Promoting Women’s Employment, Income and Livelihood Opportunities
Women's economic dependence on men and unequal access to resources, including land and income-generating opportunities, increases the likelihood of women and girls engaging in a variety of unsafe sexual behaviors including transactional sex, coerced sex, earlier sexual debut, and multiple sexual partners, and thus increases their risk of becoming infected with HIV (Gillespie and Kadiyala, 2005).
A Womans Economic Stability Can Enhance Her Ability to Insist on Safer Sex
Married women and women in partnerships often accept risky behavior by their partners due to the need for economic security. A study in Vietnam in 2004 and 2005, consisting of interviews with 23 husbands and 23 wives, along with 15 key informant interviews found that because women needed the economic benefits of marriage, women acquiesced to their husband's multiple partnerships or purchasing sex with sex workers. Independent sources of income and employment for women may allow women to insist on safe sex (Phinney, 2008). Similarly, a qualitative study in Brazil among women with children enrolled in a day care center found that financial dependence is the factor that most contributes to accepting a man's multiple sexual partnerships. As one woman put it: "She accepts his infidelity because... she's thinking... How will I care for the children? How will I find a job?" (Hebling and Guimaraes, 2004: 1215). The authors point out: "The results show that although women know how they should prevent... AIDS -- by using condoms -- they feel powerless to do so, since they feel that this depends on the man's wishes. They admitted that they don't have the real decision power... where 'the man always has the final word.' Fear of separation was associated with loss of financial... stability" (Hebling and Guimaraes, 2004: 1216). A study in South Africa found that the women interviewed claimed that if they had jobs, they would be able to refuse sex to men who refused to wear condoms. The women said, "Poverty makes prostitutes of us" (Susser and Stein, 2000: 1044). A study consisting of group discussions with 160 men and women and in-depth interviews with 29 men and women found that financially dependent women feel they have no choice but to accept risk or try to leave a risky marriage to seek financial security whereas financially autonomous women will negotiate condom use with their husband. Gender norms require that married women are responsible for ensuring protection against their husband's infidelity, despite the fact that men decide on condom use (Bandali, 2011b).
"The owners of the fish nets are men. The woman comes to this man who says 'You want some fish, give me sex.' The woman has to feed her family, so she cant say no." --Malawian man (Kathewera-Banda et al., 2006: 655)Economic independence may not always have a clear-cut role in HIV acquisition, however. One study found that both wealth and poverty may have associated risks and protective effects for HIV acquisition, depending on the different contexts. "Being poor or being wealthy may be associated with sets of behaviors that are either protective or risky for HIV infection" (Parkhurst, 2010: 524). For example, a woman who has no resources may have sex with multiple partners to feed her children; men who are wealthy may have multiple partners as a sign of status. A review of 41 studies found that context specific factors influence whether financial autonomy is protective or associated with increased risk of intimate partner violence in low and middle-income countries (Vyas and Watts, 2009). Another more recent study found that women who gained employment in India following unemployment were at increased risk of violence (Krishnan et al., 2010).
In certain circumstances, providing microfinance for women can reduce unsafe sex (Pronyk et al., 2008a). Although there is a need for better indicators to measure the HIV/AIDS-related impact of economic empowerment on women and girls, studies have consistently shown that increasing women's access to information, skills, technologies, services, social support, and income increased their ability to protect themselves from HIV (Weiss et al., 1996 cited in Weiss and Gupta, 1998; Kaufman et al., 2002).
Condom use is an example of this. Women's "inability to negotiate [condom use] is closely linked with women's inferior economic situation: women's frequent dependency on men renders them more likely to fear abandonment and the destitution that might ensue as a result of confronting or leaving their partners" (Mane et al., 2001: 10). With financial independence, women are better able to negotiate protective behaviors. Women around the world describe economic dependence on men. In the words of a sex worker in India, "I used to think why I should live such a horrible life with him. But I know how difficult it is to survive without any support" (Panchanadeswaran et al., 2008).
Conditional cash transfers (CCT) are being introduced to address risk factors for HIV, including a CCT program in Malawi to encourage girls to stay in school (Baird et al., 2012), and the ongoing RESPECT (Rewarding STI Prevention and Control in Tanzania) study. Cash transfer programs are not without controversy. For example: Should they be conditional or unconditional? What are appropriate conditions or behaviors to target through a cash transfer program? What is the appropriate length of a cash transfer intervention? What happens when the intervention ends? A randomized trial found evidence of effectiveness (Baird et al., 2012), but clarification is needed on the "mechanism by which the intervention worked" (Pettifor et al., 2012c: 1). A literature review by Concern and Oxfam GB on conditional cash transfers found that in some cases, cash transfers worsened relations in the community by displacing sharing strategies which could result in increased long-term food insecurity. They can also reinforce, rather than challenge, women's traditional household roles. On the other hand, transfers may increase women's self-efficacy to handle money and increase male acceptance of women handling money. An additional issue is that "men are often negatively stereotyped as self-serving... and irresponsible... Some men may... feel excused from responsibilities or disempowered..." (Brady, 2011: 12, 17-18). "Women's empowerment is not an automatic by-product of a cash transfer program" (Brady, 2011: 26).
Economic Empowerment Can Greatly Enhance Womens Lives
The International Community of Women (ICW) network has found that "the most commonly expressed need from women in sub-Saharan Africa is support and training on establishing income-generating projects in the hope that they can earn income which will alleviate the difficulties they face in their day to day lives" (Manchester, 2004: 95). As one woman living with HIV from Cameroon put it: "We have to look for ways and means to get out of this abyss. Rather than seek alms we must look for an honest livelihood" (ICW, 2000: 11, cited in Manchester, 2004).
Access to treatment can be beneficial in increasing employment access for people living with HIV. In India, access to HAART resulted in a rapid increase in employment and income for 1,238 HIV-positive patients (including those not eligible for HAART) followed between 2005 and 2007. At six months after initiation of treatment, patients were 10 percentage points more likely to be economically active and at 24 percent the employment increases remained large and significant, although the effects were nearly twice as high for men as for women. One possible explanation for this is that employment outcomes in the study did not include domestic work such as cook or housekeeper, jobs of relevance to women (Thirumurthy et al., 2011).
Economic empowerment of women and girls requires that they have access to vocational training, and opportunities to develop practical and business skills. Women also need access to financial resources to support the establishment of small businesses. The loans through microfinance programs are often very small "...and would more accurately be viewed as increasing the ability of households to survive rather than as 'economic empowerment'..." (Dworkin and Blankenship, 2009: 465). But skill sets taught by microfinance programs, such as assertiveness, recognition of gender norms, etc. may help women negotiate safer sex (Dworkin and Blankenship, 2009).
Finally, in some countries, women (and men) living with HIV face employment discrimination because of their HIV status. For example, some employers require HIV testing as a condition of employment, while others have abused the employment rights of workers who test positive (HRW, 2004a; CHANGE, 2009). Laws to protect people living with HIV and AIDS, especially women, from employment and other forms of discrimination must also be enacted and enforced. [See also Advancing Human Rights and Access to Justice for Women and Girls]