An analysis of more than 300 television public service announcements (PSAs) from 36 countries revealed that women are not being given messages on how to protect themselves from HIV infection. As the numbers of women who become HIV-positive through sexual transmission are rising alarmingly, PSAs should modify their portrayals of women.

She is 48 years old with red curly hair and bags beneath her eyes. She slouches slightly in the office chair, stretching out her feet. From her eye shadow to her sneakers, everything is blue. Married to one husband for 28 years, she has children and grandchildren. She also has AIDS. She did not use drugs or have multiple sexual partners. She did have sex with her husband without a condom.

For some years now, I have been listening to women living with HIV/AIDS tell their stories. In support group after support group, I have heard how they trusted their partners and how that trust was violated. These women live with angry emotions they try to repress, if only because they know the damage stress can do to their T-cell counts.

One 23-year-old had a boyfriend with haemophilia; he never used condoms and never mentioned HIV, even though he had already infected another woman. A divorced man with two children did not tell his 46-year-old girlfriend he had AIDS, even when he was hospitalized with an AIDS-related infection. A 7-year live-in partner of a third woman denied infecting her, even though he tested positive for HIV; she did not know he was having sex outside their relationship.

What messages are delivered?

Public education efforts around HIV/AIDS almost never deliver the message that these women needed to hear to protect themselves. My analysis revealed that, for the most part, educational "commercials" emphasize the risks that men, not women, run. They either ignore women entirely or provide factual information without any suggestions on how to use this information in either a casual or committed relationship.

In almost half the PSAs I studied, there were no women at all. This was true even in countries where women's infection rates equal men's. When women did appear in the PSAs, it was usually in ways that reinforced their subordinate status. The PSAs featured twice as many male as female authorities, three times as many male celebrities, and a whopping ten times as many male narrators.

The number of women did outstrip men, however, in self-effacing, care-giving roles as wives, mothers and friends of people living with HIV/AIDS. At first glance, putting women in positive roles may seem laudable. But in health education, putting women in any role can be problematic. Being a wife or mother has never protected any woman from HIV/AIDS. And sex workers who use latex condoms properly all the time are just as safe as anyone else. Showing women in such roles denies their multifaceted individuality and reduces them only to what they represent to others: a wife to a husband, a mother to a child, a sex worker to a client. It strengthens longstanding notions of "good" and "bad" women. It is an easy way out for PSA creators, because it makes the message seem inclusive when, in fact, it is mostly likely exclusive.

When PSAs emphasize the risks of HIV that men, not women, run, they undercut women's rights in relationships by positioning men as the sole sexual decision-makers. Even worse for prevention, they equate safe behaviour with staying away from sex workers and being faithful to one's wife. We are already experiencing a backlash from these PSAs as literally thousands of women who thought themselves "safe" are finding themselves infected.

Some PSAs have tried to shake middle-class women out of this complacency. But they did not strike at the heart of the problem - women's inclination to believe and trust men implicitly. They simply showed women in comfortable surroundings explaining how they became infected:

*  Great Britain: Josephine had only two boyfriends. Because "we were perfectly ordinary", they did not use condoms.

*  USA: an African-American woman with a baby did not know "my man was shooting up drugs and sharing needles". Not until he died.

*  Australia: Tracy never dreamed her partner had used a needle. When the doctor said she had AIDS, Tracy replied, "You have made a mistake. I cannot have AIDS. How could I have that?"

PSAs like these keep women in their place. The women accept what their partners have done and, at most, regretfully shake their heads. There is no attempt to model responsible behaviour for HIV-infected men. And female viewers learn nothing from the PSAs about how to ask the right questions at the right time to assess their personal risk.

In a handful of PSAs, women in casual relationships do broach the subject of condoms, but the scenarios are repetitive and traditional:

*  Australia: two pairs of feet, male and female, rub each other in bed. A woman's husky voice asks, "You have got the condoms, haven't you?" The man breathlessly replies, "No, I forgot." "But we agreed to use one," she protests. "I know, but I haven't got AIDS, have I?" he argues. Turning away, she says, "Sorry. No condom. No sex."

*  United States: a woman in bed tells her male partner, "Don't take this the wrong way." The man says, "What?" She asks, "Do you have protection?" Affronted, he demands, "Do you think I am gay?" "You don't have to be gay to get AIDS," she explains. He gets up to find a condom.

*  Hong Kong: a naked couple are making love. The woman asks, "Do you have a condom?" "Of course," he replies. "Can I do it for you?" she offers.

The difficulties

None of these scenarios faces up to the real difficulties. It is one thing to ask a casual partner to slip on a condom; it is quite another to ask this of a man who has sworn fidelity to you and been with you for years. But in both long- and short-term relationships, gender-based power imbalances can make suggesting condoms unthinkable.

Consider a woman in Peru, known to health educators, who struggled for decades with poor eyesight. After she lost a pair of glasses, her husband refused to buy another pair. She was too stupid, he said. Imagine her asking him to use condoms.

A nurse working with women in the USA found it was easier to help them stay off drugs than to get them to ask their partners to use condoms. If a woman did have the courage to bring up the subject, the man often refused. Some even became abusive. Studies in two cities found that almost half the intravenous drug-using women who are HIV-positive have experienced domestic violence.

In many cases, women fear that asking men to use condoms will lead to rejection or abandonment. If the woman is economically dependent, she and her children could end up on the street. Condoms also carry a stigma. Studies on every continent demonstrate that both men and women perceive condoms as for having sex with "others", not stable partners, or for women "of the street, not the home". Even sex workers who are scrupulous about using condoms with clients tend to avoid them with boyfriends and husbands. All too often, condom use has become a (negative) sign of the level of trust in a relationship rather than simply a sensible means of protection.

What is needed

With the percentage of new cases in women skyrocketing, it is time to acknowledge that past approaches to HIV prevention have not worked. We need to rethink how we portray women, how we deal with gender-related power imbalances and how we avoid the simplistic logic that if women only knew how to protect themselves, they would.

We could begin by creating HIV/AIDS-related PSAs specifically for women. These would build on the premise that women are individuals, not appendages of men and children. Separating HIV/AIDS risk from roles, these PSAs would focus on how women in any role communicate with partners. Viewers need to watch women express and stand up for themselves in the best ways then can.

For some women, this will mean choosing the right moment to ask a partner what he knows about HIV/AIDS. For others, it will begin with a conversation about bisexuality or drug use. For still others, it may mean telling a partner they have put condoms in the nightstand. Effective communication is the point.

PSAs can teach women to empower themselves by little steps; they do not need to jump to the big one right away. For example, educational messages could show how to use humour to bring up touchy subjects, how to question men in direct rather than indirect ways about their health and how to be assertive in ways than enhance rather than threaten relationships. Some PSAs fortunately already do this:

*  Sweden: a woman who wants to start using condoms playfully snaps one on her partner's bare buttocks. They laugh and start talking about it.

*  Germany: a woman who has had sex with someone else thinks through how to tell her live-in partner that they need to start using condoms.

Taking responsibility for their sex lives is not easy for many women who think of sex as something that happens to them rather than something they choose; but that can change. In US secondary schools, teenagers are learning how to resist social pressure and stand up for what they want through practising refusal skills, or how to say "no" without destroying their relationships. Admittedly, this is a long way from asking a husband of 28 years to start using condoms. However, the underlying premise that an individual has the right to take care of herself and to communicate this to others is a new and significant shift.

Of four women I know with AIDS, two discovered they were HIV-positive when they became pregnant; another casually took a free test at a class; the fourth was tested after her husband died of AIDS in jail. Not one of these women's sexual partners had told her that he was, or could be, HIV-positive. This has to change.