HIV prevention strategies that command the most funding and primacy are male-controlled - the male condom and male circumcision. The extent to which male sexuality decides and acts is central to both these prevention approaches. It is men who use condoms, and women who negotiate their use. This emphasis is neither value-free nor coincidental. It is the result of a confluence of the gender prejudice and gender priorities that shape dominant HIV and AIDS discourses and responses.
The fact that women are the most infected and affected world-wide because of gender power relations, should proffer an approach that places women at the centre of the HIV prevention response. The reality is - despite how much we know about gender as a vector of transmission and women's social, biological and economic vulnerability to HIV risk - that we have not prioritised female-controlled preventative measures.
Two such methods are female condoms and microbicides. The former has the potential to facilitate a much needed shift of control over HIV prevention from men to women. However, their high price and the lacklustre approach to making female condoms accessible, as well as the negative social perceptions associated with their use, have undercut their potential as a powerful protective tool for women. There is also promising research on microbicides - which are easy to administer and, given the fact that they may not be visible, the need for negotiating use with a male partner is minimised.
This failure to prioritise female-controlled preventions is a lost opportunity to transform gender power relations - which create the very conditions in which HIV and AIDS flourish. To the contrary, much of mainstream prevention responses reveal just how existing gender and sexual relations have been entrenched. By example, the ABC approach is underpinned by dangerous assumptions related to women's sexuality, monogamy and gender equality. Take the married woman who is faithful to a husband, and who knows he has multiple partners but cannot negotiate condom use due to economic dependency and fear of violence in the relationship. Are we to assume or hope that she will manoeuvre around the contextual barriers that both shape her HIV risk and stymie her sexual agency and choice?
In this sense, HIV - which follows the path of least resistance - forces us to confront the power at play in real life sexuality. The epidemic is the window into the complex factors that render persons without the power to be safe. These social factors directly affect an individual's sexual behaviours and choices.
All too often the emphasis is misplaced on fidelity while we know that "faithful" women are at risk as a result of the sexual behaviour of their partners. Having less sex is also punted with insufficient attention to the fact that it is the safety of sex, rather than the frequency, that is most critical.
Promoting a conservative moralism, as the basis for public policy and funding priorities, most often means turning a blind eye to the sexuality of youth, and weakening women's sexual agency. In addition, ABC masks the realities of human sexuality and perpetuates the silencing of sexual diversity. It also obscures the social and cultural context that largely defines how sexual choice is manifested in the lives of individuals. For sexuality reflects intersecting dynamics of context, power, desire, and control.
In generalised epidemics there is a need for both general and targeted prevention strategies that speak to the specific risk factors facing lesbians, gay men, heterosexual women, sex workers, people living with HIV, and other stigmatised sexualities. Effective and context-based HIV prevention education has to ensure openness about sexual practices, and the breaking of taboos around sexuality in society in all its forms.
Poor quality of care, limited services to meet the demand, lack of adequate training, overcrowding and under-resourcing are all part of more systemic health system failures. Poverty deepens and entrenches these barriers to healthcare. It stands to reason that people who lack social and economic power will feel the might of these failures disproportionately. This also has a knock-on effect on women not being prioritised for HIV prevention, and not being in the position to access treatment services, due to limited resources and facilities.
One cannot talk sexual health without talking sexual rights. The latter necessitates women's equality and freedom from discrimination, sexual coercion and violence. Addressing gender and sexual inequality and prejudice should be central to HIV and AIDS programming if we are to tackle the broader social context which shapes people's sexual health and choices.
- Melanie Judge is a human rights activist who works at Inyathelo - The South African Institute for Advancement. She writes in her personal capacity. This article was first published in the Cape Times Newspaper and is republished here with the permission of the author.