University of Zambia Medical Library

Women and AIDS: UNAIDS Best Practice Collection Point of View (June 1997)

In industrialized countries, practically all infections used to occur in men. No longer. While women comprised around 12% of the AIDS cases reported in France in 1985, ten years later this figure rose to around 20%. In Spain, women's share of reported AIDS cases more than doubled over the same ten-year period – from around 7% to 19%. Brazilian women have experienced an even more spectacular increase in risk. While only one woman was infected for every 99 men in 1984, a decade later women accounted for a quarter of all those with HIV.

Asian women face an enormous challenge from their region's runaway HIV epidemic. Typically, one-third or more of prostitutes in cities in Cambodia, India and Thailand are infected. Even among women who are not occupationally exposed, the risk is growing. Nationwide in Thailand, in 1991, fewer than 1% of pregnant women attending antenatal clinics were found to be infected. By 1995, the figure was more than 2%. In Africa south of the Sahara, there are already 6 women with HIV for every 5 men. Close to four-fifths of all infected women are African.

In the younger age brackets (15-24 years), the HIV risk for African girls is even more disproportionate. In countries where youngsters account for 60% of all new infections, young women outnumber their male peers by a ratio of 2 to 1. Currently, close to half of the 7500 adults worldwide who become infected daily are women. And over 9 out of 10 infected women live in a developing country.
More than four-fifths of all infected women get the virus from a male sex partner (heterosexual transmission). The remainder become infected from a blood transfusion or from injecting drugs with a contaminated needle. Studies in Africa and elsewhere have shown that many married women have been infected by their one partner – their husband. Simply being married is a major risk factor for women who have little control over abstinence or condom use at home or their husband's sexual activity outside.

Women with a sexually transmitted disease (STD) like gonorrhoea are often unaware of it because the infection is "silent". Conclusive proof now exists that STDs facilitate the spread of HIV. An untreated STD in either partner increases the risk of HIV transmission during unprotected sex* 3- to 4-fold. The STD epidemic, with 333 million new cases a year, thus fuels the AIDS epidemic. AIDS prevention campaigns often fail women by assuming that they are at low risk, or by urging prevention methods that women have little or no power to apply, such as condom use, abstinence and mutual fidelity. (*Unprotected sex means intercourse without a condom).

Women continue to make strides towards equality with men. Wherever they are educated, able to generate income, and enjoy equal protection under the law, they are in a position to have some control over their economic, social and personal life.But for millions of women, these goals are still remote. These are the women who are the most vulnerable to infection with HIV, the virus that results in AIDS.

Biological vulnerability:
Research shows that the risk of becoming infected with HIV during unprotected vaginal intercourse is as much as 2-4 times higher for women than men. Women are also more vulnerable to other sexually transmitted diseases. As compared with men, women have a bigger surface area of mucosa exposed during intercourse to their partner's sexual secretions. (In women, the genital mucosa is the thin lining of the vagina and cervix.) And semen infected with HIV typically contains a higher concentration of virus than a woman's sexual secretions. This makes male-to-female transmission more efficient than female-to-male. Younger women are at even greater biological risk. Their physiologically immature cervix and scant vaginal secretions put up less of a barrier to HIV. There is evidence that women again become more vulnerable after the menopause. Tearing and bleeding during intercourse, whether from "rough sex", rape or prior genital mutilation (female "circumcision"), multiplies the risk of HIV infection. Throughout the world, women run a similar risk from unprotected anal intercourse. Sometimes preferred because it preserves virginity and avoids the risk of pregnancy, this form of sex often tears the delicate tissues and affords easy entry to the virus.

A final important biological factor is an untreated STD in either partner, which multiplies the risk of HIV transmission by 300-400%. Between half and four-fifths of STD cases in women go unrecognized because the sores or other signs are absent or hard to see and because women, if they are monogamous, do not suspect they are at risk.

Social and economic vulnerability:
Biologically vulnerable does not mean unprotectable. Experience from the past decade proves that both men and women can be helped to avoid HIV. Around the world, infection rates have been lowered by screening blood for transfusion, by frank information about how HIV can spread, by clear prevention messages urging abstinence, fidelity or safer sex, by condom promotion, by needle exchange programmes for drug users, and by encouraging and enabling people to get prompt care for STDs. However, for millions of women, many of these services are inaccessible and many of the messages irrelevant or inapplicable. Because of their socioeconomic circumstances, women's autonomy is crippled. Lacking economic resources of their own, and fear-ful of abandonment or violence on the part of their male partners, they have little or no control over how and when they have sex and hence over their risk of becoming infected with HIV. This is the meaning of vulnerability. Millions of young girls are brought up with little understanding of their reproductive system or the mechanics of HIV/STD transmission and prevention. Even when human sexuality is taught at school, girls are at a disadvantage because, especially in developing countries, they are taken out of school earlier than boys. At the same time, girls are taught to leave the initiative and decision-making in sex to males, whose needs and demands are expected to dominate. Male predominance often comes with a tolerance for predatory, violent sexuality. It also carries a double standard whereby women are blamed or thrown out for infidelity, real or suspected, while men are tacitly expected or allowed to have multiple sex partners.

Failure to respect the human rights of girls and women in terms of equal access to schooling, trai-ning and employment opportunities reinforces their economic dependence on men. The reliance may be on a "sugar daddy", a husband or stable partner, a few steady male partners who have fathered the children, or, for women in pros-titution, a succession of clients. Indeed, for girls and women in many cultures, sex is the "currency" in which they are expected to pay for life's opportunities, from a passing grade in school to a trading license or permission to cross a border.

A woman in a stable relationship who is economically dependent on her partner cannot afford to jeopardize his support even when she suspects he has HIV. If she refuses him sex or asks him to use condoms, she is breaking the conspiracy of silence that surrounds his extramarital activity – or, even worse, intimating or admitting that she was unfaithful. And while some men agree to use condoms, many react with anger, violence or abandonment. A further dilemma is that condoms are incompatible with pregnancy. Couples wanting children need to know their HIV status and, if both are uninfected, agree to remain faithful or refrain from unsafe extramarital sex. Obstacles are unwillingness to discuss these issues openly and a lack of voluntary HIV testing and counselling services.

STDs, which augment a woman's biological vulnerability to HIV, often go untreated even when symptomatic. Women are brought up to accept ill health and especially "women's troubles" as their lot in life, and in general have poor access to appropriate health services. Because sexually transmitted infections carry a heavy social stigma (less so for men), women tend to avoid STD clinics for fear of being recognized. And the health workers to whom women do have access, in primary health or maternal and child health clinics, are often unsympathetic, judgmental, and unprepared to diagnose and treat STDs.

Prostitution constitutes another setting in which women have little power to protect themselves from HIV. Girls forced or sold into sex work, even before puberty, are generally unaware of the AIDS risk and unable to run away or take protective action. The sexual exploitation of girls is one of the most pernicious forms of child abuse.

Not all prostitution is forced. While for some women it is a choice, many turn to occasional or steady sex work as an alternative to dire poverty, exchanging sex for the basic necessities of life for themselves and their children. Often, these are women whose lives have been disrupted by war, or divorcees or widows who because of inequitable laws and customs have lost their property as well as their husband's earning power. While many sex workers risk violence or loss of income if they request condom use, in some places prostitutes have banded together to demand condoms from all clients, or work in brothels where the government has instituted a "condoms-only" rule. Ironically, these women may enjoy more protection than housewives who have no "social permission" to request or negotiate safer sex. A vulnerable woman is one who is lacking in power or control over her risk of HIV infection. The remedy is empowerment.

Combat ignorance:
Improve the access of girls to formal schooling. Ensure they have information about their own bodies, education about AIDS and the other STDs, and the skills to say no to unwanted or unsafe sex. UNAIDS is testing and comparing different approaches to skills-building and determining the best practices in this area.

Provide women-friendly services:
Ensure that girls and women have access to appropriate health care and HIV/STD prevention services at places and times that are convenient for them. Expand voluntary HIV testing and counselling services. Make condoms and STD care available where women can go without embarassment. UNAIDS is helping to ensure that women's family planning options help rather than undermine their ability to avoid HIV.

Develop female-controlled prevention methods:
The male condom, currently the only barrier method available for HIV prevention, urgently needs to be comple-mented by methods that women themselves can use, if necessary without the know-ledge or cooperation of their male partner. UNAIDS is facilitating the development of and access to several such methods, including the female condom and vaginal microbicides – virus-killing creams or foams that women can insert vaginally before intercourse. A microbicide that does not kill sperm and prevent conception would be helpful to millions of couples worldwide.

Build safer norms:
Support women's groups and community organizations in questioning behavioural traditions which have become deadly with the advent of AIDS, including tolerance of child abuse, rape and sexual coercion. Educate boys and men to respect girls and women, to engage in respon-sible sexual behaviour, and to share the responsibility for protecting themselves, their partners and their children from HIV and the conventional STDs. UNAIDS speaks out for safer, egalitarian norms and supports concrete efforts to build these in and out of school.

Reinforce women's economic independence:
Multiply and strengthen existing training opportunities for women, credit programmes, saving schemes and women's cooperatives, and link them with AIDS prevention activities. For example, UNAIDS is supporting efforts to enable Zambian women fish traders to form a cooperative that will give them interest-free loans. With these, they will no longer have to exchange sex with the fishermen or truck drivers who control their access to fish and to transport.

Reduce vulnerability through policy change:
UNAIDS' message is that policies from community to national level must be reshaped if women's vulnerability to HIV is to be reduced. Among other things, this means protecting their human rights and funda-mental freedoms and improving their economic independence and legal status. This cannot be achieved without a greater political voice for women.

UNAIDS Best Practice materials:
The Joint United Nations Programme on HIV/AIDS (UNAIDS) is preparing materials on subjects of relevance to HIV infection and AIDS, the causes and consequences of the epidemic, and best practices in AIDS prevention, care and support. A Best Practice Collection on any one subject typically includes a short publication for journalists and community leaders (Point of View); a technical summary of the issues, challenges and solutions (Technical Update); case studies from around the world (Best Practice Case Studies); a set of presentation graphics; and a listing of key materials (reports, articles, books, audiovisuals, etc.) on the subject.

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Last updated August 27, 1997

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