From the time a woman is born, her biological, social, cultural and economic susceptibility to HIV is greater than a man’s, simply by virtue of gender.

The female body is more vulnerable to HIV infection because women have more mucosal tissues that may be exposed to seminal fluids during condomless sex with a male partner, and heterosexual sex is the primary way women acquire HIV.

During sex, the virus in semen can gain access to the mucosal tissues in the vagina or rectum, where it may remain for several hours. If HIV is present in bodily fluids, the virus may enter the bloodstream through tiny abrasions in the vaginal or rectal lining that occur during sexual intercourse.

What’s more, if a woman has a sexually transmitted infection (STI) or damage to the tissues that line these body parts, those areas become more vulnerable to HIV transmission. Women are affected by STIs in different ways than men and are more likely to suffer long-term harm from an STI, especially one that goes untreated. This may occur because women are less likely than men to have symptoms of common STIs such as chlamydia and gonorrhea; furthermore, symptoms of STIs such as syphilis may not be easily visible for women.

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Once a woman has contracted HIV, the virus affects her menstrual cycle. Many women living with HIV who aren’t pregnant or undergoing menopause may notice changes in the frequency, duration and amount of blood they pass or may not menstruate (amenorrhea) for more than three months. But menstrual irregularities are less common if women have a high CD4 count and are on antiretroviral (ARV) treatment.

What’s more, women with HIV are likely to experience more frequent and severe gynecologic illnesses, such as genital herpes and HPV (human papilloma virus, which can lead to cervical cancer), than women who don’t have HIV. Additionally, women with HIV are more likely to develop pelvic inflammatory disease and vaginal yeast infections and may experience menopause at an earlier age.

However, the primary worry for many women of childbearing age is passing the virus to their unborn children. But the good news is, there are ways for moms-to-be living with HIV to plan for healthy pregnancies that can reduce the risk they’ll transmit the virus to their babies.

Today, people with HIV live much longer lives because of ARV medicines. For women, advancing age and menopause means more bone loss (osteoporosis), and because a woman has smaller bones than a man, these effects are amplified. When older women living with the virus are on treatment, there’s an even higher risk their bones may weaken and break easily because some ARVs might increase some individuals’ risk of osteoporosis.

In addition, some HIV medicines, such as Viramune (nevirapine) and Norvir (ritonavir), may cause different side effects in the sexes. Findings show that women on HIV treatment are more likely than men to accumulate fat buildup throughout the body and face problems with their pancreas.

Then there’s stigma, which has shadowed the lives of men and women living with the virus since the beginning of the epidemic. “I was diagnosed with HIV 20 years ago,” says Maria Davis, a music industry promoter and HIV advocate who in 2014 became a spokesperson for I Design, a national HIV education campaign launched by Merck, a pharmaceutical company. “I am surprised that there are still misconceptions about HIV. I was recently asked if HIV is spread through saliva or if someone can get the virus by using a bathroom after someone with HIV has used it.” Editor’s note: It’s not, and you can’t.

Findings and stories about women all over the world who live with the virus show that the negative effects of HIV-related stigma are even greater for females. “These effects occur both for women and girls at risk of getting HIV and those already living with it,” say advocates writing about the issue for The Well Project, a nonprofit organization dedicated to providing information about women and HIV.

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Across the globe, the lives of women and girls are shaped by a number of gender-based inequities, such as less power in sexual decision-making and earning or controlling income as well as policies that deny women their rights pertaining to inheritances, education or reproduction. Even in the United States, women are at an increased risk for HIV as a result of such injustices.

According to the Centers for Disease Control and Prevention, poverty can act to limit women’s access to HIV testing and medications that lower the level of virus in the blood to undetectable, which reduces the risk of transmission to effectively zero. In addition, those who cannot afford the basics in life may end up in circumstances that increase their risk for HIV infection.

This description uniquely defines the economic status of many of the almost 16.3 million American women living in poverty in 2016, notes the National Women’s Law Center. (Poverty rates were highest for Black women followed by Native American and Latina women.)

Globally, too, social factors that predominate in different places combine with poverty to doubly burden women. The financial cost of having HIV triggers a cascade of progressively worse effects. For instance, when a woman is the sole breadwinner and she becomes ill, her family is affected. In some areas of the world, she may also be unable to see a doctor.

These circumstances can destroy the financial base for her family. Children might miss school or, in some cases, be forced to become caregivers, which can limit their potential to secure future employment opportunities.

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Women everywhere face another problem that raises risk for HIV: gender-based violence (GBV).

According to a United Nations paper on reducing HIV, “One in three women has been beaten, experienced sexual violence or otherwise abused in their lifetime. One in five will be a victim of rape or attempted rape.”

GBV can include sexual, physical or emotional abuse. What’s more, these assaults on women take many forms and are predominantly perpetrated by their intimate partners.

But no matter what guise acts of violence assume, they’re all proven drivers of HIV transmission for females.

“Trauma related to childhood physical trauma—as well as sexual abuse and intimate partner violence in adulthood—is related to increased risk for   HIV infection among women,” explain psychologists Lily D. McNair, PhD, and Cynthia M. Prather, PhD, in their report on factors that influence African--American women’s risk and reaction to HIV and AIDS published in the Journal of Black Psychology.

The authors add that a scarcity of African-American men available for romantic partnerships is yet another inequity that uniquely affects Black women’s risk of acquiring HIV.

This imbalance makes them less likely to ask about their partner’s HIV status or demand that a man with whom they’re involved use condoms.

“A lot of women I talk to don’t feel comfortable having that conversation with their partner—whether they just started dating or are in a committed relationship,” Davis says.

“They think it will bring up trust issues,” she adds. “It’s not easy to have this kind of conversation with your partner, but it’s important.”

In an effort to make women less vulnerable to HIV exposure, activists and advocates worldwide continue to work to empower women in all aspects of their lives. Part of the solution is to ensure that women can engage in their societies’ decision-making processes.

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In 2016, among black women in the United States, new rates of HIV dropped by 21 percent. Although experts called this decrease an “encouraging trend,” African-American women continue to be affected by the virus far more often than women of other races and ethnicities.

Still, Davis is optimistic that educating individuals about the virus will eventually help end the epidemic as well as strengthen self-determination among women and the ability to achieve their full potential.

“Get tested and know your status,” she advises. “Go with your partner to the clinic if you need to. Love yourself enough to have an open and honest conversation to help protect your health, and your partner’s health.”

Better Treatment for Her

Antiretrovirals can keep women healthy regardless of their HIV status.

 

Although males and females are alike in many ways, they differ in key aspects of their biology and behavior. This is why researchers worked hard to address women’s needs in HIV prevention, management and therapy. The result? Medications and drug formulations that help females in more effective ways.

For example, treatment as prevention, or TasP, refers to the use of antiretroviral (ARV) medications to prevent HIV. This protocol is used by mothers-to-be living with the virus to stop them from transmitting HIV to their babies during pregnancy, birth and breast feeding.

Another TasP therapy, Truvada (tenofovir disoproxil fumarate/emtricitabine) as pre-exposure prophylaxis, or PrEP, reduces a woman’s chances of contracting HIV by 90 percent—99 percent for men—if the medication is taken daily. (Note: PrEP doesn’t protect against other sexually transmitted diseases, such as syphilis and gonorrhea, but condoms do.)

In addition, the Food and Drug Administration recently approved Descovy (emtricitabine and tenofovir alafenamide), an ARV, for use as pre-exposure prophylaxis.

Now, scientists want to study Selzentry (maraviroc) to determine whether the med is an effective alternative to Truvada as PrEP. In a small study, scientists found that the drug was safe and well tolerated among women.

Meanwhile, advocates support continued research on ARV microbicide gels or creams that could be applied vaginally or anally to help stop HIV transmission despite debate about whether studies for these drugs—sometimes called “topical PrEP”—should continue to get funding.

Some would prefer that the limited research dollars go to studies on injectable meds as PrEP, such as cabotegravir and rilpivirine.