Gender matters in HIV prevention

A growing number of women are becoming infected with HIV compared to at the start of the epidemic, when HIV affected primarily gay men and men who have sex with men. This rising rate of HIV infection is a reason to take stock of our prevention approaches and place a greater emphasis on women’s issues and needs as we move forward. How can we address gender inequalities in our HIV prevention programs?

What is the difference between sex and gender?

 “Sex” refers to biological characteristics that distinguish males, females and intersex individuals, and is based on a person’s biology and reproductive anatomy.

“Gender” refers to the socially constructed roles, attitudes, behaviours, norms, values and influences that “a given society considers appropriate” for men, trans men, trans women and women.¹ Gender roles in many societies place a woman in a position in which she is less able to protect herself from HIV—either by making it difficult for her to practice safer sex and safer drug use or by limiting her ability to access HIV prevention services. For example, in some communities, women are responsible for the home while men are responsible for supporting the family.¹ In this situation of economic dependency, women may have less access than men to education, income and employment, which could, in turn, limit her ability to negotiate safer sex or access prevention programs.

What’s in a number?

Women now account for a significantly larger number of new HIV infections in Canada (incidence) and a significantly larger proportion of people living with HIV (prevalence) compared to the beginning of the epidemic. HIV statistics tell us that women (aged 15 and older) represent an increasing proportion of positive HIV tests—up from 12% before 1999 to 26% in 2008.² Estimates of the number of people living with HIV at the end of 2008 (HIV prevalence) suggest that there were 14,300 women, a 17% increase from 2005.²

These numbers tell us that there is cause for concern but they don’t tell us why HIV incidence and prevalence rates are on the rise. They don’t unveil the complexities of women’s lives or identify factors that increase some women’s vulnerability to HIV. They tell us nothing of how the social determinants of health—such as education or ethnicity, among others—affect women’s HIV risk-taking behaviours. They tell us nothing about how the social expectations placed on women in Canada can affect their behaviours. They also tell us nothing of how gender intersects with homophobia, classism, racism or other social inequities, which can all affect HIV vulnerability. They also provide no information about trans women or trans men. Understanding and addressing these issues are essential for the development of gender-sensitive and effective HIV prevention strategies. 

UPDATE: For more up-to-date epidemiological information see the CATIE fact sheet on the Epidemiology of HIV in Canada.

HIV prevention programs through a gender lens

Not addressing gender in HIV programming assumes that women are as free as men to make informed choices about HIV risk-taking behaviours and have equal access to essential information, programs and services. However, gender and gender-based norms have a profound impact on women’s vulnerability to HIV.³ According to the World Health Organization:

The effectiveness of HIV/AIDS programmes and policies is greatly enhanced when gender differences are acknowledged, the gender-specific concerns and needs of women and men are addressed, and gender inequalities are reduced.¹

Because of this, it is essential that we look at our HIV prevention programs and policies through the “lens of gender” to identify the gender-specific issues that are barriers (or facilitators) to HIV prevention in our context.^1,4 This ensures that we take into consideration issues of gender inequity as we develop, implement and evaluate our HIV prevention policies and programs.^5,6,7,8

According to the World Health Organization, we need to address women’s inequities in all aspects of program design and delivery by:

• Integrating the needs of women into HIV prevention program design by conducting women-specific needs assessments and addressing these needs
• Building the capacity of program staff to address women specific issues and inequalities
• Reducing barriers to HIV services for women by, for example, increasing awareness of programs and services, and addressing psychological needs
• Promoting women’s participation in program design and delivery as embodied in the GIPA principle
• Addressing gender in monitoring and evaluation
• Advocating for gender-responsive health policies⁹

For example, when we evaluate our frontline programs, we need to develop specific “indicators” to measure how successful we have been in accomplishing various goals. Gender issues make it essential to develop indicators that take gender differences into account—we cannot just assume that our programs will be equally successful for women, men, trans women and trans men.¹⁰ Simply counting the overall number of individuals taking part in an HIV prevention program is insufficient. While this information is important, a true gender-based analysis means asking ourselves if the needs of both men and women are being met.

Rather than simply counting the number of men and women, we might also collect data that tell us about how our prevention programs are helping to address women and trans women’s needs. Examples of such indicators include:

• Extent to which they feel in control over their sexual relations and decision-making
• Extent to which they control sexual encounters , including condom use with male partners
• Experiences of domestic violence
• Experiences of depression and stress
• Barriers to accessing prevention services such as extent of care-giving burden, amount of free time that women have to participate in HIV prevention programs

How can we use a “gender lens” in our programs?

The use of a gender sensitivity checklist or gender-based framework in the development and implementation phases of HIV prevention programs or policies can help us consider the effects of HIV prevention approaches on different genders.^1,11 An example of a gender sensitivity checklist was developed by UNAIDS but you may find others that work better for your organization. 

Asking gender-related questions and determining gender-sensitive “indicators of success” when developing HIV prevention programs and policies can assist in ensuring all genders—or at least those that we intend to reach—benefit from our prevention programs. Here are some questions to ask yourself:

• Does your prevention program take into consideration the different expressed needs of all genders represented among your participants in the development phase? In the implementation phase?
• Does this program improve the well-being of women and trans women? What about men and trans men? 
• What resources does a person need to benefit from this program? Does everybody have equal access to the resources? 
• Who controls the decision-making processes related to this program? Are the gender identities found among your participants represented in the decision-making circle? How are the genders of your participants represented and given voice in other ways?
• Has this program had any unexpected negative effects on women and trans women? On men and trans men? Do you anticipate any in the future and what can be done about this? 
• Does this program benefit one gender over another? Does it benefit men more than women? Is this intended? Why might this be?

Conclusion

When discussing the factors that affect the health of your clients and assessing how to implement and evaluate the success of programs that address health inequities, it is necessary to recognize gender as a key determinant of health. While both men and women are impacted by gender norms, women and trans women are particularly vulnerable in the context of HIV. The use of a gender lens in the development, delivery and evaluation of HIV prevention programs is critical to ensure that the risk determinants unique to each gender are taken into consideration to help prevent the spread of the virus.

References

1. a. b. c. d. e. World Health Organization (2003). Integrating gender into HIV/AIDS programmes. Geneva: WHO [http://www.who.int/hiv/pub/prev_care/en/IntegratingGender.pdf]
2. a. b. Public Health Agency of Canada (2010). HIV/AIDS Epi Update: HIV/AIDS among Women in Canada. [http://www.phac-aspc.gc.ca/aids-sida/publication/epi/2010/5-eng.php].
3. Clow B. An invisible epidemic: the implications of gender neutrality for managing HIV/AIDS in low-incidence countries. Centres of Excellence for Women's Health Research Bulletin. 2006;5(2):4-5.
4. Gahagan J and Ricci C (Eds.). HIV/AIDS prevention for women in Canada: A Meta-Ethnographic Synthesis. Halifax: GAHPS Unit report, 2011.
5. Ikorok M and Akpabio I. (2007). Women's choice of strategies for improving utilization of HIV/AIDS screening services. Health Care for Women International. 2007;28(8):700-11.
6. Gollub E. A neglected population: drug-using women and women's methods of HIV/STI prevention. AIDS Education and Prevention. 2008;20(2):107-20.
7. Public Health Agency of Canada. What makes Canadians healthy or unhealthy? 2003 [http://phac-aspc.gc.ca/ph-sp/determinants/determinants-eng.php#gender].
8. Gahagan J. Gender and research: theory, design and implementation. In: Skills-building for gender mainstreaming in HIV/AIDS research and practice. Cape Town: Human Sciences Research Council; 2007.
9. World Health Organization (2003). Integrating gender into HIV/AIDS programmes in the health sector: Tool to improve the responsiveness to women’s needs. [http://www.who.int/gender/documents/gender_hiv/en/index.html]
10. Gahagan J, Fuller J, Proctor-Simms M et al. (2011). Barriers to gender-equitable HIV testing: Going beyond routine testing for pregnant women in Nova Scotia, Canada. International Journal for Equity in Health. 2011;10(18):1-12.
11. Commonwealth Secretariat and Maritime Centre of Excellence for Women’s Health (2002). Gender mainstreaming in HIV/AIDS: Taking a multisectoral approach. London: Commonwealth Secretariat.

About the author(s)

Jacqueline Gahagan, PhD, is a professor of Health Promotion, Chair of the Health Promotion Department, and Director of the Gender and Health Promotion Studies Unit in the School of Health and Human Performance at Dalhousie University. Jacqueline has been working in the field of HIV/AIDS activism, research and policy for over twenty years. Her current funded program of research includes a comparative analysis of HIV rehabilitation policies in Canada and the UK, the acceptability of rapid point-of-care testing in Nova Scotia, an Atlantic regional policy-to-programming response to HIV and hepatitis C prevention among youth, and a gender-based analysis of existing primary and secondary prevention policies.