Women are now on the front line, so our strategy for fighting Aids must change

Aids is becoming a female epidemic. That is the most striking conclusion from the the latest biennial report from UNAids. Yet while the epidemiology of the disease is changing, the international community persists with a strategy that is outdated, misdirected and failing to help those at greatest risk.

Aids is becoming a female epidemic. That is the most striking conclusion from the the latest biennial report from UNAids. Yet while the epidemiology of the disease is changing, the international community persists with a strategy that is outdated, misdirected and failing to help those at greatest risk.

For most of its 20-plus year history, the worst disease of modern times has affected men more than women. It was first recognised among the white, middle-class gay patrons of the bathhouses of San Francisco. Even a decade ago, in sub-Saharan Africa, the disease was dominated by men, who had left their homes and families in rural areas for jobs in the towns where they found consolation with female sex workers.

But in recent years the virus has taken hold among women because of their greater biological and social vulnerability. In the act of sexual intercourse the virus transmits more readily from men to women, and the lower social position of women and their lack of power means they cannot negotiate to avoid sex or to protect themselves with condoms.

In 1997, women accounted for 41 per cent of people living with HIV. By 2002, this figure was almost 50 per cent and rising. In sub-Saharan Africa it is up to 57 per cent and among young women and girls it is 75 per cent. In South Africa, teenage girls are five times more likely to be infected with HIV than men, principally because their first sexual experience tends to be with an older man who is often already infected himself.

What is the appropriate response to this trend? The key element of the Aids prevention campaign remains the ABC strategy - Abstain, Be faithful or use a Condom. Yet, as Peter Piot, executive director of UNAids, admitted yesterday, this is irrelevant to most women.

Abstaining from sex is not an option for most women, and violence may be the result for those who try. Using a condom in marriage is difficult in any culture and even in long-term relationships may be taken as a sign of distrust. Fidelity applies to both partners, but it is often men who have sex with prostitutes or mistresses who then infect their wives.

For men, Aids is a distant threat. A disease that takes 10 years to kill hardly ranks against all other perils in countries where poverty and hunger are the norms. But for women, the disease shapes their lives. They care for the sick, worry about passing on the virus to their children and worry about who will care for them when they are gone. Older female siblings are pulled out of school to care for the family when the parents fall ill. In South Africa, more than half a million children have been orphaned by Aids and the number is projected to triple by 2010.

The Global Coalition on Women and Aids was launched last year and there have been arguments at national and international level over what direction the Aids prevention strategy should take. One view says efforts should be targeted at empowering women while another has it that only by getting men to change their behaviour will women be protected.

Yet women have the incentive to change - to protect their families - that men lack. Women attending antenatal clinics for HIV testing offer the ideal opportunity for intervention. They should have priority for treatment with anti-retroviral drugs so that their lives can be preserved long enough for them to rear their children who would otherwise be orphaned. If the help were focused on women, it would be more likely to be taken up and, through them, have the greatest chance of impacting on men.

More weight must be given to the arguments of the Global Coalition on Women and Aids and the global strategy needs to be re-oriented to protect and treat the female victims of the epidemic. Greater efforts are needed to protect their property and inheritance rights, to reduce violence against them and to improve their education. The feminisation of Aids demands a feminist political response.