"Access for All," the theme of next month's International AIDS Conference in Bangkok, sets an appropriately high standard for the world's response to the pandemic. Unfortunately, all too many prevention and treatment programs fail to address the needs of most of those living with the virus, especially in Africa: women and girls. It's time to design programs targeted to the risks that women and girls face in a world of AIDS.
Most prevention messages, and certainly those favored by the Bush administration, focus on the "ABC" approach to fighting HIV-AIDS: abstinence, be faithful, and use condoms. While important messages, these things are often not within women's power to control. It is urgent that we develop a "DEF" approach that responds to needs repeatedly expressed by women living with HIV-AIDS and by AIDS activists in Africa.
The need to go beyond "ABC" grows out of the stark statistics. Sixty percent of those living with HIV in sub-Saharan Africa are women and girls. Girls between the ages of 15 and 19 are infected at rates as much as five times higher than boys their age. This disproportionate impact is linked to social and economic factors that severely undermine women's control over their sexual lives. In a climate where sexual abuse and exploitation of women and girls are widespread and usually goes unreported, how can they practice abstinence? When married women, many of whom were child brides, have been faithful to the husbands who are infecting them, how do messages about monogamy help them protect themselves? When girls are pulled out of school to take care of sick relatives and are denied opportunities to gain skills that would break their economic dependency, how can they avoid survival or transactional sex and negotiate condom use?
I asked a leading Ugandan AIDS activist about the lessons of the "ABC" campaign in his country. He replied that "ABC" is insufficient without "D," for "disclosure," which incorporates the importance of knowing your HIV status, changing your behavior appropriately and living positively. Yet women living with HIV-AIDS risk violence or abandonment in disclosing their status and are often blamed for bringing the virus into the household, even when their partners infected them. To address those realities, "D" should be "disclosure in safety," to help women disclose their status with appropriate social and economic support structures, including legal recourse in cases of violence. Training police and law enforcement officials on the links between gender-based violence and HIV-AIDS establishing safe shelters and referral services for women and girls, and providing support to women living with HIV-AIDS are examples of programs that would help women to disclose safely.
Throughout the hardest-hit countries in Africa, as well as in many other parts of the world, women's vulnerability to infection is linked to their lack of access to education -- "E" -- which worsens their economic exploitation. Dealing with this requires going beyond the rhetoric of expanding educational opportunities for girls: It means appropriate curricula on HIV-AIDS in schools, scholarships and skills training for women and girls from AIDS-affected communities, and keeping schools safe for girls, because they are too often at risk of HIV infection from teachers and fellow students who prey upon them with impunity.
In the absence of a vaccine, one of the most critical tools for women to protect themselves from infection requires female-controlled prevention methods, "F," especially microbicides and female condoms. The high HIV rates in young women underscore the need to find safe and effective ways for women to gain access to prevention technology that they can control, that they don't have to negotiate. This calls for increased funding for microbicides research, wider distribution of female condoms and the integration of HIV services into reproductive health and family planning clinics.
"HIV is everybody's disease," a young HIV-positive woman in South Africa told me last month. "Access for All" is the right response to her grim reminder. The international AIDS conference must propel concerted and targeted actions to counter the current inequality of access for women and girls, or its failure will be measured in millions more lives.
The writer is an adviser to the Global Coalition on Women and AIDS, an initiative of UNAIDS, and chairs the gender committee of the Center for Strategic and International Studies HIV/AIDS Task Force.