Women and HIV/AIDS

“This epidemic unfortunately remains an epidemic of women.”Michel Sidibé, Executive Director of UNAIDS¹

At the end of 2011 it was estimated that out of the 34 million adults worldwide living with HIV and AIDS, half are women.² The HIV/AIDS epidemic has had a unique impact on women, which has been exacerbated by their role within society and their biological vulnerability to HIV infection. Every minute one young woman becomes infected with HIV, with some countries reporting that more than 10 percent of young women aged 15-24 are living with HIV.^{3 4}

Generally women are at a greater risk of heterosexual transmission of HIV. Biologically women are twice 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.^{5 6}

Additionally, millions of women have been indirectly affected by the HIV and AIDS epidemic. Women’s childbearing role means that they have to contend with issues such as mother-to-child transmission of HIV. The responsibility of caring for AIDS patients and orphans is also an issue that has a greater effect on women.

There are a number of things that can be done in order to reduce the burden of the epidemic among women. These include promoting and protecting women's human rights, increasing education and awareness among women and encouraging the development of new preventative technologies such as post-exposure prophylaxis and microbicides.

back to top Women, HIV and AIDS - the global picture

Globally, HIV/AIDS is the leading cause of death among women of reproductive age.⁷ The percentage of women living with HIV and AIDS varies significantly between different regions of the world. In areas such as Western and Central Europe, Eastern Europe and Oceania, women account for a relatively low percentage of HIV infected people. However, in regions such as sub-Saharan Africa and the Caribbean, the percentage is significantly higher.

Sub-Saharan Africa

Sub-Saharan Africa is one region of the world where the majority of HIV transmission occurs during heterosexual contact. As women are twice as likely to acquire HIV from an infected partner during unprotected heterosexual intercourse than men, women are disproportionately infected in this region.

In 1985 in sub-Saharan Africa there were as many HIV infected men as there were women. However as the infection rate has increased over the years, the number of women living with HIV and AIDS has overtaken and remained higher than the number of infected men. In 2011 around 58 percent of people living with HIV in sub-Saharan Africa were women, which equates to around 13.6 million women living with HIV and AIDS, compared to about 9.9 million men.^{8 9} UNAIDS have estimated that around three quarters of all women with HIV live in sub-Saharan Africa.¹⁰

The Caribbean

The Caribbean has also seen an alarming increase in the number of HIV infected women, and again the main mode of HIV transmission is through heterosexual sex. HIV prevalence is six times higher today than in 2001.¹¹ Women are more affected by HIV than men in this region, accounting for more than half of people living with HIV in 2010.¹² Young women are also more likely to be infected with HIV than young men, with HIV prevalence reported to be twice as high among young women.¹³ Female sex workers are particularly at risk of HIV infection in the Caribbean. In some countries, HIV prevalence is significantly higher among this group than the general population; in the Dominican Republic, for example, 4.7 percent of sex workers are living with HIV compared with 0.7 percent of the general population.¹⁴

The Americas

The Centers for Disease Control and Prevention (CDC) estimated that in the USA, the number of newly HIV infected women increased between 2004 and 2007.^{15 16 17} It is estimated that 300,000 women above the age of 15 are living with HIV in the United States of America.¹⁸

The main way in which women get infected with HIV in the USA is through heterosexual sex. This mode of transmission accounts for around 72 percent of female HIV infections. The other main transmission route among women is injecting drug use, which accounts for 26 percent of HIV infections.¹⁹

In the USA, African American and Hispanic women account for 80 percent of AIDS cases, even though they represent less than one fourth of all women.^{20 21} Generally in industrialised countries, the epidemic has had a disproportionate effect on women in marginalised sections of the population, such as ethnic minorities, immigrants and refugees.

In Latin America, around 36 percent of adults living with HIV and AIDS are women.²² The epidemic started primarily among sex workers and men who have sex with men, but in recent years has spread to the general population. Whilst the main route of transmission across Latin America remains through sex between men and injecting drug use, in some South American countries, heterosexual sex accounts for the majority of HIV infections.²³

Asia

UNAIDS estimates that 5 million adults are living with HIV in Asia.²⁴ The number of women living with HIV and AIDS in Asia varies greatly between different countries, and in places largely affected by the epidemic, such as India, the numbers vary significantly between different states. In some Asian countries, women are often perceived to be at low risk of HIV infection because it is not common to have more than one lifetime sexual partner. However, a great number of women are put at risk of HIV infection as a result of their husbands having unprotected sex outside of marriage or injecting drugs. It has been estimated that 90 percent of women living with HIV in Asia were infected by their husband or long-term partner.²⁵

The number of adults living with HIV and AIDS in India is estimated to be 2.3 million, of which 38 percent are women.²⁶ As HIV transmission in India is largely through heterosexual contact, the infection rate for women is increasing, and the low economic and social status of women continues to be a barrier to preventing new infections. In countries such as Indonesia, Vietnam and Pakistan, HIV transmission is largely through injection drug use. Not only are female injecting drug users (IDUs) at a high risk of contacting HIV but also increasing numbers of women are becoming infected with HIV from male IDU partners.

back to top How is the HIV and AIDS epidemic affecting women?

Responsibility of care

In areas with few palliative care facilities, when a person becomes ill from AIDS 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.²⁷ 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 AIDS 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.²⁸

The AIDS 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 an HIV positive woman passes the virus 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.²⁹ Without treatment, a large number of these children will not live to adulthood.

Although there are drugs that can reduce the chances of a child acquiring HIV from its mother from about 40 percent to less than 2 percent, many women and children still cannot access them. In recent years drugs companies have significantly reduced the price of drugs such as nevirapine and AZT, which help in preventing mother to child transmission of HIV in developing countries. However, many women are still not receiving these drugs, because of limited human resources and poor infrastructures.

back to top 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 getting infected with HIV. 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”Renita³⁰ .

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 husbands³¹

“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 Kenya³² .

Violence against women

Women who are victims of sexual violence are at a higher risk of being exposed to HIV, and the lack of condom use and forced nature of rape means that women are immediately more vulnerable to HIV infection.^{33 34} In some countries, nearly half of women have experienced sexual or physical partner violence.³⁵ 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.³⁶ 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.³⁷

“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” Enya³⁸ .

In countries where armed conflict is rife, there have been reports of rape being used as a ‘tool of war’. Amnesty International reported that between 1999 and 2000 in every armed conflict that they investigated, the torture of women was reported.³⁹ In some cases, women have been intentionally infected with HIV, with the aim of causing a ‘slow death’.⁴⁰

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 a woman’s inheritance and property rights can increase her 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.^{41 42}

back to top Women and HIV - What needs to change?

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 raped, 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.

• Research is being carried out into the development of a microbicide - a gel or cream that could be applied to the vagina without a partner knowing and which would prevent HIV infection. Trials have been taking place for a number of years, but none have been successful and a microbicide for HIV prevention does not yet exist.

However, protecting women from HIV is not solely women's responsibility. Most women 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, became infected with HIV at 19 years old⁴³ .

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 Nath⁴⁴ .

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. As most of the inequalities that women face are denying them their basic human rights, it is thought that promoting these rights will enhance their status within society and help protect them against the risk of HIV infection.⁴⁵

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.⁴⁶ For many men, masculinity is linked with taking risks and being tough, which can increase vulnerability to HIV infection and discourage men from seeking testing and treatment.⁴⁷

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, Ethiopia⁴⁸

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.⁴⁹

Education is particularly important for protecting girls against HIV infection. 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, are more independent, and are more likely to earn a higher income in the future.⁵⁰

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 fight against HIV and AIDS 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 on socially and criminalised. 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.

back to top HIV positive women

AIDS 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.

Elizabeth Glaser

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.⁵¹ 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 AIDS 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.

Gugu Dlamini

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’s neighbours beat her to death. 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

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 AIDS awareness. She has toured throughout America, educating about HIV prevention and safer sex, and the reality of living with HIV and AIDS.⁵²

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References back to top

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 (2012) 'Women Out Loud: How Women Living with HIV Will Help the World End AIDS'
4. UNAIDS (2012) ‘Global Report: Annexes'
5. UNAIDS (2009, May), 'A strategic approach: HIV & AIDS and education'.
6. UNAIDS 'Women and girls'.
7. UNAIDS (2012) 'Women Out Loud: How Women Living with HIV Will Help the World End AIDS'
8. UNAIDS (2012) 'Global Fact Sheet 2012: World AIDS Day 2012'
9. UNAIDS (2012) 'Regional Fact Sheet 2012: Sub-Saharan Africa'
10. UNAIDS (2010) 'UNAIDS report on the global AIDS epidemic'
11. UNAIDS (2012) ‘Global Report: UNAIDS Report on the Global AIDS Epidemic 2012'
12. UNAIDS (2011, November) 'World AIDS Day Report 2011'
13. UNAIDS (2012) ‘Global Report: UNAIDS Report on the Global AIDS Epidemic 2012'
14. UNAIDS (2012) 'Regional Fact Sheet 2012: Latin America and the Caribbean'
15. Centers for Disease Control and Prevention (2007) 'HIV/AIDS Surveillance Report'. Vol. 19.
16. CDC Features (2007, 10th March) 'National Women and Girls HIV/AIDS Awareness Day'.
17. NIAID (2010, 10th March) 'Statement of Anthony M. Fauci, M.D'
18. UNAIDS (2012) ‘Global Report: Annexes'
19. Centers for Disease Control and Prevention (2007) 'HIV/AIDS Surveillance Report'. Vol. 19.
20. UNAIDS/UNFPA/UNIFEM (2004) 'Women and HIV/AIDS: Confronting the crisis'.
21. Centers for Disease Control and Prevention (2007) 'HIV/AIDS Surveillance Report'. Vol. 19.
22. UNAIDS (2011, November) 'World AIDS Day Report 2011'
23. UNAIDS (2011, November) 'World AIDS Day Report 2011'
24. UNAIDS (2012) 'Regional Fact Sheet 2012: Asia and the Pacific'
25. UNAIDS (2009), 'HIV transmission in intimate partner relationships in Asia'.
26. UNAIDS (2010) 'UNAIDS report on the global AIDS epidemic'
27. UNAIDS (2008) 'Report on the global AIDS epidemic'
28. UNAIDS/UNFPA/UNIFEM (2004) 'Women and HIV/AIDS: Confronting the crisis'.
29. UNAIDS (2012) 'Global Fact Sheet 2012: World AIDS Day 2012'
30. Renita's personal story received by AVERT.
31. UNICEF, UNAIDS, WHO (2002) 'Young people and HIV/AIDS: Opportunity in crisis'.
32. Koki's personal story received by AVERT.
33. UNIFEM & ActionAid (2009), 'Together we must...End violence against women and girls and HIV & AIDS'.
34. 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).
35. UNAIDS (2012) ‘Global Report: Annexes'
36. 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.
37. 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).
38. Enya's personal story received by AVERT.
39. Amnesty International USA (2007) 'Stop violence against women. Rape as a tool of war: a fact sheet'.
40. UNFPA (2005) 'State of the world population' 'Women and young people in humanitarian crises'.
41. UNDP (2009, 12th August), 'HIV and women's inheritance and property rights'.
42. UNAIDS (2010) 'UNAIDS report on the global AIDS epidemic'
43. Chan's personal story received by AVERT.
44. Nath, Madhu Bala (2001) 'From tragedy towards hope: men, women and the AIDS epidemic'. Commonwealth Secretariat.
45. UNAIDS (2010) 'UNAIDS report on the global AIDS epidemic'
46. International Planned Parenthood Foundation (2009), 'The truth about men, boys and sex: gender transformative policies and programmes'.
47. WHO (2007), 'Engaging men and boys in changing gender-based inequity in health'.
48. International Planned Parenthood Foundation (2009), 'The truth about men, boys and sex: gender transformative policies and programmes'.
49. Global Campaign for Education (2004, June) 'Learning to survive: how education for all would save millions of young people from HIV/AIDS'.
50. The Global Coalition on Women and AIDS (UNAIDS) (2005) 'Educate girls, fight AIDS'.
51. Elizabeth Glaser Pediatric AIDS Foundation (2007) 'Foundation History'.
52. 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'