As new pandemics – Zika, Ebola, MERS, SARS – take turns dominating the headlines, HIV and AIDS have been pushed out of the public eye. But they have not gone away. According to the World Health Organization (WHO), more than 34 million people have died of AIDS (acquired immune deficiency syndrome) over the past 25 years, making it one of the biggest pandemics of our time. The spread of HIV (human immunodeficiency virus), the virus that can lead to AIDS, is still a major health emergency, with about 37 million people living with HIV and 5,480 new infections every day.
And, in many parts of the world, women are still among the groups most affected by HIV/AIDS. Globally, AIDS remains the leading cause of death among women aged 14 to 55 years old.
Like other groups experts refer to as “key affected populations” – including men who have sex with men, sex workers and migrants – women suffer discrimination and often stigma, which can put them at particular risk of HIV infection. In sub-Saharan Africa, which carries most of the burden with almost 70 percent of the global total of new HIV infections, more than half of the adults living with HIV are women. And their chances of avoiding the virus are getting worse. According to the United Nations Population Fund (UNFPA), young women in the region between the ages of 15 and 24 are now more than three times more likely to be infected than young men.
“This epidemic unfortunately remains an epidemic of women,” said Michel Sidibé, executive director of the Joint United Nations Programme on HIV/AIDS (UNAIDS), in 2010, as he stressed the urgent need to keep up awareness of the disease.
There are biological and physiological reasons why women are more affected by HIV/AIDS. During unprotected vaginal sex, HIV passes more easily from a man to a woman than in the other direction. The virus also spreads through blood, rectal fluids and breast milk.
But the more overarching, and complicated, reason is gender inequality and discrimination. Only 28 percent of young women in sub-Saharan Africa know how to protect themselves from HIV, according to UNAIDS. Healthcare providers often lack the training to help young women avoid and cope with HIV, while many countries have laws that limit access to contraceptives for young people. In Kenya and Senegal, for example, more than 70 percent of unmarried sexually active girls aged 15 to 19 cannot get hold of contraceptives.
And even if a woman can get access to contraception, she might not be allowed to use it. “A wife, even if she knows her husband has many partners, can’t insist on his using condoms when he is with her,” said Ulla Müller, CEO and president of women’s health organization EngenderHealth. “It is not so much multiple partners that women object to. They don’t like it, but culturally it’s an acceptable norm. But it is not the norm and they are not empowered to ask that he protect her from HIV.”
Young women in relationships with older men face an uneven power balance that means they are often forced to engage in unsafe sexual behavior, including not using condoms.
Gender inequality can also lead to gender-based violence, which further raises the risk of HIV infection for women. According to a study reported in the Lancet, “Violence is a consequence of gender power inequities, at both a societal and relationship level,” and it often goes hand-in-hand with high-risk sexual behavior, such as low condom use with multiple partners, substance abuse and transactional sex. One study cited by WHO in a 2013 report estimates that 22 percent of new HIV infections could be attributed to violence from an intimate partner.
Cultural expectations around gender roles also make it more difficult for women to access health services and information. And the stigma associated with sex and disease stops many women from seeking out available healthcare options for HIV/AIDS out of fear of being rejected, abandoned or abused.
Helping Women Fight the Pandemic
In general, HIV/AIDS programs either focus on preventing the spread of the virus – through services like testing and counseling, and needle-exchange programs – or treating those who are infected.
Progress has been substantial. Without intervention, the rates of mother-to-child transmission – when the baby of an HIV-positive woman is exposed to the virus through pregnancy, childbirth or breastfeeding – can range from 15 to 45 percent, according to the WHO, but they can be reduced to below five percent with treatments such as providing antiretroviral therapy to pregnant and breastfeeding HIV-positive women.
But these solutions only touch on part of the problem, say experts, because they don’t take into account the social norms and prejudices that allow the virus to spread. Some women face multiple, compounding factors that increase their vulnerability to HIV. “The more non-conventional women are, you find that there are greater chances of HIV or violence or both,” said Claire Mathonsi, gender and gender-based violence adviser at the International HIV/AIDS Alliance. By nonconventional, Mathonsi doesn’t just mean lesbian or bisexual women but also heterosexual women who don’t conform to social norms, such as when they start having children, at what age they get married or whether they choose to marry at all.
WHO and international health NGOs are calling for a human rights-based approach to tackling HIV/AIDS: funding programs that uphold, respect and support a woman’s right to make her own decisions; giving women information and options to help them make choices regarding their health and bringing women into the decision-making process on health policies and initiatives.
There are groups and governments already trying to address some of those issues with projects that seek to empower women. These include providing microfinance and cash transfers to reduce poverty and increase food security; helping women secure inheritance rights to land and property; advocating for changes in laws that increase the risk of violence against sex workers and giving women better access to comprehensive care after they have been raped, including HIV post-exposure prophylaxis.
Some of these programs appear to be working. The U.N. Development Program reports that cash transfers to girls and young women in Malawi resulted in HIV prevalence that, after 18 months, was 64 percent lower in the group of school-going girls who received transfers compared to the girls in the control group.
Formidable challenges remain, however. “Women’s rights and principles are not at the center of work around HIV and women,” said Mathonsi. “People have learned gender-speak or women-speak, but when it really comes to advancing gender equality, within the HIV sector as well, we have a long way to go.