Biological and Gender Aspects Shaping the Epidemic

Gender roles and relations powerfully influence the course and impact of the HIV/AIDS epidemic. The different attributes and roles societies assign to males and females profoundly affect their ability to protect themselves and to cope with the impact of HIV/AIDS (Koitelel 2004: 2). Political, economic and social system that deprive women of the power to make decisions regarding sexuality, reproduction and resource allocation increase women’s vulnerability to HIV. (Siplon 2005: 23)

In order for people to be infected, they need to be exposed to the virus. Exposure does not necessarily lead to infection. In order for infection to occur, sufficient viral particles must penetrate the body’s defenses and enter the blood. Several biological factors determine how likely that is to occur. At the early and later stages of the infection, an HIV-positive person has higher viral loads, which increase the risk of

exposure for partners (Stillwagon 2000 cited in Whiteside 2005: 102). Research indicates that women are two to four times more vulnerable to HIV infection than men during unprotected intercourse because of the larger surface areas exposed to contact(Addis Ababa City Administration Health Bureau 1999: 37) and younger women are more prone to infection as the vaginal tissues are less mature and more prone to tearing. Related to this, sexual violence increases the chance of women being infected of HIV.(Stillwagon 2000 cited in Whiteside 2005: 102) The connection between rape and HIV is more complex than the risk of transmission during non-violent sex. Violent or forced sex is more likely to result in HIV transmission than non-violent sex. Forced vaginal penetration creates abrasions and cuts facilitating the entry of the virus when it is present through the vaginal mucosa.

(UNAIDS 2006:13) The study, which was conducted by ENARP in 1996, indicates that the HIV prevalence rate among Wonji Sugar factory women workers in Ethiopia was 31.6% which is higher when it is compared with their male counterparts and this was associated with the incidence of rape (Mekonnen et. al 2001: 48). A Study, which was conducted on the same factory in the year 2004, also supports the above finding indicating that HIV will affects female workers due to sexual assault at their workplace. (Negash 2005:44)

The other indirect impact of sexual violence is that it leads to behaviors that are likely to expose one to HIV infection and reduce service seeking behavior.

According to UNAIDS, women with a history of partner violence may not be able to negotiate condom use. Childhood sexual abuse, coerced sexual initiation and current partner violence may increase sexual risk taking (e.g., having multiple partners or engaging in transactional sex). Violence or fear of violence may deter women from seeking HIV testing, prevent disclosure of their status and delay their access to AIDS treatment and other services. The other likely impact is that women who experience violence may be in partnerships with older men who have a higher likelihood of being infected with HIV (UNAIDS 2006:13). For example, studies indicate that in sub-Saharan Africa, women are infected more often and earlier in their lives than men. Young women aged 15–24 are between two and six times as likely to be HIV-positive than men of a similar age. (UNAIDS 2006: 4)

The average probability of the transmission of HIV/AIDS during unprotected intercourse can be affected by various factors including the form of intercourse.

Other physical factors include the presence of another Sexually Transmitted

Infection (STI), the use of post-exposure prophylaxis and the infectiousness of the infected partner (which can be influenced by anti-HIV drugs) (Ellis et al. 2003: 13).

Despite the fact that there are no accurate serial prevalence data on STIs in Ethiopia, several recent studies indicate that the prevalence of herpes simplex virus type 2 (HSV-2) is high and may be fuelling the HIV/AIDS epidemic in Ethiopia. (Garbus 2003: 8) Relatedly, a study conducted to identify risk factors for HIV infection on 2,526 participants recruited from different location in and around Addis Ababa indicates that male sexual behaviors and past history of syphilis were strongly associated with HIV infection. (Fontanet and W/Michael 1999:13-14) Supporting this argument a study, which has been conducted among sex workers in Addis Ababa, indicates that females with relatively larger number of sexual partners and those who had previous exposure to STDs, had a higher prevalence of the HIV/AIDS infection. (Mehret et al. 1999b). A report by the U.S. National Intelligence Council has indicated that infection rates range from 30 to 40 percent in STD-positive individuals. (U.S. National Intelligence Council 2002)

Men who have been circumcised are at lower risk of HIV infection than men who have not. Foreskin cells are thought to be more vulnerable to HIV infection (Clark et al. 2003: 9, BBC 2007). However, female genital mutilation increases the risk of HIV infection for it leads to bleeding during intercourse (Brady 1999:712). Female circumcision is widespread in Ethiopia and 80% of all women have been circumcised (Garbus 2003: 31).

Women are more affected by HIV for they lack decision-making power concerning the use of condoms. Men's behavior is strongly influenced by perceptions of masculinity. Most cultures expect men to be sexually active, often with more than one partner. Attitudes towards risk-taking lead many men to reject condoms as something which lessen their masculinity and they consider sexually transmitted infections a minor disruptions (Martin 1998: 3). Women's inability to influence men reflects the fact that men usually dominate women's sexual lives; generally it is men, not women, who dictate whether or not intercourse will take place and whether a condom will be used (Martin 1998: 4). For example in Ethiopia there is evidence that men refuse to use condoms saying that HIV does not exist after 10 pm. There are also destructive sayings used by opponents of condom use for HIV/AIDS intervention which undermines the seriousness of the disease, such as “achesew

yacheseh” meaning, “do it and accept all the consequences” (Negash 2005:45) or

"One does not eat a toffee which is still wrapped in paper" (The Courier 2003:69).

Various forms of marriage arrangements often put Ethiopian women in a vulnerable position. Early marriage is quite prevalent in Ethiopia for example in Amhara region girls may be as young as 10 to 12 years old. Marriage by abduction, polygamy and widow inheritance is practiced across the country.

Economic and social factors play an important role in the spread of HIV. Poverty and underdevelopment create impediments on people’s choices and their ability to avoid risky behavior. (Stillwaggon 2006: 81) Women in Ethiopia are much more likely than men to be illiterate or have a very poor education, which result in less opportunity to obtain “decent” jobs. Ethiopian women live in less secure conditions than men and do not enjoy the same levels of financial autonomy and economic power as men. Women are often employed in unpaid family work. They are more likely to be employed in the service or leisure industry, such as hotels, bars and restaurants. These types of occupations introduce them into situations in which they are more likely to become involved in commercial sex work (Tassew et al. 2005:

33).

Research indicate that in Ethiopia risky sexual behaviors were strongly associated with HIV infection in males. While, in females, socio-demographic factors like living alone, having low income, and having low education, are associated with HIV infection. (Fontanet and W/Michael 1999:13-14, Fontanet et al. 1999:107) Women’s lower status in society and their poorer income-generating possibilities make them more vulnerable to the economic impact of HIV/AIDS. The majority of women in Ethiopia are economically dependent on men. Economic dependence may also determine with whom a woman has sex. (Mekonnen et al. 2001: 52) Economically poor women are lured to men for money. (Negash 2005:47)Famine is a recurrent situation in Ethiopia. Lack of food, coupled with a subsequent breakdown in family structure may force people to practice risky sexual behavior. Women and girls may undertake sex work to survive. They may also offer sex to workers involved in transporting and distributing food aid to try and obtain preferential treatment in the distribution of supplies and services (Garbus 2003: 42).

In Ethiopia, with increasing rural and urban poverty, the number of women and girls who engage in prostitution has increased. In 1990, it was estimated that over 7% of Addis Ababa’s adult female population was involved in prostitution. A surveys which was carried out among female sex workers indicates that the majority of the respondents were forced to start practicing prostitution because they lacked financial support for continuing education and because of family related problems. 94.1% of the respondents mentioned that they would like to change their profession If other opportunities were available (Gebrekidan 1999).

In Ethiopia women tend to migrate more than men as a result they are often the victims of sexual, financial and labor exploitation. In 1999, they represented 57% of total migration and 58% of rural-urban moves. Uneducated and with very low skills levels, women migrate to cities and towns to be employed as domestic workers and/or prostitutes (Tassew et al. 2005:7).

As in most traditional societies, Ethiopian women are usually charged with the task of caring for sick family members which can expose them to the virus if they do not take the necessary precautions. They also face difficulties when the male head of the family becomes sick and dies since they lack the economic options available for men. Due to low economic status of Ethiopian women who have lost their husband they may resort to commercial sex work in order to support their families, further increasing the risk of HIV infection. Due to the above mentioned facts women in Ethiopia are disproportionally affected by HIV/AIDS. In line with this, for example, in the year 2003, HIV prevalence in Ethiopia was 5% and 3.8% for women and men respectively (HAPCO 2006:6).