Critical Need to Pay Attention to HIV Prevention for Women: Minority and Young Women Bear Greatest Burden
CDC estimates that, in the United States, between 120,000 and 160,000 adult and adolescent females are living with HIV infection. In just over a decade, the proportion of all AIDS cases reported among adult and adolescent women nearly tripled, from 7% in 1985 to 22% in 1997. HIV/AIDS was the fourth leading cause of death among U.S. women aged 25-44 in 1996 (the most recent year for which complete death information is available), and the leading cause of death among African-American women in this same age group. Today, AIDS-related deaths among women are decreasing, largely as a result of recent advances in HIV treatment. However, AIDS deaths among women are not declining as rapidly as AIDS-related deaths among men.
Further, HIV data from a recent CDC study comparing HIV and AIDS diagnoses in 25 states* with integrated reporting systems showed that a substantial number of women were newly diagnosed with HIV in these states. Between 1995 and 1996, there was a 3% increase in initial HIV diagnoses among women, while HIV diagnoses declined 3% among men during this same period.
Comparing HIV to AIDS diagnoses in these states provides a clearer picture of recent shifts in the epidemic, with a larger percentage of HIV than AIDS cases diagnosed among women, especially women of color. During the period from January 1994 through June 1997, women represented just 17% of all AIDS
*Alabama, Arizona, Arkansas, Colorado, Idaho, Indiana, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Nevada, New Jersey, North Carolina, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Utah, Virginia, West Virginia, Wisconsin, Wyoming
diagnoses, but 28% of all HIV diagnoses. Young people (ages 13 to 24) also accounted for a much greater proportion of HIV than AIDS diagnoses (14% versus 3%), and nearly half of the HIV diagnoses in that age group were among young women.
Epidemic Among Women Spreading Fastest Among Minorities
Over the past decade, the epidemic has increased most dramatically among women of color. Prior to the impact of new combination drug therapies to treat HIV infection, AIDS incidence was increasing at rates of 15% to 30% each year among African-American and Hispanic women. African-American and Hispanic women together represent less than one-fourth of all U.S. women, yet they account for more than three-fourths (76%) of AIDS cases reported to date among women in our country.
Most women with AIDS were infected through heterosexual exposure to HIV, followed by injection drug use. In addition to the direct risks associated with drug use (sharing needles), drug use also is fueling the heterosexual spread of the epidemic. A large proportion of women infected heterosexually were infected through sex with an injection drug user. Reducing the toll of the epidemic among women will require efforts to combat substance abuse, in addition to reducing HIV risk behaviors.
Female adolescents and young adult women under the age of 25 are at higher risk for HIV/STD infection than older women. This increased risk is likely due to their greater tendency to have multiple sex partners, to engage in risky behaviors, or to be unable to negotiate safer sexual practices with partners.
Young and minority women are also disproportionately affected by other STDs - gonorrhea, syphilis, and chlamydia, for example - that make women at least 2-5 times more vulnerable to HIV infection. Improved STD treatment will be a critical strategy for slowing the heterosexual spread of HIV.
Building Better Prevention Programs for Women
Even if women know how to protect themselves from HIV infection, awareness of the facts must be coupled with the skills and support needed to change behavior. CDC works with states and communities to provide the information and tools needed to design and implement effective local prevention programs for women. To guide prevention activities, CDC works to provide the best available science in the areas of monitoring the epidemic, conducting and disseminating the findings from research, and evaluating what works. As part of this process, CDC conducts an ongoing research synthesis process that seeks to identify the most recent and relevant scientific findings from around the world, both published and unpublished, and make them available to prevention program planners. CDC constantly combs the scientific literature, reviews domestic and international scientific databases, and speaks with colleagues around the world to identify effective interventions for all populations at risk, including women.
Continuing progress is needed in the following areas to slow the HIV epidemic among U.S. women:
Pay attention to prevention for women! The AIDS epidemic is far from over. Data from states that have integrated confidential HIV and AIDS case reporting show that a larger proportion of women are reported with HIV than are reported with AIDS. Scientists believe that cases of HIV infection reported among 13- to 24-year-olds are indicative of overall trends in HIV incidence (the number of new infections in a given time period, usually a year) because this age group has more recently initiated high-risk behaviors - and young women made up nearly half (44%) of HIV cases in this age group.
Implement programs that have been proven effective in changing risky behaviors among women and sustaining those changes over time, maintaining a focus on both the uninfected and infected populations of women. For example, CDC's Women and Infants Demonstration Project, a community-level behavioral intervention research project focusing on young women ages 15 to 34, most of whom are members of racial/ethnic minority populations, is designed to improve understanding of factors influencing women's behavior changes regarding condom and contraceptive use, as well as the development and delivery of interventions. Preliminary results are very promising in terms of increases in condom use among women in the treatment group compared with other communities.
Develop effective female-controlled prevention methods and disseminate them widely. More options are urgently needed for women who are unwilling or unable to negotiate condom use with a male partner. CDC researchers are working with scientists worldwide to evaluate the effectiveness of female condoms in preventing HIV, as well as to develop effective topical microbicides that can kill HIV and the pathogens that cause STDs. As with any new tools for prevention, we must not only determine effectiveness, but also evaluate people's willingness and ability to use these methods.
Increase emphasis on prevention and treatment services for young women and women of color. Many U.S. women reported with HIV or AIDS are unable to identify their risk for acquiring HIV infection, indicating that they may be unaware of their partners' risk factors.
Knowledge about preventive behaviors and awareness of the need to practice them is critical for each and every generation of young women - prevention programs should be comprehensive and should include participation by parents as well as the educational system.
Address the intersection of drug use and sexual HIV transmission. Women are at risk of acquiring HIV sexually from a partner who injects drugs and from sharing needles themselves. Additionally, women who use noninjection drugs (e.g., "crack" cocaine) are at greater risk of acquiring HIV sexually, especially if they trade sex for drugs or money.
Better integrate prevention and treatment services for women across the board, including the prevention and treatment of other STDs and substance abuse and access to antiretroviral therapy.
Make medical and behavioral solutions work together. Medical advances can't work by themselves - women first need access to them, then they need the skills and support to use them. While behavioral interventions can help uninfected women stay that way, they also can work with medical treatments to help infected women stay healthier and keep from infecting others.
Preventing HIV infection is by far the best strategy. Preventing infections saves lives, eliminates the need for complex and sometimes debilitating therapies, and saves a great deal of money that would otherwise be spent on medical treatment. But, linking women with care and prevention services as soon as possible after infection has occurred is also an important goal, both to protect their own health and that of their sex partners and children.
CDC Presentations Related to Women
"Case-Control Study of Cervical Cancer and HIV Infection in Abidjan, Côte d'Ivoire," Georgette Adjorlolo-Johnson
"New HKA-A11 HIV-1 Subtype E Cytotoxic Lymphocyte (CTL) Epitopes Identified in Studies of Thai HIV-Infected Female Sex Workers," Kyle Bond/Janet McNicholl
"Decline in Prevalence of HIV Infection and Sexually Transmitted Diseases and Increase in Condom Use Among Female Sex Workers in Abidjan, Côte d'Ivoire," Mamadou O. Diallo
"Study Drug Adherence and Tolerance Within a Randomized Clinical Trial to Evaluate a Short-Course Regimen of Zidovudine to Reduce Mother-to-Child Transmission of HIV-1 in Abidjan, Côte d'Ivoire," Ehounou Ekpini
"Adherence to Currently Prescribed Antiretroviral Therapies: Results from a Multisite Interview Project," Allyn Nakashima/Jeffrey Jones
"Randomized Placebo-Controlled Trial of Short-Course Oral ZDV to Reduce Perinatal HIV Transmission, Thailand," Nathan Shaffer
"HIV-Specific Cytotoxic T Lymphocytes (CTLs) in Thai Exposed Uninfected (EU) Female Sex Workers (FSWs) are Directed to Multiple Regions of HIV-1 Subtype E," Busarawan Sriwanthana
"Comparison of the Amount of HPV 16 DNA in Cervicovaginal Secretions of HIV-infected and Uninfected Women, Using Quantitative Competitive-Polymearase Chain Reaction (QC-PCR)," Tom Wright/Tedd Ellerbrock
"RNA and DNA PCR for Early Diagnosis of Infants Born to HIV-Infected Mothers, Thailand," Nancy Young
"Consistency of Condom Use for Disease Prevention Among Unmarried Sexually Active Women - Data from a National (U.S.) Survey of Reproductive Age Women," Robert M. Brackbill
"U.S. Women at Risk of HIV/STD: Who Wants and Who Uses Female Condoms," Rebecca Cabral
"The Effect of Theory-Based HIV Prevention Intervention on Condom Use with Main Partners in Samples of U.S. Women," Rebecca Cabral
"Clinical Outcome and Survival Associated with Perinatal HIV-1 Subtype E, Bangkok, Thailand," Kulkanya Chokephaibulkit
"Safety, Tolerance and Adherence of Late Oral ZDV to Reduce Perinatal HIV Transmission, Bangkok," Rutt Chuachoowong
"Local HIV-1 Expression in the Female Genital Tract Following Treatment of Cervical Intraepithelial Neoplasia," Tedd Ellerbrock
"Active Production of HIV-1 in the Female Genital Tract," Tedd Ellerbrock
"Humoral Immune Response to Human Papillomavirus (HPV) 16 an 18 in Serum and Cervicovaginal Secretions of HIV-infected and Uninfected Women," Tedd Ellerbrock
"Presence of Anti-HIV Antibodies in Cervicovaginal Fluid of HIV-Seronegative Female Sex Workers in Abidjan, Côte d'Ivoire," Peter D. Ghys
"Cytomegalovirus and Herpes Simplex Virus are Not Associated with Acute Pelvic Inflammatory Disease in HIV-infected Women," Kathleen Irwin
"Prevalence of HIV and Syphilis Infections Among Pregnant Women Attending Urban Antenatal Clinics in Côte d'Ivoire," Sidibé Kassim
"Oral Sex and Barrier Use Among HIV Infected and At-Risk Uninfected Women Reporting Recent Sexual Contact with a Woman," Meaghan Kennedy/Jan Moore
"Declining Seroprevalence of HIV-1 Among Childbearing Women in Upper Northern Ireland," Peter Kilmarx
"Leaving Sex Work: Work History in a Cohort of Female Sex Workers in Northern Thailand," Peter Kilmarx
"Immune Activation Markers and Chemokine Receptor 5 (CCR5) Genotype in Highly Exposed But Persistently Seronegative Female Sex Workers in Abidjan, Côte d'Ivoire," Stephania Koblavi-Deme
"Female Sex Workers in Abidjan, Côte d'Ivoire: Determinants of Entry into Sex Work and Perspectives for Leaving," Yao Konan
"Adequacy of Prenatal Care and Perinatal Zidovudine Use to Prevent HIV Transmission," Amy Lansky/Jeffrey Jones
"Disease Progression and Mortality Among HIV-Infected Female Sex Workers in Upper Northern Thailand," Khanchit Limpakarnjanarat
"Trends in Condom Use Between 1991 and 1997 and Obstacles to 100% Condom Use in Female Sex Workers (FSWs) in Abidjan, Côte d'Ivoire," G Mah-bi
"Partner Violence and Women's Decision to have an HIV Test," Julie Maher/Mary Louise Kamb
"Patterns of Condom Use Reported by HIV Infected and At-Risk Women at Three Time Periods," Jan Moore
"Barriers to Condom Use Identified by HIV Infected and At-Risk Women," Jan Moore
"Changes in Plasma Viral Load Related to Short-Course Oral Zidovudine (ZDV) During Late Pregnancy," Anuvat Roongpisuthipong
"Negative Partner Reactions and Sex Roles: Influences on Male Condom Use," Janet Saul/Jan Moore
"Cord Blood ZDV Concentration After Intermittent Oral Administration During Labor, Thailand," Wimol Siriwasin
"Utility of Single or Dual Rapid Tests in the Detection of HIV in Pregnant Women, Kenya," Richard Steketee
"HIV and Malaria Overlap and Do Interact in Sub-Saharan African Pregnant Women," Richard Steketee
"Perceptions of HIV Transmission Risk Among Regular Partners and Prospects for the Evaluation and Use of Vaginal Microbicides in Northern Thailand," Shambavi Subbarao
"HIV Infection and Risk Behavior Among Urban Female Sex Workers: Missed Opportunities for Intervention," Jennifer Von Bargen/Robert Janssen
"Where do Female Sex Workers Go for Sexual Health Care? A Study from Abidjan, Côte d'Ivoire," Beatrice Vuylsteke
"Prevention of Perinatal Transmission on the U.S.: A Population-Based Evaluation of Prevention Efforts