Issues Paper No. 3

Female Genital Health and the Risk of HIV Transmission
Regina McNamara

TABLE OF CONTENTS

EXECUTIVE SUMMARY
INTRODUCTION
GENITAL INFECTION AND TRAUMA
DIAGNOSIS AND TREATMENT: THE OBSTACLES
SUMMARY AND RECOMMENDATIONS
ANNEX
BIBLIOGRAPHY
ACKNOWLEDGEMENTS
BIOGRAPHICAL NOTE

EXECUTIVE SUMMARY

This paper is concerned with the genital conditions that facilitate the transmission of the human immunodeficiency virus (HIV) in women. It examines the barriers to the prevention and treatment encountered by women in developing countries.

The vaginal epithelial mucosa is the female's normal protection against infection; if it is not intact, susceptibility is increased. The association of some sexually transmitted infections (STIs) with HIV infection has been documented, but there has been little attention as yet to other causes of female genital lesions, infections and inflammation that are plausible pathways for HIV transmission. The causes include intravaginal insertion of foreign objects for contraception or abortion, early initiation of sexual activity and childbearing, trauma during sexual intercourse, lower reproductive tract infections and infibulation, among others.

Diagnosis and treatment of genital conditions are possible only when women have access to health care providers with the skills and means to identify correctly their condition and supply appropriate medication. This can be difficult or impossible for one or more of the following reasons.

Women often are not aware they suffer from vaginitis and cervicitis which are the most common types of vaginal infection.

Access to health services is limited; facilities, skills and drugs are in short supply. Demographic and health survey data show that in many countries the majority of women, especially those without education and those in rural areas, receive no prenatal care and far fewer deliver with trained assistance. Even as a family planning client, a woman may pass through her entire life without a pelvic examination.

The problem of limited access to health care common throughout developing countries is exacerbated for women by their lack of autonomy, money and transportation. The discrepancy in access between men and women is intensified when the condition evokes the stigma of a sexually-related infection and by the image of women as the source of HIV infection.

A sense of personal modesty, that is, the reluctance to expose genitalia to health workers, is a common feeling among women and a powerful deterrent to utilization of health services.

Women are counseled regarding consistent and correct use of condoms to prevent HIV transmission, but condoms are used by men and the counseling presumes communication and agreement between partners for each act of intercourse. Communication about sex is rare in many cultures and, under conditions of sexual inequality and male refusal, an insistent woman risks the loss of economic, social and emotional support.

The changes that must be made in the legal, economic and cultural spheres over the long term are immense; over the short term there are collective actions women can take in their local communities. Women, as well as men, must learn about their bodies and be able to speak of them without shame or embarrassment. They must be assisted with information, with sensitive and appropriate health services, with legal aid, and with opportunities for education and economic independence.

Simple, inexpensive diagnostic techniques for STIs should be a priority on research and aid agendas. Some techniques have already been tested and further development and subsidies for their wide distribution are urgently needed. Of paramount importance is the need for improved methods of prevention, especially virucides and barrier methods that can be used by women. These may not only be more effective than the inconsistent use of condoms; they will also give a women some control over resources for her own physical and mental health and well-being.

INTRODUCTION

This paper is concerned with preservation of the intact surface of the female genital tract as a defense against heterosexual transmission of HIV. If the vaginal epithelial mucosa, the female's normal barrier against infection, is not intact when the male deposits infectious semen, susceptibility to HIV transmission may be significantly increased. STIs are one source of damage to that barrier and their association with HIV transmission is well-documented. (See e.g. Wasserheit, 1990; WHO, 1990.) Other causes of genital trauma and infection in both women and men that may open a pathway to HIV infection have been given little attention. For women, cultural conditions and inadequate health services compound the disadvantages of sexual and social inequality, increase their vulnerability to infection and limit their resources for treatment.

This discussion of genital infection and trauma is intended to convey the widespread nature of the problem and its roots in the social and economic context of the lives of women in developing countries. Barriers to diagnosis and treatment of genital conditions are often specific to women, varying in different cultures but with common themes: lack of information; differential access to health care; violation of norms of personal modesty; and ignorance or denigration of women's needs. These barriers can be lowered with education, economic opportunities, better and more available health services and preventive methods that women can control themselves. To accomplish this, the health and well-being of women must be prominent on national and international research and aid agendas.

GENITAL INFECTION AND TRAUMA

In the following discussion it is understood that: intact vaginal epithelial mucosa alone may not be sufficient protection against HIV transmission during intercourse; the use of condoms is important even in the absence of a sexually transmitted infection or other genital condition; and the study of HIV continues and current knowledge indicates that genital health can decrease, but not eliminate, susceptibility to infection.

Sexually transmitted infection

Genital ulcers caused by syphilis, chancroid and herpes are believed to facilitate penetration of HIV through disruption of epithelial mucosa or through the increased local concentration of lymphocytes which are target cells for HIV. A World Health Organization (WHO) expert committee meeting in 1989 concurred that it is biologically plausible for all STD pathogens that cause genital ulcers or inflammation to be a factor in increased infectiousness or susceptibility to HIV (WHO, 1989). Other sexually transmitted infections, such as gonorrheal, chlamydial and trichomonal infections, may also enhance susceptibility (Oxtoby and Gayle, 1990). Trichomoniasis may be a far greater risk than genital ulcer disease because of its extensive prevalence in many parts of the developing world (Wasserheit, 1990).

The term sexually transmitted infection extends the list of traditional venereal diseases (gonorrhea, syphilis, chancroid, lymphogranuloma venereum and granuloma inguinale) to cover more than 20 organisms and syndromes, including chlamydia, genital herpes, and human papillomovirus infections. The major primary manifestations of sexually transmitted infections throughout the world include urethritis in men, cervicitis and vaginitis in women and genital ulcers, genital warts and enteric infections in both men and women. With infections of the lower reproductive tract, women can experience abnormal vaginal discharge, a burning feeling with urination, abnormal vaginal bleeding and genital pain or itching.

The prevalence of sexually transmitted infections, and thus the patterns of disease, vary greatly among and within world regions and within countries. In western countries, at present, the herpes simplex virus (HSV) is the most common cause of genital ulcer disease (GUD); in many developing countries, syphilis and chancroid appear to be the most common causes (Hatcher et al., 1989). Infection rates are approximate since facilities for testing and treatment are scarce in developing countries, private physicians in developed countries frequently do not report their patients' sexually transmitted infections, population-based studies are rare and much of the research is subject to biases inherent in studies of selected groups (e.g., commercial sex workers, STD clinic patients, prenatal and family planning clients).

Although a female is more likely than a male to be infected from a single act of intercourse with a partner who has a sexually transmitted infection (Hatcher et al., 1989), women are seriously undercounted in sexually transmitted infection data in all countries, in part because their conditions are often asymptomatic, but also because services they can or will use are not available. Clinical diagnosis or screening for infection is rarely incorporated into services offered at family planning, antenatal or maternal and child health (MCH) clinics. Sexually transmitted infection clinics, when they are available, are usually not acceptable to women. Consequently, estimates of the gender distribution of the incidence of sexually transmitted infections cannot be made with any confidence.

Wasserheit (1989), in an international review of female reproductive tract infections, found greater prevalence reported in African studies than those conducted among Asian or Latin American populations. The median of the rates of gonorrhea was 10 per cent in the studies in African countries; 1 per cent in Asian countries and 6 per cent in Latin America. Median rates of trichomoniasis were 19 per cent, 11 per cent and 12 per cent for African, Asian and Latin American studies, respectively (Dixon-Mueller and Wasserheit, 1991).

Since the major immediate causes of infertility in women are probably gonorrhea, chlamydia and other reproductive tract infections, infertility serves as an indirect measure of sexually transmitted infection prevalence. Untreated, these infections lead to pelvic inflammatory disease, which leads to tubal inflammation, damage or distortion, which leads in turn to inability to conceive or to spontaneous abortion (Sherris and Fox, 1985). The measure of female infertility used in most population studies is childlessness at the end of the reproductive years. However, this incorrectly assigns all childlessness to female rather than male infertility, and misses infertility that follows first or later births. The indices vary widely, from as low as 1.0 to 1.5 per cent in Korea and Thailand to as high as 13 per cent in urban areas of Colombia and 23 per cent in one rural area of New Guinea (Belsey, 1980).

In sub-Saharan Africa, the highest levels of childlessness have been found for the most part in three zones: southwestern Sudan and northwestern Zaire; Cameroon and Gabon; and southeastern Angola and northeastern Zambia. These areas, and regions in Burkina Faso and Uganda, have reported infertility levels of over 21 to 40 per cent. In adjacent areas, levels of childlessness are still well above 3 per cent which is considered a normal fertility benchmark. (Frank, 1983). A large multicenter study conducted by the WHO found tubal occlusion, often resulting from sexually transmitted infection, as a cause of infertility in 11 per cent of infertile women from developed countries, 16 per cent from non-African developing countries, and 49 per cent from African countries (cited in Hatcher et al., 1989). Differences in the prevalence of sexually transmitted infections, or in access to treatment, may well explain differences in infertility rates.

Genital trauma

Sexually transmitted infections are a major but not the sole source of damage to the female genital tract. Additional sources of infection or trauma that could damage the epithelial barrier include female genital mutilation, childbearing, insertion of objects into the vagina and trauma during sexual intercourse. Maintaining cleanliness of the genital area under the harsh conditions of nomadic life, drought or life-long water scarcity requires heroic measures. Infections probably caused by inadequate cleansing of cloths used to absorb menstrual blood are also reported (Wasserheit et al., 1989).

Female genital mutilation is a plausible cofactor for HIV transmission which has not been adequately studied. Of the three types of operations performed on young girls, the gravest is infibulation, also called pharaonic circumcision. The clitoris, labia minor and parts of the labia major are removed and the two sides of the vulva are fastened together, leaving a small opening for urination and menstruation. Consequences of infibulation, such as inflammation of the genital area, partial closure of the vaginal orifice, abnormal anatomy or friable scar tissue are conditions that, according to the WHO, may increase susceptibility to HIV (WHO/GPA, 1990). Long-term consequences of infibulation are chronic urinary retention, urinary tract infections, incomplete healing and excessive scar tissue (or keloids) which can cause vaginal obstruction. Childbirth (when the infibulated section is cut open for passage of the infant) can be severely traumatic with consequences as grave as rupture of the vagina. Complications caused by these female genital operations are not reported with any regularity, in part because of the reluctance of the women to expose their genitals for medical examination (Gordon, 1991).

In northern Sudan, according to preliminary reports from the demographic and health survey, 82 per cent of married women had undergone pharaonic circumcision. An additional 15 percent of the married women underwent Sunna circumcision, the "mildest" form in which the tip of the clitoris is removed, or an intermediate type of excision when the whole clitoris and often adjacent parts including the labia minor are removed (Ahmed and Kheir, 1990). The intermediate and Sunna forms are practiced more widely in sub-Saharan Africa and the Middle East than is the pharaonic (which is reported mainly in southern Egypt, Ethiopia, Somalia, Djibouti and in other Red Sea coastal areas). Current estimates of the total number of African women who have undergone some form of circumcision or infibulation approach 100 million (Women's International Network, n.d.).

The Safe Motherhood Initiative launched in Nairobi in 1987 brought to the fore of international discussion the problems of maternal mortality in developing countries. Research and interventions have focused on the risk of death yet, during each delivery, women confront the risk of damage to the genital tract. Tears or incisions during childbirth, with potential for infection, are common traumas of childbirth and massive infections can result from induced or spontaneous abortions. Very young women are especially vulnerable to risks associated with delivery (especially when childhood nutrition has been poor, infections are frequent and growth is stunted). Childbirth at very young ages is not a rare event. In Mauritania, for example, 15 per cent of girls have given birth by age 15; in Bangladesh, 21 per cent have had at least one child by age 15 (United Nations, 1991:59).

When the pelvis is immature or underdeveloped, cephalopelvic distortion and prolonged obstructed labor can cause damage as severe as vesico-vaginal fistula (VVF). With VVF, there is an opening between the urinary bladder and the vagina and the afflicted women continuously leak urine, wetting their clothes and excoriating their mutilated vulvae and vaginas. Reports on VVF from Egypt, Ghana, India, Kenya, Nigeria, Pakistan, South Africa, Sudan, and Turkey indicate obstetric causes for 80 to 100 per cent of the cases identified (Tahzib, 1989). In one Nigerian hospital, 30 per cent of those suffering from VVF were under age 15; 59 per cent were under age 18 (Ampofo, et al., 1990). The number of women with VVF is not known; many are believed to be suffering quietly out of sight, shunned as pariahs by family and community and without protection.

Other causes of genital trauma abound and include such traditional practices as the 'gishiri' or 'salt cut' in Nigeria which involves incision of part of the interior vaginal wall by a traditional birth attendant, traditional healer or occasionally by the woman herself. The purpose is to cure a variety of vaginal conditions and infertility (Adebajo, 1989).

Herbs, traditional preparations and foreign objects inserted into the vagina can cause inflammation, abrasions and infections, and so increase risk of HIV transmission. Practices may be intended to increase the male partner's pleasure during intercourse. Among pregnant women studied at a hospital clinic in Malawi, 12 per cent reported using one or more of the following to tighten the vagina: herbs, aluminum hydroxide, cloth or stones (silica gel, potassium permanganate or pumice-like stone). Not surprisingly, stones were found to have an irritating and erosive effect on vaginal mucosa and the data reported suggest that they may facilitate entry of HIV (Dallabetta et al., 1990).

Globally, women are known to insert objects into the vagina as medication, for contraception or to induce abortion. The array of items used for these purposes in Mexico, for example, includes herbs, pills, soap and lime (Shedlin and Hollerback, 1981). A more complex process is described in Nigeria:

To prepare [the abortifacient], leaves and seeds from certain local trees (ejirin seeds and itu leaves) are ground and the juice from another tree (epin) added to form a paste. The paste is then made into small balls and dried. As they become dry, more juice is added two or three times. The balls are inserted into the vagina and, according to our informants, they have the effect of destroying the foetus (Adebajo, 1989:14).

A cross-cultural study of indigenous fertility regulation conducted in seven countries illustrates the diversity of potentially damaging objects (Newman, 1985). In Afghanistan, women reported intravaginal insertion of wooden spoons or sticks treated with copper sulphate to cause heavy bleeding and abortion (Hunte, 1985). Egyptian women use aspirin, lemon juice, black pepper and plant stems (Sukkary-Stolba, 1985). In other countries, bamboo leaves, grass, the midrib of the coconut palm, water pumped under high pressure, hangers, knitting needles and umbrellas are used as abortifacients (Ngin, 1985; Low and Newman, 1985).

Genital conditions conducive to HIV transmission may also result from sexual intercourse especially in the absence of foreplay when the unlubricated surface is irritated by penile penetration. Among older women, atrophic vaginitis may cause mucosal tears during sexual intercourse (Peterman, 1990). The contraceptive sponge may absorb vaginal secretions excessively and cause dryness (Hatcher et al., 1989), and drying out the vagina before intercourse to increase penile friction has been reported in Zambia (S.K. Hira, cited in Feldman, 1990).

Damage to the female genitalia and increased susceptibility to HIV infection can result from rape or other modes of violent assertion of sexual supremacy by men. This is a risk factor, especially for sex workers who have repeated encounters with drunk and violent clients. In a Harare, Zimbabwe study, half the sex workers interviewed said that their most recent client was drunk (Wilson et al., 1989). An additional genital hazard comes with the use of condoms for frequent acts of intercourse in a short time period. According to recent reports from focus groups with sex workers in Thailand, the customer with a condom takes a longer time to ejaculate, the lubricant wears off, and friction and irritation follow (Sittitrai et al., 1989).

DIAGNOSIS AND TREATMENT: THE OBSTACLES

Recognizing the major role played by the integrity of the female and male genitalia in reducing heterosexual transmission of HIV can be an important contribution to global prevention efforts, but diagnosis and treatment are possible only when women and men can present themselves to someone with the skills and means to identify correctly their conditions and supply appropriate medications.

Utilization of health services

Little is known about what use women in developing countries make of health services for themselves. They are usually questioned only about their use of services that are related to reproduction or to their children's health. The most recent, comprehensive source of information on use of services related to pregnancy is the demographic and health surveys conducted in the 1980s in 29 developing countries. They indicate that many of the women interviewed had at least one visit to a trained midwife or physician at some time during pregnancy, but far fewer delivered with trained assistance. Table 1 shows socio-economic and geographic differentials within countries, as well as between countries, in prenatal visits and delivery assistance in Egypt, Ghana, Guatemala, Mali and Thailand.

In Egypt, 42 per cent of rural women receive some prenatal care from a physician or trained nurse or midwife; yet only 19 per cent deliver with trained assistance. Seventy-eight per cent of rural women in Ghana have at least one prenatal visit; only 29 per cent have trained assistance at childbirth. In rural Guatemala and Mali, fewer than 20 per cent have trained help at delivery and percentages with prenatal care are scarcely greater. In all countries, urban women are more likely than rural women to use these services.

Strong upward trends in utilization of trained assistance are seen as women's educational levels rise from no education to secondary school education. In Guatemala, for example, prenatal care increased from 18 to 86 per cent, in Mali from 27 per cent to 95 per cent in Mali (Chayovan, 1988; Sayed, 1989; Ghana, 1989; Guatemala, 1989; Traore, 1989).

Distance from home to the health facility, lack of transportation and lack of funds undoubtedly explain some of the births not attended by trained personnel, yet the differential between source of care for prenatal visits and deliveries also suggests that deliberate choices are being made. The value given to a natural and familiar setting and the spiritual and material support for the cosmological conceptions of the patient offered by traditional birth attendants strongly influence a decision to give birth in the home community (Twumasi, 1987). These factors weigh heavily against the lack of privacy in a health facility, the use of unfamiliar positions during childbirth, shame at crying out before others and the indignity of exposure (Auerbach, 1982; Rehan, 1984; Schuler et al., 1985; Beeson et al., 1987; Kerns, 1989).

The statistics on utilization do not take into account the quality of care (training and skills of the provider or shortages such as supplies or equipment, including specula and gloves for internal examinations). In a typical prenatal examination, the woman is weighed, blood pressure is taken, the abdomen may be palpated, urine may be tested and sometimes blood may be drawn for testing. The woman may be asked about vaginal discharge, itchiness or other symptoms, but a pelvic examination is not always performed if it is not indicated by her history or condition. Even a woman using a modern family planning method, unless it is an intrauterine device (IUD) or tubectomy, might not be examined internally.

Women often are not aware they have vaginitis and cervicitis, which are the most common syndromes in lower tract infections (Hatcher et al., 1989; Wasserheit, 1989). It is estimated that 10 to 50 per cent of women with trichomoniasis, 25 to 30 per cent with gonococcal cervicitis and probably over 50 per cent of women with chlamydial cervicitis or bacterial vaginosis experience no symptoms (Wasserheit et al., 1989 citing Holmes et al., 1984). Such symptoms as vaginal discharge may be taken to be a fairly normal condition, not requiring medical attention (Orubuloye et al., 1990). The discharge and even a substantial degree of discomfort are often ignored (McFalls and McFalls, 1984).

Access to health services

Differences in access to health care between men and women, as widely reported, are acute with regard to conditions affecting sexual organs. A man with symptoms might go for STI treatment, at least at an advanced stage; his wife is more likely to remain untreated. This is not always because women are unaware of what is happening to their bodies but because their bodies are devalued and are not seen as requiring care. Preferential health care for male children is documented in Asia, principally in Bangladesh and India, and in the Middle East (Cook, 1987). This apparently leaves its cultural mark on the adult female.

In the rural areas throughout developing countries, women doctors are rare; in the Moslem culture especially, women are not allowed to be examined by a male doctor. Distances to health facilities can be very great, and women lack autonomy and money. They are often not released from household and child-care duties to go to a clinic during office hours or to wait at hospitals or dispensaries. Travel outside their immediate community may be forbidden (Kloos, 1987) or inhibited by lack of education and the confidence needed to deal with the official systems. More efficient means of transportation -- such as bicycles, motorbikes, horses and donkeys -- may be for use only by males (Stock, 1983).

Where they are confined to purdah, as in Hausa society, a woman must obtain the permission of her husband before leaving the home compound. Many men are reluctant to allow their wives to make long, unescorted journeys for health care, particularly if the husband perceives the wife's illness to be non-threatening and amenable to traditional treatment (Stock, 1983).

Men are often the intermediaries between women and health services and assessment of the severity of a condition and the choice of an appropriate source of treatment, if any, may be made by the husband or by senior male members of the family. In Zaire, sufferers retain decision-making rights only if they are adult, capable of walking and travelling, financially able to pay for care and, usually, male (Janzen, 1978).

The obstacles many women face in access to health care are caused by poverty, lack of education, inferior position in society, and inadequate health systems, among others. The result is that, if a woman does not have prenatal care, or if her one or two visits do not include an internal examination, she may pass through her entire life and bear her children, yet never have an internal examination.

Personal modesty

Even if symptoms are recognized, and even if services are available, obstacles remain. For women, a strong deterrent is reluctance to undergo a pelvic examination. This was emphatically demonstrated by a survey on female genital operations in the Sudan. Ninety-five percent of the sample population, 3,210 women, were interviewed, but only 12 of the women were willing to be examined (Gordon, 1991). Some of the women may have wished to conceal the evidence that they had undergone mutilation; the majority were more likely to be expressing a strong sense of personal modesty.

Reluctance to expose the genitals is not unique to women in developing countries. In the United States, for instance, fear of a pelvic examination was cited by 25 per cent of adolescents queried as to their reason for not coming sooner to a family planning clinic (Zabin and Clark, 1981). As Scrimshaw states emphatically: "Any woman from just about any culture who has ever had a pelvic examination knows how undignified and embarrassing it feels" (1973:10).

Embarrassment or shame has particular force in some cultures, as is evidenced by the unpopularity of contraceptive methods that require genital exposure and contact. Injection, for example, has been recommended for women in India so that they might avoid both the mortifying experience of exposure to medical scrutiny and the need to handle their genitals when using a method (Marshall, 1973). Embarrassment with genital exposure associated with IUD insertion is reported from Indonesia where the Islamic religion plays a major role in choice of contraceptive method. Many Moslems object to the intimate physical contact between IUD providers and their clients, despite recent rulings from high Moslem councils conditionally endorsing IUD use (Molyneux et al., 1990).

Modesty as a value central to the image of womanhood is notable in the care taken to cover the genitals of females even in infancy, as in Latin America, while male children are free to expose their genitals until they approach puberty. Douches and coitus-dependent contraceptive methods which violate standards of modesty are rarely used by women in Colombia (Browner, 1985) and never among the Aguarunas in Peru, who interpret any viewing or manipulation of female sexual organs as erotic (Berlin, 1985). Some Mayan women in Guatemala do not remove their skirts even for childbirth (Beck, 1991). Mexican women asked to name the parts of their bodies could find no word for the vagina except "la parte" (the part), and that was uttered with manifest embarrassment (Shedlin, 1982).

The depth and force of modesty is exemplified by the pregnancy and childbirth practices of rural Hausa/Fulani women in the northern region of Nigeria. Muslim women in purdah do not openly admit to their pregnancies. They often labor alone in their compound (with other women keeping within hearing distance in case assistance is required). The traditional birth attendant (TBA) is called in after the child is born to cut the cord and look after the mother and baby (Sokoto Maternal Health Project, 1990).

Fear and stigma surround problems relating to the sexual organs and women suffer in silence. In India, inhibitions about drawing attention to the body can be so great that even female health workers must rely upon verbal accounts of the symptoms of women who will not subject themselves to a physical examination (Ramasubbam, 1990).

Feelings of "verguenza", or shame, and their influence on attendance at family planning clinics, were examined by Scrimshaw in detail (1973). Many of the women interviewed in Guayaquil, Ecuador, who never undressed completely before their husbands, were forced to expose themselves to male doctors at the clinic without even a drape over their legs during the pelvic exam. With a drape, at least, the woman cannot see the doctor and has some illusion of privacy.

Moroccan women report feeling inhuman when they are ordered to take off their pants and sit in a drafty hall where people walk by while they are waiting to see the service provider for family planning (Mernissi, 1975). This study, the Scrimshaw work also from the 1970s and a much earlier study by Stycos in Puerto Rico (1955) gave serious scientific attention to a subject that is still acutely and universally felt by women, still a grave problem and still for the most part ignored.

Sexual inequality and stigma

Restrictions on travel, fear of pelvic examination and violation of the sense of personal privacy are formidable barriers in themselves, without the added stigma of a sexually-related infection. An association of STIs and promiscuity, references to sexually transmitted infections as the woman's disease in popular parlance in some languages and common use of the term reservoirs of infection to describe prostitutes place the onus solely on the female, regardless of the male's multiple relationships. Research in Zaire found that when men are infected, their wives are suspected of infidelity; when women are infected, they are assumed to have strayed (Schoepf, cited in Bledsoe, 1989:11). The image of women as the source of disease is reinforced by the media and public health announcements, as in the Zambian advertisement: -Avoid AIDS. Take Time to Know Her (Bledsoe, 1989:11).

Counseling women about prevention and the need for treatment of their partners may presume incorrectly that they are free to discuss sex and condom use without jeopardy. Discussion of this emotionally charged topic is rare in many cultures. A survey of spousal communication in Asian countries, for example, found that close to one third of the women interviewed in the Philippines never talked to their husbands about sexual matters, nor did 47 per cent in Singapore or 53 per cent in Iran (UNESCAP, 1974). In sub-Saharan Africa, sexual activities are rarely discussed either between spouses or between the generations (Caldwell et al., 1989). In Latin American culture, communication between men and women (or parents and children) regarding sex is not the norm (Worth and Rodriguez, 1987; Santos-Ortiz, 1990). In a study of decision-making on the use of family planning in Mexico, 35 per cent of the survey sample had never discussed the subject of birth control with their spouse (Folch-Lyon, 1981). In focus groups, women expressed the difficulties they experienced in any discussion of sexual relations with their husbands. Castro de Alvarez (1990) observed that cultural norms in their patriarchal society dictate that Latin American women appear naive about sexual matters and that a woman knowledgeable about and prepared for a sexual encounter is considered loose. It is thus very difficult to realize the necessary conditions for promoting condom use and persuading a partner to be treated for a sexually transmitted infection. They are: relative sexual equality between men and women; the possibility that other sex partners can be acknowledged; and options other than motherhood to define self-identity or self-esteem (Worth, 1989).

When there is no communication about sex, and when women fear that their relationships will be jeopardized by asking for safe sex practices, promotion of condom use among women is likely to fail. The anger at being made to feel responsible for men's sexual behaviour expressed by women in a New York City study probably has near universal application. Women claimed men decide what is going to happen sexually and that if the staff wanted men to wear condoms, they would have to talk to them, not to women (Worth, 1989). Prevention strategies that place the onus on women ignore the subordinate position of the many who are economically and emotionally dependent on their male sexual partners. For these women, negotiation, even perhaps discussion, is not an option (Maldonado, 1991).

Among the sociocultural and psychological constraints to overcome in promoting condom use in Zaire are strong beliefs and feelings about the contribution of semen to women's health and the importance of reproduction (Schoepf et. al, 1988). The decision to use a condom is a decision not to reproduce as well as not become infected. The general use of condoms may, therefore, be in direct conflict with the desire of women to fulfill their reproductive roles and with the expectations of their partners and families that they do so. It is also a decision that must be made for each act of intercourse. Women must repeatedly address the issue of sexual decision-making and sexual control, and each time this is done they are emotionally, sexually, physically and economically vulnerable (Worth, 1989).

SUMMARY AND RECOMMENDATIONS

The causes of damage to the epithelial barrier that allows vaginal transmission of HIV are numerous: sexually transmitted infections, insertion of objects into the vagina, trauma during sexual intercourse and genital mutilation practices, among others. Obstacles to prevention, diagnosis and treatment are also numerous. Most are embedded in the cultural and economic context of women's lives and can be overcome only with concerted effort at the level of both local communities and the national health systems. These issues must be given priority in national and international research and aid agendas.

Recommendations in this section are given with the caution that a change in women's knowledge, and behaviour is necessary, but women alone do not carry the responsibility for prevention of HIV transmission. Men, in their political and economic positions of power as well as in their sexual partnerships, are responsible for change, as it is women's subordination -- lack of control over their bodies and their lives -- that is the primary HIV risk factor (Hamblin and Reid, 1991; Carovano, 1990).

Community level

On the level of the local community, the starting point for education of women and men is the message that women's health is important for reasons other than childbearing. Knowledge about their bodies, ability to speak of sexual organs and processes without shame, hygienic practices (especially as regards menstruation) and signs and symptoms of genital-urinary problems must be communicated through social networks in the community. By whatever means, women must be helped to talk of these things together in their own idiom, without embarrassment, and to help each other devise strategies for raising these issues with men. Men must be helped to be at ease speaking of their own and women's sexuality, with each other and with women, candidly and not crudely. Role models must come forth who in their knowledge of and attitudes toward women can redefine the masculine image. Knowledge about sexuality and reproductive biology is transmitted by older experienced women, in many societies, especially where social separation of sexes emphasizes communication between women rather than between partners (Newman, 1985). The local setting may suggest other rules for discussion of sexually-related matters, as in Tunisia where women never speak of family planning with their daughters or with anyone of a different age group (Huston, 1978). Women's groups are a near universal resource and women can use them to learn to speak of their bodies, sexuality and genital health in their own way, according to their own customs.

Preferences for local, familiar and predictable midwifery services for childbirth suggest that traditional midwives can play an important role in developing awareness of threats to genital health and the ability to recognize symptoms of STIs and in providing advice on resources for treatment. Training TBAs for safe delivery and health education is a fairly widespread practice. Although the trainers usually discourage midwives from performing internal examinations, in order to avoid infections, and their curricula do not usually cover sexually transmitted infections and other genital conditions, midwives can be trained to ask about symptoms, to advise and, when linked to a health service system, to refer women for diagnosis and treatment.

Research on traditional medicine rarely examines conditions other than pregnancy that motivate women to seek care. However, evidence generally supports the view that traditional practice is popular and addresses a broad range of women's conditions. Traditional medicine co-exists with modern medical practice, and it is not uncommon for consultations with both systems to occur serially or concurrently (Janzen, 1978; Cosminsky and Scrimshaw, 1980; Heggenhougen, 1980; Green and Makhubu, 1984; Cleland and van Ginneken, 1988; Good, 1988; Ingstad, 1990).

In Malaysia for example two traditional systems (Ayurvedic and Chinese) and the local Malay folk medical system, accepted as parts of general Malaysian culture and society, are linked to the official health system and used widely as additions or alternatives to modern medical practices (Heggenhougen, 1980). A Guatemalan plantation population can have simultaneous access to folk curers (curanderos), herbalists, midwives, spiritists, shamans, injectionists, pharmacists, private physicians, public and private clinics and hospitals and home remedies (Cosminsky and Scrimshaw, 1980). Good (1988) estimates that most African rural areas have at least one part-time traditional healer for every 200 to 300 persons; in the towns, there is one healer for every 400 to 800 persons. In Swaziland, at least 85 per cent of the population is believed to make use of the services of traditional healers (Green and Makhubu, 1984). Many of these opinion leaders and therapists are female. While the role of traditional healers in communicating information on genital health and its protection is not universal, they are an ubiquitous and influential resource.

Health systems

Strengthening health service systems for prevention and treatment of genital infections and other conditions must be a major national and international priority that should go beyond traditional categories of service. The narrow focus of public health programs concerned with women is apparent in their labeling as maternal and child health services. The rationale for this lies in the belief that improving women's health is an important precondition to child health. A recent variation on this reasoning focuses on the woman as a potential transmitter of HIV to her infant and as a caregiver to people with HIV infection and related illness and orphaned children.

Health systems reflect this limited view of women's lives and potential and the pervasive gender inequalities which deny women control over their own bodies. Expansion of the concept of women's health to encompass the breadth of their activities and concerns is an immediate public health responsibility. Grants for study and research, support for networks of organizations, forums, training, policy analysis, advocacy and new and improved programs are all required to bring attention to the restrictions on the health services women are now offered. These health services are restrictive both because they are difficult of access in many areas and because they respond only to a narrow range of women's health needs.

Prenatal services provide a good opportunity for health care workers to counsel women on protection of the genital tract and to diagnose and treat genital-urinary tract infections. Training of clinical personnel to be alert to adverse genital conditions is necessary; equally necessary are respect for the patients' sense of inappropriate or shameful exposure and care to ensure privacy to the maximum degree possible. Screens constructed from local materials, drapes made from local cloths -- to shield exposed areas, minimum time without full clothing -- these are in themselves indications of concern for feelings as well as relatively simple measures to make services more acceptable to women. Increasing the supply of female medical personnel on all levels is essential. In the prevailing absence of educational opportunities for women from the earliest grades through university degrees, more women must be given scholarships.

Much of the work needed does not require advanced training and extensive employment. In-service training of local women in health centres and in the community can reduce barriers while extending the availability of services. Primary health care and family planning services have amply demonstrated the value of recruiting and training paramedical personnel from the local population. If there is genuine community participation, especially of women's organizations, in facility and service planning, then needs, perceptions, problems and expectations can be freely expressed, respected and addressed.

Family planning providers can lead the formal sector in exploring how health services can reduce the institutional obstacles women encounter. Their programs could provide services for diagnosis and treatment of genital lesions, inflammations and infections, and could be the only available source of health care for sexually active women, especially poor women. Functions that would be relatively easy to integrate into family planning services, given appropriate training and supplies and a commitment to genital as well as reproductive health are as follows: substituting modern contraceptives for objects damaging to the vagina (which will also diminish their use as abortifacients); educating women and men about risks; and diagnosing, treating and counseling sex partners.

The scarcity of resources for health care in developing countries is glaringly evident. There is a shortage of laboratories and supplies for diagnosis, as well as medication for treatment of STIs. In the shorter term, rapid expansion of laboratory testing is not feasible. However, it is possible to develop and subsidize distribution of supplies for inexpensive, relatively simple diagnostic techniques using cervical swabs, vaginal KOH odor and dipstick assessment of vaginal pH, as demonstrated in a study of reproductive tract infections in Bangladesh (Wasserheit, et al., 1989). As appropriate tests are developed, the health systems must undergo the changes necessary to put them to use.

Research and aid agendas

Priorities for research and development assistance are not easily set for a topic so seldom examined in its personal and social complexity. It is urgent that technological advances be made to develop and provide inexpensive diagnostic tests for women in developing countries. Female providers in traditional and modern sectors must be trained to educate, diagnose and treat. Their work should be evaluated through operations research.

The dilemma, or paradox, of condom use as the main strategy to prevent women from contracting HIV stems, of course, from the fact that it is a strategy for men. Since it can not be used when the male is dominant and resistant, alternative means of mechanical or chemical barrier protection must be found quickly, they must be distributed widely at little or no cost and they must have appeal to women.

Spermicides and diaphragms shift the focus of control over prevention to the woman, a preference demonstrated by women who were given the choice in studies in Cameroon and Ghana (Spieler, 1990) and Rwanda (Allen et.al., 1988). Barriers that depend on the woman alone may be less effective than condoms, yet more effective in the long run if they are consistently and widely used and the condom is not (Stein, 1990). Laboratory and clinical studies indicate that vaginal spermicidal contraceptives which place a chemical barrier between infected fluids and vulnerable mucous membranes offer women considerable protection against STIs (see North, 1990, for a literature review), although use with a condom is more certain.

Nonoxynol-9 (N-9), the most widely used spermicide, has been tested as an HIV virucide and laboratory findings suggest that it offers some protection. However, it has not been determined whether spermicides alone, without any mechanical barriers, protect against HIV infection (Cates and Stone, in press). Problems encountered in interpreting results of clinical studies have stemmed from a research focus on special populations (e.g., prostitutes with rates of sexual activity far exceeding the general population) and confounding factors such as use of N-9 with a vaginal sponge, which could itself cause microlesions or irritation from high concentrations of N-9 (Gollub, 1991). Female condoms (e.g., pouches made of polyurethane or latex) are being tested, although they are not now in a form that is likely to have wide acceptability.

A vaginal virucide which would offer protection against transmission without preventing conception is vital for women who desire children and who need to have them in societies where their status and economic security depend upon procreation (Stein, 1990). A promising avenue for the research is the possibility that concentrations of N-9 lower than recommended as a spermicide may be effective as a virucide (Stein and Gollub, 1991). The urgency of the need to investigate this and other virucides and the necessity for rapid development of a method women can use to protect themselves cannot be overstated.

The literature on the possible association of female mutilation with HIV transmission is sparse and speculative. Infections of the mutilated area, trauma caused by sexual intercourse, and blood transfusions necessitated by excessive bleeding at childbirth are plausible reasons. The universality of the practice in some African regions suggests that there may be a group of women at risk of infection of appalling dimensions as the epidemic expands geographically. A vigorous investigation of the relationship between female mutilation and HIV transmission must be undertaken.

Societal transformations

The place of women in society is a primary cause of exposure to risk of HIV infection and a primary barrier to use of health services. Some of the consequences of this role of women are: little or no information; restrictions on movement outside the local community; fear of strange environments that are often with justification perceived as hostile; and the role of the men as mediators between women and the health system. The changes that must be made in the legal, economic and cultural spheres over the long term are immense and must be made largely by those who are favoured by the present inequities.

Yet over the short term there are collective actions women can take in their local communities. Women working together are learning to develop strategies for communication with their sexual partners about HIV, sexually transmitted infections, use of condoms and other sexual behaviors, finding as well the courage and determination to face opposition. Collectively, women are developing strategies to stand up to the official systems, to change men's behaviour and to realize the strength of unity for survival. They must be assisted with information, with legal aid, with health services and with opportunities for education and economic independence. A woman's lack of control over the resources for her own physical and mental health and well-being is a violation of human rights that constitutes a direct threat to her life.

ANNEX

TABLE 1: PERCENTAGE OF WOMEN WITH PRENATAL VISITS AND TRAINED ASSISTANCE AT DELIVERY, IN SELECTED COUNTRIES, BY RESIDENCE AND EDUCATION

  * Educational levels for Thailand: 0-3, 4-7, 8+

_____________

Sources: Demographic and Health Surveys: Egypt, Ghana, Guatemala, Mali and Thailand.

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ACKNOWLEDGEMENTS

 This paper was prepared by Regina McNamara under the guidance of Elizabeth Reid, Policy Advisor on HIV and Development to the Administrator of the United Nations Development Programme. It is intended to review the literature on women's needs for and use of health services for genital conditions in order to ensure that strategies developed to help women protect themselves from HIV infection are based on existing knowledge of the causes of conditions which may facilitate HIV transmission in women and of the obstacles to their diagnosis and treatment. The author gratefully acknowledges the contributions of colleagues and experts who reviewed drafts and made numerous helpful suggestions, including Lucile F. Newman, Mallica Vajrathon, Judith N. Wasserheit, James McCarthy, Deborah Maine, Catherine Maternowska and Gail Cairns.

BIOGRAPHICAL NOTE

Dr. McNamara is Assistant Professor of Clinical Public Health at the Center for Population and Family Health, Columbia University, New York City. Her current research is on the determinants of sexual partner change and other behavioural patterns critical to the transmission of HIV in Thailand, and the design of operations research for HIV prevention strategies among adolescents in Thailand and Uganda. Recent work includes the development and evaluation of family planning programs in several countries of sub-Saharan Africa and research on the determinants of infant and maternal mortality.

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