United Nations (UN) agencies now speak about feminization of the HIV/AIDS pandemic because women comprise an increasing proportion of people affected by HIV and AIDS around the world (1). They include girls, women of reproductive age, and post-menopausal women, although most new infections occur in women of childbearing age. By December 2005, it was estimated that 40.3 million people were living with HIV worldwide; of these, 17.5 million were women. The percentages of women among HIV-positive adults aged 15-49 years range from 18% in East Asia to 57% in sub-Saharan Africa; in the latter region, young women aged 15-24 years are at least three times more likely to be HIV-positive than their male peers (2).
A number of factors make women more vulnerable to HIV infection. As is well-known, women are physiologically more susceptible to infection through acts of unprotected sex than men (1). In most societies, large numbers of women are unable to insist on monogamy or consistent condom-use by their male partners due to gender-based imbalances in decision-making between the sexes. Where homosexuality is heavily stigmatized, considerable numbers of men who have sex with men and who marry women to conform to societal expectations do not reveal their homosexual activity to their female partners. This may be because they fear discrimination and violence if their homosexual encounters become known or because they feel that it is none of women's business. In either case, they often do not broach use of condoms with their wives because it could cause suspicion or would prevent them from fathering children (3). Women who engage in sex work due to poverty frequently feel unable to demand use of condoms by clients. Marginalized women, such as female injecting drug users, girls, and women living on the streets who engage in transactional sex, are also often in this position.
Women are much more frequently victimized than men in domestic violence and sexual assaults in all countries of the world (4), placing them at direct risk of HIV infection and unwanted pregnancies as a result of rape. Actual and threatened psychological and physical violence also plays a role in their being unable to use contraceptives, including condoms. Poverty and lack of property rights can prevent women from leaving marriages characterized by domestic and sexual violence (5-6).
These situations, which increase the vulnerability of girls and women to HIV and sexually transmitted infections (STIs), violence, and unwanted pregnancies, clearly indicate that high priority must be given to meeting the reproductive health needs of women. This is particularly the case for women living with HIV since their problems may be exacerbated. For example, it appears that women who disclose their HIV status may risk violence from their partners, families, or social environment (7).
To assess whether attention is indeed being paid to the broader reproductive health needs of women affected by HIV and AIDS, literature reviews were carried out to identify which reproductive health issues appear to be relatively neglected in relation to HIV/AIDS. The reviews showed that these issues included: contraceptive information tailored to the needs of HIV-positive people; voluntary HIV counselling and testing during antenatal care, labour, and delivery; parenting options for HIV-positive people besides pregnancy through unprotected intercourse (i.e. assisted conception and legal adoption or foster care); unwanted pregnancy; and abortion-related care. An additional finding that emerged from the reviews was that stigma and discrimination were frequently cited as barriers to enjoyment of reproductive rights by HIV-positive women.
Subsequently, a pilot project was initiated in which non-governmental organizations (NGOs) in developing countries used benchmarks to ascertain whether a number of the neglected issues identified in the literature reviews were addressed in local programmes and interventions serving affected women. …