Who transmits HIV?

en the epidemic began in the early 1980s, AIDS was known as the disease of homosexuals and was referred to as "the gay cancer" or "the gay plague". When reports of an emerging heterosexual AIDS epidemic started to circulate a few years later, they were met, in the beginning, with skepticism.

While this may have led to speculations that an HIV epidemic based on heterosexual transmissions alone was probably not possible, the epidemic was creating havoc in sub-Saharan African countries, now home to almost two-thirds of total HIV cases worldwide. In these countries, most infections are attributed to heterosexual transmissions, with a rapidly growing number of women becoming infected with HIV.

Meanwhile, an increasing number of women reported with HIV attributed to heterosexual contact was also recorded in various countries, thereby supporting earlier reports of an emerging heterosexual AIDS epidemic. In fact, as more and more new cases of HIV occurred among discordant couples, marriage was referred to as "a leading source" of new HIV infections in developing countries.

Yet despite the great advancement in our understanding of HIV, a number of "basic" questions remain unanswered.

Why did the epidemic reach such devastating proportions in sub-Saharan Africa while it was quickly subsiding in most advanced countries? This question, for example, continues to stir debates.

Various theories however have been proposed, in particular the practice of "concurrent sexual partnerships" in many sub-Saharan African countries, uncommon in other parts of the world. One of the ensuing controversial questions is: Are black people genetically more vulnerable to HIV infection?

Another nagging question is: Why are there so few known cases of woman-to-man sexual transmission of HIV, if such transmissions are as common as they are understood to be? Clearly, a heterosexual epidemic is going on, but perhaps somebody "forgot" to mention that the virus was mostly passing from men to women.

As for women giving it to men sexually, one can hardly ignore the draught of documented literature on the subject.

It certainly looks like scientists might have shied away from getting to the bottom of this "politically incorrect" subject. Perhaps they are purposefully ignoring the possibility that such transmissions may actually be highly unlikely unless under very specific circumstances, considering that "safe sex" messages may lose much credibility if such a scientific discovery was announced to the public.

Naturally, there might also be a hidden agenda to actually nurture the widespread belief that women can transmit the virus sexually to men just as easily as men can pass it sexually to women and to other men.

Experts claim that commercial sex is a significant risk factor in the spread of HIV. HIV prevalence rates among sex workers are indeed generally high. Except for the studies in Kenya and Thailand, however, little is known about HIV prevalence rates among men who buy sex from women. A number of questions relating to HIV-positive men who say they have contracted the virus from sexual contact with women, mainly female sex workers, also remain unanswered.

For example, have these men had sex only with the women or also with male sex workers and/or other men? Have they experimented with injecting drug use some time in their lives? How do they perceive stigma? How knowledgeable are they about HIV?

"Clients of sex workers" have been called an emerging risk group that may serve as a bridge for transmissions of HIV to the general population.

However, while prevention programs targeting this group were called for, experts did not explain how, specifically, most clients of sex workers could be reached in countries where prostitution was illegal, such as Indonesia.

In the developing world, women bear a heavier brunt of the AIDS-stigma compared with men. In countries such as India, for example, women are blamed for their husbands' illnesses and deaths. In many countries, women have been ostracized, shunned, and quarantined. Indeed, women are often blamed for the infection of their partners although there is little evidence to support the allegation.

Researchers agree that most women in developing countries have little control over their social and sexual relationships with men. But there has been an increasing awareness that programs focusing on women alone will not improve gender relations, as such programs tend to ignore the needs of men. Therefore, if the endpoint is "women empowerment", programs need to involve men as well, given that men's attitudes towards sex and sexuality remain little understood.

Quite possibly, cases of woman-to-man sexual transmission of HIV are few, indeed, as it is likely that such transmissions may only occur under very specific circumstances. So perhaps, as a start, we should ask men why they say they got HIV from women, considering that risk factors linked to HIV-infections are based on self-reports.

While self-reports may be substantiated, they are also subject to biases, such as problems of recall, self-deception, perceived stigma, social desirability, etc. By involving men, more effective HIV prevention methods may be produced. Perhaps then, we will also gain a better understanding on how to address the broader inequalities that pose a threat to sexual health.

Only then, there is hope that society will be able to appreciate that women are often blamed as the vectors for HIV infections when they are, in fact, unsuspecting victims.

The writer has a Master's degree in Social Behavior Studies in HIV/AIDS from the University of South-Africa. The above article is based on her PhD thesis proposal. She can be contacted at apelint@bit.net.id