Globally 20 million women and girls are HIV-positive. The 2004 World AIDS Campaign, with the strapline ‘Have you heard me today?,’ seeked to raise awareness about the many issues affecting women and girls around HIV/AIDS. We all know: They have a unique and valuable role to play, both in society and in fighting the disease. Women hold families and communities together and they are a source of great strength in the face of HIV/AIDS.

The AIDS epidemic in women is overwhelmingly heterosexual and almost entirely so in Africa and South and SE Asia. In other areas, a proportion of women are infected through: A) sex with a bisexual or drug injecting partner B) their own injecting drug use C) heterosexual sex without these factors or D) blood transfusion (in developing countries where blood is not routinely screened). Many women and girls are vulnerable to HIV because of the high-risk behavior of others.

The COM.PASSION project aims at children and women affected by HIV/AIDS because they represent the weakest parts of societies. For the 15th World AIDS Conference 2004 we held several meetings at Goethe Institute Bangkok – not only to discuss the situation, but to find solutions for a problem which is constantly growing. Every panelist agreed that unequal gender (social, economic, and power) relations are driving the epidemic.

The highly recomendable TV documentaries „AIDS – The Woman’s Story“ (produced by Irene van Ditshuyzen/NL) and „Mouth to Mouth“ (directed by Ian White/AUS) were screened to underline the facts: Women are not only highly vulnerable to the infection. Moreover they bear the psychosocial/physical burden of AIDS care and suffer particular discrimination as they are often blamed for spreading the infection. Clinical management, for too long based on research undertaken on men, must be tailored to women`s particular symptomatology, disease progression and HIV related illnesses.

Why are women more vulnerable to the HIV infection?

• Biologically: Larger mucosal surface; microlesions which can occur during intercourse may be entry pointsfor the virus; very young women even more vulnerable in this respect. More virus in sperm than in vaginal secretions. As with STIs, women are at least four times more vulnerable to infection; the presence of untreated STIs is a risk factor for HIV. Coerced sex increases risk of microlesions.

• Economically: Financial or material dependence on men means that women cannot control when, with whom and in what circumstances they have sex. Many women have to exchange sex for material favours, for daily survival. There is formal sex work but there is also this exchange which in many poor settings, is many womens only way of providing for themselves and their children.

• Socially and culturally: Women are not expected to discuss or make decisions about sexuality. They cannot request, let alone insist on using a condom or any form of protection. If they refuse sex or request condom use, they often risk abuse, as there is a suspicion of infidelity. The many forms of violence against women mean that sex is often coerced which is itself a risk factor for HIV infection. For married and unmarried men, multiple partners (including sex workers) are culturally accepted. Women are expected to have relations with or marry older men, who are more experienced, and more likely to be infected. Men are seeking younger partners in order to avoid infection and in the belief that sex with a virgin cures AIDS and other diseases.

What will make a difference?

• Women must be empowered so that they are able to control their own lives and in particular their sexual relations. This implies a profound shift in social and economic power relations between men and women. It cannot be achieved tomorrow but action must start today, through: Increased educational and employment opportunities for girls and women Public education campaigns on the harmful - fatal, in the case of AIDS - effects of unequal gender relations.

• It is essential to develop a prevention method which is cheap, safe and effective and under women`s control. In the absence of a vaccine, this is a method likely to have an immediate and significant impact on the alarming rate of new infections in women. A massive investment in international research and development of a microbicide is required. An issue which must be dealt with is the desire for children. A microbicide for preventing both pregnancy and STIs including HIV (dual protection), and a microbicide which is not also a spermicide must be developed.

• Treatment and prevention of sexually transmissible infections have to be enhanced. Women are more vulnerable to STIs; the consequences are more serious. Many STIs are asymptomatic in women. The management of STI in women is more difficult than in men. The stigma associated with STIs is greater for women (suggests promiscuity), so they are often afraid or unwilling to seek care.

• Blood has to be safe. Women and children are the chief recipients of transfusions; women - during and after delivery. The following action is required: Antenatal care and adequate nutrition to reduce some of the need for transfusion Appropriate clinical use of blood to avoid unnecessary transfusion Screening of all blood as the ultimate aim.

• Education for prevention including the use of condoms is needed: Condoms, male and female, are currently the only protection methods available. The access through free distribution, subsidies, or social marketing has to be increased. They need to be more widely accepted, available and used. It has been shown that even in the most favourable circumstances, condom use (male and female) is low. The acceptability of these methods remains problematic. The female condom is if anything more cumbersome than the male condom and considerably more expensive. Furthermore, women cannot control their use. Impact will continue to be low if people`s preferences and therefore their actual use of methods, are not given due attention.

• Women are responsible for the health care of all family members. Care is only one of the many productive and reproductive activities of women which include farming, food preparation, collection of firewood and water, child care, cleaning, etc. Care is provided free but has a cost! During illness, women`s productive labour is lost; this has serious impact on long term wellbeing of the household. Care of orphans lies with grandmothers and aunts. Women carers are often HIV positive themselves.

• Men have to be more responsible: Little attention has been paid to men`s participation in efforts to protect women Men are hard to reach and educate but some are concerned about sexual health of their own and their partners. Raising awareness of their own risk has been shown to change certain behaviours. Interventions must be aimed at men (as well as at women) if women are to be protected.

• The new COM.PASSION documentary „SOLD OUT!“ deals with forced and child prostitution and the issue of trafficking – „the recruitment, transportation, transfer, harbouring or receipt of persons, by use of force or other forms of coercion... for the purpose of exploitation“ (United Nations Convention Against Transnational Organized Crime, Article 3, November 2000). Trafficking and AIDS go hand. Most of the victims do not have access to prevention and health care programs. Only gender equality could lower the demand for (young) sex workers.

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