|Year : 2010 | Volume
| Issue : 1 | Page : 15-27
|Looking at complicating non-biological issues in women with HIV
Chaturaka Rodrigo1, Senaka Rajapakse2
1 University Medical Unit, National Hospital of Sri Lanka, Sri Lanka
2 Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Sri Lanka
Click here for correspondence address and email
|Date of Web Publication||20-Jan-2010|
| Abstract|| |
Introduction: The increasing number of women acquiring Human Immunodeficiency Virus (HIV) has resulted in a 'feminization' of the epidemic. In this article we are reviewing whether females are disadvantaged in the epidemic, due to factors independent of the biological differences in sexes. Materials and Methods: We searched MEDLINE and EMBASE for articles with key words 'Women', 'Gender,' and 'HIV' in any field. The search was restricted to articles published in English within the last 10 years (1999-2009). Data were coded independently by two reviewers from 94 selected sources. The coded data were categorized under five commonly encountered concepts; violence, poverty, gender norms, prevention-/treatment-related issues, and Highly Active Anti-Retroviral Treatment (HAART). Results: The link between inter-partner violence (IPV) and HIV risk for women is observed by many authors. In assessing the link between poverty and HIV, indicators such as food insufficiency and income inequality may be better indicators compared to wealth itself. Although women are disadvantaged with male-dominated gender norms, evidence suggests that the traditional norms are changing in many societies. A positive association between living in urban communities, education, and better HIV knowledge has been observed in females, although it is not always synonymous with reduced risk behavior. Conclusions: Women are still disadvantaged in many HIV-related issues such as poverty, violence, and gender norms. At least in Africa, there is evidence of a positive change in spheres of education and gender norms. However, the situation in Asia is largely unexplored.
Keywords: HIV/AIDS, Women, Gender
|How to cite this article:|
Rodrigo C, Rajapakse S. Looking at complicating non-biological issues in women with HIV. J Global Infect Dis 2010;2:15-27
|How to cite this URL:|
Rodrigo C, Rajapakse S. Looking at complicating non-biological issues in women with HIV. J Global Infect Dis [serial online] 2010 [cited 2020 Dec 1];2:15-27. Available from: https://www.jgid.org/text.asp?2010/2/1/15/59246
| Introduction|| |
The latest estimates of the HIV (Human Immunodeficiency Virus) epidemic suggest that 33 million people live with it worldwide. Fifty percent of them are women.  However, in 1985, only 35% of the infected were women.  The main mode of transmission has shifted from male homosexual contact to heterosexual contact over the last 20 years. More women getting infected via heterosexual intercourse has resulted in 'feminization of HIV/AIDS'.  The percentage of infected women varies in different regions, but the numbers are increasing (Sub-Saharan Africa = 60%, Caribbean = 45-50%, Asia and Latin America = 30-40%, Eastern Europe and Central Asia = 30%).  This changing face of the epidemic calls for a careful review of gender-related differences of HIV.
An analysis of sexual behavior in 59 countries has shown that in many developing countries the age of sexual initiation has risen for women. Still, due to the late age in marriage, the prevalence of premarital sex has increased.  This and other trends in sexual behavior are dependent on local factors such as poverty, culture, gender norms, media influence, and so on. Transmission of HIV and other sexually transmitted diseases (STDs) are also influenced by these issues, which may affect men and women differently. Identifying these factors and their gendered effects will have major implications in prevention strategies.
During the synthesis of our review, it seemed logical to broadly categorize the gender-related variables as biological and nonbiological. The clinical manifestations, differences in pathogenesis, pregnancy-related issues, response to HAART, and side effects are some biological issues. As the scope of the topic is vast, we restricted our review to examine only the nonbiological factors, with gender implications, and how they relate to women at risk and women living with HIV/AIDS.
| Materials and Methods|| |
We searched the electronic databases; MEDLINE and EMBASE with the keywords 'Women' 'Gender,' and 'HIV' in any f ield, using the software Endnote X1.01, to the filter articles. The search was limited to articles published in English over the last 10 years (1999-2009). Bibliographies of cited literature were also searched. Relevant publications and epidemiological data were also downloaded from websites of international agencies such as the World Bank, United Nations Joint Program on HIV/AIDS (UNAIDS), and World Health Organization (WHO). All abstracts were read independently by the two authors, and relevant articles were identified for review of the full articles.
Sources were screened for relevance to the topic, originality, a well-described methodology, rigor of statistical analysis, and an adequate sample size, where relevant. Sources were excluded where sample size was inadequate (except in qualitative studies), methodology was not well-described, statistical analysis was unclear, and where the full article was unavailable. Ninety four sources from a selected 115 (81.7%) were reviewed. Coding was done by two reviewers independently blinded to each other. Codes were grouped into concepts commonly encountered (e.g., gender norms, violence, poverty, treatment- and prevention-related issues) during the search, under the broader category of nonbiological factors. Data sources included reviews published in core clinical journals, cohort studies, qualitative studies, interventional studies, case-control studies, cross-sectional analysis, and epidemiological data. The inter-reviewer agreement for data included in the final synthesis was 100%. A summary of cited literature is shown in [Table 1],[Table 2],[Table 3].
Violence against women can occur in different settings including civil wars, communal disputes, and domestic violence. , The gender based violence (GBV) defined in this article includes all forms of physical, sexual, and emotional abuse against women. A cross-sectional survey in eight African countries revealed that 18% of the women had experienced GBV within one year.  Another multicenter study in ten countries (n-24,097) reported the lifetime risk of inter-partner violence (IPV) to be in the range of 15-71%, indicating a wide range of variation in communities. 
It is established that HIV is more likely to be transmitted in an act of forced penetration rather than during voluntary sex, due to factors such as inability to negotiate on safer sex and breach of epithelial barriers (with trauma) making it easier for the virus to enter the blood stream.  Forced sex increases the woman's chances of contracting a sexually transmitted disease (STD) four-fold. 
Violence makes women vulnerable to HIV
A population-based survey in Tanzania concluded that women had a significantly higher risk of HIV [Odds ratio(OR)-2.0] if they had experienced coerced sex before 18 years of age.  Fonck et al.  reports a two-fold higher risk of lifetime intimate partner violence for HIV positive women. A cross-sectional survey by Dunkle et al.  in South Africa has shown that intimate partner violence (OR-1.48) and high level of male control in a relationship (OR-1.52) was associated with HIV infection.
However, Jewkes et al.  has shown that while IPV is strongly associated with many HIV risk factors, it was not directly or significantly correlated with HIV positivity when corrected for other risk behaviors. A similar conclusion of an indirect relationship between IPV and HIV is suggested by Pettifor et al. and Langen et al. , This difference can be partly explained by the sample selection (general population vs. at-risk population). Many risk factors having a direct association with HIV, such as, age gap between the partners, frequency of intercourse, and number of sexual partners in the past year can be linked to IPV as well. In fact, Jewkes et al.  have demonstrated an association between such HIV risk factors and IPV, although a direct association has not been seen between IPV and HIV positivity.
An interventional prospective study in South Africa, by Pronyk et al.,  showed that economic empowerment and skill development of women reduced IPV by 55% in the intervention group. The microfinance initiative was linked with an HIV awareness program. However, neither the risk behaviors nor the HIV prevalence showed a significant difference at the end of follow up (after three years) between groups.
Studies outside Africa report a strong association between violence and HIV risk. In a cross-sectional survey of adolescents in USA, Viosin et al.  have reported that those exposed to family or community violence are three to four times more likely than their peers to engage in HIV risk behaviors. However, this association was more common in boys than in girls. In a survey of Hispanic women in Boston, USA, Raj et al.  have reported increased HIV risk for abused women than non-abused women. In India, a systematic multistage survey delineated a close relationship between IPV and risk behavior [men with extramarital affairs and STD symptoms were more likely to abuse their wives (OR-6.22 and 2.43, respectively)]. 
In addition to IPV, women are victimized by other means, especially in times of war and civil unrest. Rape of women is well-documented in many civil wars in Africa (Rwanda, Sierra Leone, and Liberia). In some situations women were deliberately raped by HIV positive individuals to inflict psychological trauma and a 'painful' death.  In Nepal, at the beginning of the Maoist insurgency (1999), the HIV prevalence in Kathmandu stood at 2.7%. Three years later it had shot up to 17%.  Vulnerability of refugee women for transactional sex was identified as a risk factor for HIV in a survey of the Lugufu refugee camp (Tanzania) by Rowley et al.  A significant proportion of refugees reported forced sex (P < 0.001) compared to the villagers outside the camp. Many instances of forced sex had occurred after the displacement. Younger age of sexual initiation for boys, poverty and high-risk partners in the 15-24 age group were identified as risk factors for HIV among refugees (compared to villagers), in addition to vulnerability of women. Interplay of these risk factors may result in an increased rate of unprotected intercourse (by force or by consent) within the camps. In this sample, 20% of the refugees admitted to transactional sex (92% of instances since displacement) as opposed to 4% among villagers. However 82% of these encounters were with a fellow refugee rather than an outsider. Similarly, although the incidence of forced sex was high among refugees (10 vs. 4%), in many instances (64%) the perpetrator was the intimate sexual partner.
Sex trade is another form of female exploitation and HIV spread. Child sex and trafficking of women for prostitution is a burden for many countries. The Indo-Nepal border is notorious for such activity and it is estimated that 5000-7000 Nepali women are taken across the border to India annually in sex trafficking.  Subsequent analysis of the sero-status of such sex-trafficked Nepali women have shown disproportionately higher rates of HIV infection compared to native Indian sex workers. , While many studies and interventions have targeted female sex workers (FSWs), few have observed the STD profile and HIV risk of male clients of FSWs. They are an important source of spreading the infection via heterosexual intercourse. Recent studies in Mexico, China, and India have all shown high risk behaviors and fairly high rates of HIV and other STDs in this group. ,,
HIV positivity makes women vulnerable to violence
Violence following disclosure of the sero-status is not a universal phenomenon. It depends on the locality studied. Studies in United States have failed to demonstrate a higher rate of domestic violence against HIV-positive women when compared to sero-negative women. ,, In a study by Gielen et al.  , only 4% of the sample reported physical abuse immediately following disclosure. Still 45% reported some form of abuse since the time of disclosure.
A study in Tanzania showed that HIV-positive women had a higher risk of physical and sexual violence than HIV-negative women.  Violence was more likely to occur when the sero-status of the partner was unknown. In a prospective study in Kenya, 10% of the women experienced violence or disruption of the relationship following disclosure. 
In a statistical analysis of UNAIDS data from 77 countries, Talbott et al.  have identified that income inequality within a country has a positive correlation with HIV prevalence. Several studies reporting a link between violence and HIV also report a correlation between poverty and HIV. ,, Limited financial power limits autonomy in sex for women. Langen et al.  reports that women who are economically dependent on their partners are less likely to insist on condoms during sex. There are several other studies conducted in Sub Saharan Africa that correlates low socioeconomic status with a high HIV risk. ,,
Food insufficiency is a marker of poverty that places women at a significant disadvantage to acquire HIV. In a population-based, cross-sectional study in Swaziland and Botswana, Weiser et al.  report that food insufficiency is associated with many risk behaviors for HIV (inconsistent condom use with a non-primary partner [Adjusted odds ratio (AOR) -1.73], intergenerational sexual relationships (AOR-1.46), sex exchange (AOR-1.84), and lack of control in a sexual relationship (AOR-1.68)). Interestingly, men reported fewer instances of food insufficiency and a lesser correlation between that and risk behaviors. Dunkle et al.  and Oyefara  have independently confirmed some of these associations with food insufficiency.
Several studies outside Africa, have demonstrated a positive correlation between HIV risk and poverty, for women. A study in China on FSWs has shown that some entered the trade voluntarily.  However, the driving force for selling sex was poverty. If social poverty was avoided it is assumed that these women would not sell sex and will not be at risk of acquiring HIV. Many 'low end' FSWs in India (streetwalkers) are unable to negotiate with the client to minimize risk behaviors. Unfortunately they account for a larger proportion of all FSWs.  Interestingly in Australia, a wealthier country, no difference in lifetime self-reported STDs have been observed in streetwalkers, private and brothel based sex workers. 
Migration for economic reasons is another risk factor for HIV in both sexes.  Women have become a sizable proportion of the migrant population, which may have a significance in the feminization of the epidemic. , Migrant male workers' risk of acquiring an STD has been linked to the time spent in the host country.  In the South Asian context, these men are an important source of infection for women (both spousal and non-spousal partners). ,
The studies by Oyefara  , Dunkle et al.  and Weiser et al.  need special mention as they have not restricted the measures of poverty to family income. There may be differences in the way income is distributed in a family, which may be disadvantageous to the women. This phenomenon may create a state of 'relative poverty' for women and female children (depending on the gender norms of the society) although the family income is reasonable. Pronyck et al.  in their interventional study failed to show a reduction in HIV incidence or risk behaviors in the intervention group, despite the upliftment of economic standing, which may be a result of the above phenomena. The study in Botswana and Swaziland showed little correlation between low socioeconomic status and HIV risk, while there was a significant risk correlation for food insufficiency.  In fact food insufficiency may be a better marker of poverty as it represents a final common pathway of poverty than income. It is important to identify similar markers of poverty in different societies that might better correlate with HIV risk than wealth.
Gender norms and culture
Gender norms can be defined as appropriate behaviors, beliefs, attitudes and conduct per gender as directed by society. It is a learnt behavior. In assigning gender roles, the phenotypical differences of genders are redefined as feminine and masculine with different capabilities in societal functioning (e.g., division of labor, power sharing, economic responsibility, dominance and submission).  Such gender norms are different in various societies and subject to change with time.  Yet, in many countries, especially in the developing world where HIV is spreading fast, females serve a subservient role to men as dictated by gender norms and culture. , These traditional norms place women at an increased risk as they have less freedom in choosing their partners, initiating and pacing sexual activity and negotiating on safer sex. , In addition, some traditions, customs and beliefs are also harmful to women (wife inheritance, having sex with a virgin as a cure for HIV). ,
In our review, we have identified several studies linking gender roles to risk behavior. In a cross sectional analysis of females in detention in Georgia, USA, Voisin et al.  concludes that gender norms favoring male dominance as well as high-risk peer norms were significantly associated with STD risk (P < 0.05). A cross-sectional analysis by Harrison et al.  in South Africa gives an insight on changing gender roles and their impact on HIV. Their results were different to what was expected. Among men, hyper-romanticism and favoring of male dominance were associated with more consistent condom use (especially with the primary partner). More open sexual ideology was associated with less consistent condom use. Interestingly, more open sexual norms and hyper-romanticism in women was significantly associated with more partners. Similar unexpected findings were reported by Kaufman et al.  They showed that endorsement of traditional male dominant gender norms were associated with less HIV risk behavior for men. However, a negative attitude toward women showed (as expected) a positive correlation with risk behavior.
Qualitative studies may be a better tool to assess the complex interactions between gender norms and HIV, although the generalizability of findings remains doubtful. The interference of prevalent gender norms with HIV-prevention strategies is delineated by Go et al.  in a qualitative study in slum communities of Chennai, India. Risk behaviors such as multiple partners for men were 'acceptable' by the prevalent norms. Using condoms with regular partners was rare even when women were aware of its protection (as it would imply questioning a man's fidelity). Refusal of sex with husband was not an option even when the wife perceived a risk of infection. Similar findings were reported by Hebling et al.  Despite being educated on HIV transmission risks, women were unable to take precautionary measures due to prevalent gender norms and male dominance. In a study on African American adolescents in USA, Kerrigan et al.  explain how the female gender ideologies of care taking and emotional strength (standing by the man) can make them value relationship intimacy more than protection against HIV/STDs.
Despite their obvious negative impact on AIDS control, the traditional norms may have served a protective role against HIV too. In many developing nations, premarital sex is discouraged by tradition and is highly stigmatized. The 'virginity' of a female is still expected till marriage in many Asian and African societies. ,, Though it is a marker of discrimination against women, the fear of such discrimination may have discouraged premarital sex among adolescents helping to keep the epidemic at bay. It is interesting to note how the changing gender norms have made an impact on premarital sex, virginity norms, and HIV prevalence.
Gender differences in adherence to prevention and treatment measures
It is a commonly held view that women have less access to HIV/STD prevention programs, especially in developing nations. In three high prevalence African countries (Burkina Faso, Ghana, Zambia), a better knowledge of HIV in females was associated with living in a community with more opportunities (better education, higher age in marriage and initiation of sex).  A positive association between HIV knowledge and education has been reported in several other studies in Africa. ,,,, A community-based study in rural Malawi has shown that while both sexes had a good knowledge of transmission of HIV/AIDS, men were more knowledgeable than women. Age, education, occupations other than farming, and childhood residency in a city were associated with better knowledge. 
The few studies conducted outside Africa (within our search limitations) showed conflicting results. A cross-sectional analysis among university students in Afghanistan showed that only 28.3% of students had a good knowledge of AIDS and the scores were better in females.  A similar study in China has shown that the overall knowledge scores were significantly high in males compared to females (P < 0.0001) and a better awareness was associated with the number of years spent in the university and coming from an urban area.  Yet, the level of education had a minimal impact in certain situations. A survey among secondary school girls in New Delhi, India has shown gross inadequacy of HIV- and STD-related knowledge (30% thought HIV can be cured, 21% thought oral contraceptive pills (OCP) would protect against HIV). 
The importance of educational interventions for women has been underscored in several studies. ,,,, Diclemente et al.  in a randomized controlled trial demonstrated that adolescent girls who underwent a comprehensive educational package on HIV/AIDS had significantly less risk behaviors in a 12-month follow-up period. Gavin et al.  in their study on adolescent females in Zimbabwe have shown that those who had sex education in schools had a decreased risk of HIV (OR-0.43). Chhabra et al.  and Hecej et al.  have reported better risk reduction practices in adolescent females compared to males following an educational program in India and Croatia, respectively. Interestingly a similar program targeting a different high-risk group in China (clients of FSWs) has shown promising results, with a significant increase in those using prevention services (OR-2.2). 
HIV testing, risk perception, and disclosure of sero-status are also reported to show a gender difference. Age, literacy, good doctor-patient relationship were associated with disclosure for men while having children, and being religious were associations for disclosure in women.  A cross-sectional survey among African American adolescents in the US has shown that females were significantly more likely to undergo voluntary HIV testing (OR-2.4 to 2.7) than males. 
However, several studies involving sexually active females have shown that a good knowledge of HIV is not synonymous with avoiding risk behavior. ,, In other words the knowledge is not put to practice. There are two main reasons for this paradox, impaired risk perception , and social barriers, that limits sexual autonomy for women. Some authors suggest a gender difference in risk perception as well. 
The paradoxical impact of education on HIV in the early 1990s in Africa is worth mentioning. HIV was associated with a better education in the early days of the epidemic in Africa. Some authors explain this phenomenon by the hypothesis that better educated had better jobs, more money, and more access to paid sex and IV drug use.  Education without an effective sex education component may have a minimal role in countering the epidemic. Asia today, may be in the state Africa was two decades ago.
Highly active antiretroviral therapy
In this section we discuss the results of studies that have looked into a gendered difference in HAART-related issues (availability, accessibility, and adherence), excluding those related to the biological differences of sexes (side effects and clinical and viral response).
An analytical study of 23 sero-converter cohorts from Europe, Australia, and Canada have shown that women fared better after HAART was introduced. Comparing the pre-HAART (before 1997) period and the HAART era, authors have reported a lesser risk of AIDS and death in women compared to men (OR-0.76 and 0.68, respectively).  Moore et al. and Chen et al. have both reported a better outcome for females in two cohorts on HAART. ,
It is speculated that women in resource-limited settings may have restricted access to treatment due to socioeconomic constraints and gender norms.  However, the evidence is contrary to this. Chandra et al.  , Muula et al.,  and Braitstein et al.  have all shown that women are not at a disadvantage in access to HAART, in resource-limited settings. The epidemiology update of UNAIDS for 2008 confirm these findings. In 45 developing countries (with the exception of Chile and Belize) the coverage was better for females with HIV. Still, it is important to note that the overall coverage of HAART in these settings was low. In many countries, coverage of the HIV-positive population with HAART was less than 40% for both men and women. Only 35% of pregnant women had access to the therapy in 2008. 
Adherence to therapy is another dimension of interest. Several authors have reported women to be less adherent to HAART. ,,,, Several possible associations with this observation are depression, , alcohol dependence, , other substance misuse, , and increased side effects in women. 
| Discussion|| |
In summary, as expected, violence, gender norms, and poverty placed women at a disadvantage with regard to HIV/AIDS (increased risk of contracting HIV and increasing the burden of those living with the disease). However, regarding access to HAART, females fared better than males in many parts of the world.
In interpretation of the available evidence, the following issues need attention:
The vulnerability of sex-trafficked women, prostitutes, and victims of rape to HIV is obvious. However, the rise in the rate of infections at times of war and displacement is simply not a case of women being raped by the 'enemy'. It may be the result of a complex interaction of several risk factors like, transactional sex, poverty, lack of opportunities, breakdown of civil order, and less rigid sexual norms.
Many studies only demonstrate that HIV positive women were significantly subjected to violence compared to the HIV-negative population. It is not clear whether the violence increased or began after sero-status disclosure. More studies are needed to identify which comes first; violence or HIV, or is it a vicious cycle.
Poverty and its relation to HIV is simply not an issue that can be reduced to the availability of money. Low income countries obviously may have many risk factors for HIV spread such as illiteracy, unemployment, and lack of opportunities for women. Yet, countries with a better income also have their own risk factors (fast life style, overcrowding in cities, and prostitution). Even in the affluent countries there may be microenvironments that are disadvantaged and not any different from the developing world with regard to HIV risk. When the data are generalized to the whole country, these significances go unnoticed. This argument is further supported by the findings of Talbott et al.  who showed that while the gross domestic product (GDP) of a country shows little or no relation to HIV/AIDS prevalence, the income inequality shows a positive correlation.
Regarding gender norms, there is the obvious need to discuss the conflicting or rather unexpected findings of some studies, , which do not collaborate with the view of high HIV transmission risk and traditional gender norms. This may be partly explained by the theory that traditional gender roles are changing in contemporary societies. Evidence for such change has been documented in the educated younger generations of South Africa. , Such contrasts may also be influenced by the improved awareness of the transmission of HIV. The more consistent use of condoms by dominant males may be an expression of responsibility or a measure for their own protection as they are likely to have multiple partners. More open sexual ideology being associated with less condom use may be an indicator of trust and selection of an educated and similar partner. Still the association of hyper-romanticism and open sexual ideology with more partners, in females, is difficult to explain. However some weaknesses in the study methodology may have influenced the outcome. The samples were not representative of the general population (Harrison et al.  used a sample with a disproportionate number of females in the ratio of 2:1, while Kaufman et al.  used a sample of high-risk males only). The sample sizes were limited to generalize the findings to a larger community.
On educational interventions and their gender implications, many studies have demonstrated a positive link between living in urban communities, education, and better HIV knowledge for women. ,,,, Faced with the epidemic, many Sub Saharan countries have initiated educational campaigns for the public, with funding from global agencies. The positive impact of such interventions are clearly visible, specially with regard to females. , However, the picture in the Asian context is less promising. Although many countries in Asia are still considered to be low prevalence, this can be a false state of complacency. Despite the fact that cultural barriers may prevent effective sex education at schools; the risk behaviors are high even among those having access to education. , Male dominance and gender norms limit a woman's ability to protect herself from infection despite being educated about HIV/AIDS. Therefore, we propose that a successful education program must concentrate on both sexes equally and be sensitive to prevalent gender norms in the society.
The evidence does not support the commonly held belief that women are at a disadvantage with access to HAART in resource-limited settings. This may be explained by the fact that women have two motives to enter a treatment plan to treat themselves and to prevent mother-to-child transmission.
There were several limitations in our review; it was limited to articles published in English only, and it is possible that important studies published in other languages were missed. Most of the data was from African and Asian countries; data from Latin American and Eastern European countries was minimal. Data on response to HAART was predominantly available from cohorts in developed countries. Such gaps in the available data affect the validity and generalizability of our conclusions.
We have recognized the following as areas with 'gaps in knowledge'. These issues should be explored with further research.
- Incidence and form of violence against HIV-positive women by intimate partner and others, following disclosure of sero-status in developing countries is not well explored.
- Specific markers of poverty that may reflect the relationship between HIV and women better than wealth itself, needs to be investigated. Such markers may be different in each community (as food insufficiency was an indicator in some African countries).
- Changing gender norms and their impact on women and HIV has been inadequately explored in Asia. The protective role (if any) of traditional gender norms and virginity norms needs to be identified.
- Specific issues in different societies that cause discordance between knowledge and practice has to be analyzed as this has a direct impact in policy design on prevention.
- Why do women have better access to HAART (as shown by statistics) despite the commonly held belief to the contrary? It is important to keep track of sex ratios on HAART as more people gain access to it, to avoid discrimination of women.
- Identification of culturally appropriate educational tools to impart sex education for adolescents is a need of the hour.
| Conclusion|| |
The gendered implications of many aspects of HIV are apparent. The traditionally held view that women are at a disadvantage is true with regard to several issues such as violence, poverty, and gender norms. In treatment-related issues, women (at least in Africa) have made significant gains with better awareness. The access to HAART was better for females in many resource-limited settings, although the overall coverage was unsatisfactory.
Much of the work done in the last decade has focused on the Sub Saharan Africa, which is the hub of infection with large numbers of patients. However, the social and cultural dynamics of Asia and Africa are quite different. Although many Asian countries (India, China) are considered to be low prevalence ones for HIV, the disease burden may actually be considerable in Asia for two reasons; the large population (even a smaller percentage equates to a large number of infections) and under-reporting. Given the potential reservoir of infection, the focus of research in the coming decade should be Asia.
| References|| |
|1.||UNAIDS/WHO. AIDS Epidemic Update. 2008 [updated 2008; cited 2009 Apr 30]; Available from: www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/ . |
|2.||Dworkin SL, Ehrhardt AA. Going beyond "ABC" to include "GEM": Critical reflections on progress in the HIV/AIDS epidemic. Am J Public Health 2007;97:13-8. |
|3.||Wellings K, Collumbien M, Slaymaker E, Singh S, Hodges Z, Patel D, et al. Sexual behavior in context: A global perspective. Lancet 2006;11:1706-28. |
|4.||Kaye DK. Gender inequality and domestic violence: Implications for human immunodeficiency virus (HIV) prevention. Afr Health Sci 2004;4:67-70. |
|5.||Whetten K, Reif S, Whetten R, Murphy-McMillan LK. Trauma, mental health, distrust, and stigma among HIV-positive persons: Implications for effective care. Psychosom Med 2008;70:531-8. |
|6.||Andersson N, Ho-Foster A, Mitchell S, Scheepers E, Goldstein S. Risk factors for domestic physical violence: National cross-sectional household surveys in eight southern African countries. BMC Womens Health 2007;7:11. |
|7.||Garcia-Moreno C, Jansen HA, Ellsberg M, Heise L, Watts CH; WHO Multi-country Study on Women′s Health and Domestic Violence against Women Study Team. Prevalence of intimate partner violence: Findings from the WHO multi-country study on women′s health and domestic violence. Lancet 2006;368:1260-9. |
|8.||Campbell JC, Baty ML, Ghandour RM, Stockman JK, Francisco L, Wagman J. The intersection of intimate partner violence against women and HIV/AIDS: A review. Int J Inj Contr Saf Promot 2008;15:221-31. |
|9.||Sa Z, Larsen U. Gender inequality increases women′s risk of hiv infection in Moshi, Tanzania. J Biosoc Sci 2008;40:505-25. |
|10.||Fonck K, Leye E, Kidula N, Ndinya-Achola J, Temmerman M. Increased risk of HIV in women experiencing physical partner violence in Nairobi, Kenya. AIDS Behav 2005;9:335-9. |
|11.||Dunkle KL, Jewkes RK, Brown HC, Gray GE, McIntryre JA, Harlow SD. Gender-based violence, relationship power, and risk of HIV infection in women attending antenatal clinics in South Africa. Lancet 2004;363:1415-21. |
|12.||Jewkes R, Dunkle K, Nduna M, Levin J, Jama N, Khuzwayo N, et al. Factors associated with HIV sero-status in young rural South African women: Connections between intimate partner violence and HIV. Int J Epidemiol 2006;35:1461-8. |
|13.||Pettifor AE, Measham DM, Rees HV, Padian NS. Sexual power and HIV risk, South Africa. Emerg Infect Dis 2004;10:1996-2004. |
|14.||Langen TT. Gender power imbalance on women′s capacity to negotiate self-protection against HIV/AIDS in Botswana and South Africa. Afr Health Sci 2005;5:188-97. |
|15.||Pronyk PM, Hargreaves JR, Kim JC, Morison LA, Phetla G, Watts C, et al. Effect of a structural intervention for the prevention of intimate-partner violence and HIV in rural South Africa: A cluster randomised trial. Lancet 2006;368:1973-83. |
|16.||Voisin DR. The relationship between violence exposure and HIV sexual risk behavior: Does gender matter? Am J Orthopsychiatry 2005;75:497-506. |
|17.||Raj A, Silverman JG, Amaro H. Abused women report greater male partner risk and gender-based risk for HIV: Findings from a community-based study with Hispanic women. AIDS Care 2004;16:519-29. |
|18.||Martin SL, Kilgallen B, Tsui AO, Maitra K, Singh KK, Kupper LL. Sexual behaviors and reproductive health outcomes: Associations with wife abuse in India. JAMA 1999;282:1967-72. |
|19.||Karkee R, Shrestha DB. HIV and conflict in Nepal: Relation and strategy for response. Kathmandu Univ Med J J 2006;4:363-4. |
|20.||Rowley EA, Spiegel PB, Tunze Z, Mbaruku G, Schilperoord M, Njogu P. Differences in HIV-related behaviors at Lugufu refugee camp and surrounding host villages, Tanzania. Confl Health 2008;2:13. |
|21.||Nepal B. Population mobility and spread of HIV across the Indo-Nepal border. J Health Popul Nutr 2007;25:267-77. |
|22.||Silverman JG, Decker MR, Gupta J, Maheshwari A, Willis BM, Raj A. HIV prevalence and predictors of infection in sex-trafficked Nepalese girls and women. JAMA 2007;298:536-42. |
|23.||Sarkar K, Bal B, Mukherjee R, Chakraborty S, Saha S, Ghosh A, et al. Sex-trafficking, violence, negotiating skill, and HIV infection in brothel-based sex workers of eastern India, adjoining Nepal, Bhutan, and Bangladesh. J Health Popul Nutr 2008;26:223-31. |
|24.||Lau JT, Wan SP, Yu XN, Cheng F, Zhang Y, Wang N, et al. Changes in condom use behaviors among clients of female sex workers in China. Sex Transm Infect 2009;85:396-82. |
|25.||Subramanian T, Gupte MD, Paranjape RS, Brahmam GN, Ramakrishnan L, Adhikary R, et al. HIV, sexually transmitted infections and sexual behavior of male clients of female sex workers in Andhra Pradesh, Tamil Nadu and Maharashtra, India: Results of a cross-sectional survey. AIDS 2008;5:69-79. |
|26.||Patterson TL, Goldenberg S, Gallardo M, Lozada R, Semple SJ, Orozovich P, et al. Correlates of HIV, sexually transmitted infections, and associated high-risk behaviors among male clients of female sex workers in Tijuana, Mexico. AIDS 2009;23:1765-71. |
|27.||Cohen M, Deamant C, Barkan S, Richardson J, Young M, Holman S, et al. Domestic violence and childhood sexual abuse in HIV-infected women and women at risk for HIV. Am J Public Health 2000;90:560-5. |
|28.||McDonnell KA, Gielen AC, O′Campo P. Does HIV status make a difference in the experience of lifetime abuse? Descriptions of lifetime abuse and its context among low-income urban women. J Urban Health 2003;80:494-509. |
|29.||McDonnell KA, Gielen AC, O′Campo P, Burke JG. Abuse, HIV status and health-related quality of life among a sample of HIV positive and HIV negative low income women. Qual Life Res 2005;14:945-57. |
|30.||Gielen AC, McDonnell KA, Burke JG, O′Campo P. Women′s lives after an HIV-positive diagnosis: Disclosure and violence. Matern Child Health J 2000;4:111-30. |
|31.||Maman S, Mbwambo JK, Hogan NM, Kilonzo GP, Campbell JC, Weiss E, et al. HIV-positive women report more lifetime partner violence: Findings from a voluntary counseling and testing clinic in Dar es Salaam, Tanzania. Am J Public Health 2002;92:1331-7. |
|32.||Gaillard P, Melis R, Mwanyumba F, Claeys P, Muigai E, Mandaliya K, et al. Vulnerability of women in an African setting: Lessons for mother-to-child HIV transmission prevention programmes. AIDS 2002;16:937-9. |
|33.||Talbott JR. Size matters: The number of prostitutes and the global HIV/ AIDS pandemic. PLoS One 2007;2:543. |
|34.||Adimora AA, Schoenbach VJ, Martinson FE, Coyne-Beasley T, Doherty I, Stancil TR, et al. Heterosexually transmitted HIV infection among African Americans in North Carolina. J Acquir Immune Defic SynDr. 2006;41:616-23. |
|35.||Dunkle KL, Jewkes RK, Brown HC, Gray GE, McIntryre JA, Harlow SD. Transactional sex among women in Soweto, South Africa: Prevalence, risk factors and association with HIV infection. Soc Sci Med 2004;59:1581-92. |
|36.||Hargreaves JR, Morison L, Chege J, Rutenburg N, Kahindo M. Socioeconomic status and risk of HIV infection in an urban population in Kenya. Trop Med Int Health 2002;7:793-802. |
|37.||Gavin L, Galavotti C, Dube H, McNaghten AD, Murwirwa M, Khan R, et al. Factors associated with HIV infection in adolescent females in Zimbabwe. J Adolesc Health 2006;39:596. |
|38.||Weiser SD, Leiter K, Bangsberg DR, Butler LM, Percy-de Korte F, Hlanze Z, et al. Food insufficiency is associated with high-risk sexual behavior among women in Botswana and Swaziland. PLoS Med 2007;4:1589-97. |
|39.||Oyefara J. Poverty, food insecurity, and HIV/AIDS pandemic: Evidence of relationship from reproductive behavior of commercial sex workers in Lagos metropolis, Nigeria. International Conference on HIV/AIDS, Food and Nutrition Security. Durban, South Africa.SAHARA. 2007;4:626-35. |
|40.||Hong Y, Li X. Behavioural studies of female sex workers in China: A literature review and recommendations for future research. AIDS Behav.2008;12:623-36. |
|41.||Chandrasekaran P, Dallabetta G, Loo V, Rao S, Gayle H, Alexander A. Containing HIV/AIDS in India: The unfinished agenda. Lancet Infect Dis 2007;7:178-9. |
|42.||Seib C, Debattista J, Fischer J, Dunne M, Najman JM. Sexually transmissible infections among sex workers and their clients: Variation in prevalence between sectors of the industry. Sex Health 2009;6:45-50. |
|43.||Krishnan S, Dunbar MS, Minnis AM, Medlin CA, Gerdts CE, Padian NS. Poverty, gender inequities, and women′s risk of human immunodeficiency virus/AIDS. Ann N Y Acad Sci 2008;1136:101-10. |
|44.||DeHaan A. Livelihoods and poverty: The role of migration-a critical review of the migration literature. J Dev Stud 1999;36:1-47. |
|45.||Mercer A, Khanam R, Gurley E, Azim T. Sexual risk behavior of married men and women in Bangladesh associated with husbands′ work migration and living apart. Sex Transm Dis 2007;34:265-73. |
|46.||Azim T, Khan SI, Haseen F, Huq NL, Henning L, Pervez MM, et al. HIV and AIDS in Bangladesh. J Health Popul Nutr 2008;26:311-24. |
|47.||Khanam R, Mercer A, Gurley E, Uddin J, Kabir H, Saha NC. Vulnerability to HIV and AIDS of migration-affected families. Dhaka: Int Cen for Diar Dis Res, Bangladesh; 2006.p. 32. |
|48.||Worell J. Encyclopedia of women and gender: Similarities and differences and the impact of society on gender: Vol. 1. Worell J, editor. San Diego: Academic press; 2001. p.1075. |
|49.||Lerdboon P, Pham V, Green M, Riel R, Tho le H, Ha NT, et al. Strategies for developing gender-specific HIV prevention for adolescents in Vietnam. AIDS Educ Prev 2008;20:384-98. |
|50.||Go VF, Sethulakshmi CJ, Bentley ME, Sivaram S, Srikrishnan AK, Solomon S, et al. When HIV-prevention messages and gender norms clash: The impact of domestic violence on women′s HIV risk in slums of Chennai, India. AIDS Behav 2003;7:263-72. |
|51.||Greig A, Peacock D, Jewkes R, Msimang S. Gender and AIDS: Time to act. 2008;22:35-43. |
|52.||Luginaah I, Elkins D, Maticka-Tyndale E, Landry T, Mathui M. Challenges of a pandemic: HIV/AIDS-related problems affecting Kenyan widows. Soc Sci Med 2005;60:1219-28. |
|53.||Richter LM. Baby rape in South Africa. Child Abuse Review 2003;12:392-400. |
|54.||Voisin DR, DiClemente RJ, Salazar LF, Crosby RA, Yarber WL. Ecological factors associated with STD risk behaviors among detained female adolescents. Soc Work 2006;51:71-9. |
|55.||Harrison A, O′Sullivan LF, Hoffman S, Dolezal C, Morrell R. Gender role and relationship norms among young adults in South Africa: Measuring the context of masculinity and HIV risk. J Urban Health 2006;83:709-22. |
|56.||Kaufman MR, Shefer T, Crawford M, Simbayi LC, Kalichman SC. Gender attitudes, sexual power, HIV risk: A model for understanding HIV risk behavior of South African men. AIDS Care 2008;20:434-41. |
|57.||Hebling EM, Guimarães IR. Women and AIDS: Gender relations and condom use with steady partners. Cad Saude Publica 2004;20:1211-8. |
|58.||Kerrigan D, Andrinopoulos K, Johnson R, Parham P, Thomas T, Ellen JM. Staying strong: Gender ideologies among African-American adolescents and the implications for HIV/STI prevention. J Sex Res 2007;44:172-80. |
|59.||Molla M, Berhane Y, Lindtjørn B. Traditional values of virginity and sexual behavior in rural Ethiopian youth: Results from a cross-sectional study. BMC Public Health 2008;8:9. |
|60.||Leclerc-Madlala S. Virginity testing: Managing sexuality in a maturing HIV/AIDS epidemic. Med Anthropol Q 2001;15:533-52. |
|61.||Stephenson R. A community perspective on young people′s knowledge of HIV/AIDS in three African countries. AIDS Care 2009;21:378-83. |
|62.||Smith DJ. Premarital sex, procreation, and HIV risk in Nigeria. Stud Fam Plann 2004;35:223-35. |
|63.||Jarama SL, Belgrave FZ, Bradford J, Young M, Honnold JA. Family, cultural and gender role aspects in the context of HIV risk among African American women of unidentified HIV status: An exploratory qualitative study. AIDS Care 2007;19:307-17. |
|64.||Prata N, Vahidnia F, Fraser A. Gender and relationship differences in condom use among 15-24-year-olds in Angola. Int Fam Plan Perspect 2005;31:192-9. |
|65.||de Walque D, Nakiyingi-Miiro JS, Busingye J, Whitworth JA. Changing association between schooling levels and HIV-1 infection over 11 years in a rural population cohort in south-west Uganda. Trop Med Int Health 2005;10:993-1001. |
|66.||Barden-O′Fallon JL, deGraft-Johnson J, Bisika T, Sulzbach S, Benson A, Tsui AO. Factors associated with HIV/AIDS knowledge and risk perception in rural Malawi. AIDS Behav 2004;8:131-40. |
|67.||Mansoor AB, Fungladda W, Kaewkungwal J, Wongwit W. Gender differences in KAP related to HIV/AIDS among freshmen in Afghan universities. Southeast Asian J Trop Med Public Health 2008;39:404-18. |
|68.||Li X, Lin C, Gao Z, Stanton B, Fang X, Yin Q, et al. HIV/AIDS knowledge and the implications for health promotion programs among Chinese college students: Geographic, gender and age differences. Health Promot Int 2004;19:345-56. |
|69.||McManus A, Dhar L. Study of knowledge, perception and attitude of adolescent girls towards STIs/HIV, safer sex and sex education: (a cross sectional survey of urban adolescent school girls in South Delhi, India). BMC Womens Health 2008;8:12. |
|70.||DiClemente RJ, Wingood GM, Harrington KF, Lang DL, Davies SL, Hook EW 3 rd , et al. Efficacy of an HIV prevention intervention for African American adolescent girls: A randomized controlled trial. JAMA. 2004;292:171-9. |
|71.||Hirsl-Hecej V, Stulhofer A. Condom use and its consistency among metropolitan high school students in Croatia, 1997-2001: Has anything changed? Coll Antropol 2006;30:71-8. |
|72.||Chhabra R, Springer C, Rapkin B, Merchant Y. Differences among male/ female adolescents participating in a School-based Teenage Education Program (STEP) focusing on HIV prevention in India. Ethn Dis 2008;18:123-7. |
|73.||Di Noia J, Schinke SP. Gender-specific HIV prevention with urban early-adolescent girls: Outcomes of the Keepin′ It Safe Program. AIDS Educ Prev 2007;19:479-88. |
|74.||Ndiaye C, Boileau C, Zunzunegui MV, Koala S, Aboubacrine SA, Niamba P, et al. Gender-related factors influencing HIV serostatus disclosure in patients receiving HAART in West Africa. World Health Popul 2009;10:24-35. |
|75.||Arrington-Sanders R, Ellen J. Prevalence of self-reported human immunodeficiency virus testing among a population-based sample of urban African-American adolescents. J Adolesc Health 2008;43:306-8. |
|76.||Baker D, Collins J and Leon J. Risk Factor or Social Vaccine? The Historical Progression of the Role of Education in HIV/AIDS Infection in Sub-Saharan Africa. Paris: UNESCO; 2009. P. 12. |
|77.||Jarrin I, Geskus R, Bhaskaran K, Prins M, Perez-Hoyos S, Muga R, et al. Gender differences in HIV progression to AIDS and death in industrialized countries: Slower disease progression following HIV seroconversion in women. Am J Epidemiol 2008;168:532-40. |
|78.||Moore AL, Sabin CA, Johnson MA, Phillips AN. Gender and clinical outcomes after starting highly active antiretroviral treatment: A cohort study. J Acquir Immune Defic SynDr. 2002;29:197-202. |
|79.||Chen SC, Yu JK, Harries AD, Bong CN, Kolola-Dzimadzi R, Tok TS, et al. Increased mortality of male adults with AIDS related to poor compliance to antiretroviral therapy in Malawi. Trop Med Int Health 2008;13:513-9. |
|80.||Kumarasamy N, Venkatesh KK, Mayer KH, Freedberg K. Financial burden of health services for people with HIV/AIDS in India. Indian J Med Res 2007;126:509-17. |
|81.||Chandra PS, Satyanarayana VA, Satishchandra P, Satish KS, Kumar M. Do Men and Women with HIV Differ in Their Quality of Life? A Study from South India. AIDS Behav 2009;13:110-7. |
|82.||Muula AS, Ngulube TJ, Siziya S, Makupe CM, Umar E, Prozesky HW, et al. Gender distribution of adult patients on highly active antiretroviral therapy (HAART) in Southern Africa: A systematic review. BMC Public Health 2007;7:63. |
|83.||Braitstein P, Boulle A, Nash D, Brinkhof MW, Dabis F, Laurent C, et al. Gender and the use of antiretroviral treatment in resource-constrained settings: Findings from a multicenter collaboration. J Womens Health (Larchmt) 2008;17:47-55. |
|84.||Cook JA, Cohen MH, Burke J, Grey D, Anastos K, Kirstein L, et al. Effects of depressive symptoms and mental health quality of life on use of highly active antiretroviral therapy among HIV-seropositive women. J Acquir Immune Defic SynDr. 2002;30:401-9. |
|85.||Cook JA, Grey DD, Burke-Miller JK, Cohen MH, Vlahov D, Kapadia F, et al. Illicit drug use, depression and their association with highly active antiretroviral therapy in HIV-positive women. Drug Alcohol Depend 2007;89:74-81. |
|86.||Mathews WC, Mar-Tang M, Ballard C, Colwell B, Abulhosn K, Noonan C, et al. Prevalence, predictors, and outcomes of early adherence after starting or changing antiretroviral therapy. AIDS Patient Care STDS 2002;16:157-72. |
|87.||Turner BJ, Laine C, Cosler L, Hauck WW. Relationship of gender, depression, and health care delivery with antiretroviral adherence in HIV-infected drug users. JJ Gen Intern Med 2003;18:248-57. |
|88.||Berg KM, Demas PA, Howard AA, Schoenbaum EE, Gourevitch MN, Arnsten JH. Gender differences in factors associated with adherence to antiretroviral therapy. J Gen Intern Med 2004;19:1111-7. |
|89.||Applebaum AJ, Richardson MA, Brady SM, Brief DJ, Keane TM. Gender and Other Psychosocial Factors as Predictors of Adherence to Highly Active Antiretroviral Therapy (HAART) in Adults with Comorbid HIV/AIDS, Psychiatric and Substance-related Disorder. AIDS Behav 2009;13:60-5. |
|90.||Uldall KK, Palmer NB, Whetten K, Mellins C; HIV/AIDS Treatment Adherence, Health Outcomes and Cost Study Group. Adherence in people living with HIV/AIDS, mental illness, and chemical dependency: A review of the literature. AIDS Care 2004;16:71-96. |
|91.||Floridia M, Giuliano M, Palmisano L, Vella S. Gender differences in the treatment of HIV infection. Pharmacol Res 2008;58:173-82. |
|92.||Strebel A, Crawford M, Shefer T, Cloete A, Henda N, Kaufman M, et al. Social constructions of gender roles, gender-based violence and HIV/AIDS in two communities of the Western Cape, South Africa. SAHARA J 2006;3:516-28. |
|93.||Mantell JE, Needham SL, Smit JA, Hoffman S, Cebekhulu Q, Adams-Skinner J, et al. Gender norms in South Africa: Implications for HIV and pregnancy prevention among African and Indian women students at a South African tertiary institution. Cult Health Sex 2009;11:139-57. |
|94.||USAID. Sub Saharan Africa; Education. 2007 [updated 2007 Aug 22; cited 2009 Jul 28]; Available from:www.usaid.gov/locations/sub-saharan_africa/sectors/ed/index.html. |
University Medical Unit, National Hospital of Sri Lanka
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3]
|This article has been cited by|
||Women and HIV
| ||Jane Anderson |
| ||Current Opinion in Infectious Diseases. 2012; 25(1): 58 |
|[Pubmed] | [DOI]|
||Gender and Mental Health Aspects of Living with HIV Disease and Its Longer-Term Outcomes for UK Heterosexual Patients
| ||Lorraine Sherr,Claudine Clucas,Fiona Lampe,Richard Harding,Margaret Johnson,Martin Fisher,Jane Anderson,Simon Edwards,Switching Team |
| ||Women & Health. 2012; 52(3): 214 |
|[Pubmed] | [DOI]|
| Article Access Statistics|
| Viewed||3607 |
| Printed||258 |
| Emailed||2 |
| PDF Downloaded||94 |
| Comments ||[Add] |
| Cited by others ||2 |