Gender Dimensions of the HIV and AIDS Epidemic Valerie Beach Horne

Thirty years into the AIDS epidemic, three years before the time set for achievement of the Millennium Development Goals (MDGs) and despite the many advances in care and treatment, available evidence shows that more females than males are affected by the disease.  Women account for nearly half of the estimated 34 million people living with HIV worldwide . In sub-Saharan Africa, over seventy per cent of the young people (aged 15-24 years) living with HIV are female while in 2011 in the Caribbean, fifty three percent of people living with AIDS were women.
If the spread of HIV is to be reversed, the critical role that gender relations plays in an individual’s sexual and reproductive life, and how it affects HIV prevention must be addressed. The changing face of the epidemic brings into sharp focus the need for a Human Rights approach to care and treatment.  Only by so doing can we reduce the gender and social inequalities that shape people's behaviours and limit their choices.
Let us examine some of the contributing factors
1.    Many HIV prevention strategies and approaches tend to assume that we live in an ideal world where everyone is equal, free and empowered.  They do not take into consideration that varying circumstances can prevent even the well intentioned from opting to abstain from sex, stay faithful to one partner or using condoms consistently. Expecting consistent use of condoms becomes irrelevant and not the first priority, if a woman is being beaten and raped.   
2.    In reality, in some societies, and based on economic circumstances many women and girls in particular, face a range of HIV-related risk social factors and vulnerabilities that men and boys are exempt from. Many women are in danger of being beaten, abandoned or thrown out of their homes if their  HIV-positive status is known, regardless of the source of their infection.
3.    Gender is a factor in health-seeking behaviour.  Stigma associated with HIV & AIDS is a major factor preventing many women and men from accessing services.  This fact is exacerbated by societal status, norms and values, e.g. for sex workers and  difference sexual orientations.
4.    Male identity is very much linked to sexual performance.  In many societies including ours, men feel pressured to have several sexual partners and experiences to 'prove' their masculinity. Safer sex, which entails a reduction in the number of possible partners, avoiding "one night stands" and greater selectivity in sexual partnership may therefore be seen as a threat to masculinity. Young men, in particular, may feel pressured to take unnecessary risks to assert their male identity.
5.    The other side of the coin is very different.  In some societies, if a woman for her own safety seeks information about safe sex, she may be considered promiscuous or adulterous. In cultures where  high value is placed on virginity, some young unmarried women and young girls may engage in high-risk behaviors such as anal sex to preserve their virginity.  In addition, a woman’s risk for HIV is further exacerbated because she is physiologically two to four times more susceptible to infection than a man. Women have a larger mucosal surface where micro-lesions can occur. Young girls and adolescents, due to their under developed reproductive tracts, are even more susceptible to STIs and HIV.
6.    Vertical STI and HIV and AIDS services may deter vulnerable women and transgender persons from accessing care.  In addition, health providers need to be aware of and sensitive to the possibility of gender violence in the home which can impact negatively not only on accessing care, but on disclosure of HIV + status.
7.    Changes in the family structure due to economic vulnerability of women and men resulting in economically motivated migration and homes headed by grandparents or older siblings.  Men also become vulnerable due to migration and occupation, for example, long haul drivers, soldiers or policemen and miners.

Much sexual risk-taking by girls and young women is marked by unequal gender relations, and unequal access to resources, assets, income opportunities and social power.  We must take into consideration the role of sexual exploitation at work and at home, transactional and intergenerational sex.  In this regard more must be done to ensure sustainable livelihoods for women and girls, particularly those living in female-headed households.  Doing so will equip them to protect themselves against HIV infection and deal with its impact. Creating economic opportunities and social power for women should be seen as an integral component of potentially successful and sustainable AIDS strategies.
In addition we must accept the fact that the vulnerability of same-sex practicing, and gender non-conforming men and women drives an interlocking set of human rights violations and social inequalities.  These factors which result from their sexual and gendered behavior and identity, heighten HIV risk and produce disproportionate HIV prevalence.

Gender issues Need Revisiting in the Caribbean
HIV affects women and girls and is disproportionately affecting transgender persons as well.  Therefore gender issues can no longer be limited to or defined by conventional male or female socially accepted roles.  The issue of gender must be ventilated at all levels of society so that we can achieve a clear understanding of how many genders exist in the region and what role sexual orientation plays in the redefinition of gender.  Issues confronting gay, transgender or transsexuals should be taken into consideration in this debate.    We also need to consider the following:
1.    A Rights Based approach to HIV&AIDS and other reproductive health services must become the norm and not the exception.  Far more must be done to ensure sustainable livelihoods for women and girls.  
2.    If HIV-prevention activities are to succeed, they need to occur alongside other efforts that address and reduce violence against women and girls; particularly those living in female-headed households.
3.    Development of gender sensitive strategies designed to raise awareness among women, men, boys and girls about the ways in which gender differences affect them.
4.    Review of the present definitions of masculinity and femininity and identify ways in which the specific needs of all gender can be met.
5.    Creation of a truly enabling environment which would promote awareness of the dire impact of AIDS on the entire community, encourage improved dialogue between the sexes at an early age, and enhance the sensitivity of men and women to the changing nature of societal roles including sexual roles
Women and AIDS" chapter of the AIDS Epidemic Update 2004 (UNAIDS WHO)
UNAIDS KS111 (2011)