Since the start of the global HIV epidemic, in many regions, women have remained at a much higher risk of HIV infection than men.
Young women and adolescent girls in particular, account for a disproportionate number of new HIV infections among young people living with HIV. There are an estimated 380,000 new HIV infections among young women aged 15-24 every year, accounting for 60% of all new HIV infections among young people in 2013. 80% of all young women living with HIV live in sub-Saharan Africa.1
Moreover, HIV remains the leading cause of death among women of reproductive age, yet access to HIV testing and treatment remains low.
Why are women particularly at risk of HIV?
Gender inequality and gender-based violence (GBV) prevent many women, particularly young women, from protecting themselves against HIV.1
A number of studies show that intimate partner violence (IPV) increases the risk of HIV infection as well as unwanted pregnancy. For example, a study from South Africa found that young women who experienced IPV were 50% more likely to acquire HIV than those who did not experience violence.2
Societal norms regarding GBV also increase a woman’s risk of HIV. A study from Tanzania showed that while women are expected to be loyal to their partner even if they are in an abusive relationship, men are encouraged to engage in unprotected extramarital sex.3
Another study of over 20,000 couples in India found that abusive husbands were more likely to be infected with HIV than non-abusive husbands.4 In 2012, 37% of women living with HIV worldwide were thought to have been physically assaulted. 5
Disproportionately high levels of HIV infection are found among young women in relationships with older men. Relationships with large age differences are commonplace in sub-Saharan Africa and are often associated with unsafe sexual behaviour and low condom use due to unequal power in the relationship.6
Lack of access to healthcare services
In some countries, women face significant barriers to accessing healthcare services. A lack of access to comprehensive HIV and sexual and reproductive health (SRH) services means that women are less able to look after their sexual health and reduce their risk of HIV infection.
In many settings, access to youth-friendly SRH and HIV services is inadequate, and where they do exist, are primarily for married women with children. In Kenya, Rwanda and Senegal, over 70% of unmarried sexually active girls aged 15-19 have not had their contraception needs met due to age restrictions.7
Moreover, healthcare providers often lack the training and skills to deliver youth-friendly services and do not fully understand laws around the age of consent and abortion legislation. This can lead to women choosing to have an abortion because they are misinformed about their options and how to protect their health as well as their child's.8
Even where women are able to access HIV and SRH services, stigma and discrimination create additional barriers. Judgemental attitudes of healthcare professionals around youth sexuality can result in the denial of healthcare services, while others are coerced into using them.9
Lack of access to education
There is a wealth of evidence that shows how increasing women’s educational achievement is linked to better HIV and SRH outcomes.1
When girls attend school, the likelihood that they get married or pregnant when young decreases.10 However, in sub-Saharan Africa, 80% of young women have not completed secondary education and a third cannot read.11
One study of 32 countries found that women who had some level of secondary education were five times more likely than non-literate women to have knowledge of HIV. Moreover, non-literate women were four times more likely to believe that HIV could not be prevented.12
As many girls drop out of school, their male peers are more likely to access comprehensive sex education. SRH education builds awareness of HIV and how to negotiate relationships, so it is crucial that access to education is scaled up for women.1
However, many women who do remain in school do not receive adequate HIV and sex education.13 In sub-Saharan Africa, only 28% of young women reportedly know how to protect themselves from HIV.14 In many places, schools are not guaranteed safe learning environments for young women. One study from South Africa found that 30% of young female rape survivors were assaulted in or near their school.15
Lack of recognition under the law and legal restrictions
In 2014, nine countries reported laws that create obstacles stopping women and girls from accessing HIV prevention, treatment, care and support services.16
Mandatory parental consent has been shown to deter young women from accessing vital HIV and SRH services due to fear of disclosure or violence.17 The proportion of women who have experienced physical or sexual violence and then seek help, ranges from just 18% in Azerbaijan to 52% in Colombia.16
In many places, discriminatory social and cultural norms are translated into laws which repress the autonomy of young women. For example, many become pregnant within child marriage. In 146 countries, laws allow girls under 18 to marry with the consent of their parents, while in 52 countries, the same applies to girls under 15.10
Age-restrictive laws, such as those that ban contraception under a certain age, also act as barriers to healthcare for young women. As a result, young women face a much higher risk of HIV infection than women in the general population.18
Women belonging to other key affected populations are also negatively affected by laws that criminalise injecting drug use, sex work and homosexuality.18
For example, in many countries healthcare services for female sex workers are not available to those who are under the age of 18. Limited access to these services for women who inject drugs is well documented in Eastern Europe and Central Asia.19
Women who sell sex or inject drugs are also subject to stigma and prejudice from healthcare workers.18
HIV testing and counselling (HTC) for women
A major gap in HIV service provision for women can be found in HIV testing and counselling (HTC), with HTC a vital gateway to treatment services.
In many parts of the world, access to HIV testing is particularly low among young women. Only 15% of women aged 15-24 in sub-Saharan Africa were aware of their HIV status in 2013.20
By comparison, access to HTC for pregnant women is rising but remains too low. In 2013, 44% of pregnant women living with HIV in low- and middle-income countries received HTC, up from 26% in 2009.21
Community and home-based testing have been put forward as an effective way of reducing the social and economic costs of going to a facility to test. It is also important that pregnant women who test negative have the opportunity to retest to identify seroconversion (the development of antibodies to HIV) during pregnancy or breastfeeding. Moreover, all testing and counselling should be provided confidentially and voluntarily.1
Antiretroviral treatment (ART) for women
As of 2013, new World Health Organisation (WHO) treatment guidelines have made all pregnant women living with HIV eligible for treatment.
Although substantial progress has been made in providing services to prevent the mother-to-child transmission of HIV (PMTCT), 27% of pregnant women living with HIV in 2014 still didn't access antiretroviral drugs (ARVs) for PMTCT.22
In addition, women lack accurate information about the use of ARVs. Misunderstandings about treatment have been linked to poor adherence and loss to follow-up, increasing the chances of drug resistance and treatment failure.23
A lack of youth-friendly HIV treatment, support and care services prevents many young women from accessing antiretroviral treatment (ART). Studies from Southern Africa have shown how loss to follow up a year after enrolling on ART is higher among young people compared to both adults and children.24 25
HIV prevention programmes for women
The WHO promotes a number of approaches to help reduce women’s vulnerability to HIV.26 A few of these are discussed below.
Cash transfers are social protection programmes often targeted at women in a household to reduce poverty, build human capital (for example, sending girls to school) and enhance food security.
In terms of preventing the sexual transmission of HIV, addressing poverty has been shown to reduce sexual risk behaviour, particularly among young women in low and middle-income countries.27
However, some cash transfer programmes implemented in Latin America have seen increases in partner violence.29 For example, a review of Mexico’s PROGRESA/Oportunidades programme recorded that five to nine years after the intervention, women in beneficiary households were just as likely to experience both physical and non-physical abuse as non-beneficiary women.30
School-based interventions aim to promote equitable gender norms before other norms are fully ingrained in the lives of adolescents. Increasingly, school-based curricula is being implemented to address violence against women and to prevent HIV.26
A 2011 systematic review of engaging men and boys through school education recorded reductions in sexual violence and other forms of violence in seven out of nine studies. Of the 47 studies that examined attitudes towards acceptability of violence, ten showed significant improvements in attitudes and less tolerance of violence against women.31
Another systematic review of comprehensive sex education showed that this has been effective in improving sexual and reproductive health and HIV behaviours. For example, in Ethiopia, where sexuality education is a compulsory part of human studies and has strong links to youth-friendly services, 4,300 unintended pregnancies, 7,200 STIs and 2,000 HIV infections among adolescents aged 15–19 were averted between 2001 and 2009.32
Addressing violence in HIV risk-reduction counselling
Risk-reduction education and counselling includes specific messages about equitable decision-making with partners; violence against women and its links to HIV; supporting women to negotiate safer sex in unequal power relationships and provides referrals to support services.26
Several interventions in the USA have used these strategies to address violence faced by different groups of women. Interventions have included a safety planning intervention for drug-using female sex workers in Miami, Florida; a counselling intervention for women involved with the criminal justice system in Portland, Oregon; and an enhanced negotiation intervention with African-American drug users in Atlanta, Georgia.33 34 35
All three interventions showed reductions in unprotected sex or risk-associated behaviour. The interventions in Miami and Atlanta also showed reductions sexual abuse. Trials with female sex workers in Mongolia and South Africa and married women in India have also reported less exposure to violence.36 37 38
Addressing violence in HTC, PMTCT and treatment services
HIV testing and counselling, PMTCT and treatment services can address violence towards women in a number of ways. Healthcare workers can be trained to recognise the signs of partner violence, promote gender equality in the community, increase women’s access to services and teach women partner communication and negotiation skills.26
This may improve identification of, and care and support to, women experiencing violence provided that systems of care and referral are in place.
A systematic review of universal screening interventions where women are routinely asked by a healthcare professional if they have experienced intimate partner violence, shows that screening is not effective in either reducing partner violence or improving women’s quality of life.39
As a result, the WHO recommends identifying women based on signs and symptoms of partner violence rather than universal screening.40
Laws addressing gender equality and violence against women
Laws and policies that promote gender equality create an environment that increases the likelihood of success and sustainability of efforts to reduce violence against women and their vulnerability to HIV.26
125 countries have legislation criminalising at least some forms of violence against women (e.g. domestic partner violence, sexual violence, child sexual abuse, sexual harassment).
Despite this progress, definitions of what constitutes violence against women, sanctions and penalties, and evidence for establishing a crime are weak. For example, only 52 countries recognise rape within marriage as a crime, making it difficult for women to protect themselves from sexual violence within marriage and negotiate safer sex.41
Legal reforms to protect women from violence have shown some evidence in increasing the reporting of violence and improving the quality of response from authorities. However, no studies have looked at the impact of law reforms on partner violence, particularly in low- and middle-income countries.42
Reducing MTCT of HIV among pregnant women
Family planning is one of the most important measures to prevent the mother-to-child transmission of HIV. Reducing the number of unintended pregnancies among women living with HIV would reduce the number of children born with HIV. Spacing out pregnancies is also beneficial to the health of mothers.
One model from 2009 in Uganda showed that while PMTCT services could avert 8.1% of new HIV infections in the country, 19.7% could be avoided with proper family planning. In this scenario, unintended pregnancies accounted for 21.3% of new child infections.43
If all women wanting to avoid pregnancy used modern family planning methods, unintended pregnancies would decline by an estimated 71%.44
Integrating health services so that they cover maternal and child health as well as HIV and SRH services have been shown to produce better health outcomes for pregnant women.1
For example, a Zambian study showed how twice as many pregnant women eligible for treatment started ART as a result of an integrated HIV treatment and antenatal care scheme compared to those simply referred to an ART clinic.45
Another study from Kenya showed how integrating family planning into HIV services increases contraception uptake and decreases pregnancy rates.46
Increasing male involvement
Couples testing and counselling allows couples to learn their HIV test results with a trained counsellor or healthcare worker present. Unfortunately, these services are often unavailable.1
Research from Kenya recorded a 45% decrease in MTCT rates and mortality among women whose partners attended antenatal clinics, and a 41% decrease in MTCT among women with partners who had tested for HIV.47
Involving male partners also provides an opportunity to identify discordant couples and facilitate access to treatment.1
The provision of services needs to go beyond the health centre and into the community.1
Specifically, psychosocial support has been shown to improve services to prevent MTCT. One study of a clinic-based support initiative that employed mothers as peer educators found that those participating were more likely to:
- disclose their HIV status
- receive CD4 count testing during pregnancy
- receive ARVs for themselves and infants
- practice exclusive breastfeeding.1
Respecting human rights
Protecting human rights ensures women living with HIV come forward and access HIV services, avoid HIV transmission to their child, and adhere to their treatment. In recent years, progress has been made in this area.1
Other forms of human rights violations include forced sterilisation. In 2013, the African Commission on Human and People’s Rights adopted a resolution condemning forced sterilisation as a human rights violation and called on African countries to adopt measures to prevent it.48
In June 2014, WHO, UNAIDS, OHCHR, UN Women, UNDP, UNICEF and UNFPA adopted an interagency statement committing to ending forced and coercive sterilisation.49
The way forward
The HIV epidemic poses a particular burden on women, especially young women. Pervasive social, legal and economic barriers faced by women reduce their ability to protect themselves from HIV infection, and limit access to essential HIV and SRH services.
It is now widely recognised that gender equality is vital to an effective HIV response. However, there needs to be renewed political and financial commitment to eliminate gender inequalities and gender-based violence, and increase the capacity of women and girls to protect themselves from HIV.
"This epidemic unfortunately remains an epidemic of women." - Michel Sidibé, Executive Director of UNAIDS 50
Photo credit: ©AVERT by Corrie Wingate. Photos are used for illustrative purposes. They do not imply any health status or behaviour on the part of the people in the photo.
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