The discussion around HIV and AIDS in the United States typically focuses on men. After all, African-American men and men who have sex with men are the two highest–risk groups in this country.1 But women, particularly African-American women, have their own unique risks for infection and, once infected, are significantly less likely than men to enter treatment, receive antiretroviral therapy (ART), and be virally suppressed.1-3
One example is a recently published study evaluating outcomes of HIV-infected individuals released from jail, a third of whom were women. The researchers found that by six months after release, just half of the women were retained in HIV care (versus 63% of men); 39% had received a prescription for ART (versus 58% of men), and just 28% demonstrated adherence to ART, defined by viral suppression, compared to 44% of men. 3
These disparities are not just between women and men; but between white women and women of color. A 2013 report from the Centers for Disease Control and Prevention (CDC) found that black women in the United States are 20 times more likely than white women to become infected with HIV, and twice as likely to die with AIDS.1
Recently, several review articles and editorials have been asking the question: “What’s going on?” And, more importantly, how can we improve preventive efforts among all women, particularly black women?2,4-6
Understanding the Risk
Numerous biological, social, and gender-related issues contribute to the high risk for HIV infection among women, particularly African-American women. Biologically, it appears that women’s reproductive tracts are simply more hospitable to the virus, increasing susceptibility to infection. This is due to a confluence of factors, including inflammation related to irritation or infection, inflammatory cytokines with HIV-enhancing factors, and changes in the acidity of the reproductive biome.4
Other reasons include partner characteristics such as circumcision status and HIV viral load, the presence of other sexually transmitted infections, anal intercourse (which appears to be increasing in prevalence), prostitution (often triggered by economic circumstance), and multiple partners.4,7 Other research finds that many women feel they have limited control over their partner’s use of condoms, and are less assertive in ensuring their own protection.8
Women may also be less likely to recognize the threat of HIV. As CDC researchers wrote in a 2004 report on best practices for prevention: ““For many low-income women, child care, nutrition, and safety are more important than HIV testing.”9
The social circumstances of women also play a role, said Adaora Adimora MD, professor of medicine at the University of North Carolina School of Medicine in Chapel Hill. For instance, African American women are far more likely to be the victims of domestic violence, to live in poverty, and to encounter gender inequality and discrimination, all of which increases the likelihood that they will find themselves in high-risk situations or engage in behaviors that put them at risk for HIV infection.10-12 Other factors include lack of access to medical care and health insurance, financial dependence on their partners, and the high proportion of HIV-infected men in their social sphere.2
“The combination of poverty, discrimination, which is often racial, economic discrimination, and gender inequality really does structure women’s risk for HIV and puts them in harm's way,” she said.
Addressing the Problem
To date, most interventions targeting women occur in sexually transmitted infection clinics or other medical settings, not in a “real world” setting or by utilizing women’s social networks.13 Yet a pilot study of just such an approach found it could be quite effective in improving knowledge and reducing risky behavior.
The study evaluated the impact of The Girlfriends Project, a community-based intervention that uses a Tupperware party to educate and empower black women about HIV and risk reduction, as well as to provide on-site testing. Women receive financial incentives to host parties in their homes for friends and families. During the two-hour party, trained facilitators provide rapid testing, information about risk reduction, referrals for addiction and domestic violence, and support for empowered sexual decision-making.13
A study evaluating the results of 29 parties, which included 61 women who attended the HIV-information parties and 88 who attended control-group parties, found that 87% of women who attended parties where HIV testing was available were tested (92% in the intervention group; 78% in the control group), and all returned for their results (none was HIV positive). The researchers also found that women in the intervention group demonstrated significant improvements in their knowledge of HIV, use of condoms, and the number of conversations they had with their partners about risk and risk reduction compared to the control group.
Individual approaches to addressing these issues help but aren’t enough, notes Dr. Adimora. “We’re so busy looking only at individual-level interventions that we don’t take into account the social forces that affect health.” The Affordable Care Act represents one such societal approach, she said, also called a “structural intervention,” because it removes cost as a barrier to care.
1. Centers for Disease Control and Prevention. Diagnoses of HIV Infection in the United States and Dependent Areas, 2011 (2013)
2. Hodder SL, Justman J, Haley DF, et al. Challenges of a hidden epidemic: HIV prevention among women in the United States. J Acquir Immune Defic Syndr. (2010) 55 Suppl 2:S69-73.
3. Meyer JP, Zelenev A, Wickersham JA, et al. Gender Disparities in HIV Treatment Outcomes Following Release From Jail: Results From a Multicenter Study. Am J Public Health (2014) 104:434-441.
4. Adimora AA, Ramirez C, Auerbach JD, et al. Preventing HIV infection in women. J Acquir Immune Defic Syndr. (2013) 63 Suppl 2:S168-173.
5. Ivy W, 3rd, Miles I, Le B, et al. Correlates of HIV Infection Among African American Women from 20 Cities in the United States. AIDS Behav. (2013) Epub ahead of print. DOI 10.1007/s10461-013-0614-x
6. Demoss M, Bonney L, Grant J, et al. Perspectives of middle-aged African-American women in the Deep South on antiretroviral therapy adherence. AIDS Care. (2014) 26:532-537.
7. Satterwhite CL, Kamb ML, Metcalf C, et al. Changes in sexual behavior and STD prevalence among heterosexual STD clinic attendees: 1993-1995 versus 1999-2000. Sex Transm Dis. 2007;34(10):815-819.
8. Carmona JV, Robero GJ, Loeb TB. The impact of HIV status and acculturation on Latinas’ sexual risk taking. Cultural Diversity and Ethnic Minority Psychology. Cultural Diversity and Ethnic Monthly Psychology. 1999;5(3):209-221.
9. Centers for Disease Control and Prevention. Best Practices in Prevention Services for Persons Living with HIV, December 2004.
10. Sharpe TT, Voute C, Rose MA, et al. Social determinants of HIV/AIDS and sexually transmitted diseases among black women: implications for health equity. Journal of women's health. (2012) 21:249-254.
11. Cene CW, Akers AY, Lloyd SW, et al. Understanding social capital and HIV risk in rural African American communities. J Gen Intern Med. 2011;26(7):737-744.
12. Cargill VA. Linkage, engagement, and retention in HIV care among vulnerable populations: "I"m sick and tired of being sick and tired". Topics in antiviral medicine. 2013;21(4):133-137.
13. Hawk M. The Girlfriends Project: Results of a pilot study assessing feasibility of an HIV testing and risk reduction intervention developed, implemented, and evaluated in community settings. AIDS Educ Prev. 2013;25(6):519-534.
14. Baird SJ, Garfein RS, McIntosh CT, et al. Effect of a cash transfer programme for schooling on prevalence of HIV and herpes simplex type 2 in Malawi: a cluster randomised trial. Lancet. 2012;379(9823):1320-1329.