Intimate Partner transmission of HIV

Laos PDR
This summary is based on research undertaken by Plurpol Consulting (1) for UN Women. Updated statistics and references are cited as appropriate.
According to available estimates, national HIV prevalence in Lao PDR is 0.2% among adults aged 15-49 (2). Eighteen per cent (18%) of current reported people living with HIV recorded by CHAS are housewives. The estimation and projection show a slight increase in prevalence of this group until 2020. The age group most affected by new infections is 25 to 35 years olds. The National Strategy and Action Plan 2006-2010 did not specifically refer to intimate transmission or sero-discordant couples (1), but the National Strategy and Action Plan 2011-2015 does include reference to low risk women (3): spouses and regular sexual partners of most-at-risk populations are also susceptible to HIV infection, especially since condom use within spousal relations and regular partners appears to be lower than with casual or commercial partners. The strategy also acknowledges that reaching people at higher risk and their partners has challenges, and an effective response requires strategic information, especially surveillance and formative research (3). Although lower risk men and women account for majority of people living with HIV in Lao PDR (in both reported cases and in projections), there has been no recent populationbased study to examine this group to date (4). Surveys and data collection has so far concentrated on key affected populations, particularly, sex workers, men who have sex with men and people who inject drugs (1).

Womens status in legislation

In Lao PDR the Family Law declares equality between men and women, and simultaneously demands that women (and their families) are compensated in cases where men have sex with an unmarried woman. Whilst this may serve as a deterrent for men to commit sexual violence against women, it reflects a continuing emphasis on societys differing expectations of women and men, namely that it is more dishonourable for a woman to have sex outside marriage than a man. The Lao PDR government faces the same challenges as all other governments: how best to ensure the protection of an underclass without reinforcing their lower status in society. This applies to the affirmative references to women in the healthcare and family laws, which promote womens inclusion without necessarily their empowerment, unlike the law on the Development and Protection of Women which focuses on strengthening womens economic positions.

any increase in service availability will reduce peoples travel costs and the need to stay overnight for appointments. Lao PDR faces further challenges in that over half of women deliver their babies at home and do not attend antenatal care services which have conventionally been a key mechanism for reaching pregnant women in other countries in the region. The role of traditional birth attendants offers opportunities for reaching 20% of women, but the need to reach the remaining 55% is a challenge not easily overcome.

Vulnerability to HIV transmission among women in relationships

Some common themes emerged from the three-country study of Laos PDR, Indonesia and Thailand. Sex work is perceived very differently in the three countries despite its widespread prevalence: in Lao PDR sex work mostly takes place informally through women working in bars, although a few brothels also exist. The acceptance/denial of sex work and the forms in which it takes place have implications for how effective each countrys national HIV response is. Lao PDR has responded to sex work with a 100% condom use campaign, following Thailands lead. Given the more informal nature of sex work in Lao PDR it can be hard to reach all women who sell sex, although arguably women working in bars perhaps have more control over who they sell sex to, as they are not obligated in the same way as a woman in a brothel. At the same time sex tourists are reportedly coming to Lao PDR because of the perceived lower risk of STIs and with the intention of

Availability of treatment
Currently, 40-59% of people who are eligible to receive antiretroviral therapy are accessing treatment (5). Although Lao PDR currently has limited comprehensive services coverage, several hospitals provide examples of constructive interaction and supportive approaches to people living with HIV. These should be considered important lessons during the scale up of voluntary counselling and testing coverage. In particular, the increase in HIV related services must not be at the expense of the provision of direct financial support to people living with HIV to access them. Ideally

seeking sex without condoms. Informal street-based sex work is increasing including contacting women (and men) by telephone. In Lao PDR, as in Thailand, traditional practices affect HIV transmission, namely womens abstinence from sex during pregnancy which effectively legitimizes mens extra marital sex during this time. Also in Lao PDR there are opposing expectations of relationships between men and women, with more men looking for short term relationships while women seek long term relationships. Migration affects countries as their citizens leave their borders to work in industries with higher risk of HIV transmission (e.g. sex work) or work for extended periods away from their families and with more opportunities for exposure to HIV and STI infection. At the same time, within countries, migrant workers are often deterred from accessing health services for numerous reasons, such as language barriers, the cost of access for non-citizens, and the illegality of their status in many cases. The impact of migration can be seen in Lao PDR where significant proportions of both women and men migrate internally to the cities industrial areas and over borders. Often men work in the construction industry in countries such as Thailand. The vast majority of women migrate illegally and there seems little that the Lao PDR health sector can do to identify these women as having increased vulnerability due to their migration. Stigma and discrimination continue around HIV and STIs, as does misinformation. In Lao PDR this translates to a relatively low level of knowledge, compared to, for example, Indonesia where myths seem pervasive and are closely linked to mens image of their masculinity and therefore their invulnerability to infections. The lack of information and the existence of misinformation put both men and women at higher risk of HIV and STI transmission.

Most people do not know their HIV status, thereby increasing the risk of HIV transmission within sero-discordant couples for both women and men.

Few women engage in commercial sex as their sole source of income but many women in the service industry (i.e. those working in bars) sell sex sometimes, and increasingly commercial sex is becoming accessible on the street and by telephone.

In Vientiane there is a high HIV prevalence among men who have sex with men, making them and their partners (both male and female) vulnerable to HIV transmission.

Gender inequality reinforces womens low negotiation power in sexual relationships (including condom use in commercial and non-commercial sex) and increases barriers to womens access to information and treatment.

Mens reluctance to attend clinics or seek treatment means they do not prioritise their or their partners sexual health.

The highly dispersed population in rural areas have very low coverage of services.

The sexual patterns of men often include having multiple concurrent partners and the sexual patterns of women include having serial monogamist relationships.

Bibliography CHAS/UNAIDS. (2011). CHAS/UNAIDS Estimation and projection by AEM CHAS/UNAIDS. (2012). Global AIDS Response Progress: Country Report, Laos Kaybryn, J. (2009). Responding to the Feminization of AIDS: Women and Intimate Bangkok: UN Women.

modelling, 2011. CHAS/UNAIDS.

PDR, 2012. CHAS/UNAIDS.

Partner Transmission of HIV, Indonesia, Laos PDR and Thailand.

Summary of womens vulnerabilities to HIV infection in Lao PDR

Seasonal migration for work is a major vulnerability factor for both men and women. 50% of people who migrate externally (especially to Thailand) are women who work in the domestic services or entertainment industry with no legal status or protection. Significant internal migration also occurs from rural to urban areas. The risk of STI and HIV transmission is low in Lao and consequently perception of risk and therefore condom use are also very low among the general population.

NCCA. (2010). National Strategic and Action Plan on HIV/AIDS/STI Control and Control of AIDS.

Prevention 2011-2015. Vientiane: Laos PDR National Committee for the

UNAIDS. (2012). UNAIDS Report on the Global AIDS Epidemic 2012. Geneva: UNAIDS.

Plurpol Research Summaries 2012

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