June 9, 2005 - The face of the typical AIDS patient is fast becoming female. It's happening all over the world -- and the U.S. is no exception.
If you think this can't be so, follow Frances H. Priddy, MD, MPH, on her rounds at Atlanta's Grady Memorial Hospital. The Grady AIDS ward mirrors AIDS across America, says Priddy, medical director of the Hope Clinic at Emory Vaccine Center and assistant professor of medicine at Emory University.
"When I go onto the wards at Grady with my medical students, we see that more than half the AIDS patients are women," Priddy tells WebMD. "And those women are 10-to-1 minority women. Many of these women are in their 20s. That brings the feminization of the AIDS epidemic home very quickly. It is really a catastrophe."
The Feminization of AIDS
Julie Overbaugh, PhD, of Seattle's Fred Hutchinson Cancer Research Center, has studied AIDS since the early days of the epidemic.
"In this day and age, if you are talking about women's health, you have to talk about HIV and AIDS," Overbaugh tells WebMD. "One thing particularly concerning is that new infections with HIV and HIV prevalence keep going up for women. These cases are representing more and more of the HIV/AIDS population."
They note that the latest CDC statistics show that U.S. AIDS is growing 15 times faster in women than in men. What is happening? Sub-Saharan Africa offers a clue. There, 60% of HIV infections -- and 75% of HIV infections in people aged 15-24 -- are in women.
"In Africa, the burden of HIV in younger women in their first decade of sexual activity is higher than that of men in the same age frame. We see their risk is several times that of their male counterparts," Overbaugh says.
It's being called the "feminization" of AIDS. Priddy does not prefer that term.
"'Feminization' implies a lot of the nice qualities of women such as grace and intuition and empowerment. Unfortunately, we are not seeing that," she says. "The proportion of women with HIV is increasing. It makes all the sense in the world that this has happened to the most vulnerable members of society, who are often the most hard hit by diseases involving sexuality. I would like to find a better word that portrays the powerlessness of women in this epidemic."
Women's Issues Key to AIDS Prevention
One might argue that women are nowhere more empowered than in America. But the women in America who most lack economic and social empowerment -- minority women -- are precisely those bearing the brunt of the AIDS epidemic.
In the U.S., Quinn and Overbaugh note, AIDS is diagnosed in black women at a rate 25 times higher than in white women and four times higher than in Hispanic women. Eight out of 10 of these infections come from heterosexual sex with an infected partner.
"The data in the U.S. in many ways reflects the issues that women in developing countries are dealing with," Priddy says. "These issues have a lot to do with women's sexual and economic power in their societies. In the reasons they have HIV, these minority women have a lot of similarities to women in resource-poor countries. I don't mean racial similarities -- I mean they experience the same social and cultural barriers to protecting themselves from HIV."
Some of these issues are biological. A heterosexual encounter with an HIV-infected partner is more dangerous for a woman than for a man. This is particularly true for adolescents, whose immature genital tracts are especially susceptible to HIV infection. The use of hormone-based contraceptives, such as the pill, appears to heighten a woman's vulnerability to HIV infection -- and, possibly, to speed AIDS onset once a woman is infected.
Intertwined with these biological factors are social and cultural issues:
- Young women having sex with older men are less able to negotiate safe sex.
- Poverty forces women to focus more on immediate needs -- food, shelter, and personal safety -- than on the more distant risk of AIDS.
- Little access to health care means that HIV-positive male sex partners are not being tested -- or treated -- for their infections. This means higher virus levels in the positive partner, and a higher risk of passing on the AIDS virus.
- Poor access to health care also means that many women don't learn they are infected with HIV until they develop serious AIDS-related infections.
- A strong emphasis on having children necessitates unprotected sex.
- Married women often cannot negotiate safer sex with their spouses. Safe sex means condom use -- a form of protection that women do not directly control. The female condom, while useful in some situations, does not fill this need.
The Search for Solutions
"In the last five years there has been increased awareness that women carry a heavy burden of HIV. Not just in terms of mother-to-child transmission, but greater awareness that women themselves are carrying a heavy burden," Overbaugh says. "And I hope where it is leading us is to find and prioritize strategies that might reduce risk in women."
The holy grail of AIDS research is an effective vaccine. That goal remains elusive, although progress is being made.
There's another way women might protect themselves. It's called a vaginal microbicide. Researchers all over the world are racing to develop a safe cream or gel containing drugs that kill HIV or keep it at bay.
"Microbicides are good because they are private and female-controlled," Priddy says. "We need to give women that power over their own protection. Even here in a population like Atlanta we see a clear need for women to protect themselves."
Priddy says a vaginal microbicide won't be ideal if it has to be applied prior to every sexual encounter.
"What's needed is something that doesn't have to be applied every time, like a pill or an injection or an intravaginal ring that would give off a steady flow of a microbicide," she says. "There is definitely a lot of work to do in biomedical ways for women to protect themselves against HIV infection."
But there's only so much science can do.
"When you talk about gender disparities, sexual inequity, and poverty, there are no ready solutions," Priddy says. "In the scientific community, there is a feeling that we don't know exactly how to address those issues. So in dealing with HIV and AIDS, the medical and scientific fields have had great success in developing antiretroviral drugs, but HIV/AIDS prevention has not caught up with the technological advances of HIV/AIDS treatment. ... We say this is a multifactorial problem, but maybe our approach to a solution has not been so multifactorial."