Official Bank Sites
August 11, 2006—More than two decades ago, when the AIDS epidemic was still in its infancy, those battling the disease in Africa made a serious miscalculation.
Instead of telling men to wear condoms, they tried to educate female commercial sex workers about their benefits.
“But women don’t wear condoms,” observes Debrework Zewdie, Director of the Global HIV/AIDS Program at the World Bank.
As a result, the epidemic took a very different course on the African continent than it took in the United States—once the other epicenter of the disease.
The AIDS epidemic began at roughly the same time among gay men in the north and commercial sex workers in the south, says Zewdie.
While educated gay men in America used condoms, reduced sex partners, lobbied for medication, and improved their odds, poor and female commercial sex workers in Sub-Saharan Africa didn’t wear condoms, and neither did their clients.
In fact, the clients often offered more money for sex without condoms, says Zewdie.
The result 20 years later: an infection rate so high that Sub-Saharan Africa has 60 percent of the world’s HIV cases, despite having only 10 percent of the world’s population. About 50 million Africans have been infected with HIV since the epidemic began.
Of the 25.8 million people in Sub-Saharan Africa currently living with HIV, almost 60 percent are women and girls.
And there is still no widely accepted effective female-based HIV prevention method available, says Zewdie.
The female condom is 10 times as expensive as male condoms and difficult to use, she says, and microbicides that could kill HIV on contact are not yet on the market.
“We did very little for women,” Zewdie says.
Today some AIDS/HIV experts at the Bank and other organizations believe that short of an AIDS vaccine or other major breakthrough, empowering women may be the key to overcoming the disease.
Inequality between men and women fueled the AIDS epidemic, they argue, by discouraging safe sex, i.e. sex with condoms, and encouraging relationships between young women and older men more likely to be infected with HIV.
Women’s lack of economic power, education, job opportunities, and effective rights to property in many countries often drives them into relationships in which they don’t have the ability to negotiate safe sex, and may be exposed to HIV through their partner’s other liaisons, says Elizabeth Lule, head of the Bank’s AIDS Campaign Team for Africa (ACT Africa).
Early marriage of girls—as young as 12—to men 10 or more years their senior increases their risk to HIV infection. About 40 percent of girls in Africa and 48 percent in Asia marry before their 18th birthday, with rates as high as 76 percent in Niger and 74 percent in the Democratic Republic of the Congo, according to the United Nations Population Fund.
“At the beginning of the epidemic, the entire focus was on commercial sex workers. Nobody bothered to look into the HIV status of married women. But when they did, they saw the same HIV prevalence rate in married women as in commercial sex workers,” says Zewdie.
The reason—they got HIV from their husbands, she says.
Most studies of HIV-positive married women in Africa and South Asia find that about 70 percent of the women were faithful to their husbands, she says.
Even so, HIV-positive married women suffer discrimination and stigma, and are blamed for bringing HIV into the home, Lule adds.
The Bank and its partners have been trying to reduce stigma and change behavior through the Multi-Country HIV/AIDS Programs (MAPs) for Africa, says Lule.
The MAPs support HIV/AIDS initiatives of community organizations, non-governmental organizations and the private sector to address the problem on many fronts: prevention through education and awareness programs, with emphasis on vulnerable groups such as youth and women of childbearing age and other vulnerable marginalized groups, better access to health care and treatment, and efforts to empower women through legal reform and job training, among other approaches.
When a MAP is initiated in a country, the Bank insists national AIDS program representatives meet with women, youth and people living with HIV and incorporate their input in designing the program, says Zewdie.
The Bank has so far committed $1.12 billion to fighting AIDS in 29 countries through MAPs, and has dedicated another $107 million to four sub-regional projects, including a project to fight the spread of HIV among transport workers, migrants, commercial sex workers and local people in the Abidjan-Lagos Corridor through providing condoms, prevention information and health care.
“We have strong programs,” says Zewdie. “But we could do more, and we should do more.”
One problem is countries’ strategic AIDS plans haven’t addressed the reasons why increasing numbers of women and girls are being infected, she says.
But now many countries are planning new AIDS strategies, offering the Bank and other international organizations an opportunity to help countries target the source of HIV infection and also to address gender inequality and the low status of women as a way of fighting the disease.
“It’s the best chance we have,” says Zewdie.
The new strategies may mean targeting commercial sex workers or injecting drug users—two groups many countries are ashamed of and fail to deal with effectively, she says.
“The biggest nut to crack is the education of policy makers, because in most of these societies, commercial sex workers and drug injectors are not seen as a priority for government.”
“If you’re a country in Eastern Europe, and if the epidemic is driven by injecting drug use, you’d better put your money in that population, because from that population it spreads into the general population.”
Zewdie recently took representatives of six countries—India, Pakistan, Afghanistan, Kazakhstan, Uzbekistan and Kyrgyz Republic—to a workshop in Tehran, Iran, on that country’s program to prevent injecting drug use in prisons and elsewhere.
Iran has waged a vigorous war on HIV with a campaign that declares AIDS the “Plague of the Century” and advises the use of condoms. The country’s Health Ministry is also distributing free needles at pharmacies to prevent HIV transmission through needle-sharing among injecting drug users.
But elsewhere, stigma and descrimination over the disease discourages such openness.
In Africa, stigma discouraged groups working on reproductive health to incorporate HIV/AIDS services earlier on in the epidemic says Lule.
“And I think we are paying the price for being short-sighted in that area, because the RH programs were in place, trained providers were there, but because of the stigma, HIV and RH programs remained separate.”
Lule would like to see a “comprehensive response to a woman’s reproductive and sexual health needs,” including access to information and services on pregnancy, antenatal care, maternal services, and “information to allow her to protect herself, to be able to have the skills to negotiate condom use, to be able to make the choices that allow her both protect herself decide how many children to have.
“What I’d like to see is something that enables men and women to also discuss those issues fairly openly and bring down that culture of silence that prevents couples from discussing those intimate issues,” Lule says.
“And I also believe we made one mistake in that when we talk about gender and equality and we talk about the feminization of HIV/AIDS, there is a missing link—the other half of gender. The men are a part of the solution.”