Some years ago I met a woman in Uganda who had decided, when her husband died of AIDS, that she didn't want to marry his brother and surrender her children, her property and herself to his control, as most other women in her situation had done. Instead she went to court to fight for her freedom and her right to raise her children herself.
When a girl does get a chance at an education….and access to reproductive health care and information, she can control the number and timing of her children to become a stronger wage earner and social actor, transforming her family and community in the process.
She won, and her story made nationwide news. That opened my eyes to the heavy burden women carry in male-dominated cultures, especially now that HIV/AIDS is pandemic. What made that woman react differently than other widows? What gave her the strength to oppose prevailing social norms? And how can we change those norms so that court action won't be necessary?
Among the field troops in the battle against HIV/AIDS, I am unusual as neither a doctor, a nurse, nor a community organizer, but as a psychologist. Since graduate school, what has fascinated me is the way we think about our bodies and those of others, and how those notions affect our health decisions. In the early 1980s, when I first got involved in trying to prevent HIV, there was no treatment and no cure, and I was startled to see that the greatest burden of the disease was – and is – on women.
Why, for example, are women in so many places blamed and shamed for bringing HIV into a home when studies show that most high-risk behavior is by the men in their lives? What can we do about the stigma of being HIV-positive, which is so pervasive that it stops people from even being tested, much less seeking treatment? And how should we counsel women living with HIV about their prospects for a healthy sexual and reproductive future?
On that same trip to Uganda, I met a nurse from a poor family whose father had chosen to send her to school instead of her brother. When the father's friends condemned this very non-traditional decision, he told them his daughter was smarter and more reliable than his son – and would therefore take better care of her aging parents. That taught me how much the lives of most women in the developing world depend on men's choices, and that those choices arise from complex motives.
Millions of young girls come second to their brothers in their chances and options in life – for food, health care, education or employment. When a girl does get a chance at an education, like that nurse, and access to reproductive health care and information, she can control the number and timing of her children to become a stronger wage earner and social actor, transforming her family and community in the process. This seemed so clear to me that it has motivated my work ever since.
My grandparents came to Chicago from Ireland as indentured servants at the turn of the 20th century and had to fight against poverty and anti-Irish prejudice all their lives. My mother's chief regret was that she went to secretarial school rather than university in response to her mother's insistence that she needed a marketable skill. She was fierce in telling me and my three siblings that education was our one ticket to a good life – that, and relentless pushing for what we knew was right.
At the Center for AIDS Prevention Studies that I co-founded at the University of California in San Francisco in 1986, and later at the AIDS Research Institute there and now at the Center for World Health at UCLA, my colleagues and have I worked to link reproductive health care to HIV prevention because it is the right thing to do. When a pregnant woman comes to an antenatal care clinic and is found to have HIV, she is too often scolded and punished, ordered to stop having sex or wanting children. This moralism has no place in health care, especially now that available medications mean the woman does not have to infect her baby and has a good chance of living to dance at that baby's wedding.
Funding for programs and equipment to broaden the reach of such medications is essential to erasing the stigma of HIV/AIDS, encouraging people to learn their HIV status and make responsible choices about their behavior as they enter and maintain treatment. Through such programs, testing is slowly becoming a routine part of prenatal care for women and health care for everyone, the first step toward patient-centered services that can make the disease a kind of manageable chronic condition rather than a death sentence.
Reactionary forces opposed to equal treatment for girls, women, and men who have sex with men are losing ground. But we must continue to advocate for inclusive and rational policies of diagnosis, care and treatment. The battle against AIDS is not a sprint to the finish line but a marathon race.
Thomas J. Coates, PhD, is the Director of the UCLA Center for World Health, and is the Michael and Sue Steinberg Endowed Professor of Global AIDS Research within the Division of Infectious Diseases at UCLA.