Challenging Dogma

...Using social sciences to improve the practice of public health

Saturday, April 21, 2007

Public Health’s Inattention to Paternalism - How Ignorance of Social Realities Affects Safe-Sex Promotion - Divya Errabelli

The world has witnessed HIV/AIDS as a major pandemic in the late twentieth and early twenty-first century. (1) The recent UNAIDS 2006 report shows that there are 39.5 million people living with HIV, among which women constitute 45 per cent of the total. (1) Approximately 4 million new infections occur every year and 2.9 million die due to AIDS. Sub-Saharan Africa and Asia bear eighty per cent of the HIV infection burden in the world and contribute to eighty five per cent of the new HIV infection rate per year. (1) Women, especially in paternalistic societies, constitute an increasing majority of the new victims of HIV/AIDS. For example, the data released by the National AIDS Control Organization in 2005 for prevalence of HIV/AIDS in India indicates that women account for a growing proportion of people living with HIV (38% in 2005), especially in the rural areas. The bulk of the HIV infections in India in these women are reported to be occurring during unprotected heterosexual intercourse. A large proportion of these women with HIV appear to have acquired the virus from regular partners who were infected during paid sex. There has also been mounting evidence that there are increasing number of men having sex with men and then transmitting the virus to unsuspecting wives and long-term female sexual partners. The 2006 UNAIDS report states that similar to India, women in Sub-Saharan Africa bear the AIDS burden disproportionately. (1) They are more likely than men to be infected with HIV and are also more likely to be sole caretakers for people infected with HIV in their families and communities. For example, in South Africa, young women (15-24 years) are four times more likely to be HIV-infected than are men in the same age group. A study conducted in 2005 shows that HIV prevalence was 17% among young women compared with 4.4% among young men. (2) This evidence is corroborated with another national survey of 15-24 year olds that showed 15.5% of young women and 4.8% of young men were HIV-infected. (3) Why are we seeing this disproportionate increase in prevalence of HIV among women? Are some of the intervention strategies against HIV infection inadequately addressing the needs of women? This paper is a critique of some of the current HIV public health intervention strategies promoted in some paternalistic societies such as India and in Sub-Saharan societies. This paper will draw from the ‘theory of gender and power’, ‘social learning theory’ and ‘cognitive behavioral theory’ for the critique of some of the intervention strategies in practice.

A majority of the HIV intervention strategies have a three-pronged approach to HIV/AIDS advocacy programs which include (1) promotion of condom use, (2) reduction in number of sexual partners, and (3) treatment of sexually transmitted diseases, as the likelihood of HIV infection is increased in STD populations. For example, the President’s Emergency Plan for Aids Relief (PEPFAR) prevention initiative logo is commonly known as ‘ABC’ has a three-prong representation of (1) Abstinence (2) Be faithful and (3) Correct and Consistent Condom use. The abstinence programs promote abstinence from any sexual activity to unmarried individuals as the best and only guaranteed way to prevent HIV infection and other STDs. (4) The programs profess and equip individuals with skills to delay the first sexual encounter until marriage and have adopted social and community norms in many countries that support delaying sex until marriage. The Be Faithful approach encourages individuals to practice fidelity in marriage and other sexual relationships as a critical way to reduce risk of HIV infection. (4) The Be Faithful programs are geared towards development of skills for fidelity, building mutual faithfulness and maintenance of long-term sexual relationships and endorsement of social and community norms that denounce cross-generational sex and forced sexual activity. And finally, the Correct and Consistent Condom approach of PEPFAR is the provision of information for correct and consistent use of condoms; while maintaining that condoms reduce the risk of HIV infection but does not eliminate it. (4)

The ABC approaches of PEPFAR towards HIV prevention efforts are undoubtedly effective in reducing the rates of HIV in some communities. Since its implementation of the ABC program in Kenya, there had been a 50% decrease in the percentage of 20-24 year old men with more than one sexual partner. The median age of first sex in women increased to 18 years from 17 years and condom use increased among women who engaged in risky behavior. Similar trends have been observed in other countries in the Sub-Saharan African countries4. However, the behavioral model of ABC ignores the barriers that women in paternalistic communities face within Sub-Sahara and India, especially in regards to the practice of contraceptive use in their relationships. Often, these women occupy a lower social and economic status both in the relationship and in their society. For these women, their status and standing in society is a colossal barrier to overcome before they can insist on correct and consistent contraceptive use in their sexual relationships. The ‘C’ prong of the ABC approach is based on the Health Belief Model. It relies on perceived susceptibility and severity of AIDS by women and assumes a low perception barrier for the action, i.e. consistent and correct use of condoms. The level of control of condom use is assumed to be accessible at the individual level and relies on the rational decision making process of women and the resulting intent to change behavior. ABC focuses on the individual characteristics of motivation and skill to change voluntary behaviors such as contraceptive use. These models that ABC relies on were initially built to address the rise of HIV in homosexual communities; they might have been appropriate for urban, gay-identified men but have limited applicability to women whose choice and actions are constrained by poverty, gender roles, and cultural norms. (5) Often, the threat of violence from their partners discourages most women from insisting on condom use. Furthermore, gender based inequality has been associated with limited access to testing sites (for HIV and STDs), information meetings and support for most women. Even though ABC acknowledges the social and economic status of women in some of these societies, it fails to provide a method to address these overarching constraints on women and their dependence on their partners for sexual decisions, social acceptance and self-esteem that are furthermore reinforced by culture and popular media in these paternalistic societies. (6) Also, many of these safe-sex promotion approaches such as ABC do not consider the low self-efficacy that dictate women’s behavior in paternalistic societies. A majority of these women have low self-esteem, and coupled with low self-efficacy, they do not believe that using contraceptives is a realistic goal for them.

The ‘A’ and ‘B’ prongs of the ABC approach are irrelevant for women in paternalistic societies. For example, in India the sexual freedom of women is restricted given the social and cultural expectations of them. Women are rarely promiscuous in their relationships. In Andhra Pradesh, Karnataka and Tamil Nadu, the southern states of India, the HIV infections are shown to occur predominantly via heterosexual contact, due to husbands having unprotected sex with commercial sex workers. (7) Furthermore, historically condoms are not an established method for marital sexual intercourse, just as the promiscuity of their husbands is rarely questioned. To further complicate matters, intramarital rape is a socially sanctioned practice. These issues make it extremely daunting for these women to protect themselves from HIV infection. The same scenario is true for Ghana, where marriage appears to be a significant risk factor for HIV infection. Married women were almost three times more likely to be HIV-infected than unmarried women. (8)

To address some of these challenges one study assessed Malawi women and their social-cultural barriers to HIV prevention. The researchers conducted focus groups with Malawi women to ask them about the impact of HIV/AIDS on their lives, their role in prevention and the barriers that they face in preventing the spread of the disease. (7) The research highlighted a recurring theme, expressed by these women as, ‘We are just vessels for our husbands.’ That statement encompasses their roles, the gender-power relationships and issues of disempowerment that these women encounter on a daily basis. The study highlights the need for a multidisciplinary approach that includes women’s education, economic empowerment as well as modifying legal and social structures that contribute to the spread of HIV/AIDS. (9) The identification of these issues from within (the Malawi women) is a first step. This discussion with the affected women then provides room for partnerships between health, education, women’s development groups, and political and social leaders to be able to reduce the impact of HIV/AIDS. (9) Beeker et al also reiterate that empowerment themes underlying the theories of ‘Gender and Power’, ‘Social Cognitive’ and ‘Social Behavioral’ focus not just on health-specific risk beliefs and behaviors in individual women but on beliefs and practices that can provide a link to organizational and community change such as voting patterns and other such collective actions. (6) Some studies (9) that emphasize the empowerment of women have shown the effectiveness of HIV prevention activities that concentrate on improving women’s skills in negotiation of condom use with their partners through role-playing, guided imagery, cognitive rehearsal and peer-education methods. These interventions empower women and equip them with skills to counter their social status.

In conclusion, many of the safe-sex programs such as ABC intervention programs overlook the importance of empowerment and skills-based knowledge that are vital for making safe-sex decisions. Empowering these women for enhancing their self-esteem and community standing is one step closer to the goal of reducing HIV infections than just telling them to use contraceptives in their sexual encounters.


1. AIDS Epidemic Update, December 2006. Joint United Nations Program on HIV/AIDS and World Health Organization.
2. Shisana O et al. South African national HIV prevalence, HIV incidence, behavior and communication survey. Pretoria Human Sciences Research Council. 2005.
3. Pettifor A E et al. HIV and Sexual behavior among young South Africans: a national survey of 15-24-year olds. April 2004. Johannesburg Reproductive Health Research Unit.
4. President’s Emergency Plan for AIDS Relief. Chapter 1: Critical Intervention in the Focus Countries, Prevention.
5. Ickovics JR and Rodin, J. Women and AIDS in the United States: Epidemiology, natural history and mediating mechanisms. Health Psychology. Vol.11 (1-16). 1992.
6. Beeker C. et al. Community Empowerment Paradigm Drift and the Primary Prevention of HIV/AIDS. Social Sciences and Medicine. Vol. 46 (pp831-842). 1998.
7. Stones W. et al. HIV and AIDS in India: Will the Next 20 Years Be Different? Harvard Health Policy Review. 2006
8. Ghana Statistical Service, Noguchi Memorial Institute for Medical Research, ORC Macro, 2004.
Lindgren T. et al. Malawi women and HIV: socio-cultural factors and barriers to prevention. Women’s Health. Vol. 41 (1) (pp 69-86). 2005.
9. Lindgren T. et al. Malawi women and HIV: socio-cultural factors and barriers to prevention. Women’s Health. Vol. 41 (1) (pp 69-86). 2005.

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