Critical Need to Pay Attention to HIV Prevention for Women: Minority and Young Women Bear Greatest Burden June 1998

The CDC estimates that, in the United States, between 120,000 and 160,000 adult and adolescent females are living with HIV infection. In just over a decade, the proportion of all AIDS cases reported among adult and adolescent women nearly tripled, from 7% in 1985 to 22% in 1997. HIV/AIDS was the fourth leading cause of death among U.S. women aged 25-44 in 1996 (the most recent year for which complete death information is available), and the leading cause of death among African-American women in this same age group. Today, AIDS-related deaths among women are decreasing, largely as a result of recent advances in HIV treatment. However, AIDS deaths among women are not declining as rapidly as AIDS-related deaths among men.

Further, HIV data from a recent CDC study comparing HIV and AIDS diagnoses in 25 states⁽¹⁾ with integrated reporting systems showed that a substantial number of women were newly diagnosed with HIV in these states. Between 1995 and 1996, there was a 3% increase in initial HIV diagnoses among women, while HIV diagnoses declined 3% among men during this same period.

Comparing HIV to AIDS diagnoses in these states provides a clearer picture of recent shifts in the epidemic, with a larger percentage of HIV than AIDS cases diagnosed among women, especially women of color. During the period from January 1994 through June 1997, women represented just 17% of all AIDS diagnoses, but 28% of all HIV diagnoses. Young people (ages 13 to 24) also accounted for a much greater proportion of HIV than AIDS diagnoses (14% versus 3%), and nearly half of the HIV diagnoses in that age group were among young women.

Epidemic Among Women Spreading Fastest Among Minorities

Over the past decade, the epidemic has increased most dramatically among women of color. Prior to the impact of new combination drug therapies to treat HIV infection, AIDS incidence was increasing at rates of 15% to 30% each year among African-American and Hispanic women. African-American and Hispanic women together represent less than one-fourth of all U.S. women, yet they account for more than three-fourths (76%) of AIDS cases reported to date among women in our country.

Most women with AIDS were infected through heterosexual exposure to HIV, followed by injection drug use. In addition to the direct risks associated with drug use (sharing needles), drug use also is fueling the heterosexual spread of the epidemic. A large proportion of women infected heterosexually were infected through sex with an injection drug user. Reducing the toll of the epidemic among women will require efforts to combat substance abuse, in addition to reducing HIV risk behaviors.

Female adolescents and young adult women under the age of 25 are at higher risk for HIV/STD infection than older women. This increased risk is likely due to their greater tendency to have multiple sex partners, to engage in risky behaviors, or to be unable to negotiate safer sexual practices with partners.

Young and minority women are also disproportionately affected by other STDs - gonorrhea, syphilis, and chlamydia, for example - that make women at least 2-5 times more vulnerable to HIV infection. Improved STD treatment will be a critical strategy for slowing the heterosexual spread of HIV.

Building Better Prevention Programs for Women

Even if women know how to protect themselves from HIV infection, awareness of the facts must be coupled with the skills and support needed to change behavior. CDC works with states and communities to provide the information and tools needed to design and implement effective local prevention programs for women. To guide prevention activities, CDC works to provide the best available science in the areas of monitoring the epidemic, conducting and disseminating the findings from research, and evaluating what works. As part of this process, CDC conducts an ongoing research synthesis process that seeks to identify the most recent and relevant scientific findings from around the world, both published and unpublished, and make them available to prevention program planners. CDC constantly combs the scientific literature, reviews domestic and international scientific databases, and speaks with colleagues around the world to identify effective interventions for all populations at risk, including women.

Continuing progress is needed in the following areas to slow the HIV epidemic among U.S. women:

• Pay attention to prevention for women! The AIDS epidemic is far from over. Data from states that have integrated confidential HIV and AIDS case reporting show that a larger proportion of women are reported with HIV than are reported with AIDS. Scientists believe that cases of HIV infection reported among 13- to 24-year-olds are indicative of overall trends in HIV incidence (the number of new infections in a given time period, usually a year) because this age group has more recently initiated high-risk behaviors - and young women made up nearly half (44%) of HIV cases in this age group.

• Implement programs that have been proven effective in changing risky behaviors among women and sustaining those changes over time, maintaining a focus on both the uninfected and infected populations of women. For example, CDC's Women and Infants Demonstration Project, a community-level behavioral intervention research project focusing on young women ages 15 to 34, most of whom are members of racial/ethnic minority populations, is designed to improve understanding of factors influencing women's behavior changes regarding condom and contraceptive use, as well as the development and delivery of interventions. Preliminary results are very promising in terms of increases in condom use among women in the treatment group compared with other communities.
• Develop effective female-controlled prevention methods and disseminate them widely. More options are urgently needed for women who are unwilling or unable to negotiate condom use with a male partner. CDC researchers are working with scientists worldwide to evaluate the effectiveness of female condoms in preventing HIV, as well as to develop effective topical microbicides that can kill HIV and the pathogens that cause STDs. As with any new tools for prevention, we must not only determine effectiveness, but also evaluate people's willingness and ability to use these methods.
• Increase emphasis on prevention and treatment services for young women and women of color. Many U.S. women reported with HIV or AIDS are unable to identify their risk for acquiring HIV infection, indicating that they may be unaware of their partners' risk factors. Knowledge about preventive behaviors and awareness of the need to practice them is critical for each and every generation of young women - prevention programs should be comprehensive and should include participation by parents as well as the educational system.
• Address the intersection of drug use and sexual HIV transmission. Women are at risk of acquiring HIV sexually from a partner who injects drugs and from sharing needles themselves. Additionally, women who use noninjection drugs (e.g., "crack" cocaine) are at greater risk of acquiring HIV sexually, especially if they trade sex for drugs or money.
• Better integrate prevention and treatment services for women across the board, including the prevention and treatment of other STDs and substance abuse and access to antiretroviral therapy.
• Make medical and behavioral solutions work together. Medical advances can't work by themselves - women first need access to them, then they need the skills and support to use them. While behavioral interventions can help uninfected women stay that way, they also can work with medical treatments to help infected women stay healthier and keep from infecting others.
• Preventing HIV infection is by far the best strategy. Preventing infections saves lives, eliminates the need for complex and sometimes debilitating therapies, and saves a great deal of money that would otherwise be spent on medical treatment. But, linking women with care and prevention services as soon as possible after infection has occurred is also an important goal, both to protect their own health and that of their sex partners and children.