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Women and HIV/AIDS Concerns - a focus on Thailand, Philippines, India and Nepal

Chapter 1

INTRODUCTION

"Women’s educational attainment, work patterns, income levels, access to and control of resources and social roles – all have considerable impact on their health and the well-being of their children, in general, and on their reproductive health, practice of family planning and involvement in fertility decisions, in particular". Perhaps the most powerful adverse determinant of women’s overall reproductive health – as well as the most historically overlooked – is gender inequality .

Throughout the developing world the impact of HIV on women has been significant and rising. Women are more vulnerable than men, both epidemiologically and biologically.

Women are frequently less educated than men. This disparity is critical because literacy rates for women are strong predictors of infant mortality rates and fertility decisions. Discrimination against the female gender begins during the pregnancy of the mother, as manifested in the high incidence of abortion of female foetuses. Female infanticide has been on the rise in many countries. Cultural preference for sons results in preferential allocation of family resources (food, schooling, health care) to them. Girls are allotted disproportionate burden of housework, which is a detriment to their self-esteem

The life cycle of women is also impacted by sexual and domestic violence. In different parts of the world, between 16% and 52% of women suffer physical violence from their male partners, and at least 1 in 5 women suffer rape or attempted rape in their lifetimes, often by known men . Rape survivors live in shame, restrained by fear of social stigma and unable to bring legal action.

Violence against women and girls is a major health and human rights issue. The need for more research on the connection between human rights, legal and economic issues, and the public health dimensions of violence is clear . In addition to broken bones, third degree burns and other bodily injuries, sexual abuse can have long-term mental health consequences, including depression, suicide attempts and post traumatic stress disorder, more so if they acquire HIV.

Gender is only characteristic among many that people use to distinguish themselves or to unite with others. Skin colour, sexual orientation, social class, occupation, lineage, national identity, geographic location, political ideology and physical status are just a few other dimensions that may have a particular relevance in different women’s lives and experiences with HIV/AIDS. Women who are prisoners of domestic worlds or state sanctioned violence cannot act until conditions of safety can be assured .

HIV continues to ravage the developing world. New estimates of the infection by UNAIDS and WHO state that over 30 million people globally are living with HIV including 1.1 million children. New infections in females are occurring faster than in males .

Around 16000 new infections a day in 1997

· More than 90% occur in developing countries · 1600 are in children under 15 years of age · About 14000 are in adults, of whom: Ø Over 40% are women Ø Over 50% are 15-24 years old

By the beginning of the next century, women living with HIV or AIDS through out the world are likely to outnumber the men .

UNAIDS is helping the national programs to frame policies that will ease the impact of HIV on women. Estimates of infection among women in the developing world are limited.

	India	Thailand	Philippines	Nepal
Prevalence of HIV (sentinel surveillance)	22.5/1000		No. of cases 1086	No. of cases 1000
Prevalence in pregnant Women	0.4-2.5%	1.68%	14 cases only	Not available
Prevalence in Sex workers	5-35%	26.14%
Prevalence in blood donors	0.9%	0.57%	11 cases only
Prevalence in IDUs	30-70%	40%	5 cases only
Prevalence among STD clinic attendees	10-15%	6.79%

 

HIV positive women experience a social death, as do many people living with HIV, but they often still carry the responsibility to care and provide for their family. The following testimonies by women in Thailand, Nepal, India, and the Philippines describe the additional challenges and discrimination facing women living with HIV.

"We are HIV +ve, but all we ask is treat us like you treat any other human being. We need care and support not discrimination and isolation. We need counseling and help on nutrition, yoga, meditation and treatment for OI. We are not asking for the sky – antiretrovials – because our govt. cannot afford and we do not have the laboratory backup. We want to be accepted by the community and live as anybody else".

A positive group in Manila

The following story of how young girls are lured from the confines of their home and led into the dark world of sex work illustrates how adolescent women are put at risk by their "husbands" and have limited control over their sexual and reproductive health.

At sixteen, my head was full of romantic notions. The bracing air in Katmandu enhanced my skin and complexion and I was full of life and picture of good health. My parents were strict and orthodox. But I did not care for an arranged marriage, which would be my lot considering that my family attached so much to old-fashioned values. People admired my vivacity and I began giving myself a lot of airs. I was not a bad kid but was silly, selfish and headstrong.

So, when Ajay sidled near me at the type writing institute and leered at me, instead of repulsing him, I was drawn to him. When he was no longer satisfied with these romantic small meetings in parks and dark cinema halls, I gave in to his advance and had no second thoughts of running away with him to the neighbouring town. We got married in a temple. Being ignorant and uninformed I did not realize that this marriage was no real marriage and had no legal sanctity.

I was horrified and scared when Ajay developed chest pain, a few days later. His friends recommended him to go to a big hospital in Bombay. Pawning whatever little jewels I possessed we left immediately for Bombay. The big bustling hospital bewildered me and I sat nervously in the visitors gallery whilst he was being examined. A lady approached me and said that Ajay was taken to another hospital for further tests and I should accompany her and stay with her. I followed her trustingly. The place was strange and I found out later that it was a brothel. Even as I was overcome by fear, spending my first night in a strange city, my stomach gnawed inside me. I realised that I had not eaten the whole day. As I crouched on a chair, a gang of men, viscous and cruel entered the room and gang raped me. I was absolutely helpless and shattered. That was not all. Abused, starved and tortured, I became a shell of my own-self, before I acceded to their demand to become a prostitute. I cursed myself for believing Ajay and berated myself for my wretched behaviour. Everyday of my life here has been a living nightmare. Soon I became pregnant. My baby was aborted and I was back in business. On some days I had to entertain no less then 8 clients. The filth, the horrid food, the dirty surroundings filled me with such disgust. My mind yearns for the fresh and cold air of the mountains. The atmosphere in the brothel was stifling. I began to feel that I would perish in this "Hell on Earth" and never ever see my beautiful land and my dear parents. God was punishing me for my vanity and selfishness.

As I sat inside my room running a comb through my hair and preparing for the night, I heard a huge commotion downstairs and peered down from the narrow window, which overlooked the street. It was a police raid. I shrugged before I realised that this raid was different. The police entered my room and barked a few questions at me, which I answered hesitatingly.

They asked me to accompany them to the station and found that I was going to be rescued with 4 other girls who had been forced into this wretched trade.

Things are so much better in the Rescue Home. It is very peaceful. Various blood tests were conducted and after I was treated for malnutrition and a few other infections, they told me that I was HIV positive. I know that I can never return to the mountains or ever meet my people. But, I have escaped from the craven place, which I described as Hell on Earth. Besides, I never knew that I had a knack for embroidery and enjoy creating beautiful work. I know that I can never have a husband or a child or even a house of my own. But I am indeed grateful for small mercies.

The severe discrimination of HIV positive women, as in the case of Prema below, begins with her husband, the likely source of her infection. Despite the route of her infection, Prema, the mother of two, is ostracized by her husbands’ family and is denied health care despite her critical condition.

As I lay exhausted and drained out on the hospital bed, I could hear the loud wailing of my new born. The young nurse who was wiping my brow smiled and said briefly "It is a boy". I smiled wanly tired but happy. My husband Krishna was looking after my eldest son Rahul who was 4 years old. We were a compact but a contented family. I was alone in the hospital but did not really mind. There was a lot of bustling and clatter around me. A nurse came in and took a blood sample. I was too tired to ask her about it. Krishna and I had decided that simultaneously I would get myself sterilised, as we were happy with two kids. Krishna and Rahul came eagerly and hurried to the bedside. They grinned at me and I grinned back. The doctor came in looking grave and drew my husband aside. There was a lot of whispering but my attention was wholly directed at my two sons who where getting acquainted with each other. The baby had just opened its eyes and was staring at Rahul and he was looking at the poor mite with wonderment. I turned around to catch the attention of my husband and spied a revolt expression on the doctor’s face. My husband refused to catch my eyes and said that he was taking me home. "What about the sterilisation" I stammered. He simply brushed me aside and lifted me bodily from bed, linen and all. My heart started hammering widely. I just could not believe that all this was happening to me. Just a few hours ago, I was so happy and blissful. As we reached home, my breast felt full and I stopped thinking of myself and went to pick up my baby who was bawling lustily. My husband snatched the baby from me saying that it would be better if the baby did not remain with me considering my condition. I stared at him completely shocked and words failed me.

My husband stalked out of the room taking the baby and dragging Rahul along with him. As I gazed after him, my eyes began to well and I began weeping silently. I was completely bewildered. He was always kind and considerate and his curt demeanour and his refusal to meet my eyes made me feel rejected. I could not fathom whatever gave that expressions of disgust whenever he looked at me. I developed a high fever and was sick for a couple of days. That evening Krishna came into my room and informed me that I had life threatening disease, which was very contagious. I was not to go near the kid. He would look after them himself. I was isolated and the entire household including the servant kept safe distance from me. When Krishna came in he always looked ready to get out of the room. I appealed him to stay and keep me company but he pretended not to hear me. My health became to deteriorate and I became listless. My eyes began to look sunken and my hair was dull and unkempt. I think I was drugged most of the time. But when I heard baby whimper I would want to gather him in my arms, but I would falter at the door where a nurse barred me from going out of the room. Soon there was a bad odour in my room. "You have got AIDS and will die soon" Krishna stated badly as if he could contain himself. He rushed out of the room. His accusatory tones resounded in my ears all the time. I could not believe my ears and began to cry bitterly at unfairness of it all. What have I ever done to earn such misery?

Things came to such a pass that my parents were called. They were inconsolable. But, no sooner my brother heard about my plight than he dropped everything he was doing and came rushing to be by my side. He was aghast to see my pitiable state. He pushed my husband away fiercely and carried me to his car. He had heard about the AIDS Centre, which was doing wonderful work in quite a way. The doctors there were horrified to see my condition. A physical examination indicated that my vagina was packed with gauze and was septic and filled with pus. That was the cause of the foul odour. They were indignant that contrary to ethical practices the blood sample was taken for HIV testing without my consent and could not believe that I was given absolutely no counselling. A series of antibiotics cured me of my temporary problems. Good food and tonics completed my recovery. My husband, who was secretly ashamed, was called and both of us were counselled at length by the wise and experienced doctors in the AIDS centre. Well, I must admit that he took things in the right spirit.

I am back home and as happy as one can be in these circumstances. My children love me and my husband is proving to be a tower of strength. Ignorance and irrationally has played havoc with my life. And I wonder if other women like me ever get a second chance like I got.

HIV has been the cause for a large number of widows, some living with HIV. The stigma faced by widows in traditional societies is immense. In some communities in India, the death of the husband is blamed on the stars of the widow. To live as widow of someone who died of HIV, or to live infected with HIV is the pinnacle of suffering in communities that are yet to restore respect to women. Widows also face harassment from the parents of their spouse who deny them even their trousseau. Most times they are forced to leave the home of the in-laws in case they were living in a joint family. Grand children are sometimes accepted, usually when they are grandsons.

I was 17 years when I finished my schooling. My father who works in a bank and my mother decided to get me married because there was an offer from a family friend. The boy was earning well and the ten stars in our horoscopes matched perfectly. After marriage I had a beautiful little girl. Soon after the first birthday of our daughter my husband started falling ill and died they say due to "meningitis". He was tested for HIV one week before he died and was found positive. They drew my blood without counselling and I was terrified when they told me I was also positive. My mother – in – law asked me to leave home saying "I killed her only son". I left my husbands’ house with a small bundle of clothes and my little girl. My in-laws said, "If it was a son we would have taken care of him". All what is due to me – Life Insurance, Provident Fund etc. have been snatched away by my in-laws. My parents are worried to take me in because I have a sister to be married. So I stay in a widows shelter home, where my little girl is happy playing with other children of HIV + widows.

One of the difficult experiences an HIV positive mother faces is knowing that her own fate will be mirrored in her child and that she will not be there to help that child. Nothing else can highlight better the necessity for HIV prevention among women and to offer support services for women and their families who are living with HIV/AIDS.

Chapter 2

 

Expert Group Meeting on Women and Health

I look forward to sharing my experiences with the participants at the Expert Group Meeting on Women and Health, in which this report will serve as a background paper to analyse how HIV affects the following areas:

Gender and tuberculosis,

Gender and health technology,

Gender and environmental health, and

Gender and health financing;

and, make recommendations towards the development of a model, to integrate gender concerns in HIV and development into health care policies and programmes as well as in health related research. The development of this model will discuss the implications of such an approach for bringing about an institutional change.

I believe that this study is appropriate in its time and objectives, and that this study will serve to urge, through its observational remarks and review of literature, national programs and civil society organizations to devote additional resources to gender and HIV initiatives.

GENDER AND TUBERCULOSIS

Over 900 million women and girls are infected with TB world wide. This year alone, one million women will die, and 2.5 million will get sick from the disease. TB mainly affects people between the ages 15 and 44, making it the single leading cause of deaths among women of reproductive age .

TB accounts for 9% deaths worldwide among women aged between 15 and 44, compared with war, which accounts for 4%, HIV 3% and heart disease 3%. A 1996 study by the World Bank, WHO and Harvard University shows TB as a leading cause of ‘healthy years lost’ among women of reproductive age. 8.7 million ‘disability adjusted life years’ (DALYs) were lost as a result of TB compared with 8.5 million due to sexually transmitted diseases, 3.6 million due to HIV, 2.3 million due to diarrhoeal diseases, and 2 million due to malaria .

TB drugs are affordable. The Department of Health in India, Nepal, Philippines and Thailand also offers them free. Yet TB continues to take young women’s lives along with HIV. HIV infected individuals are 30-50 times more likely to develop active TB .

Dr Piot, states, "As HIV makes people more vulnerable to tuberculosis and tuberculosis goes on to kill people with HIV, these dual epidemics have together become the most serious public health threat of the decade."

Women of reproductive age, are more susceptible to fall sick once infected with TB, than men of the same age. Women in this age group are also at greater risk for HIV infection .

Very high prevalence of TB was reported in discussions in Nepal and Thailand. In India, tuberculosis is the major opportunistic infection detected in 63% of people with AIDS . In a study of 100 patients in Madras in 1995 it has been reported that among women 38% had Pulmonary TB and 14% presented with extra-pulmonary TB . The Tamilnadu State AIDS Control Society reports that in Tamilnadu, HIV prevalence among TB patients increased three fold in the last 4 years with a rate of 7.8% during 1998. Since 1996, the TB control programme in the Philippines has implemented the Directly Observed Treatment, Short course (DOTS) strategy in areas covering 2% of the population; the goal is to extend DOTS to 80% of the population by the year 2001. Fortunately, the prevalence of multi-drug resistant (MDR) TB seems to be very low in these countries. Specifically, in Nepal, less than 1% of the 900 samples screened were positive for MDR TB. In all countries visited, women appeared to better comply with treatment than men, though they constituted less than a third of those accessing treatment for TB. In some centres in Nepal, due to drug shortages, physicians wrote out prescriptions for paid purchases. In general, the trend in all these countries appeared to be treating for 8 months (modified from DOTS), and did not offer prophylaxis for those with HIV and TB, thereafter.

There seemed to be an over-reliance on radiological diagnosis of TB, which delayed the process of starting treatment, and necessitated multiple visits by a patient to the medical centre. In Nepal, the use of sputum smear for AFB was also widely used, which is recommended. None of the centres currently offer counselling for TB, the availability of which is likely to enhance compliance and testimonial patient referrals for treatment.

Women with HIV and TB in all the countries visited were malnourished. Malnutrition compounds the deteriorating heath of these women leading to wasting.

GENDER AND HEALTH TECHNOLOGY

Access to health technology is a critical concern for women in developing countries: this includes, female controlled HIV prevention technology, reproductive health services such as blood transfusions, access to family planning services, abortion services, HIV testing and counselling services, STD treatment services and diagnosis and treatments for gender specific clinical manifestations of HIV.

Barrier contraception and HIV

Attempts to limit the spread of HIV infection in women through education for men such as partner reduction, condom use and early detection and treatment of STDs have been limited. All currently available methods to prevent sexual transmission of HIV to a woman require male co-operation, which is not always forthcoming. One could speculate that the age gap between younger women and their sexual partners is likely to worsen this trend.

Therefore, developing an HIV control technology within the personal control of women is a global priority.

Women in Thailand, India, Nepal and Philippines identified fear of non-consensual sex, domestic violence, or economic abandonment as barriers to their ability to use the male condom. The ideal female-controlled method would be easy to use, prevent other STDs, and could be used discretely without her partner's consent or knowledge. The female condom has yet to attain full acceptability but has the potential to emerge as an important female-controlled contraceptive and a barrier to sexually transmitted infections .

Vaginal microbicides for prevention of STDs and HIV are in various stages of research and development. Nonoxynol-9 was initially considered a vaginal microbicide of great promise. Recent research however shows that vaginal film containing Nonoxynol-9 does not confer any additional protection to women from HIV beyond that provided by condoms . The US National Institute of Health (NIH-NIAID) funded HIV network for prevention trials now include a vaginal microbicide, Buffergel, a carbopal, which is not absorbed and can neutralize twice its volume of base buffers like semen . BufferGel is non-detergent based and therefore possibly less abrasive. It is currently in Phase I trials in Rhode Island, USA and research is planned for four international sites including India and Thailand .

Reproductive Health

The prevalence of HIV among the general population usually measured by the extent of spread among women presenting at antenatal clinics has led to the undesirable practice of mandatory testing for HIV of the antenatal women in most private sector medical establishments in India, Philippines, and Nepal. On the other hand public sector maternity facilities do not perform mandatory testing and thus offer medical services also to HIV positive pregnant women.

However, in these countries anecdotal evidence suggests that HIV positive pregnant women face stigmatisation in the public sector maternity while the private sector facility routinely refuse antenatal care.

In Thailand, the first case of HIV positive antenatal women was managed ten years ago. The medical response has since matured and both private and public sector facilities now provide obstetric care.

In Nepal and Thailand, the majority of women are anaemic due to malnutrition, which is compounded during pregnancy. Anaemia in women is best managed by improved nutrition and iron supplements. All of the four countries studied predominantly manage anaemia through single unit blood transfusions, but this practice does not have any substantive benefit, increases the demand for blood and increases the possible exposure of HIV.

Countries	Prevalence among Voluntary blood donors
Thailand	0.57%
India	0.90%
Government of India has banned the use of paid blood donors since 1998.

In the group discussions it emerged that in India and Nepal, injections are perceived to be more effective than oral medications. Women demand injections and medical practitioners are happy to oblige as this ensures compliance. The "quacks" (traditional healers, pharmacists, etc.) take advantage of this situation and administer vitamins or at times even distilled water. Needles and syringes, including disposable, are being reused on many patients without proper sterilisation. Participants also mentioned injection site abscesses, an indicator of unsterile injecting equipment.

While it may difficult to document the number of HIV infections transmitted through unsterile medical injections, in developing countries where HIV is widespread (India, for example) the risk of HIV transmission by medical injection is real .

Pregnant women should be provided access to other HIV prevention and treatment services (e.g., counselling, drug-treatment and partner-notification services) as needed.

The gold standard for preventing mother-to-child transmission continues to the ACTG 076 protocol. Developing countries however lack the infrastructure and the resources to maintain this elaborate protocol.

CDC recently announced the promising efficacy results of the trials in Thailand in which a short course of AZT given late in pregnancy and during delivery reduced the rate of HIV transmission in infants born to HIV infected mothers. The result showed a 50% reduction in transmission (13-48% , otherwise). The Government of India is planning to study the feasibility of providing AZT prophylaxis to interrupt mother to infant transmission; the phase I of this study will begin in five metropolitan cities by the end of 1998.

STDs in women

STDs cause infertility and fuels the spread of HIV because they cause genital lesions and inflammation. The infection can spread to the pelvis (pelvic inflammatory disease) which in turn is a major cause of infertility in many parts of the world. Syphillis, gonorrhoea and chlamydia can be passed on to infants during pregnancy and childbirth; their effect ranges from abortion and stillbirth to severe eye infections and pneumonia in the newborn .

Women with STDs have a higher risk of complications during pregnancy, including sepsis, spontaneous abortion and premature birth.

Male-to-female transmission of HIV appears to be 24 times as efficient as female-to-male transmission; in fact due to a large mucosal area exposed to virus in the case of women, and greater viral inoculum present in semen as compared to vaginal secretions. Young girls are particularly vulnerable as their immature cervix and relatively low vaginal mucosal production presents fewer barriers to HIV. In addition, some STDs increase a woman’s vulnerability to the HIV virus, as well.

The Indian National STD Program provides for a VDRL test for all antenatal women attending Government facilities in the first trimester of their pregnancy. In contrast, the Philippines National Program on STD has not included this service for the antenatal clinic attendees.

It is commonly reported among the Thai, Filipino, Indian and Nepalese women that the symptoms of STDs were ignored until they became unbearable. While access to economic resources did matter in terms of accessing private physicians, the barrier to government services was the attitude of service providers.

Family planning and abortions

Studies conducted during 1972-89 in India indicate that mean age at marriage for girls is 12.6 years.. In Nepal, nearly 50% of the 15-19 year old girls are married

Rapidly changing conditions, especially urbanization, have brought additional problems for Asian adolescents, including drugs, alcohol and the spread of STIs.

Social, economic and gender differences among adolescents are significant. For example, girls do not have the same education and employment opportunities as boys and face societal and family pressures for early marriage and early childbearing. Women therefore tend to marry early, to have children early, and to go on having children till they have the number of sons that the family desires. .

Child bearing during early or middle adolescence, before girls are biologically and psychologically mature, is associated with adverse health outcomes for both the mother and child. Infants may be premature, of low birth weight, or small for gestational age.

Adolescent pregnancy, whether it occurs within or outside the bounds of a socially sanctioned relationship, has tremendous physical and social consequences for the woman, in many cases more so than adult pregnancy. In all economic settings, adolescent mothers have consistently higher maternal and infant mortality rates as their access to care is often limited, and because for younger adolescents (less than 15 years of age) their pelvic bones may not be fully developed, which can lead to obstructed labour. The younger the girl, the more chances for her to have injuries during penetration, increasing her chances to acquire HIV.

According to studies in late 80’s, 43% of 15-19 years old girls in Thailand, 24% in Indonesia, 20% in Sri Lanka and 18% in Philippines were using some form of family planning, including traditional methods . However, adolescents are seeking abortion in rising numbers in India, Thailand, Nepal and Philippines. In one centre at Manila, there are 6 requests for abortion everyday.

Yet among 35 Asian countries only 3 offer abortions on request and in 15 it is illegal or there are very strict conditions. Young women are at particular risk for unsafe abortions, in countries where the medical system will not give reproductive health care to unmarried women, and adolescents in general tend to seek health care later than adults, leading to later-term abortions. In general, women under twenty are less likely than their older counterparts to seek prenatal care when it is available, and are less equipped to recognize the normal or abnormal signs of pregnancy.

In countries where abortion is illegal, expensive or difficult to obtain, women may resort to unsafe abortions, at times with fatal consequences. In a study in Bombay, India, 20% of all pregnancies of adolescent abortion seekers occurred because of forced sex, 10% from rape by a male domestic servant, 6% from incest, and 4% from other rapes

Unlike in India and Nepal where abortions of female foetuses are greater, in Philippines and Thailand both boys and girls are equally welcome as children. The continued and sustained availability of safe abortions becomes essential in developing countries.

Adolescents who give birth within a marriage usually enjoy emotional and economic support from their society; the other face of adolescent pregnancy is that outside of a sanctioned relationship. Nonetheless, sexual activity before marriage is common worldwide and for both married and unmarried adolescents, contraceptive use is quite low. Combined with a declining age at menarche in many areas and, frequently, a lack of sexual education or family planning knowledge, this low level of contraceptive use leads to a high risk of adolescent pregnancy outside of marriage.

Despite this range of strong societal reactions to adolescent fertility, policy makers in the world, have a long history of ignoring the issue of adolescent sexuality. Thus again, the fact that this issue was openly addressed at ICPD and recognized for its public health consequences, both within and outside marriage, is a remarkable achievement. The Programme of Action states that "information and services should be made available to adolescents that can help them understand their sexuality and protect them from unwanted pregnancies, sexually transmitted diseases and subsequent risk of infertility".

Clinical Manifestations in women with HIV

There is an increasing attention to the clinical symptoms of women with HIV . Women have shorter survival rates than men primarily because they come later for treatment or are less likely to seek it . Disease management strategies have also been less well developed for women . Recent studies suggest, however, that this survival gap has diminished , but this is also perhaps dependent on aggressive management of HIV disease.

Symptoms of middle-stage HIV in women, as in men, are extremely non-specific, including night sweats, diarrhoea, fatigue, cough, and weight loss. There are no glaring differences between the sexes in the presentation or natural history of such common AIDS-defining diseases as pulmonary TB, Candidiasis, Pneumocystis carinii pneumonia (PCP), cryptococcus, toxoplasmosis, gastro-enteropathy and CMV. Very specific symptoms in women are vaginal candidiasis, cervical cancer, abortions, anaemia, etc.

GENDER AND ENVIRONMENTAL HEALTH

The issue of health as a human right has been raised in several global conferences. The right to a safe and hygienic living environment is considered a basic human right. Violations of health as a human right occur due to poverty issues and environmental discrimination. Dumping of toxic chemicals in poorer regions, violence against women, inadequate housing, contaminated water supply, and lack of decent sanitation system affect millions of people globally. The Global Commission on Women’s Health focuses on issues of health as a human right for women since violence, lack of education, and other violations of basic rights continue to influence their environment.

Environmental policy requirements in countries such as India, Nepal, Thailand, and the Philippines are not addressing the needs of poor women living in urban slums or rural areas.

Violence involving sexual assault also carries risk for STD/HIV infection, unwanted pregnancies, and other sexual and reproductive health problems. Men who rape are most unlikely to use condoms. The assaults are intended to injure women’s psychological health as well as their bodies and often involve humiliation as well as physical abuse. In Thailand, researchers found that one in 10 victims of rape had contracted a STD because of the attack [Gender Division WHO, 1997 #33].

The physical environment (sanitation etc) and the social environment (violence, destitution etc) in which women live, make significant contribution their vulnerability to HIV. The gender impacts of HIV are several: retardation of female literacy; forced prostitution as a means to augment family resources; and, abandonment/destitution by husband’s family after his death.

In the Philippines, for example, women have a relatively high status and access to education, yet problems such as hygienic health facilities, unsafe abortions, poor working conditions in export zones, and exclusion from agrarian policies and reform are still problems for women in this region . Women in rural areas suffer even more from lack of a healthy and safe living environment due to inadequate health services. Pollution and environmental degradation have increased poor women’s work burden since their play a primary role in providing for the basic needs of their family.

In Northern Thailand, client-patron relationships of sex workers and brother owners indicate a best practice where the woman is able to protect herself from sexually transmitted infections. Those working in established brothels are better positioned to protect themselves that are young village girls who are sought after by men for casual sex. Young women engage in sex work to cope with landlessness and poverty, to support parents and children (in some cases, debt bondage), or to flee unhappy and abusive homes.

GENDER AND HEALTH FINANCING

Providing reproductive and child health, TB, STD and HIV services require tremendous resources, especially in developing countries where the women will be unable to afford any private initiatives. These are related sectors of health care, and national policies should provide a fine balance.

Many countries simply cannot afford to launch a treatment programme for HIV/AIDS, which is exceedingly expensive. To make matters worse, some strains of STD pathogens are becoming resistant to treatment, thereby requiring new and more expensive medications.

The World Bank reports that AIDS related deaths, often among individuals between 15 and 50 years of age, require a disproportionate share of total health care demands. This increase in demand also means that in many developing countries, the supply of care available at a given price will be reduced.

As presented by the World Bank report on policy choices, increases in health expenditure will occur in the following areas:

Maintaining safety for medical procedures

Attrition of health care workers who become HIV infected (increased labor costs for training and recruiting), and

Salary compensation for medical staff who perceive high risk of contracting HIV on the job.

As governments and international organizations try and address increases in health expenditure due to this epidemic, care for patients with AIDS continues to be poor. Developing countries such as India, Nepal, Philippines, and Thailand have HIV programmes financed by international donors. In Nepal, for example, a commercial sex worker HIV programme would shut down if organizations such as USAID and DFID terminated funding. Other hospital programs would not be able to provide a safe delivery ward for pregnant women, where gloves and sterile equipment may be too expensive without international funding.

Health financing of AIDS treatment for women is compounded by gender disparity as women go undiagnosed and untreated for longer periods of time than men. There is also a need to ensure that the psychological problems including managing anxieties have treatment options. In the absence of capacity to pay for such services, it becomes the responsibility of the state to provide for such services within the public sector.

Gender disparities are also reinforced by economic inequities. "Women’s work," namely child rearing, household upkeep, and often agricultural labour, is almost universally undervalued as a contribution to the national economy. The resulting poverty and dependence on one’s spouse leads to less access to health care and education, and can force women into prostitution, which carries obvious sexual and mental health risks. Conversely, access to financial resources can positively impact women’s reproductive health, as demonstrated by the Grameen Bank in Bangladesh, a micro-credit agency established in 1976. The loans are mainly used for small-scale income – generating activities such as processing paddies, keeping livestock, or selling crafts, and the repayment rates are generally excellent. Women who participate in this programme generally increase their mobility, financial resources, and standing in their families, all of which has been shown to have strong positive effect on contraceptive use and sexual health.

Direct costs for health management in women include those incurred by the police, courts and legal services to prosecute perpetrators of abuse; the costs of the treatment programmes for men who batter, and other offenders; the medical care costs of treating the direct medical consequences of sexual and physical abuse; and social service costs, including child protection services.

Chapter 3

International Conference on Population and Development (ICPD)

"The empowerment and autonomy of women and the improvement of their political, social, economic and health status is a highly important end in itself and goes on to describe the range of power relations and inequities that impede women’s progress globally. It, further states that population and development programmes are most effective when steps have simultaneously been taken to improve the status of women. In response to this, this programmes places a significant emphasis on education so at to empower women with necessary knowledge and skills needed for participation in development and related activity".

From CHAPTER 4, ICPD

The 3^rd significant conceptual shift in the ICPD Programme of Action is the view that family planning services should not be provided in a vertical program, but as one part of a broad range of reproductive health services.

The argument for providing family planning in a reproductive health context largely emerges from the recognition of a complete picture of women’s health. For example, the connection between reproductive health and general female morbidity (and mortality, as discussed below) is undeniably clear. A survey of maternal morbidity in 5 countries found that 70% of the 16,000 subjects reported a health problem related to maternity or chronic conditions arising from pregnancy or childbirth. Similarly, there were many women who had contraceptive-related complaints. These results are echoed in regional studies throughout the world. To take one example, a study of two villages in Egypt found that only 15% of the women were free of gynecological and related condition. Data such as these suggest the need to develop programming in broader reproductive health areas, but the Programme didn’t answer the serious concerns as to how to find the additional financial support for such activities.

Directed family planning programs can inadvertently exclude segments of the female population, which is important not only for reasons of equity – a non-sexually active woman may be in need of reproductive health care but excluded from programs focused on family planning – but also for medical reasons. That is, childhood health problems, such as malnutrition resulting in an underdeveloped pelvis, sexual abuse, can lead to serious maternal health, and women’s health. This all argues for an integrated approach that includes all these reproductive health issues.

In light of these arguments, the Programme contains a remarkable definition of reproductive health that recognizes that vast social and medical consequence of women’s reproductive behaviour:

"Reproductive health is a state of complete physical, mental, and social well being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when, and how to do so… In line with the above definition of reproductive health, reproductive health care is defined as the constellation of methods, techniques, and services that contribute to reproductive health and well being through preventing and solving reproductive health problems. It also includes sexual health, the purpose of which is the enhancement of life and personal relations, and not merely counseling and care related to reproduction and STDs "

For all its universal coverage, the ICPD document does not discuss the needs and circumstances of women and children in sex work. Neither the ICPD Conference nor the Beijing Conference have a single phrase addressed towards women in sex work/prostitution.

The commitment made by Governments to the ICPD by the developing countries provides that

Reproductive health programs should increase their efforts to prevent, detect and treat sexually transmitted diseases and other reproductive tract infections, especially at the primary health-care level. Special outreach efforts should be made to those who do not have access to reproductive health care programs. (ICPD 7.30)

All health care providers, including all family planning providers, should be given specialized training in the prevention and detection of, and counselling on sexually transmitted diseases, especially infections in women and youth, including HIV/AIDS. (ICPD 7.31)

Health providers, including family planning providers, need training in counselling on sexually transmitted diseases and HIV infection, including the assessment and identification of high-risk behaviors needing special attention and services... (ICPD 8.31)

Promotion and the reliable supply and distribution of high-quality condoms should be integral components of all reproductive health-care services. ...Governments and the international community should provide all means to reduce the spread and the rate of transmission of HIV/AIDS infection. (ICPD 7.33)

Condoms and drugs for the prevention and treatment of sexually transmitted diseases should be made widely available and affordable and should be included in all essential drug lists. (ICPD 8.35)

Programs to reduce the spread of HIV infection should give high priority to information, education and communication campaigns to raise awareness and emphasize behavioral change. (ICPD 8.31)

With a wide ranging technical support available in house and through consulting assignments, the respective country offices of UNAIDS actively engage themselves in advocating and advising increased government spending on AIDS prevention, support and care initiatives. The World Bank has been providing soft loans to provide the needed impetus, which may otherwise be lacking for want of resources.

Each of the countries visited have developed their unique national policy, responding to the stage of the pandemic in the respective countries. The policies of the four countries visited are tabulated below highlighting their gender sensitivity.

Chapter 4

RECOMMENDATIONS

The ICPD Programme of Action and the Beijing conference recognize that (1) advancing gender equality and equity and the empowerment of women (2) the elimination of all kinds of violence against women; and, (3) ensuring women’s ability to control their own fertility, are corner stones of population and development related programmes.

Women are creators of new life, the caretakers of daily life and the custodians of community norms and social values. However, in developing countries, one half of all HIV infections occur in women. How will the loss be borne?

The thematic approach to HIV prevention among women involves educating men and women about their bodies and sexual responsibilities, preserving their reproductive health through investment in public sector reproductive health care service delivery and improving the economic status of women.

Knowledge alone is not sufficient when women do not have the power to act on it. Yet our understanding of the empowered women are too often informed by what she is not .

For HIV positive men and women empowerment begins when they change their ideas about the causes of their powerlessness, when they recognize they systemic forces that oppress them and stop blaming themselves for their situation, and when they begin to act to change conditions in their lives.

Women must share a common political concern and recognition of their mutual vulnerability vis-à-vis the disease if they are to mobilize effectively for HIV/AIDS prevention. Program areas must include promoting empowerment of women through women’s collectives and income generating cooperatives.

Specific research and program priorities are given below:

Vertical transmission:

Health-care providers should ensure that all pregnant women are counselled and encouraged to be tested for HIV infection to allow women to know their infection status both for their own health and to reduce the risk for perinatal HIV transmission.

Counselling should include information regarding the risk for HIV infection associated with sexual activity and injecting-drug use, the risk for transmission to the woman's infant if she is infected, and the availability of therapy to reduce this risk. HIV counseling, including any written materials, should be linguistically, culturally, educationally, and age appropriate for individual patients.

Specific strategies and resources will be needed to communicate with women who may not obtain prenatal care because of homelessness, incarceration, undocumented citizenship status, drug or alcohol abuse, or other reasons.

Uninfected pregnant women who continue to practice high-risk behaviours (e.g., injecting-drug use and unprotected sexual contact with an HIV-infected or high-risk partner) should be encouraged to avoid further exposure to HIV and should be offered testing for HIV after the window period.

For women who are first identified as being HIV infected during labour and delivery, health-care providers should consider offering intra-partum and neonatal ZDV according to published recommendations.

Research should recognize that human relationships are complex and that the urge for biological children may be high among childless HIV discordant couples. Post-exposure prophylaxis to prevent partner transmission is thus an important research area.

Another area of research into drugs, which will allow lactation without exposure to HIV and thus retain the gains of breast-feeding, realised in the developing world.

Clinical trials must however be designed to be scientifically valid and ethically defensible.

While there is "no convincing evidence" that HIV infection leads to more severe malaria or that malaria accelerates HIV progression. However, an interaction between HIV and placental malaria may be an exception. "Two of the greatest medical challenges facing Africa today are HIV infection and malaria, yet the interaction between these two infections has been little studied". Because T cells are believed to play an important role in all stages of malaria, the presence of HIV infection may have a major effect on the host's ability to mount an effective immune response

Female controlled methods to prevent HIV

Consistent condom use, one cornerstone of primary prevention strategy, is not always feasible for many women. Consequently, women urgently need infection prevention technology that is within their personal control.

The female condom which is being made available through a special access programme of the UNAIDS in Africa is a definite step forward but it is not a product that is accessible or affordable in many parts of Asia; furthermore, it is not a product that can be used discretely. Also required are acceptability studies of the female condom among women, who do and do not identify themselves as sex workers, and their partners.

Vaginal microbicides have been developed now for many years. No effective product has reached the market yet. As new research is being designed, they must take into consideration the economic realities of the developing world. NGOs from India, Thailand and Philippines pointed out that otherwise, the divide that exists now in treatment will unfortunately extend to prevention as well.

The study of natural history of HIV in women.

Scientific studies that measure the rate of progression of HIV disease in women as related to biological, social and hormonal differences are urgently required in developing countries. Treatment of HIV related morbidity, particularly gynaecological, will benefit from these studies.

Tuberculosis

The growing concern for the TB/HIV dual epidemic among young women requires not only implementation and access to Directly Observed Treatment, Short course (DOTS) and prevention programs, but also the incorporation of TB education and information materials into MCH and HIV/AIDS programs.

More research is needed in to the biological, epidemiological, social and cultural differences in the occurrence of TB in men and women and their access to TB treatment strategy especially DOTS. Specific areas of research could be TB and pregnancy, diagnosis of TB in women, adherence to treatment and patient education.

Emphasis must be placed on the 5 elements that comprise DOTS:

Political commitment

Case detection through sputum smear microscopy

Directly observed short-course treatment

Regular drug supplies

Monitoring systems with evaluation of treatment outcome for each patient

Improved access to DOTS could prevent many needless deaths among women and children and improve our control of this infectious killer" said Dr Dolin of WHO. "Outreach services, flexible opening hours for clinics, and health workers trained to respond to women’s needs could make DOTS more user-friendly for this risk group".

Clinical manifestations in women

Women living with HIV are more prone to cervical dysplasia, which further leads to malignancies. In the developing countries the high fertility rate compounds the problem of cervical dysplasia. Research in to technology for early and easy identification and management of cervical dysplasia becomes relevant.

Integrated HIV/AIDS prevention information and care

Programme managers must address the following issues in respect of integrating HIV prevention and care into existing reproductive health services.

At the community, institutional and national level:

Operational approaches to integrating RH and STD/HIV

Enabling factors for the integration of RH and STD/HIV

Barriers to their integration and solutions to overcoming the barriers

Expected outcomes of the integration

The challenges faced by AIDS are by no means exclusively economic ones. Even if poor women had access to health care providers, they may hesitate to obtain services if the attitudes of service providers are not encouraging.

 

Education programs that aim to prevent HIV among women should address men as well

Many forces conspire to increase the risk of infection for women in developing countries. Programme design should not ignore the differential power that between men and women, especially when negotiating for safe behaviours. Investment in structural changes and community development in addition to issues on education and personal responsibility is required. AIDS is a political issue in most countries. Gender and class dynamics systematically mute women’s voices.

Intertwining with wide spread poverty and lack of economic opportunities, the growth of sex tourism in south and east Asia has led to an increased demand for younger sex workers in India, Nepal and Thailand. The Government of India estimated that 30% of all sex workers in 6 major cities were below the age of 20 and that almost 40% of them entered the profession before they were 18 years of age . Trafficking of young girls and boys for profit is a lucrative practice. The situations that lead to child slavery as in India and Nepal, or forced prostitution as in India, Nepal and Thailand, require the attention of the law.

Women and men working together can do more to address these issues.

Adolescent reproductive health

That adolescent pregnancy occurs in all the four visited countries indicates the greatest need to provide accurate information to young people. All young people share this need: rich and poor, sexually active and inactive, married and unmarried, male and female. They prefer to get their information about sexuality from caring adults, but often learn about sex from their peers. Unfortunately much of this information is either inaccurate or insufficient .

Strategies should be designed to address the distinct needs of sub-groups of adolescents: the first group includes those who have not yet begun sexual intercourse. These adolescents almost invisible and their needs are usually not addressed, but there is an opportunity to sustain safe behaviours among them. The second group includes those who have engaged in sexual intercourse but with no unhealthy consequences such as unwanted pregnancy, unsafe abortion, Sexually transmitted infections, Reproductive tract infections, HIV or abusive/violent sex. They need information, skill building, counselling services to adopt safe behaviours. And a third group of adolescents, who contribute a substantial share of adverse health consequences and are also the group that those delivering services have in mind. They require different set of interventions including safe abortions, contraceptive counselling and STD/HIV services.

STD Control

The success of STD control programs significantly depends on the attitudes of the service providers. Where the service is provided in a discriminatory, coercive or directive environment, patient access is hindered. Besides enhancing diagnostic skills, STD programmes should invest in improving user friendliness of facilities.

Most women are unlikely to access STD clinics because of social stigma. They are more likely to approach their primary physicians or the reproductive health clinics. The STD control programme should provide for wide spread training of primary care physicians and physicians at the reproductive health clinics in basic STD management.

Training for Ob&Gyn specialists

Antenatal women face discrimination in the hands Obstetricians and Gynaecologists. It is important not only to regularly update current Ob&Gyn practice as is relevant to HIV, but also to invest in training programs that address the provider attitudes towards HIV.

Investment in Education and opportunities for employment

The International Center for Research on Women states that:

One additional year of schooling for women reduces child and maternal mortality and increases women’s earnings by up to 20%

Women are one third of the worlds paid labor force and now enter the labor market at rates faster than men do, although typically in low wage, unprotected jobs.

Women micro-entrepreneurs have an extremely high payback rate on loans over 95%

Economic co-operatives that promote economic independence among women and specific female literacy initiatives should be supported in developing countries.

Social factors

"Where else has the fundamental condition of all women, whatever the status or the state of their personal freedom, been so intensely debated, or seen to be so relevant to the next century?"

From the closing ceremony at the 1994 ICPD Conference, CAIRO

Clearly, since only women become pregnant and bear children, the crux of the ICPD Programme of Action is women, as agents of change, as individuals deserving of reproductive health and rights, and as the ultimate determinants of fertility behavior.

Research must focus into the gender differences constantly faced by women in each stage of the life cycle and the coping strategies, self identity, self esteem, sexual identity, social role and family studies that evaluate intergenerational impact of male dominance and resultant violence.

Many men believe that women, especially wives and daughters, can and should be beaten, or believe that they can even kill women with relative impunity, as they are men’s property. However, research from countries such as Afghanistan show that the men want to promote the status of women as human beings and to prevent violence against them.

Men as well as women must work to minimize violence against women and girls. Such diverse responses to the gender as seen in the developing countries makes one wonder if there at all there would be a change of the status of women.

 

Event	Response if male	Response if female
Pregnancy	Better nutrition; lesser work allotted for the mother	Possible abortion
Birth	Celebration	Infanticide? Otherwise indifferent and the quest for a male child continues
Education	The best of the education; no house hold chores that could interfere with the education	Is it necessary? What will she achieve? If we save money now that can be used for the dowry. So education at low or no fee payable institutions; quality of education not criterion; emphasis on discipline (read as development of the trait of submissiveness)
Life as an adolescent/adult	Career oriented education and training – say engineering, medicine etc May procure paid sex; may pick up STDs but is not only forgiven but is likely to be protected	Works at home, cooks and cleans; Get married at this phase of life May be subject to incest, abuse, violence and may pick up STD/HIV as a result and will be subject to critical review
Recreation options	Movie houses, clubs, beach	Restricted to some TV and Radio programs at home
Marriage	Proud; marriage can be delayed           In marriage, he can demand "I need sex now; come and lie down" He will say "You have not given your full dowry; go home and get it now" He can beat and kick her and get away with it	To be married off as early as possible even at the cost of education or a career; where dowry is involved constant reminder from the parents how unfortunate to have had a daughter She may think "I am tired; how can I tell him; he may beat me" She can feebly protest "My parents are trying hard to collect some money; please let me stay here some more days" (she knows she will not be welcome home if she picks up a fight)
Bearing children	Can demand that the child be a boy (does not matter what the XY chromosome does) and say "how dare you give birth to a girl" if a girl	Can at best pray and hope that it could be a boy
If no children in married life even if man is using a condom to prevent HIV transmission to wife	INLAWS: He has been married to a barren woman; we shall get our son married a second time	HER PARENTS: They suffer with the girl
Death of spouse	Remarry	Burdened widowhood

A crisis such as HIV/AIDS challenges basic premises and assumptions, people’s trust and faith in their future and tolerance. The experience of living or coping with HIV/AIDS can also enlarge our differences as people distinguish themselves in order to create an illusion of greater control over their lives. Gender differences along with other social attributes may increase as more women are infected and this crisis deepens. It will be a tragedy for everyone if we allow our differences to divide us in our willingness to respond. The diversity of other experiences and ways of addressing this disease must be recognized and respected if we are to make any headway in preventing, controlling and living with HIV/AIDS.

APPENDIX 1: OPPORTUNISTIC INFECTIONS IN WOMEN

Studies of HIV disease progression in women are limited. Data available are not country specific because of great differences in economic, sociologic, medical, and public health conditions. We need to do a research in Resource Poor Settings (RPS).

One report summarized a dozen studies that overall reveal that the survival and course of disease in men and women is not substantially different when patients are matched for socio-economic status, risk group, and access to care.

The pattern of opportunistic infection and other complications in women may differ from that in men. There are data suggesting that esophageal candidiasis is more common in women then men. Vaginal infection with candida, an extremely common affliction in normal women, not only may be more severe and more refractory to treatment in HIV-infected women but also may occur earlier than oral candidiasis, raising the possibility that vaginal infection could serve as an early marker of disease progression in women. The CDC have added vulvo-vaginal candidiasis and pelvic inflammatory disease to their revised classification system of HIV infection, grouping them under category B. Category B includes conditions that, not considered to meet the definition of CDC-defined AIDS, are considered attributable to HIV infection or indicative of a defect in cell-mediated immunity and/or are considered by physicians to have a clinical course or to require management that is complicated by HIV infection.

Among New York Medicaid recipients (of which 60% of the men and women were IDUs), treatment with zidovudine and PCP prophylaxis was equal in IDUs, but non-IDU women were less likely to receive zidovudine or PCP prophylaxis. Among drug users, women survived slightly longer than men, and among non-drug users, survival was similar for both sexes.

A CPCRA study looked at 3779 men and 768 women with median T-cell counts higher than the men (median 240 in women versus 137 in men) and found that women were at increased risk of death (with a relative risk of 1.3) during a 15-month period. It is important to note that there was no increased risk of HIV disease progression in women. Equally as important, the increased risk of death was found primarily among IDUs, and the deaths were secondary to bacterial pneumonia and endocarditis, both likely related to injection drug use. The study authors concluded that these findings might represent differential access to care, treatments, or social support. The most important predictors of survival or progression appear to be CD4 count, viral load, and the specific AIDS-defining diagnosis -- not gender.

Lack of access to care, minimal self-motivation, attention to the health care of their children over that of themselves, and disenfranchisement among a large proportion of women all contribute to decreased rates of early detection and intervention. Medical providers need to maintain a low threshold to counsel and test for HIV, remembering that women who have HIV through heterosexual transmission may be unaware of their partners' HIV status even if aware and therefore do not perceive themselves at risk for HIV. HIV and AIDS for women is an issue of access to health care, and the care system is not always well suited to their needs.

HIV infection in pregnancy

Reports of maternal death associated with the development of PCP during pregnancy led to concerns that pregnancy might have a significant impact on maternal morbidity and mortality from AIDS and resulted in some clinicians advising pregnancy termination on the basis of maternal indication even apart from issues of vertical transmission of the virus. Current data are too limited to determine whether pregnancy may accelerate disease progression. In addition, increasingly effective prophylaxis and therapy for HIV-related opportunistic infection, as well as anti viral therapy, may improve the chances for maternal survival sufficiently to preclude a deleterious effect of inter current pregnancy, even in women with advanced disease. The greatest maternal danger may in fact occur in pregnant women whose HIV infection is not detected or in women known to be HIV infected who receive inadequate prenatal or routine HIV care.

Almost all opportunistic infection in pregnancy are life threatening and thus, in general, the benefit to the mother of treatment far outweighs any risk to the foetus. Most drugs used for opportunistic infection, however, have been used to only a limited extent in pregnancy. Trimethoprim-Sulfamethoxazole appears safe and effective for both prophylaxis and therapy for PCP in pregnancy. Although Trimethoprim-Sulfamethoxazole has been reputed to cost neonatal kernicterus when given to women at term, most believe this to be only a theoritical risk and consider it first time prevention and therapy in the pregnant women. Given its excellent efficacy in the treatment of acute PCP and superiority as a prophylactic agent.

There are few data on the safety of fluconazole in systemic fungal disease during pregnancy and animal studies have demonstrated possible antiestrogen effects. In contrast, there is substantial clinical experience using Amphotericin B in pregnancy with no reported associated teratogenicity.

Sulfa drugs including sulfadiazine are considered safe in pregnancy. Clindamicin has been used widely in pregnant women without apparent adverse fetal outcomes. Pyrimethamine is the main stay of therapy for Cerebral toxoplasmosis. There is no evidence of teratoganicity when used in pregnancy and thus it should be used.

Pulmony tuberculosis is the most common opportunistic infection in both men and women. There is significant experience with anti- tuberculosis drugs in pregnancy, and in general, the same indication for prophylaxis and treatment for tuberculosis should be in pregnant as in non-pregnant HIV-infected patients.

Malignancies

 

Kaposi's Sarcoma

Kaposi's sarcoma (KS), seen frequently in homosexual men, is found in less than 2% of HIV-infected women as an initial AIDS diagnosis. When KS has been seen in women, it most frequently has been associated with sex with a bisexual man, but it has been seen in women whose risk was injection drug use or transfusion. There is strong evidence that Kaposi's sarcoma in persons with or without HIV infection is associated with newly identified human herpes virus 8 (HHV8), and can be transmitted sexually. HHV8 has been identified in tissues from people with all kinds of KS, including KS associated with AIDS, endemic cases in Africa, classic KS in elderly men of Mediterranean descent, and KS arising from organ transplantation. HHV8 has been detected in semen and sperm, peripheral blood lymphocytes, nasal secretions, and saliva, as well as endothelial cells. The presence or absence of HHV8 in women's fluids (breast milk, vaginal and cervical secretions) has not been determined.

In one cohort of 1,239 patients, 123 had KS diagnosed between 1988 and 1995; 12 were women. All of the women had heterosexual contact with men at risk for HIV, 5 of the 12 had contact with bisexual men, and 3 of the women were commercial sex workers. Both the men and the women in the cohort were matched for stage of HIV disease at the time of initial presentation. KS in these women was more aggressive and advanced, with more non-cutaneous disease, more lymphedema, and more lymph node and visceral involvement. Several reports suggest the course of KS in women can be aggressive, even when KS was the initial manifestation of AIDS.

The case of a 22-year-old woman whose KS and HIV were diagnosed when she went to her dentist because of a violaceous lesion on her hard palate emphasizes that all health practitioners must be alert for signs of HIV in both high-risk and seemingly low-risk populations. This counsel is particularly germane to women who may contract HIV or HHV8 disease through heterosexual transmission, as they often are unaware of their risk factors and do not perceive themselves at any risk. A recent report describes an HIV-infected woman who presented with vulvar pain, vaginal discharge, and a vulvar mass that proved to be KS. This case emphasises the point that unusual presentations of KS are likely to occur.

Gynecologic Manifestations

Much attention has been given to disorders that may be more frequent, more severe, and less responsive to therapy in HIV-infected women (particularly those with advanced immuno-suppression) than in HIV-uninfected women: human papillomavirus (HPV), associated cervical disorders such as cervical intraepithelial neoplasia (CIN), Candida vaginitis, and pelvic inflammatory disease (PID). These disorders are recognised as HIV-associated conditions in the expanded CDC case definition.

Cervical Disorders

Human Papilloma Virus and Cervical Neoplasia. Limited evidence suggests an increased occurrence and aggressiveness of cervical cancer in women with HIV infection. As of 1993, cervical cancer constitutes an AIDS diagnosis. In the general population, invasive cervical cancer is more common among black women living in the south, which is typical of women diagnosed with AIDS due to their invasive cervical cancer.

Immune suppression appears to make one particularly susceptible to infection by HPV.

HPV prevalence, acquisition, and retention are higher in HIV-positive women than in matched controls. By DNA analysis, types 16, 18, and 33 are associated most frequently with CIN in HIV-positive women and controls, especially in women with CD4 counts of less than 200 cells/mm³. An increased frequency of abnormal Papanicolaou (Pap) smear results was first noted in women attending clinics for HIV, methadone maintenance, and cervical dysplasia. In an early study, 40% of 35 HIV-positive women had squamous intraepithelial lesions on cervical cytologic examinations compared with 9% of 32 HIV-negative women.

Are Pap Smears as Sensitive in HIV-infected Women?

Because CIN is more frequent and more aggressive in women with severe immuno-suppression, some practitioners routinely recommend a Pap smear every 6 months, particularly for women with more advanced immunodeficiency. The WIHS study also suggested that Pap smears were highly sensitive in HIV-positive women. Subsequent studies confirm that Pap smears also were equally sensitive for detecting cervical disorders in HIV-positive and HIV-negative women. One study also demonstrated that 15% of the dysplasia in HIV-positive women seen in a large dysplasia referral clinic was limited to vulvar, vaginal, or perianal lesions detected only by colposcopy. These lesions would have been missed if only a cervical Pap smear had been performed. Although colposcopy would be the most sensitive and specific diagnostic tool, the general lack of availability and standardisation especially in developing countries require assiduous attention to appropriate Pap smear tests and follow-up.

The Women's Interagency Health Study (WIHS), a large natural history study of HIV-infected women, is currently being conducted and the results will define the optimum interval for Pap screening. At this time, performing a Pap screening every 6 months along with careful vulvar, vaginal, and anal inspection appears prudent, especially with more immunosuppressed patients with T cells less than 200 cells/mm³. Colposcopic evaluation of women should be performed with any atypical squamous cells of unknown significance (ASCUS), atypical glandular cells of unknown significance (AGCUS), low-grade and high-grade SIL on any Pap smear, or any persistent inflammation that is unresolved after treatment for GC, Trichomonas, or Chlamydia. Initial colposcopy could be considered for women with poor likelihood of follow-up, or suspicion of extra cervical disease. Pregnancy did not affect the incidence of abnormal smears in women enrolled in the Women and Infants Transmission Study.

Treatment of Cervical Intraepithelial Neoplasia (CIN).

CIN I which is diagnosed on biopsy (not just Pap smear) does not appear to progress to invasive cervical cancer. Follow-up is required, however, to detect progression to a higher grade of CIN. CIN II and CIN III require definitive therapy to avoid invasive cervical cancer. Modalities such as loop electrosurgical procedure (LEEP), cryotherapy, and laser vaporisation are effective when the endocervical region can be well visualized and there is no endocervical involvement.

Cervical colonization is indicated for women who do not meet those criteria. In sero-negative women, there is a small risk (5 to 10%) of CIN II or III recurring after therapy. All of the treatments for CIN appear less effective in HIV-infected women, especially those with more advanced immuno-suppression. In HIV-positive women, the risk of recurrence is much higher and requires careful surveillance. The treating clinician should be prepared to treat recurrences with the knowledge that doing so is preventing the development of invasive cervical cancer.

Genital Ulcerative Disease

Genital ulcerative disease is a well-described risk factor for transmission of HIV, particularly in studies in developing countries where STDs are more prevalent. A wide array of etiologic agents may be causative, including HSV, CMV, syphilis, chancroid, gonorrhea, acid fast bacteria, other bacterial or fungal pathogens, and malignancies. Genital ulcers are painful, disabling, and difficult to treat. Such ulcers should be evaluated with a full work up.

Herpes Simplex Virus (HSV).

Severe ulcerative genital herpes was the AIDS-defining diagnosis in 18% of 44 HIV-infected women prospectively followed who developed AIDS. Genital HSV infections are prevalent in the population at large and may be particularly refractory in HIV-infected men and women. HSV may present atypically, and recur frequently. Common sites of presentation include the labia majora, labia minora, the sacrum, and buttocks.

Augenbraun et al. demonstrated that HSV-2 shedding was nearly four times greater in HIV-positive than in HIV-negative women and that 79% of the shedding was asymptomatic. As immunosuppression progresses, measured by declining CD4 count, shedding of HSV-2 became more common.

There is every reason to assume that the consistent finding of HIV (5000 copies of HIV RNA per micro litre) in the HSV lesions of HIV-infected men occurs in women as well. This presence of HIV in recurrent HSV lesions explains in part the increased rates of HIV transmission when ulcer disease is present. (See also the chapter on HSV in this volume.)

Giant Idiopathic Aphthous Genital Ulcers.

Giant idiopathic Aphthous genital ulcers are infrequent but painful, disabling, and difficult to treat. Such ulcers should be evaluated with a full work up for HSV, CMV, syphilis, chancroid, gonorrhea, bacterial or fungal pathogens, and malignancies. The pathogenesis may be similar to giant esophageal Aphthous ulcers. Anecdotal reports suggest that thalidomide may be effective for esophageal ulcers, but there is negligible experience with genital ulcers in women. A rigorous application process would be required in order to give thalidomide on a compassionate-use basis.

Pelvic Inflammatory Disease (PID)

HIV is prevalent in women with pelvic inflammatory disease (PID), and it has been suggested that PID may be more severe with advanced HIV disease. PID responded to therapy equally in HIV-infected and HIV-uninfected groups.

HIV-positive patients may present with lower white cell counts than their non-HIV positive counterparts. Tubo-ovarian abscess formation has been reported to occur in as many as 25% of HIV-infected women with PID versus 12% of HIV-uninfected controls with PID. Therefore, more surgical intervention is required, especially in AIDS patients with more advanced disease. Standard antibiotic regimens that include anaerobic coverage can be used initially. If treatment fails, more aggressive anaerobic coverage should be instituted. Most clinicians maintain a low threshold to hospitalize, especially if the HIV disease is advanced.

In the region majority of OBGYN in private practice refuse surgery and those in government institutions have poor attitude and avoid surgery.

Menstrual Disorders

Currently, no data are available to suggest that the diagnosis or treatment of menstrual disorders should be different from that for HIV-negative women. In HIV-positive women, however, further documentation of the specific types of menstrual irregularity, the frequency, and the hormone interaction is needed. These menstrual disorders are relevant not only because of personal discomfort but because unsuspected pregnancy may masquerade as a delayed period. Menstrual irregularities make prediction of time of fertility difficult for those wishing to conceive or avoid pregnancy and may potentially increase exposure to menstrual blood for a partner.

A 1997 study emanating from the Women's Interagency HIV Study (WIHS) looked at 2,000 HIV-infected women and compared them to 500 seronegative controls. Amenorrhea (defined as no menstrual period for greater than 90 days) was noted in 7% of HIV-infected women and 5% of seronegative controls. The risk factors for amenorrhea in the study were found to be HIV infection, heroin use, low albumin, and live births. Lower CD4 lymphocyte counts, serum albumin levels of less than 3.0 g/dl, or use of heroin or amphetamine increased the risk of amenorrhea. Many HIV-infected women (61%) reported irregular periods in the past 6 months, but this finding was not statistically significant when compared to controls. The majority of these women had amenorrhea on the basis of hypothalamic dysfunction with low or normal levels of follicle-stimulating hormone and low levels of estradiol.

Acknowledgement

India

M/s Sarah Chandha. YWCA. Sahodari Project – Chennai

Kalaiselvi Karunalaya – Chennai

Arogyam – Chennai

SOS – Dr Ramesh Goud, A-Wing, Umiya Apts., Canada Corner, Nasik - 422005, Maharashtra

Neena Seshu – Sangli – Maharashtra

Anjali Gopalan – NAZ Foundation - Director, The Naz Project India Trust, D 45 Gulmohar Park, New Delhi-110 049– Delhi

INP+ - Chennai

Radhika Ramasubhan – Bombay – Maharashtra

ADDRESS – Chennai

and many others from different parts of India

Nepal

PWA from PRERANA and Freedom Centre, C/o LALS, PO Box: 7151, Dillibazar, Kathmandu, Nepal.

Dr Amaya Maw Naing, UNAIDS

Dr Glenn L Post Chief, Health and Family Planning Office, USAID/Nepal, Rabi Bhawan, PO Box: 5653, Kathmandu, Nepal. / Matts Friedman / Ms Mangal Shakya - USAID

Dr Benu B Karki – Director– National Centre for AIDS and STD Control, Teku, Kathmandu, Nepal.

Prof. Mathura P Shrestha – Chairman – Nepal Health Research Council, PO Box: 7626, Ram Shah Path, Kathmandu, Nepal.

M/s Bharati Silawal Giri – Sr. Gender Specialist, United Nations Development Programme – PO Box: 107, Pulchowk, Kathmandu.

Dr Bill Pigott – WHO Rep. To Nepal, WHO – Ãå±±½ûµØBuilding, GPO Box No. 108, Pulchowk, Kathmandu, Nepal.

Ms. Misbah M Sheikh, Aid Coordination Specialist, PO Box 107, Kathmandu, Nepal. Ms Sudha Panth, Ms Anjali Pradhan, Ms Charu Prasada, Ms Caroline Bakker – Gender Focal Points for Ãå±±½ûµØagencies.

Dr Dirgha Singh Bom

Ms Durga Ghimire – ABC/Nepal

Ms Armina - Maiti Nepal

Philippines

M/s Florence M Tayzon – Asst. Representative – UNFPA, Neda Sa Makati Bldg., 106 Amorsolo St., Legaspi Village, 1229 Makati City.

Dr Ma Elena G Filio – Borromeo – Program Manager - National AIDS-STD Prevention and Control Program, III Floor, Building No.12, Dept. of Health, San Lazaro Compuond, Sta. Cruz, 1014 Manila, Philippines.

Dr Renee P Faldas, STD/AIDS Coordinator, National AIDS-STD Prevention and Control Program, Regional Health Office No. XI, Bajda, Davao City 8000.

Mr Jeramie C Diaz – President - and his friends – Pinoy Plus Association Inc. – Bahay Lingap, San Lazaro Hospital, Quiricada St., Sta. Cruz, Manila, Philippines.

Dr Junice Lirza Demeterio – Melgar – Executive Director– Likhaan – A centre for women’s health care, education, organizing and research, 92 Times St., West Triangle, Quezon City 1104, Philippines.

Dr Ferdinal M Fernando – MO & Program Manager – Reach out, 2030 M Adriatico St., Malate, Manila.

Focus group with women from low socio economic group

Focus group with girls working part-time in the hotel

Thailand

UNAIDS, III Floor, United Nations Building, Rajadamnern Nok Ave., Bangkon – 10200, Thailand – WHO – etc. – Group

Ms Tanawadee Tajeen and her team – Director – Friends of Women Foundation

Mr Jon Lingpakorn – Access

Dr Wiput Phoolcharoen – Director Division of AIDS – Dept. of Communicable Disease Control – Ministry of Public Health, 88/21 Moo 4, Tivanont Road, Amphur Muang Nonthaburi 11000.

Dr Ying Rulo – Medical Officer – HIV/AIDS – WHO

Dr Somsit – The Bumrajnaradoon Hospital

Focus group of girls at hotel

Interview with sex workers and pimps

Mr Ennio Cufino – Project Officer (Health HIV/AIDS) – UNICEF

Mr Pornchai Suchitta – Asst. Representative – UNFPA

Ms Laksami Suebsaeng – Asst. Admin. Officer – WHO

Mr Jayasankar Shivakumar – Country Director – The World Bank

Ms Shoko Ishikawa – Programme Officer – UNIFEM

Mr Sompong Chareonsuk – LNO/HIV/AIDS Management Specialist – UNDP

Dr Revathi Balakrishnan – Rural Sociologist & Women in Development Officer – FAO

Ms Lucille Gregorio – Programme Officer – UNESCO

Ms Maria Pia De Palo – Programme Officer - UNDCP