GAM

Variables

Exposure & Vulnerability

Outcomes & Impact

Access & Utilization

Biological & Physiological factors

Social factors (Class, caste, education, Occupation, rural /urban, tribal, ethnic groups …)

Qualitative analysis of observed difference for role of Gender

GAM: TUBERCULOSIS

Variables

Exposure & Vulnerability

Outcomes & Impact

Access & Utilization

Biological & Physiological factors

Prevalence of TB among men & women is  2:1

TB is the single most significant cause of death among women in the world.

The health facilities that women use provide only maternal & child health AND family planning services

Social factors (Class, caste, education, Occupation, rural /urban, tribal, ethnic groups …)

Women are more vulnerable:
- Under-reporting,
- more likely to pick up infection as care provider to infected husband and other relatives

Qualitative analysis of observed difference for role of Gender

When Husband is diagnosed as positive for TB wife is expected to care for him. But when she is diagnosed, she is more likely to be denied care, sometimes even deserted.

State has more focus on ‘Population control’ and women are seen to be the convenient point of intervention for such programs.

Variables

Exposure and Vulnerability

Outcomes and Impact

Access and Utilization

Biological & physiological factors

·               Epidemiological data show that tuberculosis, particularly pulmonary tuberculosis, is more common among males than among females. According to reported statistics the prevalence of tuberculosis is two males to one female.

·               Tuberculin test data show that more males than females have a positive result to the test. Annual reports of new cases of tuberculosis sent to the WHO from all countries - industrialized as well as developing - show nearly twice the number of males compared to females.

·               The reason for this could be because women may exhibit lower delayed type hypersensitivity (DTH) responses than males. It is not clear why older men have a higher risk of progression from infection to disease in comparison to women of older ages. Cellular immunity may diminish more quickly in men than in women.

·               Age differences: Statistics show that upto the age of 14 years there is very little difference in prevalence rates among males and females but the gap widens after this with 20-70% higher in males than females. Hormonal changes could be responsible for this.

·               The low level of notification of female tuberculosis patients in the reproductive age(15­35 years) indicates the presence of gender disparities in notification. In younger children, there is no difference in reporting between male and female children.

·               Older women aged 35 and above have higher levels of under reporting and so 'higher levels of under diagnosis. This could be because women of this age group are not in contact with health services because they are not having children.

·               Deaths: Statistics reveal that TB is the single most significant cause of death among women in the world. It is the largest killer of women in the reproductive age group (15-44 years) in the South East Asia Region. Tuberculosis killed half a million women in the Region in the year 1997.

·               Pregnancy: Although exact data are not available, indications from Africa show that tuberculosis is the major cause of morbidity and mortality in pregnant women.

·               Progression of disease and case fatality:
Progression of disease is faster and case fatality higher among women than men TB patients. In a prospective cohort study in Bangalore, India, among those aged 10-44 years, the progression rate of tuberculosis in females was 130% higher than that in males. This seems, to indicate that though the percentage of women infected may be less, once they get infected the disease progresses faster among women. The faster progression from infection to disease in women could also be responsible for the low tuberculin positive results in screening programmes.

·                Co infection with HIV: Both HIV and tuberculosis occur in reproductive age groups. Co infection with HIV is common in new cases of tuberculosis. There is a difference in the sero prevalence in male and female TB patients in different parts of the world. In Africa the sero prevalence of HIV is higher in female TB patients than in male but in Asia the reverse is true. In a study in Cameroon it was seen that 24% of female TB patients and only 12.5% of male TB patients who were tested were sero positive. Estimations show that during the 1990s around 8% of all new TB cases were attributable to co-infection with HIV. Co­infection with HIV will also lead to an increased development of drug-resistant mycobacteria.

·               The health facilities that women usually use provide only maternal and child' health and family planning services.

·               Pregnancy: Although exact data are not available, indications from Africa show that tuberculosis is the major cause of morbidity and mortality in pregnant women.

Social: Class, caste, education,

occupation, rural \ urban, tribal groups

·               Though epidemiological evidence shows that ~ the number of cases is higher in men compared to women social cultural realities indicate that women are more vulnerable to infection due to a variety of reasons. Women are also vulnerable to infection as service providers for infected husbands, in-laws, children and other family members..

·               'W'hen TB control programmes set 70% case ~ detection as a target, the undetected cases are more likely to be female due to the low notification of female cases.

·               Women do not report to health centres when they have symptoms.

·               Social stigma does not allow women to discuss TB with others.

·               Women are sent back to the natal home when found to be infected due to the expense for treatment. Moreover illness reduces their potential for earning and carrying out household tasks.

·               Information about disease is low among women due to illiteracy.

·               Women with TB are more likely to be deserted or divorced and men may marry again pushing women into further dependency condition.

·               While Male TB patients continue to be supported and cared for by their spouses and other family members, the same does not hold true for women TB patients, especially the' young' married ones.

·               Women TB patients are sometimes secluded within the family and care of own family and children is denied due to perceived danger of infection.

·               Women TB Patient is more likely to spread the disease to children.

·               Women face problems in seeking medical help and symptom reporting. Due to delay in diagnosis, treatment is started late and complications are more likely

·               Once diagnosis is made there is unwillingness as the part of women to spend money and time on continued treatment as they need to leave the home for availing treatment many times.

·               Cultural constraints prevent women accessing services especially for long term treatment in tuberculosis. Demands on women's time at home and low access to money and travel facilities withhold women from taking treatment.

·               Married women are concerned more about rejection by husbands and families than about adherence to treatment

·               The requirement of an initiative from the patient to seek health care (under DOTS) may be insensitive to the conditions of women and poor people in developing countries.

·               Too many visits to health centers for services.

Qualitative analysis of observed

difference for role of gender

·               Case studies show that when the husband is diagnosed as positive for tuberculosis the wife is expected to care for him. But when the wife is diagnosed, she is more likely to be denied care and treatment and sometimes even deserted.

Variable

Exposure and Vulnerability

Outcomes and Impact

Access and Utilization

Biological & physio­logical

factors

Age and risk of exposure:

·               Low age at marriage, child prostitution and rising number of street girls increases exposure and risk of HIV infection among girls.

·               AIDS rate among women reaches a peak in late twenties, indicating that many girls are I infected in their late teens.

·               There is increased susceptibility to HI\' for women under 18 years because the vaginal mucous membrane in young women does not acquire a cellular density that acts as an effective barrier until after 18 years of age.

·               Post menopausal women are also vulnerable because after menopause the vaginal mucous membrane becomes thinner and weaker and is more vulnerable to HIV.

·               Men are older in marital and sexual relationships and could be already infected. Men tend to want to have sexual relations with younger women exposing them to infection.

Sex and risk of exposure:

·               The epithelial quality of the vaginal mucous membrane is more vulnerable to infection than the penis.

·               Male to female transmission is 2 - 4 times more effective than female to male due to the large vaginal surface and the cell content of semen.

·               Semen remains in the vaginal tract or rectal tract for a longer period than vaginal fluids on the penis. This increases the risk of exposure to women.

·               Semen is more infectious than vaginal fluid. HIV requires cells to be transmitted. Semen is very rich. in cells and so it is more infectious

·               Wives of migrant laborers, truck drivers, wives of drug abusers, defense and marine personnel are at higher risk

·               Frequency of sexual intercourse and multiple partners among commercial sex workers places them at higher risk.

·               Use of spermicides could lead to higher vulnerability of vaginal surface.

Opportunistic infections are severe in women

·               Pattern of opportunistic infections and their severity differ in men and women. However studies of HIV disease progression in women are limited.

Effect of HIV on pregnancy

·               Most of the opportunistic infections are life threatening in pregnancy. TB is a major opportunistic infection in HI\' and this combined with pregnancy increases risk to women.

·               Children born to HIV positive women may be sero positive. Women may thus avoid pregnancy and are more likely to seek abortion placing themselves at risk.

·               Treatment of pregnant women to reduce Mother to child transmission affects the health of the women. .

·               Most school based AIDS education starts only in secondary schools or colleges when it is already too late and most girls have left studies and are already married and have entered into a sexual relationship.

·               Even among highly educated women knowledge of HIV/AIDS is more often gained through friends and relatives and this knowledge is more likely to be inaccurate.

·               Prohibitions on access to sex and related information for women further hampers access to information and services.

·               Services do not encourage women for testing due to fear of repercussions.

·               Testing is associated more with pregnancy giving a false indication that it is not serious among other women.

·               The risk approach which targets only same sections of community is biased.

·               Treatment of men and women not done.

·               Treatment for women is focused on pregnant women showing that it is the health of the unborn baby which is to be protected while the infected woman is neglected.

·               Opportunistic infection in pregnancy are treated only after weighing their effect on the foetus.

·               Condom use is promoted with women more often than men by health and family planning staff.

·               The promotion of condom as an effective preventive method is not gender sensitive since it is a male controlled method and women are not 10 a position to negotiate for the use of condom in the context of unequal social and sexual relations.

·               Women's lower educational and literacy level, lower attendance at school further reduces their access to mass media through which AIDS awareness campaigns are often promoted

Social: Class, caste,

education,

occupation, rural \

urban, tribal groups

·               Women suffer more than men from STDs which increases the risk of HIV infection through heterosexual relations. In many cases STDs are asymptomatic in women, which impede early detection and timely treatment.

·               Women receive proportionally more blood transfusion than men, and have a higher risk of contracting HIV / AIDS.

·               Women sex workers are at greater risk of infection due to the high risk behavior of their partners, rather than their own. Multiple sex partners and low use of condoms puts many of these women at risk through their relationships with high risk male partners.

Gender and risk of exposure

·               Women constitute 75% of the new cases of infection. Women are at greater risk socially and psychologically than men.

·               The social and psychological constructs of gender and sex roles restrict women from taking steps to protect themselves against risky sexual behaviour by male partners.

·               Knowledge and awareness gaps are more likely in women leading to higher rate of vulnerability. ,

·               Education and awareness is less among women.

·               Married women traditionally have faith in the fidelity of the husband that he will not engage in extra marital relations. She is shocked when she is detected as HIV +ve.

HIV positive women face a social death:

·               Women especially sex workers are often stereotyped as transmitters of HIV and STDs. Therefore the stigma attached to seropositivity is particularly severe for these women as it may lead to loss of livelihood.

·               Married women who are seropositive may be blamed and abused by their husbands and even abandoned or divorced. Given the limited property rights of women and their economic dependence on men this could result in destitution.

·               Single women who are known to be HIV positive are unlikely to find a partner. Widows whose husbands have died of AIDS are unlikely to be remarried. Such women are thus particularly vulnerable where employment opportunities are rare and inheritance rights are weak.

·               HIV positive women who become pregnant face further psychological and social pressure. The child may be seropositive. Fear for the future of the child and may pressurize them into having an abortion.

·               Women are primary care givers at the household and community levels. The burden of caring for the sick relatives often falls on them. This will be doubly difficult if women themselves have AIDS.

·               Psychological trauma.

·               Women’s responses to HIV surveillance are different than men's. Women are less likely to come for testing or treatment due to social stigma. Therefore, in surveillance data there is under-estimation for women.