On this World AIDS Day, it is important to remember that sex and gender have long been known to affect HIV risk, yet research and programming to address these critical factors remain inadequate. Women are not equally represented in research studies, and when they are included, results are not always disaggregated by gender or analyzed to report sex differences.
In the early days of the HIV epidemic in the United States, women were omitted from prevention and treatment research. Until 1993, females were excluded from the Centers for Disease Control and Prevention (CDC) case definition of AIDS. This past marginalization of women in HIV/AIDS studies and policies is concerning since physiological differences, as well as socioeconomic factors, can increase the risk of HIV infection for women.
Women now represent just over half of all people worldwide living with HIV and nearly 60 percent of cases among young people in sub-Saharan Africa. . Globally, rates of new HIV infections among young women, aged 15–24, are 44 percent higher than among men of the same age group. In sub-Saharan Africa, women comprised 56% of new infectious among adults 15 years and older, girls account for three in four new HIV infections among adolescents (aged 15–19), and in the West African countries of Cameroon, Côte d’Ivoire, and Guinea, they experience infection rates that are five times higher than adolescent boys of the same age.
A combination of biological, social, and economic factors places women and girls at disproportionate risk of HIV. Unequal access to resources, especially education, is a key contributor to women’s HIV risk. But education is also an important HIV prevention opportunity. Across multiple studies in several developing nations, girls’ education has proven to be a potent protective factor against HIV. In fact, research has found that staying in school makes a girl more than three times less likely to acquire HIV. In Swaziland, which has the highest adult rate of HIV in the world, the powerful effects of education are underscored: two-thirds of out-of-school teenage girls are HIV positive, a sharp contrast to the one-third for their peers who attend school. Each year of school decreases a girl’s risk of acquiring HIV by six to twelve percent, according to studies conducted in Malawi and Botswana, respectively.
This growing body of evidence suggests that investing in girls’ education is an important strategy in the fight against HIV/AIDS. Schooling increases exposure to sex education and HIV prevention information. Educated young women at all levels are more responsive to HIV prevention campaigns, and their partners are more likely to use condoms. In Kenya, women with a secondary education are more than three times more likely to get tested for HIV and have higher general health literacy. Educated married women at all socioeconomic levels are also more likely to discuss HIV with their husbands and feel more empowered to refuse sex.
Educating women and girls is important in its own right. It provides girls with knowledge, social support, strengthens their self-esteem, prevents early marriage, increases women’s participation in the workforce, and increases lifetime earning potential. Providing women with educational opportunities also promotes more equal partnership dynamics and decreases women’s reliance on their male partners. This in turn increases women’s economic security, which can help prevent the necessity to engage in transactional sex—a significant risk factor for HIV.
Transactional sexual relationships, concurrent sexual partners, and the “sugar daddy” phenomenon characterized by a large age and economic asymmetry between male and female partners, are believed to be significant factors in the spread of HIV among young women in Sub-Saharan Africa. A study conducted in Kisumu, Kenya, found that 70 percent of men in relationships were at least five years older than their partners, and 83 percent provided material economic assistance to them. Transactional sex with an older man is associated with lower condom use and increased risk of sexually transmitted infections. “Sugar daddies” in sub-Saharan Africa were found to be 39 percent less likely to use a condom at last sexual intercourse with their younger female partners, according to a study conducted in Kenya. Their riskier sexual practices can lead to a cycle of transmission that is in part fueling the HIV/AIDS epidemic among young women: older men pass HIV to their younger female partners, who in turn transmit the virus to new partners, often also “sugar daddies” who go on to transmit it to other young women, and so on.
The U.S. government has made some promising steps to support the rights and health of women and girls globally. The support of women’s rights was a key element of the U.S. Department of State’s first Quadrennial Diplomacy and Development Review (QDDR) in 2010. That same year, the State Department initiated gender mainstreaming in all of its initiatives and programs, including tracking the budget for gender equality programs, which totaled $1.3 billion in 2017 (down from a peak of $1.91 billion in 2014). This commitment to supporting women’s empowerment was reinforced in the 2015 QDDR, and was a priority of USAID development programs.
Empowering girls through programming and education is an important component of the President's Emergency Plan for AIDS Relief (PEPFAR). Established in 2014, DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) is a public-private partnership among PEPFAR, the Bill & Melinda Gates Foundation, and other organizations that have committed to reducing HIV among adolescent girls and young women in 10 countries in sub-Saharan Africa. Its core package of interventions addresses the structural factors affecting HIV risk for girls and women, such as providing educational subsidies to help keep girls in school. Other US Department of State programs have also been initiated, including a dedicated Office of Global Women’s Issues established in 2009, to elevate these issues to the forefront of the U.S. foreign policy agenda.
However, the current Administration has not appointed an Ambassador to lead this program since January 20, 2017, and the Office of Global Women’s Issues in the U.S. Department of State is languishing without much needed support for its work. Significant gaps remain in disaggregating data to ensure that programs target women’s unique needs. Increased investment is required for HIV programming that addresses the structural drivers of HIV infection, including lack of education. Additionally, the Administration’s re-implementation of the Mexico City Policy—which prohibits U.S. global health funding to non-U.S. nongovernmental organizations that advocate, provide, counsel, or refer patients for abortions, even if using the organization’s own funds for these activities—will negatively affect the health and well-being of girls and women in the developing world.
Over the past 30 years, significant progress has been made in the fight against HIV/AIDS. The number of people with HIV on antiretroviral treatment has increased dramatically, deaths from AIDS have fallen significantly, and the number of new infections is declining every year worldwide. However, this good news is not benefitting women in some parts of the world. To defeat HIV/AIDS globally, the underlying socioeconomic factors that contribute to vulnerability to HIV infection in women must be addressed.
That means increasing women’s empowerment through education and boosting economic security to help them negotiate safer sexual practices and make healthier choices. It means ending violence against women, and increasing access to services including prevention and treatment interventions targeting the unique needs of girls and women. Gender disaggregated data should be collected and reported from research studies to ensure that these goals are met. Ensuring education and economic security for girls and women, and providing them with access to health care services, are the cornerstone of efforts to end the HIV/AIDS epidemic now and in the years ahead.
Rear Admiral Susan Blumenthal, M.D., M.P.A. (ret.) is the Senior Policy and Medical Advisor at amfAR, the Foundation for AIDS Research who served as US Assistant Surgeon General and the first Deputy Assistant Secretary for Women’s Health. She is also a Senior Fellow in Health Policy at New America and a Clinical Professor at Tufts and Georgetown University Schools of Medicine. Dr. Blumenthal served for more than 20 years in senior health leadership positions in the Federal government in the Administrations of four U.S. Presidents. She has been involved in the fight to end HIV/AIDS since the beginning of the epidemic. Admiral Blumenthal has received numerous awards including honorary doctorates and been decorated with the highest medals of the US Public Health Service for her significant contributions to advancing health in America and worldwide.
Samuel Cai is a junior at Brown University studying Economics and International Relations and served as an intern at New America in Washington DC.