At long last, the international community appears to be coming together in a concerted effort to combat the AIDS pandemic that has overtaken much of the developing world. Mobilizing increased attention and resources to this ongoing crisis among governments around the world was one of the key priorities identified at the Millennium Summit of world leaders at the United Nations (UN) this fall. HIV/AIDS was the subject of a UN Security Council meeting earlier this year, marking the first time ever that the council has considered a health issue to be a matter of national and human security. And as far as U.S. foreign assistance is concerned, support for programs designed to address the HIV/AIDS crisis in the developing world are slated for a record increase in funding.

AIDS is now the fourth most common cause of death globally and the leading cause of death in Africa. Its toll is so severe that demographers now project population declines in at least three African countries—Botswana, South Africa and Zimbabwe—as a direct result of soaring infant mortality and sharp reductions in life expectancy caused by the disease.

In light of these dire circumstances, some policy and opinion leaders in and out of Congress are taking a new look at the U.S. population assistance program. A few ideological opponents of family planning already are citing the AIDS pandemic as an excuse for spending less on population assistance, if not abandoning the program altogether. They argue that family planning is part of the problem, asserting that it both further contributes to population declines and "encourages" sex. Proponents counter forcefully that the desire for family planning services continues unabated, even in the countries hit hardest by AIDS, and that women everywhere have an inherent right to protect their reproductive health and control their own fertility, notwithstanding the demographics.

The Joint United Nations Programme on HIV/AIDS (UNAIDS) has responded definitively that when it comes to fighting HIV/AIDS, family planning and reproductive health care are an integral part of the solution, not part of the problem. In a 1999 report, UNAIDS emphasized that "reproductive health care has a central role to play in AIDS prevention, and [it] should be given the highest priority in the fight against the epidemic."

Adolescents, Women and AIDS

According to Karen Stanecki, chief of the Health Studies Branch of the U.S. Census Bureau's International Programs Center, the proportion of women infected with HIV worldwide is rising inexorably; in Sub-Saharan Africa, 55% of all HIV infections are among women. And the virus is spreading most rapidly among the young: Half of all new infections beyond infancy occur among 15-25-year-olds. In countries with high HIV prevalence, adolescents are at great risk, because high infection rates in the general population mean that this large cohort of young people is likely to encounter infected partners earlier in their sexual lives.

Women, biologically, are more vulnerable to becoming infected than men. During unprotected vaginal intercourse, women are up to four times more likely than men to contract HIV, according to UNAIDS. Compounding the problem is that women in poor countries have a high incidence of other sexually transmitted diseases (STDs), which makes them more susceptible to HIV infection. Poor overall health and malnutrition also contribute to the risk. But the most fundamental factor accounting for women's higher susceptibility to HIV/AIDS, and the one that is perhaps the most difficult to overcome, has to do with the prevailing social, cultural and economic norms that limit the formal education women receive, the information about reproductive health available to them, their ability to negotiate safer-sex or to say no to sex at all, and their ability to survive independently.

Women's low status not only places them at higher risk of infection, says Geeta Rau Gupta, president of the International Center for Research on Women, it also means that "HIV- positive women bear a double burden: They are infected and they are women." In a paper delivered at this summer's International AIDS Conference in Durban, South Africa, Gupta described how infected women often are ostracized or abandoned altogether. And because of societal stigmas, infected women who otherwise might avoid the dangers of transmitting the virus to their newborns through breastfeeding might breastfeed nonetheless, lest community members draw conclusions about their HIV status. Increasingly, women with AIDS are even being murdered because of their illness.

Women Want Choices

Against this grim backdrop, African women, like women everywhere, are seeking to have more say and take more control over their lives, including and perhaps especially over their reproductive lives. In general, while African women still want larger families than do women in Asia or Latin America, their notion of an ideal family size also is getting smaller. The result is a gradually rising unmet need for family planning and other reproductive health services, according to a new study by Bamikale Feyisetan and John B. Casterline published in the September 2000 issue of International Family Planning Perspectives.

The demand for family planning services has evolved slowly in Africa, and there is no indication it has lessened even in the face of the AIDS epidemic. It seems that individual women, regardless of the demographic implications, still want the right to determine the timing and spacing of their children. Obtaining that right and having the ability to exercise it are themselves major steps toward women's empowerment. In turn, Gupta explains, a woman who has attained some degree of autonomy increases her chances of escaping HIV infection.

It is possible that surrounded by the ravages of AIDS, women may be even more motivated than under other circumstances to avoid an unintended pregnancy or, failing that, to seek out an abortion. When an HIV-infected woman does become pregnant, even if she has access to drugs that can greatly reduce the risk of transmission of the virus in utero, there is still a high likelihood that either during pregnancy, the birth process or through breastfeeding, her infant also will contract HIV. But even if that infant is lucky enough to be born uninfected and remain healthy, no real treatments are available for the mother. Sooner or later—usually sooner—she will die, leaving behind a young orphan along with any older children she may have. According to UNAIDS, almost 10 million children have been orphaned by AIDS, 90% of whom live in sub-Saharan Africa, and the burden of caring for them is straining extended families, communities and entire countries to the breaking point.

Mutually Reinforcing Goals

"In settings where HIV or sexually transmitted disease prevalence is high, information and counseling about how to effectively avoid unwanted pregnancy should also include information about how women can protect themselves against exposure to sexually transmitted disease, including HIV," says Margaret Neuse, director of the U.S. Agency for International Development's Office of Population. In order for a woman to make an informed decision in choosing a contraceptive method and also to protect her health and the health of her partner, she says, voluntary counseling about HIV/AIDS is very important; access to confidential testing services would further inform her decision-making process. Knowing her HIV status can help a woman or couple make decisions about whether and when to have a child. "For families coping with the many consequences of HIV/AIDS," notes Neuse, "including care for orphans and the sick, access to family planning services and information is more important than ever."

As is the case with family planning, responding to HIV/AIDS is as much about social, cultural and developmental issues as it is a medical issue. Involving men in understanding and promoting reproductive health and rights is central to a successful family planning program, explains researchers Ushma D. Upadhyay and Bryant Robey in the July 1999 issue of Johns Hopkins University's Population Reports. It is also a prerequisite to men taking more responsibility in helping to prevent the spread of HIV by using a condom. Similarly, focusing on the special reproductive health needs of adolescents is critical, both because they are about to enter their childbearing years and because of the rapid spread of HIV/AIDS in this age-group. More needs to be done to ensure better linkages between counseling and testing programs and access to family planning services, since people are likely to seek the information about their HIV status only if there is a course of action available for them to take. Finally, according to the Johns Hopkins report, since the presence of other STDs increases the risk of contracting HIV, family planning clinics can play a key role in reducing HIV exposure in their ongoing efforts to mitigate STDs, such as through their male and female condom distribution programs and educational efforts on safe sexual behavior.

AIDS and the 'Cairo Paradigm'

In 1994, a revolutionary worldwide consensus emerged from the fourth UN-sponsored International Conference on Population and Development in Cairo: that improving the status of women should be the central focus of both efforts to address world population pressures and efforts to sustain global development. For the first time at such a gathering, it was explicitly recognized that for a population program to succeed, its components must include facilitating women's autonomy by providing them better information, enhancing their legal rights, fostering cultural norms that respect their decision-making and offering them higher-quality reproductive and general health services. These are at the center of the post-Cairo population agenda and, not surprisingly, at the core of successful AIDS prevention strategies as well.

Slowly, the purely demographic rationale for population programs is beginning to give way to an approach that emphasizes meeting individual needs rather than national demographic goals. And the so-called Cairo paradigm, beyond changing the global philosophical dialogue, is being reflected in subtle but important changes in programs, too. In that light, the real question is not whether there still is a need for population assistance in the age of HIV/AIDS, or even whether population assistance is more or less important than efforts to combat HIV/AIDS, but rather, as suggested by UNAIDS itself, how to better integrate family planning services with HIV/AIDS prevention programs in order to promote reproductive health and to save lives.