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Beyond the Male Condom: The Evolution of Gender-Specific HIV Interventions for Women

Annual Review of Sex Research, 2003 by Exner, Theresa M, Dworkin, Shari L, Hoffman, Susie, Ehrhardt, Anke A

As the number of HIV infections in women has increased, there has been a concomitant recognition that prevention efforts to reduce sexual transmission must address the gendered context in which risk behavior occurs. This paper provides a longitudinal perspective on the emergence of the HIV epidemic in U.S. women and the parallel development of interventions to reduce risk. In the first portion of this paper, we briefly discuss the growth of the epidemic among women and how public health responses reflected the early discourse about infected women. We also address methods of protection available to women, and the emerging recognition of the importance of gender relations. In the second half of this paper, we show how gender-specificity in prevention efforts has evolved, using a framework developed by Geeta Gupta (2001) and relying on published reviews of the intervention literature in the past 10 years. Finally, we discuss in detail several recent examples. We conclude with a discussion of future directions.

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Key Words: gender specific HIV interventions, gender theory, women and HIV

Since the onset of AIDS in the late 1980s, the global pandemic has claimed 25 million lives (UNAIDS, 2000, 2002a, 2002b). Worldwide, 42 million people are currently living with HIV/AIDS (UNAIDS, 2002b). In 2002, UNAIDS reported for the first time that 50% of all adults living with HIV/AIDS were women. In the United States in 2001, women accounted for 26% of all newly diagnosed adult AIDS cases and 32% of newly identified adult HIV infections (Centers for Disease Control [CDC], 2002a), a percentage that has been increasing steadily. As recognition of the impact of HIV on women has emerged over the past 10 years, there also has been a growing understanding that efforts to slow the spread of the virus need to account for the ways that gender structures women's lives and sexual interactions, creating both constraints and possibilities. In this paper we trace historically the evolving epidemic among U.S. women and the parallel evolution of interventions directed to their sexual risk behavior. We do not aim to present a comprehensive review of interventions for women, as several overviews have been completed in recent years (Choi & Coates, 1994; Exner, Seal, & Ehrhardt, 1997; Fisher & Fisher, 1992; Ickovics & Yoshikawa, 1996, 1998; Kelly & Kalichman, 2002; Logan, Cole, & Leukefeld, 2002; Mize, Robinson, Bockting, & Scheltema, 2002; Oakley, Fullerton, & Holland, 1995; Wingood & DiClemente, 1996). Rather, by broadly reviewing developments over time and presenting a more detailed discussion of recent gender-specific interventions, we hope to highlight trends, identify unanswered questions, and lay the ground for future interventions.

The Evolution of the HIV Epidemic Among U.S. Women

HIV disease in the Western world first appeared among men who have sex with men and intravenous drug users (IDUs). Although women who used intravenous drugs were among those early affected, attribution of infection in women to heterosexual transmission was slow to emerge (Holmes, Karon, & Kreiss, 1990). This was true even though heterosexual transmission was the dominant mode in sub-Saharan Africa and the Caribbean (UNAIDS, 2002b). To this day, guidelines set by the CDC are hierarchical, whereby a case can only be attributed to heterosexual transmission among women if there is no evidence of intravenous drug use. By the end of 1992, over 18,500 U.S. women had officially died of AIDS (CDC, 2002b). However, the CDC AIDS case definition at that time did not include some common disease manifestations unique to women (e.g., recurrent vaginal yeast infections and invasive cervical cancer [Hankins & Handley, 1992; Wright, Ellerbrock, Chiasson, Van Devanter, & Sun, 1994]). Following pressure from women's advocates, in 1993 the AIDS case definition was expanded (CDC, 1992)-a year that saw an explosion of women officially recognized as having AIDS. This delay in recognizing HIV disease presentations in women compounded difficulties many faced in accessing treatment and procuring ancillary social services, as government aid was contingent on an AIDS diagnosis (Corea, 1992). Women were also often excluded from early drug trials and from natural history studies of disease progression (Fox-Tierney, Ickovics, Cerrata, & Ethier, 1999; Strebel, 1995), leading to inadequate diagnosis, poor understanding of disease manifestation, and delayed treatment (Cohan & Atwood, 1994).

Although slow to be recognized, the HIV epidemic among women was growing rapidly. Between 1984 and 1995 the proportion of AIDS cases among women tripled, from 6% to 19% (CDC, 1995; CDC, 1996a). Concurrent with this growth was the increasing proportion of cases attributable to heterosexual transmission. In 1994, heterosexual contact surpassed intravenous drug use as the predominant route of transmission to U.S. women with a diagnosis of AIDS (CDC, 1995), and HIV infection became the third leading cause of death for women aged 25 to 44, following cancer and unintentional injuries (CDC, 1996b). By the mid 1990s, there was no longer any doubt that HIV had become a major health problem for women.

Beyond the Male Condom: The Evolution of Gender-Specific HIV Interventions for Women

Annual Review of Sex Research, 2003 by Exner, Theresa M, Dworkin, Shari L, Hoffman, Susie, Ehrhardt, Anke A

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