An exploratory study conducted by Population Council/Egypt is published recently, focusing on married women's vulnerability to HIV infection. Although there are no national statistics that document the rising prevalence among women in Egypt, anecdotal findings by service providers in voluntary counseling and testing centers suggest an increase in the number of women infected with HIV. In many cases, women may not be aware of the husbands’ risky behavior and hence are not themselves aware they are at risk for HIV. The current study focused on examining the behavioral, sociocultural, economic, programmatic, and legal factors that aggravate Egyptian women’s vulnerabilities to HIV/AIDS. The results of this study can lead to more gender–sensitive policies and programs.
Egypt has a low prevalence of HIV (<0.01 among the general population) with higher prevalence rates among men who have sex with men and people who inject drugs (5.7– 5.9% and 6.5– 6.8%, respectively). Although there are no national statistics that document the rising prevalence among women in Egypt, anecdotal findings by service providers in voluntary counseling and testing centers suggest an increase in the number of women infected with HIV. The 2010 Bio– Behavioral Surveillance Survey noted that approximately one–fifth of men who have sex with men (MSM) and one–half of male people who inject drugs (PWID) were ever married to female partners. In many cases, women may not be aware of the husbands’ risky behavior and hence are not themselves aware they are at risk for HIV. The current study focused on examining the behavioral, sociocultural, economic, programmatic, and legal factors that aggravate Egyptian women’s vulnerabilities to HIV/AIDS. The results of this study can lead to more gender–sensitive policies and programs.
The study used the following methodology: 1) literature review and critical appraisal of relevant existing national laws and policies related to HIV and sexual and reproductive health (SRH); 2) in–depth interviews with 20 of each of the following groups: MSM, PWID, internal migrant workers, and external migrant workers, to assess the vulnerabilities faced by their wives from their perspective; 3) in–depth interviews with 20 women married to migrant workers; 4) in– depth interviews with 20 women living with HIV (WLHIV); and 5) 12 focus group discussions with married women aged 18–40 years. The study was conducted in governorates with a high prevalence of target populations, namely Cairo, Alexandria, Sharkiya, Fayoum, Minia, Sohag, Luxor, and Red Sea.
The current study revealed that women and men are both vulnerable to HIV infection as a result of several interacting factors: the culture of silence around HIV, taboos around the discussion of sexual matters and limited access to HIV–related information. However, the toll of societal norms, gender inequality, economic dependence on a husband, legal discrimination against women, and faulty understanding of religious teachings affect women disproportionately, rendering them more vulnerable to HIV and more stigmatized in case of infection with HIV, a disease that is often linked to “promiscuity.”
Women and men interviewed for the current study had limited knowledge and prevalent misconceptions related to HIV. Men did not perceive themselves or their wives as being at risk for acquiring HIV and had a false sense of security with regard to their risk of contracting HIV, considering it “a disease of foreigners.” The women who were the focus of this study, although did not engage in risky behaviors themselves, turned out to be vulnerable to HIV for being in a marital relationship with men who practiced high risk behaviors including injecting–drug use and/or having heterosexual or homosexual relations. Furthermore, these husbands had limited HIV–related information, negative attitudes toward condoms, and most of them treated their wives violently. The vulnerability of these women is further exacerbated by inequitable gender norms and economic dependence on their husbands, both of which render women powerless to discuss their husbands’ risky behavior if they suspect it. Furthermore, women who tried to protect themselves by refusing to have sex with their husbands or insisting that their husbands use condoms were subjected to both physical and sexual violence from their husbands. Some WLHIV even accept the fact that their husbands, who knew they were HIV–positive and could transmit infection, did not bother to tell them of their status or protect them from HIV.
For low–prevalence settings like Egypt, the focus should be on targeted interventions as they are the most strategic and cost–effective. Hence, efforts should be made to reach out to MSM and PWID and to promote harm–reduction interventions including endorsing safe sex and safe injection and provision of condoms and sterile syringes. Ongoing harm–reduction interventions should be scaled up, both geographically by expanding to more governorates, and programmatically by incorporating activities focusing on husband–wife communication. Interventions should include outreach to wives to raise their HIV awareness and enhance their condom use, self–efficacy, and negotiation skills while nevertheless maintaining the confidentiality of their husbands.
Additionally, there should be targeted interventions directed toward internal migrants, specifically those working in tourist attractions, and external migrants, especially those living and working in Western countries. The focus should be on HIV awareness–raising with a special focus on the preventive role of consistent, correct condom use, and creating a cadre of peers that could provide psychosocial support and HIV counseling to those workers.
To function smoothly and effectively in a highly stigmatized setting like Egypt, MSM– and PWID– targeted activities should be complemented with HIV awareness–raising campaigns among the general population to combat HIV–related stigma and discrimination and negative attitudes linked to condom use. Social campaigns focusing on condoms should be encouraged both at the level of the general population and among key populations. Furthermore, premarital and antenatal care programs should include HIV awareness–raising and provider–initiated counseling and testing after screening of women to identify those at risk for HIV infection. Concurrently, efforts should be made to empower women (e.g. through microloans, vocational training) as well as addressing inequitable gender norms and revisiting legislations and policies that discriminate against women and exacerbate their vulnerability to HIV.