Posted: Apr 6, 2017
Addressing Gender to Ensure Effective PrEP Introduction
Pre-exposure prophylaxis (PrEP) was conceived to ﬁll the urgent need for a woman-controlled HIV prevention method. However, biomedical technology alone will not alter the underlying gender inequalities that make women and girls vulnerable to HIV. As new HIV prevention methods are rolled out, women, girls, men who have sex with men (MSM), and transgender people will face barriers to product access and use that stem from cultural norms, lack of power in relationships and society, and limited access to resources. Gender analyses conducted in Kenya, South Africa, and Zimbabwe identiﬁed ways to address these potential barriers during PrEP introduction. Most critically, PrEP introduction plans must prioritize a rights-based, positive approach that normalizes use of the new products and makes them available to those who need them most.
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Posted: Jan 27, 2017
Sexuality and the limits of agency among South African teenage women: theorising femininities and their connections to HIV risk practices
In South Africa, both HIV and gender-based violence are highly prevalent. Gender inequalities give men considerable relational power over young women, particularly in circumstances of poverty and where sex is materially rewarded. Young women are often described as victims of men, but this inadequately explains women’s observed sexual agency. This paper takes a different approach. We use qualitative interviews and ethnographic observation among 16 young women from the rural Eastern Cape to explore ways young women construct their femininities and exercise agency. The data were collected as part of an evaluation of Stepping Stones, which is a participatory behavioural intervention for HIV prevention that seeks to be gender transformative. Agency was most notable in particular stages of the dating ‘game’, especially relationship initiation. Constructions of desirable men differed but generally reflected a wish to avoid violence, and a search for mutual respect, sexual pleasure, romance, modernity, status and money. Agency was constrained once relationships were consented to, as men expected to control their partners, using violent and non-violent methods. Women knew this and many accepted this treatment, although often expressing ambivalence. Many of the women expressed highly acquiescent femininities, with power surrendered to men, as a ‘choice’ that made their lives in cultural terms more meaningful. In marked contrast to this was a ‘modern’ femininity, centred around a desire to be ‘free’. A visible third position, notably emerging after the Stepping Stones intervention, rested not on a feminist challenge to patriarchy, but on an accommodation with men’s power whilst seeking to negotiate greater respect and non-violence within relations with men. These multiple and dynamic femininities open up possibilities for change. They demonstrate the need to engage with women, both as victims of patriarchy and active supporters of the gender order. The multiplicity of women’s hopes and desires and circumstances of emotional and relational fulfilment provides potential for interventions with women that acknowledge existing gender inequalities, validate women’s agency, reduce violence and prevent HIV.
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Jewkes R, Morrell R. Sexuality and the limits of agency among South African teenage women: Theorising femininities and their connections to HIV risk practises. Social Science and Medicine. 2012 Jun; 74(11): 1729-37. DOI: 10.1016/j.socscimed.2011.05.020.
Posted: Jan 16, 2017
Optimizing HIV prevention for women: a review of evidence from microbicide studies and considerations for gender-sensitive microbicide introduction
Introduction: Microbicides were conceptualized as a product that could give women increased agency over HIV prevention. However, gender-related norms and inequalities that place women and girls at risk of acquiring HIV are also likely to affect their ability to use microbicides. Understanding how gendered norms and inequalities may pose obstacles to women’s microbicide use is important to inform product design, microbicide trial implementation and eventually microbicide and other antiretroviral-based prevention programmes. We reviewed published vaginal microbicide studies to identify gender-related factors that are likely to affect microbicide acceptability, access and adherence. We make recommendations on product design, trial implementation, positioning, marketing and delivery of microbicides in a way that takes into account the gender-related norms and inequalities identified in the review.
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Methods: We conducted PubMed searches for microbicide studies published in journals between 2000 and 2013. Search terms included trial names (e.g. ‘‘MDP301’’), microbicide product names (e.g. ‘‘BufferGel’’), researchers’ names (e.g. ‘‘van der Straten’’) and other relevant terms (e.g. ‘‘microbicide’’). We included microbicide clinical trials; surrogate studies in which a vaginal gel, ring or diaphragm was used without an active ingredient; and hypothetical studies in which no product was used. Social and behavioural studies implemented in conjunction with clinical trials and surrogate studies were also included. Although we recognize the importance of rectal microbicides to women, we did not include studies of rectal microbicides, as most of them focused on men who have sex with men. Using a standardized review template, three reviewers read the articles and looked for gender-related findings in key domains (e.g. product acceptability, sexual pleasure, partner communication, microbicide access and adherence).
Results and discussion: The gendered norms, roles and relations that will likely affect women’s ability to access and use microbicides are related to two broad categories: norms regulating women’s and men’s sexuality and power dynamics within intimate relationships. Though norms about women’s and men’s sexuality vary among cultural contexts, women’s sexual behaviour and pleasure are typically less socially acceptable and more restricted than men’s. These norms drive the need for woman-initiated HIV prevention, but also have implications for microbicide acceptability and how they are likely to be used by women of different ages and relationship types. Women’s limited power to negotiate the circumstances of their intimate relationships and sex lives will impact their ability to access and use microbicides. Men’s role in women’s effective microbicide use can range from opposition to non-interference to active support.
Conclusions: Identifying an effective microbicide that women can use consistently is vital to the future of HIV prevention for women. Once such a microbicide is identified and licensed, positioning, marketing and delivering microbicides in a way that takes into account the gendered norms and inequalities we have identified would help maximize access and adherence. It also has the potential to improve communication about sexuality, strengthen relationships between women and men and increase women’s agency over their bodies and their health.
Doggett, EG; Lanham, M; Wilcher, R; Gafos, M; Karim, QA; Heise, L; (2015) Optimizing HIV prevention for women: a review of evidence from microbicide studies and considerations for gender-sensitive microbicide introduction. J Int AIDS Soc, 18 (1). p. 20536. ISSN 1758-2652 DOI: 10.7448/IAS.18.1.20536
Posted: Jan 16, 2017
Gender inequity in the lives of women involved in sex work in Kampala, Uganda
Introduction: Gender inequity is manifested in the social and economic burden women carry in relation to men. We investigate women’s experiences of gender relations from childhood to adult life and how these may have led to and kept women in sex work.
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Methods: Participants were drawn from an ongoing epidemiological cohort study of women working in high HIV/STI risk environments in Kampala. From over 1000 enrolled women, we selected 101 for a qualitative sub-study. This analysis focuses on 58 women who engaged in sex work either as a main job or as a side job. In-depth life history interviews were conducted to capture points of vulnerability that enhance gender inequity throughout their lives.
Results: Most participants were young, single parents, poorly educated, who occupied low skilled and poorly paying jobs. All women knew their HIV status and they disclosed this in the interview; 31 were uninfected while 27 said they were infected. Parental neglect in childhood was reported by many. Participants described experiences of violence while growing up sometimes perpetuated by relatives and teachers. Early unwanted pregnancies were common and for many led to leaving school. Some women stated a preference for multiple and short-term money-driven sexual relationships. Needing to earn money for child care was often the main reason for starting and persisting with sex work. Violence perpetrated by clients and the police was commonly reported. Alcohol and drug use was described as a necessary ‘‘evil’’ for courage and warmth, but sometimes this affected clear decision making. Many felt powerless to bargain for and maintain condom use. Leaving sex work was considered but rarely implemented.
Conclusions: Inequities in gender and power relations reduce economic and social opportunities for better lives among women and increase risky sexual behaviour. Interventions focused on these inequities that also target men are crucial in improving safer practices and reducing risk.
Mbonye, M., Nalukenge, W., Nakamanya, S., Nalusiba, B., King, R., Vandepitte, J., & Seeley, J. (2012). Gender inequity in the lives of women involved in sex work in Kampala, Uganda. Journal of the International AIDS Society, 15(Suppl 1), 17365. http://doi.org/10.7448/IAS.15.3.17365
Posted: Jan 16, 2017
Combined structural interventions for gender equality and livelihood security: a critical review of the evidence from southern and eastern Africa and the implications for young people
Introduction: Young people in southern and eastern Africa remain disproportionately vulnerable to HIV with gender inequalities and livelihood insecurities being key drivers of this. Behavioural HIV prevention interventions have had weak outcomes and a new generation of structural interventions have emerged seeking to challenge the wider drivers of the HIV epidemic, including gender inequalities and livelihood insecurities.
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Methods: We searched key academic data bases to identify interventions that simultaneously sought to strengthen people’s livelihoods and transform gender relationships that had been evaluated in southern and eastern Africa. Our initial search identified 468 articles. We manually reviewed these and identified nine interventions that met our criteria for inclusion. Results: We clustered the nine interventions into three groups: microfinance and gender empowerment interventions; supporting greater participation of women and girls in primary and secondary education; and gender empowerment and financial literacy interventions. We summarise the strengths and limitations of these interventions, with a particular focus on what lessons may be learnt for young people (1824).
Conclusions: Our review identified three major lessons for structural interventions that sought to transform gender relationships and strengthen livelihoods: 1) interventions have a narrow conceptualisation of livelihoods, 2) there is limited involvement of men and boys in such interventions, 3) studies have typically been done in stable populations. We discuss what this means for future interventions that target young people through these methods.
Gibbs, A., Willan, S., Misselhorn, A., & Mangoma, J. (2012). Combined structural interventions for gender equality and livelihood security: a critical review of the evidence from southern and eastern Africa and the implications for young people. Journal of the International AIDS Society, 15(3Suppl 1), 17362. http://doi.org/10.7448/IAS.15.3.17362