When I think women and AIDS, the faces of women I have met in different parts of the country over the years flash before my mind: A 50-year-old woman who has spent a lifetime in a brothel in Kolkata; a 40-something woman in Chennai who has the most heart rending tales to tell of the abuse, humiliation and sexual exploitation in the Tamil cine industry; A 40-ish devadasi woman in Bagalkot, north Karnataka, who recounts being 'dedicated' to a goddess when she was 9 and sent to a brothel in Karad four years later; a 40-ish middle-class AIDS widow in Mumbai, HIV-positive and on antiretroviral treatment, playing single parent to two young children and working as a health worker.
These stories - and the breadth of social and economic conditions they represent - point to unspeakable sexual violence in the home and in workplaces, increasing women's vulnerability, and the risk of contracting HIV, the virus that causes AIDS. This also means that the expression 'women at risk' can no longer be used to describe only those engaged in sex work, and that strategies to address women's vulnerability to HIV must therefore take into account their varied risks. At a recent International AIDS Conference at Colombo, Dr Purnima Mane, Deputy Executive Director of the United Nations Fund for Population Activities (UNFPA), said that while measuring violence is not easy, we do know it is extremely, unacceptably, high.
There is a wide range of circumstances from which women face risks:
Sexual exploitation in workplaces: In Tamilnadu, domestic maids said they were exploited by male members of the household - sometimes both father and son. In Kolkata, women construction labourers said contractors demand sexual favours in return for work. In Karnataka, vegetable vendors in wholesale markets said if they were unable to repay the daily debt, the trader demanded sex in exchange.
At risk from husband/partner: National surveillance data from antenatal clinic sites shows that a majority of women getting infected are under 30; more than 90 per cent of them monogamous. Women are unable to protect themselves even when they know their husband has other partners, or is HIV positive. Women said their husbands knew they were HIV positive yet subjected them to unsafe sex. Condom use with husband/ partner is negligible.
Women in sex work: Although condom use in paid sex has increased over the years, thanks to AIDS awareness campaigns, gaps still remain. Dr Protim Ray, who manages the 62 STI clinics DMSC runs across West Bengal says condom use has shot up from 12 to 85 per cent since DMSC began in 1992. HIV prevalence has stabilized at 5 per cent. However, gaps still remain with regular partners or 'babus' the women have. Further, the sex trade is also moving out of the brothel. More and more women are being pushed into it because of economic distress. NGOs working on HIV prevention say this 'hidden' sex worker is an extremely mobile, invisible, and difficult-to-reach population.
Knowledge is prevention
A number of reasons make women more vulnerable than men. To start with, male-to-female transmission of HIV is more efficient than female-to-male transmission. Secondly, given that in most relationships men are older than women, there are more chances of the man being the infected partner. Further, nearly always, men determine when, where and how sex takes place. They determine whether a condom - the most effective, cheap, easily available means of preventing HIV transmission - is being used. It is little wonder, therefore, that women's vulnerability to HIV is wide-spread, and that social and economic differences between women do not seem to matter very much in determining their risks of infection.
Delay age of first sexual encounter
One way of reducing the risk is ensuring that young people delay the age of their first sexual encounter. Evidence from school AIDS education programmes such as the one organised by Andhra Pradesh State AIDS Control Society as early as 2003 showed young people in rural areas were more sexually active than their urban counterparts. Sexual abuse of young women and girls working in fields is high. Teen marriage remains a reality in many parts of India. Most women in sex work say they were initiated while still in their teens. In traditional communities such as the Devadasis in Bagalkot, Karnataka, for instance, women said they were in their early teens at age of first sex.
Whether it is marriage, sex work, or consensual sex, it is important to delay age of sexual debut. For one, the more immature the reproductive tract, the more vulnerable the women are to infection to HIV and other sexually transmitted infections. Evidence shows the more the age difference between partners, the more likely it is that the man has had previous sexual encounters, likely many of them unsafe. For women to be aware, have the knowledge and information to protect themselves it is important to delay age of sexual debut.
Where marginalised communities such as sex workers have formed collectives, they are able to save money, invest, take loans at moderate interest rates, and escape exploitation by middle-men. In Sonagachi, Kolkata's redlight area, for example, sex workers' collective Durbar Mahila Samanway Committee has formed the Usha Cooperative Society. With 8000 members and an annual turnover of about Rs 8 crores, the Society has created history of sorts by helping women buy land, build houses, put their children in boarding school.
Across, women say it is difficult to negotiate safe sex with their husband/partner/boyfriend. Some say there is pressure to be naÃ¯ve and ignorant about such matters, others say asking for condom arouses suspicion. Some even say asking for the condom is asking for violence. Young women have found a solution in women-controlled methods such as the newly introduced female condom. Older women, especially those who have worked on HIV prevention among their communities, say they are not willing to let any romance cloud judgement. With a new-found confidence, they are able to insist husbands and partners use condoms.