(December 2000) Elizabeth Chidonza of South Africa is a mother of two, whose husband died of AIDS last year; Elizabeth has HIV. While pregnant with her daughter, Elizabeth was not offered drugs to reduce the risk of transmitting HIV to her child, nor was it suggested to her that she not breastfeed. Her 6-year-old daughter, Bernice, also has HIV. Her older son, born before Elizabeth was infected with HIV, is healthy and says he will do anything he can to save his family. Hundreds of thousands of other women in the less developed world face similar situations.

Some Facts About Women and HIV/AIDS

The AIDS epidemic is increasingly female, young, and poor. The rate of infection among women has increased each year since the early 1990s and continues to grow. Young women are the fastest growing group of people infected with HIV — 50 percent of them are between the ages of 15 and 24. Also more than 90 percent of women with HIV/AIDS live in the less developed world. These women are, however, more than just statistics. As one woman from Zambia put it, “Do I look like a figure or a statistic? I am a person, a woman living with HIV.”

The face of AIDS is increasingly female. By the end of 1999, 34.3 million adults were living with HIV/AIDS, 15.7 million of whom were women, according to UNAIDS. Though the numbers suggest lower infection rates for women, a closer examination highlights the growing HIV infection rates among women and the challenges these scenarios pose.

Regional HIV/AIDS statistics, WHO, December 1999

Epidemic started Adults and children living with HIV/AIDS % of women with HIV
Sub-Saharan Africa late ’70s–early ’80s 23.3 million 55%
North Africa & Middle East late ’80s 220,000 20%
South and South-East Asia late ’80s 6 million 30%
East Asia & Pacific late ’80s 530,000 15%
Latin America late ’70s–early ‘80s 1.3 million 20%
Caribbean late ’70s–early ’80s 360,000 35%
Eastern Europe & Central Asia early ’90s 360,000 20%
Western Europe late ’70s–early ’80s 520,000 20%
North America late ’70s–early ’80s 920,000 20%
Australia & New Zealand late ’70s–early ’80s 12,000 10%

Examples can be found in both the more developed and less developed worlds. In Spain, women’s share of reported AIDS cases more than doubled between 1985 and 1995, from around 7 percent to 19 percent. Brazilian women have experienced an even more spectacular increase in risk. In 1986, there were 16 men with HIV/AIDS for 1 woman; in 1997, there were 3 men for 1 woman. In sub-Saharan Africa, the region hardest hit by the AIDS pandemic, there are 6 women with HIV for every 5 men. As Dr. Peter Piot, executive director of the Joint United Nations Programme on HIV/AIDS, explains, “new evidence clearly shows for the first time that women infected with HIV outnumber men. Some 10 years ago, it was hard to make people listen when we were saying AIDS wasn’t just a man’s disease.”

The majority of women have been infected through unprotected sex, especially in Africa and South and Southeast Asia. In some cases, women’s exposure to multiple partners, intravenous drug use, unscreened blood transfusions, and other high-risk behavior has led to HIV infection. In many cases, however, HIV infection is part of a long chain of transmission, beginning with husbands or boyfriends who had been infected through drug use, through relations with sex workers or other female sex partners, or by having sex with other men. For example, in India, high infection rates among prostitutes and their male clients have been followed by a wave of HIV transmission among wives. Or as one woman from Peru explains, “the majority of HIV-positive women get the virus at home, not on the streets; they get it in their own bed.”

The face of AIDS is increasingly young. Today, UNAIDS calculates that more than 50 percent of all new HIV infections around the world occur in children and youth between 10 years and 24 years old. Women are becoming infected at significantly younger ages than men. Luckily, there are some signs that young people are avoiding behavior that led their parents and older siblings to HIV infection. Since young people account for a large proportion of the population in many regions of the developing world, reaching youth before they become sexually active is key to fighting the epidemic.

Young girls are particularly vulnerable to the sexual transmission of HIV. While both young girls and boys engage in consensual sex, girls are more likely than boys to be uninformed about HIV, to be coerced or raped, or enticed into sex by someone older, stronger, or richer. As Antigone Hodgins of the International Community of Women Living with HIV/AIDS (ICW) explains, “young women face most of the issues that women do, you just have to add 10 times more difficulty…”

Increased incidence of HIV/AIDS in young women has led to an increase in transmission of the virus from mother to child as well. Since the start of the HIV epidemic, an estimated 3.8 million children have died of AIDS before their 15th birthdays, nearly a half million of them in 1999 alone. Another 1.3 million children are currently living with HIV; most will die before they reach their teens. In recent years, much has been learned about preventing HIV transmission from mother to child. However, many hurdles to implementing prevention programs on a large scale in the less developed countries remain.

The face of AIDS is increasingly poor. The overwhelming majority — about 95 percent — of all people living with HIV/AIDS at the end of 1999 were in less developed regions. Sub-Saharan Africa bears a disproportionate burden of the epidemic. Of the 34.3 million adults living with HIV/AIDS, 24.5 million live in sub-Saharan Africa. Obviously, HIV infection is not confined to the poor, but poverty has made an enormous contribution in the spread of the infection by creating a situation of vulnerability. A vicious cycle emerges: AIDS deepens the poverty of households and nations, and poverty favors the spread of HIV/AIDS.

“Breaking this cycle will require not only greatly increased investments in more effective HIV prevention and care, but also more effective measures to combat poverty,” said Robert Hecht, UNAIDS Associate Director for Policy, Strategy and Research, at the worldwide AIDS 2000 Conference in Durban, South Africa.

Women’s Special Vulnerability to HIV Infection

Biological and socioeconomic factors contribute to women’s increased vulnerability to HIV infection. Women are physically more susceptible than men to HIV because of anatomical differences. Women are also at a greater risk of HIV infection if they have unprotected sex during menstruation, if they experience bleeding during intercourse, or if either partner has an untreated sexually transmitted infection (STI). STIs make women more vulnerable to HIV infection because they provide easier access for HIV (see box). Tearing and bleeding during intercourse, whether from “dry sex,” coerced sex, or prior genital cutting also multiplies the risk of HIV infection.

Women’s higher risk due to biological aspects

• The vagina is a larger surface area of mucosa exposed during intercourse and is a particularly hospitable environment for the virus

• The semen has a higher concentration of virus than vaginal secretions (makes male-to-female transmission more efficient)

• Untreated STIs in either the man or woman multiply the risk by up to 10-fold

• Coerced sex or genital cutting increase the risk of tearing and bleeding during intercourse

Specific symptoms of HIV infection in women

• Vaginal yeast infections and other vaginal infections (bacterial vaginosis, gonorrhea, chlamydia, and trichomoniasis)

• Severe herpes

• Genital ulcers

• Human papillomavirus (HPV) infections

• Pelvic inflammatory disease (PID)

• Menstrual irregularities

However, the reasons for HIV infection often have less to do with biology and more to do with fundamental issues of power and control. Women’s vulnerability to HIV infection may be increased by economic or social dependence on men. As AIDS and Men editor Martin Foreman notes, it is usually men “who determine whether sex takes place and whether a condom is used.” In situations of economic dependence, women’s ability to insist on condom use is further curtailed. If women refuse sex or request condom use, they may risk abuse and suspicion of infidelity, be abandoned or be forced to leave the house — alone or with their children.

This dynamic also controls the lives of many female sex workers and women who occasionally exchange sexual favors to provide for themselves and for their children. While some are able to negotiate condom use or work in “100 percent condom use” scenarios, many risk violence or loss of income if they request condom use. Concerns over immediate survival often take precedence over the specter of AIDS looming in future. As one sex worker in the Philippines explains, “AIDS may make me sick one day. But if I don’t work, my family would not eat and we would all be sick anyway.”

How Can Women Reduce Their Vulnerability and Risk?

To reduce women’s vulnerability and risk to HIV infection, women’s access to information and services must increase, but more importantly, structural changes are needed to redress the power imbalance between women and men. In the few countries that have programs on women and AIDS, the emphasis continues to be on education, counseling, partner reduction, male condom promotion, and monogamy. The messages aimed at women often disregard the power imbalances that act as barriers to women’s active use of most of these options.

Successful programs that reduce the growth of the epidemic among women aim to empower women economically. Programs that reinforce women’s economic independence by strengthening training opportunities, credit programs, saving schemes, and women’s cooperatives can be linked with AIDS prevention activities. One UNAIDS-funded project in Zambia provides interest-free loans to women fish traders who have formed cooperatives. With these loans, women no longer have to exchange sex with the fisherman or truck drivers who control their access to fish and transport.

Other programs have aimed to develop communication strategies for young people to discuss STIs, HIV/AIDS, the use of condoms, and other sexual behaviors. In Uganda, the government and other groups in society, including religious leaders and community development organizations, have developed an effective campaign to reduce HIV infections. The Straight Talk Foundation, a nonprofit group established in 1994, produces a weekly radio program that reaches more than 1.5 million young people, helping them learn how to communicate and negotiate their way out of difficult sexual situations.

Other interventions have occurred at the local level, targeting those most vulnerable and engaging community participation. In Nepal, the trafficking of Nepali women to brothels in Bombay, Delhi, and Calcutta is responsible for the spread of HIV. The Maiti Project in Nepal has worked to address this problem. The project has established camps that provide education, vocational training, and support and counseling for young girls who escaped from traffickers or for those who are in danger of being sold.

Governments’ commitment is key to addressing the epidemic, as are social mobilization, resource availability, and other structural changes in health services. Dr Roy Anderson, of the University of Oxford, explained at the AIDS 2000 Conference that common features of success stories are “strong leadership from government, the allocation of significant funds for interventions, the seeking of international aid to support public health measures and wide, plus frank, publicity of the seriousness of the problem.”

The Future for Women

The information presented at the AIDS 2000 conference, held in Durban, South Africa, July 9-14, 2000, illuminates dramatically the huge extent of the HIV epidemic. The overall impact encompasses more than just the lives of those infected with HIV/AIDS. It changes community dynamics, undermines the structure of the family, and threatens children’s future.

On the medical front, progress has been made with new antiretroviral drugs (drugs that inhibit the development of full-blown AIDS). These drugs allow some people with HIV to live longer. However, they are costly and therefore remain a luxury for all but people with AIDS who live in more developed countries. In his message on World AIDS Day last year, Dr. Peter Piot said, “While antiretrovirals have brought hope to many people with HIV who are fortunate enough to have access to them, they are not a panacea, and they are not available in most of the world…The key to fighting AIDS is preventing new infections. For this, more resources are needed—to implement the prevention strategies we have today, and to develop new and better tools…”

Progress has also been made on female-controlled barrier methods. The female condom, when used consistently and correctly, provides protection against HIV/STIs. Again, many women in less developed countries do not have access to this technology. The methods are costly, scarce, and depend on partners’ consent — an obstacle that many women cannot overcome.

Microbicides provide another alternative to lowering HIV infection rates by reducing transmission of STIs. Women with STIs are more likely to contract HIV if exposed to the virus. However, initial indications that microbicides could directly prevent HIV infection have not proved true.

Successful country-level efforts have highlighted that with political commitment, sufficient resources, and good information, sexual behavior can change; for example, men would use condoms. Yet the battle against HIV/AIDS is just beginning. Only more efforts like these will keep the face of AIDS from becoming increasingly female, young, and poor.

Justine Sass is international programs fellow at the Population Reference Bureau. Sara Adkins-Blanch is administrator MEASURE Communication at the Population Reference Bureau.