India, the second most populous country in the world, accounting for 17% of the world’s population is also home to an estimated 21.17 lakhs of People Living with HIV. With such large numbers the country is second only to Sub-Saharan Africa and Nigeria.  HIV has ceased to remain a mere bio-medical infection which can be adequately addressed by strengthening the health systems. It is a social issue that impacts and is impacted by the social context it is rooted in. Over the last decade, the world has witnessed the changing face of HIV. Amongst the most significant change is the feminization of the epidemic.

Women are the worst affected and the most marginalized groups when it comes to HIV. In India, women account for about 2/5th of the total HIV positive population. It is well known that HIV affects women differently and disproportionately vis-à-vis men. Gender inequality is the singular most important reason for this unequal and unjust impact of HIV on women. This inequality manifests itself in myriad ways at all levels. The discrimination that begins with a son preference is visible in every sphere where the access to most basic rights is severely restricted to the women. Women are pushed to the periphery when it comes to education, ownership of economic resources, health care facilities.

Violence – Cause & Consequence of HIV For Women

The forced nature of a violent sexual intercourse results in wounds and deep abrasions that put them at a higher risk of contracting HIV. This coupled with the absence of condom use under such circumstances exacerbate the vulnerability of the woman to HIV. Apart from sexual violence, what enhances the risk for women is the culture of silence surrounding everything related to sex and sexuality. Inexperience and lack of information in this regard is looked upon as a mark of being a “cultured” woman.

It is one area where being uninformed is prized as opposed to being armed with correct knowledge. Not only is the right of women for correct information nullified under the garb of tradition, they are also disempowered by the lack of control about their own sexual and reproductive decisions. Actual or perceived violence can greatly hinder the ability negotiate safer sex or seek HIV prevention services.  In the case of HIV positive women, fear of violence also extends to the point where women choose to not disclose their status or seek counselling & treatment services because of the possibility of stigma and discrimination.  

Due to socio-economic power imbalance, women have restricted access to economic resources making them financially dependent upon the menfolk in the family, be it fathers, husbands or sons. This is evident in most social structures where the ability of women to own and access economic resources is acutely curtailed. Low level of education as well as income earning opportunities force women to stay in situations that accentuate their vulnerability. More often than not women are denied of their property and inheritance rights which pushes them further into poverty and economic deprivation. Sexual favours are often given by poor and marginalized women in exchange for the basic survival multiplying the risk of being infected with HIV. Sex then is treated as a commodity to be traded off to keep from plunging into poverty.

The example that best illustrates the linkage of the socio-economic factors mentioned so far that increase the vulnerability of women to HIV is the rise in prevalence rate among married monogamous women in states where a high degree of mobility and out migration is recorded. Men who migrate for work as labourers, stay away from families for long stretches of time and contract the virus through risky sexual behaviours and upon their return infect their wives.

The marginalization of women is all pervasive and exists at all levels. The socially sanctioned and gendered roles that women are expected to fulfill only fuel their vulnerability. In cases where both husband and wife are diagnosed HIV positive, it is the woman who bears the blame. Denied of the shelter and economically disempowered, a large number of women are forced to leave their homes. A patriarchal society like ours, assigns women the role of primary care givers of their families, prioritising the heath needs of the male members of the family over their own. The traditional expectations from a woman coupled with the limited access to health care facilities compounds their already precarious relationship with HIV.

Trans* people and HIV-Risk

While women as a group are a marginalized, drug use, sex work and deviation from the socially accepted gender identity (with respect to trans* people) push people further towards the outermost boundaries of society. When a person belongs to any of these categories, The degree and the frequency of discrimination increases and is often sanctioned by the state.

A study conducted by the National AIDS Control Organization, UNDP and National Institute of Epidemiology estimates a population of more than 70,000 trans* people across 17 States of the country. Trans* people have reported the highest prevalence rate of 8.8% amongst all the High Risk Groups. The social attitudes that look down upon a trans* person and a law from the Victorian era that criminalises consensual sex between same sex adults, leave very little window for the trans* people for a safe space to voice their concerns. State sanctioned violence and discrimination at health care centers impede effective access to HIV prevention and care services. Without the required social & emotional safety nets to fall back upon and hardly any jobs opportunities, many trans* people in India take the route of sex work as a means of keeping poverty at bay.

The landmark judgement of the Supreme Court 2014 recognised diverse gender identities and affirmed the constitutional rights and freedoms of trans* people. However, two years down the line, no consequential change is witnessed in the social situation of trans* people. Similarly, in another watershed development, the Supreme Court has responded favourably to the curative petition on Section 377. However, until these legal victories are transformed into attitudinal change, it would be hard to make a significant dent in the infection rate among trans* people.

Women Should Be In The Centre of HIV Conversations

The stigma against HIV positive women is almost palpable and manifests itself in some of the most horrific ways. The blatantly discriminatory manner in which women are treated results in a very negative perception that they develop about themselves. This deeply internalised shame and self-stigma has adverse effect on their self-esteem and their willingness to adopt positive health seeking attitude.

Women comprise 48.5% of the total population of the country. Despite being almost half the population, they are kept at the margin in the name of tradition and preservation of social values. Women need to be provided access to the arenas they have been so far denied access in order to secure and enforce their socio-economic and health rights. Until women are kept in the centre of the HIV, we would way off the mark in dealing with the epidemic effectively.  


Featured Image: Women walking past a large HIV ribbon on a beach | nytlive.nytimes.com

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