LITERATURE REVIEW AND THEORETICAL FRAMEWORK 2.1 Literature Review
2.1 Prevalence of HIV and Tb Co-infections
2.1.9 Gender, HIV Vulnerability and Treatment Adherence
More than 60% of HIV-infected adults in sub-Saharan Africa are women, who are disproportionately affected by the HIV-1 epidemic for both biological and socio-cultural reasons (El-Khatib, Ekstrom, Coovadia, Abrams, Petzold, Katzenstein, Morris and Kuhn, 2011). Women bear 10% of the global burden of HIV with youths and in particular young women vulnerable to the infection (NACA, 2010a). The HIV/AIDS pandemic reflects gross socio-economic and gender inequalities in developing countries. The female-to-male ratio of new HIV infections is significantly higher in sub-Saharan Africa and the Caribbean than in the Western countries. The vulnerability of women and girls to HIV remain particularly high in sub-Saharan Africa, about 76% of all HIV positive women in the world live in this region (UNAIDS, 2009).
Women‘s lack of property rights, differential access to literacy and education, lower wages and lack of assets also shape their HIV/AIDs risks. Research has confirmed that sexual double standards, harmful cultural practices (e.g. widow cleansing, a practice that involves a widow having sexual relations with relatives of her late husband) and sexual violence heightens women‘s HIV/AIDs risks (Dworkin and Ehrhardt, 2006). The Joint United Nations Programme on HIV/AIDS report detailed that in several countries 50% of new infections were occurring between spouses and that those women were most often at risks from their male partner.
The concept ―feminisation of HIV/AIDS‖ was conceptualised with evidence-based studies reinforcing the necessity of placing comprehensive, long term efforts that focus on gender relations in the forefront of the fight against HIV/AIDS (Dworkin and Ehrhardt, 2007).
HIV/AIDS is no longer confined to high-risk populations, it is becoming increasingly feminised and it is clearly linked to cumulative patterns of gender inequality, economic disruption and population movements. Stigma and discrimination, entrenched gender inequalities, gender-based violence, human rights violations, mobility and economic power are some of the major structural drivers that hamper HIV prevention efforts and impede progress towards universal access.
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48 Conflict-affected populations are vulnerable to gender based violence and risk of HIV infection. A study conducted in Ethiopia among refugees elucidated there been subject to gang rape, sexual violence, coercion and kidnapping coupled with their inability to access health services. Various barriers were stated by the refugees from seeking health care in their host country. Such barriers included lack of awareness of HIV/ health risks and available services, low confidence in availability and quality of services, language barriers between providers and survivors, stigma related to gender based violence (Wirtz, Vu, Pham, Rubenstein, Singh and Glass, 2012).
In Nigeria, internally displaced persons are faced with several problems such as sexual violence which has increased the prevalence of HIV/AIDS. The situation is worrisome with the neglect of these persons from services including HIV/AIDS prevention and treatment. In a study conducted by Enwereji (2009), on internally displaced persons in Abia State, Nigeria, it was documented that none of the organisations including governmental institutions provided social services or assistance in prevention of HIV/AIDS to internally displaced persons. The main services provided were provision of food, clothing, money, spiritual counselling and resolution communal conflicts which were provided on an ad hoc basis. The fact that government does not have services for internally displaced prisons indicates lack of support for internally displaced persons.
Women who test positive to HIV are highly vulnerable populations that need specialised, long-term services focusing on their being integrated back into their communities and homes.
Survivors of war violence are perceived as being HIV positive after rape, contributing to their isolation. Often times these women are stigmatised and often repudiated by their husbands and families. Integrating religious and community leaders into programs that respond to negative attitudes towards survivors will be vital in addressing the stigma towards these women.
Numerous studies in heterosexual relationships found an association between intimate partner violence and high rates of risky behaviours (such as multiple sex partners, non-use or inconsistent use of condoms and sexual coercion) and Sexually Transmitted Infections (STIs) such as HIV. There are several explanations for this relationship which are the socialisation of women and men in relation to their gender which are socially defined and constructed.
Also, the patriarchal societies is constructed to idolise men's strengths and toughness, phenomenal sexual success and clustering of violent, anti-social and risky sexual practices as
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49 well as women's submissiveness. In such societies, women's sexuality might pose a threat to the socially accepted norms and behaviour, as it challenges men's control over women, and provokes jealousy in the women's spouses (Jewkes and Morrell, 2010; Dunkle, Jewkes, Nduna, Levin, Jama, Khuzwayo, Koss Duvvury, 2006].
Women who follow such socially prescribed norms are at high risk of acquiring HIV infection subsequent to their partners' high-risk behaviour (Osinde, Kaye and Kakaire, 2011).
Social and cultural systems in many African societies dictate that women have no control over their sex lives, or the sex lives of their husbands outside marriage. This culturally prescribed lack of control on their sexual relationships has made women, particularly married women, highly vulnerable to HIV infection. Wives are not allowed to refuse sex from their husband, or to use a condom, even if the husband is infected with HIV (Buve, Bishikwabo-Nsarhaza and Mutangadura, 2009). Similar findings were observed in normative gender relations studies in Zimbabwe, Cameroon and Nigeria where men make decisions and husbands have power over their lives sexuality/fertility (Koster, Bruinderink and Kuijper, 2012).
Tun, Keesbury, Simmonds, Sheehy, Moyo, Rathner and Kalibala (2012) in their study on gender issues and its implications for HIV prevention programmes in Zambia observed that inequitable gender norms are pervasive affecting women‘s vulnerability to HIV and gender based violence. Consequently marital rape which is a form of sexual violence that happens covertly increases women‘s vulnerability to HIV infection. Marital rape in a study conducted among respondents in rural and urban Tanzania connotes ‗normal‖ and a ‗common‘ practice.
The sexual norms forbid married women from denying sex to their husbands in whatever circumstances. Findings from the study revealed that women had to comply with marital rape due to the social construct of marriage and their duty to serve their husbands (Kachuchuru, Matungwu, Chenha, Visser, Vanreeuwijk, Maro, Massawe, Kalongola, Francis, Changalucha and Mshana, 2012).
According to the NDHS 2008, 28% of all women reported experiencing physical violence since the age of 15, and 15% of women experienced physical violence in 12 months preceding the survey. Forty five percent of the respondents reported their perpetrator was their current husband or partner while 7% stated that the perpetrator was a former husband or partner. Half the women in the study indicated that the perpetrator of their sexual violence was a stranger (28%), friend or acquaintance (12%), relative (11%) and family friend (7%).
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50 Further findings from the study revealed that 34% of Nigerian women who ever experienced physical or sexual violence sought help to stop the violence, 8% did not sought help but told someone while 45% of the women did not seek help or tell anyone about the violence.
Alarming findings are the susceptibility of HIV positive women to domestic violence such as physical violence, verbal violence, emotional violence, sexual deprivation and sexual violence in Nigeria. Most of the violence stems from the woman‘s age, marital status, disclosure, multiparity and partner‘s education (Iliyasu et al., 2011; Ezeanochie, Olagbuji, Ande, Kubeyinje and Okonofua, 2011; Ezechi, Gab-Okafor, Onwujekwe, Adu, Amadi and Herbertson, 2009). Thus there is the need to address the power imbalances between men and women that contribute to HIV risk and focusing on male norms and behaviours that contribute to gender based violence.
In addition women empowerment programmes should be considered as an effective way for HIV prevention with government strengthening and implementing policies fostering women sexual and reproductive rights. Similarly, Nyirenda et al (2006) showed that fewer women from the 15-29 age group accessed counselling and testing services, but more were positive (4% of men, against 18% of women). More women also tested positive in the over-24 age group (40%) compared to men (26%).
Studies on adherence to ARVs have hardly set out to consider gender issues underpinning adherence; some have analysed gender differences as a by-product of the socio-demographic analysis. As such much attention has not paid to gender issues in treatment-taking behaviour.
At the same time, evidence suggests that women often encounter gender-related barriers to accessing health services of which ARVs are a part. In Africa, many women have to obtain permission from their husbands or male relative to seek any health care and this can become more difficult if women request for money. In addition, where costs for treatment are involved, families may prioritise paying for men‗s treatment (Herstad, 2010). Herstad (2010) argues that HIV-positive women‗s access to information, treatment and support is also affected by stigma and discrimination because of social values surrounding the importance of female purity and virginity.
Recently, studies have started to explore women‗s and men‗s experiences related to adherence by including discussions of gender issues. Muula and Kataika‘s (2008) assessment of the uptake of ARVs in Malawi found that men were unlikely to access treatment out of fear of marital consequences. That is, men testing positive were perceived to have contracted
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51 HIV as a result of infidelity; most women think that HIV transmitted from one spouse to another is indicative of husbands‘ infidelity (Muula and Kataika, 2008). Given that the desire for marital harmony affects men‘s willingness to access testing services, men clearly face a barrier in obtaining and maintaining treatment.