In 2004 UNAIDS/UNFPA/UNIFEM published a global report called Confronting the Crisis on the HIV epidemic and its impact on women. This substantial piece of work acknowledged the changing nature of the epidemic and its increasing impact on women worldwide. It brought together up-to-date information and thinking about how to respond to this crisis and some of the key messages from the report are outlined below.

Globally, women now make up almost half of the people living with HIV, with UNAIDS estimating that 17.6 million adult women were living with HIV as of December 2004.

Many of these women live in sub-Saharan Africa, where they account for 57% of all individuals living with the virus. However, the increase in the proportion of women living with HIV is happening in all areas of the world, notably in Eastern Europe, Latin America, the Caribbean and Asia. This means that globally young women are 1.6 times more likely to be living with HIV/AIDS than young men. It is notable that the higher-prevalence the area, the higher the proportion of women infected. (See ‘HIV epidemiology’ for more details).

Proportion of people living with HIV who are women, 2004

This situation is described as a ‘cause of great concern’ particularly when considered alongside the roles that women perform in the world where they tend to be responsible for caring for people with HIV/AIDS, AIDS orphans and their own families.

Anatomically, young women are more vulnerable to HIV infection. But Confronting the Crisis describes the situation as largely arising from gender inequality which leads to women being expected to be monogamous or celibate yet at the same time it is accepted that males are likely to have several partners.

In addition to this gender inequality in terms of sexual health, in many parts of the world women are economically dependant on men and are not able to own property thus placing such women at risk of abusive power relationships. In some circumstances women may be living in violent relationships, being unable to insist on preventative measures to prevent HIV transmission.

Confronting the Crisis goes on to describe how a culture of violence, perhaps during times of war or other crises can make women more at risk of rape and sexual abuse.

In many regions of the world there is a ‘culture of silence’ around sexual health. This silence leaves women with a lack of knowledge and therefore reduces her ability to protect herself. A lack of knowledge of the transmission routes for HIV is also apparent.

For example, in studies reported in Confronting the Crisis, in Vietnam almost half of all young women surveyed believed they could get HIV from a mosquito bite while in Cambodia 30% of young women believed that HIV could be contracted by supernatural means and nearly 35% believed a healthy looking person could not be infected. This culture of silence also relates to more general sexual health issues, for example, in one Zambian study less than a quarter of the women asked believed that, even if a woman knew her husband had multiple partners, she would be able to refuse to have sex with him, and only 11% of the women believed she had a right to ask him to use a condom.

When considered alongside the poverty which can force many women into sexual relationships sometimes in exchange for money or food it can be appreciated how women’s place and roles in society increase their vulnerability. One way in which families in some regions attempt to alleviate poverty is through marrying of young girls to older men. This puts girls at risk as shown by evidence from a Kenyan study where 50% of women with husbands at least ten years older than them were positive compared to no women whose husbands were up to three years older. These inequalities have been attributed to the older men’s greater experience and therefore risk of exposure to HIV coupled with the women having no opportunity to negotiate sexual relations in terms of protecting herself from HIV infection.

These circumstances make clear the huge challenge facing agencies trying to prevent the further spread of HIV in women.

Access to health care and treatment

Many of the positive women in the world are living in areas where access to ART is limited, in sub-Saharan Africa, for example, only approximately 3% of individuals requiring ART actually received it in 2003. However, it is not only the availability of ART which impacts on women’s access to treatment; in some areas the treatment of men is prioritised over women. Therefore, if women are not economically independent they may be unable to access treatment on their own behalf. For example, a survey with Zambian women revealed how families on limited budgets chose to pay for treatment only for men in the household and also how property rights – where property of a man who dies passes to his family not to his wife – mean that widows can often be left with no means of support.

Thus, in areas where health services and family planning are not free and easily available women will not be able to access health care or contraception.

Women and prevention

Women’s traditional roles and relationships in society leave them vulnerable to HIV infection, in some areas the biggest risk factor for HIV infection in women is being married, for example, a Kenyan study found that 33% of married girls were HIV-positive compared to 22% of unmarried sexually active girls. (NAT). The need for prevention strategies that can inform women and young girls is ‘urgent’ as in some countries infection rates amongst young girls is over five times higher than for boys. However, traditional messages about ‘safer sex’ are inadequate in the face of the cultural issues outlined above.

In order to give women and adolescent girls the information and means they need to protect themselves form HIV, Confronting the Crisis summarised principles for prevention strategies which are known to work:

• Challenging the social norms and values that contribute to the lower social status of women and girls and condone violence against them.
• Increasing the self-confidence and self-esteem of girls.
• Strengthening the legal and policy frameworks that support women’s rights to economic independence including the right to own and inherit land and property.
• Ensuring access to health services and education, in particular life-skills and sexuality education for both boys and girls.
• Empowering women and girls economically.

These principles, however, are addressing fundamental aspects of some societies. The political will required to address some of the political and legal aspects will be huge.

A UK perspective

While the principles of prevention strategies outlined above may seem most relevant to the developing world a strong argument could be made for their importance within the UK. Social norms about male and female sexuality continue to portray these as different, with different moral values attached, and women tend to earn less than men and be more likely to be carers of children and other dependant family members. While some areas are encouraging sexual health awareness education for young people via projects such as the SHARE initiative in Scotland, a comprehensive prevention programme for women remains elusive.

Traditional prevention campaigns have either been targeted at gay men or a population level behaviour change approach. While recently there have been initiatives promoting testing within the African community there is little in the way of general messages for women. One of the difficulties in developing such an approach is that knowledge about what might work is limited. It has been suggested that, since most women are infected by men, a way forward might be to target initiatives at men (for example IV Drug Users or gay and bisexual men who have sex with women). However, this would not reach all vulnerable women could be seen as placing women as ‘victims’ in the epidemic by not allowing them the means to protect themselves.

Developing an effective prevention campaign for women is a complex issue. It seems unlikely that prevention messages for ‘heterosexuals’ will not be effective as this term embraces a diversity of groups and does not distinguish between women and men and therefore cannot be specific about risks.

Most women in Britain who know they have HIV were unaware that they were at risk when they became infected. Often, HIV-positive women report that they knew the risks associated with HIV, but did not know that this risk was related to them. So, despite the challenges, it is important that something is done to address this area or women will continue to consider themselves at low risk for HIV.

Although both female and male condoms protect both partners from the risk of HIV and other STIs neither can be used by a woman without the co-operation of her partner. One way to address this gap in the means of protection may be through the development of microbicides.

Microbicides

A microbicide is ‘any product which can kill or prevent infection form one or more microbes that can be transmitted during sexual intercourse. (Weeks 2004). A microbicide would be used in the form of a gel, sponge or lubricant would enable individuals to protect themselves against HIV and pregnancy without the knowledge of their sexual partner.

Microbicides are not yet available and are currently being researched. The aim is to develop two agents: one that will protect against HIV and pregnancy and the other to act against the virus only to allow couples to conceive while protecting against HIV transmission. It is estimated that a microbicide which was only 60% effective could prevent over 2.5 million infections within three years of it becoming available. However, the cost of developing microbicides is huge (estimated at $775 million to test existing agents) and activists are currently campaigning for more funding to be put into this field.

References

Weeks M, Mosack K, Abbott M, Sylla L, Valders B and Prince M. American Sexually Transmitted Diseases Association, Microbicide Acceptability Among High Risk Urban U.S. Women: Experiences and Perceptions of Sexually Transmitted HIV Prevention, 2004.

Women and HIV/AIDS: UNAIDS/UNFPA/UNIFEM, 2004

National AIDS Trust. HIV Prevention Factsheet, 2005

For information on the SHARE programme please contact Healthy Respect at NHS Lothian on 0131-536 9000.

An extensive discussion of research evidence regarding gender and HIV is available from UNAIDS: Gender and HIV/AIDS: Taking stock of research and programmes is available from www.unaids.org, and a selection of links to other material on Women and HIV can be found in the Links section at NAM's website, http://www.aidsmap.com/

ACT-UP New York: Women, AIDS and Activism, South End Press, 1990.

Corea, Geena: The Invisible Epidemic - The Story of Women and AIDS, Harper Perennial, 1992.

Gorna, Robin: Vamps Virgins and Victims: How can women fight AIDS? Cassell, 1996. See especially chapters eight and nine.

Gupta, Geeta Rao: Gender, Sexuality, and HIV/AIDS: The What, the Why and the How. Plenary address 13^th International AIDS Conference, Durban, South Africa, 2000.

Houar-Knipe, Mary and Rector, Richard: Crossing Borders: Migration ethnicity and AIDS, Taylor and Francis, 1996.

O'Sullivan S and Thomson K (eds) Positively Women, Sheba, 1992, re-print due from Pandora, 1995.

Women Like Us - Positively Women's Survey on the Needs and Experiences of HIV-positive Women, Positively Women, 1994.