Is it time to adopt a family approach to HIV prevention?
I recently read a couple of articles from the Key Correspondents (KC) that really got me thinking about the HIV risk that married women and women in a monogamous relationship face.
One article was on cultural barriers women face in accessing HIV prevention and the other about multiple concurrent partnerships.In fact the title of this entry comes from a play that was developed in Southern Africa to address the practice of multiple concurrent MCP, mentioned in the latter article.
Typically when thinking about the HIV epidemic in Africa, we see it as a ‘generalised’ epidemic which affects the overall population of a country. This also makes the assumption that HIV transmission is happening between women and men having sex without using condoms or other methods to prevent transmission of HIV and other sexually transmitted infections (STIs). So doesn’t this mean that married women and women in monogamous relationships should be at less risk for HIV?
On the contrary, there is increasing evidence that women in monogamous relationships and especially those who are married are at more risk of contracting HIV than those who aren’t in monogamous relationships.
According to the South African National AIDS Council (SANAC) Communications Advocacy and Campaigns Manager Junaid Seedat, “In Kenya, around 40% of new HIV infections are happening among married women while in Uganda, about 65% of new HIV infections are found in cohabiting couples.” (Quote from Experts tackle HIV within married and cohabiting couples)
Various cultural and social practices such as multiple concurrent partnerships, early marriage, wife inheritance and intimate partner violence are all barriers for married women to access HIV prevention services and negotiate safer sex with their husbands and supposed ‘monogamous’ partners. If these women decide to get tested for HIV or insist on using condoms, the consequences may result in violence and accusations that the women have not been ‘faithful’ to their partners. These types of power dynamics also impact negatively on the ability of mothers to care for their children’s health and well-being.
When considering married women’s vulnerability to HIV, we really need to look at the whole family and the complexities of the individuals that are part of the family. For example, in most cultures it is customary for men to get married to a woman once they have reached a certain age or status. What happens if a man’s sexual orientation is truly towards other men? Most likely he will get married and raise a family, while secretly having sexual relations with men. And even if he wanted to have protected sex with his wife, he can’t because of the social norms of marriage. When there is stigma and discrimination the fear of experiencing social exclusion is so great that people will go into hiding, making it difficult to reach them with HIV prevention services.
It might just be time to start approaching HIV prevention and services from a family perspective, utilising the strength of family influence to ensure that women and children get the services they need.
In order to address some of the challenges married women face in testing for HIV and dealing with a positive diagnosis within the family, innovative programmes are taking testing and treatment to family settings to improve couple testing and family counselling and disclosure. A programme in Uganda offered VCT to people in their homes 2,348 household members were tested with only 25 refusing a test. Of these, 74% had never taken an HIV test before. The programme also led to the testing and diagnosis of children living with HIV and their referral for treatment.
Programmes are also responding to evidence on the importance of fathers and other male relatives in the survival, care and well-being of mothers and children. Male involvement in prevention of mother to child transmission (PMTCT) services can see greater attendance and adherence, as well as lower transmission rates and improved child survival. In a study from Kenya women accompanied by a partner for PMTCT services were three times more likely to return for antiretroviral therapy (ART) and had improved post-partum follow up and adherence to treatment. Partners involved in the PMTCT intervention are better able to support women play an active role in applying advice on exclusive breastfeeding which can lead to reduced rates of transmission from mother to child.