Expert Group Meeting on
"The HIV/AIDS Pandemic and its Gender Implications"
13-17 November 2000
Windhoek, Namibia
Women, Youth and HIV/AIDS in Kazakhstan
Prepared by*
Baurzhan Zhusupov
Public Opinion Research Centre
Kazakhstan
*The views expressed in this paper, which has been reproduced as received, are those of the author and do not necessarily represent those of the United Nations.
WOMEN, YOUTH AND AIDS/HIV IN KAZAKHSTAN
CONTENTS
1. General information about the country
2. The epidemiological situation with the HIV infection in Kazakhstan
3. The use of drugs
3.1. Gender aspects of the drug use
3.2. The risk degree of drug users behavior
4. Sexual behavior
4.1. The STI incidence rate
4.2. Awareness about STI/AIDS/HIV and ways of protection
4.3. Sources of information about safe sex and STIs
4.4. Treatment of STIs
4.5. The degree of a woman’s responsibility for her health
4.6. Gender distinctions in seeking of safe sexual relations (cultural aspect)
5. An analysis of the current activity in prevention of the HIV/AIDS spread
5.1. Actions of the state bodies
5.2. The role of the commercial sector
5.3. The role of public organizations
6. Recommendations
1. General information about Kazakhstan
Kazakhstan is a unitary democratic secular state with the presidential form of government. President is selected for the period of 7 years. The Parliament, whose functions include adoption of laws, amending them, ratification and denunciation of international agreements, consists of two Chambers.
There are 14 oblasts (provinces) in the Republic. Local state governance is performed by representative bodies of power – maslikhats elected by the population, and by executive bodies headed by akims nominated by the President. The capital is the city of Astana.
The territory of the Republic of Kazakhstan is about 2,700,000 km2. In terms of territory, Kazakhstan is the 9th in the world. The Republic is situated in the Central Asian region and borders on China, Russia, Uzbekistan, Kyrgyzstan and Turkmenistan. As of 1 January 1999, the population was about 15 mln. The population density is 5.5/km2.
National composition: 52 % -- Kazakhs, 31 % - Russians, 17 % - other nationalities. The shares of urban and rural population make up 55.9 and 44.1 %, respectively. The literacy level of the adult population is almost 100 %.
The transition period, which all CIS countries are going through, has caused dramatic changes in all social spheres. The Human Development Index (widely considered as an important characteristic of the quality of life) has considerably declined owing to two indicators – GDP and average life expectancy. As a result, Kazakhstan’s HDI rank of 33 in 1991 went down to 76 in 1998 years.
2. The epidemiological situation with the HIV infection in Kazakhstan
If compared with other regions, Kazakhstan belongs to the countries with a low HIV infection prevalence level: just slightly above 1,000 cases were registered by the end of 1999. At the same time, experts believe that the real number of HIV cases exceeds the above mentioned figure at least tenfold. The reason for that is low technical equipment for diagnostic procedures at the so-called "Aids Centers" – the network of official establishments entitled to engage in all issues concerning the AIDS/HIV prevention and treatment in the country. It is noteworthy that 833 cases of the HIV infection out of the total (83 %) are accounted for by Temirtau, a factory town in Central Kazakhstan with the population of 150,000. According to the UNAIDS experts, there are about 3 thousand injectional drug users. The scenario of the spread of the HIV infection can be called "classical" – 84 % of all HIV infected are injectional drug users. The conclusion follows that, having in the centre of the country a case of a local HIV infection epidemic among injectional drug users, Kazakhstan, nevertheless, can be entered into the list of the countries with a HIV infection incidence rate. Such a situation at this point in time provides a unique opportunity for an attempt to prevent the further spread of the infection. A delay would be mortally dangerous: the year of 2000 has witnessed a growth in the number of HIV infection cases in other cities – Shymkent (Southern Kazakhstan) and Pavlodar (Northern Kazakhstan); a catastrophic increase in the STI morbidity level has been observed.
There is a powder keg under a huge country in the center of the Central Asian region "quiet" in respect of an AIDS/HIV pandemic …
3. The use of drugs
It is necessary to note an increased level of drug use. According to a sociological research carried out by commission of UN OODCP, not less than 170,000 people in the republic regularly use drugs, two thirds of them being hard drugs (opium and heroin). The majority of the users are young people in the age up to 35. The primary way of drug application is intravenous. The significant growth of the number of drug users causes alarm. One of its main causes is availability of drugs as a result of transparency of borders and their proximity to Afghanistan, the largest drug producer. The yield of raw opium this year there is predicted to be up to the level of 5000 tons.
3.1. Gender aspects of drug use
In order to develop efficient interventions for prevention of AIDS/HIV prevalence, it is important to establish determinants – the causes affecting behavior that raises the risk of HIV infection. The majority of such determinants differ with regard to gender. Thus, 80 % of the registered HIV infected people are men (injectional consumption rate among them is a few times higher, and the current dominant way of HIV transfer is sharing syringes during the use of injectional drugs). But the situation is changing: the statistics shows a growth of the share of women among the persons subject to narcotic dependence, which strengthens the degree of women’s vulnerability with respect to the HIV infection.
According to the results of a research (UN ODCCP, 2000) every 5th Kazakhstani in the age of 15 - 49 has tried a drug at least once in his/her life. Such "curiosity" is five times higher among men than women, which was not the news for the researchers.
An alarm-causing fact is a greater growth of the number of drug dependency cases among the women in comparison with those among the men (data for 1999 - 2000). The following determinants influencing the decision of a Kazakhstani to try a drug were determined:
- stereotype of a "man's behavior" (a "real man" man must try everything);
- use of alcohol and tobacco (hedonistic behavior style);
- adverse climate in the family;
- influence of the nearest environment – negative examples;
- weak influence of cultural traditions and social norms of behavior (restrictors).
What is happening today to women in Kazakhstan – an Asian country? Is the stereotype "only men are subject to the smoking and alcohol habits" quite correct? For the last seven years, the level of tobacco consumption in Kazakhstan increased by 8 %, but among the women this parameter increased by 12 %. The same situation is observed in the statistics of the alcohol consumption growth.
Dramatic socioeconomic changes of the transition period – 10-year-long independence of the country – could not but render a negative effect on other determinants that play a role in increasing the risk of drug abuse in women: the above mentioned and the varying stereotypes of behavior in the family, the negative influence of the milieu (mass import of western pop culture of doubtful value) and the change in the moral norms of behavior in society.
3.2. Degree of the risk of drug users behavior
The express analysis of the situation (UNAIDS, 1998) in the two largest cities of Kazakhstan -- Almaty and Shymkent -- has shown that among injectional drug users (IDUs) the behavior connected with the HIV infection risk is widely spread: 80 % of the studied IDU group practiced sharing syringes or solutions. The behavior of the men and women in this case was identical. Gender differences were revealed to the full extent when the analysis of the sources of means for the purchase of drugs was carried out. A significant part of the IDU women earned the money for purchasing drugs by prostitution, which sharply increases the probability of the HIV going beyond the limits of the IDU population group.
4. Sexual behavior
The stage of vertical development of the HIV infection through joint intravenous drug use is currently coming to an end. This is testified by the data according to which about 40 % of new cases of the HIV infection are connected with heterosexual contacts.
The dramatic scenario of the AIDS/HIV spread in other countries can be repeated in Kazakhstan where the society is not ready to independently cope with the solution of this problem.
4.1. The STI incidence rate
The STI incidence rate is an important parameter of the incidence of the sexual behaviour connected with the HIV infection risk. According to the results of the sociological research carried out among the university students of Almaty – the largest city of the republic, up to 30 % of the respondents have had sexually transmitted infections (STIs).
A dramatic growth in syphilis from the beginning of the 90s from the level of 1.4 cases/100,000 population up to a level 640/100,000 (current official statistics for 2000) in combination with the data testifying to a faster relative growth of heterosexual HIV infection in Kazakhstan give cause to a serious concern about the epidemic spread in the country and in the Central Asian region.
It is impossible to disregard a problem of prostitution that has become a widespread phenomenon during the transition period of the country’s social development. According to UNAIDS experts, only in Almaty with the population of 1.5 mln., there are about 30,000 people involved into commercial sex business. Medical examinations of this population group have revealed about 70 % of STI cases. This phenomenon is not only conducive to distribution of the HIV infection, but also negatively influences women’s status and situation in society, aggravating the already clearly expressed stereotypes about their subordination.
4.2. Awareness about STI/AIDS/HIV and ways of protection
More than 90 % of the young population of the country (UNAIDS, 1999) are informed about existence of the STIs, mainly syphilis and gonorrhea. In the opinion of 95 % of the respondents, unprotected sex (without a condom) results in a high risk of the STI infection. It is of special importance that half of the surveyed students believe that the risk also exists in sharing plates and glasses, towels and the toilet with an STI-infected person. Thus, the erroneous opinion that the STIs are transferred not only through sexual contact is widely spread. As a matter of fact, girls are more susceptible to this error and are afraid of imaginary dangers more than young men. The consequence of such delusions is that, as compared with men, only 41 % of the surveyed women would agree to look after an HIV-infected relative at home, while among the men the corresponding figure is 64 %. The high level of stigmatization of the HIV-infected and their relatives is reflected in actual cases. In Pavlodar, a mother of a convicted HIV-infected woman could not find people to look after her child even for pay. Suicide has become the leading mortality cause among the HIV-infected people.
4.3. Sources of information about safe sex and STIs
The main source of the information about the STIs in Kazakhstan is the mass media. The second source of the information in terms of influence is an informal dialogue with the people around. What's more, it is astonishing how insignificant a role parents and educational institutions play in forming of a safe sexual behavior of the youth (see Table)
Table. Sources of information about safe sex and STIs
(Survey of 400 Almaty students, 1999)
Sex |
||||
Men |
Women |
|||
Cases |
% |
Cases |
% |
|
| TV & radio | 107 |
53,5% |
137 |
68,5% |
| Press | 123 |
61,5% |
138 |
69,0% |
| Peers | 102 |
51,0% |
98 |
49,0% |
| Sexual partners | 52 |
26,0% |
37 |
18,5% |
| Parents/relatives | 67 |
33,5% |
42 |
21,0% |
| VD dispensary | 9 |
4,5% |
9 |
4,5% |
| Special literature | 7 |
3,5% |
11 |
5,5% |
| School/colledge/university | 14 |
7,0% |
||
| Others | 1 | 0,5% |
5 |
2,5% |
| TOTAL | 300 |
237,3% |
200 |
245,5% |
This is all explainable. The former Soviet ideology did not allow even imagining a discussion between the parents and children of the theme of safe sex. A familiar expression "There is no sex in the USSR" of a female participant of the USSR-USA TV bridge needs no comment. With elimination of the total ideological communist control on the pages, flows of information of erotic and pornographic nature rushed on newspapers and TV screens. In the conditions of long information famine, the consumption of information could not be selective. The reaction of any person, when he or she cannot separate dangerous and useful phenomena, is predictable. Such a person is afraid of everything. Parents, when they oppose sexual education of schoolchildren, are guided by the same logic. The parents’ fears are obvious: in their opinion, sexual education of teenagers reduces cultural taboos on extramarital sexual contacts and raises a probability of an early sexual debut. Unfortunately, the theme of sexual education in Kazakhstan’s secondary schools did not become a subject of public debate, and there has been no research of the influence of education in the area of the HIV infection and sexual health on the sexual behaviour of young people.
But it can be already stated now that the cultural norms of morals and behavior of today's Kazakhstan limit access to useful information for women, both teenage and older. Young men speak with their male peers about sex more freely than girls, for whom it frequently remains taboo.
It is remarkable that use of different sources of the information results in a significant difference in their further behavior. The majority of the young people who had received the information about STIs from their peers and sexual partners in a case of disease resorted to self-treatment or addressed people without medical education as compared with the students who had received the information from medical specialists.
4.4. Treatment of STIs
According to the data of researches, in a case of disease the smaller part of young people addressed state hospitals that have the exclusive right to treat venereal diseases. They are not satisfied with the service and, most importantly, the degree of confidentiality.
The situation is aggravated by the fact that the system of STI/AIDS/HIV prevention and treatment was and remains repressive. All measures connected with these diseases are still in the competence of the state bodies. According to legislation, an infected person has to disclose his or her contacts. The practice of compulsory STI treatment is still in place. However, the actual practices show that such conservatism does not correspond to the realities of life. The proof is in the sharp growth of the STI incidence, whereas the number of visits in state medical establishments has considerably decreased –their share makes up only from 20 to 40 % of STI cases. Despite an obvious inefficiency of the system of STI treatment, venereologists are very much opposed to demonopolization of their activity arguing that GPs are unable to treat STIs. However, a model experiment in Jezkazgan, in which family ambulances were allowed to examine and treat patients with the STIs, proved the opposite: the level of applications of STI patients for qualified medical help increased, whereas treatment’s efficacy was high.
4.5. The degree of a woman’s responsibility for her health
The former USSR’s public health system was effective enough in terms of prevention and treatment of infectious diseases. Its principles were comprehensive coverage, free and, under certain conditions, compulsory treatment and preventive examinations. However, in essence that system equaled to public control of the behavior of an individual resulting in dependence and a low degree of responsibility for one’s own health. Survey of 2,000 women showed that only half of them applied for qualified medical help the respective last year. The most important behavior-influencing factor connected with seeking and receipt of treatment became not the material status and health condition but the habit to address the doctor at emergence of health problems. Thus, it was found out that useful vital behavior-influencing skills and forming of the adequate attitude to one’s health are observed in a rather small part of the country’s female population.
4.6. Gender distinctions in seeking of safe sexual relations (cultural aspect)
The data received in the survey of Almaty students show that the purchase of condoms by virtue of traditions and education remains a man's prerogative: among the unmarried sexually active young people, men buy condoms three times more often than women (92 % and 30 %, respectively). The requirement for the woman to ensure the safety of sexual contacts by means of condoms is not always justified, as the condom is a man's means of preventive control, and women, frequently, have limited opportunities to influence their partners’ behavior. Therefore, preventive measures directed at reduction of the danger of sexual contacts should take into account the features of the system of mutual relations between the sexes. Unfortunately, since there have been no researches of the influence of cultural stereotypes on sexual behavior of men and women, this report is limited with the determinant of family violence against women. In our opinion, a lint can be traced between family violence and women’s vulnerability in sexual relations, since in both cases women are in the conditions that render them incapable to fence off the undesirable influence of men and to affect their behavior.
The sociological research carried out among 1500 women in 1999 showed that 28 % of married women were exposed to violence on the part of their spouses.
The following factors rendering independent influence on the probability of family violence were determined:
The change of the society’s attitude to the use of alcohol, formation of equal responsible attitude to family duties, decrease in the influence of the stereotype of the woman’s subordination are capable to reduce, in opinion of researchers, prevalence of family violence against woman.
5. An analysis of the current activity in prevention of the HIV/AIDS spread
An analysis of the situation with the AIDS/HIV incidence in the republic and the factors contributing to it would be incomplete without the analysis of the position and actions of the key agents: the state, business structures and public organizations.
5.1. Actions of state bodies
One would like to believe that the Government of the country sufficiently realizes the gravity of the situation. Thus, for example, there exists an authorized plan of measures directed at counteracting the AIDS/HIV spread. However, the proposed approach to the decision causes concern. The state sees the spread of AIDS/HIV, first of all, not as a social, but as a medical problem, the ways of whose resolution lie in the regulatory and administrative dimensions. The inefficiency of such an approach was already revealed in connection with the sharp growth of STI morbidity. After becoming independent, the state has never allocated any budgetary means for funding public projects in the sphere of AIDS/HIV prevention.
A positive fact is joint developing by the Government and UNAIDS of a strategic plan based on the assessment of the situation and the conducted measures. The plan is expected to result in a maximum efficiency of the subsequent actions in the sphere of prevention of the AIDS/HIV spread. Young people have been determined as one of the priority groups of this action plan. The plan was developed with the account of gender distinctions and an attempt to reduce the level of women’s vulnerability. As to practical implementation of this plan at the level of state structures and public organizations, it would be a large exaggeration to speak about any positive changes and results to date.
5.2. The role of the commercial sector
The commercial sector is showing practically no activity in this issue. The reasons are banal enough: absence of the traditions of charity in combination with the tax policy of the state, which makes charity disadvantageous. One exception has become financing of the project on prevention of AIDS/HIV in the town of Temirtau where a foreign company ISPAT KARMET (India) owning the largest metallurgical combine of the former Soviet Union that is located in this town has understood the gravity of the problem (and possible the economic losses from the AIDS/HIV epidemic) and has allocated of 100,000 US dollars for support of the syringes exchange projects for drug users.
5.3. The role of public organizations
Their creation and activity did not become a reflection of the realized public needs, that is a grassroots initiative. The merit in formation of the third sector belongs to the international organizations financing NGOs and de facto determining their policy. Moreover, the actions of NGOs directed at prevention of AIDS/HIV and syringes exchange projects, in particular, not always find understanding among the population. According to sociological researches, the majority of the people in Kazakhstan is inclined to strengthening a repressive policy even in relation to drug consumers, let alone the persons involved in their trafficking.
Thus, the actions of the society as a whole in reply to the AIDS/HIV epidemic in
Kazakhstan cannot be called adequate. The major factor in this situation is insufficient
understanding of the determinants causing the spread of AIDS/HIV and dissociation of the
actions of the key agents capable to affect them. 6. Preliminary recommendations
Initiation of public debate on the theme of necessity of education in the field of sexual health among schoolchildren considering the availability of reliable and authentic researches showing influence of this education on sexual behavior of the youth.
Conduct of a gender research aimed at defining cultural, social and economic determinants on the sexual behavior of the youth.
Formation and support of a research network, introduction of modern methods of behavioral researches that take into account the gender specificity; search of sources of funding of these researches.
Coordination of the actions of international donors and UN agencies in the spheres of HIV/AIDS prevention, drug abuse, and formation of safe sexual behavior.
Development of a special project aimed at informing the officials of the state bodies and persuading them to increase the degree of responsibility for formation and implementation of an adequate policy of prevention of the AIDS/HIV spread in Kazakhstan.
Formation of a public opinion through developing of a special project for organization of the system of trainings for local journalists.
Involving of the network of NGOs, including public female organizations, in the sphere of prevention of AIDS/HIV.
Increase of the level of knowledge of various population groups of Kazakhstan through step-by-step measures, namely:
1) precise segmentation of target groups by gender, age, geographical and professional attributes;
2) development and introduction of the special information-and-educational programs for these population groups considering their real and potential danger in the spread of the infection; degrees of their influence on the behavior of other people; peculiarities of their perception of information and the level of available knowledge about the issue in question;
3) development of a system of assessment of the success of these programs.