Women, girls, focus of the World AIDS drive 2004

Nafsiah Mboi, Senior Consultant, National AIDS Commission, Jakarta

On March 8, Indonesians celebrated International Women's Day (IWD) along with people in many countries around the globe. The theme of IWD this year is "Women, Girls, HIV and AIDS".

If we look at the development of the AIDS epidemic in this country and the way AIDS has moved across the globe it is clear that discussion of this issue is timely. Indonesia's current National AIDS Strategy (2003-2007) states that "Indonesia is among the Asian countries experiencing an HIV/AIDS epidemic where prevalence is escalating rapidly and shows no signs of slowing down."

Thus, the Government of Indonesia, the UN "Country Team", Indonesian women leaders, and community organizations have welcomed this opportunity to highlight the multiple impacts of AIDS on women and their crucial roles in responding to the epidemic. Further, celebration of IWD 2004 will be used as the occasion to launch Indonesia's participation in the World AIDS Campaign 2004 with the same theme.

At the end of 2003 an estimated 40 million people -- men, women, children -- were living with HIV/ AIDS. Women comprise about half of all people living with HIV/AIDS today. In the age group 15 -- 24 they represent an even larger proportion of the total, an estimated 64 percent of young adults living with AIDS.

In some areas infection rates among adolescents are even more skewed, infection among girls, running 4 to 6 times higher than boys of the same age. Infection rates of women/ girls are climbing at a faster rate than those of men.

In terms of absolute numbers, sexual transmission is the primary cause of the spread of HIV/ AIDS in Indonesia. However, recently a rising proportion of HIV infection has been associated with injecting drug use especially among young men. The practice of needle sharing among those injecting drugs is extremely dangerous in the presence of HIV.

Once HIV enters a community of drug users, infection rates rise steeply and rapidly. This represents an enormous danger to the community at large as the men and women involved invariably have unprotected sex with partners often spreading infection to a wider public.

It should be noted that high infection rates from sexual causes among women/girls are generally not because of their own high risk behavior. Data shows that as many as 80 percent or more of pregnant women who are HIV positive across the developing world have only one sexual partner. Specifically among young girls, infection is often acquired from unwanted sex -- sex they dared not turn down lest they loose affection, status, support or all three. Incidental studies in Indonesia show similar patterns.

In many parts of the world, including Indonesia, both men and women are placed at increased risk of infection by notions of "femininity" and "masculinity" which dictate how they will interact sexually. Boys/men are taught that experience with multiple sex partners is part of growing to full manhood. Girls/women have traditionally been socialized to defer to male partners who expect and enforce such compliance.

Sex workers, unless protected by effective regulation, are particularly vulnerable. Forced by their work to accept multiple sex partners, they have little chance to protect themselves from infection or, in fact, from gender-based violence, if a client does not oblige.

But women's vulnerability to HIV is not exclusively social. Women and particularly younger adolescents are physiologically and anatomically particularly vulnerable to infection. A woman having sex with an infected man is more than twice as likely to become infected than a man having sex with an infected woman. Furthermore, information about sex, sexually transmitted infections including HIV, and ways to protect against them reach only limited numbers of women/ girls.

But is infection the only way that women are affected by HIV/AIDS? In every country touched by HIV/AIDS, women, in the end, carry a double burden. They risk infection but particularly in countries like Indonesia they also care for the sick, support the healthy, and comfort the grieving in the home, the community and often in health care settings. When infected herself, to her other concerns is added worry about care of her children when she is gone.

Generally, the situation of women becomes progressively worse as more time is needed for nursing, more money is needed for medicine, and less time and energy is left over for economic activity. In Indonesia and around the globe, the spiral of deprivation and poverty are accentuated by the social isolation and discrimination which are often the lot of people known to be HIV positive. In many cases HIV+ women cannot even get appropriate care and treatment because they are shunned even in health care settings.

Such discrimination can have an impact in the next generation. Women may be deprived of needed treatment, for example, anti- retrovirals which given to an HIV+ woman can protect her unborn child from possible HIV infection before or during birth or through breast milk. Women's advocates point out that such treatment should be available to women (regardless of their pregnancy status), as it is to men, for its known positive effects in most cases delaying development of AIDS and improving the quality of life.

What can be done? Experience indicates four key issues are acceptance, empowerment, information and service.

Wide acceptance is needed by the public as well as community and government leaders that AIDS is a challenge in their own community, a challenge which can be effectively met but only if full attention is given to the special needs of women/ girls. In Indonesia this will require, among other things, significant new effort to assure collection, analysis, and constructive use of data disaggregated by age, sex, and location (Urban/Rural).

Empowerment of women is crucial. It has been achieved in many places by increasing women's access to full and appropriate information, education, opportunity for economic activity and the development of effective support groups.

These can increase women's understanding of the risk of HIV, desire to avoid infection, and skill in doing so. However, this happens only where there is political will as well as changes in public policy and public opinion, attitudes and behavior of men/ boys, as well as women/ girls.

Information has a crucial role to play in breaking the chain of HIV infection. Given the importance of sexual transmission as a driving force in Indonesia's epidemic, information targeted to adolescent girls and boys and young adults must be a priority. Young people need help learning to manage their emerging sexuality in non risky ways.

They need to learn how to change their own behavior and their interaction with each other to reduce high risk activity and increase sexual responsibility among young men, to increase self respect and assertiveness among girls/ young women. Peter Piot, Executive Director of UNAIDS pointed out that "In every country were HIV transmission has been reduced, it has been among young people that the most spectacular reductions have occurred". Abstinence has increased as has the practice of safer sex.

Improved services -- general health, reproductive health, HIV counseling and testing, administration of anti-retrovirals among others -- are crucial in the fight to control the AIDS epidemic. Studies show that services need to be more "user friendly" and more appropriate in content and must reach women/girls regardless of whether they are married or single, HIV positive or free of infection if the epidemic is to be controlled. There are many possible entry points.

Women/girls are directly in the path of HIV/AIDS as it sweeps through any community. Specific needs of women and girls have been overlooked in dealing with the epidemic. If the power of HIV/AIDS is to be broken in Indonesia, we must do better. Women's concerns must have higher priority. International Women's Day and the World AIDS Campaign 2004, should be used to focus attention and mobilize new energy on that task.