In 2004 UNAIDS published a report on women and HIV/AIDS in response to what they saw as a ‘growing challenge’ in the epidemic. Within this report they describe factors which increase women’s vulnerability to HIV infection. Engender Health produce a useful summary where they describe these factors as: biology vulnerability, social and cultural vulnerability and economic vulnerability and these are discussed below. Findings from the UNAIDS report are discussed more fully at the end of this chapter.

Biological vulnerability

The biological make up of women’s bodies make them more vulnerable to HIV infection. During penetrative vaginal sex the area of mucosal surface exposed to sexual fluids is much greater than the comparable area exposed in a man. This greater surface area coupled with the fact that sperm is a more efficient carrier of HIV than vaginal fluids means that it is around 20 times more risky for an HIV-negative woman to have vaginal sex with an HIV-positive man than vice versa.

The mucosal surface of the vagina can, at times, be damaged during sexual intercourse. These microlesions may allow greater entry to the virus. The risk from this sort of damage is increased in young women and during coerced sex.

Women are more likely to attend hospital and require blood transfusions due to procedures associated with pregnancy and childbirth. Before donated blood products were routinely screened for HIV (and other viruses) this could also increase women’s vulnerability.

Social and cultural vulnerability

The position of women in respect of sexual relationships remains difficult both in the developed and developing worlds. Women are not expected to discuss or make decisions about sexuality and there are barriers to requesting or ensuring that sexual partners use condoms. In some cultures, refusal of sex may lead to a risk of abuse or suspicions of infidelity.

Women’s first sexual experiences are most likely to be with older men. Traditional views of male sexuality mean that promiscuity in men is seen as more acceptable than promiscuity in women who are expected to remain virgins until they marry. Thus women often have less experience in negotiating sexual relations and less accurate information. In some cultures women may engage in anal sex to maintain their virginity. Some surveys report as many as 25% of women as having had anal sex as part of an ongoing heterosexual relationship. Again this carries the additional risks of cuts and abrasions.

Female genital mutilation - Infibulation

This can increase vulnerability due to the likelihood of bleeding during intercourse. Infibulation is illegal in many areas therefore women undergoing this procedure may be at risk from poor procedures and blood transfusion. The United Nations Family and Population Agency estimates that two million young women undergo this operation each year, largely in Africa.

Drying agents

In some areas of Africa it is the custom to use agents such as herbs to dry or tighten the vagina to increase male pleasure. This may cause cuts and abrasions which increase the risk of HIV transmissibility.

Virginity as healing

Some traditional healers perpetuate the myth that by having sex with a virgin an HIV-positive man may become HIV-negative. This increases the vulnerability of young women.

Violence

Many women experience sexual violence within established relationships. In a UK study a significant proportion of HIV-positive women reported that they had experienced abuse or violence while a study of South African women reported that 30% have had their first experience of sexual intercourse forced on them and 11% had been raped. Coercive sex is more likely to lead to abrasions which increase the risk of vulnerability to HIV infection.

Economical vulnerability

Financial or material dependence on men means that women cannot control when, with whom and in what circumstances they have sex with many women having to exchange sex for material favours, for daily survival. This exchange, as well as formal sex work (in which there are more women than men engaged), occurs in many poverty stricken settings, and is often many women’s only way of providing for themselves and their children.

Women tend to be less economically independent and therefore may decide it is not in their interests to try to persuade a partner to use a condom for financial as well as personal safety reasons.

References and further reading:

Gielen AC, McDonell KA, Wu AW, O’Campo P and Faden R. Quality of life among women living with HIV: the importance of violence, social support and self-care behaviours, Social Science and Medicine 52: 315-322, 2001.

UNAIDS 2004 Report on the Global AIDS Epidemic

UNAIDS Fact Sheet – Women and AIDS – A Growing Challenge

Women’s Vulnerability and Risk, part 3 of Engender Health papers: http://www.engenderhealth.org/res/onc/hiv/transmission/hiv3p6.html