1. “AIDS has a woman’s face”
In Sub-Saharan Africa, nearly 60% of people living with HIV/AIDS are women
Teenage girls in parts of Africa and the Caribbean are five times more likely to have HIV than their male peers
AIDS is the leading cause of death among African-American women aged 25-34
Over half (54.%) of all women between are HIV positive in Botswana
Without “drastically expanded” prevention efforts, 45 million more people will become HIV infected by 2010
Carol Bellamy, a United Nations spokeswoman, first used this phrase -- “AIDS has a woman’s face” -- in That was the first year in which at least half of the all the people living with HIV and AIDS worldwide were women and girls.
In wealthier countries, men still make up the majority of the HIV infected population. But that’s not true in poorer countries. And the worldwide balance is shifting. In 2003, half of all the the people newly infected with HIV in 2003 were women. This gender shift is occurring most rapidly among younger people. Young women and girls make up two thirds of the people under 24 who are living with HIV. As you see, in some countries teenage girls are five times more likely to have HIV that boys the same age.
Even in a wealthy country like the US, AIDS is the leading killer of young African American women between 25 and 34. Across the world in Botswana, women’s risk is so high that over half of all Botswanan women in their late 20s are HIV infected. Imagine what it would be like to live in a community in which half of your peers were facing AIDS!
Women are at higher risk of becoming HIV infected than men for a wide variety of reasons. We will talk about some of those reasons – the factors that help explain the tragic numbers we see here.
Why is this happening? How do we get to the “drastically expanded” prevention efforts that the UN says are required to keep the pandemic from doubling by 2010?

2. How women are at risk: Biology: Economics: Cultural:
Semen=more HIV than vaginal secretions
Larger mucosal surface exposed
Young bodies are not fully matured
Economics:
Financial dependence. Many women cannot afford to leave risky partners.
Cultural:
infidelity accepted for men, not women
violence, ignorance about sex and gender inequality make condom negotiation difficult -- if not impossible
Why are women at higher risk of HIV infection than men? The answer is part biology, part economics and part culture.
Biologically, women are more vulnerable because semen carries more HIV than vaginal secretions do. The folds of the vaginal lining give the virus a large mucosal surface to attack. It also has a longer survival time inside the vagina to do its work. If a man has sex with an HIV positive woman, any virus on the surface of his penis will die when he pulls out and it is exposed to air. Bur women don’t have that advantage.
Girls and young women are particularly at risk because immature vaginal lining is easily damaged, giving the virus an even faster route into the woman’s bloodstream.
Economics are a factor in women’s risk because financially dependency makes it difficult -- if not impossible -- to say no to unprotected sex. In many places, women get less access than men to education, job opportunities, property and credit. Many are not able to support themselves and their children without the help of a husband or boyfriend. Without enough education and employment opportunities – a woman may not be able to leave her male partner, even if he is putting her at risk of HIV.
Culture is a risk when it requires women to be subservient. Many societies expect women to be passive and ignorant when it comes to sex, giving their men control over when and how sex happens. Any deviation from that norm may be punished by violence or the threat of violence or abandonment. Even monogamy will not protect a woman in societies where infidelity among men is permitted, even expected. The typical woman who gets infected with HIV has only one partner – her husband or steady boyfriend.

3. Domestic violence raises the level of HIV risk:
Rape likely to cause genital bleeding, condom use unlikely
Abuse limits negotiation of any kind of safety – including safer sex
Childhood abuse may lead to riskier sexual behavior in adulthood
Disclosing HIV status can trigger domestic violence
Since women are more susceptible to HIV infection than men overall, it’s not surprising that women dealing with violence in their lives are at the highest risk of all. And, as we’ve seen, risk can be increased at several levels simultaneously.
At the purely physical level, we know that domestic violence often includes rape and sexual abuse. Obviously, the batterer is not likely to agree to a condom in a forced sex situation. The woman’s risk of becoming HIV infected is also increased if the rape causes bleeding or tears her skin internally or externally – since those injuries make it easier for the virus to get into the blood stream.
The psychological impact of violence can also increase HIV risk. Research has shown, for example, that people who lived through childhood sexual abuse may engage in more high-risk sexual behaviors and may be less able to refuse sexually aggressive partners that those who weren’t abused. This pattern further contributes to the linkage between abuse and HIV risk.
Finally, we know that people who have HIV may be at risk of domestic violence or abandonment when they disclose their HIV status, adding yet another layer of connection between HIV and violence.
Abuse is all about power and control. A big part of staying safe is maintaining control over one’s own risk level. In abusive relationships where people are being controlled by their partners, it’s almost inevitable that risks like violence and infection will be higher.

4. The link is there….
HIV+ women up to 3 times more likely to have a violent partner currently than HIV- women
HIV+ women under 30 ten times more likely to be living with violence than HIV- peers (Tanzania, Maman, 2001)
Abusive men more likely to have sex outside relationship and contract STD
(India, Martin et al, 1999)
Women with violent partners have 50% higher odds of being HIV positive
(South Africa, Jewkes et al, 2004)
Research tracks the link between domestic violence and HIV risk in study populations.
Social researchers Suzanne Maman and her team measured the prevalence of violence in the lives of 340 women attending a HIV counseling and testing clinic in Tanzania. They found that the odds of experiencing physical or sexual violence, or both, from a current current partner were almost three times higher for the women testing HIV positive than for the women who were negative. Among women under 30, the odds of being in a violent relationship were ten times higher among HIV positive women.
In India, researchers interviewed over 6000 men about physically and sexually abusive behaviors. The men who reported engaging in abusive behavior were also those who most frequently reported extramarital sex and symptoms of sexually transmitted diseases. This gives us another piece of the picture of the HIV risk faced by abused women.
And in a South African study, the odds of a woman in a violent relationship being HIV positive were 50% higher than the odds for women who weren’t in violent partnerships.
The central themes here are similar and they apply to women all across the world. The research shows that the impact of domestic violence on HIV risk takes 3 general routes:
direct impact – because violence makes it hard, often impossible, for women to
insist on condoms
- indirect impact – because a woman’s life history with violence, including
childhood abuse, may increase her own risk-taking behavior
- and through her partner’s other behavior, since men who are violent also tend
have a higher probability of being HIV positive through their own risky activity.

5. What do we do?
Make sure domestic violence services address sexual abuse and HIV needs
Make sure HIV-related services address violence issues (current and history)
Help women protect themselves by assuring
Education, economic opportunity, support and targeted social services for themselves and their children
Gender equality and legal protection of their civil rights to safety, jobs and health care
HIV/STD prevention methods they control, such as Microbicides…
So we see that women who are coping with violence are also women at increased risk of HIV infection -- or perhaps living with HIV already. Surprisingly, this overlap isn’t always discussed in the social service agencies reaching out to these women. Many AIDS service organizations don’t routinely ask the women they serve if they are dealing with abuse in their lives or have a history of abuse. But it’s really important to do this, and to have counselors on staff who are skilled in this area, to deal effectively with the trauma that such questions may reveal and help the woman get access to the specific services she may need.
Similarly, domestic violence service providers may not think to ask whether a woman is experiencing sexual violence in addition to other forms of abuse – and whether she wants to get HIV testing as part of her physical care. They may not think to talk about her sexual risk when they discuss other safety planning issues. But the need is often there.
I think we’d all agree that there is no magic solution. Complicated, entrenched social factors make up the whole framework of gender inequality – less education, less access to good paying jobs, lack of adequate legal protection from abuse and rape, lack of access to health care. All these contribute to making women more vulnerability to both violence and infection. All these need to change and the work that many of you are doing is helping to bring about the big social changes that must happen.
But I’d like to move now to talking about one particular kind of help that may be available in the near future. One of the many things women need is a way to protect themselves during sex without having to ask a man to use a condom. Women need microbicides.