Facts and figures

• Of 33.6 million people living with HIV/AIDS around the world today, 14.8 million are women
  
  
• Of 5 million adults newly infected in 1999, 2.3 million are women
  
  
• Of the 2.1 million people who had died of AIDS by 1999, 1.1 million were women
  
  
• In Africa, 12-13 women are currently infected for every 10 men
  
  
• Half a million children under 15 are HIV positive -- most were infected through mother-to-child transmission
  
  
• Among groups of adults with infection, women account for 55% in Sub-Saharan Africa, 30% in Southeast Asia, 20% in Europe, and 20% in the USA

Modes of transmission

The AIDS epidemic in women is overwhelmingly heterosexual; this is almost entirely so in Africa and in South and Southeast Asia.

In other areas, a proportion of women are infected through:

• sex with a bisexual or drug-injecting partner
  
  
• their own injection drug use
  
  
• heterosexual sex without these factors
  
  
• blood transfusion (primarily in developing countries where blood is not routinely screened)

Why are women more vulnerable to HIV infection?

Several factors make women more vulnerable than men to sexual infection with HIV.

Biologically

• Larger genital mucosal surface exposed during intercourse; microlesions that can occur during intercourse are believed to be entry points for the virus. Very young women are even more vulnerable in this respect because they have not reached physiological maturity.
  
  
• More virus is present in sperm than in vaginal secretions.
  
  
• As with sexually transmitted infections (STIs), women are at least four times more vulnerable to infection. The presence of untreated STIs is a risk factor for HIV.
  
  
• Coerced sex increases the risk of microlesions.

Economically

• Financial or material dependence on men means that women cannot always control when, with whom, and in what circumstances they have sex.
  
  
• Many women have to exchange sex for material favours and survival. Formal sex work clearly involves this exchange but there is also another, less formalized exchange which, in many resource-poor settings, is the only way for many women to provide for themselves and their children.

Socially and culturally

• Women are not expected to make decisions about or even to discuss sexuality.
  
  
• Many women cannot request, let alone insist on using a condom or any form of protection.
  
  
• If women refuse sex or request condom use, men often suspect infidelity. Therefore, women often risk abuse by refusing sex or requesting condom use.
  
  
• There are many forms of violence against women; often, sex is coerced. Sexual assault is a risk factor for HIV infection.
  
  
• For married and unmarried men, it is culturally acceptable to have multiple partners, including sex workers.
  
  
• Women are expected to have relations with or to marry older men, who are more sexually experienced and more likely to be infected. Conversely, men are seeking younger and younger partners in order to avoid infection and in the belief that sex with a virgin cures AIDS and other diseases, putting more and younger girls and women at risk. These misguided notions may be contributing to increases in sexual assault.

Why must the response be gender-based?

There are three main reasons for a gender-based response:

1. Unequal gender relations, with powerful social, economic, and political dimensions, are driving the HIV epidemic, i.e., contributing to the spread of HIV infection.
   
   
2. Women are disproportionately affected by the epidemic. Again, they are highly vulnerable to infection. Women often are forced to bear the psychosocial and physical burden of AIDS care. Women also suffer particular discrimination -- they are often blamed for spreading infection and become targets for anger and violence.
   
   
3. Gender differences exist in HIV/AIDS pathology. Clinical management of HIV disease (based too often on research undertaken in men) must be responsive to women's particular needs, symptoms, types of HIV-related illnesses, and so forth.

What will make a difference?

Physical and material independence and security for women that is independent of the "protection" of a man or men is necessary. Women must be empowered to control their own lives and in particular their sexuality, and men must participate in this process (primarily by responding with respect). This implies a profound shift in social and economic power relations between men and women. Such a shift cannot be achieved immediately but action must start now, through:

• Increased educational and employment opportunities for girls and women, and
  
  
• Public education campaigns on the harmful -- in the case of AIDS, fatal -- effects of unequal gender relations.

Microbicides: our best hope

The development of a prevention method that is widely affordable, safe, effective, and under women's control is essential.

• In the absence of a vaccine, this method is likely to have an immediate and significant impact on the alarming rate of new infections in women.
  
  
• A massive investment in international research and development of a microbicide is required.
  
  
• A microbicide for preventing both pregnancy and STIs including HIV (dual protection), and a microbicide that is not also a spermicide, which would permit pregnancy, must be developed.

Proven effective interventions

A number of proven interventions comprise key strategies to control the spread of the epidemic. These strategies, which must be used in combination, are particularly important for women.

Treatment and prevention of sexually transmissible infection

• Women are more vulnerable to STIs; the consequences are more serious.
  
  
• Many STIs are asymptomatic in women and therefore go undetected and untreated.
  
  
• Syndromic management of STI in women is more difficult than in men.
  
  
• Because the social stigma associated with STIs is greater for women (suggests promiscuity), they are often afraid or unwilling to seek care.

Safe blood

Women and children are the chief recipients of blood transfusions, related to childbirth and frequently given during and after delivery. The following action is required:

• Antenatal care and adequate nutrition would reduce some of the need for transfusion.
  
  
• The appropriate clinical use of blood could help to avoid unnecessary transfusion.
  
  
• Screening of all blood is the ultimate aim.

Education for prevention including the use of condoms

Condoms, of both the so-called male and female varieties, are currently the only protection methods available. They need to be more widely accepted, available, and used.

• Education is needed to promote their use.
  
  
• Increasing access must be created through free distribution, subsidies, or social marketing so that condoms are truly affordable.

It has been shown that even in the most favourable circumstances, male and female condom use is low. The acceptability of these methods remains problematic. The female condom is often felt to be more cumbersome than the male condom and considerably more expensive. Furthermore, women cannot insist upon or control the use of female condoms, either. Impact will continue to be low if people's preferences and therefore their actual sexual practices and use of methods are not given due attention.

Women as caregivers

Women often are forced to take full responsibility for the health care of all family members.

• The provision of care to family is only one of the many productive and reproductive activities of women. In many places, women's daily activities also include farming, food preparation, collection of firewood and water, child care, cleaning, etc.
  
  
• Women care providers are often HIV positive themselves.
  
  
• Women's family care activities may seem to be free of charge but there are actually costs involved. When women are ill, their productive labour is lost. This loss of productivity has serious impacts on the immediate and long-term well being of the household. Care of orphans after the death of a mother or father often falls to grandmothers and aunts.

Involving men -- making them more responsible

• Men are often hard to reach and educate but many are concerned about sexual health -- their own and their partner's. Raising awareness of men's own risk has been shown to change certain behaviors.
  
  
• Little attention has been paid to men's participation in efforts to protect women. Men must take part in change -- interventions must be aimed at men as well as at women if women are to be protected.
  
  
• Sexual health and reproductivity must involve men as well as women, who must both be viewed as integral parts of families -- not just women.

This article was adapted from the World Health Organization (WHO) Fact Sheet No. 242.

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