Women’s Vulnerability and Risk

The number of women living with HIV/AIDS has been steadily increasing over the past decade. AIDS now ranks as one of the leading causes of death for women between the ages of 20 and 40 in parts of Europe, Sub-Saharan Africa, and North America. In Sub-Saharan Africa, rates among women have now surpassed those among men: women now account for 55% of all infections, and rates of infection among pregnant women are extremely high in many countries. Women are vulnerable to infection for biological, social, and economic reasons.

Biologically, the risk for transmission from male to female is greater than from female to male for several reasons. These include:

• There is a greater exposed surface area in the female genital tract than in the male genital tract.
• There are higher concentrations of HIV in semen than in vaginal fluids.
• There is a larger amount of semen exchanged during intercourse than vaginal fluids.
• Coercive or forced sex might lead to microlesions in the genital tract that facilitate entry of the virus.
• Traditional practices, such as female genital cutting, can expose women to risk if the cutting instruments are not properly cleaned.
• Women often have STIs that are left untreated, which increases vulnerability to HIV.

All over the world, social factors stemming from gender inequalities also make women particularly vulnerable to HIV infection caused not by their own behavior, but by that of their partner. These factors include:

• Women are often expected to remain monogamous, yet being married often places them at high risk for infection (because men are not often expected to be monogamous, and in some cases, are even encouraged to have multiple partners).
• Women lack the social power to reduce their risk for infection.
• The threat of physical violence, the fear of abandonment, or the loss of economic support can act as significant barriers for women to negotiating condom use, discussing fidelity with their partners, or leaving relationships they perceive to be risky.
• Cultural norms often deny women knowledge of sexual health.
• When women possess knowledge of sexual health, it is often considered inappropriate for them to reveal this knowledge, which makes partner communication about risk and safety impossible.
• Women often have little control over their bodies and little decision making power; men make most decisions about when, where, and how to have sex.
• Social pressure to bear children may also affect women’s choice concerning the relative importance of pregnancy versus protection from disease.
• Women are at greater risk than men for rape, sexual coercion, or being forced into sex work or sexual slavery.

Lack of economic power can also lead to vulnerability for several reasons, including:

• Some women are forced to enter into sex work and/or multiple or temporary partnerships in hopes of bartering sex for economic gain or survival, including food, shelter, and safety.
• Many women are at risk simply because they are economically dependent on their husbands for survival and support, which limits their decision-making and negotiating power.
• Sex workers in general are at an extremely high risk for infection, particularly when they do not have the ability to negotiate with clients who refuse to wear a condom or when they are in settings where commercial sex work is illegal.

Risks for Men

A variety of social factors also put men at risk for infection. Socially ingrained concepts of masculinity and common attitudes and behaviors can translate into risk behaviors that threaten men’s health and the health of their partners.

For example, cultural norms of “masculinity” that expect men to be experienced and knowledgeable about sex may place them at risk (especially young men) because they are less likely to seek information about risk reduction for fear of admitting a lack of knowledge. Attitudes about masculinity encourage men to demonstrate sexual prowess by having multiple partners and by consuming alcohol or other substances that may contribute to risk-taking behavior. Men are often socialized to be self-reliant, to not show emotion, and to not seek assistance in times of need or stress—ideas that do not support men in protective or health-seeking behaviors. Men are also more likely to use injection drugs.

In many cultures, communities deny the existence of men who have sex with other men, which results in a lack of prevention, care, and health information directed to men who may be at risk. Discrimination and stigmatization against men who have sex with other men contribute to denial and secrecy, making it difficult to reach these men with HIV prevention interventions.

To safeguard men’s health and the health of their female partners and their children, health care services and providers must address the relationship between men’s behavior and HIV transmission, to encourage men and boys to make a strong commitment to preventing the spread of the infection, and to promote programs that respond to the needs of both men and women.

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