

Until year 2000 the main HIV transmission route was through injecting drug use, but since year 2004 the heterosexual transmission route prevails, it constituted 75.8% in year 2008 compared to 48.2% in year 2004. The feminization of the epidemic brought to an increase of the share of HIV-infected women from 26.5% in year 2001 to 43.9% in year 2009.[7]

Several subpopulation groups are thought to be at higher risk of acquiring HIV in the general population: mobile populations (e.g. migrants and truck drivers), young people, sexual partners of people engaging in high-risk sexual encounters (partners of migrants, female partners of clients of FSWs), but few prevalence studies have been conducted thus far to document the actual transmission rates in these subpopulations. A survey to estimate the HIV prevalence in migrants is currently under way and will be finalized in 2010. The National AIDS Center reports that a cumulative number of 194,618 tests have been performed in migrants prior to leaving the country in the years 2003-2009 and 166 were HIV-positive, a prevalence of 0.09%.[8]

HIV/AIDS Epidemic Feminization

The feminization of the epidemic brought to an increase of the share of HIV-infected women from 21.8% in year 1996 to 43.9% in year 2009(Figure 1). The highest proportion of HIV new cases among women were registered in year 2004, when 45.0% of new registered cases were women.[9]

Figure 1 Trends in the proportion of women in HIV incidence, years 1996-2009, Republic of Moldova

The coverage of pregnant women with HIV testing during 2003-2007 is within the 96.0-99.4% range. An increase in the number of newly reported HIV cases among pregnant women has been attested in the period of years 2002 - 2006 with HIV prevalence among pregnant women going up to 0.18% and being on a decreasing trend to 0.14% in year 2009 (Figure 2).[10]

Figure 2 Trends in HIV incidence among pregnant women screened for HIV, year 2002-2009, Republic of Moldova

Gender Policies and Institutional Framework in the Republic of Moldova

In the Republic of Moldova the legislation and the policies in the area of gender equality are quite well developed. The gender equality is a founding principle set by the supreme law, the Constitution, and there is a specific law on gender equality. The Republic of Moldova has adhered to the Millennium Development Goals (MDG) where the thirdpriority is promoting gender equality and has included this objective in its Strategy for National Development. In addition,a national program to promote gender equality has been developed for the years 2010-2015. The Republic of Moldova has adhered early on to international conventions addressing gender inequality: it has ratified Committee on the Elimination of Discrimination against Women Convention (CEDAW) in year 1994.

The Constitution of the Republic of Moldova establishes that men and women are equal in front of law and local pubic authorities. [11] A law that promotes equal opportunities for women and men was adopted by the Parliament on 9 February 2006. Its main goal is to ensure exercise of equal rights of women and men in the political, economic, social and cultural aspects of life, which are guaranteed rights by the Constitution of the Republic of Moldova, in order to prevent and eliminate all forms of gender-based discrimination.[12]

In reality, some experts consider that the gender equality legislation is mainly declarative, including because of patriarchal traditions and the traditional perceptions regarding women's role in the society.[13] A report on monitoring the implementation of the new law has shown that its implementation is difficult because of insufficient legal enactment mechanisms and poor familiarity of the population and employers with the content of the law.[14]