Human Immunodeficiency Virus (HIV)1, the causative agent for acquired immunodeficiency syndrome (AIDS), remains a significant contributor to the global burden of disease with negative implications for a country’s development (Want et al., 2016). As of 2016, an estimated 36.7 million individuals were living with HIV worldwide (WHO, 2017). 51% of those living with HIV are women aged 15 and older with about 60% of cases among adolescent girls and young women between that ages of 15 and 24 (UNAIDS, 2017). Sub-Saharan Africa (SSA) carries an unequal burden of HIV infection accounting for 71% of all cases with 25% being in South Africa, 6% in Uganda, 6% in Zimbabwe and 4% in Malawi (Kharsany and Karim, 2016). The HIV epidemic in many countries has had devastating effects on the economic development and growth of the nation, as HIV primarily affects those in their most productive years.
Substantial efforts have been made in behavioural, structural and biomedical strategies for HIV treatment and prevention. Due to the remarkable progress in the development and global scale-up of antiretroviral therapy (ART), there have been major reductions in HIV associated mortality, morbidity, transmission and stigma as well as great improvements in the quality of life of those living with HIV (Bain et al., 2017). For example, there was a 48% decrease in AIDS-related deaths from 2005 to 2016 (UNAIDS, 2017). Additionally, the rollout of ART is considered the most potent intervention in reducing sexual transmission of HIV, where uninfected individuals living in high ART coverage areas were less likely to acquire HIV than those living in low coverage areas (Tanser et al., 2013). However, the feasibility of achieving high ART coverage remains a challenge. This is mainly because ART initiation requires an HIV diagnosis and high ART coverage requires high retention of patients on treatment, both of which have yet to be achieved in many countries (Maartens et al., 2014).
Despite global efforts to strengthen HIV prevention and reduce transmission, the pace of decline in HIV incidence is far from reaching its target (Bain et al., 2017). Infection trends remain high with about 1.9 million new infections diagnosed in 2016 of which two-thirds were in SSA (UNAIDS, 2017). The primary mode of transmission in the region is through unprotected heterosexual sex (Bain et al., 2017). As a result, females aged 15 and older bear a disproportionate burden of HIV infection, accounting for 56% of new cases (UN Women, 2016). Furthermore, females aged 15-24 years acquire HIV infection 5-7 years earlier than their male counterparts (Kharsany and Karim, 2016). UNAIDS (2012) reported that every minute, a young woman becomes infected with HIV. While global scale-up of treatment has provided a better quality of life to those living with HIV and enabled reductions in transmission, the sustainability of such success now depends on reducing new infections and particularly among women.
2. The Need for the Study:
The gender disparity in HIV prevalence and incidence in SSA can be attributed to multiple structural, economic, sociocultural, behavioural and biological factors. Biologically, women are more vulnerable than men because during sexual intercourse (1) women have a larger area of mucous membrane exposed to the virus and infectious fluid for more extended periods, and (2) larger quantities of possibly infected fluids are transferred from men to women (Gilbert and Selikow, 2011). Placing these biological factors within the broader sociocultural context of gender-inequalities gives a more comprehensive understanding of the situation. A multitude of factors including earlier sexual debut among females, high proportions of transactional sex as a result of economic dependency on men, multiple partners with concurrent sexual partnerships, gender-based violence against females and low condom use contribute to increased vulnerability among adolescent girls and young women (Ramjee and Daniels, 2013).
Currently, there are many proven opportunities for HIV prevention including voluntary medical male circumcision (VMMC), programming for behaviour change, promotion of condom use, provision of post-exposure prophylaxis (PEP) and more recently pre-exposure prophylaxis (PrEP) (AUTHOR, DATE). The combination of these prevention packages has excellent potential in preventing HIV infection from vaginal and anal sexual intercourse. In particular, uptake of VMMC and consistent condom use are considered two of the main interventions in reducing heterosexually acquired HIV (AUTHOR, DATE). However, VMMC and female and male condom use require male consent, meaning the male partner determines the preventative measures a woman can take against HIV. Among women considered at higher risk of sexually transmitted HIV, the nature of female-male relationships constricts women’s agency over their health and sexual rights (AUTHOR, DATE). Thus, prevention becomes ‘inaccessible’.
Realising the gendered nature of current interventions and the need for more female-controlled options, researchers have started looking into other possibilities. In the Partners PrEP Study, the administration of PrEP – i.e. ART in HIV-negative individuals to prevent HIV infection – showed promising results among serodiscordant heterosexual couples with 75% reduction in HIV transmission among female partners (Baeten et al., 2014). Another study found that PrEP resulted in 62% reduction in HIV transmission (Thigpen et al., 2012). However, further investigation into the potential of prevention using PrEP among younger single women in SSA proved that it was ineffective (Van Damme et al., 2012). This was due to poor adherence stemming from concerns around stigma associated with the use of drugs intended for the treatment of HIV and fear of adverse side effects (ibid.). To address some of these issues, vaginal microbicides – formulated as gels, creams, suppositories or films – were developed (Cottrell et al., 2014). Despite the efficacy of microbicides, the unpredictable pharmacokinetics of microbicides in different individuals was concerning (ibid.). More importantly, the same issue present in other female-centred interventions remained: adherence was low.
1 Throughout the commentary, HIV refers to HIV-1 and does not include HIV-2.