Prevention for Women

What Works

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In 2008, more than one million people living with HIV had initiated antiretroviral treatment yet another 2.7 million individuals became HIV-positive (Sepulveda, 2008). More than half of new infections were among women, with the largest proportion among young women. If the HIV pandemic is to be contained, primary prevention efforts for women and men based on scientifically-derived evidence must accompany rapid expansion of antiretroviral treatment (Stover et al., 2007).

Unfortunately, “HIV prevention is neither simple nor simplistic. We must achieve radical behavioural changes—both between individuals and across large groups of at-risk people—to reduce incidence” (Coates et al., 2008:  670).  Prevention efforts need to be tailored to the epidemiologic and socio-cultural realities of each country and region, and the specific needs women face.  Behavior change (e.g. condom use, partner reduction, use of clean needles) needs to be promoted through a variety of means, including structural changes, such as changes in legal and gender norms, and promoting girl’s education and employment opportunities. [See Chapter 11. Strengthening the Enabling Environment] In some countries in sub-Saharan Africa, where 10–30% of the population is living with HIV, everyone must understand the widespread risk for HIV transmission and general interventions for women may be warranted. In other countries, specific key populations of women have much higher levels of HIV prevalence and need to be the focus of prevention efforts. [See Chapter 4. Prevention for Key Affected Populations]

Sexual behaviors and the sharing of injection equipment that cause most HIV infections worldwide occur due to a variety of motivations (e.g., reproduction, desire, peer pressure, desire to please, access to material goods, gender norms, coercion, etc.).  Epidemiological studies have shown that multi-partner sex, paid sex and STIs are important risk factors in the AIDS pandemic, no matter what stage of the epidemic (Chen et al., 2007b). Sustaining behavioral change among individuals, couples, families, peer groups, networks, institutions and/or communities is no easy task, but can occur through educational, motivational, peer-group, skills-building or community normative approaches (Coates et al., 2008).

“A quarter of a century of AIDS responses has created a huge body of knowledge about HIV transmission and how to prevent it, yet every day, around the world, nearly 7,000 people become infected with the virus…with no vaccine in sight and the number of new infections outpacing the progress in access to treatment, we clearly need to take a long-term view in planning our actions…Prevention work takes the longest time, is largely outside of health services, and has no ‘quick win.’ If not tackled, prevention work will also continue to undermine all the other gains” (Piot et al., 2008: 845, 855, 857).

Prevention Efforts Can Succeed

Prevention successes among women and men have been reported in Cambodia, Kenya, Zambia, Zimbabwe, India and Haiti. In these countries sizable shifts in behavior have occurred, through a combination of government leadership and community activism (Global HIV Prevention Working Group, 2007). In Zambia, among women younger than age 17, HIV seroprevalence declined from 12% in 2002 to 7.7% in 2006 (Stringer et al., 2008). In Kenya, adult prevalence has declined from 10% in the late 1990s to less than 7% by 2004 (Cheluget et al., 2006). Thailand and Uganda reduced rates of HIV infection. Senegal averted an epidemic. Brazil, Côte d'Ivoire, Malawi, Tanzania, Zimbabwe have all reported decreases in HIV transmission related to changes in sexual behavior, as has rural parts of Botswana, Burkina Faso, Namibia and Swaziland and urban parts of Burundi and Rwanda (Kippaz and Race, 2003; Stoneburner and Low-Beer, 2004; UNAIDS, 2001 cited in Coates et al., 2008). Prevalence decreased from 15% in 1995 to 11% in 2002 in Côte d'Ivoire (Msellati et al., 2006). As of 2008, Namibia has increased HIV prevention skills in 79% of secondary schools; as a result, sex before the age of 15 years and the percentage of people reporting multiple partners has dropped (UNAIDS, 2008 cited in Coates et al., 2008).[3]

Special Risks for Women

Still, despite the many documented successes of prevention programs, in 2007 fewer than 10% of individuals at risk worldwide received key prevention services (Merson et al., 2008). Those that do receive prevention services are not always the only appropriate target. “When HIV programmes largely focus on sex work, drug use and male-to-male-sex, it contributes to low HIV risk perceptions in the general population. Intimate partners are often left out and there is [a] lack of couple communication about sexual matters” (UNAIDS, 2009e: 15). There is also lack of communication about related matters, such as alcohol use, which is associated with risky sex.  A review of 73 articles representing research conducted in 19 different sub-Saharan countries published between 1992 and 2007 found that HIV seropositivity and high-risk sexual behavior was correlated with alcohol use (Woolf and Maisto, 2008). Alcohol use inhibits judgment and can lead to unprotected sex and violence.  A survey of 3,073 people in Tanzania found that lifetime alcohol users and those who reported intoxication in the past months had greater odds of having recent unprotected sex (Kilonzo et al., 2008b) and a study of 12 focus group discussions in rural Uganda in 2002 found that both men and women viewed men’s alcohol use as related to rape; agreeing with the assumption that women who accept alcohol from men will agree to have sex (Wolff et al., 2006).

Rape survivors need timely access to post-exposure prophylaxis (PEP), as do health providers who have an occupational exposure. Despite the absence of a randomized clinical trial on efficacy of PEP, there is significant evidence from animal transmission models, perinatal HIV transmission studies, observational studies, studies of PEP in health care workers, and meta-analysis indicating that PEP is effective in reducing HIV transmission (CDC, 1998; Bell, 1997; Young et al., 2007 cited in Siika et al., 2009). Although the efficacy of post-rape antiretroviral prophylaxis has not been determined, zidovudine reduces the transmission of HIV after needle stick injury by 81% (Cardo et al., 1997; Petra Study Team, 2002 cited in Carries et al., 2007). “As such, there is current consensus that HIV prophylaxis should be provided immediately after an exposure where there is judged to be risk of HIV acquisition” (Siika et al., 2009: 48). [See also Chapter 11B. Strengthening the Enabling Environment: Addressing Violence Against Women]

More prevention interventions are needed on a universal level so that everyone—including married women, for example, who may not realize their level of risk—can communicate with their partners and protect themselves. 

What Works in Prevention for Women

A number of prevention strategies already work to help women prevent HIV. These include male and female condom use, partner reduction, and seeking treatment for sexually transmitted infections.  In addition, male circumcision works for men and will likely, in the long run, also protect women.  Each of these areas has substantial evidence to justify their use and a number of promising strategies to help women protect themselves from HIV. While partner reduction can potentially have the greatest impact, less evidence exists for how people can be encouraged to reduce the numbers of concurrent sexual partners, both as adults and adolescents. Each of these topics is discussed in more depth in sections A–D of this chapter.  Preventions efforts must be informed by “what works to support women and girls,” particularly to strengthen the enabling environment by transforming gender and legal norms; addressing violence against women, legal capacity, inheritance and property rights; increasing opportunities for employment and income, reducing stigma and discrimination, and promoting women’s leadership. [See Chapter 11. Strengthening the Enabling Environment] Women have multiple types of sexual partnerships: some women have only one sexual partner but are still at high risk for HIV acquisition from their sexual partner; some women have multiple sexual partnerships to survive economically [See Chapter 4. Prevention for Key Affected Populations]; some women are young and are engaged in cross-generational sex, placing them at high risk [See Chapter 5. Prevention for Young People and Chapter 12B. Care and Support: Orphans and Vulnerable Children]. HIV prevention efforts will need to be tailored to a wide spectrum of risks for women. Women, themselves, have been leaders in HIV prevention efforts and creating awareness of the epidemic both at grassroots community levels as well as at the highest levels of government in fighting for prevention efforts to meet their varied needs.  These efforts must be encouraged and promoted.

Some Women Are Overlooked in Prevention Programming

Older women and women with disabilities also need attention in HIV prevention programming but are often neglected. Additional research is necessary to discern the major risks facing these women and to evaluate interventions addressing those risks. 

Women Over the Age of 50

Women past the age of childbearing are often ignored in HIV prevention (Conde et al., 2009). HIV prevention and education efforts are needed for people over the age of 50. A WHO review of HIV in developing countries found that “sexual activity of older individuals in the developing world is barely researched. Many older individuals everywhere are sexually active” (Schmid et al., 2009: 162).  A study in hospital of 706 cataract surgery patients over age 50 in Ethiopia found an HIV seroprevalence rate of 5% (35 out of 706) (Kassu et al., 2004). A review of medical records at a health center in Kampala, Uganda found 45 clients over the age of fifty who were HIV-positive, over half of whom were women. Condom use was low and many had multiple partners and low levels of treatment literacy (Nabaggala, 2008). In Brazil, 51,255 AIDS cases reported from 1982 to 2006, 2,668 were 50 or older. The proportion of patients age 50 or older has steadily increased from 11% in 2000 to 15% in 2005. Of the 1,686 aged 50 or older from 2000 to 2006, 37% were women (Sanches and Guillen, 2008). “Elderly grandmothers…appear to be forgotten in terms of their need for HIV/AIDS prevention information and education” (Sepulveda et al., 2007). Due to ARV therapy, more HIV-positive women are reaching menopause. Interventions for post-menopausal HIV-negative women, such as evaluation of cardiovascular risk, osteoporosis, etc. are also believed to benefit women living with HIV (Conde et al., 2009).

Women With Disabilities

Women with disabilities are also at risk for HIV but are often overlooked in HIV prevention strategies. A study in South Africa interviewed twenty-five people with disabilities and caregivers, and found that people with disabilities are “abused through sexual purification rituals, sexual exploitation and have less access to prevention and treatment” due to cultural misconceptions surrounding disability (Hanass-Hancock, 2008).  Those with disabilities also experience stigma and a lack of recognition of their sexual activity.

Interventions are needed to integrate HIV/AIDS prevention and services with disability and mental health services.  The Brazilian National AIDS Program launched a national campaign (year not specified) to integrate STI/AIDS services with disabilities care and found that it was difficult to dispel misconceptions about sexuality and behavior of people with disabilities. The program also found a lack of accessible information for people with disabilities and cultural and sexual practices involving people with disabilities need to be considered in order to improve HIV/AIDS prevention efforts (Drummond Cordeiro et al., 2008).

A program in Uganda (year not specified) integrated women with disabilities into HIV/AIDS services by combining the efforts of AIDS Services Organizations and Disabled Peoples Organizations to remove barriers of physical access and stigma. The program found that Disabled Peoples Organizations and AIDS Services Organizations wanted to integrate services but lacked capacity, funding or acknowledgment. They also discovered that explicit effort to connect women with disabilities to AIDS services resulted in reducing stigma of both groups and increasing the quantity of people accessing AIDS services (Tataryn and Shome, 2008).

Services specifically for disabled populations are more likely to be used than general services.  For example, a 2003-2007 study in Kenya that provided deaf mobile VCT services indicated that deaf clients were more likely to access deaf mobile VCT services than regular VCT services.  In Kenya, it is estimated that more than 3 million people are deaf, with higher rates of HIV.  Deaf mobile VCT services use trained deaf personnel to provide counseling. 2,098 deaf clients accessed deaf mobile VCT services as compared to 1,536 deaf clients accessing regular VCT services (Sati, 2008).

Little evidence is available regarding what works specifically for women over the age of fifty and disabled women and much more research is necessary. 

Critical Prevention Approaches Under Development

A number of biomedical prevention technologies are currently in clinical trials to assess their safety and effectiveness. These include vaccines, microbicides and the use of ART as prophylaxis.  Once these are shown in clinical trials to be safe and effective, they can be optimized to impact the epidemic. Vaccines, microbicides and other female-controlled technologies represent a large gap in primary prevention for women.  Further progress in these areas is urgently needed. For updates on biomedical HIV prevention research, please refer to: www.avac.org.

Vaccines

While recent trials have been promising, an HIV vaccine is yet to be developed.  A vaccine can have special benefits for women. An effective vaccine would provide women autonomy to protect themselves against HIV acquisition. A recent trial of an HIV vaccine with 16,402 healthy men and women ages 18 to 30 in Thailand found a vaccine efficacy of 31.2 percent, a modest efficacy, with less HIV acquisition among women than men among those on the vaccine as compared to placebo. The vaccine efficacy may have been greater in persons at lower risk of HIV acquisition.” …After the exclusion of the subjects who were infected with HIV-1 before vaccination, the modified intention-to-treat analysis showed a significant, though modest, reduction in the rate of HIV-1 infection, as compared with placebo” (Rerks-Ngram et al., 2009: 8-9). As some vaccine experts note, however: “It is misleading to say that a vaccine is the solution” as even once a vaccine is invented in five to ten years hence, “the AIDS epidemic will be with us for many years.” It is unlikely that the first generation of vaccines will be 100 percent effective. “We remain cautiously optimistic that a substantial increase in our understanding of HIV infection and disease will lead to creative ideas about how to design an effective vaccine” (Johnston and Fauci, 2008: 890). However, “scientists agree that with no prospect of an effective vaccine to curb the HIV/AIDS pandemic in the foreseeable future, expanding the repertoire of prevention tools is all the more important” (Stephenson, 2008: 1529).

Microbicides

Microbicides, a female-controlled technology, refer to a variety of topically applied products that holds great promise for women to be able to protect themselves from HIV, other STIs (Global Campaign for Microbicides, 2007), and unwanted pregnancy.  Where the status of women makes it difficult for women to refuse sex or negotiate condom use, microbicides would greatly improve women’s ability to protect themselves. Microbicides are being designed to be applied by the woman in her vagina so that women could use this future HIV prevention tool more autonomously. “Because the majority of new infections, certainly in Africa, occur in married women who contract the infection from their husbands’ presumed extramarital relationships, methods that allow for discreet use may be especially attractive in marital or long-term partnerships” (Mantell et al., 2008a: 97). However, in most clinical trials of microbicides, male involvement was the desired norm among female participants. Building on the experience observed in clinical trials, focusing on sexual pleasure may increase future use. Microbicides for anal use are also under development.

The first generation of microbicides is expected to be less than 100 percent effective and will ideally need to be used with a condom. However, even if used alone, a partially effective microbicide could have a significant impact on HIV incidence (assuming risk taking does not increase with the use of this method). However, in 2009, leaders in the field of HIV/AIDS noted, “….we are still many years away from either a vaccine or a microbicide to protect against HIV transmission” (Piot et al., 2009: 1). Women need access to both contraceptive and non-contraceptive microbicides, because some women will want to prevent HIV, STIs, and pregnancy, while other women will want to conceive without the risk of disease transmission.

Pre-Exposure ART

Pre-exposure prophylaxis with antiretroviral drugs is currently being studied as a prevention technique.  Delivery of pre-exposure prophylaxis with ART can be by oral ART pills, topical (vaginal or anal) formulations such as gels, films, suppositories, rings or injectable/implantable antiretrovirals. Pre-exposure prophylaxis would be delivered orally and microbicides would be delivery topically. “To date, …topical products …have not proven effective” (Mastro et al., 2008: 5). Seven human randomized, placebo controlled clinical trials of the safety and efficacy of oral ART pre-exposure are either ongoing or planning to start in 2009 (Mastro et al., 2008).   One study of daily use of pre-exposure ART in HIV-negative women did not find an association with clinical or laboratory adverse events (Peterson et al., 2007).   The implications for women of ART for prevention, including through “test and treat,” approaches, needs to be considered carefully. For example, an increased push for HIV testing could have negative implications for women. [See Chapter 6. HIV Testing and Counseling for Women and Chapter 9. Safe Motherhood and Prevention of Vertical Transmission] 

Prevention For All Women and Girls

The prevention strategies in this chapter are applicable for all women; however certain groups of women and girls have particular prevention needs. Therefore, while this chapter presents what works for generally for all women, the two following chapters (Chapter 4. Prevention for Key Affected Populations and Chapter 5. Prevention for Young People) provide additional considerations and strategies for groups such as sex workers, female drug users, women and girls in complex emergencies, young people, etc. The three chapters should be viewed together as a whole to identify what works in prevention for women. 

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[3] Attributing prevention efforts as a direct cause of HIV prevalence decline is speculative. If HIV prevention programs are implemented when HIV epidemics are at or near their peak, the subsequent decrease in prevalence might be incorrectly attributed to prevention programs (Chin and Bennett, 2007).

Strategies

• Prevention for Women
  • Male and Female Condom Use
  • Partner Reduction
  • Male Circumcision
  • Treating Sexually Transmitted Infections (STIs)
• Prevention for Key Affected Populations
• Prevention for Young People
• HIV Testing and Counseling for Women
• Treatment
• Meeting the Sexual and Reproductive Health Needs of Women Living With HIV
• Safe Motherhood and Prevention of Vertical Transmission
• Preventing, Detecting and Treating Critical Co-Infections
• Strengthening the Enabling Environment
• Care and Support
• Structuring Health Services to Meet Women’s Needs