Treatment Issues for Women
|
SOURCE |
GENDER |
AFRICAN |
COLOURED |
INDIAN |
WHITE |
|
Wage/Salary |
Women |
R 1188 |
R 1170 |
R 2106 |
R 2955 |
|
Men |
R 1479 |
R 1558 |
R 2986 |
R 5578 |
|
|
Income |
Women |
R 1831 |
R 1831 |
R 5026 |
R 7036 |
|
Men |
R 4310 |
R 6005 |
R 11802 |
R20270 |
Source: Hurt and Budlender:
This table reflects disparities in wages on the basis of both race and gender.
TABLE 2: Unemployment Rates by gender 1994 - 1997
|
GENDER |
1994 |
1995 |
1996 |
1997 |
|
Women |
24% |
20% |
25% |
28% |
|
Men |
17% |
14% |
17% |
19% |
Source: Budlender:
2.2 Feminisation of Poverty
Statistics show that 70% of the world’s poor are women. The New Internationalist highlighted a study which focused on poverty over a 20 year period, [1970 – 1990], noted that the number of rural women living in poverty had increased by 50%, reaching 565 million, while poverty in men showed a 30% increase to 400 million. There is no indication that this trend has decreased in the past 10 years.
Women are more likely to be poor and malnourished and are less likely to have access to services [health, sanitation, clean water, education] and formal sector employment [Todaro 2000]. Female-headed households in South Africa are generally poorer than male headed households. In 1995 the average annual income of households headed by men was R48 000-00 compared to only R25 000-00 for women-headed households. [Hurt and Budlender 1998]
Even when women have access to income and assets [including land, equipment, employment, knowledge and skills] these are often controlled by men and women are less able to get out of the poverty trap [May 2000].
2.3 Gender based violence
Violence [domestic abuse, rape] is experienced by many women and girls and is often overlooked as a health issue. Violence against women and girls leads to serious injuries, mental health problems, disabilities and in some cases death. Violence is linked to HIV in two ways.
HIV as a consequence of rape and sexual abuse - women and children may become infected as a result of being raped or sexually abused. Women who are raped have no access to post-exposure prophylaxis and live with the fear of possible sero-conversion.
HIV as a cause of violence – often when women disclose their HIV status to their partner, or they are so sick that they are unable to look after children they are often beaten. Even the fear of violence may prevent women from insisting on safer sex practices or disclosing to partners and families.
3. Gender inequalities in health
Gender inequality impacts on every aspect of health and illness. This includes differences in:-
vulnerability to illness and disease,
prevention,
the response of the individual to their symptoms,
organisation and delivery of health care,
the politics of diagnosis,
questions asked by clinical researchers,
the knowledge and understanding of disease and treatment
[Lorber 1997].
For example, women are more vulnerable to HIV infection than men, partly due to physiology but also due to their often limited ability to protect themselves from infection. This is heightened by a lack of women controlled barrier mechanisms and the socially constructed "rules" of heterosexual sex, where men have the power to decide when, where and how sex takes place. Much of the care that women receive is linked to their reproductive role. Likewise, much of the research into women and AIDS is focused on the prevention of mother to child transmission. We know relatively little about HIV/AIDS in women, even less so in developing countries and this obviously impacts on treatment issues. [Patton, 1994, Johnson, 2000, Bass 1999. MacNeil, 1999]
3.1 Social construct of health
Disease and illnesses are not neutral and are also products of socialisation. The transformation of symptoms into a "label" is often influenced by societal beliefs, for example, HIV/AIDS emerged as a disease of stigma and discrimination, and one of intense moral judgments.
Gender has a major impact on how women and men are treated – including in health and illness [Lorber 1997]. This has been demonstrated in the way women have been viewed in relation to HIV/AIDS. The focus has been on women as responsible for the spread of HIV – either to their partner and child/ren. For example, sex workers were [and still are] stigmatized and blamed for bringing HIV into the "general population". Similarly, no mention is made of the father when talking about mother – to child transmission. Fortuin [1995] notes that in general, "women are continuously blamed and victimised for the illness of their children, partners and parents" p25
3.2 Gender bias in medical research
Medical research is a profoundly gendered activity. It is most often determined from a male perspective. This includes what topics are chosen, what methods are used (what data is collected) and how the data is analysed. Common problems experienced by women receive little attention if they are not seen as part of women’s reproductive role. For example, tropical diseases are a major cause of disability and death in sub-Saharan Africa and biological factors vary between the sexes and influence susceptibility and immunity. [Garcia-Moreno 1999]. Gender roles influence the degree of exposure and also the access and control of resources needed to protect women and men from infection. Research highlighting gender differences have focused on "women’s reproductive lives, assessing the effects of tropical diseases on fertility and pregnancy outcomes" [Manderson 1993 in Garcia-Moreno]
If the same disease affects both men and women many researchers have ignored possible differences in diagnostic indicators, in symptoms, in prognosis and in the relative effectiveness of different treatments. [Garcia- Moreno 1999, Doyal 1994, Foster 1995]
Women’s exclusion in research is justified on the grounds that cyclical hormonal changes make it difficult to interpret results and/or the fact that women may become pregnant and put the fetus at risk. Yet, "results obtained from research on predominately male subjects are applied with little question to [potentially] pregnant women patients" [De Bruin 1994 in Garcia-Moreno 1999]
Women are treated on the basis of information gathered from research:
On drugs that have not been tested on women’s bodies,
In diseases which may not have been studied in women, and,
In which women’s experience of illness and treatment is not adequately explored
Research that takes gender into account has to consider;
biological differences,
The differences between women and men’s roles and responsibility, For example, a bilharzia study showed that while the rate in males drops around 15 years the case is not the same for women. This is due to the fact that women are mainly responsible for water related activities and such duties require constant exposure.
their experience and knowledge about illness and disease,
their position in society,
their access to and use of resources and
The social codes governing women and men’s behaviour.
3.3 Access to care
On a global scale, in both a developed and developing context, there is a lack of attention of health issues for women who are poor. Studies carried out on households in various countries show that less is spent on health care for women and girls. This, according to Garcia – Moreno [1999] reflects women’s lower social status and lack of decision making power. In many instances, finances are controlled by men and what money women do spend is usually spent on their children. Female headed-households spend more income on the nutritional needs of the household’s members. [Posel 1997]. According to May [in Posel 1997] if consumption patterns in male headed-households were to mirror those in women headed households, the incidence of under-nutrition in South Africa would fall by 12%.
Men and women often show different patterns of health seeking behaviour. In developed countries women tend to consult health care professionals more than men. This trend is reversed in some developing countries. [Garcia-Moreno 1999]. For example, large numbers of men in malaria clinics in many countries led to the assumption that males were more at risk. Research in Thailand showed that rates of exposure were similar in men women and children and that variances were due to differences in health seeking behaviour.
Women are more likely to put the health care needs of others, such as a partner or children before their own needs. [Garcia – Moreno 1999, Koblinsky, Timyan and Gay 1991]. The health seeking behaviour of women is mainly based on their reproductive role [either as a pregnant woman or as a mother with a sick child] – and is usually what brings women into the health care arena [Garcia-Morena 1999, Koblinsky, Timyan and Gay 1991]
while a mother is quick to identify and respond to symptoms of illness and disability in others, she appears less assiduous in monitoring her own health. Her role in caring for others appears to blunt her sensitivity to her own needs. Being ill makes it difficult for individuals to maintain their normal roles and responsibilities: since mother’s roles and responsibilities are particularly indispensable, mothers are reluctant to be ill. [Graham in Miles 1991].
Other factors that impact on women’s health seeking behaviour include time, mobility, access to funds/resources, fear of health care providers / facilities and other social constraints which discourage women from attending health care facilities. [Koblinsky, Timyan and Gay 1991].
Fortuin [1995] noted that women in the South African context face unique difficulties and are dis-empowered by a lack of assertiveness skills. This creates a barrier for women to act on health information even if access is guaranteed. Women continue to feel unconfident, unassertive and intimidated by health officials. Access to health is affected by finances, language spoke at clinics, hours of operation and the attitudes of health care workers.
Garcia – Moreno [1999] notes that ingrained in many women is the fact that "suffering is her lot". Health problems, for example, a vaginal discharge, may be so widespread among women that it is accepted as normal and that women have "no expectation that things could be different" [p24]
The focus on reproductive health of women has implications for access to health in the following ways:
Young women, menopausal and postmenopausal women and women who decide not to have children are denied access to adequate and appropriate health care during important periods in life
Women of childbearing age have not found it easy to obtain health care for non-reproductive health, due to a focus on reproduction health especially in research and programmes [Koblinsky, Timyan and Gay 1991]
3.4 Quality of care
Gender dimensions of health can be causal factors in limiting the quality of care women receive. The quality of care received is often dependent on the power dynamic between the health care provider and patient/client. In the western medical model, which is, in many communities the dominant model, most doctors and health care establishment managers are men and most nurses are women. There is a definite hierarchy that is rigid – medicine is a privileged profession which gives health care workers, especially doctors, great authority, prestige and high incomes. Doctors dominate the flow of health care services. Trained in the biomedical model, they are taught to listen to symptoms or test results and not to the patient or client.
Women’s subjective experiences of medical encounters include sexism of doctors, and biases inherent in the institution of medicine make experiences demeaning for women. This does not necessarily improve much with nurses.
|
AFRICAN |
COLOURED |
INDIAN |
WHITE |
|
31% |
8% |
4% |
11% |
Source. Hurt and Budlender
Treatment knowledge is limited since few young women or young men have participated in clinical trials. At present, opportunistic infection treatment for post-pubertal adolescents follows clinical guidelines for adults. As pubertal / hormonal changes may affect medications, dosage is based on the Tanner staging rather than age.
TABLE 4: Dosage according to Tanner Stages
|
TANNER STAGE |
STAGE OF DEVELOPMENT |
DOSAGE |
|
Tanner Stage I / II |
Early puberty |
Pediatric dosing |
|
Tanner Stage III / IV |
Mid-puberty |
Dependent on whether growth spurt is complete or not |
|
Tanner Stage V |
Completed puberty |
Adult dosage |
Source: Anderson 2000
3.2 Lesbian women
Women to women transmission appears to be a rare occurrence, however there are lesbians living with HIV. Statistics from the US as at the end of 1998 showed that of the 109 311 women living with HIV, 2 220 women identified as lesbian or bisexual. Data from South Africa of lesbians living with HIV is non-existent – and women with HIV/AIDS are assumed to be heterosexual. At the session on lesbians and AIDS at the "Listen, Learn and Live to Break the Silence – 2nd National conference of People living with HIV/AIDS, held in March 2000, which was attended by 30 women, the issue of the invisibility of lesbians was highlighted and the challenges this poses, discussed.
Heterosexual, bisexual and lesbian women share many of the same health concerns and issues. Lesbian women often have little information about their health needs, which may include:
Need for information and screening for cervical and breast cancer
Treatment for STI’s
Mental care issues
Substance use
Domestic violence
Lesbian pregnancy
The treatment needs for lesbian and bisexual women living with HIV/AIDS need to be researched. Health care providers must begin to provide appropriate, informed health care in a non-judgmental or non-discriminatory way.
4. Some Treatment Issues
There are three basic purposes for treatments available for people living with HIV:
Treatments used to prevent opportunistic infections [prophylaxis] and drugs to treat opportunistic infections
Treatments used against the virus itself [anti-retrovirals]
Treatments used to relieve or eliminate symptoms associated with HIV disease and the side effects of other treatments
[Australian Federation of AIDS Organisation / NAPWA – Australia 1999]
There are differences between men and women in the course of the disease, which are reflected in differences in viral load and opportunistic infections. The implications this has for treatments will be discussed below.
4.1.Differences in Viral load, CD4 count and disease progression
"In the field of AIDS we still have only hints about differences in dosing, clues of metabolic differences and suggestions of what viral load levels could mean in terms of HIV progression in women" [MacNeil p4 1999]
HIV positive women may have a higher risk of progressing to AIDS than men with the same viral load [MacNeil 1999]. This finding was based on a study of drug injecting women and men but may or may not be applicable to non-injecting women. This means that women living with HIV who inject drugs can develop AIDS with less virus than positive men who inject drugs. Based on the results of the study questions were raised about whether the initiation of anti HIV therapy at a lower viral threshold may be justified. The study recommended that viral load should be considered to be a gender variable [Michelle 1998].
In January 2000 a meeting of scientists and treatment activists was held in the United States, to discuss and debate the issue of gender differences in treatment. The following points, based on research to date were highlighted:
Women may have lower viral levels than men in early HIV disease [in the first five years of infection]
Differences may not persist over time – the cause and significance of the differences remains unclear
No changes have been recommended for the use of anti-HIV therapy among women
Racial and ethnicity differences in viral load may be equally important to gender differences and should be explored
[Project Inform: Perspective No 30 August 2000]
4.2 Combination therapies and anti-retrovirals
The decision to begin combination therapy is made on the following:
Viral load
Damage done to immune system [CD4+ count]
Ability to keep up the treatments on a regular basis for life
The response of women to drug therapies is the area where most information is needed. There are too few women enrolled in clinical trails to determine whether or not there are differences between men and women. What is known is that women metabolise the drugs at a more rapid rate. [Currier and Johnson 1997]. In 1995 a Dutch study showed that AZT released 42% slower in a woman’s blood. This impacts on the correct drug dosage that is needed to suppress HIV in women. Dr Katheryn Anastos, principal investigator from the Women’s Interagency Health Study [WIHS] states". drugs are working, which is extremely important and saving lives but we may be blasting women with higher doses than we need to" [Gender –AIDS 468 1999]
According to Project Inform [1999] the differences in viral loads between men and women make interpreting guidelines for the onset of antiretroviral therapy difficult. For example, a women with a CD4+ count of 475 and a viral load of 6000 copies/ml is roughly at the same risk of disease progression as a man with a similar CD4+count but with a viral load of 10 000 copies/ml. Guidelines would suggest that the man consider anti-HIV therapy but that the women wait until her viral load is greater, even though she is at the same risk of disease progression as the man is.
The AT LAST study [Anti-retroviral Therapy Looking at Sex and Treatment] is underway in various cities in the USA. The study will evaluate the differences between men and women by examining the impact of a treatment regimen on hormones, menstrual cycles and the impact of hormone levels on the risk of developing metabolic changes.
An issue relevant for women is the impact of anti-retroviral treatment on pregnancy. At present the guidelines for optimal anti-retroviral therapy in pregnancy are the same as those for non-pregnant adults. Anderson [2000].
More research is needed to determine the effects of the long term of anti-retroviral treatment on the fetus. In conclusion, present knowledge would suggest that the drugs are equally effective in women and in men. However, drugs may be more toxic in women. Women tend to show more side effects or have more severe side effects than men do. For example, women are more likely to develop a severe rash as a side effect of Nevirapine than men are. Drug levels in the blood are higher in women.
It is obvious that more information is needed to understand both the difference in viral load in men and women and what this difference actually means.
[Project Inform 1999, Project Inform 2000].
Some critical research Issues for the future include:-
|
Adverse outcome |
Relationship to HIV infection |
|
Spontaneous abortion |
Limited data but evidence of possible increased risk |
|
Perinatal mortality |
No association in developed countries, but data is limited |
|
Pre-term delivery |
Evidence of possible increased risk, especially with more advanced disease. |
|
Fetal malformation |
No evidence of increased risk |
Source: Anderson 2000
Pregnancy is associated with various conditions that may have specific treatment implications for women living with HIV:
increased yeast infections
bacterial vaginosis
primary HSV infection during pregnancy associated with spontaneous abortion and pre-maturity
Furthermore, common opportunistic infections in women living with HIV may impact on the pregnancy:
Genital warts
Syphilis
4.3.5 Emotional / psychological issues
As discussed previously the World Health Organisation definition of health includes mental health as an important component of well being. Discussing treatment issues that affect women should also extend to psychological and emotional health. The management of HIV/AIDS requires a holistic response where the mental health is as important as the physical health. It has been well documented that mental illness can impact negatively on physical health and physical illness can in turn impact on mental health.
Mental illness can take many forms and can often be successfully treated. Stress and trauma often bring on mental illness. These are some of the realities of living with HIV/AIDS. The South African response to HIV/AIDS has focused on the training of health care workers, usually nurses as counsellors to do pre, post test and ongoing counselling. Often counselors and doctors are not sufficiently trained to recognise mental illness and it may be necessary to get treatment from a social worker, psychologist or psychiatrist. For the purpose of this paper the most common mental problem in women living with HIV/AIDS, depression, is discussed.
Depression