International Perspectives on Women and HIV

Samuel A MacMaster, Brian E Bride, CINDY DAVIS, Samuel A MacMaster, Brian E Bride, CINDY DAVIS

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781317994886
• Edition: 1
• Topic: Medicina
• Subtopic: SIDA y VIH

Throughout the world, the threat of HIV/AIDS to women's health has become the focus of increased concern. The Joint United Nations Programme on HIV/AIDS (2004) reports that almost 20 million women and girls are living with HIV globally, accounting for nearly half of all people living with HIV worldwide. Infection rates among women are rising in every region worldwide including high-income countries in which heterosexual intercourse may now be the most common mode of transmission. Although there are many contributing factors to the current trends in HIV, most women who become HIV-infected do not practice "high-risk" behaviour. Women worldwide may individually view themselves as less susceptible than men, and may pay less attention about how HIV is transmitted and how to prevent infection. There are also gender inequalities, stemming from sexual double standards that constrain women's access to care, treatment, and support. This work focuses on international perspectives on women and HIV casting a deliberately wide net addressing the issue of the interaction between HIV and gender in a specific geographic area. Our intention is to provide a forum for innovative manuscripts whose contribution to the literature is found in their unique approach to this interaction and application of empirical investigation to unique problems and/or populations.

This materialwas published in the Journal of Human Behavior in the Social Environment.

Rapid Ethnographic Assessment of HIV/AIDS among Garífuna Communities in Honduras: Informing HIV Surveillance among Garífuna Women

Miriam Sabin

George Luber

Keith Sabin

Mayte Paredes

Edgar Monterroso

Garífuna, an Afro-Caribbean ethnic group living on the north coast of Honduras, has been noted to have one of the highest HIV prevalence (8.4%) rates in Central America (Sierra et al., 1999). Garífuna women of child-bearing age are at particularly high risk for becoming HIV-infected, raising the specter of increased maternal to child transmission of HIV (Trujillo, Paredes, & Sierra, 1998). Garífuna women are burdened with issues affecting HIV transmission such as negotiating safe sex, low levels of HIV prevention knowledge (Tercero, Arana, & Miranda, 2002), and poor access in some regions to HIV testing or treatment for HIV-infected individuals (Stansbury & Sierra, 2004; Tercero et al.). In addition to HIV, Garífuna women, and women in general in Honduras, face such structural issues as poverty, intimate partner violence, low literacy and poor access to comprehensive healthcare (Tercero et al.; UNAIDS/UNFPA/UNIFEM, 2005). All these factors likely contribute to high HIV prevalence and poor HIV-related health outcomes among Garífuna women.

Owing to their high risk of acquiring HIV, Garífuna in Honduras are considered a focus population for HIV prevention activities by the Honduras Ministry of Health and its partners (CDC & World Bank, 2003). Garífuna women require effective public health and social service interventions to lessen the burden of HIV in their communities. These interventions should be informed by the stakeholders. Surveys linking HIV prevalence and HIV-related risk behaviors over time, including sexually transmitted infection (STI) rates, should be used to monitor and evaluate the effectiveness and impact of the interventions developed according to Second Generation Surveillance guidelines (UNAIDS & WHO, 2000). Second Generation Surveillance often employs repeated behavioral surveys that can include biomarkers for either or both HIV and selected STIs. The surveys are commonly referred to as Behavioral Surveillance Survey Plus Biomarkers (BSS+; Family Health International, 2000). Such behavioral surveillance surveys also provide insight into the most effective way to target HIV prevention interventions. Planning for care and treatment of HIV-infected individuals uses estimates and projections of HIV transmission rates derived from STI and HIV seroprevalence over time in combination with behavioral factors (CDC, 2005).

In this article, we briefly describe the Garífuna and provide an overview of the HIV epidemic in Honduras and among Garífuna at the time of this assessment. We will then discuss how rapid ethnographic assessment (REA; Scrimshaw & Hurtado, 1987), a formative, qualitative methodology, was used to inform a BSS+ survey of HIV/AIDS among Garífuna communities on the north coast of Honduras. The purpose of this assessment is to guide effective public health surveillance and ultimately improve HIV interventions through on-going monitoring and evaluation.

GARÍFUNA

Garífuna origins can be traced back to 1675 when a ship carrying West African slaves destined for the Americas shipwrecked and the would-be slaves escaped (Gonzalez, 1988). Over time, Garífuna migrated throughout the Caribbean and Central America, forming, to some extent, family units with the local Amerindian population and maintaining many West African cultural traditions (Gonzalez). Such distinct ethnic groups that differ from the surrounding local populations require sensitive attention to ethnomedical, non- “Western-tradition” health beliefs, treatment-seeking, and social structure to adequately validate any survey methodology and its questionnaires (Herman & Bentley, 1993).

Garífuna utilize a range of traditional healers for health care needs (Barrett, 1995; Coe & Anderson, 1996; Blanchard & Bean, 2001). The term witchcraft is used, and witches, or buiyes, perform and lead community ceremonies closed to outsiders, often incorporating rituals, dances, drumming, trances to contact the dead: at times these ceremonies are conducted to seek revenge (Gonzalez, 1988). Sick individuals often visit traditional healers first for non-biomedical interventions to assist with illnesses, including AIDS-related illnesses (Tercero et al., 2002). Surveys examining treatment-seeking behavior in the informal (ethnomedical) sector should carefully assess any effects healers and this treatment-seeking may have on a given health condition (Scrimshaw & Hurtado, 1987).

Health-seeking behaviors among indigenous groups in resource-poor settings are often constrained by socioeconomic factors that must be adequately assessed prior to survey implementation. Farmer (1999) notes that biomedical interventions are expensive by local standards and there is often little to no access for such care; indigenous people of low socioeconomic status may seek traditional healers because they are often cheaper and more readily available. This may be the case among Garífuna communities where access to biomedical care for HIV/AIDS is limited primarily to the regional center La Ceiba, a city on the north coast, a day's travel (with mandatory overnight) from the more remote Garífuna communities.

Status of Garífuna Women

Garífuna women live in a society in which the majority of men migrate seasonally to the United States or other locations for work and thus spend significant periods of time away from the community (Tercero et al., 2002). Because the primary male partner of a Garífuna woman is often away, Garífuna women are in charge of household affairs (Tercero et al.). Garífuna women reportedly have sufficient social status to be heads of household, share income-related decisions, and have multiple sex partners (Tercero et al.). However, a qualitative HIV risk factor survey for the Honduras Ministry of Health in 1999 reported widespread intimate partner violence (IPV) by Garífuna men against Garífuna women. Garífuna women's status may not be linked to full social access. Further review of Garífuna women's actual social status and power within the family and society is needed (Stansbury & Sierra, 2004). Myths that reflect an exoticism to Garífuna culture may interfere with accurately assessing gender interactions important to HIV transmission. Any quantitative survey, such as the BSS+, needs to carefully delineate the extent to which these common beliefs may mis-inform survey practices among Garífuna and prospectively correct them prior to survey implementation.

Economic progress among Garífuna has been difficult since Hurricane Mitch devastated Honduras in 1998 (Inter-American Development Bank, 1999). Of Garífuna who remain in Honduras, many men earn a living from wage work in San Pedro Sula, the largest North Coast city, in textile (maquila) factories or by fishing/conch diving (Stansbury & Sierra, 2004). A subsequent coconut blight that struck the North Coast devastated the majority of coconut trees in the region; Garífuna struggle to find sufficient quantities of palm fronds for housing, community structures, food, and coconuts for making bread, puddings, and shells to make carved jewelry that support their income (Canadian Interdevelopment Agency, 2002).

Status of Women in Honduras

Honduran women, in particular those of lower socioeconomic status, are faced with similar social and economic barriers as Garífuna women face owing, in general, to poor access to credit, technology, training, equal salaries, and land (Canadian Interdevelopment Agency, 2002). As with Garífuna, it is estimated that 8 of 10 women experience IPV in Honduras (U.S. Department of State, IWRAW). Honduras passed the Law Against Domestic Violence in 1997 (National Congress of the Government of Honduras, 1997) to increase the penalties for domestic violence crimes. Physical and sexual violence are reportedly widespread; the UN Population Fund (2000) estimates that 8 of 10 Honduran women experience such violence in their lifetimes. The same proportion of working women (8 of 10) is living under the poverty line. In 1998, the national per capita income per woman was 47.3% of men's national per capita income (Canadian Interdevelopment Agency). According to the UN World's Women report the percentage of deliveries attended by skilled health staff in 1996 was 47%; the maternal mortality ratio was 220 per 100,000 Uve births for 1998. Illiteracy rates are similar for Honduran women (27.2%) and men (27.1%); the majority of Hondurans complete only elementary school (85.4%) (Perfil Ambiental de Honduras, 1997). Overall, women in Honduras confront multiple problems of daily living to survive.

Overview of HIV/AIDS in Honduras

Honduras, with 17% of the population of Central America, at the time of this assessment, had 44% of Central America's reported AIDS cases, in part owing to a stronger AIDS case reporting system than its neighboring countries (UNAIDS, 2004). An estimated 63,000 people are living with HIV/AIDS (PLWHA) in Honduras, and there is a national HIV prevalence of 1.9% (UNAIDS, 2005), however, the Global Fund estimates that 30–50% of HIV cases are not reported (Global Fund, 2004). There has also been a steady increase in the prevalence of women with AIDS as compared with men with AIDS (UNAIDS), with a one to five percent range of HIV prevalence among antenatal clinic (ANC; clinics for pregnant women) surveillance sites. The AIDS cumulative incident case rate in 1997 in the Department of Atlantida, on the northern coast of Honduras, and an area where the majority of Garífuna live, was reported to be 357.2 per 100,000 (Trujillo, Paredes, & Sierra, 1998).

HIV Prevalence and Related Risk Factors among Garífuna

In 1998, the Honduras MoH conducted a serosurvey (N = 310; Sierra et al., 1999) among high-risk groups in Honduras, including Garífuna. Ten percent of commercial sex workers (CSWs) were HIV-infected; 8% of men having sex with men (MSM) and 7% of male prisoners were HIV-infected. Five percent of 16- to 20-year-olds were HIV-infected. The HIV prevalence rate among Garífuna was found to be comparable, 8.4%. Sixteen percent of Garífuna 16- to 20-year-olds, in comparison to 5% of 16- to 20-year-olds in the general population were HIV-infected. HIV prevalence was relatively evenly distributed among male and female Garífuna (8.5% of males and 8.2% of females, respectively), suggesting the epidemic largely involves heterosexual transmission (Sierra et al.). The 1998 AIDS cumulative incident case rate in the same region was 2,000 per 100,000 (Trujillo et al., 1998) or 18% higher than the population incident rate in Atlantida (357.2 per 100,000; Trujillo et al.). There have been no additional surveys in the past 7 years, and at the time of publication in 2008, these rates may no longer apply.

Stansbury and Sierra (2004) report the Association El Buen Pastor conducted a Knowledge, Attitudes, Behaviors and Practices survey among Garífuna communities in 2000; findings suggested a knowledge gap in which knowledge of HIV/AIDS was high among participants (90%), but awareness of specific risk factors was low. For example, only 5.5% of participants self-reported that mother to child transmission was a risk (p. 458).

A 2002 REA on the cosmology (Garífuna universe) and behavior around AIDS among Garífuna in North Coast communities with the highest AIDS incidence rates examined Garífuna HIV/AIDS risk perceptions and behaviors (Tercero et al., 2002). In general, the authors suggested high incidence of HIV among Garífuna is largely due to multiple sex partners, migration to and from the United States where migrants are ostensibly becoming infected, use of Traditional Healers instead of Western medicine, and poor access to preventive care and services (p. 2). The results from the qualitative analysis indicated factors involved in the high rate of HIV among Garífuna women included sexual debut in adolescence, little to no condom use, poor knowledge of HIV risk behaviors nor accurate awareness of prevention messages, and gender-power gap issues (such as, ability to negotiate condom use, IPV and drug and alcohol abuse by male partners; p. 31). Pregnant adolescent females may be especially vulnerable to becoming HIV-infected because...