We have known for a long time that AIDS in Africa is increasingly a woman's disease. In 2002, when Kofi Annan, then the UN Secretary General, famously declared that "AIDS has a woman's face," young women in sub-Saharan Africa (aged 15-24) were about twice as likely to be infected with HIV as men of the same age. Today, in the nine hardest-hit African countries, young women are about three times as likely as young men to be HIV positive.
A big part of the problem is that in societies where women have low status and enjoy few rights, they have little opportunity to practice safe sex. (One study in Lesotho, for example, found that 47% of men, and 40% of women, agreed that women have no right to refuse sex with their husbands or boyfriends.) Rampant sexual violence exacerbates women's vulnerability. So do conditions of extreme poverty. Too many school girls engage in risky sexual behaviors in return for access to education.
Two recent studies offer some hope. The first, largely funded by USAID, involved a microbicide that appears to reduce HIV infection significantly in women and girls. Scientists working in two South African communities found that women who used the gel were 39 percent less likely to contract HIV than those who took a placebo, and those who applied the gel regularly were 54 percent less likely to be infected. Although more tests and more funding are needed before the product can go on the market, the discovery caused celebration in the scientific community.
A successful microbicide has been much sought after in the HIV world precisely because women can control its use. She can apply it up to 12 hours before or even after intercourse, without telling her partner. Previous microbicide trials, however, have ended in failure, so the results of this recent study were greeted enthusiastically, with some predicting that a roll-out of the microbicide has the potential to change the course of the AIDS epidemic. The second study, funded primarily by the World Bank and the Gates Foundation, involved monthly cash payments (up to $15 per month) to schoolgirls and their families in Malawi as long as the girls attended school regularly. The goal was encourage girls to stay in school, but an unexpected outcome of the Malawi study was how the cash transfers led to important changes in sexual behavior, particularly a drop in risky transactional sex. Overall, the school girls receiving cash had less sex and also chose fewer and safer partners, resulting in lower HIV infection rates. After 18 months, HIV prevalence among girls who received the cash payments was 60 percent lower than among girls who did not, and herpes prevalence in the cash group was less than a third of that in the control group. In extremely poor countries, girls often enter sexual relationships because the man provides gifts or money. In the Malawi study, for example, 90 percent of girls in the control group said they received an average of $6.50 in gifts or cash from their sexual partners, a not insubstantial sum in a country where GDP per capita is roughly $300. Girls' desire to attend school is well-known, and the pay-off from girls' education is incontrovertible: higher lifetime earnings and productivity, improved health and nutrition for the next generation. Less discussed is the dangerous sexual behavior girls engage in today to be able to afford the books, uniforms, and "teacher tips" required in poor countries like Malawi. Clearly, the $15 per month provided in the study was sufficient to change that behavior. Such cash transfers may prove to be a cost-effective means of disrupting the vicious cycle of poverty and disease among vulnerable girls in sub-Saharan Africa. Prevention of HIV is certainly more preferable than treatment. The increasing feminization of AIDS in sub-Saharan Africa requires that preventative measures address the cultural and social realities that drive unsafe behaviors. At the root of these behaviors is the low status of women, which is why putting women in control of prevention-based strategies is a crucial part of the solution. Budgetary pressures in the U.S. and other industrialized countries are inevitably putting stress on efforts to expand treatment, giving preventative measures greater urgency. The success of the microbicide study in South Africa and the cash transfer initiative in Malawi provides a rare glimmer of hope.