HIV/AIDS &

Gender Equality

For additional information on the World Bank’s approach to Gender and HIV/AIDS, please contact A. Waafas Ofosu-Amaah (x85872) or Elizabeth Lule (x33787)

Why Gender Equality Issues are Important in the Fight against HIV/AIDS

HIV/AIDS threatens human welfare, socio-economic advances, productivity and social cohesion. This pandemic does not affect all people equally. The imbalances between female and male risks and vulnerabilities have become evident as the differences in the rates of infection have grown. Although at present more males are infected than females, women’s infection rates have spiraled. In Sub-Saharan Africa, where HIV/AIDS is the leading cause of death, young women (15-24 years) in some countriesare six times more likely to be infected than are young men.

Key Issues to Consider

  • What are the differences, in gender roles, gender division of labor, access to resources, legal protection, and decision-making that affect women’s and men’s abilities to protect themselves against HIV/AIDS?
  • Do sector-specific interventions incorporate a gender-sensitive approach to HIV/AIDS prevention, treatment, and care?
  • Do sectoral ministries and national HIV/AIDS strategies incorporate relevant gender issues into HIV/AIDS policies and implementation?
  • How do capacity building programs for public and private sector workers and civil society participants address gender issues?
  • Do monitoring and evaluation systems assess different impacts of project activities on males and females and include gender-sensitive indicators?

Factors Contributing to Gender-Based Inequalities in HIV/AIDS

Gender inequality and the role of power in sexual relations, especially women’s and men’s relative access to economic resources and power, are important factors in the spread of HIV/AIDS.

Economic factors: Economic dependency and insecurity are at the core of the gender dynamics of HIV/AIDS. For both married and unmarried women, their comparatively limited access to and control of economic assets increase the likelihood of their: 1) inability to negotiate safe sexual practices; 2) likelihood of exchanging sex for money (survival sex); or 3) pressure to stay in a relationship that they perceive to be violent or risky. In HIV/AIDS affected societies, women’s and girls’ responsibilities for family and community caregiving can increase as they are called upon to meet the demands for care that exceed the capacities of health systems. Under normal circumstances, these activities limit women’s participation in productive economic activities (such as farming, school attendance, and income generation). A recent study in South Africa revealed that households experiencing illness or death from HIV/AIDS were twice as likely to be poor than non-affected households. The burden on women and young girls in the care economy is increasing. In Swaziland, girls’ school enrollment is estimated to have fallen by 36 percent as a result of their having to provide home-based care while their mothers or grandmothers seek waged employment.

Widow-headed households are likewise disproportionately vulnerable to poverty. In Rwanda, female widows of AIDS-victims make up 22 percent of all households and the rate of extreme poverty is 49 percent. Due to poverty, boys also put themselves out into the street to earn money, sometimes by offering sex services. Rising urbanization and migration in the quest for employment, especially employment that separates families, also increase both male and female risk. Some commercial sex workers resort to unprotected sex because of the higher economic gains that riskier practices could bring.

Socio-cultural factors:Some socio-cultural norms prevent both women and men from obtaining critical information about HIV/AIDS. For example, many societies have a culture of silence around sexual matters and an emphasis on virginity for young women and girls. Female participation in voluntary testing and counseling (VCT) is often lower than it could be because some females risk abuse, discrimination, or rejection if they test positive. Evidence from two pilot projects in Côte d’Ivoire and India confirm that when offered VCT as an isolated service, women, especially pregnant women, are less likely to attend because of the stigma attached to it. Integrating VCT with existing health services can reduce the stigma associated with HIV/AIDS.

In many cultures, notions of masculinity are associated with pride/machismo/cool that emphasize multiple sex partners and a presumption of sexual knowledge. Some cultural practices which have sexual components or connotations, such as female genital cutting (FGC), widow inheritance, and ritual cleansing, also increase vulnerability to HIV/AIDS. Other cultural and traditional practices and norms, such as circumcision and loyalty to one partner, have been shown decrease HIV risk and should be part of prevention efforts.

The stigmatization of men who have sex with men (MSM) in many instances causes males who engage in those activities to demonstrate their masculinity by having heterosexual sex as well, exposing their male and female sexual partners to HIV risk. Some male-dominated professions, which require long absences from home, such as truck driving, mining, and migrant work tend to be associated with risky sexual behavior.

Legal factors: Gender-discriminatory legal and regulatory frameworks covering HIV-relevant issues such as reproductive health, marriage, rape, sexual abuse, inheritance and succession, access to property rights, and land tenure have implications for gender-based vulnerability and risk factors. These frameworks may also reduce victims’ access to HIV services and treatments. In many countries, women lack legal recourse and experience discrimination in legal rights and protection. Many systems of law favor male ownership of property or assets. Some legal systems do not adequately protect victims against sexual violence between intimate partners. And many legal systems, by outlawing homosexual practices, drive the activity underground, which can increase risky behavior.

Physiological factors: Because of anatomical differences, women are many times more likely than their male sexual partners to contract HIV and other sexually-transmitted diseases (STDs). There is also a 30-45 percent risk of mother-to-child transmission (MTCT), especially with prolonged breast feeding. This is the primary cause of infection for the 2.3 million children (0-14 years) living with HIV/AIDS worldwide. Research is currently underway to identify measures to counter women’s physiological vulnerability to HIV/AIDS. These measures include female-controlled prevention methods, such as microbicides and the female condom. Testing and treating HIV-positive pregnant women with antiretroviral medication also significantly reduces the rate of MTCT.

The World Bank and HIV/AIDS

The World Bank is the largest long-term financier ofHIV/AIDS prevention and mitigation in developing countries. Recently, the World Bank’s Africa Region HIV/AIDS Agenda for Action (AFA) 2007-2011 was released. The AFA acknowledged the urgent need to respond to the deepening gender-based inequalities in rights and status that are exacerbating young girls’ and women’s HIV vulnerability and risk. The World Bank collaborates with stakeholders from civil society, the private sector, and multiple agencies of government to emphasize the feminization of the epidemic. The AFA calls for conducting knowledge sharing workshops to build capacity among decision makers to address the gender and legal dimensions of HIV/AIDS among law, justice, medical, and health professionals. The Agenda emphasizes the importance of establishing gender-sensitive indicators that reflect the goals and targets established by a country, or by the international development community, such as the Millennium Development Goals, or the United Nations General Assembly Special Session (UNGASS) Declaration on HIV/AIDS.

The Gambia: HIV/AIDS Rapid Response Project

In 1991, a group of women operated a one-room clinic to improve health outcomes for women and combat HIV/AIDS in their village. Today, the

Foundation for Research on Women’s Health, Productivity, and the Environment (BAFROW) is a fee-for-service network of clinics that operates in three districts, and plans to replicate its programming in additional districts. BAFROW offers services and preventative care to women, men, and youth, with support systems focusing on economic sustainability through entrepreneurial education and full beneficiary participation. As of March 2006, more than 60% of grants had been awarded to women’s groups.

A Social and Gender Assessment of HIV/AIDS among Refugee Populations in the Great Lakes Region

In 2005, the World Bank conducted a study on the HIV vulnerability and risk of internally-displaced people (IDPs) of the Great Lakes Region of Africa. This region is currently experiencing high levels of forced migration and displacement, leading to economic and social vulnerability. The crowded encampment of the refugee camps, growing poverty, poor living conditions, and lack of formal work often lead women and girls to engage in high-risk sexual activities for additional food or income.

Strikingly similar characteristics in all countries in the region include: (i) The use of sex as currency; (ii) Increased sexual and gender-based violence that is fueled by displacement and uncertainty about returning home and feelings of powerlessness; (iii) Inadequacies of health services to promote prevention and treatment.

Providing information on HIV prevention and condom use may discourage future high-risk behavior. This assessment recommended improving health facilities to better detect HIV/AIDS and STIs among IDPs; peer education about vulnerability and risk factors; and better provision of basic services so that women and young girls do not have to engage in risky sexual behavior.

Building a Gender-Informed Response to the AIDS Crisis: A Trainers Facilitation Manual

In 2007, the World Bank’s Africa Region developed a Trainers Facilitation Manual was developed to: (i) enhance capacity and knowledge about the role that gender plays in the spread, control, and management of HIV/AIDS; and (ii) create core teams of trainers in each country to train field workers on how to integrate gender dynamics into their work. This manual includes:

  • Tools for training field workers on how to integrate gender into their HIV and AIDS activities;
  • Information on the gender dimensions of HIV and AIDS;
  • Monitoring and evaluation methods to assess progress of training methods.

Expected outcomes of the training course are the understanding, implementation, monitoring and evaluation of key gender dimensions in national HIV/AIDS programs at the macro level for developers and governments. At the meso-level and micro-levels, outcomes are specified for service providers, non-governmental organizations, and recipients of services.

For additional information on the World Bank’s approach to Gender and HIV/AIDS, please contact A. Waafas Ofosu-Amaah (x85872) or Elizabeth Lule (x33787)