AIDS: The State of the Art

Document on Women in the HIV/AIDS Epidemic

Susan Vandale(I)

Introduction.

Fifteen years after the HIV/AIDS epidemic was first known, the XI International Conference on AIDS was held in Vancouver, B.C.,Canada, from July 7 to 11, 1996. As in earlier international conferences, this event was held as a scientific and social exercise aimed at rapidly communicating to all the countries of the world, the status of knowledge concerning HIV/AIDS and for fast adoption of strategies which are deemed useful for the control of the pandemic.

According to official information, fifteen thousand delegates attended the XI Conference at a cost of approximately 18 million dollars. The program of events included 16 plenary addresses summarizing the most important advances and 163 sessions concerning important themes. In addition, there were more than 6,000 presentations in poster format, and a fraction of these were commented in oral sessions. All the thematic sessions were divided into four "tracks": 1) basic sciences, 2) clinical sciences, 3) epidemiology and public health, and 4) social aspects and policy formulation. There were also three pathway divisions, one of which referred specifically to women and AIDS.

This document summarizes the state-of-the-art of research and activism related to the HIV/AIDS epidemic in women. The monograph focuses on issues related to public health and social aspects of this epidemic. We consider here, the current knowledge in this area before the Conference, as well as that which was made available during the recent event. It also alludes to those themes which are considered to be the main challenges for the future. The document concludes with a short list of recommendations concerning research and action to prevent and control AIDS in the female population.

Furthermore, this document is concerned with research and action for the control of the HIV/AIDS epidemic in women of Latin American and Caribbean countries and, on the other hand, with those aspects which appear to be useful for work on AIDS in this part of the world. It is already widely known that the epidemic is having a great impact on the female population in this region; nevertheless, there is very little information on this subject. When the international literature is consulted, it would appear that the epidemic is not a serious problem for women in this part of the world, except, perhaps, in Brazil, Honduras, and part of the Caribbean.

Given the fact that the epidemic in this part of the Americas has not reached the levels it has in Africa and Asia, we still have an opportunity to implement interventions which can help prevent this situation from reaching disastrous proportions. In order to be able to do this, there must be more research and action in the region. There is particular need to focus on a number of economic and cultural factors which are aggravating the AIDS epidemic in women. Among these factors are the economic crises and the poverty which are affecting a large part of the population, as well as the clearly unfavorable gender relations which are widely prevalent in the majority of the countries in the region.

It is well known that there are particularities related to gender relations in this part of the world, and that these create a great difference between what is expected of men and what is expected of women. These factors in themselves cause important social inequalities between the sexes, and in the context of the AIDS epidemic, they have enormous consequences (1) .

In addition to these problems, there are others which should be mentioned. These include: the long delay in starting-up studies on the specific problems of women in the epidemic, the reduced number of research and action projects to date, and the shortage of funding which has been assigned to this kind of work(2).

This document was written to serve as a source of information for decision makers in health, economics and related areas, with regard to the ways that the epidemic affects the female population. The monograph takes the position that there are certain social, cultural and economic factors shared by Latin American and Caribbean countries which expose the women of this region to high HIV risks. It is hoped that the issues which are presented here will be useful for governments and other organizations in their considerations about what types of actions could be effective in helping slow down the epidemic in the female population in Latin American and Caribbean nations.

If correct public and social policies are speedily implemented, there is still time for effective actions. What is needed here is to work toward three different broad tasks; these are: 1) specific programs which serve to curb the expansion of the AIDS epidemic in women in the region; 2) actions aimed at improving the health and well being of the women who are living with the virus, while taking measures to ensure that the sons and daughters of these women are able to live a decent life; and 3) improvements in the social conditions of all women with regard to their rights and opportunities, so that they can take steps to better protect themselves from HIV infection.

What was known on this subject before the XI Conference

General data on the epidemic

One decade ago, most people thought that the AIDS epidemic mainly, if not exclusively, affected people with high risk personal behaviors, such as male homosexuals, users of intravenous drugs (IDU) and sex workers. This judgement resulted from incomplete evidence derived from observations in the first years of the epidemic in the United States of America and several European countries. A few years later it became clear that this initial appraisal was false, and that in parts of Africa and in Haiti, men and women were suffering alike from the AIDS epidemic. In these parts of the world, the two sexes were almost equally affected by the virus as a result of the dominant heterosexual epidemic(3).

At the present time, there are estimates that more than 21 million people in the world are living with HIV/AIDS. Women make up 42% of this population, and this proportion will be increasing in the upcoming years. For the year 2000, there will be as many female as male AIDS cases(4). All this means that within a shorter or longer period of time, according to country, the epidemic will reach the general population. At that time, the rates of HIV infection in women will begin to surpass that of men, due to the greater vulnerability of women to the HIV virus. In several countries in the African Sub-Sahara, where the epidemic has been active for several decades, this is already the case(5).

There has been much discussion of the role of poverty as an important factor in the world epidemic. It is known that the great majority of new infections happen in developing countries, and, as time goes on, it is clear that more AIDS cases occur in the most economically deprived sectors of most nations(6). Furthermore, it is known that women are part of the poorest population in almost all parts of the world. This situation complicates the possibilities of women to protect themselves from HIV infection(7).

The Latin America and the Caribbean region accounts for 13.4% of the total AIDS cases in the world and 29% of the cases in the American continent. Moreover, there are estimates that 1.3 million people are living with HIV/AIDS in Latin America, representing 6% of the infected people in the world(8). In terms of total numbers and case incidence rates, the epidemics in Brazil and Honduras are by far the most important in all of continental Latin America.

In the Caribbean, it is estimated that there are more than 250,000 persons who live with the virus and this figure corresponds to 1% of the world total. The case rates in several Caribbean nations are extremely high. For example, the prevalence of infection in Haiti and the Bahamas is only surpassed by some parts of Africa.

At the same time, we know that the characteristics of the AIDS epidemic are not uniform in all countries of the region. This has resulted from the different periods in which HIV was introduced in one society or the other; it is also related to particular social and economic conditions which differentiate the subregions. It should also be pointed out that 7 out of 10 HIV infections in the region occur in Brazil and Mexico. Similarly, just two countries, Haiti and the Dominican Republic constitute 85% of all the cases in the Caribbean area.(4) (The many cases in Puerto Rico are usually reported as part of those in the United States of America).

At a global level, heterosexual relations account for 70% of all virus transmission(8). Nevertheless, in the Latin American and Caribbean region, as in North America, homosexual and bisexual behaviors continue to be the cause of most AIDS cases. On the other hand, transmission by heterosexual contact is rapidly increasing in almost all countries in the region. HIV infections associated with the sharing of needles and syringes among intravenous drug users (IDU ) is also important in some large cities of the region(9).

At the same time, in all Latin American and Caribbean nations, there is a marked decrease in the proportion of AIDS cases in men as compared with women. Recently, the cumulative AIDS case ratio (males/females) was 4: 1 in Latin America and 1.6:1 in the Caribbean(10). These rates indicate that the heterosexual component of the epidemic is on its way to dominance in the region. This situation results from the extension of the epidemic to the general population, and, therefore, over time the impact will be similar in males and females. Furthermore, the problem of AIDS is an even greater source of preoccupation in the region, with low levels of condom use and high prevalence of people who have multiple sexual relationships. This last characteristic is especially true for men(4).

In the majority of Latin American and Caribbean countries, some studies have been carried out concerning HIV sero-prevalences in specific female populations, such as sex workers and pregnant women. Great differences are observed in the figures which result from these surveys, from society to society, and from city to city within countries. For example, in surveys held from 1990 to 1995, there were reports of sero-prevalences as low as 0.0% in pregnant women in urban areas of Colombia and Cuba, while these ranged from 2 to 7% in cities of the Bahamas, the British Virgin Island, Guyana, Haiti, and Honduras. Among female sex workers in urban areas in the same period, HIV prevalences were seen to vary from 0% a 5% in Aruba, Colombia, El Salvador, Dominican Republic and Mexico; at the same time, there were reports as high as 15 to 70% in Honduras, Guyana and Haiti(11).

Sero-prevalence data concerning pregnant women and female sex workers provide useful information for the health care services, and when tests are performed on a voluntary basis, they can be an advantage for individual women. The results of these studies tend to be helpful in planning strategies to halt the spread of HIV from women to men and from women to children. On the other hand, it is difficult to determine what is happening with regard to HIV prevalence in heterosexual and bisexual men of the general population. No doubt they are implicated in the chain of events; nevertheless, they tend to be "invisible" in the light of the methodologies most used to obtain information on sero-prevalences.

For this reason, many activists and scholars who work on aspects of the epidemic say that most sero-prevalence studies result from a wrong emphasis which tends to place the blame on the "victims". In the case of the female sex worker, it is much easier for the client to transmit the infection to her than vice versa, because of the difference in levels of infectivity from men to women in comparison with that from women to men. Moreover, the great majority of pregnant women have been infected by their husband or stable sex partner.(12)

Virus transmission in women

At the present time, it is necessary to recognize that a great part of the AIDS epidemic is occurring in the heterosexual population and, therefore, women in general are at risk of infection. This situation is already evident in a number of countries of the region, including Mexico, Chile and Honduras, where the large majority of the AIDS cases occur in housewives and a very small fraction corresponds to sex workers. For these reasons, it is urgent that broad measures be implemented to support social change that can help reduce the risks of HIV infection in the general female population(13).

This task is complicated by the fact that the majority of women have only one stable sex partner and, therefore, do not consider themselves at risk of HIV infection. They tend to trust their sex partner and, for this reason, are not demanding the use of the condom nor questioning their partners about whether they have sex relations with other people or habits of drug abuse(14).

At a global level, contaminated blood transfusions are not a very important cause of AIDS, representing only 3% to 5% of the total cases(8). On the other hand, this exposure route has been clearly a problem in the epidemic in women in several Latin American countries. This situation results from the contamination of blood banks which occurred in several parts of the region during the second half of the past decade. The blood problem has had a greater impact on AIDS in the female population in the region. Women received, and continue to receive, more blood transfusions than men due to the high prevalence of Cesarean sections and other gynecological surgeries.

In a few Latin American countries, such as Mexico, where it was possible to document the impact of contaminated blood banks(15), it is known that blood transfusion was the cause of the first AIDS epidemic in women. Acting in response to this threat, almost all goverments in the region have taken great efforts to assure the innocuousness of blood bank supplies. It is evident that blood and blood products will have to be monitored for many decades and at a high cost. It is also clear that it will be necessary to further rationalize the requirements for performing surgery and for providing blood transfusions, in order not to expose women unnecessarily to this potential risk(8).

Each year, more illegal drugs are produced and distributed in Latin America and the Caribbean. There also exists a trend toward the use of the more addictive drugs such as heroine and cocaine. There is a subepidemic of AIDS in the majority of countries in the region which is caused by contact with infected needles and syringes. Most nations in the region have not reported drug use as an important HIV transmission route; on other hand, it is known that a great number of women have been infected indirectly by this risk behavior, for having had sex with men who are drug addicts(16).

Only Brazil and other countries of the southern part of South America report intravenous drug use as an important exposure route in women(10). In the case of Brazil, the route of the AIDS epidemic in both men and women, has been traced from city to city and from town to town along the roads which serve for drug trafficking(17).

Vertical transmission

According to official estimates, as of the middle of 1996, approximately 3 million children have acquired HIV, and one-fourth of them were infected by their mothers during pregnancy or at the time of birth. Of the 500,000 children world-wide who were infected by mother-to-child transmission during 1995, 10,000 live in Latin America and 5,000 in Caribbean countries(8). The contribution of this exposure route to the country-level epidemics varies, and this is largely dependent on the prevalence of the virus in the female population. For example, it is reported that the following proportions of all cases are due to vertical transmission: Andean Area , 1.7%; Southern part of South America, 3.3%; Brazil 2.7%; Central America, 3.3%; Caribbean nations, 8.0%; Mexico, 2.0%(10).

At the global level, more than 75% of the women who are living with HIV/AIDS are of reproductive age. Therefore, many of them have one or more pregnancies after they become infected. When the mother infects her child, this is referred to as vertical transmission. With the objective of having more information on this problem, health institutions in many countries are providing voluntary testing for HIV in the prenatal and obstetric services. Nevertheless, the great majority of pregnant women never receive an HIV test, because of limited health care coverage or due to the fact that they do not ask for it, as they consider themselves at low risk for AIDS. When the epidemic began to spread throughout the general population, it was seen that the only a few of the women had some risk behavior, and for most of them, the risk resulted from having an infected husband or stable partner. Whatever might be their exposure route, all seropositive pregnant and post-partum women deserve the very best medical care available, for their own health as well as their infant's(18, 19).

Vertical transmission is a relevant issue in the AIDS epidemics throughout the world. Part of the impact of this transmission is due to the sad fact that HIV-infected babies and young children will live only a few years at best. It is also true that the testing and treatment needed for the illnesses of HIV infected children are not usually available and too costly for developing countries(20). Up until some months ago, vertical transmission occurred in 25% to 35% of all infants born to HIV infected women. Recently, it has been shown in a clinical trial that a smaller proportion, 10% to 15% of infants, are infected when the mother undergoes anti-retroviral treatment from the first trimester of pregnancy and when both she and her child receive treatment with these drugs in the first few weeks after the birth.

Another problem related to vertical transmission which continues to be a source of concern is the small fraction of the children who become HIV-infected from breast milk. Breast feeding of babies has been the universal recommendation of the World Health Organization, because it is hygienic, nutritious and has excellent immune qualities. This health policy has been changed for HIV infected mothers in areas of the world where there are good substitutes for breast milk. Nevertheless, in very poor countries there continues to be an important controversy over what infant feeding policy to follow. Meanwhile, in Tanzania and other poor African countries, the breast feeding of babies continues to be the norm, regardless of whether or not the mother is living with HIV/AIDS(21).

The rights of seropositive mothers and those of their children

It is in the interest of all countries to provide medical care and other services to improve the health status of that part of the population which is most needy. This is true because many of the most serious threats to health are created by society, and arise from negative factors as poverty, illegal drug traffic, and the paltry allotment dedicated to education and health services. In the case of HIV sero-positive women, it is clear that many of them are more like "victims of circumstances" than perpetrators of societal wrongs. Nevertheless, there is evidence which indicates that women who live with HIV/AIDS receive injustice at both social and institutional levels. While this problem has been amply commented, much remains to be done in order to understand and combat the most frequent forms of discrimination against HIV sero-positive women(22).

Discrimination is particularly important for HIV infected pregnant women who receive societal rejection, due mainly to their probability of transmitting the virus to their children. For this reason, in many nations of the world and of the region, there are groups struggling to protect the sexual and reproductive rights of sero-positive pregnant women, as well as those of all other HIV infected women.

There are a number of ethical problems in this context which are causing controversy. Among these are: the right to elective, and non-coercive, abortion for the pregnant women who do not wish to carry a child to term, the need to avoid a policy of forced sterilization of sero-positive women, as well as to prevent compulsory HIV testing in pregnant women(23).

Equally important from the ethical standpoint is the situation of the sons and daughters of sero-positive mothers, and here we speak not only of children who have contracted the virus, but also those who have not. Because HIV/AIDS often occurs in families, including father, mother and the small child, all of them will require long and complex medical care and. almost always, these costs cannot be undertaken by other family members. Moreover, sooner or later, the parents die of AIDS-related illnesses, and the other children of the family are left orphaned. These "other children" of the AIDS tragedy deserve to receive adequate care by other family members, or when this is not possible, there must be alternative living arrangements provided by the government or private institutions. With the growing numbers of orphans resulting from the AIDS epidemic, it is necessary to take legal and administrative action to assure temporary and permanent care for these children(23).

It is estimated that before the year 2000, from 5 to 10 million children in the world will be orphaned due to the AIDS epidemic. As examples at the regional level, there are predictions that in the same year, there will be approximately 30,000 orphans in Honduras and 40,000 in the Dominican Republic(9).

The XI Conference: main themes and relevant issues

This section of the monograph is an analysis of the information on women and AIDS which was presented during the recent Conference. It has the purpose of outlining the current trends in our knowledge of the epidemic and the state-of-the-art of research and action related to this theme. This part of the document comments on the main themes and relevant issues in conference abstracts concerning women in the AIDS epidemic, regardless of the country of origin, but giving special attention to the information concerning women and HIV/AIDS in Latin American and Caribbean countries.

This analysis results from two types of activities. First, the author was present in the majority of sessions which were mentioned in the Conference program as referring to the track on " Women and HIV" (see the description of the Conference in first page of this document). After having listened to the material which was presented in these sessions, the second step was to organize the information which was presented in the Conference. This task was made easier with the use of the information bank which included the more than 6,000 papers presented in the Conference. The information bank was prepared by the drug company "Merke" in the form of a software program comprised of three diskettes, and was made available to Conference delegates free of charge.

The search was done by asking the Conference information bank program to provide all the papers which included the words "women" and "epidemic". The search produced 126 papers, with their corresponding abstracts. It was necessary to limit the number of papers to be discussed in this document to a subset of all the Conference material on women and AIDS; 50 abstracts were chosen, representing material from almost all parts of the world. Brazil, Mexico and Argentina produced most of the papers from the Latin American and Caribbean region, with 27, 8 and 3 abstracts, respectively. Almost all papers which referred to the region were included.

Actions for prevention in specific groups of women

Several groups of women have been identified as being particularly vulnerable in the HIV/AIDS epidemic. Up-dated material concerning the trends in female AIDS cases are very important for two reasons: first, this information helps to identify the groups of women who are most vulnerable; and second, it indicates the changes that are occurring in the epidemic in the past few years(24-26). The review of the information showed six papers concerning trends in the AIDS epidemic in Brazilian women(27-31) and one concerning Mexican women(32). The under reporting of AIDS cases is another aspect which is relevant for AIDS statistics because it makes it difficult to interpret the real trends in the epidemic. This theme was covered in a paper from Argentina, but it is an important problem throughout the region(33).

Another relevant paper was an analysis of all the HIV/AIDS research in Mexico, which showed that the epidemic in women has been a frequent theme for studies. Unfortunately, very few of these studies have been published in international journals.

It is necessary to focus our attention on the problems of the groups of women which are most affected by the HIV/AIDS epidemic. We do not know enough about why they are so vulnerable to the epidemic, nor why many of them have little HIV risk awareness. We need this information in order to develop strategies to help women reduce their risk of AIDS. The following groups have been identified as those mostly affected by the HIV epidemic.

Young women. In several countries of the region, the average age of female AIDS cases is from 20 to 30 years. This means that many of these women have acquired the infection during adolescence or soon after commencing sexual relations. There are a number of specific HIV risks for young women. Many of them are using the contraceptive methods which are highly effective to prevent pregnancy, and very few use condoms. It should also be mentioned that it is common for these women to have a sex partner who is some years older, and thus with a greater probability to have had ample sexual experience and be HIV infected. Very young girls have the additional problem of increased vulnerability due to their immature genital anatomy(29, 34-36).

The problems of the younger female population are a strong concern in the Latin American and Caribbean region, where in many areas, from 35% to 50% of the population is less than 20 years of age. There is no doubt that men and women in this age group are at high risk of HIV. Nevertheless, the women living with HIV/AIDS tend to be younger than the men with the infection(31), due to the highly generalized custom of men to have female sex partners who are some years younger.

Sex workers. Given the difficult economic conditions and social unstability in many areas of the world, large numbers of women are forced to do sex work, where they are often exposed to high risks of sexually transmitted diseases including HIV infection(37-39).

In this region, as in most parts of the world, there have been more research and action projects concerning sex workers in brothels and other types of establishments, such as bars and massage parlors. On the other hand, there is an important expansion of the numbers of women who are now doing part time sex work for drugs and for other needed goods and services. Many of the new groups do sex work in the streets, where they lack physical protection against violence and are exposed to high HIV risk(40-41).

Women with a male partner who has multiple partners. There is another group of women identified as being at high risk of HIV infection. These women have a stable male partner who has sexual relations with other partners; furthermore, a fraction of these men also have sex with other men. Many of the women in this group are married and do not consider themselves at risk of HIV infection. Given the clandestine nature of the sexual behavior of these men, it is extremely difficult to identify the women who make up this group. Nevertheless, given their vulnerability to the AIDS epidemic, it is necessary that research be carried out concerning this problem. There were several reports on the prevalence of this problem in Brazil, and how this has been an important factor in the AIDS epidemic in women in that country(27, 42-44).

From a more positive viewpoint, there are reports of projects in Africa and other parts of the world(45), where they are carrying out national and local campaigns, aimed at helping women to better understand this kind of risk and take an active role in promoting safer male sex behavior.

Pregnant women. It is known that pregnant women are one of the most vulnerable groups of the population, and in the age of AIDS, this fact is even more evident (46). In many countries of the world, anonymous HIV testing is being carried out in the population of pregnant women in order to estimate the probable trends in vertical transmission. This type of studies are referred to as sentinel surveys and are used to monitor the general course of the AIDS epidemic. There is a great deal of concern about whether this kind of testing is ethical, because it is useful only as a research tool and is costly. Because the testing is not linked to personal data, the results cannot be used to inform individual women of their sero-positive status(47-49). There is also concern that more pregnant women should be given the option of voluntary HIV testing, without this becoming compulsory(46). This last problem has been amply discussed with regard to pregnant women in Brazil(50-52).

Problems for AIDS prevention in women

So far, the primary focus of national AIDS control programs has been on prevention in particular groups of the population. The growth of the HIV epidemic in women creates profound demands for the governmental programs which try to achieve prevention in this sector of the population, using the same strategies which were developed a few years ago. At that time, most people involved in AIDS prevention believed that, if they could identify the people who make up risk groups, it would be possible to reach those most likely to be infected and to offer them information and counseling. Today, most AIDS control workers agree that with this strategy, only a fraction of the population at risk can be reached. Moreover, despite the fact that many spokesmen for the AIDS epidemic are aware of the changes in HIV trends, this has not been adequately communicated to the general population in most countries, where they continue to associate AIDS with groups which often have high HIV risk behaviors, and heterosexual men and women do not consider themselves to be at risk(53-55). This situation was amply reported in papers from several countries during the Conference(34, 43, 56, 57).

The situation of drug addiction in women is particularly important in the AIDS epidemic in the United States and Canada (58, 59). It also affects the AIDS rates in women in several countries of the Latin American and Caribbean region(60, 61).

For all these reasons, it is said that women in general are socially vulnerable for the AIDS virus, and many persons are demanding that women be granted social power ("empowerment") in order to reduce their HIV risks(54, 62). If women are to take effective measures to protect themselves against HIV, it is necessary for them to have the knowledge and the means to carry out preventive methods. The great majority of the world's women do not have the capacity to take preventive measures, because they are dependent on men, and men almost always determine the moments and the conditions for sexual relations. Unfortunately, most men do not want to use condoms with their female partners. Moreover, the availability of condoms in sufficient amounts and at an accessible price for mass use has yet to be insured in most of the world(38,63, 64).

At the same time, national family planning programs in many countries have privileged contraceptive methods which are judged as highly effective in preventing pregnancy, and they have given minimal attention to barrier methods. In fact, many government-sponsored family planning programs do not recommend or provide condoms to their clients. Usually, these programs do not detect or treat sexual diseases. All this creates great obstacles for women to become knowledgeable about sexually transmitted diseases and to have the means to lower their risk of acquiring HIV. Thus, most women have not given much thought about the need for using condoms and/or other barrier methods.

Given all these considerations, it has become clear that women need to have "female controlled methods" and to be motivated to use them. Barrier methods should be inexpensive (which they are not at this time) and in adequate supply in order to assure that they can be used widely in all countries(65). Some new products, such as the feminine condom and microbicidal substances are now available, and a few organizations in the region are doing small scale studies to determine the acceptability of these methods(64).

It is also known that health care services of some countries are now starting to integrate what were several different programs for women. Thus, prevention of AIDS and detection and treatment of sexually transmitted diseases are being incorporated in family planning services, and this seems to be an important step for HIV control in women(66, 67). In order to ensure quality of care in the new services, it is necessary to understand the current limitations of health personnel (68). They need training to learn more about the the detection and treatment of sexual diseases in women and to develop positive attitudes toward persons living with HIV/AIDS.

Considerations on poverty, illegal drugs and migration

The concept of increasing "pauperization" has been used to characterize the epidemic in much of the world(30,69). It appears that this is a topic of supreme importance for AIDS control. It has been recognized that this situation existed from the beginning of the AIDS epidemic. The first countries in which the virus appeared, and the ones most seriously affected are the poorest, those with the least possibility of slowing down the epidemic. These nations suffer from social and economic crises, have low educational levels and strong pronatalist traditiosn. The female population of these countries has an even lower educational level and less economic resources than the male population, and, thus, the women are almost completely dependent on the male property and protection.

The marketing of hard drugs is another theme that is related to poverty and AIDS. There has been much written about drug addiction and its role in the epidemic in industrialized countries(54, 61, 59). In these parts of the world, actions have been taken to motivate women to reduce their risks associated with the use of drugs. By means of massive educational campaigns, IDU are urged to stop injections with needles and syringes that are potentially contaminated. Some countries have begun large-scale programs to offer clean syringes to IDU in exchange for those which have been used. This is only a stop-gap measure and there are still very few programs to offer the prolonged treatments which are needed in order to help female IDU to end their addiction to hard drugs(70, 58).

Combatting women's lack of social power

In spite of what might seem profound pessimism concerning women's vulnerability to HIV, there are some sources which report good news on groups of women that are beginning to take actions to protect themselves from HIV infection and to improve their general reproductive health. First, it has been shown in several countries that many women learn prevention skills and the means to negotiate the use of condoms with their male partners, when they have the opportunity to participate in small discussion groups (called "focus groups")(56, 66).

In some parts of the region, and particularly in Brazil, there are studies about ways to combine family planning services and maternal-child health care with those of HIV prevention, along with the detection and treatment of other sexually transmitted diseases. This type of care is called integrated reproductive health services. These integrated services have several advantages for women, inasmuch as they stress the combined use of safe contraceptive methods and barrier methods in order to avoid sexually transmitted diseases and HIV infection(66, 67). There is also much interest in strengthening the more traditional health services that are dedicated to detection and treatment of common sexual diseases, because many of these infections facilitate HIV transmission(70, 71).

Good results from focusing on multi-sector activism

Due to participation of goverment AIDS programs, community groups(72, 73) and other non-governmental organizations (NGOs) in the Conference, we received good news about the valuable work that is being done by different types of organizations, in the prevention of HIV transmission, as well as in providing physical care and promoting the human rights of seropositive people(74-77). Also, in several areas of the world, groups of seropositive women and men are organized and carrying out excellent AIDS control projects(78). To achieve better results, AIDS control activities should be based on multisector activism.

Topics which deserve more investigation and action

The situation of the rural women

Referring principally to the situation in Africa, some sources have commented on high HIV prevalences in rural communities. Most of the infected women in these areas have contracted the disease from their husbands or stable sex partners, who are or have been migrant workers in areas with high or medium HIV prevalence. For this reason, it is necessary to identify the characteristics of the migrants and their partners in such communities in order to understand the dynamic of what has been called the "ruralization" of the AIDS epidemic and to plan better intervention strategies. While there has been some mention of a similar situation in several areas of the region, there is almost no literature on research and action related to migration and AIDS in women in rural communities of Latin America and the Caribbean.

Prevention actions for and by sex workers

Organizations in several countries have carried out successful preventive action programs in groups of sex workers. There are also reports of how sex workers have organized themselves in order to struggle together to improve their working conditions and to do prevention from inside the sex trade. There was a Conference session in which sex workers spoke about their concerns. We need more documentation on the work being done to understand how sex work is related to the AIDS epidemic in the region and what types of prevention efforts have been successful in this setting.

Different forms of "machismo" and its impact in the epidemic

There can be no doubt that "machismo" is a strong cultural factor in Latin America. Nevertheless, this set of male customs has different expressions from country to country. Our search of Conference material produced only a few papers, and all of them concerned the situation in Brazil. In that country, and certainly in many more, an important part of the AIDS epidemic in women has come about because men commonly have several sex partners (some also have male partners). We know that this type of conduct is very widespread in the region, but there is little written about the problem and its potential solutions in other areas of the region.

On the other hand, there is some evidence that most of the national AIDS control programs in the region are not yet convinced of the need, nor prepared to carry out massive preventive campaigns, aimed at changing the heterosexual practices of the general population. Until this type of program is undertaken, with preference in collaboration with other organizations and community groups, the HIV epidemic in women (and men) will continue to expand.

Necessary actions for reducing drug abuse

There are many advantages which result from producing and offering services and products in the industries that are devoted to the "illicit" behavior, such as the hard drug market and the "sexual tourist trade". These terrible situations produce conditions that perpetuate the transmission of AIDS and other serious illnesses such as hepatitis B.

In almost all the countries of the region, and especially in those where there is little basis for sustained economic growth, characters emerge that create the necessary conditions in order to become multimillionaires at the expense of the society. The concentration of so much money coming from the international hard drug traffic causes deleterious influences on many parts of the political and social system; this situation has also had a strong impact on the AIDS epidemic in the Latin American and Caribbean region.

We need to know more about the strategies which can be used in order to combat drug trafficking and drug addiction in countries of the region, and particularly where this problem has been associated with higher rates of HIV infection in women.

Use of AZT in pregnancy to reduce vertical transmission

The use of anti-retroviral drugs for the purpose of reducing the rates of vertical transmission is just beginning to be carried out in small groups of pregnant women in some parts of Latin America and the Caribbean. On the other hand, due to their high cost and the lack of coverage for voluntary HIV testing in prenatal services, there is doubt as to whether these treatments can be generalized throughout the region. We need more local studies on the use of these drugs in pregnancy in order to derive regional policies on this matter.

Several topics related to poverty

One aspect related to poverty and AIDS is the role of women as the weaker part of the labor force. In general, the female population is a dependent sector, subject to staying at home, caring for family members, and deprived of rights for payment for their services. With too much to do, great stress levels and almost no money, women neglect their personal health, spending their efforts in pleasing others, offering them their time and their scarce resources. Recently, the economic crises have been involved in the creation of a great number of homes where the woman is the head of the family. In several countries of the region, the proportion of families with a woman as head adds up to 50% or more of the total.

When the woman is left alone to maintain dependent family members, she looks for ways to earn money. Without education and without contacts in the world of formal employment, most poor women accept work as domestic workers, launderers or traveling saleswomen. Some of them find that the sex trade offers more economic benefits than other potential employments, and in that environment they are exposed to high HIV risks.

The economic development plans of most countries look mainly for ways to expand opportunities for men to do work, because the male population is considered to be "more stable," more capable for heavy jobs, and requiring less additional compensations; (this can be read as days of absence for personal reasons which often include days for caring for children and other members of the family who are sick). Part of the answer to the epidemic of the AIDS depends on finding multiple options for employing women, so that they can rise above penury and thus overcome some of their risks of HIV infection and other sexual illnesses. Unfortunately, we know very little about how economic policies have affected women and their interaction with factors which increase the HIV rates.

Another topic related with the important levels of poverty in the region has to do with the constant movements of the population in search of employment. National and international migration is a requirement of the operations of modern economy and has been a decisive factor in the spread of HIV from one country to another and from one continent to another. We know that there are constant migratory movements from one country to another in the region and within the borders of each country. More frequently, migrants are men and they commonly return to their communities of origin. Some of them have been HIV infected and they transmit the virus to women in their home towns. Nevertheless, we do not have reliable reports on this situation.

Young women also migrate, usually from the countryside to the city, and their life in the new environment makes them change their customs, including those related with sexual behavior. Thus, many of them, far from their family, end up looking for sexual relationships with men. Frequently the men with whom they establish sexual relations are older and have had a greater chance of acquiring risky personal behaviors. The "maquila" industry or large-scale production for exports has been widely adopted in many countries of the region. This type of industry usually hires young women and a large part of them are migrants. As is the case with male migrants, we lack data on the real or potential HIV risks for young women migrants.

Some guide-lines for policy and action

The following section is a list of short-term recommendations on how to reduce HIV risks in women in Latin America and the Caribbean, while at the same time seeking to improve the health and the well-being of the women and children who live with the virus.

Need for research on many topics

It is urgent to promote more research on the AIDS epidemic in Latin American and Caribbean women, with regard to a wide variety of topics, and particularly those mentioned above. In order to summarize some points related to this enormous task, this section of the monograph is devoted to outlining some themes for priority research and action.

First of all, it is necessary to include the perspective of gender in the study of the AIDS epidemic; and here we refer to considerations on women's vulnerability to HIV infection because of both biological and social conditions. Also, it is necessary that certain risk factors in America Latin and the Caribbean be analyzed, factors that interact with gender relations such as "machismo", the economic base, the existence of indigenous groups, the role of women in the labor market, and the age structure of the population.

The following are some of the main issues that must be addressed in order to better understand the AIDS epidemic from a gender perspective(79):

Women's lack of HIV risk awareness;
Obstacles to the negotiation of safer sex practices;
The role of different social institutions as proponents or opponents in the AIDS control campaigns;
Models and effective schemes for integrated reproductive health services, including family planning, AIDS prevention, detection and treatment of sexually transmitted diseases and HIV/AIDS, maternal and child health care, and prevention of breast and cervical cancer;
Requirements of the different groups of women in the integrated reproductive health services, including sex workers, indigenous people, housewives and adolescents;
Models of individual and family counseling services on HIV/AIDS and for intervention programs for changing personal behavior;
The situation of women in the legislation at the country level, concerning their reproductive rights and regarding the rights of persons living with HIV/AIDS, as well as the those laws which influence the general social conditions of the female population, including legislation on work, abortion, right to inherit and sex work;
The international framework for the human rights of people who live with the HIV/AIDS and how this has been interpreted in the laws of the different countries and analysis of the structures which have been created in order to protect the rights of seropositive women and their children.

Urgent proposals for action

The following proposals represent necessary steps for slowing down the AIDS epidemic in women and improving the health and well-being of persons who live with the virus in Latin America and the Caribbean:

Include, in HIV/AIDS control strategies, the use of educational messages, which are geared to particular groups of women according to their life styles and their age group;
Achieve the production, distribution and lowered cost of female condoms and other barrier methods which women can control;
Support the efforts in order to increase the coverage and the accessibility of integrated reproductive health services, that include AIDS prevention, along with the detection and treatment of other sexually transmitted infections;
Increase the opportunities to send out educational messages to the general public with regard to risky sexual behavior and the real possibilities to adopt safer sex practices;
Support community groups and other NGOs in their projects aimed at fighting the expansion of the AIDS epidemic and at solving some of the problems of seropositive women and their families;
Consider adolescent women (and men) as the group that requires more sex education and AIDS prevention efforts, because they are in the stage of the life in which they could better incorporate the prevention behaviors;
Implement training programs for health personnel, at all levels, so that they can provide quality care to persons who live with HIV/AIDS, and motivate this group to actively participate in prevention activities;
Search for more funds for research-action and establish multi-sector alliances and collaborations.

There can be little doubt that the efforts of governmental and other macro-social prevention programs have to find "echo" in actions in the local communities. In addition to voluntary behavior change campaigns, it is essential to undertake innovative community strategies aimed at helping to enhance the protection of the female population. This needs to be done both by women and by men, on behalf of their stable sex partners and all their other partners. Also inside the families, mothers and parents will have to look for ways to talk to their adolescent daughters (and sons) about the need to use methods to prevent virus transmission. Finally, it has been repeatedly observed that the communities of people who live with HIV are loyal and effective allies in the planning and implementation of AIDS control actions.

______________________

I. The author wishes to thank the following persons for their valuable comments and administrative support in the writing of this document: Dr. Blanca Rico, Ms. Ana María Cuevas, and Ms. María Victoria Bonilla, all of whom are part of the Secretariat of the Project: "Latin American Working Group on Women and AIDS", National Public Health Institute, Cuernavaca, Morelos, Mexico.

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