Are women at risk?
Yes. Although the number of infections among women is still thankfully small, the rapid increase in cases in the past few years is alarming. Women are one of the fastest growing populations being infected with HIV, and the number of AIDS cases among women is doubling every 1 to 2 years.(1) During 1991 the proportion of AIDS cases increased most among women, African-Americans and Hispanics, and persons exposed to HIV through heterosexual contact.(2)
In 1993 women represented 16% of all AIDS cases in the US; 55% of those were African-American women. Injection drug use, and heterosexual contact with an injection drug user (IDU) accounted for over 60% of all cases.(3)
HIV infection was the leading cause of death for women aged 25-44 in 13 cities in the US, ranging from 13% of all deaths in Stamford, CT, to 40% in Newark, NJ.(4) HIV infection is the fourth leading cause of death among women aged 25-44 nationwide.
What places women at risk?
In 1992 for the first time in the US, heterosexual contact replaced injection drug use as the leading source of HIV infection for women.(5) Male-to-female transmission is much more likely than female-to-male; in 1993, 37% of women contracted HIV through heterosexual contact, as opposed to 4% of men. Reasons for this are twofold: there are more men than women in the US infected with HIV, which increases the likelihood that women would have an infected sex partner; and HIV is more easily transmitted from men to women due to the greater exposed surface area in the female genital tract.(1)
The annual number of women aged 20-29 with heterosexually acquired AIDS has increased by 96.7% since 1988.(5) The majority of these women were infected as adolescents or young adults. Prevention programs for adolescents should be a high priority.
Sexual coercion places many women at risk. In a study of unmarried Latina women across the US, 20% reported a history of sexual abuse or rape.(6) Public health agencies need to raise public awareness about sexual coercion and help women and men develop the skills needed to prevent it.
Injection drug use among women has not been studied adequately. Most drug treatment programs are staffed by men and oriented towards male clients. Allowing pregnant women to enroll in drug treatment, and allowing women to bring children with them would be helpful. Treatment programs sensitive to women, especially African-American and Latina women, are an urgent necessity.(7)
How can women protect themselves?
Women are capable of protecting themselves against HIV infection, but a lot more can be done to support them. The National AIDS Behavioral Surveys showed that among women with multiple partners, only 25.5% of women always use condoms with their primary partner, and 34.1% always use them with secondary partners.(8) Behavioral barriers to HIV protection, as well as physical barriers must be addressed.
Women do not wear the condom. For women to protect themselves from HIV infection, they must not only rely on their own skills, attitudes, and behaviors regarding condom use, but also on their ability to convince their partner to use a condom. Gender, culture and power may be barriers to maintaining safer sex practices with a primary partner. HIV prevention strategies must target both women and men in heterosexual couples and address gender norms in sexual decision-making.(9)
Many minority women living in poverty are disproportionately affected by HIV. For these women the struggle for daily survival may take precedence over concerns about HIV infection, whose impact may not be seen for several years.(10)
What are the methods for protection?
Women are more likely to protect themselves from pregnancy using methods that do not depend on partner cooperation, such as oral contraceptives. Likewise, female-controlled methods to prevent HIV transmission are needed. Traditionally, abstinence, condoms and dental dams have been the main methods of protection. In 1993, Reality¨, a female condom, was introduced on the market and is currently being studied. A concerted program to develop vaginal virucides that would prevent STD transmission but allow for pregnancy, should become a national priority.(11)
What can be done now?
Despite the problems, some programs have successfully helped women protect themselves. Programs that address the barriers felt by women are especially helpful. A study of women-focused prevention programs found that programs located in places where women already go were effective. Programs located at family planning and women's health clinics, AFDC application sites, food stamp programs, migrant farmworker camp kitchens, and in women's homes, among other places, proved effective.(12)
Programs that use multiple approaches to addressing women's needs can be more effective. A program for young women at an inner-city family health center serving a minority population found that counseling by physicians achieved more changes in knowledge of sexual risks, whereas peer education achieved greater changes in knowledge about injection drug use.(13)
School-based sex education, especially if started young, can protect girls by delaying the onset of sexual activity or encouraging condom use among sexually active adolescents.(14) Since adolescents are at a particularly high risk for HIV infection, more programs aimed at school-age youth are needed.
Interventions that promote HIV counseling and testing for both members of a couple should be considered. A program in Rwanda, Africa provided education and confidential testing and counseling to all participants in a research clinic, as well as their sexual partners. Rates of new HIV infections decreased significantly in women whose partners were tested and counseled.(15)
More effective programs aimed at men go a long way toward protecting women. Social marketing of condoms to men has been extremely successful in several countries around the world. In the US, the National Institute on Drug Abuse (NIDA) found that an effective message to motivate African-American male drug users to use condoms was concern about being the father of an "AIDS baby."(16) Condom campaigns that target men in a positive way to help "protect the family" can also benefit women.
What needs to be done?
More research needs to be done on women's risks and prevention needs. This includes basic research in modes of transmission and risks, as well as evaluations for innovative, women-specific interventions. Funding for women's prevention programs needs to be increased. In addition, different interventions need to be implemented that address broader community concerns for women, especially adolescent and African-American and Latina women. Interventions that address sexuality, family, culture, empowerment, self-esteem and negotiating skills, as well as interventions located in varying community settings are especially important.
Addressing women's needs is a crucial part of a comprehensive public health strategy. Steps towards more research on women and including women in drug trials are encouraging. Other public health strategies not necessarily targeted to women can also play an important role for women. Syringe exchange and drug treatment are important strategies, since almost half of all infections in women are due to injection drug use. Because women are more likely to be infected by men, and AIDS cases due to heterosexual contact are increasing, programs that specifically target men (especially IDUs) will have a beneficial impact on women.
References:
Prepared by Pamela DeCarlo
Reproduction of this text is encouraged; however, copies may not be sold. The Center for AIDS
Prevention Studies at the University of California San Franciso is the source of this
information. For additional copies of this and other HIV Prevention Fact Sheets, please call the
National AIDS Clearinghouse at 800/458-5231. Comments and questions about this Fact Sheet may
be e-mailed to prevention_factsheets@quickmail.ucsf.edu. ©1996, University of California
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