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The disproportionate impact of the HIV epidemic on women can be attributable to several factors including biological, social, behavioral, cultural, economic and structural. In SSA a combination of these factors has led to the disparate increase in HIV infection rates among women compared to their male counterparts [15].

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Studies in Uganda, Rwanda and Zimbabwe have shown that pregnant women are at a higher risk of HIV infection than lactating or other women, possibly due to physiological changes that a woman undergoes during pregnancy [29]. High levels of oestrogen and progesterone either during pregnancy or from exogenous sources could cause changes in the structure of the genital mucosa or cause immunological changes, such as an increase in mucosal lymphoid aggregates or hormone-induced overexpression of co-receptors associated with HIV infection. Increased levels of oestrogen are also associated with cervical ectopy in young women which in turn increases risk to HIV infection [29].

Supporting evidence suggests that women have a window of vulnerability approximately seven to ten days after ovulation in their menstrual cycle in which the potential for viral infectivity in the female reproductive tract is increased. This is due to the suppressing influence of sex hormones on the innate, humoral and cell-mediated immune systems. This takes place in the upper and lower female reproductive tract, and overlaps with the upregulation of co-receptors for HIV uptake and the recruitment of potentially infectable cells [30].

For women in SSA, probabilities of HIV exposure, acquisition and transmission is influenced by a range of factors such as infectiousness of the male partner according to the stage of the disease, or presence of ulcers in the male partner in the event of unprotected sexual intercourse. At a broader societal level, several factors influence the scale and rate of the epidemic spread such as overall HIV and STI prevalence, sexual practices, marriage and other cultural norms including structural factors not in control of the individual.

In the last two decades, nearly all SSA countries have faced slowing economic growth which has influenced spending on social services [32]. This has further impoverished African populations, with increases in unemployment rates and the decrease in provision of social services, including education and health services. The deterioration of education, health, and other social services implies a loss of opportunities for HIV prevention [32], particularly in women.

Transactional sex (sex for money) is common in SSA. Many women engage in sex work which is defined as the provision of sexual services in exchange for money, goods, or other benefits [43]. Globally, female sex workers (FSWs) are at high risk of HIV infection and are 13.5 times more likely to be living with HIV than other women [2]. An estimated fifteen percent of HIV in the general female adult population is attributable to (unsafe) female sex work. The region with the highest attributable fraction is SSA with 98,000 HIV-related deaths [44] compared to an estimated 106,000 deaths worldwide which are a result of female sex work [45]. FSW is an important contributor to HIV transmission and the global HIV burden. Studies from South Africa and Kenya suggest sex workers engage in high risk behavior such as dry sex [46, 47] and anal sex (fetching a high price) which further increase their risk.

The vulnerability to HIV infection increases by engaging in unprotected anal sex by 13 fold compared to oral sex [59]. This is primarily due to the fragility of the rectal mucosa [29]. Although it is difficult to ascertain the percentage of women who participate in heterosexual anal sex in Africa, some studies and surveys have shown that between five [60] and twelve per cent [61] of women in the general community in South Africa report engaging in anal sex. However, this practice could be as high as forty per cent in female sex workers [59]. Effective HIV prevention measures exist and have been successfully targeted at key populations in many settings. It is however difficult to attract this high risk population group due to the different settings in which the FSWs conduct their business. Regular surveillance, prevention and treatment of HIV among FSWs would benefit this often neglected vulnerable group and the general population as a whole [2].

Alcohol abuse in much of Africa is characterized by irregular episodes of heavy drinking, frequently in the form of weekend bingeing [29]. These drinking patterns may have independent effects on sexual decision-making, and on condom-negotiation skills and correct condom use. Studies have demonstrated that women with heavy episodic drinking patterns are more prone to use condoms inconsistently and incorrectly, experience sexual violence; and acquire an STI, including HIV [29, 62].

Discrimination is often based on gender, race/ethnicity, sexual orientation, and HIV status [74]. Stigma and fear of status disclosure has been a large factor in individuals seeking HIV testing and subsequent treatment and care [33, 75]. Stigma can occur at different levels, including community, interpersonal, legislative and institutional (e.g. workplaces, schools and health facilities) levels [75]. Women often suffer the heaviest burden of HIV stigma and discrimination, as they are often expected to uphold the moral traditions of their societies; being HIV infected is considered evidence that they have failed in this regard [33, 74]. HIV positive women experience discrimination, stigma and other human rights violations within families and communities, by legal and social services, in health-care settings, and in their work environment. Health-care settings often refuse to provide information or provide the wrong information on HIV prevention and treatment, sexual and reproductive health, and family planning [33]. HIV positive women have also experienced the denial of services, lack of confidentiality, harsh and judgmental treatment, and lack of informed consent [33]. As a result of stigma, women are often reluctant to seek HIV testing and are not empowered to enact HIV prevention [74].

Success with research among HIV discordant couples showed a decrease in HIV acquisition when a negative partner in a dicordant partnership was provided with oral pre-exposure prophylaxis (PrEP). Partners taking oral tenofovir or tenofovir plus emtricitibine (Truvada) as prophlaxis had a reduced rate of HIV acquisition 67% (95% CI 44 to 81) and 75% (95% CI 55 to 87) respectively [84]. The higher the adherence the greater the efficacy. Unfortunately a study among women in east and southern Africa testing the same drug, Truvada, for HIV prevention did not show any efficacy in preventing HIV due to poor adherence to the study product [85].

Treatment with ARV for prevention (TasP) has been reported to be highly efficacious (96%) among both men and women in a discordant couple relationship where the positive partner was provided ARV treatment to reduce HIV transmission to the negative partner [86]. Thefore it appears that when both sexual partners have the knowledge of their HIV status and are targeted together for HIV prevention the intervention is likely to be aceptable and used.

HIV counseling and testing is recognized as a critical component for all HIV prevention interventions. Testing provides the opportunity to identify people who are HIV positive and in need for treatment and care and can also identify people who are HIV negative and referred for HIV prevention and care. Regular HIV testing will be critical for prevention interventions using PrEP. HIV counseling and testing not only allows women, couples, and families to learn their HIV status and obtain personalized risk reduction counseling and further care appropriate to their status, but can also assist communities in addressing stigma and discrimination associated with HIV/ AIDS [87, 88].

Microfinance programs attempt to ease poverty by offering access to credit, savings or business skills. In South Africa, a study using an integrated curriculum of gender equity, anti-violence work and HIV/AIDS education together with an existing microfinance program demonstrated higher levels of HIV-related communication by women in addition to a 55% reduction in domestic violence. Women in this study were less likely to have had unprotected sex at their last sex act and more likely to have accessed HIV Counselling and Testing [96]. In Malawi, girls receiving cash transfers had a lower prevalence of HIV and HSV-2 than those who were not because of less sexual activity, delayed sexual debut, having younger and fewer partners and decreased transactional sex [88]. A Tanzanian trial suggested a 25% lower incidence of STIs in both women and men receiving monetary incentives [88]. A Kenyan project provided HIV and safe sex education, small business management training and startup funds to women engaged in sex work. The project showed an increased sense of pride and wellbeing, a decrease in the number of sexual partners and an increase in condom use [97]. In response to the increase in HIV incidence caused by migration, a project in Tanzania distributed and promoted condom use, raised HIV awareness, encouraged reduction in the overall number of sexual partners and encouraged peer-based STI/HIV education among truck drivers. The number of condoms distributed increased by 100 000 and HIV awareness among truck drivers increased [97].

Violence against women is a common form of human rights violation, and intimate partner violence (IPV) appears to be the most significant component of violence. The aim of this study was to examine the association between women decision-making capacity and IPV among Women in Sub-Saharan Africa. The study also looked at how socio-demographic factors also influence IPV among Women in Sub-Saharan Africa.

Though related socio-demographic characteristics and women decision-making capacity provided an explanation of IPV among women in sub-Saharan Africa, there were differences in relation to how each socio-demographic variable predisposed women to IPV in Sub-Saharan Africa. 350c69d7ab


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