Journal of HIV & Retro Virus Open Access

Keywords

Empowerment; HIV; Knowledge; Violence; Autonomy; Estimates; Decision Making; Vulnerability

Abbreviations

AIDS: Acquired Immuno Deficiency Syndrome; CAB: Clinical, Anthropometric and Biochemical Testing; CAPI: Computer Assisted Personal Interviewing; DHS: Demographic and Health Surveys; HIV: Human Immunodeficiency Virus; NFHS: National Family Health Survey; SRH: Sexual and Reproductive Health; UNAIDS: United Nations Programme on HIV and AIDS; UNPOPIN: United Nations Population Information Network; UTs: Union Territories

Introduction

Kofi Annan, former Secretary General of U.N., cited "There is no tool for development more effective than the empowerment of women". Women Empowerment basically refers to the creation of an environment where women can make independent decisions on their personal development which leads them to have equal rights in community, society and workplaces [1]. India is mostly known for its cultural heritage, traditions, civilization, religion and geographical features. On the other hand it is also popular as a male chauvinistic nation [2]. Women in India remained within the four walls of their household where they totally depended on their counterparts for a long time. After extensive struggle women has been delivered the property rights, voting rights, equality in civil rights before the law in matters of marriage and employment [2]. The fact cannot be denied that women in India have made a considerable progress in almost seven decades of Independence, but they still have to struggle against many handicaps and social evils which resist the advancement and upliftment of women folk. The feminization of poverty also reflects the indifferent treatment that women face throughout the world. It is unfortunate that women constitute a greater proportion of world’s poor. Due to poverty and lack of opportunities women had become the most dormant segment of India’s population [1]. According to Human Development Report in 2015, India ranks 130th out of 188 countries on gender inequality index and 108th out of 145 countries on gender gap index according to World Economic Forum in 2015 [3,4].

Women not only are kept aloof from economic opportunities but are denied of access to health care services in many parts of the country. The vulnerability of women can be attributed to a socio-economic and cultural context of India. Women are always susceptible and, therefore, lack awareness in various fields including health which has resulted in the growth of women suffering from HIV. According to India HIV estimations 2015, National adult (15–49 years) HIV prevalence is estimated at 0.26% (0.22%–0.32%) in 2015 [5]. Further, the prevalence in 2015among males is estimated at 0.30% and among females is estimated at 0.22% in comparison to 2007 which estimated 0.40 among males and 0.26 among females. There is a clear decline in the infections nationally but the gender gap is found narrowing in new HIV infections. Data also reveals that women continue to account for more than 40% of people living with HIV infection in the country [6]. Women in context of health are considered more vulnerable compared to men because poor women in both rural and urban areas have limited exposure to mass media and less formal education which also inhibits their access to information [7]. These uneducated and unaware women carry the risk of transmission to their husbands as well as children also, which is crucial for the nation to reach the MDG and end AIDS by 2030. There have been programmes related to women empowerment such as ‘National Mission for Empowerment of Women’ by Ministry of Women and Child Development in India. It is because of these programmes women in India now participate in areas such as education, sports, politics, media, art and culture, service sector and science and technology [8]. Though amelioration in the position of women is seen, but their true empowerment is still awaited. According to Nochiketa Mohanty, "There is a huge need to ramp up education and awareness about HIV infection among women besides upgrading the social status of women in order to empower her to make choices related to her sexual partner". Women should not only be aware of their voting and political rights but also human rights including sexual and reproductive rights. For this, the government has to show effectiveness in their implementation of awareness generation programmes which should not only provide beneficial support system but also a healthy environment to learn about all issues related to their physical, mental and sexual health.

The purpose of this study is to analyze the linkages between women’s empowerment and their vulnerability to HIV in India. The study on women’s empowerment in terms of ownership of household assets, autonomy in household decision making and experiencing spousal violence will open a broader perspective of the vulnerability faced by women in India. Further, the women’s awareness and knowledge of HIV/AIDS and the relevant protection against HIV when linked with the women’s vulnerability will provide the situation of changing scenario of HIV in India.

Data and Methods

The data is taken from National Family Health Survey (NFHS) which is conducted in all the states and Union Territories of India under Ministry of Health and Family Welfare: Government of India, with the objective to set benchmarks and examine the progress in health sector the country has made over time and identify the need for new programmes for the emerging issues in this area. The nodal agency for this survey has been International Institute for Population Sciences, Mumbai in collaboration with ORC Macro, Calverton, Maryland, USA and the East-West Centre, Honolulu, Hawaii, USA. This survey has completed three rounds and the data used in this study is from the fourth round of NFHS.

The National Family Health Survey 2015-16 (NFHS-4), the fourth in the NFHS series, provides information on population, health and nutrition for India and each State / Union territory. Among the four survey schedules provided, this study has specifically focussed upon the women’s data aged (15-49) where information on the woman's, reproductive health, sexual behaviour, HIV/AIDS, domestic and spousal violence, empowerment and awareness regarding contraception etc. are taken into consideration for the study. NFHS-4 fieldwork for all 17 states and UTs were completed by august 2015. The details coverage of Households, Woman and Men in all 17 states and UTs are given in Table 1.

Table 1: Sample Size of Completed States/UTs in Phase 1, NFHS-4, 2014-15.

Results

Women’s empowerment

The subject of empowerment of women has become a burning issue all over the world including India since last few decades. The position and status of women all over the world have risen incredibly in the 20^th century [9]. According to United Nation Population Information Networks Guidelines, Women's empowerment has five components: women's sense of selfworth; their right to have and to determine choices; their right to have access to opportunities and resources; their right to have the power to control their own lives, both within and outside the home; and their ability to influence the direction of social change to create a more just social and economic order, nationally and internationally [10]. NFHS-4 has assessed women empowerment by measuring 3 indicators namely ownership of household assets, women experiencing spousal violence and women’s participation in household decision making.

Table 2 in this study shows the percentage of women owning different household assets namely ownership of house/land, having a bank/saving account and owning a mobile phone. In terms of ownership of house/land by women, Manipur seizes the highest rank (70%) followed by Bihar (59%), Meghalaya (57%) and Tripura (57%). Similarly, little more than half of women in Karnataka (52%) and half women in Telangana (50%) own a house/ land. On the other hand, less than half of women in Maharashtra and one-fourth of women in West Bengal and one-fourth of women in Sikkim own a house/land. In case of women owning a bank account, more than 80% women in Goa and Andaman and Nicobar Islands have their own bank/saving account followed by women in Tamil Nadu (77%), Puducherry (68%), Andhra Pradesh (64%) and Sikkim (60%). Further, around 50-60% of women in Telangana, Karnataka, Tripura and Uttarakhand reported having their own bank/saving account. On the other hand only a little more than two-fifths of women in Maharashtra and only onefourth of women in Bihar have their own bank/savings account. When the ownership of mobile phone was considered, it was found that more than one-fourth of women in all the states and union territories own a mobile phone. More than 80% of women in Goa and Sikkim followed by a little less than three-fourths of women in both Andaman and Nicobar Island and Puducherry own mobile phone. Madhya Pradesh is the only state where less than 30% of women own a mobile phone.

Table 2: Percentage of women who have ownership of Household Assets.

Spousal violence is a problem that is entrenched in many societies around the world and India is no exception. Although societal awareness and condemnation of the issue have increased in recent years, spousal violence remains a hidden and persistent problem because of the power and control held by the abuse and humiliation suffered by the victims of this crime [11]. Table 3 gives the comparative percentage change from NFHS-3 to NFHS-4 in ever married women experiencing spousal violence. The data reveals that there has been a decline in overall spousal violence in most of the states except for Haryana, Manipur and Meghalaya. Among all the states the highest decline around 16% of women experiencing spousal violence is found in Sikkim, Tripura and Bihar. Similarly, the decline in spousal violence of ever-married women is found in states like Uttarakhand by 15%, Madhya Pradesh by 12% and Maharashtra and West Bengal by less than 10%. In contrary, the women experiencing spousal violence has tremendously increased by 16% in Meghalaya followed by 9% in Manipur and 5% in Haryana. Though the prevalence is still high but it shows a declining trend in most of the states.

One of the important indicators in measuring empowerment of women is the autonomy of women in decision making both in social and household life [12]. Table 3 also represents the change from NFHS-3 to NFHS-4 in the percentage of women who participates in household decision making. Result depicts that as a whole there is an increase in the participation level at household level by more than three-fourths of women in all the states except for the state of Haryana and Tamil Nadu. In these two states the participation level at household is found decreasing by 7% and 3% point. The participation of women in household level decision making has crossed more than 90% in states like Sikkim, Goa, Meghalaya, Manipur and Tripura.

Table 3: Percentage of married women who have ever experienced spousal violence and women who participate in household decision-making (NFHS-3 to NFHS-4).

HIV vulnerability

The vulnerability of HIV among women in different states of India is assessed through capacity building of women which is measured on the account of two indicators namely comprehensive knowledge of HIV/AIDS and consistent condom use as a protection against HIV. Since the beginning of the global HIV epidemic, women have remained at a much higher risk of HIV infection than men in many regions [13]. In some countries, women face significant barriers to accessing healthcare services. This inclines lack of access to comprehensive HIV and sexual and reproductive health (SRH) services which ultimately leads to incapability of women to look after their sexual health and reduce their risk of HIV infection. Even where women are able to access HIV and SRH services, stigma and discrimination create additional barriers [14].

By Comprehensive knowledge of HIV/AIDS in our study we mean knowledge of using a condom and having just one uninfected partner that limits the risk of getting AIDS, knowledge that a healthy looking person can also have AIDS and knowledge of rejecting the two most common misconceptions about AIDS transmission (transmission by mosquito bites and by sharing food). Data pertaining to women having comprehensive knowledge of HIV/AIDS describes that overall there is not much difference found in the knowledge level of HIV/AIDS among women from NFHS-3 to NFHS-4.

Table 4 shows that less than 30% of the women have comprehensive knowledge of HIV/AIDS in states and union territories like Andhra Pradesh, Puducherry, Telangana and Andaman and Nicobar islands in NFHS-4. Though there has been increase in comprehensive knowledge of HIV/AIDS in Tripura by 10-19% point but in some states like Goa, Haryana, Meghalaya, Sikkim, Tamil Nadu, Maharashtra and West Bengal it has only increased by less than 10% point. Further, the comprehensive knowledge of HIV/AIDS among women in states like Bihar, Karnataka, Madhya Pradesh, Manipur and Uttarakhand is seen decreasing which limits the country to reach the Millennium Development Goals.

Table 4: Percentage of women who have comprehensive knowledge of HIV/AIDS (NFHS-3 to NFHS-4).

There are a number of factors - Biological, Socio-cultural and Economic which make women more vulnerable to HIV/AIDS. Women are twice as likely as men to contract HIV from a single act of unprotected sex [15]. Condom use is a critical element in a comprehensive, effective and sustainable approach to HIV prevention and treatment [16]. Women can play a vital role in the prevention of HIV as it will not only help them in protecting themselves but also their children against it [17]. Therefore, it is important to assess the awareness or knowledge of women regarding consistent condom use as a protection of HIV/AIDS. Table 5 represents the change in percentage data from NFHS-3 to NFHS-4 for women having knowledge that consistent condom use as protection against HIV. The data shows that overall in all the states there is an increasing trend in the awareness level of women regarding condom use as protection against HIV. In some of the states like Goa, Maharashtra and West Bengal, there has been an increase in the awareness level by more than 20% point followed by an increase in awareness level of women in Meghalaya and Tripura by 10-19% point. Whereas in states like Bihar, Haryana, Madhya Pradesh, Sikkim, Manipur and Uttarakhand there has been an increase in the awareness level by less than 10% point among women regarding the knowledge that consistent condom use is a protection against HIV.

Table 5: Percentage of women having knowledge of consistent condom use as protection against HIV/AIDS (NFHS-3 to NFHS-4).

Changing HIV scenario in India

This section of the study focuses on the changing scenario of HIV/ AIDS in India where the trend of prevalence of HIV among adults aged 15-49 is comprehended in four year time span (2012-2015) from recent HIV estimates. The estimate provides a detailed description in what manner the prevalence of HIV in different states of India has changed over the period of time.

According to UNAIDS, Gap Report India has the third largest HIV epidemic in the world. Though this number sounds very less compared to other middle-income countries but because of the large population in India, this percent equates to a huge number. A recent study says that there has been a massive decline in the prevalence of HIV. Table 6 presents the trend in the percentage of HIV prevalence among adults aged 15-49 years in different states from 2012 to 2015. The trend of HIV prevalence is found decreasing in almost all the states except for Sikkim and Tripura. Apart from that the prevalence of HIV in the states like Haryana, Meghalaya and Uttarakhand has remained constant all these years. In Karnataka, the HIV prevalence is reduced by 0.6% followed by Goa where HIV prevalence is reduced by 0.5% point. In other states like Bihar, Tamil Nadu and West Bengal the reduction in HIV prevalence from 2012 to 2015 is by 0.2% point and in Madhya Pradesh it is just reduced by 0.1% in four-year time span. The overall scenario shows that the country is showing a success in responding to HIV epidemic.

Table 6: Percentage of HIV Prevalence among Adult (15-49) years by States.

The overlapping Figure 1 reflects the women’s autonomy in household decision making and knowledge about consistent condom use, which may be treated as protection against their HIV vulnerability among adult women age 15-49 in 15 states of India. Further, it also shows the trend of HIV prevalence in these states as per the recently completed Integrated Biological and Behavioural Survey (2014-15). The graph portrays a contentious relationship between women’s autonomy in decision making, awareness to consistent condom use and the prevalence of HIV. There is high level of women’s autonomy in household decision making and awareness of consistent condom use as a protection against HIV in states like Haryana and Uttarakhand along with the Andaman and Nicobar Island, which has a negative association with the prevalence of HIV. On the other hand, it is surprising to know that the prevalence of HIV is very high in states like Andhra Pradesh, Maharashtra, Manipur and Karnataka despite of high women’s autonomy in decision making and high awareness regarding consistent condom use as a protection against HIV. But unpredictably in other larger states like Madhya Pradesh, Bihar and West Bengal, the prevalence of HIV maintain to be very low (between 0.09 to 0.25%) despite low level of awareness regarding consistent condom use as a protection against HIV (between 34 to 54%).

Figure 1: Womens autonomy in Decision Making awareness about Consistent Condom use as a Protection Against HIV and HIV prevalence in 15 states and Uts of India.

Discussion

This paper has highlighted that there is a substantial increase in women’s autonomy in household decision making and ownership of household assets in the country in the recent years. Women’s autonomy also leads to lowered fertility and more positive attitudes toward educating female children, which is congruent to the trend of women’s participation in overall development process [18-25]. Furthermore, in almost all the states except in Haryana, Manipur and Meghalaya there is a profound decline of the proportion of ever married women experiencing spousal violence, which has positively impacted the overall health and wellbeing of women in the country. State like Haryana, with skewed sex ratio and higher prevalence of traditional patriarchal norms are more likely to face spousal violence [26]. But it is surprising to find the fact that women in Meghalaya, which is a state of matrilineal society, also experience spousal violence despite of high women autonomy. This can be attributed to the fact that since there is a say of women in Meghalaya, hence the reporting must have been high in comparison to other states in India where women don’t open up easily. It can also be possible that the reason for spousal violence could be related to substance abuse and its consequences.

Woman’s vulnerability to HIV/AIDS may be higher among women from states like Sikkim, Goa and West Bengal, where women’s autonomy in decision making has improved considerably but the knowledge about consistent condom use as protection from HIV infection is still low. Similarly, women from Bihar and Meghalaya also lack awareness regarding HIV and its protection despite of high ownership of household assets. The probable reasons might be women are provided with autonomy and technology to some extent but the use of technology for awareness purpose is low. The study by Amin (2003) depicts that awareness messages in India mostly remain neutral in addressing the negative gender and sexual norms fuelling the epidemic. He further argues that most awareness programs scarcely address their risk and need for prevention information. He supports his argument with the following example: Awareness campaigns mainly target high-risk groups to promote and emphasize condom use when practicing high-risk behaviour, but rarely insist that these groups use condom with their wives who remain "uninformed, unaware and unprotected” [12].

Our finding that regardless of decreasing HIV estimates in India, states like Andhra Pradesh, Maharashtra, Manipur and Karnataka are still suffering from high HIV prevalence has also been found in other studies. A recent study by Indian Health Action Trust in 2010, reported that the prevalence of HIV in Maharashtra is high among MSM. So, in Maharashtra the reason for high prevalence might be that HIV exists among MSM (male having sex with male) where female have no role to play. Further, Gregory Armstrong in his study of Injecting drug users in North-East found that youth below age of 25 in Manipur is vigorously injecting drugs in their body which might be the cause of high HIV prevalence. The reason for high prevalence of HIV in Andhra Pradesh and Karnataka might be because of unemployment, migration, poor health and unhealthy sexual practices.

Though India has successfully shown progress in halting and reverting the HIV epidemic by expanding treatment, care and support services yet in some states HIV prevalence has been found increasing [5]. As per the report of HIV estimates in India, 2015 it is obvious that the overall trend in HIV prevalence is decreasing but in an account of gender, the prevalence is still high among women. This gives light to the point that there is a lack of comprehensive knowledge about HIV/AIDS and its protection among women especially which is increasing their vulnerability towards HIV.

Conclusions and Recommendations

Results of this paper establish a contentious relationship between women empowerment and vulnerability of women towards HIV/AIDS. It has been consistent in the results from NFHS-3 to NFHS-4 that those states where there is autonomy provided to women in household decision-making, the incidence of spousal violence has reduced and the awareness about consistent condom use as a protection against HIV has increased. However, change in comprehensive knowledge of HIV/AIDS among women in NFHS-4 is not prominent compared to NFHS-3. This is posing a serious threat to the development of the country as a whole because one of the eight-millennium development goals is to combat HIV/AIDS. Lack of awareness can lead to narrowing gender gap in HIV prevalence in India. To achieve this change, it requires policy and programmes that will improve women's access to secure livelihoods and economic resources, alleviate their extreme responsibilities with regard to housework, improve status of women along with decision-making capacity at all levels in all spheres of life, especially in the area of sexuality and reproduction, develop skills in every possible way and raise social awareness through effective programmes of education and mass communication. In addition, issues such as stigma, power/ organizational networks and existing norms regarding gender and sexuality should be addressed and a conducive support system and enabling environment should be provided to women.

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