Twenty-five percent of the people living with HIV in the United States are female. So are over 50 percent of people living with HIV/AIDS around the globe. In 1990 only 11 percent of all new AIDS cases were in women. The growth of the HIV epidemic in women has received less attention in the United States than that in men and it's easy to forget that women are still contracting HIV.
The good news is that there is promising evidence on a new female-controlled HIV prevention method, a vaginal ring that releases an antiretroviral drug . Released a few weeks ago, it has reignited the conversation about women and HIV. If it lives up to its promise, this new method should help to overcome many barriers that have led to HIV infection among women. However, it cannot overcome them all.
HIV prevention is different for women than for men. Women are not men with vaginas. Women and girls face unique social challenges to both preventing HIV and living a healthy life with HIV. Deeply embedded social roles, culture, communication and power structures have far too often disadvantaged women, especially women of color.
As we commemorate National Women and Girls HIV/AIDS Awareness Day on March 10th, we should reflect on these challenges and commit to finding better solutions to help overcome them.
Balancing work and family responsibilities
While paid employment among women with HIV actually helps them take better care of their HIV and overall health, marriage does not. Paid employment can bring financial security, sense of purpose, an enlarged social network, health and retirement benefits. Marriage, on the other hand, means unpaid labor taking care of home, husband and children and often parents, taking time away from a woman's ability to care for her own health.
Several years ago, we conducted a study that found that a woman living with HIV who was married was less likely to be able to self-manage her HIV, compared to a woman who was unmarried. Since women are unlikely to stay single or get a divorce the ultimate solution will be to change social norms and expectations so that men also share in family responsibilities. Initiatives such as Recognize, Reduce and Redistribute, recently advocated for by Melinda Gates is likely to yield novel interventions to help us achieve this goal.
Trauma and Violence
Both men and women living with HIV report higher rates of past and current traumatic experiences such as rape, domestic violence, sexual, physical and emotional abuse than the general population. While trauma and violence can affect anyone, women and girls are disproportionally affected. Trauma undermines women's health outcome, because they suffer increased rates of depression, fatigue, anxiety, medication failure, faster development of opportunistic infections and early death.
This intractable problem will require multicomponent solutions such as the awareness campaign "He for She" to create a gender equal world. For survivors of trauma and violence, a growing number of health care providers are embracing trauma-informed care, a model of health care delivery which emphasizes the impact of trauma on a woman's current symptoms and health. The Positive Women's Network-U.S.A. has recently advocated for resources to make trauma-informed care the standard of HIV health care delivery in the U.S.
Poverty
Underpinning these structural challenges is one of the toughest to overcome -- poverty. Research demonstrates that women living with HIV are likely to be impoverished, relying heavily on a social safety net, when it exists. Poverty can also increase the likelihood of a woman becoming infected with HIV.
The 2015 Sustainable Development Goals adopted by the United Nations last September sets ambitious goals to reduce poverty among women, including supporting universal and equitable quality education for girls and young women, giving women equal rights to economic resources, and achieving full and productive employment for all women and men, with equal pay for work of equal value. Recent research found that two interventions help reduce the impact of poverty among women living with HIV -- improving access to quality housing and food.
The Good News
There are so many challenges they can seem overwhelming and it can be hard to imagine meaningful progress is even possible. But the good news is that the energy focused on bringing these issues, and their impact on living with HIV, to the forefront has never been greater. The theme for the 2016 National Women and Girls HIV/AIDS Awareness Day is "The Best Defense is a Good Offense." This theme focuses on the very promising individual-level prevention strategies against HIV.
But to help defend women and girls against new HIV infections, and to help the 16 million women and girls already living with HIV to have the healthiest life possible, we also need to address the structural challenges women face.