Int. Med J Vol. 6 No 2 December 2007

Review on: The Health Status of Muslim Women with HIV/AIDS in Arab Countries

Falah A.M Salih* and Quazi Manjurul Haque

Faculty of Medicine, International Islamic University Malaysia,

ABSTRACT

The number of people worldwide living with human immunodeficiency virus/ acquired immunodeficiency virus (HIV/AIDS) is more than 40 million, among them 17.7 millions are women (UNAIDS/WHO, 2006) The latest report from the Eastern Mediterranean Region shows that at least one million people are infected with HIV; among them 30% are women. The great majority of reported cases in the Region are men. However, the ratio of men to women cases varies in different countries. It ranges between “9:1 (as for example in Egypt), to 2:1” (as in Morocco and some parts of Yemen). Due to religious, social and cultural values regarding female purity, women and girls living with HIV and AIDS are subjected to greater discrimination than men. WHO reports show that a large percentage of the infected women in Arab countries have contacted the infection from their husbands especially migrants and drug abusers.  In Arab countries, studies conducted show that 86% of women choose not to disclose their status of infection for the fear of abandonment, rejection, discrimination, violence, upsetting family members, and accusations of infidelity from their partners, families, and communities. As a result, many women only seek help at the last minute when they are already been terminally ill.  Violence against women and girls in its different forms increases women's vulnerability to HIV infection and undermines AIDS control efforts. The fear of violence prevents many women from accessing HIV information, from getting testing and seeking treatment. Stigma and discrimination may also prevent them from carrying out their normal life activities. When women are blamed, this can lead to heightened levels of sexual and domestic violence, abandonment by families and communities, forced abortion or sterilization, dismissal from employment and loss of livelihood opportunities. A study of AIDS-related discrimination in Arab region found that over ten percent of women had lost financial support from family members since being diagnosed as HIV positive.  There is a great deal of evidence to establish the significant link between gender-based violence and rising rates of HIV infection among women and girls throughout the world. HIV-positive women must be supported to make their own reproductive choices about whether and/or when to have children. Promote male involvement in sexual and reproductive health programmes. Finally the stigma, discrimination and violations must be stopped.

KEYWORDS: HIV/AIDS, Women, Arab countries

INTRODUCTION

As in mid of 2007, 26 years have passed since the first case of AIDS was reported. During this period, over 40 million people were infected with HIV/ AIDS, and 20 million died. In 2006, about 47 000 people died of AIDS in Arab countries and 2.8 million died worldwide (UNAIDS/WHO 2007).

Globally there were more than 17.7 million women living with HIV in 2006 – an increase of over one million compared with 2005. In sub-Saharan Africa, almost 60 percent of people living with HIV/AIDS in 2006 were women¹.

Arab countries, previously considered as protected from HIV/AIDS due to religious and cultural norms, are facing a rapidly rising threat now. Sexuality, considered a private matter, is a taboo topic for discussion in this area.

Among the one million infected people estimated by UNAIDS in the Middle East, approximately 320,000 are women^{2, 3,}

⁴.

The social stigma related to HIV/AIDS that exists in all societies is much more pronounced in Muslim culture. This stigma prevents those at risk from coming forward for appropriate counseling, testing and treatment, as if it involves disclosure of risky practices.

“If we try to explore the reason behind HIV-related stigma and discrimination, we find that it is largely due to fear. The fear arises out of misunderstanding about the modes of transmission of the infection, its relation to socially unacceptable behaviors, and the belief that HIV is a fatal disease. However, it is well known now that the infection has very specific modes of transmission and is not transmitted by casual contact as part of daily life. We must therefore improve our efforts to control stigma and discrimination against people living with HIV/AIDS in our schools, workplaces, health facilities and throughout the community. Stigmatization and discrimination against people living with HIV/AIDS are against our religious, humanity, and are major barriers preventing them from obtaining the care they need².”

The purpose of this paper is to explore the HIV/AIDS problem in Arabic countries and discuss the Health Status of Muslim Women with HIV/AIDS, also to focus on the stigmatization and discrimination against people living with HIV/AIDS.

SITUATION OF AIDS IN ARAB COUNTRIES

According to UNDP analyst and HIV/AIDS Program Coordinator Ali Salman Saleh, the number of HIV/AIDS cases reported in Arab countries has increased by 300% during the past three years (2003-2006). U.N. resident representative Sayed Aqa said that there are more than one million people living with HIV/AIDS in the region, and 47,000 deaths from AIDS-related illnesses were reported last year in the region. Saleh said that the "staggering rate of increase is mainly due to factors like ignorance, lack of awareness, denial and misinterpretation of facts.

Sudan (more than half a million HIV infections), Djibouti and Somalia are the most affected countries in the Region.  

In recent years, the overall proportion of HIV-positive women has steadily increased. In 1987, women accounted for 11% of the total number of people living with HIV. Today this percentage has increased to 40% ¹.

Statistical evidence indicates that the percentage of women among people living with HIV/AIDS is lower in the Middle East and north Africa (lower than 25%) than in other regions (for example, 57% in sub-Saharan Africa)⁵ Table 1.

STIGMATIZATION AND DISCRIMINATION

Stigma and discrimination are burdens faced by people infected with HIV, in addition to the agony of the sickness itself. The right to education, to access to health care, to work, to freedom of mobility and travel, to dignified living and to equity are often denied to men, women and children who have been infected with HIV. Divorce, humiliation, exclusion from families and communities, unemployment or exclusion from school, homelessness, poverty and sickness are all consequences of stigma and discrimination for people who have been infected with HIV, as well as those related to them or taking care of them⁶. Stigma and discrimination are caused mainly by fear of the disease and lack of knowledge and misconception about the modes of transmission of HIV.

The information regarding the HIV transmission is well-known⁷.

Alleviating stigma and discrimination against people living with HIV/AIDS and those affected by it is not only crucial for their well-being, but is also a practical measure to ensure the success of all the efforts to fight the epidemic. By reassuring people that they will not lose their basic human rights because of HIV/AIDS and we can encourage them to voluntarily learn and disclose their sero-status, and consequently, seek the proper treatment and take adequate action to prevent further transmission^{7, 8, 9} .

“I’m positive was the shame I had brought on my family. I, therefore decided to keep this information to myself, after all it wouldn’t be long till I die”.

                                                   (An AIDS women from Arab. World AIDS Campagaign 2004)

4. Stigma, discrimination and human rights violations against women with AIDS

Women are often blamed for bringing HIV into the family and may be subjected to violence by their spouse or in-laws.

A study of AIDS-related discrimination in Asia found that over 50 percent of women had lost their jobs since being diagnosed as HIV positive, compared with 14.6 percent of men, while 22 percent of HIV positive women had been forced to change their place of residence, compared with 6 percent of men^{10, 11}.

HIV positive women in Arabic countries are often subject to degrading and discriminatory treatment, causing blame, isolation and shame, and leading to restricted freedom of choice⁸. Gender inequalities can lead to the abuse of women’s sexual and reproductive rights, while also undermining their legal, economic and political rights. Women’s unequal social, economic, and legal status is increased by a positive HIV status, and vice versa. Violations of reproductive rights faced by HIV positive women include not being allowed the freedom to decide to have children or not to have children, or to decide on the number and spacing of children. In many countries, women with HIV/AIDS are also excluded from inheriting property, evicted from land and homes by in-laws, stripped of possessions, or subject to widow inheritance in order to retain the access to their property^{12, 13}.

Women and girls living with HIV/AIDS must have access to the antiretroviral medicines that will save their lives, the World Health Organization (WHO) said in a statement released on World AIDS Day, 1 December 2006, WHO is calling on countries to set specific national targets for treatment of women and girls and to take measures to ensure equitable access to AIDS prevention and treatment services.

WHO is also highlighting the need to address violence against women and girls as an integral part of the response to the AIDS pandemic.

"Violence against women can not be tolerated at any level," said Dr Peter Piot, UNAIDS Executive Director. "The fear of violence prevents many women from accessing HIV information, from getting testing and seeking treatment. If we want to get ahead of the epidemic we must put women at the heart of the AIDS response."

"If we are to succeed in addressing two of the most critical public health problems facing us today - violence against women and the AIDS pandemic - it is also essential to challenge social norms which condone and even promote violence against women. This includes male behaviors which put themselves, their partners and children at risk of HIV infection," said Joy Phumaphi, Assistant Director-General of Family and Community Health.

It is crucial that HIV positive women are supported to make their own reproductive choices about whether and/or when to have children, free from discrimination, coercion and violence. To support HIV positive women in considering their reproductive choices, accurate, impartial and accessible information is required on issues such as: effective contraceptive methods to prevent pregnancy, including recommending dual protection; the effects that HIV will have on a woman’s health as the disease progresses, along with the implications this may have for planning a family; the low risk of transmitting HIV to an uninfected partner while trying to become pregnant; the low risk of mother-to-child transmission in cases where appropriate advice and resources are available; and the possible increase in adverse pregnancy outcomes as a result of being HIV positive (UNFPA/WHO 2006).

Where women are blamed, this can lead to heightened levels of sexual and domestic violence; abandonment by families and communities; forced abortion or sterilization; dismissal from employment; and loss of livelihood opportunities. This kind of extreme discrimination, especially when combined with heavy domestic responsibilities and restrictions on access to resources, presents a powerful barrier to positive women seeking care, treatment and support for HIV and AIDS – or even to getting tested in the first place^{5, 6}.

The social stigma attached to HIV/AIDS that exists in all societies is much more pronounced in Arab cultures due to the religious doctrine regarding illicit sex and drug related practices. There are greater negative sanctions for illicit sexual conduct than drug use. Even if there is a suspicion of illicit sexual conduct, the affected person(s) is discriminated against and shunned by the family as well as by the community. The stigma attached to risk behaviors thus prevents those at risk from coming forward for appropriate counseling, testing and treatment, as this would involve disclosure of their risky practices. This results in creating barriers to successful implementation of prevention and treatment strategies where they do exist.

"This stigma is largely out of fear. And this fear arises out of misunderstanding about the mode of transmission of the infection, its relation to socially unacceptable behaviors and the belief that HIV is a fatal disease" said Hussein Al- Gezairy Regional Director of WHO Eastern Mediterranean Region office.

The fear of violence prevents many women with HIV/AIDS from accessing HIV information, from getting testing and seeking treatment, which may also be observed in nonmuslim society.

Violence against women and girls with HIV/AIDS in its different forms increases women's vulnerability to HIV infection and undermines AIDS control efforts. For millions of women with HIV/AIDS, violence and the fear of violence is a daily reality and increasingly, so is AIDS. Women with HIV/AIDS in every culture around the world face violence, most often at the hands of their partners and within the so-called safety of their homes and families.

This includes male behaviors which put themselves, their partners and children at risk of HIV infection," said Joy Phumaphi, Assistant Director, General of Family and Community Health.

IGNORANCE/ MISINFORMATION

In developed countries, a majority of the population is aware of the modes of transmission for HIV infection, whereas in the developing and Arab countries, misconceptions about the disease and its causes are rampant. Most persons residing in Arab countries assume that all HIV infections are transmitted only through immoral sexual behaviors and are unaware that it can also be transmitted inadvertently through mother-to-child, accidental pricking of skin and contact with contaminated blood (as in the case of health care professionals) or the possibility of an innocent spouse getting infected by the husband who may have acquired HIV though sexual or drug related contact with other infected persons. Therefore, due to lack of education, expression of compassion towards HIV/AIDS patients is perceived as tolerance towards the practices that lead to acquiring the infection¹⁴.

CHALLENGES

The issue of HIV/AIDS prevention in Arab countries is a complex problem and requires a multifaceted approach with particular attention to cultural norms. In order to devise harm reduction strategies for HIV prevention in these countries, it is important to study the social dynamics and practices of the populations at risk. Analysis of the cultural context in which risk behaviors occur provides meaningful insight into those factors that shape and define the external reality within which these behaviors take place. Knowledge of why people behave in certain ways and the resources available to them becomes helpful in assisting them to access and utilize available preventive and therapeutic resources. In the context of high-risk groups, it is important to understand that even within them, some individuals choose to indulge in risk behaviors while others do not¹⁵.

Table 1. Reported AIDS cases in Arab countries by the end of 2006.

¹Saudis constitute 2,316 out of 10000, while the rest (7,805) are foreigners. (Shahid Ali Khan: AIDS Cases on Rise in Saudi Arabia Monday, 08 January 2007, the Saudi Gazette RIYADH.

Note: An estimated 35,000 [16,000-65,000] people in the region acquired HIV in 2007. An estimated of 25,000 [20,000-34,000] people died of AIDS-related illnesses in 2007.

 Sources: 1. UNAIDS/WHO AIDS Epidemic Update: December 2007 - Mon, 17 Dec 2007.

               2. Global AIDS epidemic 2006. A UNAIDS 10th Anniversary special edition.Geneva, UNAIDS, 2006.

SUMMARY

In summary, stigma, discrimination and violence are the main causes for women health ignorance, which is due to the fear of AIDS infection resulting from the misunderstanding of the disease itself. There is a great deal of evidence to establish the significant link between gender-based violence and rising rates of HIV infection among women and girls throughout the world. In order to mitigate the epidemic among females, we must dedicate resources to the development, testing, and implementation of effective behavioral, biomedical, and social interventions that address violence as both a cause and a consequence of HIV infection.

Stigma and discrimination may also prevent patients from carrying out normal life activities.

 Women’s vulnerability to infection with HIV/AIDS is primarily due to inadequate knowledge about the disease, their insufficient access to HIV prevention services, and a lack of female-controlled HIV prevention methods, such as microbicides. Women make up a large proportion of people living with HIV/AIDS in need of care, treatment and support. 

MESSAGES AND RECOMMENDATIONS FOR ACTION TO DECISION-MAKERS

1. Fight stigma and discrimination towards women living with HIV/AIDS whenever you observe it, in an appropriate way.
2. Be convinced that it is your responsibility, ethically and religiously, to provide HIV-infected people with the support they need, no matter how the infection was transmitted to them.
3. Deal with HIV/AIDS patients in the same compassionate way you deal with all other patients. Do not allow discriminatory ideas to interfere with that compassion.
4. Try to gain the confidence of people with HIV, and allow time for sufficient counseling.
5. Supporting women’s rights to care, treatment and support.
6. Promote male involvement in sexual and reproductive health programmes.
7. Protecting women’s livelihood opportunities.
8. Promoting the meaningful involvement of women and girls living with HIV and AIDS.
9. Comprehensive sexuality education that promotes sexual and reproductive rights, gender equality and skills development, as well as full and accurate information, for all children and youth in and out of school.
10. Strengthen HIV/AIDS Programs: Protect all women’s health and rights through HIV/AIDS programs.
11. Provide support for women’s economic empowerment in order to reduce their dependency.

REFERENCES

1.   Women and girls need access to AIDS treatment and protection from violence.Overview of the Global AIDS Epidemic 2006. Report on the Global AIDS Epidemic.

2.   Hussein A. Gezairy. Regional Director WHO Eastern Mediterranean Region on the occasion of WORLD AIDS DAY, 1 December 2006

3.   Message from Dr Hussein A. Gezairy. WHO Regional Director for the Eastern Mediterranean. World AIDS Day 1 December 2006

4.   Message from Dr Hussein A. Gezairy WHO Regional Director for the Eastern Mediterranean World AIDS Day 1 December 2005.

5.    The Global Coalition on Women and AIDS (GCWA) and ICW (2006a) Violence against HIV positive women, ICW fact sheet.

6.   The Joint United Nations Programme on HIV/AIDS (UNAIDS) (2004) Violence against Women and AIDS

7.   Falah, A. M. Salih: HIV/AIDS/STD and Healthy Sex Education. National Conference on Sex Education. 10^th - 11^th  Feb, 2007. IIUM, KL, Malaysia.

8.   Falah, A.M. Salih: AIDS In Arabian Countries: 1^st International Conference on HIV Infection, Tuberculosis and Respiratory Disease. (India) 8-10 Jan. 1994.

9.   Fournier AM, Carmichael C: Socioeconomic influences on the transmission of human immunodeficiency virus infection: the hidden risk. Arch Fam Med 1998, 7(3):214-217. [PubMed Abstract]

10.  Women and Girls living with HIV/AIDS: Overview and Annotated Bibliography. Report prepared at the request of Irish Aid by BRIDGE in collaboration with the International Community of Women Living with HIV and AIDS (ICW). By Emily Esplen February 2007.

11.  WOMEN SEXUAL VIOLENCE AND HIV. An amfAR Symposium Rio de Janeiro, Brazil July 25, 2005. The Foundation for AIDS Research.

12.  AIDS Care 2005, 17(7):892-901. [PubMed Abstract]. UNESCO: A Cultural Approach to HIV/AIDS Prevention and Care. Summary of Country Assessments. An International overview.

13.  In UNESCO/UNAIDS Research Project. Studies and Reports, Special Series. Division of Cultural Policies, UNESCO; 2002.

14.  BMJ 2006; 333:851-854 (21 October), doi:10.1136/bmj.38994.400370.7C Analysis and comment. HIV in the Middle East Carla Makhlouf Obermeyer, Department of HIV/AIDS, World Health Organization, Geneva, 1211, Switzerland.

15.  AIDS, the Hidden Crisis In Arab, Islamic Countries By Mustafa Abdel-Halim, IOL Staff CAIRO, December 1 2006   (IslamOnline.net). 

Correspondence
Falah A.M Salih,

Assistant Professor,

Faculty of Medicine,

International Islamic University Malaysia,  

P. O. Box 141,

25710 Kuantan, Pahang,

Malaysia

H/P:  +60-129541145,

E-Mail:  falah_salih@yahoo.com