94 © 2015 Conscientia Beam. All Rights Reserved. FEMINIST PERSPECTIVE OF HIV AND AIDS: CASES FROM THE KATHMANDU VALLEY OF NEPAL Tej Bahadur Karki1 1PhD Scholar, Dr. K. N. Modi University, Rajasthan, India ABSTRACT Human Immunodeficiency Virus (HIV) is behavior disease transmits from one person to another person due to unsafe sexual practices. HIV infected females are more suffered from the social stigma and discrimination. The main objective of this study is to identify the risk of HIV transmission among the women or girls from the feminist perspective. Simple random sampling technique was used to select the respondents from the vulnerable groups of Kathmandu valley of Nepal. Total 404 respondents were included from the reproductive age (15-49) groups. Analytical research design used to analyze the data. There was significant association found among the respondents in relation to the polygamy, human trafficking, trust on sex partners, gender based violence, early marriage system and gender inequality as an associated factor with increasing the risk of HIV transmission at .05% significance level. On the global scenario, women are more vulnerable than male for HIV transmission because of their biological as well as socio-cultural characteristic. In Nepal, majority of male are found living with HIV and AIDS than female but female are facing the stigma and discrimination than male because of the patriarchy thought. Basically, socio-cultural practices are supporting the risk practices in Nepal so prevention program should be launched adopting the gendered based approach. Keywords: AIDS, HIV, Feminist, Gender, Nepal, Socio-culture. Received: 7 March 2015/ Revised: 3 June 2015/ Accepted: 8 June 2015/ Published: 12 June 2015 Contribution/ Originality This study contributes in the existing literature from the two aspects; one, it will provide the knowledge of feminist perspective of HIV and AIDS, second, it will provide research gap to address the issue of HIV and AIDS from the socio-cultural perspective. Humanities and Social Sciences Letters Vol. 3, No. 2, 94-104. ISSN(e): 2312-4318 ISSN(p): 2312-5659 DOI: 10.18488/journal.73/2015.3.2/73.2.94.104 © 2015 Conscientia Beam. All Rights Reserved. http://crossmark.crossref.org/dialog/?doi=10.18488/journal.73/2015.3.2/73.2.94.104 Humanities and Social Sciences Letters, 2015, 3(2): 94-104 95 © 2015 Conscientia Beam. All Rights Reserved. 1. INTRODUCTION Gender relation is the base of family structure so male and female is equally responsible to address the social issue. Nancy Chodorow has argued that gender identity is socially constructed differently for women and men because women are the primary caretakers. This inequality can be corrected by a fundamental reorganization of parenting (Chodorow, 2011). Because of the long history of socio-cultural orientation of society, gender base stratification and discrimination is still high in rural society of Nepal. In the case of HIV infection, female has to face the double discrimination from the family and society. Females are marginalized in the different level of society. Considering the issue of female, Feminists have advocated on theoretical and practical issue of female. Berger and Luckmann (1996) has explained the issue of HIV and AIDS from the feminist perspective that AIDS is a socially constructed disease and much of the response and attitudes towards HIV-infected individuals' center around the pre-existing concept, paradigms and societal construction of those affected. Social construction theory is concerned with way in which societies interpret, judge and ascribe meaning to groups, conditions and events (Beine, 2003). Feminist Theory states that men and women should be politically, economically and socially equal. Feminist theory separated the social from the biological, insisting that there is difference between what is the product of human ideas, hence something mutable and changeable, and what is the product of biology, hence something (relatively) stable and unchangeable. Feminist theory is very much related with the Behaviors of human being. HIV and AIDS is a Behaviors disease. Consideration of on equal basis female has the right to “Say No” (Khan, 2000) regarding the sexual relation. But, coercion and rape are common in many sub-Saharan African countries meaning that many young women are unable to negotiate condom use or to refuse unwanted sexual advances. It may increase the risk of HIV transmission if trauma to the genital tract was sustained at coital debut due to rape " (Audrey and Pettifora, 2004). Globally, in total estimated 35.3 (32.2–38.8) million people; 17.7 million [16.4 million – 19.3 million] women were living with HIV in 2012 (UNAIDS, 2013). When one isolates the statistics by region and gender, they show considerable variation, with a higher percentage of women infected, especially in Sub-Saharan Africa. The recognition of this inequality leads to the development of the term, „feminization of AIDS,‟ which points to the social and biological features of women that place them in a vulnerable position (Warren, 2010). According to the Abramson, the spread of HIV and AIDS in countries around the world has drawn attention to the serious lack of scientific research on human sexuality (Richard and Parker, 1991). In early scientific, policy, and popular discourses around HIV and AIDS, polygyny often features as a cultural practice that facilitates the spread of the epidemic (Gausset, 2001). Due to misconceptions and incorrect belief; "Young girls are at particular risk of rape and sexual coercion because it is believed that sex with a virgin "cleanses" or "cures" HIV and AIDS of men" (Sharma, 2006). It is reported that "young women often face physical and sexual violence from their husband, family members, teachers, partners and employers as a result unwanted pregnancies, Sexually Transmitted Infection (STI) and HIV and AIDS were rampant" Humanities and Social Sciences Letters, 2015, 3(2): 94-104 96 © 2015 Conscientia Beam. All Rights Reserved. (WHO & UNAIDS, 1999). Physical and sexual violence creates the unsafe environment to female which makes them vulnerable for Sexually Transmitted Infection. A common belief is that child marriage protects girls from promiscuity and, therefore, disease; the reality is quite different. Married girls are more likely than unmarried girls to become infected with STIs, in particular HIV and human papilloma virus (HPV). In sub-Saharan Africa, girl's ages 15–19 years are 2–8 times more likely than boys of the same age to become infected with HIV (Laga, 2001). As Joint United Nations Programme on HIV and AIDS, World AIDS Campaign 2004, stated that the risk of acquiring HIV from a single act of unprotected vaginal intercourse is 2–3 times greater for women than men (Nour, 2006). In Nepal, the total number of people living with HIV for 2011 is estimated at 50,200 with an overall national HIV prevalence of 0.3 per cent. This is a decline from 2010 national prevalence of 0.38 per cent. By sex, more than two-thirds of the infections have occurred among males (66.5%). 33.5% of infections are in women, out of which around 84% are in the reproductive age group of 15-49 (National Centre for AIDS and STD Control, 2012). As the NCASC report of December 2013, 28% of women of 15 - 49 ages were living with HIV (of estimated adult PLHIV). Annual number of new infection of Male to Female ratio was 1,408 (1.9). Similarly, Annual number of new HIV infections of Male was 937 and Female was 471. The data of Nepal shows the high prevalence among the male than female but in reality, females are found socially and economically more suffered than the male because of the stigma and discrimination from the family and society. The study is the original work focused to explore the association between socio-cultural practices and risk of HIV transmission from the feminist perspective. 2. METHODOLOGY Descriptive and analytical research design was adopted in study. Cross-section non- experimental data was collected. Study was conducted among the 404 respondents of garment factory workers, brick factory workers, transport workers and health workers of Kathmandu valley of Nepal in 2013. Multi-stage simple random sampling technique was used to select the study area and respondents. Respondents were selected from the reproductive age (15-49) groups. Concurrent mixed method was applied to collect the qualitative and quantitative data. Structured questionnaires survey was done to collect the quantitative types of data and key-informant interview was done to collect the qualitative data. Quantitative data was analyzed by using the SPSS (20 version) and manual editing was done to analyze the qualitative data. The ethical approval was taken from the Nepal Health Research Council (NHRC). Written consent was taken from the respondents also. 3. RESULT AND DISCUSSION The study had collected the demographic information of respondents. In total, 29.46% females participated in study. Similarly, 57% respondents were married and rest was unmarried. As per ethnicity 53.2% of respondents were Janjati (ethnic group) followed by 30.44% Chhetri and Humanities and Social Sciences Letters, 2015, 3(2): 94-104 97 © 2015 Conscientia Beam. All Rights Reserved. Brahmin, 11.38% Dalit and 5% Muslim/Yadav were participated in research. The mean age of the respondents was 27.31 years and Std. Deviation was 7.614, which ranges from 15 years to 49 years. In total, 4.7% respondents were illiterate, 7.92% were just literate, 25.50% respondents had completed primary level of education followed by 21.29% had lower secondary level, 13.12% had secondary level and 27.48% respondents had Higher secondary level and above. 3.1. Association between Polygamy (Multiple Sexual Partners) and Risk of HIV and AIDS Legally, polygamy system is punishable in Nepal but it is found is practice of individual life. Because of social or economic factors, people engaged with multiple sexual partners which increase the risk of HIV transmission. In polygamy system, female becomes the more victim. So regarding this problem, respondents were asked about the association between polygamy and risk of HIV transmission. The responses of respondents are tabulated in table 1. Table-1. Polygamy and risk of HIV and AIDS Sources: Field survey, 2013 In total, 87.4% of respondents were strongly agreed that polygamy is associated with increasing the risk of HIV and AIDS in Nepalese context. Similarly, 6.9% respondents were agreed followed by 3.2% were neutral, 1.5% strongly disagree and 1% were disagreeing. In single sentence, it is found that more than 95% respondents were agreed that there is association between polygamy and increasing the risk of HIV and AIDS. The findings of the study can be discussed with the similar study. As Cates and Stone (1992); Kost and Forrest (1992) mentioned that a large number of sexual partners were an important indicator of an elevated risk of contracting an STD, including HIV." Similarly, IOM (1997) also reported that "adolescents are more susceptible to STDs than adults because they have a higher probability of having multiple sexual partners" (Guang Guo, 2008). There was significant association (p=.002; it is less than .05) found between respondents of different occupation in their perception on polygamy as an associated factors with increasing the risk of HIV and AIDS. From the feminist perspective, polygamy is taken as the violence on female so we found the perceptual association among the different groups of respondent. Humanities and Social Sciences Letters, 2015, 3(2): 94-104 98 © 2015 Conscientia Beam. All Rights Reserved. 3.2. Association between Human Trafficking and Risk of HIV and AIDS Human trafficking is one of the major social problems which create the gender based violence in society. Illiterate and innocent females are more suffered from the human trafficking problem. As the report of Embassy of the United State, Kathmandu, Nepal, it is stated that Nepal is a source, transit, and destination country for men, women, and children who are subjected to forced labor and sex trafficking. Nepali women and girls are subjected to sex trafficking in Nepal, particularly in the adult entertainment industry and massage parlors, as well as in India, the Middle East, China, Malaysia, Hong Kong, South Korea, and Sweden. The Nepal Police Women‟s Cell conducted 144 sex and labor trafficking investigations under the HTTCA during the Nepali fiscal year ending in on July 15, 2013, compared to 118 cases in the previous fiscal year (Embassy of the United State, 2014). Respondents were asked about association between the human trafficking and risk of HIV and AIDS. 71.5% respondents were reported that they strongly agreed that there is association between human/girls trafficking and increasing the risk of HIV transmission followed by 22.1% were agreed. Only 2% respondents were reported disagree (table 2). Table-2. Human trafficking and risk of HIV and AIDS Sources: Field survey, 2013 The previous study in "Trafficking in Persons Report” 2004, p. 23 stated that between 70 and 90 percent of contemporary traffic in women and children in Europe and Asia is related to prostitution and other forms of sexual exploitation (mainly the pornography industry) (Aromaa, 2006). Similarly, 109 (38.0%) were found HIV positive among 287 sex-trafficked and repatriated Nepalese girls and women receiving services at Maiti Nepal between January 1997 and December 2005 (Jay and Silverman, 2007). There was significant association (p=.000; it is less than .05, df = 12) found on perception of respondents on that human trafficking as an associated factors with increasing the risk of HIV and AIDS. In Nepalese context, girl trafficking is taken as the serious violation against women so it is punishable. Nepali victims are trafficked within Nepal, to India, the Middle East, and other areas are forced to become prostitutes, domestic servants, beggars, factory workers, mine workers, circus performers, child soldiers, and others. The most common root cause or vulnerability factor of trafficking in Nepal, India and Bangladesh is economic insecurity or poverty. Poverty stricken states are the most vulnerable to trafficking. In India, Humanities and Social Sciences Letters, 2015, 3(2): 94-104 99 © 2015 Conscientia Beam. All Rights Reserved. although economic growth is rapidly increasing, the gap between rich and poor remains high. Women especially have lack of access to education and employment. Women and girl children face both gender inequality and caste discrimination in India and Nepal. Lower caste people have less access to education and jobs, and if they are women they have fewer options. The unique feature of the Devadasi and Deuki (culturally sanctioned prostitution) system that produces the supply of young women into commercial sexual exploitation is a distinct vulnerability factor of trafficking in India and Nepal. The number of bonded laborers is also high in India. It is also a part of the cultural practices in the rural areas where in order to repay parents‟ debt people are forced to debt bondage. Child labor also remains a severe problem in India and also in Bangladesh and Nepal. Millions of children work in hazardous situations in the glass bangle factories, brick kilns and circus industry where Indian, Bangladeshi and Nepali children are trafficked and exploited. In the case of Bangladesh, children are trafficked for camel jockeying. Natural disasters and organ trade are other important root causes of trafficking, especially in Bangladesh (Uddin, 2013). 3.3. Trust on Sex-Partner Is One Cause of HIV Transmission Trust on sex-partner is one cultural practice of majority communities. Basically, in Nepalese cultural, women and men both do not try to raise the question about the sexual behavior of their sex partners. I talked with 28 years married Mrs. Thapa (name changed) is living with HIV from 2008 about the causes of HIV transmission. She said "My husband became the HIV positive due to lack of awareness on HIV and AIDS, there may be negligence also. On the other hand, my blind trust towards my husband made me also HIV positive." Similarly, during the questionnaires survey, 48.3% respondents strongly agreed that trust on sex partners is associated with increasing the risk of HIV transmission followed by 28.7% respondents agreed. 5.9% respondents were reported that there is no association between trust and risk of HIV and AIDS followed by 4% respondents were reported strongly disagree (Table 3) Table-3. trust and risk of HIV and AIDS. Sources: Field survey, 2013 Humanities and Social Sciences Letters, 2015, 3(2): 94-104 100 © 2015 Conscientia Beam. All Rights Reserved. There was significant association (p=.001; it is less than .05, df = 12) found between the respondents on their perception on trust on sex partner as an associated factors with increasing the risk of HIV and AIDS. It is the religious and cultural orientation that mostly female follow the instruction and protection of male that they believe in kind responsibilities of male towards their family. In Nepalese context, the blind trust on husband behavior made the HIV transmission to innocent wife so perceptually all respondents had significant association on their response. 3.4. Association between Gender Based Violence and Risk of HIV and AIDS Gender based violence is one of the major factors associated with the increasing the risk of HIV transmission. Respondents were asked about the association between the gender based violence and risk of HIV and AIDS in Nepalese context. In the response of above question, 18.4% respondents were found strongly agree followed by 26.1% respondents were agree against the 9.4% strongly disagree followed by 9.4% disagree. Regarding this question higher numbers (36.7%) of respondents were found to be neutral (Table 4). Table-4. Gender based violence and risk of HIV and AIDS Sources: Field survey, 2013 As finding compared with the previous study; it found the varied result. More than 50% respondents were found disagree on association between the gender based violence and risk of HIV transmission. In previous study, it is found that gender based violence creates the high chances to be HIV infection. According to the Sharma (2006) violence against women is the most disturbing form of male power. It contributes both directly and indirectly to women's vulnerability to HIV. Similarly, WHO & UNAIDS (1999) and Audrey and Pettifora (2004) also reported that more than three-quarters of the young women often face physical and sexual violence from their husband, family members, teachers, partners and employers as a result unwanted pregnancies, Sexually Transmitted Infection (STI) and HIV \ AIDS were rampant. From the discussion in Nepalese context, there was no influence of gender based violence to increase the risk of HIV transmission. Though there was significant association (p=.000; it is less than .05) found between the respondents on their perception towards the gender based violence as an associated factors with increasing the risk of HIV and AIDS. From the field study, it was Humanities and Social Sciences Letters, 2015, 3(2): 94-104 101 © 2015 Conscientia Beam. All Rights Reserved. observed that female who was suffered the domestic violence; were compelled to involve in sex business. Sex workers are high risk group for HIV transmission. NCASC December, 2013 reports has reported that there was 2% prevalence of HIV in Sex workers. 3.5. Association between Early Marriage and Risk of HIV and AIDS In Hindu religion, it is believed that parents can get way of haven if they will arrange the marriage of daughter before her mensuration. The believe system has increased the frequency of sexual violence on female. During the time of questionnaires survey, respondents were asked about that whether there is association between early marriage and risk of HIV and AIDS or not. The responses of respondents are tabulated in following table 5. Table-5. Early marriage and risk of HIV and AIDS Sources: Field survey, 2013 In various previous literatures; early marriage was also reported as associated factor with increasing the risk of HIV transmission. One previous study conducted at Zimbabwe between November 1999 and September 2002 among the 4393 sexually active women aged 18–35 years found that HIV prevalence in this sample was 40.1%. The median age of coital debut was 18 years and 11.8% of women reporting having experienced coital debut at age 15 or younger. Women with early coital debut had a significantly higher risk profile, including multiple lifetime partners and not completing high school (Audrey and Pettifora, 2004). So this variable was also tested in the context of Nepal, but above data shows that 52% respondents are strongly disagree against the 2.7% respondents are strongly agree that early marriage is associated with increasing the risk of HIV transmission. 21.3% are in disagree followed by 16.1% are in neutral. From this study mean age of marriage age was found 22 years but more than 35% had married before 20 years of age. The early marriage system is found high in far-eastern region of Nepal and Dalit (disadvantage) communities of Terain region in compare with other part of Nepal. Though there was significant association (p=.000; it is less than .05) found between the respondents on their perception on early marriage as an associated factors with increasing the risk of HIV and AIDS. In Nepalese culture, early marriage is high in disadvantaged community. In most of the disadvantaged community living in Terain (who are living in boarder area of India) areas has early marriage practice. Because of the early marriage, they are not aware about the care and Humanities and Social Sciences Letters, 2015, 3(2): 94-104 102 © 2015 Conscientia Beam. All Rights Reserved. treatment of their reproductive health; no knowledge of sexually transmitted disease so unknowingly they have chances to suffer the sexual infection. 3.6. Association between Gender Inequality and Risk of HIV and AIDS 37 years HIV positive lady from the Brahmin community; permanent resident of Rupandehi district (out of Kathmandu valley) of Nepal shared her experiences regarding the society‟s and family's attitude towards her by saying that "In the beginning I was afraid from the social discrimination, because our society is dominated by male. But I found not so different behavior from society and family so till social and family relation is good." From the study, gender based relation is found gradually changed in society. Still society is explained as the male-headed society though female participation is also increasing in decision making position. Data was collected from the respondents by asking the question that whether there is association between gender inequality and risk of HIV transmission. Data mentioned that very few (only 8.7%) respondents gave response in strongly agree followed by 29.2% response in agree. Apart from this, 13.9% respondents disagree and 12.1% strongly disagree. Majority of the respondents (36.1%) replied in neutral answer. From this data, it is known that majority of respondents are not sure to say the association between gender inequality and risk of HIV and AIDS (Table 6). Table-6. Gender Inequality and risk of HIV and AIDS Sources: Field survey, 2013 Though there was association (p=.000; it is less than .05, df = 12) found on perception of respondents of different occupation on that gender inequality as an associated factors with increasing the risk of HIV and AIDS. Gender inequality is associated with the power relation. We can observe that still supreme power in family and society is hold by male by culture so most of the female cannot say 'no' to male for sexual intercourse. As a result, female has high chance to be HIV infected if their sex partner is HIV positive. Some previous study stated that gender relationships and sexuality are significant factors in the sexual transmission of HIV and AIDS (Sharma, 2006). Gender norms that create an unequal balance of power between women and men are deeply rooted in the socio-cultural context of each society (Unicef & UNAIDS, 2003). For social and physiological reasons, women and girls are more vulnerable to HIV infections than are men and boys (The World Bank, 2005). Humanities and Social Sciences Letters, 2015, 3(2): 94-104 103 © 2015 Conscientia Beam. All Rights Reserved. 4. CONCLUSION The study is concluded that the socio-cultural practices are changing in the following days in developing countries also like Nepal. Along with it, changes can be observed in gender relation also; the relationship between men and women in general. The socio-economic differences that creates inequality between men and women and these are typically associated with power differences in their relationships, such as work/pay and political association, and rates of violent crimes against women. Women are become more vulnerable to HIV and AIDS, because sociocultural structures of gender and sexuality are entangled within the structural framework that contributes to these vulnerabilities. But these changes in gender relations can have a positive effect on not only decreasing and hopefully stopping the spread of HIV. The sociocultural structures and traditional concepts of gender relation and norms in a society that place women at risk must be addressed from the multidimensional approach. Funding: This study received no specific financial support. Competing Interests: The authors declare that they have no competing interests. Contributors/Acknowledgement: I am very much grateful to my research supervisor Prof. Dr. Ritu Prasad Gartoulla for his close supervision and guidance during my research work. Besides that l like to give my thanks for participants of this research, and Dr. K. N. Modi University, India, Nepal Health Research Council (NHRC), Southwestern Center for PhD studies, Kathmandu, Nepal. REFERENCES Aromaa, M.L., 2006. Trafficking for sexual exploitation. Chicago Journal: Crime and Justice, 34(1): 133-227. Audrey, E. and A.V. Pettifora, 2004. Early age of first sex: A risk factor for HIV infection among women in Zimbabwe. AIDS, 18(10): 1435-1442. Beine, D.K., 2003. 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