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Women and HIV/AIDS
“This epidemic unfortunately remains an epidemic of women.” - Michel Sidibé, Executive Director of UNAIDS 1
Globally, AIDS-related illnesses are the leading cause of death among women of reproductive age. 2 In areas such as Western and Central Europe, Eastern Europe and Oceania, women account for a relatively low percentrage of people living with HIV. However, in regions such as sub-Saharan Africa and the Caribbean, the percentage is significantly higher.
At the end of 2012 it was estimated that 52 percent of people living with HIV and AIDS in low- and middle-income countries are women. 3 Every minute one young woman becomes infected with HIV, with sub-Saharan Africa reporting the percentage of young women aged 15-24 living with HIV being twice that of young men. 4 5
Biologically, women are more likely to become infected with HIV through unprotected heterosexual intercourse than men. In many countries women are less likely to be able to negotiate condom use and are more likely to be subjected to non-consensual sex. 6 7
The HIV and AIDS epidemic impact upon women has been exacerbated by certain roles within society. The responsibility of caring for people living with HIV and orphans is an issue that has a greater effect on women. Additionally, millions of women have been indirectly affected by the HIV and AIDS epidemic through issues such as mother-to-child transmission (MTCT) of HIV.
Strategies to reduce the burden of the epidemic among women and their children include:
Women and HIV - reducing the burden
Preventing HIV infection
There are a number of issues that need to be addressed in order to prevent the spread of HIV infection. The following are relatively new preventative technologies that could directly benefit women.
- The female condom is the only female-initiated HIV prevention method presently available. These condoms can potentially help women to protect themselves from becoming infected with HIV if used correctly and consistently. However, although the female condom allows partners to share the responsibility of condom use, it still requires some degree of male cooperation.
- Post exposure prophylaxis is an antiretroviral drug treatment that is thought to decrease the chances of HIV infection after exposure to HIV. This treatment could potentially benefit women who have been exposed to an HIV-infected partner, or sexually assaulted, if started within 72 hours of exposure. In many countries with high levels of sexual violence against women and high HIV prevalence, this treatment is not always freely available to women.
- There is ongoing research about microbicides - a gel or cream that could be applied to the vagina without a partner knowing and which would prevent HIV infection. Despite many promising trials into microbicide development, a safe and reliable design does not yet exist.
Sex work and injecting drug use is criminalised in some countries, and stigmatised in others. This can lead to female sex workers and drug users (especially mothers), being absent from support. Acknowledging this and targeting women with specific HIV prevention messages relating to sex work and drug use may help to reduce female HIV infections. 8
However, protecting women from HIV is not solely women's responsibility. Most women living with HIV were infected by unprotected sex with an infected man. Preventing transmission is the responsibility of both partners, and men must play an equal role in this.
“I would like to tell all women to care about themselves and know you need to understand that men do not consider themselves accountable for their actions especially when it comes to sex” - Chan. Chan became infected with HIV at 19 years old 9.
- help HIV-positive women plan their pregnancies 10
- give access to contraception to reduce the number of pregnancies (global fertility rate has reduced from 6.0 to 2.5) 11
- delay their first pregnancy (41% of girls in Sierra Leone have their first pregnancy between 12 and 14 years old) 12 13
- control the time between pregnancies
- ensure a safe childbirth, for mother and baby (Between 2003 and 2009, HIV accounted for 5.5 percent of maternal deaths). 14
Promoting and protecting women’s human rights
“‘She died after passing her HIV to her husband’. This is an often-repeated sentence in Zimbabwe. The echoes can be heard in homes in workplaces and in graveyards, at times shrill, at times in a hushed whisper. The tone, though, is always accusatory…The corollary to this statement, i.e. ‘He died after passing HIV to his wife’, is seldom heard” - Madhu Bala Nath 15.
In many parts of the world there exist major inequalities between women and men in all aspects of living – from employment opportunities and availability of education, to power inequalities within relationships. These gender roles can confine women to positions where they lack the power to protect themselves from HIV infection. It is thought that promoting womens' basic human rights will enhance their status within society and help protect them against the risk of HIV infection. 16
Reproductive rights need to be promoted. Currently there still exist reports of HIV-positive women being forcibly sterilised. In Namibia in 2012, three women went to court regarding being sterilised without knowing it, as part of their childbirth procedures. The court ruled that they were sterilised without consent, as a result of the procedure details and consent form not being available in their local language. All healthcare settings were ordered to make counselling and information regarding medical procedures available in all necessary languages, to prevent circumstances like this. 17 18 19 A similar investigation was reported in Kenya later in the year. 20
Transforming gender roles
Both men and women are affected by gender roles that define what it means to be a man or a woman. These gender-based expectations can increase vulnerability to HIV infection. For example, in many societies women are expected to be innocent and submissive when it comes to sex, preventing them from accessing sexual health information and services. 21 For many men, masculinity is linked with taking risks and being tough, which can increase vulnerability to HIV infection and discourage men from seeking HIV testing and treatment. 22
Recognising and challenging harmful gender roles is crucial to preventing the spread of HIV. Programmes that focus on men are equally important in protecting women from HIV, as they can transform men’s attitudes and behaviour towards their partners, families and women in general.
“About four years ago, a good friend of mine took me to town and offered to buy me the sexual service of a sex worker as a ‘rite of passage’ into manhood. I refused the offer and we ended up fighting. This incident was really defining for me as to how I want to live my life.” - Abdu Hassen Reshis, Ethiopia 23
Increasing education and awareness
Education is one of the most effective tools in preventing HIV infections. An estimate from the Global Campaign for Education suggests that if every child received a complete primary education, around 700,000 new HIV infections in young adults could be prevented every year. 24
Education is particularly important for protecting girls against HIV infection. Many girls marry young, to older men who are more likely to be HIV-positive. 25 School can teach vital HIV prevention methods, such as condom use, having fewer sexual partners, and the importance of greater communication about HIV prevention between couples. Also, girls who frequently attend school are more likely to be able to make decisions about their sexual lives and be more independent. 26
Increasing HIV and AIDS education can also help to reduce the stigma that people living with HIV and AIDS face. Eradicating stigma is important in the HIV and AIDS response because stigma can increase the vulnerability of a group that may already be at a higher risk of HIV infection. Sex workers, for example, are in many countries still both frowned at, socially, and criminalised, legally. It is very difficult for these women to access the healthcare services they need in order to stay healthy if they risk arrest or punishment when their profession is known.
HIV treatment for women
Women are statistically more likely to know their HIV status than men, and as a result, have greater rates of treatment uptake than men (73% compared to 57%). However, despite pregnant women being routinely tested for HIV as part of antenatal services, their access to treatment is lower than adults in general (58% in 2012, as opposed to 65% for adults overall). 27 Taking HIV treatment significantly reduces the likelihood of a person transmitting HIV; the progress made in increasing HIV treatment access among all HIV-positive women must be maintained, as it will help prevent HIV transmission to a woman's partner, or her child.
How is the HIV and AIDS epidemic affecting women?
Responsibility of care
In areas with few palliative care facilities, when a person develops AIDS-related illnesses, the care is usually a woman’s responsibility. In Africa for example, two thirds of all caregivers for persons living with HIV and AIDS are women. 28 This care giving is usually in addition to many other tasks that women perform within the household, such as cooking, cleaning, and caring for the children and the elderly.
Caring for ill parents, children or husbands is unpaid and can increase a person’s workload by up to a third. Women often struggle to bring in an income whilst providing care and therefore many families affected by HIV suffer from increasing poverty. In some areas of sub-Saharan Africa where a family’s livelihood relies on growing and maintaining crops, the death of farmers can lead to famine. 29
The HIV epidemic also affects young girls and elderly women. Often in households where both parents are ill from AIDS, the responsibility of main carer is taken on by a daughter, even if it means that she has to miss school. If both parents die then it tends to be the grandmothers, aunts or cousins who then look after the orphans.
Women and children
Mother-to-child transmission (MTCT) is an issue that directly affects women and at the same time increases the spread of HIV. MTCT occurs when HIV is passed from an HIV-positive woman to her baby during pregnancy, labour and delivery, or breastfeeding. UNAIDS say that at the end of 2011 there were an estimated 3.3 million children (under 15 years) living with HIV, most of whom were infected by their mothers. 30 Without treatment, a large number of these children will not live to adulthood.
MTCT can be prevented through accessing medical care as soon as possible when a woman becomes pregnant, providing the baby with post-exposure prophylaxis drugs, and following national breastfeeding guidelines. Women living with HIV can have healthy, HIV-negative children, and also prevent passing HIV to their partner. Mothers who adhere to a daily regimen of antiretroviral drugs significantly reduce the chances of their child acquiring HIV from about 40 percent to less than 2 percent.
However only 63 percent of pregnant women eligible in 2012 received them. 31 Limited human resources and poor infrastructure are among the reasons for why this is. Promisingly, rates of MTCT have reduced by 35 percent between 2009 and 2012. 32
More than 10 percent of maternal deaths in 13 high HIV-prevalent countries were attributed to HIV and AIDS in 2013. In the same year, there were an estimated 7,500 maternal deaths to HIV in sub-Saharan Africa. Only three other regions had more than 100 HIV-related maternal deaths in the same period: South Asia (340), Latin America and the Caribbean (130), and South-eastern Asia (110). 33
Though the number of regional deaths is relatively small, in some countries (particularly in southern Africa), the proportion of maternal deaths due to HIV is very high. For example, it is as high as 41.4 percent in South Africa and 23.5 percent in Botswana. Generally, maternal mortality rates have followed the trend of the HIV epidemic: peaking in 2005 and declining between 2010 and 2013. This is thought to be due largely to the rapid roll-out of antiretroviral treatment over the past decade. 34
Why is it difficult for women to protect themselves from HIV infection?
Inequalities within the family
In some societies, women have few rights within sexual relationships and the family. Often men make the majority of decisions, such as whom they will marry and whether they will have more than one sexual partner. This power imbalance means that it can be more difficult for women to protect themselves from HIV transmission. For example, a woman may not be able to insist on the use of a condom if her husband is the one who makes the decisions.
Marriage does not always protect a woman from becoming infected with HIV. Many new infections occur within marriage or long-term relationships as a result of unfaithful partners. In a number of societies, a man having more than one sexual partner is seen as the norm.
“Ladies just because you are married doesn’t mean anything. I actually thought that I was safe and I was sick" - Renita 35.
A study of 400 women attending an STI clinic in Pune, India showed that:
- 25 percent were infected with STIs
- 14 percent were HIV-positive
- 93 percent of these women were married
- 91 percent had not had sex with anyone other than their husbands 36
“I met this wonderful man in 1996 whom I feel in love with and we were very happy together… Then he started cheating on me with different women. The excuse he gave was that he was lonely and I was the cause of his cheating because I had refused to move in with him. I forgave him all the time and took him back every time he apologised. I wish I had not…. I had seen signs that all was not well with him for a while… He had lost close to 10kgs. I went to see a doctor who ordered an HIV test. It was positive and I felt like the whole world had sunk” - Koki, living in Kenya 37.
Women typically have more frequent access to healthcare than men due to antenatal care. This means women often know that they are HIV-positive before their partners. However the imbalanced power in the household, and a lack of education, can lead to men assuming their partner was infected first; this may cause friction that can lead to violence. 38
Violence against women
Women who are victims of sexual violence are at a higher risk of being exposed to HIV, due to a lack of condom use. 39 40 In some countries, nearly half of women have experienced sexual or physical partner violence. 41 It is thought that 37 percent of women living with HIV have been physically assaulted. 42
A South African study concluded that women who were beaten or dominated by their partners were much more likely to become infected with HIV than women who were not. 43 Another study of 20,425 couples in India found not only that HIV transmission was much greater in abusive relationships, but also that abusive husbands were more likely to be infected with HIV than non-abusive husbands. 44
“I'm a 31 year old heterosexual female that contracted AIDS as the result of rape. I repressed the events surrounding the attack until I had undergone hypnotherapy... It had been nearly two years since the rape and I had been HIV-positive without knowing it” - Enya 45.
In countries where armed conflict is rife, there have been reports of rape being used as a ‘tool of war’, and in some cases women have been intentionally infected with HIV. 46
Women’s inheritance and property rights
In many countries around the world, women do not have the same property rights as men. Especially in sub-Saharan Africa, property is typically owned by men and even when married, women still do not have as many property rights as their husbands. Inheritance rights are just as discriminatory, as when a husband dies, his property often goes to his side of the family and not to his wife.
The denial of womens' inheritance and property rights can increase vulnerability to HIV. Not being able to own property means that women have limited economic stability. This can lead to an increased risk of sexual exploitation and violence, as women may have to endure abusive relationships or resort to informal sex work for economic survival. 47 48
Women, HIV and AIDS - the global picture
- Main female HIV transmission route is heterosexual sex.
- As women are twice as likely to acquire HIV via unprotected heterosexual intercourse than men, women are disproportionately infected in this region.
- In 1985 there were as many HIV infected men as there were women.
- Today, the number of women living with HIV and AIDS has overtaken and remained higher than men.
- In 2012, 57 percent of people living with HIV in sub-Saharan Africa were women. 49
- In 2012, 92 percent of HIV-positive pregnant women live in sub-Saharan Africa. 50
- Main female HIV transmission route is heterosexual sex.
- Decrease in the number of HIV infections in women since 2001.
- Women are less affected by HIV than men, accounting for less than half of people living with HIV in 2012. 51
- Young women are almost twice as likely to be infected with HIV than young men. 52
- Trends in HIV prevalence among female sex workers have been declining since 2007. 53
- In the USA, the main HIV transmission route is heterosexual sex - accounting for 84 percent of new female HIV infections.
- Injecting drug use is the second most common female HIV transmission route.
- One in four people living with HIV are women. 54
- 300,000 women above the age of 15 are living with HIV. 55
- New HIV infections: African American women = 64 percent, Hispanic woman =15 percent and White women = 18 percent. 56
- In Latin America, domestic funding for sex worker HIV prevention programmes outweighs international funding. 57
- Main female HIV transmission route is heterosexual sex. 58
- Main HIV transmission route is heterosexual sex, causing increasing HIV infections among women.
- Indonesia, Vietnam and Pakistan - HIV transmission is mainly through injecting drug use (both as a result of personally injecting, and from being infected by male IDU partners).
- The number of women living with HIV and AIDS in Asia varies between different countries, and between different states within countries.
- 38 percent of adults living with HIV and AIDS in India are women. 59
- Women are often perceived as low risk of HIV infection because it is not common to have more than one lifetime sexual partner.
- Husbands having unprotected sex outside of marriage or injecting drugs puts their wives at risk of HIV infection.
- 90 percent of women living with HIV in Asia were infected by their husband or long-term partner. 60
- The lower economic and social status of women is a barrier to preventing new infections.
HIV has affected millions of women worldwide. Elizabeth Glaser, Gugu Dlamini and Rebekka Armstrong are a few of the many women who have become publicly known for their personal stories in the fight against HIV and AIDS.
In 1981, Elizabeth Glaser became infected with HIV through a blood transfusion while giving birth to her daughter, Ariel. At a time when little was known about the virus, Elizabeth unknowingly passed it on to Ariel through breastfeeding, and later to her son Jake during pregnancy.
When Elizabeth and her husband, actor and director Paul Michael Glaser, tried to get treatment for Ariel, they found out that the only drugs available were for adults. The drug companies and health agencies did not know that HIV was prevalent among children. 61 Ariel died as a result of AIDS in 1988.
Elizabeth decided to help other children with HIV and, with two friends, established the Pediatric AIDS Foundation. The Foundation has helped to raise money for basic HIV research and has been dedicated in supporting prevention and treatment programmes.
In 1994 Elizabeth passed away from AIDS-related illnesses and the foundation was renamed the Elizabeth Glaser Pediatric AIDS Foundation. Today, the foundation continues its influential work around the world.
Born in 1962, Gugu Dlamini lived in a town in the eastern KwaZulu-Natal province of South Africa. She was a volunteer field worker for the National Association of People Living with HIV/AIDS. On World AIDS Day in 1998 Gugu revealed on radio and television that she was HIV-positive. It was a brave attempt to help in reducing the stigma and discrimination that HIV-positive people are faced with.
A few weeks later, Gugu was beaten so badly by her neighbours that she died. They had accused Gugu of ‘shaming’ their community by revealing her HIV status. The attack highlighted the extent of the stigmatisation and rejection of HIV-positive people and caused outrage across the world.
Across the world today, many people living with HIV and AIDS are still facing violent discrimination because of their status. Education and public awareness are crucial in preventing any further horrific attacks.
Rebekka Armstrong grew up in a desert town, three hours north of Los Angeles in the USA. At 18, she moved to LA and got a job modelling swimwear and lingerie. In 1986 she was Playboy’s Miss September. At 22, after suffering from extreme tiredness, Rebekka had a routine health check, within which she had an HIV test. Much to her surprise, it came back positive.
Rebekka is still not 100 percent certain how she became infected, but suspects that it was a result of unprotected sex aged 16 or a blood transfusion. She managed to keep her HIV status a secret for five years. After a suicide attempt, Rebekka went to a seminar for HIV-positive women, which changed her life. In 1994, she announced in an American lesbian and gay magazine that she was living with HIV.
Since then, Rebekka has dedicated herself to increasing HIV and AIDS awareness. She has toured throughout America, educating about HIV prevention and safer sex, and the reality of living with HIV and AIDS. 62
Related organisations - Women and HIV
- 1. UN News Service (2010, 9th June) 'Noting progress to date, Ban urges greater efforts against HIV/AIDS'
- 2. UNAIDS (2012) ' Women Out Loud: How Women Living with HIV Will Help the World End AIDS'
- 3. UNAIDS (2013) ' 2013 UNAIDS Report on the Global AIDS Epidemic'
- 4. UNAIDS (2012) ' Women Out Loud: How Women Living with HIV Will Help the World End AIDS'
- 5. UNAIDS (2013) ' 2013 UNAIDS Report on the Global AIDS Gpidemic'
- 6. UNAIDS (2009, May), ' A strategic approach: HIV & AIDS and education'.
- 7. UNAIDS (2010) ' GETTING TO ZERO: 2011–2015 UNAIDS STRATEGY'.
- 8. Global Coalition on Women and AIDS (2010) ' Women who use drugs, harm reduction and HIV'
- 9. Chan's personal story received by AVERT.
- 10. USAID (2012) ' ISSUE BRIEF: Family Planning and HIV Prevention Integration'
- 11. UNFPA (2011) ' State of World Population 2011'
- 12. UK AIDS Consortium (2012, March) ' Girls and Women, mainstreaming HIV and AIDS in DfID's Strategic Vision'
- 13. Restless Development (2012) ' Understanding the Barriers to Young People's Access to Sexual Reproductive Health Services in Sierra Leone'
- 14. The Lancet (2014) ' Global causes of maternal death: a WHO systematic analysis'
- 15. Nath, Madhu Bala (2001) 'From tragedy towards hope: men, women and the AIDS epidemic'. Commonwealth Secretariat.
- 16. UNAIDS (2010) ' UNAIDS Report on the Global AIDS Epidemic'
- 17. International Community of Women Living with HIV/AIDS (2009) ' The Forced and Coerced Sterilization of HIV Positive Women in Namibia'
- 18. The Guardian (2012) ' Forcible sterilisation leaves legacy of pain and stigma for Namibian mothers'
- 19. The Guardian (2012) ' Namibia court rules HIV-positive women sterilised without consent'
- 20. The Guardian (2012) ' HIV-positive women 'routinely sterilised without consent' in Kenya'
- 21. International Planned Parenthood Foundation (2009), ' The truth about men, boys and sex: gender transformative policies and programmes'
- 22. WHO (2007), ' Engaging men and boys in changing gender-based inequity in health'.
- 23. International Planned Parenthood Foundation (2009), ' The truth about men, boys and sex: gender transformative policies and programmes'.
- 24. Global Campaign for Education (2004, June) 'Learning to survive: how education for all would save millions of young people from HIV/AIDS'.
- 25. UNDP (2012) ' Global Commission on HIV and the Law Risks, Rights & Health'
- 26. The Global Coalition on Women and AIDS (UNAIDS) (2005) 'Educate girls, fight AIDS'.
- 27. UNAIDS (2013) ' 2013 UNAIDS Report on the Global AIDS Epidemic'
- 28. UNAIDS (2008) 'Report on the Global AIDS Epidemic'
- 29. UNAIDS/UNFPA/UNIFEM (2004) 'Women and HIV/AIDS: Confronting the crisis'.
- 30. UNAIDS (2012) ' Global Fact Sheet 2012: World AIDS Day 2012'
- 31. UNAIDS (2013) ' 2013 UNAIDS Report on the Global AIDS Epidemic'
- 32. UNAIDS (2013) ' 2013 UNAIDS Report on the Global AIDS Epidemic'
- 33. WHO (2013) ' Trends in Maternal Mortality: 1990 to 2013'
- 34. WHO (2013) ' Trends in Maternal Mortality: 1990 to 2013'
- 35. Renita's personal story received by AVERT.
- 36. UNICEF, UNAIDS, WHO (2002) 'Young people and HIV/AIDS: Opportunity in crisis'.
- 37. Koki's personal story received by AVERT.
- 38. Global Network of People Living With HIV (2010) ' 2010 Global Criminalisation Scan Report'
- 39. UNIFEM (now UNWOMEN) & ActionAid (2009), ' Together we must...End violence against women and girls and HIV & AIDS'
- 40. Sarkar K. et al (2008, June), ' Sex-trafficking, violence, negotiating skill, and HIV infection in brothel-based sex workers of eastern India, adjoining Nepal, Bhutan, and Bangladesh' Journal of health, population and nutrition 26(2).
- 41. UNAIDS (2012) ‘ Global Report: Annexes'
- 42. UNAIDS (2012) ' Women Out Loud'
- 43. Dunkle, K.L et al (2004) 'Gender-based violence, relationship power, and risk of HIV infection in women attending antenatal clinics in South Africa'. The Lancet, 363 (9419): 1415-21.
- 44. Decker M. et al (2009, August), ' Intimate partner violence functions as both a risk marker and risk factor for women's HIV infection: findings from Indian husband-wife dyads' [abstract] Journal of Acquired Immune Deficiency Syndromes 51(5).
- 45. Enya's personal story received by AVERT.
- 46. UNFPA (2005) 'State of the world population' 'Women and young people in humanitarian crises'
- 47. UNDP (2009, 12th August), ' Women’s Inheritance and Property Rights are essential to effective AIDS response'
- 48. UNAIDS (2010) ' UNAIDS Report on the Global AIDS Epidemic'
- 49. UNAIDS (2013) ' 2013 UNAIDS Report on the Global AIDS Gpidemic'
- 50. UNAIDS (2013, May) ' UPDATE: How Africa turned AIDS around'
- 51. UNAIDS (2013) ' 2013 UNAIDS Report on the Global AIDS Gpidemic'
- 52. UNAIDS (2013) ' 2013 UNAIDS Report on the Global AIDS Gpidemic'
- 53. UNAIDS (2013) ' 2013 UNAIDS Report on the Global AIDS Gpidemic'
- 54. Centers for Disease Control and Prevention (2014, March) ' HIV Among Women'
- 55. UNAIDS (2012) ‘ Global Report: Annexes'
- 56. Centers for Disease Control and Prevention (2014, March) ' HIV Among Women'
- 57. UNAIDS (2013) ' 2013 UNAIDS Report on the Global AIDS Gpidemic'
- 58. UNAIDS (2011, November) ' World AIDS Day Report 2011'
- 59. UNAIDS (2010) ' UNAIDS Report on the Global AIDS Epidemic'
- 60. UNAIDS (2009), ' HIV transmission in intimate partner relationships in Asia'.
- 61. Elizabeth Glaser Pediatric AIDS Foundation (2007) ' Elizabeth's Story'.
- 62. The Guardian (2001, 16th October) 'A model example: Rebekka Armstrong, former Playboy Playmate turned HIV activist, talks to Polly Curtis about her journey from glamour girl to safer-sex educator'
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