Increased attention to the HIV epidemic globally has encouraged HIV policy advocates to look at HIV prevention efforts among women in the U.S. and to explore how they can be improved.
This article will highlight three major prevention efforts that may have a profound effect on HIV infection rates among women in the U.S.: the Microbicides Development Act (MDA); the Centers for Disease Control and Prevention's (CDC) HIV tracking system; and HIV prevention intervention strategies that integrate factors that increase vulnerability to HIV, such as poverty, domestic violence, and poor education.
AIDS Is a Women's Issue
AIDS is a women's issue here in the U.S., and certainly in New York City. It is a disease with great differences in different groups. The CDC reports that the percentage of new HIV and AIDS cases in the U.S. among women has more than tripled in the last two decades. Furthermore, rates of HIV infection differ greatly by race. A few facts:
Women of color represent the majority of new HIV cases among women, and the majority of women living with HIV.
In 2004, HIV infection was the leading cause of death for black and African-American women aged 25 to 34.
Latinas accounted for an alarming 82% of total AIDS diagnoses for women in 2005, although Hispanic men and women make up just 24% of the U.S. population.
Data from the NYC Department of Health from 2004 show that women make up 32% of new HIV diagnoses.
Females comprise a greater proportion of new HIV cases among blacks, compared with other groups, although the number of new diagnoses has declined slightly for both men and women.
The death rate in 2004 among persons with HIV or AIDS was 25% higher in females than in males.
"Gender in relation to the AIDS epidemic is huge and under- explored," says Dr. Judy Auerbach, of the San Francisco AIDS Foundation. "Our response has been very limited though it's more possible than ever to put HIV in the larger context of women's lives."
Dr. Auerbach and others attribute this new attention to the devastation of HIV among young women in sub-Saharan Africa. Women here share many of the same vulnerabilities with women across the world: poverty, violence, education, gender inequality, etc. Further, the very way we perceive risk for women has become a point of discussion.
Female-Controlled Prevention: The Microbicides Development Act
Microbicides are products currently being developed that women could apply to prevent transmission of HIV and other infections. Microbicides could come in a variety of forms, including gels, creams, or rings that would release a drug slowly over days or weeks. The impact of a microbicide (though still many years away) is far-reaching. Women's vulnerability to HIV increases in situations of poverty, abusive relationships, sexual violence, or other circumstances in which women cannot control their sexual encounters or cannot insist on abstinence, mutual monogamy, or condom use. Negotiation about safer sex can be even more difficult for young women. Development of a safe, effective microbicide holds the promise of a new HIV-prevention technology that takes into account the realities of women's lives.
"As we start to get more numbers from the CDC," says Anna Forbes of the Global Campaign for Microbicides, "we can expect that the current rates of infection among women, especially women of color, will go up. These data point very clearly and unequivocally to the need for a microbicide."
If passed, the Microbicide Development Act (MDA) will increase the U.S. government's commitment to microbicide research and development. Right now, barely 3% of the national budget for HIV research is spent on the development of microbicides. Forbes explains further: "A big part of the MDA would assure, by Congressional mandate, that microbicide research be prioritized." The legislation is deliberately simple, she adds, to increase the likelihood of passage, but also to create this priority and ensure coordination as we get closer to an actual microbicide.
The MDA would establish a dedicated unit for microbicide research and development within the National Institutes of Health (NIH). Right now, microbicide research at NIH is conducted under several institutes with no single path of accountability, no funding coordination, highly variable levels of interest and commitment, and a degree of competition. Over the last two years the CDC and the U.S. Agency of International Development (USAID) have expanded their microbicide efforts. Without the coordination required by the MDA, costly inefficiencies and duplication of effort may result.
The legislation would also authorize funding increases as needed at the CDC, NIH, and USAID for the development of microbicides. Finally, it would require coordination between NIH and other Federal agencies supporting microbicide development, including the CDC and USAID.
Risk and the HIV Surveillance System
Women's organizations and HIV coalitions across the U.S. are waging a campaign to change the CDC HIV Surveillance System to reflect more accurately the reality of the HIV epidemic and prevention needs of women in the U.S. These groups are tackling the issue of the "no identified risk" (NIR) exposure category.
Women who are unable to identify the risk behavior of their male partners or that their partners have HIV are automatically placed in the NIR category. Correctly classifying women's HIV infection risks is essential, given that the CDC's system affects funding allocation, monitors trends, aids in the development and evaluation of prevention programs, and helps identify new or emerging risk groups.
The National Women and AIDS Collective (NWAC) contends that the CDC's HIV surveillance system might be a key reason that women are unaware of, or choose not to believe, their own risk for HIV infection, thereby fueling a growing crisis of HIV and AIDS among American women. They state it is "based on an outmoded understanding of the epidemic from the early 1980s and ... has only been minimally revised once during the 1990s... As such, it does not accurately report or reflect why women are increasingly becoming infected with HIV."
NWAC reports that, among women testing HIV positive in their local and state programs, as many as 60% are classified as NIR by the CDC. And, according to the CDC, 47% of all women testing HIV positive in the U.S. are assigned to the NIR group. Providers and advocates widely acknowledge that women are contracting HIV because they believe they are in monogamous relationships with their male partners or they are unaware of their male partners' sexual history, risk behavior, or HIV status.
NWAC also reports that women are sometimes denied HIV testing because they do not fit into current risk categories. This is, in part, because testing sites often receive federal funding that allows them to target only high-risk groups as determined by the CDC. Therefore, the current approach has an impact not only on funding decisions but on testing. This ultimately has an impact on care, diagnoses of other illnesses, health outcomes, and HIV transmission.
The critiques of the CDC's surveillance system are especially relevant given the much-anticipated release of new data that are expected to reveal higher rates of HIV in the U.S. It's been estimated for several years that the number of new infections has been holding at about 40,000 each year, but the CDC has announced it may soon increase this estimate to 60,000.
NWAC and others propose updating the CDC's surveillance system so that an "acquisition" category is added to the system to capture information on factors known to elevate women's -- particularly women of color and low-income women's -- risk of HIV infection, regardless of presumed or identified behavioral risks. An acquisition category would allow the CDC to collect data on how women acquire HIV (including factors such as where one lives, prevalence of HIV, and poverty, among other things) as opposed to focusing solely on how HIV is transmitted via high-risk behavior.
Better Interventions to Stem the Epidemic Among Women
"At this point in the HIV/AIDS pandemic, there is general consensus ... that a comprehensive, multi-level approach to HIV prevention and the science that guides it is essential. This consensus comes from an understanding -- after 26 years of research and lived experience -- that HIV is a pathogen that is transmitted in the course of human relationships that take place in social and cultural contexts. This means that equal attention to biological, behavioral and social factors -- individually and in relation to each other -- is required in order to have a real impact on the spread of HIV." -- Dr. Judy Auerbach
Intervention approaches cannot be aimed solely at changing individual behavior; they must work also to change communities -- their programs, practices, laws or policies that place certain groups of people at increased risk of becoming infected. Further, these interventions must be based on science.
For instance, it is widely acknowledged that poverty and gender inequality are two core factors that shape HIV risk among women, yet there are very few HIV and economic interventions in the U.S., and few that integrate health concerns into them. Similarly, while there has been considerable work about how gender roles shape sexual negotiations and HIV risk, there has been much less on how these roles are reinforced through broader factors such as inequality and privilege.
There is, however, a growing movement to advance science-based prevention, meaning strategies that have been proven in clinical studies to reduce the transmission of HIV in specific groups. Despite scientific and political challenges, the HIV community is coming together to make the case that a multilevel approach is needed to advance the HIV prevention agenda for women and others. The San Francisco AIDS Foundation, in partnership with the Caucus for Evidence-Based Prevention, is spearheading discussions like these over the coming year.
Domestic advocates, providers, and consumers alike are eager to take advantage of a growing openness among decision makers to respond to the U.S. HIV epidemic among women, within the social and cultural contexts in which it exists and, unfortunately, continues to thrive.
As advocates, providers, and consumers our job going forward will be to mobilize communities to affect policy changes like the MDA; to advocate for public health systems that reflect the realities of women's lives; to bolster prevention research; and to bring our best thinking to bear on the structural drivers of the epidemic. It is through these efforts that we can have a deeper and more sustained impact on the HIV epidemic among women.
Kimberleigh Smith is Director of the Women's Program at GMHC.