為結束愛滋病毒之流行,終結性別不平等亦需實現
資料來源:刺胳針愛滋病毒醫學期刊, www.thelancet.com/hiv Vol 6 July 2019,財團法人台灣紅絲帶基金會編譯
根據「2030年平等措施」報告,利用數據的力量以促進性別平等,目前並沒有一個國家實現完全的性別平等。刺胳針醫學期刊系列關於性別平等、規範和健康的文章,顯示這種不平等嚴重地影響了全球健康上許多結果,亦鋪陳了性別規範在延續不公平現象上的角色,而愛滋病毒也不例外。
在全球範圍內,愛滋病相關之死亡是導致15-49歲婦女死亡的主要原因。在 2017年,在撒哈拉以南非洲所發生成人新的愛滋病毒感染,有59%是發生在15歲及以上之女性身上,以及在全球範圍內年輕女性(15-24歲)被感染的可能性更是年輕男性的兩倍。
在許多國家中性健康和生殖健康服務的獲得被要求需配偶或父母之同意。不符合圍繞在性行為上的社會性別規範的婦女,如參與婚前性行為,將可能面臨污名和歧視。婦女報告因擔心衛生保健工作者的批判和個人的羞恥感是性健康服務取得上的障礙。正如一篇由Weber和其同事在非洲尚比亞所做並發表於Lancet系列的論文所示,社會對婚前性行為的負面態度與女性的實際行為間的不一致,會與愛滋病毒盛行率之增加有關聯。聯合國愛滋病規劃署也報告說,有三分之一的女性愛滋病毒感染者曾經歷過與性和生殖有關的健康歧視,包括強制墮胎和產後絕育。
三分之一的女性在他們的一生中,曾報告伴侶導致的身體暴力或性暴力行為以及非伴侶的性暴力行為。有經歷伴侶暴力的女性在使用保險套、或進入愛滋病毒檢測,以及接受抗反轉錄病毒藥物治療的可能性較小。他們的治療順從性也較差,並且不太可能達到病毒被抑制。來自PARTNERS暴露前預防研究的數據顯示,那些前3個月曾經歷過親密伴侶暴力事件的女性會有50%更加可能在暴露前預防上有較低的順從性。
在愛滋病毒盛行率高的地區,親密伴侶的暴力與增加50%之HIV感染風險有關。
性別少數之群體,如跨性別的男性和女性,更面臨廣泛的污名恥辱和歧視,這接序著會對其健康產生可怕的後果。跨性別女性與一般人口相比其更可性感染愛滋病毒達49倍,他們也不太可能堅持治療,並達到病毒量被有效抑制,以及持續與照護體系有所連結。被識別為跨性別者,如2015年英國愛滋病感染者污名調查所示,是醫療保健上延遲報告或被拒絕的預測因子。
社會性別規範也對愛滋病毒有關的男性健康有害。男人不太可能比婦女更多地參與醫療保健服務和了解他們的愛滋病毒感染狀況。多項研究顯示愛滋病毒檢測和治療的接受率男人比女人為低。儘管在撒哈拉以南非洲的女性中其愛滋病毒感染率較高,但男性卻更有可能死於愛滋病相關疾病:2017年在該地區,估計因為愛滋病相關疾病而死亡的人當中,男性多於女性達3萬多人。
性別不平等影響到愛滋照護連續上的每個層面,需要進行重大的政治變革來解決這個問題。性別少數群體中缺乏愛滋病毒的相關數據,而沒有這些數據,就無法有效地改善服務以滿足其需求。 Transrespect報告中稱有57個國家和地區存在著將跨性別的男性和女性被定為犯罪或遭起訴之狀態。 每個國家都應去提供保護性別少數群體的法律架構。
圍繞在親密伴侶暴力的法律,包括對婚內強姦缺乏刑事定罪等,必須抓緊以證據為基礎的方法以減少基於性別的暴力,如What Works計畫般地要求確保行動有效。
圍繞在所謂適當的性別行為上根深蒂固的想法亦必須受到挑戰。如DREAMS,SASA!和SheConquers(註1)等計畫的調查結果,旨在賦予年輕女性能力去倡導爭取自己在性行為和生殖健康上的權益,必須有力地報導讓其他人在任何成功的基礎上再接再厲。男人也必須參與其中,像Promundo和Sonke(註2,3)這些組織一樣地,去挑戰根深蒂固的許多性別規範。
下一個 「平等措施 」報告定於2021年,如果我們期待要看到改變則法律改革上和教育上的急迫性是需要的。而實現兩性平等上的進展也應是朝向消除愛滋病毒上的進展。 ■刺胳針愛滋病毒
註1:She Conquers是南非一項為期三年的全國性運動,旨在改善南非少女和年輕女性的生活。他們致力於為南非的每個青少年女孩和年輕女性提供所需的資源,以便過著幸福、健康和成功的生活。他們相信每個女孩都應該有權決定自己的未來。這意味著受過教育、健康、不受暴力侵害。當女孩獲得知識時,她們就有機會獨立。這也為他們提供了更多改變社區和打破貧困循環的方法。當婦女和女孩成功時,社會就會成功。無論你是誰或來自哪裡,讓我們共同努力,讓女孩掌握命運,成為她們想成為的女性。
註2:Promundo是一個全球領導者,透過讓男人和男孩與婦女和女孩們合作,以促進性別公正和預防暴力。他們認為,讓男子和男孩參與合作以改變有害的性別規範和不平等的權力動態是實現兩性平等的關鍵解決方案。為了使婦女和女孩能夠繼續前進,男人和男孩必須將自己視為這一過程中的盟友。 當有害規範受到挑戰時,男人和男孩也會受益。
註3:Sonke是一個在全非洲工作的南非非營利組織。他們相信,男人和女人,女孩和男孩可以共同努力以抵制父權制,倡導性別公正,實現性別轉型。
For the HIV epidemic to end so must gender inequality
According to the Equal Measures 2030 report, Harnessing the power of data for gender equality, no country has yet achieved full gender equality. The Lancet Series on Gender Equality, Norms, and Health
shows that this inequality impacts heavily on global health outcomes, laying out the role of gender norms in perpetuating inequities, and HIV is no exception.
Globally, AIDS-related deaths are the leading cause of mortality in women aged 15–49 years. In 2017, 59% of new adult HIV infections in sub-Saharan Africa occurred in women (aged 15 years and older) and worldwide young women (aged 15–24 years) are twice as likely as young men to become infected.
Many countries require spousal or parental consent to access sexual and reproductive health services. Women who do not conform to societal gender norms surrounding sexual behaviour, such as engaging in premarital sex, can face stigma and discrimination. Women report fear of judgment by health-care workers and feelings of personal shame as barriers to accessing sexual health services. Discordance between negative societal attitudes towards premarital sex and the actual behaviours of women, as shown in a paper from Zambia by Weber and colleagues in the Lancet Series, is linked to increased prevalence of HIV. UNAIDS reports that one in three women living with HIV has experienced discrimination related to their sexual and reproductive health, including reports of coerced abortions and postpartum sterilisation.
During their lifetimes, one in three women will report physical or sexual violence by a partner or sexual violence by a non-partner. Women who experience intimate-partner violence are less likely to use condoms or to access HIV testing and antiretroviral therapy. They also have poorer treatment adherence and are less likely to be virally suppressed. Data from the PARTNERS pre-exposure prophylaxis study showed that women who experienced intimate-partner violence in the preceding 3 months were 50% more likely to have low pre-exposure prophylaxis adherence.
In areas with a high HIV prevalence, intimate-partner violence is linked to a 50% increase in the risk of acquiring HIV.
Gender minorities, such as transgender men and women, face widespread stigma and discrimination,
which in turn can have dire consequences for health. Transgender women are 49 times more likely to be
living with HIV than are the general population. They are also less likely to be adherent to therapy, to achieve viral suppression, and to remain linked to care. Identifying as transgender, as shown in the 2015 UK People Living with HIV Stigma Survey, is a predictor of reporting delays in or being refused health care.
Societal gender norms are also damaging to the health of men in relation to HIV. Men are less likely
than women to engage with health-care services and to know their HIV status. Multiple studies have shown that uptake of HIV testing and treatment is lower in men than in women. Despite a higher prevalence of HIV in women in sub-Saharan Africa, men are more likely to die of AIDS-related disease: in 2017 in the region, an estimated 30 000 more men died than women because of AIDS-related disease.
Gender inequality affects every aspect of the HIV care continuum and substantial political change is required to address this. Data are lacking on HIV in gender minorities, without which services cannot be improved effectively to meet their needs. Transrespect reports that 57 countries and territories exist that criminalise or prosecute transgender men and women. Every country should provide legal frameworks to protect gender minorities.
Laws surrounding intimate-partner violence, including a lack of criminalisation for marital rape, must be tightened Evidence-based approaches to reducing gender-based violence, such as the What Works programme, are required to ensure action is effective.
Entrenched ideas around appropriate gender behavior must be challenged. The findings from programmes such as DREAMS, SASA!, and SheConquers, which aim to empower young women to advocate for their own sexual and reproductive health, must be robustly reported to allow others to build on any successes. Men must also be involved, as in organisations like Promundo and Sonke, to challenge entrenched gender norms.
The next Equal Measures report on the gender index is scheduled for 2021 and urgency in legal reform and education is needed if we are to see change. Progress towards gender equality is also progress towards
elimination of HIV. ■ The Lancet HIV
www.thelancet.com/hiv Vol 6 July 2019