The Need for Culturally Appropriate, Gender-Specific Global HIV Prevention Efforts with Vulnerable Women

More than 25 years into the HIV/AIDS epidemic, women are rapidly becoming the face of the pandemic. An estimated 15.4 million women aged 15 or older are living with HIV—approximately 46% of the global total of people infected with HIV (UNAIDS, 2007). Women in Sub-Saharan Africa are among the most affected by HIV/AIDS, representing 61% of infections among adults in this region (UNAIDS, 2007). Furthermore, it is estimated that 75% of all women living with HIV are in Sub-Saharan Africa (UNAIDS, 2006). With approximately one in three people infected with HIV, Southern Africa continues to be the global epicenter of the epidemic (UNAIDS, 2006) and accounts for more than one third of HIV infections worldwide (UNAIDS, 2008). It is estimated that 52% of all women aged 15 or older living with HIV are in this region (UNAIDS, 2006). Throughout Sub-Saharan Africa, adolescent women, particularly orphans, are at increased risk for HIV.

Women in other parts of the world are also at increased risk of HIV infection. In Asia, for example, HIV prevalence has grown rapidly, and evidence suggests that infection rates among women are increasing more rapidly than among men. In this region, women represent between 22% and 33% of adults living with HIV/AIDS. Among young people aged 15 to 24, women comprise between 28% and 40% of people infected with HIV (UNAIDS, 2006; UNAIDS/UNFPA/UNIFEM, 2004).

In the United States, HIV/AIDS affects African Americans disproportionately. Despite representing less than 13% of the U.S. population (U.S. Census Bureau, 2000), African Americans constituted 49% of the new HIV/AIDS cases in 2005. African American women account for an increasing proportion of these cases and they are almost 23 times as likely to be diagnosed with AIDS as White women (Centers of Disease Control and Prevention, 2007).

At its core, the global HIV/AIDS crisis is one of gender inequality, with disadvantaged, underserved, and vulnerable women of childbearing age enduring the greater burden of the disease. For these women, the greatest risk for HIV infection is heterosexual contact because many lack the social and economic power to control sexual relationships with male partners. In many regions of the world, cultural expectations encourage men to have multiple sex partners, while women are expected to be abstinent or monogamous. Moreover, the culture of silence around sexual health limits women's ability to discuss safer sex practices, including condom use, with their partners. Thus, for many women, simply fulfilling their expected cultural roles places them at increased risk for infection (UNAIDS/UNFPA/UNIFEM, 2004).

Gender disparities, however, go far beyond sexual relations. In many parts of the world, women do not own property or have access to financial resources and are dependent on men for support. Because of poverty and a lack of education and job skills, many of these women are thrust into sex work as a means of survival for themselves and their families (UNAIDS, 2006). In Africa and Asia, sex workers have been found to have a higher HIV prevalence than the general population because they often engage in behaviors that put them at higher risk of infection (UNAIDS, 2006). They are also among the most marginalized and discriminated against populations in society.

The nexus of sex work, drug use, and socially constructed sexual norms often places women in harm's way. Thus, women may turn to sex work to fund their drug habits or turn to alcohol and other drug use to decrease inhibitions in order to face the challenges of sex work. Sex workers who inject drugs are at particularly high risk, as indicated by high rates of HIV and sexually transmitted infections (STIs) in countries with large populations of injecting drug users (UNAIDS, 2006).

These issues reflect the need for culturally appropriate, gender-specific interventions that address HIV risk, sexual risk, gender inequality, and victimization among women in diverse settings. However, because the nature of the HIV/AIDS epidemic differs radically in different regions of the world, prevention interventions need to be guided by prevailing regional and local conditions. Additionally, proven effective prevention services need to be accessible to the many disadvantaged and underserved women and girls around the world.

The articles in this special issue share a common theme of HIV prevention research among vulnerable women and girls, and represent study findings from countries in Southern Africa, Asia, and North America. Four of the articles focus mainly on women who engage in sex work and underscore the importance of peer involvement in interventions. Witte and colleagues highlight the importance of using formative methods to develop interventions for vulnerable women. These authors found high levels of interrelating risk factors—alcohol abuse, impaired sex, inconsistent condom use, and interpersonal violence—among sex workers in Mongolia that tend to marginalize women and place them at high risk for HIV infection. Morisky and colleagues demonstrate how an ecological intervention that incorporates community involvement (e.g., bar managers and peers) increased STI testing and HIV knowledge and condom use among Filipina female bar workers who engage in commercial sex work. Surratt and Inciardi report on the effectiveness of a tailored HIV risk-reduction intervention delivered by peers in reducing drug use, sexual risk behaviors, and violent victimization among drug-involved sex workers in Miami, Florida. Wechsberg and colleagues provide preliminary findings on the effectiveness of an adapted evidence-based intervention in increasing condom negotiation skills and thereby condom use with main sex partners among highly vulnerable women in South Africa, most of whom, as this sample showed, engage in sex work.

Two other articles document the findings from innovative pilot interventions. Dunbar and colleagues demonstrate the opportunities and challenges in developing microcredit programs with orphans in Zimbabwe. Gilbert and colleagues highlight important implications for adapting a couple-based intervention and illustrate a possible future direction for the field, as couples interventions may help change social and cultural expectations in general and begin to reduce HIV risk associated with substance use while enhancing intimate relationships among substance-using couples.

Some of these studies will be the start of much larger efforts, while others will expand with new populations and capabilities to reach male partners. However, overall, more resources are needed to expand efforts to reach vulnerable women in all corners of the globe as HIV takes on a woman's face and is characterized by poverty and inequality. Moreover, rigorous research needs to be turned into viable practice by building community-level organizational networks and working with policy makers to better inform and change policy to improve educational and employment opportunities for women and girls, and to implement harsher legal penalties for gender-based violence. Ultimately, in addition to helping women to empower themselves with specific skills and consistent condom use, cultural traditions that are detrimental to women and girls must be challenged and governments pushed to action to engender greater equality for women.

We thank our peer reviewers for their thoughtful comments and suggestions: Sally Stevens, William Zule, Li-Tzy Wu, Shelley Francis, Michelle Kaufman, Bronwyn Myers, Jennifer Kasten, Kyla Kurian, Tracy Kline, Felicia Browne, Audrey Pettifor, and Georgiy Bobashev. We also thank Jeff Novey for all of his editorial support. This special issue was partially supported by National Institute on Alcohol Abuse and Alcoholism grant R01 AA14488 (Wechsberg) and by an RTI International Professional Development Award (Luseno).

Notes

RTI International is a trade name of Research Triangle Institute.