This piece originally published in the Winter 2012 issue of the Stanford Journal of Public Health, a student-run journal “dedicated to connecting different players in the public health community in a forum for engaged scholarship.”
by Emily Rains, ’11
Previous research on incorporating gender into HIV prevention education policies in sub-Saharan Africa has focused on reducing gender-based violence in the context of HIV. However, many deeply rooted inequalities exist that exacerbate the disparity in prevalence rates between men and women in this region, and these cultural barriers have not been addressed by previous campaigns. This paper uses qualitative document analysis of various HIV prevention organizations working in Tanzania in order to ascertain how gender is incorporated in prevention education. This paper argues that focusing on women-centered responses to the crisis is too narrow. Expanding focus to engage majority groups such as heterosexual men may be a critical step towards ensuring gender equality and fighting the further gender-disparate spread of HIV in East Africa.
The World Health Organization estimates that 1 out of 14 Tanzanians are infected with HIV. About 60% of these cases affect women, as is the case in most sub-Saharan African countries in this region. Because nearly 80% of transmission occurs via heterosexual intercourse and women have higher rates of infection, evidence suggests that the dynamics of heterosexual intercourse in Tanzania lead to unequal rates of transmission. The government attributes several contextual factors that drive the gender disparate transmission, especially male-initiated behavior, economic inequality between the sexes, and extramarital affairs. Existing research on HIV and gender in sub-Saharan Africa focuses on gender inequalities inherent in patriarchal societies. This study specifically looks at organizations in Tanzania because the country has one of the highest incidence rates of HIV in sub-Saharan Africa, has an enabling political climate in which NGOs can operate, and most importantly, exhibits general epidemiological characteristics parallel to other nations in East Africa. Researchers studying Tanzania, as well as Ethiopia, Kenya, Uganda, and Botswana, stress that HIV prevention policy needs to go beyond basic knowledge distribution and must tackle gender inequality, mostly through reduction of gender-based violence. However, there are many aspects of gender inequality other than sexual violence that exacerbate the gap in HIV rates. For example, young men typically engage in much riskier sexual behavior but perceive less risk than women. Furthermore, men perceive their risk level based on their own actions, while women perceive their risk level based on their partner’s actions, which implies that the unequal power dynamic between the genders allows men to dictate the level of risk involved in the sexual behaviors of themselves and their partners.
Unfortunately, although the literature from both governmental and nongovernmental researchers almost always stresses the need to address gender inequality when creating interventions, there is very little information on how this should be done. Very few NGOs focus on education of heterosexual men to alter traditional gender roles, and of those that do, most focus on education to reduce violence and do not explicitly incorporate HIV prevention strategies. However, the existing programs to mitigate domestic violence can be adapted for HIV prevention. This has been performed in other places by organizations such as Promundo in Brazil, where cultural behaviors among Brazilian men are very similar to those of Tanzanian men. These risky behaviors stem from common cultural beliefs that men should begin having sex at a young age, should always have multiple partners, should remain in control over their partners, and that unsafe sex is more enjoyable than safe sex. Promundo researchers showed that beliefs about manhood emerge as the strongest predictor of engaging in risky behavior, both sexually and generally. They also worked directly with men in an informal education program to renegotiate perceptions of manhood to include more gender-equitable ideologies. They found that this program led men not only to agree with more gender-equitable norms, but also to engage in less risky behavior, which leads to a smaller chance of HIV contraction for themselves and their partners. Young men who participated in the program were significantly more likely to report more equitable ideologies than those at the control sites, and this change was sustained after a yearly follow up. The Promundo study concluded that educating men directly in an informal program to question traditional gender norms can be an important HIV prevention strategy.
MIT’s Poverty Action Lab successfully engaged men in a different HIV prevention strategy. Researchers evaluated the efficiency of three prototypical HIV prevention programs in Africa (one that trained schoolteachers on AIDS, one that encouraged student debates on condoms, and one that paid students to stay in school longer) and also one less common program that showed a video on the dangers of intergenerational dating in Africa. The study concluded that while young women did not reduce their sexual activity, young men increased condom use significantly. Targeting men as the audience in HIV prevention programs has a lot of potential but has not been extensively explored. This study proposes to begin filling the gaps in literature on how gender should be incorporated into HIV prevention by understanding how different types of organizations address gender norms in their HIV education. Methods
Documents from the following four categories of agencies were used: international governmental organizations, domestic governmental organizations, international nongovernmental organizations, and domestic nongovernmental organizations. One organization was selected as an example of each category based on each organization’s funding, reach (in terms of the size of their target audience), and focus on HIV prevention. The final organizations selected were the United Nations Programme on HIV/AIDS (UNAIDS), Tanzania Commission for AIDS (TACAIDS), Population Services International (PSI), and Support for International Change (SIC). Although selecting one organization for each category does not ensure a representative study, this sample provides examples of the kind of work done by different types of organizations.
To analyze the selected documents, this study used an inductive method of research in which second pass interpretative codes were developed from patterns of the first pass descriptive codes. The first pass descriptive codes looked mainly at surface level patterns of recurring organizations’ goals, target audiences, and motivations. The second pass interpretative codes explored how the organizations described their interventions in order to understand what they considered as most effective HIV prevention policy. This analysis extrapolated the organizations’ values in formulating gender-sensitive HIV policies and whom they identified as policy implementers. Isolating main target audiences seeks to address contemporary theory on the importance of guaranteeing health as a human right, particularly to vulnerable populations.
Analysis of documents indicates that human rights and empowerment rhetoric is prevalent in each of the documents. Results also show that nongovernmental documents are much more precise in their stated goals and strategies than governmental documents are, and nongovernmental documents provide much more concrete examples than governmental documents on ways to provide more than basic knowledge dispersal in order to address root drivers of the epidemic. This aligns with recent theory on the importance of the nongovernmental, nonprofit sector in delivering healthcare in developing countries.
All of the organizations incorporate human rights jargon or appeals into their documents, which becomes most clear in the governmental documents. UNAIDS explicitly targets marginalized groups and emphasizes the need to reach out to vulnerable populations because violence, economic instability, and inequality are the driving forces that leave marginalized groups more susceptible to HIV/AIDS. The documents illustrate the importance of antidiscrimination laws to protect vulnerable populations and mention many different strategies for empowering these minorities through education of rights awareness. In fact, although 80% of HIV transmission in Tanzania is via heterosexual relationships, the UNAIDS documents focus HIV prevention policy on intravenous drug users as often as they focus on heterosexual men, and men who have sex with men more often than they mention heterosexual men. With regard to gender, women are clearly defined as the main vulnerable group, and UNAIDS advocates that responses be women centered and also stresses the need for women to have access to these HIV prevention services in order to exercise their rights. Women and girls are mentioned six times as often as heterosexual men and boys in the documents.
All of the documents are rife with human rights language, although it is expressed differently in the governmental and nongovernmental documents. The UNAIDS documents stress the importance of improving HIV prevention services for marginalized groups in order to protect their rights. SIC stresses the importance of equipping people with the skills they need in order to take ownership over protecting their right to health. All of the documents stress that women are included in (if not the majority of) these vulnerable groups. Most documents focus on women as the main group vulnerable to HIV, which given that 3 out of 4 HIV positive young people in sub-Saharan Africa are women, makes sense. However, “vulnerable” includes several other categories including homosexual men and intravenous drug users. For the purposes of this study, this study is mainly concerned with women as the major vulnerable group compared to heterosexual men. As theory on the role of nongovernmental nonprofits in providing health services to poor countries suggests, the governmental documents are much more rhetorical, while the nongovernmental documents are much more focused on implementation of programs. All of the documents suggest concrete policies to implement in the fight against HIV, such as increased access to condoms and antiretrovirals, free HIV testing, funding, promotion of male circumcision etc. They also all attempt to address some of the root driving forces of the issue (the economic and social contexts that perpetuate gender and income inequality and increase risk amongst women and those in poverty). While all discuss the importance of empowering marginalized groups in order to mitigate the root drivers of the epidemic, the nongovernmental organizations incorporate more concrete solutions on how to push further to encourage transformative agency in the recipients of their programs. Transformative agency is defined here as enabling people to organize for change. Therefore, to more effectively mitigate the effects of the epidemic, education needs to transcend knowledge and move to transformative knowledge. For example, both PSI and SIC promote use of a specific brand of condom, Salama, to build consistency and trust in a local brand. This approach takes knowledge about how to use a condom a step further for their audience and begins to encourage action. PSI mainly addresses heterosexual transmission (which is more contextually relevant for Tanzania than anything else) and acknowledges that barriers between knowledge and agency include sexual violence and power imbalance. The nongovernmental documents stress the importance of both peer education for knowledge and redefining cultural constructs in order to facilitate female agency.
Global norms on human rights and empowerment permeate throughout all of the organizations’ documents. In addition, nongovernmental organizations are more contextually specific and attempt to foster environments that enable change of cultural norms. The analysis argues that organizations ascribe a worldview on how to tackle HIV that is based on their global adherence to norms ensuring human rights to vulnerable populations, including but not limited to women. While ensuring rights to vulnerable groups is undeniably important, focusing most efforts on vulnerable groups inevitably leaves other groups outside of the focus. Majority groups such as heterosexual males (who hold considerably more power than minority groups) are outside of this focus but could be effectively engaged in HIV prevention initiatives in order to help enable those in a vulnerable position. While it is important to focus some efforts on those most at risk, global adherence strictly to the worldview that prevention efforts be centered on vulnerable groups leads to a limited worldview. Focus should be expanded to also include heterosexual male groups in the fight against HIV in East Africa.
All of the different organizations identify inequalities as the driving force of the AIDS epidemic in Tanzania, but they are limited in depth on how they propose to change this. All address the devastation of gender inequality in driving the disparity of incidence rates between men and women. The documents all reflect on the power of knowledge and education in empowering women and other vulnerable groups to take ownership over their health and protect themselves from HIV. However, for full equality between the sexes, women need empowerment via knowledge as well as agency via transformative knowledge. The Population Services International documents state, “Analysis of gender role expectations, mistrust, and sexual violence provides insight into how all of these factors have the potential to undermine HIV prevention initiatives that are based on faulty assumptions about young women’s sexual agency.” Many women in strictly patriarchal societies may lose the ability to act upon their education of HIV/AIDS to protect their health. Those in power need to be educated in the importance of HIV prevention both for themselves and their partners before women can act upon their knowledge. Because current global discourse focuses mainly on empowering marginalized groups, there is consequently not enough focus on engaging heterosexual men. As described previously, these groups can be effectively engaged in HIV prevention initiatives to help enable those in a vulnerable position. Organizations do acknowledge that engaging men should be a strategy, but the rhetoric quickly shifts back to the need to empower marginalized groups. For example, the UNAIDS documents state, “traditional roles and societal values related to masculinity might encourage boys and men to adopt risky behaviors, including excessive alcohol use and concurrent sexual relationships, so increasing their risk of acquiring and transmitting HIV.” This is the first mention of men in the document that suggests engaging heterosexual men may be a strategy UNAIDS proposes, but the next sentence quickly switches back to rhetoric about vulnerable people, saying, “Many harmful norms related to masculinity and femininity also stigmatize transgender people, men who have sex with men, and other sexual minorities.”
While focusing efforts on women is unquestionably important in equipping them with the skills they need to protect themselves from HIV in situations in which they are able to make decisions, global norms that perpetuate focusing mainly on women and/or other vulnerable groups fail to address the harsh reality that even when these vulnerable people have the knowledge and will to protect themselves, they may not always have the power to do so. Organizations like Promundo in Brazil show that engaging men is an effective strategy to encourage equity, which subsequently leads to a reduction in risky behavior. If those in positions of power learn how to renegotiate their ideologies in such a way that allows more power to vulnerable groups, then women would have the agency to use the skills these programs give to them in order to protect themselves and others.
While policymakers agree that gender inequities are driving the disparity in prevalence rates between men and women, global norms have dictated that focus of prevention initiatives be women-centered. While increasing knowledge and programs for women is critically important, programs that focus on engaging men are noticeably absent from documents focused on HIV prevention. Local NGOs could benefit substantially from expanding programs in order to include more that engage heterosexual men in discussion of gender equity. Governmental organizations could also benefit from expanding their focus. International government agencies inform local discourse, so including men in their discourse could alter the global norms and frameworks in which local entities explicitly operate. If international governmental organizations expand their rhetoric to include more support for programs working with men, local actors who implement policy on the ground that engages men would have more legitimacy. Global norms that stress health as a human right tend to skew focus towards ensuring rights for the most marginalized people, but further research and efforts should be undertaken on how engaging majority groups like heterosexual men could also have a significant impact on mitigating the spread of HIV/AIDS. Achieving gender equality will require a social revolution, and this means everyone must be engaged.
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Emily graduated from Stanford in 2011 with a B.A. in Economics and Honors in the School of Education. She has spent extensive time abroad, studying in both Japan and Russia and working to promote both education in India and HIV prevention in Africa. Emily is passionate about issues in international development especially public health. At Stanford, she was a Teaching Assistant for Education, Gender, and Development, a Research Assistant for an Economics professor working with the World Bank, and she wrote her honors thesis after spending a summer working on HIV prevention in Tanzania on how organizations incorporate gender into their HIV prevention education in East Africa. She currently works as a consultant in New York City.