What are US women’s HIV prevention needs?

are women at risk?

Yes. HIV is taking an increasing toll on women and girls in the US. In 1985, women comprised 8% of all AIDS cases in the US, while by 2005, women made up 27% of all AIDS cases. In 2005, women accounted for 30% of all new HIV infections. Of these, 60% occurred among African Americans, 19% among Whites, 19% among Hispanics, and 1% each among Asian/Pacific Islanders and American Indian/Alaska Natives.

who are women most affected by HIV?

African American and Hispanic women in particular are disproportionately affected by HIV/AIDS. Although African American and Hispanic women comprise only 23% of the total female population in the US, in 2005 they accounted for 79% of all new HIV infections (African American women: 60%, Hispanic women: 19%). Accordingly, in 2004 HIV infection was the leading cause of death for Black women (including African American women) aged 25-34 years. Younger women are also affected by HIV/AIDS. In recent years, the largest number of HIV/AIDS diagnoses among women occured in women 15-39 years old. In 2005, young women represented 28% of AIDS cases among young men and women aged 20-24.

what places women at risk?

Most women are infected with HIV through heterosexual contact, especially women with injection drug using partners. In 2005, 80% of all new infections in women were from heterosexual contact. Women are more likely than men to acquire HIV via sexual intercourse, due to greater exposed surface area in the female genital tract. Injection and non-injection drug use places women at an increased risk for HIV and is strongly linked to unsafe sexual practices. Approximately 20% of new HIV cases in women is related to injection drug use. Women who use crack cocaine may also be at high risk of sexual transmission of HIV, particularly if they sell or trade sex for drugs. Sexually transmitted infections (STIs) other than HIV can increase the likelihood of getting or transmitting HIV. In the US, chlamydia and gonorrhea (both asymptomatic) are the most commonly reported STIs, with highest rates in women of color and young women and adolescents. Sexual abuse (both childhood and adult) and domestic violence play a substantial role in placing women at risk for HIV infection. In the US, annually 2.1 million women are raped and 4 million become victims of domestic violence; of these women, more than 10,000 rape victims and 79,000 violence victims require hospitalization. Women who report early and chronic sexual abuse are seven times more likely to engage in HIV-related risk behaviors compared to women without trauma history. Women disproportionately suffer from poverty, in particular women of color who are affected by HIV. Because of this, women are less likely than men to have health insurance and access to quality healthcare or prevention services. Approximately two-thirds of women with HIV in the US have an annual income of less than $10,000. Poverty can increase HIV risks such as exchanging sex for money, shelter, or drugs. In a survey of young and low-income women in California, women who reported sex work were more likely to have syphilis, herpes, hepatitis C, and a history of sexual abuse. Abuse, violence and poverty can all lessen a woman’s power to negotiate condom use or choose safer partners. They also can lead to psychological distress, such as depression, anxiety and post-traumatic stress disorder (PTSD). Having relationships that overlap in time (concurrent partners) can increase women’s risk of HIV transmission. Concurrency is more likely to occur among women who are not married, are young adults and are poor.

what can help?

Involving male partners. For women to protect themselves from HIV, they must not only rely on their own skills, attitudes, and behaviors regarding condom use, but also on those of their male partner. Often, men and women in relationships may find intimacy to be more important than protection against HIV. Involving women’s partners in HIV prevention programs can help strengthen intimacy and trust and improve sexual communication and negotiation, including asking about past and current partners. Support from other women. Many prevention programs for women offer groups to reduce women’s isolation and allow women to support each other and normalize safer behaviors. Greater social support can increase self esteem and allow women to make healthier choices. A program in Washington DC helped build support and empowerment for HIV+ African American women by holding educational groups during shared meals and providing small gifts (along with condoms) as incentives or thank-yous. Help with non-HIV factors. Women at risk for HIV face many behavioral and structural challenges beyond HIV: poverty and economic strain, unemployment, violence and unhealthy gender relations, migration, STIs, drug use, and caring for children and family members. HIV prevention programs for women should provide transportation, child care, nutritious food and compensation such as money, phone or store cards or gift packs. Programs should provide up-to-date referrals for employment, housing, medical care and mental health services trauma, abuse and depression.

what is being done?

Currently 17 women-specific interventions exist that have been approved by the CDC as best evidence or promising evidence or are part of the Diffusion of Effective Behavioral Interventions (DEBI) project: CHOICES, Communal Effectance-AIDS Prevention, Female and Culturally Specific Negotiation, Project FIO, Project SAFE, RAPP, SiHLE, SISTA, Sisters Saving Sisters, Sister to Sister, WHP, WiLLOW, Women’s Co-op, Condom Promotion, Insights, Safer Sex, and SEPA. The Women’s Leadership and Community Planning project in San Francisco, offered a 2-day training for women with HIV in California who want to take greater leadership roles in state Planning Councils. At the training, women network with each other, as well as learn skills in public speaking, decision-making, and conflict management. Women stay in touch through monthly conference calls. After the first training, 6 of 13 women moved into leadership positions on their local or state Councils. Respeto/Proteger: Respecting and Protecting our Relationships is an HIV prevention program for Latino teen mothers and fathers in Los Angeles, CA. Developed and tested with a community agency and academic researchers, the program recognizes risks young women face, including poverty, drug and alcohol use, history of STIs and physical or sexual abuse. The six-session intervention focuses on healing the wounded spirit and builds on feelings of maternal and paternal protectiveness using cultural and traditional teachings.

what needs to be done?

Because women are more likely to get HIV from their male partners, programs that target men (especially IDUs) will have a beneficial impact on women. Needle exchange and drug treatment strategies are critical. Public health agencies need to raise awareness about sexual abuse and domestic violence to not only help men and women develop the skills to prevent it, but also to curb its effect on the HIV epidemic. HIV testing campaigns that target women and women-friendly testing sites are also needed. Behavioral and structural HIV prevention interventions for women continue to be necessary, given the lack of evidence from biomedical interventions (microbicides, vaccines). However, research needs to continue on how women can protect themselves with an accessible, affordable, comfortable and discrete tool for safer sex. Although research has highlighted the subpopulations of women most affected by HIV/AIDS, it is even more important to translate and materialize study findings into tangible public health programs and effective policies. Interventions that address sexuality, family, culture, empowerment, self-esteem, and negotiating skills, as well as interventions located in varying community settings are especially valuable.

Says who?

1. Kaiser Family Foundation. Women and HIV/AIDS in the United States. Policy Fact Sheet. July 2007. 2. Centers for Disease Control and Prevention. Cases of HIV infection and AIDS in the United States and Dependent Areas, 2005. HIV/AIDS Surveillance Report. 2007;17. 3. Centers for Disease Control and Prevention. HIV/AIDS fact sheet: HIV/AIDS among women. June 2007. 4. National Institute of Allergy and Infectious Diseases at National Institutes of Health. Research on HIV infection in women. 2006. 5. Theall KP, Sterk CE, Elifson KW, et al. Factors associated with positive HIV serostatus among women who use drugs: continued evidence for expanding factors of influence. Public Health Reports. 2003;118:415-424. 6. Sangani P, Rutherford G, Wilkinson D. Population-based interventions for reducing sexually transmitted infections, including HIV infection. Cochrane Database of Systematic Reviews. 2004; 2:CD001220. 7. Weinstock H, Berman S, Cates W. Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspectives in Sexual and Reproductive Health. 2004;36:6-10. 8. Koenig LJ, Moore J. Women, violence, and HIV: A critical evaluation with implications for HIV services. Maternal and Child Health Journal. 2000;4:103-109. 9. Wyatt GE, Myers HF, Loeb TB. Women, trauma, and HIV: an overview. AIDS and Behavior. 2004;8:401-403. 10. Bozzette SA, Berry SH, Duan N, et al. The care of HIV-infected adults in the United States. HIV Cost and Services Utilization Study Consortium. New Engand Journal of Medicine. 1998;339:1897-1904. 11. Cohan DL, Kim A, Ruiz J, et al. Health indicators among low income women who report a history of sex work: the population based Northern California Young Women’s Survey. Sexually Transmitted Infections. 2005;81:428-433. 12. Adimora AA, Schoenbach VJ, Bonas DM, et al. Concurrent sexual partnerships among women in the United States. Epidemiology. 2002;13:320-327. 13. Prosper! The Women’s Collective, Washington DC. 14. Dworkin SL, Ehrhardt AA. Going beyond “ABC” to include “GEM”: critical reflections on progress in the HIV/AIDS epidemic. American Journal of Public Health. 2007;97:13-18. 15. Centers for Disease Control and Prevention. Updated Compendium of Evidence-Based Interventions, 2007. 16. Women’s Leadership and Community Planning project, CompassPoint, San Francisco, CA. 17. Lesser J, Koniak-Griffin D, Gonzalez-Figueroa E, et al. Childhood abuse history and risk behaviors among teen parents in a culturally rooted, couple-focused HIV prevention program. Journal of the Association of Nurses in AIDS Care. 2007;18:18-27. 18. Landovitz RJ. Recent efforts in biomedical prevention of HIV. Topics in HIV Medicine. 2007;15:99-103.

Prepared by Roshan Rahnama, CAPS April 2008. Fact Sheet #4ER Special thanks to the following reviewers of this fact sheet: Abby Charles, Beth Freedman, Bridget Hughes, Winifred King, Linda Koening, Maureen Miller, Adeline Nyamathi, Nancy Padian, Kate Perkins, Gina Wingood, Gail Wyatt, Toni Young. Reproduction of this text is encouraged; however, copies may not be sold, and the University of California San Francisco should be cited as the source. Fact Sheets are also available in Spanish. To receive Fact Sheets via e-mail, send an e-mail to [email protected] with the message “subscribe CAPSFS first name last name.” ©April 2008, University of CA.

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