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HIV and Women Around the World 
by Luis Scaccabarrozzi

Worldwide, approximately as many women as men are living with HIV, but there are important differences between women and men in the underlying mechanisms of HIV infection and in its social and economic consequences. These stem from biology, sexual behavior, and socially constructed gender differences between women and men in roles and responsibilities, access to resources, and decision-making power.

Women are more susceptible than men to infection from HIV in heterosexual encounters, because of the greater area of mucous membrane exposed in women during sex; the greater amount of fluids transferred from men to women; the higher viral content in male sexual fluids; and the micro-tears that can occur in vaginal (or rectal) tissue from sexual penetration.

Gender norms influence women’s vulnerability to HIV.  In many places, these norms allow men to have more sexual partners than women and encourage older men to have sexual relations with much younger women.  This contributes to higher infection rates among young women compared with young men.  Women may want their partners to use condoms (or to abstain from sex altogether), but often lack the power to make them do so.

The violence (physical, sexual, and emotional) that many women experience at some point in their lives increases their HIV/AIDS vulnerability in several ways:

• Forced sex can contribute to HIV transmission because of the tears and lacerations that can be caused by the use of force.
• Violence and fear of violence can prevent women from negotiating safer sex and getting treatment.
• Fear of violence can prevent women from learning their HIV status or disclosing a positive test result.
  

Women generally assume the major share of caretaking in the family, including for those living with HIV.  The widespread assumption that caretaking is women’s “natural” role only adds to their burden.

Many of the clinical manifestations of HIV/AIDS in women are similar to those seen in men; there remain, however, significant gender-based differences in the disease, which this article will explore.

HIV Today
In 1985, 7% of AIDS cases were in women; in 2005, 27% were, and 60% of those were African-American. Also  in 2005,  heterosexual contact was identified as the risk factor in over 72% of AIDS cases among women in the U.S.

Heterosexual contact is now the most common reported risk factor for women, overtaking injection drug use, and increasing numbers of women with AIDS are from rural and smaller metropolitan areas rather than large urban centers.

What Do We Know?

The gap in HIV prevalence rates among men and women is narrowing.
In the early stages of the pandemic, HIV infection was predominantly among men in many industrialized and some developing countries.  By the end of 2002, however, almost half of the adults living with HIV globally were women. In sub-Saharan Africa, 58% of adults with HIV are women.  

The latest estimates (2001) also show a higher prevalence rate for young women aged 15–24 years as compared with young men of the same age.  A 1998 study in Kisumu, Kenya, showed that the prevalence of HIV infection among young women was 23%, while among young men of the same age it was 3.5%.  This is probably due partly to biological factors (see below), but perhaps more importantly to the fact that social norms dictate marriage at an early age for women in many places, and that the sexual partners of younger women are often significantly older men.

There are differences between women and men in rates of HIV sexual transmission.
Studies conducted in the early 1990s in the U.S. and several European countries have shown that, controlling for other risk factors such as sexually transmitted infections (STIs), it is much easier for a woman to contract HIV from heterosexual contact than it is for the man.  This is thought to be because women have a larger surface area of mucous membrane exposed during sexual intercourse, and also because they are exposed to a larger quantity of infectious fluids (semen) than the men are.

The evidence on this subject, however, is still not complete. For example, a recent study from Uganda showed that the rate of male-to-female transmission of HIV was not very different from that of female-to-male transmission. Viral load (the amount of HIV in the blood) was the chief predictor of rates of heterosexual transmission of HIV. More virus means higher rates of transmission.

Anal penetration can occur in both male-male and male-female sex. This poses an especially high risk of HIV infection for the receptive partner because the lining of the rectum is thin and can easily tear.

The presence of an untreated STI can make a person up to 10 times more likely both to get and to transmit HIV.  Since the majority of STIs do not give rise to any symptoms in women, they are less likely not to be recognized or treated.  STIs located in the anus and rectum also often display no symptoms, so they are unlikely to be treated, implying an enhanced risk of HIV through penetrative anal sex.

Pregnancy and childbearing raise specific issues for women.
Studies from industrialized countries have found that pregnancy does not affect the progress of HIV infection in women with no symptoms or in women who are in the early stages of disease.  Care should be taken, however, not to generalize these results to the developing world, where there has been little research done on this topic.  On the other hand, a recent study indicates that, in developing countries, there is a high risk of infant death associated with maternal HIV infection. Pregnancy-related complications, such as hemorrhage, expose women to the risk of infection from blood transfusions.

Since HIV can be transmitted through breast milk, breastfeeding presents a dilemma for many women.  Those who decide against breastfeeding in favor of infant formula may reduce the risk of HIV transmission to their children, yet may expose the infants to diseases resulting from unclean water and from malnutrition.  The use of infant formula can alert others to the mother’s HIV status and lead to stigma and discrimination, mainly in developing countries.

Gender norms increase vulnerability to HIV infection, especially in young people.
In almost all cultures masculinity is associated with virility.  A UNAIDS report based on research conducted in seven countries (Cambodia, Cameroon, Chile, Costa Rica, Papua New Guinea, the Philippines, and Zimbabwe) found that notions of masculinity encourage young men to view sex as a form of conquest.  Other research found that ignorance is construed as a sign of weakness, and that men are therefore often reluctant to seek out correct information on safer sex.

The role of same-sex relations among young men in enhancing risk of HIV infection is often ignored in many developing countries, where sex between men is socially stigmatized and often illegal. The limited availability of data contributes to the invisibility of this issue.  Data for 1999 from the U.S. show that 50% of all AIDS cases reported among males of 13–24 years of age involved men who have sex with men.  According to the 2005 CDC surveillance, of the estimated 341,524 male adults and adolescents living with HIV/AIDS, 61% had been exposed through male-to-male sexual contact.
 
Early initiation of sexual activity among girls is directly related to the practice of early marriage for girls in many developing countries.  Furthermore, the sexual partners of young women are often much older than the women themselves:  research from 16 countries in sub-Saharan Africa indicates that husbands of 15- to 19-year-old girls are on average ten years older than their wives.  Early marriage may expose girls to an increased risk of STIs and HIV, especially if their partners are older and have had more sexual exposure.  HIV prevalence among young (15–24) pregnant women  attending prenatal clinics, however, has declined since 2001 in 11 of the 15 most affected countries.  

For many women, being vulnerable to HIV can simply mean being married. Many societies accept extramarital and premarital sexual relationships in men, creating a risk even for women who have had only one partner in their entire lives. For such women, “remaining faithful” is no protection.

Information from countries such as Thailand and South Africa indicates that poverty, lack of education, and limited income-earning opportunities often force women into commercial sex work, exposing them to a high risk of HIV/STI infection.

Violence is an important factor in the transmission of HIV.
Some women experience the threat of, or actual, physical violence when attempting to negotiate safer sex through the use of condoms.  Research conducted in Guatemala, India, Jamaica, and Papua New Guinea found that women often avoided bringing up condom use for fear of triggering a violent male response.
Violence in the form of coerced sex or rape may also result in HIV infection, especially as coerced sex may lead to the tearing of sensitive tissues and increase the risk of contracting HIV.  Studies in adolescents from several countries have found that many report that their first intercourse was forced, and this is particularly the case for women.  Sexual minorities such as homosexual men also encounter sexual coercion in many countries, and are similarly at risk of HIV infection.

Conflict situations such as wars aggravate some of the factors that fuel the HIV crisis.  These include the breakdown of families and communities, forced migration, poverty, the collapse of health services, and physical and sexual violence.  Women more than men are at risk of rape and sexual assault in conflict situations, and consequently of HIV infection.  Tens of thousands of women were raped in the Balkan conflict.  In Rwanda, 3% of all women were raped during the genocide.  The proportion of women testing HIV positive among those who were raped was 17%, as compared to 11% among women who were not.

Gender is a factor in health-seeking behavior.
Stigma associated with HIV is a major factor preventing many women and men from seeking and obtaining services.  Women may be more affected by stigma and discrimination than men because of social norms concerning acceptable sexual behavior in women, and because women are often more economically vulnerable than men.

Gender differences in decision-making may also affect access to health facilities.  For example, a study conducted in Tanzania found that, while men made independent decisions to seek HIV testing, women felt obligated to discuss testing with their partners before having it done.

Health program and service issues are affected by gender.
Much of the resistance to condom use is gender-related.  Several studies report that young women are reluctant to carry or suggest condoms for fear of being seen as promiscuous.  Many young men dislike condoms because of their interference with the pleasure of sex, while some may actually enjoy risk-taking behavior.

It is estimated that perfect use of the female condom may reduce the annual risk of acquiring HIV by more than 90% among women who have intercourse twice weekly with infected males.  The price of the female condom, however – up to ten times that of the male condom – makes it inaccessible to most women.

Stand-alone HIV services may deter women and young people from seeking care, since their use may be seen as an admission of having an STI, leading to stigmatization.

Health providers need to be aware of and sensitive to the possibility that women can be subjected to violence and other serious consequences within households or communities as a result of revealing that they have HIV.  In a 2001 survey in Kenya, more than half of the women surveyed who knew that they were HIV positive had not disclosed to their partners.  They feared that disclosure would expose them to violence or abandonment.  These adverse consequences of disclosure have also been documented in other settings.

In many countries HIV information and services are provided primarily through family planning, prenatal, and child health clinics, which are typically not designed to reach men or meet men’s needs. As a result, men may be less likely than women to receive HIV information, testing, or treatment.

There are gender differences in the social and economic consequences of HIV.
A UNAIDS study across seven sites found that men with HIV were hardly questioned about how they became infected and that they were generally cared for.  In contrast, women were often accused of having had extramarital sex (whether or not this was the case) and received lower levels of support.
Men, on the other hand, may be under pressure to keep their HIV infection status secret for fear of dismissal from work and of being unable to play their traditional gender roles as breadwinners.

In studies in India, Mexico, and the U.S., women much more than men had to shoulder the burden of providing care to household members suffering from AIDS, as well as of supporting their households financially when other earners were disabled.

What Research Is Needed?
More research is needed in these areas:

• Microbicides or other effective female-controlled methods that do not prevent pregnancy and do not involve the use of a condom.
• Gender differences in risk perception and behavior across different age groups.
• The role of nonconsensual sex in increasing the risk of HIV infection in adolescent girls and boys.
• Gender differences in the barriers adolescents face in gaining access to health services.
• Women’s and men’s perspectives on HIV treatment and care, including opinions on individual versus couples counseling, disclosure and partner notification, location of services, etc.
• The impact of masculinity on vulnerability to HIV, and the factors that impede men’s access to HIV testing and treatment.
• How to design programs that address the risk of disclosure leading to violence against HIV-positive women.

What Needs to Change?
Gender roles around the world pin women into positions where they lack the power to protect themselves from HIV infection and where, if they are infected, they lack opportunities to receive treatment.  Negative assumptions about women’s roles and discrimination against them must be challenged, and women must be empowered to help themselves and to protect themselves.

Women who have been raped need to have access to post-exposure prophylaxis – medical techniques that can reduce the chances of HIV infection if they are treated quickly.  In many (mainly African) countries with high levels of sexual violence against women and high HIV prevalence, this treatment is not freely available to women.

Protecting women from HIV is not solely women’s responsibility.  Preventing infection is the responsibility of both partners, and men must play an equal role in this.

Even in the U.S., much more needs to be done to protect women.  There has been criticism that sex education in schools in the U.S. is based on the idea that sexual abstinence until marriage and fidelity afterwards is the best way to prevent STIs.  This won’t protect a women if she is infected by the man she marries, and it leaves her ignorant – and thus more vulnerable – if she has sex before marriage.  Young women must be taught about condoms, which must be easily obtainable.

Violence against women, discrimination, gender-based inequalities, prostitution – these are all issues that must be addressed but that might take decades to alter.  Women who have HIV need access to treatment, and women who don’t have the virus need to be able to protect themselves.  If it is impossible in the short term to empower women to be able to insist on condom use, then efforts must be made to find an alternative solution.

Many women may not think they are at risk for HIV infection.  There is still, in some places, a myth that HIV infection is something that happens only to other people – to gay men, injecting drug users, or people from other ethnic groups.  This myth needs to be cleared up, and countries around the world must work to empower women to protect themselves.

Luis Scaccabarrozzi is Director of the HIV Health Literacy Program at ACRIA.