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AIDS: The women's epidemic.

AIDS is now the world's leading infectious cause of death. The World Health Organization estimates that 2.5 million people died of AIDS in 1998 -- nearly 1 million were women (World Health Organization [WHO] & Joint United Nations Programme on AIDS [UNAIDS], 1998).

The AIDS epidemic among women continues to grow. Of the 33.4 million people estimated to be living with HIV/AIDS worldwide, 13.8 million are women and 1.2 million are children (WHO & UNAIDS, 1998).

Women are almost half of the 14,000-plus adults who are infected with HIV each day. More than 90 percent of women with HIV/AIDS live in a developing, or Third World, country. In some countries, as many as 30 percent of pregnant women are HIV positive (WHO & UNAIDS, 1998; UNAIDS, 1997).

Young women are at especially high risk, as approximately half of all HIV infections to date have occurred in women and men younger than age 25. In many developing countries, up to 60 percent of all new HIV infections are among teens and young adults ages 15 to 24 and young women outnumber their male counterparts by a ratio of two to one (Weiss, Whelan, & Gupta, 1996).

In Sub-Saharan Africa, six women are living with HIV for every five men. In Brazil, only one woman was infected for every 99 men in 1984; a decade later, women accounted for one in four of all those with HIV (AIDS Education and Research Trust [AVERT], 1999; UNAIDS, 1996a).

In Thailand, as a consequence of HIV transmission from husband to wife, the rate of HIV infection among women attending prenatal clinics has climbed steadily -- from 0.2 percent in 1990 to 2 percent in 1994; some regions of the country show rates of HIV in women of up to 10 percent (AVERT, 1999; UNAIDS, 1996b).

Women comprised approximately 12 percent of AIDS cases reported in France in 1985; ten years later, women were 20 percent of persons living with AIDS. In Spain, women's share of reported AIDS cases more than doubled over the same 10 year period -- from 7 percent to 19 percent (AVERT, 1999). AIDS also remains a leading cause of death for women between the ages of 25 and 44 in the United States (Centers for Disease Control and Prevention [CDC], 1999).


In 1996, AIDS-related deaths declined in the United States for the first time, by 25 percent (CDC, 1998a). But AIDS deaths among women did not decline as rapidly as deaths among men (National Center for HIV, STD, and TB Prevention [NCHSTP], 1998a). And by 1999, the overall decline in AIDS incidence stopped and the decline in AIDS death rates slowed (Altman, 1999).

Among women ages 25 to 44, AIDS is the eighth leading cause of death for white women, the third leading cause of death for Latina women, and the second leading cause of death for African American women (CDC, 1999).

Women remain the fastest growing group both of newly reported cases of AIDS and also of newly reported HIV diagnoses. Between 1995 and 1996, HIV diagnoses among women increased by 3 percent but declined among men by 3 percent (CDC, 1998b). From 1992 through 1997, the estimated number of women living with HIV/AIDS also increased 2.7 times while the estimated number of men living with AIDS increased 1.8 times (CDC, 1998a).

In 1998, 10,998 AIDS cases were reported among adult and adolescent women, comprising 23 percent of total cases that year, the highest proportion yet recorded (CDC, 1998a). In the same year, women also represented a greater proportion of newly diagnosed HIV infections than of AIDS cases (NCHSTP, 1999).

In the United States, women of color continue to be the most severely affected by AIDS. While African American women and Latinas account for 21 percent of all women in the United States, in 1997 they were 82 percent of the estimated number of adult and adolescent women with AIDS -- at 63 percent and 19 percent respectively. Although Asian and Pacific Islander women and Native American women together comprised less than 1 percent of the estimated number of adult and adolescent women with AIDS in 1997, their numbers doubled in just five years -- from 1992 to 1997 (CDC, 1998a).

Older women are at high risk of infection during intercourse, in part because of normal aging changes, such as a decrease in vaginal lubrication and thinning vaginal walls. Of AIDS cases among women reported in 1998, 16 percent were in women 45 and older, an increase of 14 percent since 1997. Older women comprise a greater percentage of all AIDS cases as age increases. While women in the age cohort 50 to 59 are 6.1 percent of that age group's AIDS cases, that percentage more than doubles--to 13.2 percent -- for the 60 to 69 age group and to 28.7 percent for those 65 and older (Center for AIDS Prevention Studies, 1997b; CDC, 1998a).

A review of the literature on HIV/AIDS in older women led to the conclusion that: "HIV is often undiagnosed, misdiagnosed or diagnosed late in mid-life and older women. Many physicians do not understand that older adults, particularly women, are at risk of HIV infection, and so they do not evaluate older patients with the same clinical suspicion they apply to younger patients. In addition, many physicians evaluating older women do not take sexual histories or ask about the sexual behaviors or drug use of their spouses or partners" (Ogu & Wolfe, 1994).

The risk far HIV/AIDS is increasing most alarmingly among young women. The total number of AIDS cases in women increased 12 times between June 1989 and December 1998; however, the number of AIDS cases among teen women (ages 13 to 19) increased 18 times in the same period (CDC, 1998a). Teens and young adults ages 13 to 24 accounted for a greater proportion of HIV diagnoses (14 percent) than of AIDS cases (3 percent) and nearly half of HIV diagnoses in this age group are among teen and young women (NCHSTP, 1998b).

Data from 1990 through 1996 on the rates of HIV infection among entrants to the U.S. Job Corps program (a federally funded job training program for disadvantaged out-of-school youth from all 50 states and U.S. territories) show that young women, particularly African American women, are being infected with HIV at younger ages and at higher rates than their male counterparts (NCHSTP, 1998b).

The method of exposure to HIV for women under age 25 is overwhelmingly through heterosexual contact. Heterosexual transmission accounts for 41 percent of AIDS cases reported in 1998 and over half of the cumulative AIDS cases since the beginning of the epidemic among teen women; heterosexual sex accounts for 49 percent of reported AIDS cases in 1998 and 54 percent of AIDS cases among women ages 20 to 24 (CDC, 1998a).

Women experience greater biological vulnerability to HIV/AIDS from heterosexual contact than do men. Transmission of HIV from man to woman is far more efficient than from woman to man, in part because of the greater exposed surface area in the female genital tract; the risk of HIV infection during vaginal intercourse is two to four times higher for women than for men. Because more men than women in the United States are infected with HIV, the likelihood that a woman will have an infected partner is greater (Center for AIDS Prevention Studies, 1998a; AVERT, 1999).

Heterosexual transmission accounts for an increasing proportion of HIV/AIDS cases in the United States. More than 80 percent of all women with HIV are infected by a male sexual partner (AVERT, 1999). From 1991 to 1997, the estimated proportion of AIDS cases in adults that were attributed to heterosexual contact grew from 8.5 percent to 22.1 percent. Where confidential HIV reporting was available, the majority of cases (40 percent) were reported to have been caused by heterosexual contact (National Institute of Allergy and Infectious Diseases [NIAID], 1999; CDC, 1998a). (*)

Sexually transmitted diseases (STDs) fuel the AIDS epidemic; if left untreated, STDs increase the risk of HIV infection by 300 to 400 percent (UNAIDS, 1996a). Women under the age of 25 are at highest risk for HIV/STD infection; and STDs -- including gonorrhea, syphilis, and chlamydia -- disproportionately affect young women and women of color (NCHSTP, 1998a). Indeed, the highest rates of HIV infection are found among women and men who had been infected with other STDs (Altman, 1999).


Women experience HIV/AIDS differently than men. Studies have shown that women with HIV whose viral load is the same as men's have a higher risk of AIDS; women with half the viral load as men progress to AIDS at a similar speed (Farzadegan et al., 1998). Women also experience differences in blood levels, toxicity and side effects of drugs as compared to men (Currier, Spino, & Cotton, 1995, as cited in Lucey & Zangeneh 1999), and occurrences of opportunistic infections vary by gender (Jones et al., 1999).

Several studies show that women who are diagnosed with HIV early and who receive appropriate treatment live as long as HIV positive men and that survival times for women are shorter than for men primarily because women are less likely than men to receive an early diagnosis and treatment (NIAID, 1997).

Little is known about how HIV disease progresses in women, and even less is known about the disease in midlife and older women. Many studies do not even include women over age 45 or 49 or do not analyze data that they do have for older women. And clinical trials often exclude women who have more than one disease, as many older women do (i.e. hypertension, diabetes, osteoporosis). There also is relatively little biomedical information on HIV/AIDS for older women, including information on opportunistic infections for which older women may be at increased risk, drug interactions between medications for AIDS and for hypertension, arthritis, heart disease, diabetes, asthma, and osteoporosis, and dosage requirements and reaction to drugs (Ogu & Wolfe, 1994).

Because HIV/AIDS affects women differently than men, women with HIV/AIDS have an urgent need for doctors who are specialists in HIV/AIDS and women's health. For example, the frequency at which AIDS-defining opportunistic illnesses (Ols) first occur varies by sex as well as by exposure mode. For women, esophageal candidiasis, recurrent pneumonia, pulmonary tuberculosis and chronic herpes simplex are more likely to occur first (Jones et al., 1999). Women also experience H IV-associated gynecological ailments -- such as vaginal yeast infections, genital ulcers, human papillomavirus, pelvic inflammatory disease, and menstrual irregularities; while many of these also occur in women who are not HIV positive, they usually are less frequent or severe (NIAID, 1997).

Women living with HIV/AIDS carry a large burden of caring for children and other family members who also may be living with HIV. They often lack social support and face other challenges that may interfere with their ability to adhere to treatment regimens (NIAID, 1997).

Many women with HIV/AIDS also live in poverty and depend on Medicaid for their health care. A nationwide study of people with AIDS found that 78 percent of women relied on public insurance, compared to only 45 percent of men (Hellinger, 1993, as cited in Center for Women Policy Studies, 1997). Women with HIV often cannot afford the cost of food for themselves and their families, and those who receive food stamps cannot count on receiving them in the future (Center for Women Policy Studies, 1997).

Women with HIV infection, not full-blown AIDS, are generally in the population being moved to Medicaid managed care programs. This requires that protections must be put into place to assure that women with HIV/AIDS who depend upon Medicaid have access to specialized services, including gynecological care and aggressive monitoring and HIV treatment beginning early in the disease process (Center for Women Policy Studies, 1997).

Indeed, the progression of HIV disease can be profoundly delayed with early, appropriate medical management, enabling women with HIV to remain healthy and productive, able to care for their families and to work. Maintaining all low income people with HIV on Medicaid would be much more cost effective than waiting until they have become so ill that they finally meet the overly stringent SSI definition of disability and need intensive and expensive care when they qualify for Medicaid through SSI (Center for Women Policy Studies, 1997).

The initial findings of the Women's Interagency HIV Study (WIHS) reinforce what is known about the financial and psychosocial issues confronting many women living with HIV/AIDS -- including poverty, difficulties obtaining adequate housing and transportation, and both their own and their partners' substance abuse problems, for example. Nearly half of the women participating in the WIHS study report a history of sexual abuse and 60 percent have been victims of domestic violence; a high proportion suffer from depression (Young, 1996, as cited in Center for Women Policy Studies, 1997).

Access to appropriate care for women is facilitated by the availability of case management services. When case managers are well informed, when they help women navigate the complicated health care and social services systems, and when they treat women with respect and dignity, they make a substantial contribution to the quality of life for many women with HIV/AIDS. But when case managers fail to follow through on important matters, when they miss deadlines, and when they are disinterested or unaware of available services, women lose access to vital services and their health and well-being can be placed at risk (Center for Women Policy Studies, 1998c).

Incarcerated women living with HIV/AIDS urgently need, but often fail to receive, supportive and nonjudgmental HIV/AIDS counseling, education, and specialized medical care. They face breaches of confidentiality about their HIV status by correctional staff and halfway house counselors, which often deter women who are incarcerated from seeking vital health care and psychological support (Center for Women Policy Studies, 1996b).

A survey conducted for the CDC in 1996 and 1997 found that only 10 percent of state and federal prison systems, and only 5 percent of city and county jail systems, offered comprehensive H IV prevention programs for inmates; few offered peer-led programs, instructor education, multi-session counseling and pre- and post-test counseling (Hammett, Harmon, & Maruschak, 1999, as cited in "Prisoners much more likely to have HIV," 1999).

To date, no studies have rigorously examined woman-to-woman transmission of HIV. While HIV is found in vaginal fluids and menstrual blood, the amount of virus has not been adequately measured, though it affects women's risk from a variety of woman-to-woman sexual activities, particularly acts that may result in vaginal trauma -- such as sharing sex toys without condoms or digital play with finger cuts or sharp nails, which might pose higher risk than oral sex, which is believed to pose a relatively low risk (Center for AIDS Prevention Studies, 1997a).


In the absence of a cure, prevention is still the most effective method of combating the spread of HIV/AIDS. Yet prevention programs and messages are not reaching women, in part because they do not address the complex realities of the social, political, and economic status of women. In fact, some prevention behavioral studies indicate that the failure to acknowledge such co-factors of HIV as poverty, racism and sexism, and violence against women may make a full understanding of the determinants of women's risk behaviors impossible (Cochran & Mays, 1993, as cited in Center for Women Policy Studies, 1996a).

In addition to increased biological vulnerability, women often experience greater social and economic vulnerability to HIV infection than men. Studies in Latin America, Asia and Africa showed that sexual initiation for girls can occur before menarche and that poverty and sexual coercion underlie many young women's sexual experiences (Weiss, Whelan, & Gupta, 1996).

Studies in the United States find a number of factors to be associated with an increased risk of heterosexual HIV transmission -- including alcohol use, history of childhood sexual abuse, current domestic abuse, and use of crack/cocaine (NIAID, 1997).

Many of the women who participated in 36 in-depth interviews conducted by the Center for Women Policy Studies as part of its Metro DC Collaborative far Women with HIV/AIDS discerned a connection between their experiences as victims of violence and their HIV infection. In addition to the obvious link between abusive men with HIV who infected their women partners, some women also felt that the abuse they experienced "set them up" to be at increased risk for HIV infection; indeed, some women who had fled violent situations found themselves living on the streets and in such precarious economic -situations that they turned to commercial sex for survival or taking drugs and participating in theft. A few women felt that the psychological effects of violence, such as insecurity and low self esteem, made them vulnerable to being in relationships with the men who infected them (Viruell-Fuentes & Wolfe, 1998).

Indeed, the intersection of domestic violence with the growing AIDS epidemic among women has broad implications for HIV prevention, yet almost no data exist on the prevalence of domestic violence against women with HIV/AIDS. One study found that women who are at the highest risk of HIV infection also face an increased risk of domestic violence and another study suggests that domestic violence may contribute to the higher HIV/AIDS mortality rate among women than men (Berenson et al., 1995 and Melnick et al., 1995, as cited in Center for Women Policy Studies, 1998a). And 45 percent of providers of health care to women with HIV in Maryland reported that at least one woman patient had stated that she was afraid that her partner would physically hurt her if he knew she was infected (Rothenberg et al., 1997, as cited in Center for Women Policy Studies, 1998a).

Women do not wear condoms. In order for women to engage in safe sex, they must convince men to use condoms. However, many women endure physical and sexual abuse; and issues of gender, culture and power -- such as women's emotional, social and financial dependence on men -- also may be barriers to women's ability to maintain safer sex practices with a primary partner (Center for AIDS Prevention Studies, 1998a).

Post-menopausal women may not view condom use as important or necessary because they need not worry about pregnancy. In a national survey of people at risk of HIV, those over age 50 were one sixth as likely to use condoms and one fifth as likely to have been tested for HIV than were those in their 20s (Center for AIDS Prevention Studies, 1997b).

Young women living with HIV/AIDS identify the need for more effective HIV/AIDS prevention programs as a key AIDS policy issue, reporting that they knew little about HIV/AIDS and other sexually transmitted diseases before learning that they were HIV positive (Center for Women Policy Studies, 1998b).

Because prevention efforts have targeted so-called risky groups instead of risky behaviors, condom use is overwhelmingly associated with sex workers and casual sex in the public perception. Women often bear the burden of the stigma associated with condom use as well as the burden of negotiating condom use -- even though a recent study found that 36.6 percent of the clients of male prostitutes tested positive for HIV, compared to only 2.9 percent of the clients of female prostitutes. In addition, clients of male prostitutes revealed significant HIV risk factors, such as "serologic history of syphilis, serologic history of hepatitis B, receptive anal sex with a male prostitute, ever injecting drugs, ever using crack cocaine and little education" (Elifson et al., 1999).

The sex workers most vulnerable to HIV infection are street workers, most of whom are poor, homeless, have a history of childhood abuse and are likely to be drug or alcohol dependent. Sex workers may agree to unprotected sex if a client offers substantially more money, if they are desperate for money to buy drugs, or if business has been slow. In some cases, clients may use violence to enforce unsafe sex. The illegality of the business drives the industry underground and thus makes it difficult to conduct HIV prevention outreach (Center for AIDS Prevention Studies, 1996).

HIV prevention strategies that include early sex education and providing clean syringes and needles to injection drug users have proven to be effective and, if implemented in the United States without reservation, could ensure that the number of new HIV diagnoses could be cut in half (Coates, 1999).

Further, a nationwide survey of patients (Gerbert et al., 1990, as cited in Coates, 1999) revealed that only 15 percent had discussed HIV/AIDS with their physicians in the previous five years, although 94 percent had seen a physician during that time.

Moreover, nearly three quarters of the discussions that took place were at the patient's urging rather than at the physician's suggestion (Coates, 1999).

Women overwhelmingly choose methods to prevent pregnancy, such as birth control pills, that do not rely on partner cooperation. Unfortunately, these methods do not prevent STDs and HIV transmission. A vaginal microbicide, in the form of a topical compound, film or sponge that would kill both STD and HIV microbes would be an ideal woman-controlled HIV prevention method. While such compounds are already in various stages of development and testing, substantial resources are necessary to bring a microbicide to market (Heise, 1999).

(*.)The exposure was not identified or reported in 37 percent of HIV infection cases. CDC classified women as NIR (No Identified Risk)" who reported no history of exposure to HIV through any of the routes listed, whose cases were currently under investigation or were incomplete because of death, who declined to be Interviewed and who were born in a country where heterosexual transmission was believed to be the predominant mode of transmission (CDC, 1998a).


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Author:Gaberman, Brynn R.; Wolfe, Leslie R.
Publication:AIDS: the Women's Epidemic
Article Type:Topic Overview
Geographic Code:00WOR
Date:Dec 1, 1999

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