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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Looking at Complicating Non-Biological Issues in Women with HIV</title><author><name sortKey="Rodrigo, Chaturaka" sort="Rodrigo, Chaturaka" uniqKey="Rodrigo C" first="Chaturaka" last="Rodrigo">Chaturaka Rodrigo</name><affiliation><nlm:aff id="AF0001"></nlm:aff></affiliation></author><author><name sortKey="Rajapakse, Senaka" sort="Rajapakse, Senaka" uniqKey="Rajapakse S" first="Senaka" last="Rajapakse">Senaka Rajapakse</name><affiliation><nlm:aff id="AF0002"><italic>Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Sri Lanka</italic></nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">20300413</idno><idno type="pmc">2840969</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2840969</idno><idno type="RBID">PMC:2840969</idno><idno type="doi">10.4103/0974-777X.59246</idno><date when="2010">2010</date><idno type="wicri:Area/Pmc/Corpus">000F10</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000F10</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Looking at Complicating Non-Biological Issues in Women with HIV</title><author><name sortKey="Rodrigo, Chaturaka" sort="Rodrigo, Chaturaka" uniqKey="Rodrigo C" first="Chaturaka" last="Rodrigo">Chaturaka Rodrigo</name><affiliation><nlm:aff id="AF0001"></nlm:aff></affiliation></author><author><name sortKey="Rajapakse, Senaka" sort="Rajapakse, Senaka" uniqKey="Rajapakse S" first="Senaka" last="Rajapakse">Senaka Rajapakse</name><affiliation><nlm:aff id="AF0002"><italic>Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Sri Lanka</italic></nlm:aff></affiliation></author></analytic><series><title level="j">Journal of Global Infectious Diseases</title><idno type="ISSN">0974-777X</idno><idno type="eISSN">0974-8245</idno><imprint><date when="2010">2010</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec id="st1"><title>Introduction:</title><p>The increasing number of women acquiring Human Immunodeficiency Virus (HIV) has resulted in a ‘feminization’ of the epidemic. In this article we are reviewing whether females are disadvantaged in the epidemic, due to factors independent of the biological differences in sexes.</p></sec><sec id="st2"><title>Materials and Methods:</title><p>We searched MEDLINE and EMBASE for articles with key words ‘Women’, ‘Gender,’ and ‘HIV’ in any field. The search was restricted to articles published in English within the last 10 years (1999-2009). Data were coded independently by two reviewers from 94 selected sources. The coded data were categorized under five commonly encountered concepts; violence, poverty, gender norms, prevention-/treatment-related issues, and Highly Active Anti-Retroviral Treatment (HAART).</p></sec><sec id="st3"><title>Results:</title><p>The link between inter-partner violence (IPV) and HIV risk for women is observed by many authors. In assessing the link between poverty and HIV, indicators such as food insufficiency and income inequality may be better indicators compared to wealth itself. Although women are disadvantaged with male-dominated gender norms, evidence suggests that the traditional norms are changing in many societies. A positive association between living in urban communities, education, and better HIV knowledge has been observed in females, although it is not always synonymous with reduced risk behavior.</p></sec><sec id="st4"><title>Conclusions:</title><p>Women are still disadvantaged in many HIV-related issues such as poverty, violence, and gender norms. At least in Africa, there is evidence of a positive change in spheres of education and gender norms. 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<front><journal-meta><journal-id journal-id-type="nlm-ta">J Glob Infect Dis</journal-id><journal-id journal-id-type="publisher-id">JGID</journal-id><journal-title-group><journal-title>Journal of Global Infectious Diseases</journal-title></journal-title-group><issn pub-type="ppub">0974-777X</issn><issn pub-type="epub">0974-8245</issn><publisher><publisher-name>Medknow Publications</publisher-name><publisher-loc>India</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">20300413</article-id><article-id pub-id-type="pmc">2840969</article-id><article-id pub-id-type="publisher-id">JGID-02-15</article-id><article-id pub-id-type="doi">10.4103/0974-777X.59246</article-id><article-categories><subj-group subj-group-type="heading"><subject>Electronic Epidemiology</subject></subj-group></article-categories><title-group><article-title>Looking at Complicating Non-Biological Issues in Women with HIV</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Rodrigo</surname><given-names>Chaturaka</given-names></name><xref ref-type="aff" rid="AF0001"></xref><xref ref-type="corresp" rid="cor1"></xref></contrib><contrib contrib-type="author"><name><surname>Rajapakse</surname><given-names>Senaka</given-names></name><xref ref-type="aff" rid="AF0002">1</xref></contrib></contrib-group><aff id="AF0001"><italic>University Medical Unit, National Hospital of Sri Lanka, Sri Lanka</italic></aff><aff id="AF0002"><label>1</label><italic>Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Sri Lanka</italic></aff><author-notes><corresp id="cor1"><bold>Address for correspondence:</bold> Dr. Chaturaka Rodrigo, E-mail: <email xlink:href="chaturaka.rodrigo@gmail.com">chaturaka.rodrigo@gmail.com</email></corresp></author-notes><pub-date pub-type="ppub"><season>Jan-Apr</season><year>2010</year></pub-date><volume>2</volume><issue>1</issue><fpage>15</fpage><lpage>27</lpage><permissions><copyright-statement>© Journal of Global Infectious Diseases</copyright-statement><copyright-year>2010</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by/2.0/"><license-p>This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.</license-p></license></permissions><abstract><sec id="st1"><title>Introduction:</title><p>The increasing number of women acquiring Human Immunodeficiency Virus (HIV) has resulted in a ‘feminization’ of the epidemic. In this article we are reviewing whether females are disadvantaged in the epidemic, due to factors independent of the biological differences in sexes.</p></sec><sec id="st2"><title>Materials and Methods:</title><p>We searched MEDLINE and EMBASE for articles with key words ‘Women’, ‘Gender,’ and ‘HIV’ in any field. The search was restricted to articles published in English within the last 10 years (1999-2009). Data were coded independently by two reviewers from 94 selected sources. The coded data were categorized under five commonly encountered concepts; violence, poverty, gender norms, prevention-/treatment-related issues, and Highly Active Anti-Retroviral Treatment (HAART).</p></sec><sec id="st3"><title>Results:</title><p>The link between inter-partner violence (IPV) and HIV risk for women is observed by many authors. In assessing the link between poverty and HIV, indicators such as food insufficiency and income inequality may be better indicators compared to wealth itself. Although women are disadvantaged with male-dominated gender norms, evidence suggests that the traditional norms are changing in many societies. A positive association between living in urban communities, education, and better HIV knowledge has been observed in females, although it is not always synonymous with reduced risk behavior.</p></sec><sec id="st4"><title>Conclusions:</title><p>Women are still disadvantaged in many HIV-related issues such as poverty, violence, and gender norms. At least in Africa, there is evidence of a positive change in spheres of education and gender norms. However, the situation in Asia is largely unexplored.</p></sec></abstract><kwd-group><kwd>HIV/AIDS</kwd><kwd>Women</kwd><kwd>Gender</kwd></kwd-group></article-meta></front><body><sec sec-type="intro" id="sec1-1"><title>INTRODUCTION</title><p>The latest estimates of the HIV (Human Immunodeficiency Virus) epidemic suggest that 33 million people live with it worldwide. Fifty percent of them are women.[<xref ref-type="bibr" rid="CIT1">1</xref>] However, in 1985, only 35% of the infected were women.[<xref ref-type="bibr" rid="CIT2">2</xref>] The main mode of transmission has shifted from male homosexual contact to heterosexual contact over the last 20 years. More women getting infected via heterosexual intercourse has resulted in ‘feminization of HIV/AIDS’.[<xref ref-type="bibr" rid="CIT2">2</xref>] The percentage of infected women varies in different regions, but the numbers are increasing (Sub-Saharan Africa = 60%, Caribbean = 45-50%, Asia and Latin America = 30-40%, Eastern Europe and Central Asia = 30%).[<xref ref-type="bibr" rid="CIT1">1</xref>] This changing face of the epidemic calls for a careful review of gender-related differences of HIV.</p><p>An analysis of sexual behavior in 59 countries has shown that in many developing countries the age of sexual initiation has risen for women. Still, due to the late age in marriage, the prevalence of premarital sex has increased.[<xref ref-type="bibr" rid="CIT3">3</xref>] This and other trends in sexual behavior are dependent on local factors such as poverty, culture, gender norms, media influence, and so on. Transmission of HIV and other sexually transmitted diseases (STDs) are also influenced by these issues, which may affect men and women differently. Identifying these factors and their gendered effects will have major implications in prevention strategies.</p><p>During the synthesis of our review, it seemed logical to broadly categorize the gender-related variables as biological and nonbiological. The clinical manifestations, differences in pathogenesis, pregnancy-related issues, response to HAART, and side effects are some biological issues. As the scope of the topic is vast, we restricted our review to examine only the nonbiological factors, with gender implications, and how they relate to women at risk and women living with HIV/AIDS.</p></sec><sec sec-type="materials|methods" id="sec1-2"><title>MATERIALS AND METHODS</title><p>We searched the electronic databases; MEDLINE and EMBASE with the keywords ‘Women’ ‘Gender,’ and ‘HIV’ in any f ield, using the software Endnote X1.01, to the filter articles. The search was limited to articles published in English over the last 10 years (1999-2009). Bibliographies of cited literature were also searched. Relevant publications and epidemiological data were also downloaded from websites of international agencies such as the World Bank, United Nations Joint Program on HIV/AIDS (UNAIDS), and World Health Organization (WHO). All abstracts were read independently by the two authors, and relevant articles were identified for review of the full articles.</p><p>Sources were screened for relevance to the topic, originality, a well-described methodology, rigor of statistical analysis, and an adequate sample size, where relevant. Sources were excluded where sample size was inadequate (except in qualitative studies), methodology was not well-described, statistical analysis was unclear, and where the full article was unavailable. Ninety four sources from a selected 115 (81.7%) were reviewed. Coding was done by two reviewers independently blinded to each other. Codes were grouped into concepts commonly encountered (e.g., gender norms, violence, poverty, treatment- and prevention-related issues) during the search, under the broader category of nonbiological factors. Data sources included reviews published in core clinical journals, cohort studies, qualitative studies, interventional studies, case-control studies, cross-sectional analysis, and epidemiological data. The inter-reviewer agreement for data included in the final synthesis was 100%. A summary of cited literature is shown in Tables <xref ref-type="table" rid="T0001">1</xref>–<xref ref-type="table" rid="T0003">3</xref>.</p><table-wrap id="T0001" position="float"><label>Table 1</label><caption><p>HIV and women; a look into the nonbiological factors complicating the picture. A brief summary of studies quoted in text (in order of citation)</p></caption><table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="1" colspan="1">Author</th><th align="center" rowspan="1" colspan="1">Year published</th><th align="center" rowspan="1" colspan="1">Sample size</th><th align="left" rowspan="1" colspan="1">Study design</th><th align="left" rowspan="1" colspan="1">Conclusions</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">Andersson <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2007</td><td align="center" rowspan="1" colspan="1">20,639</td><td align="left" rowspan="1" colspan="1">Cross-sectional survey in eight Southern African countries</td><td align="left" rowspan="1" colspan="1">Eighteen percent of women reported partner physical violence within one year.</td></tr><tr><td align="left" rowspan="1" colspan="1">Garcia-Moreno <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2006</td><td align="center" rowspan="1" colspan="1">24,097</td><td align="left" rowspan="1" colspan="1">Population based survey, 2000-2003</td><td align="left" rowspan="1" colspan="1">The reported lifetime prevalence of physical or sexual partner violence or both ranged from 15-71%</td></tr><tr><td align="left" rowspan="1" colspan="1"><italic>Sa et al.</italic></td><td align="center" rowspan="1" colspan="1">2008</td><td align="center" rowspan="1" colspan="1">1418</td><td align="left" rowspan="1" colspan="1">Population-based survey of women</td><td align="left" rowspan="1" colspan="1">Significant risk of HIV<xref ref-type="table-fn" rid="T000F1">*</xref> was associated with a partner older than 10 years, if he made a low financial contribution to children's needs or if she experienced coerced sex before 18 years of age</td></tr><tr><td align="left" rowspan="1" colspan="1">Fonck <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2005</td><td align="center" rowspan="1" colspan="1">520</td><td align="left" rowspan="1" colspan="1">Survey of women attending STI clinics in Nairobi, Kenya</td><td align="left" rowspan="1" colspan="1">Prevalence of lifetime physical violence was 26%, mainly by an intimate partner (74%)</td></tr><tr><td align="left" rowspan="1" colspan="1">Dunkle <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2004</td><td align="center" rowspan="1" colspan="1">1366</td><td align="left" rowspan="1" colspan="1">Cross-sectional study of women presenting at antenatal clinics</td><td align="left" rowspan="1" colspan="1">Intimate partner violence and high levels of male control in a woman's current relationship were associated with HIV<xref ref-type="table-fn" rid="T000F1">*</xref> seropositivity</td></tr><tr><td align="left" rowspan="1" colspan="1">Jewkes <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2006</td><td align="center" rowspan="1" colspan="1">1295</td><td align="left" rowspan="1" colspan="1">Cluster randomized controlled trial in South African women aged 15-26 with HIV<xref ref-type="table-fn" rid="T000F1">*</xref> behavioral intervention</td><td align="left" rowspan="1" colspan="1">Inter-partner violence was strongly associated with most of the identified HIV<xref ref-type="table-fn" rid="T000F1">*</xref> risk factors (past year partner numbers, time of last sex, and partner's education).</td></tr><tr><td align="left" rowspan="1" colspan="1">Pettifor <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2004</td><td align="center" rowspan="1" colspan="1">11,904</td><td align="left" rowspan="1" colspan="1">Household survey of men and women aged 15-24 in South Africa</td><td align="left" rowspan="1" colspan="1">Women experiencing forced sex were 5.77 times more likely to use condoms inconsistently. Inconsistent condom use was, in turn, significantly associated with HIV<xref ref-type="table-fn" rid="T000F1">*</xref> infection</td></tr><tr><td align="left" rowspan="1" colspan="1">Langen TT</td><td align="center" rowspan="1" colspan="1">2005</td><td align="center" rowspan="1" colspan="1">2658</td><td align="left" rowspan="1" colspan="1">Women aged 18-49 years in a cross-sectional survey in Kwa Zulu Natal Province of South Africa and Botswana</td><td align="left" rowspan="1" colspan="1">Women with partners 10 or more years older than them, abused women, and those economically dependent on their partners are less likely to suggest condom use to their partners</td></tr><tr><td align="left" rowspan="1" colspan="1">Pronyk <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2006</td><td align="center" rowspan="1" colspan="1">6576 (In all three arms)</td><td align="left" rowspan="1" colspan="1">Cluster randomized intervention trial</td><td align="left" rowspan="1" colspan="1">A combined microfinance and training intervention can lead to reductions in levels of intimate-partner violence in program participants</td></tr><tr><td align="left" rowspan="1" colspan="1">Voisin DR</td><td align="center" rowspan="1" colspan="1">2005</td><td align="center" rowspan="1" colspan="1">409</td><td align="left" rowspan="1" colspan="1">Cross-sectional survey of adolescents in the United States of America</td><td align="left" rowspan="1" colspan="1">Adolescents exposed to either childhood sexual abuse or family or community violence were almost three and four times more likely than peers not exposed to such violence to report a higher number of HIV<xref ref-type="table-fn" rid="T000F1">*</xref>-related risk behaviors</td></tr><tr><td align="left" rowspan="1" colspan="1">Raj <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2004</td><td align="center" rowspan="1" colspan="1">170</td><td align="left" rowspan="1" colspan="1">Community-based survey on Hispanic women in the United States of America</td><td align="left" rowspan="1" colspan="1">Abused women were significantly more likely than those not abused in the past three months to report high STD<xref ref-type="table-fn" rid="T000F2">†</xref><sup>/</sup>HIV<xref ref-type="table-fn" rid="T000F1">*</xref> risk, gender-based risk, including sexual control by male partners and male partner risk including male infidelity</td></tr><tr><td align="left" rowspan="1" colspan="1">Martin <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">1999</td><td align="center" rowspan="1" colspan="1">6632</td><td align="left" rowspan="1" colspan="1">Cross-sectional community-based survey of men in Uttar Pradesh, India</td><td align="left" rowspan="1" colspan="1">Men having extramarital sex and STD<xref ref-type="table-fn" rid="T000F2">†</xref> symptoms were more likely to abuse their wives</td></tr><tr><td align="left" rowspan="1" colspan="1">Rowley <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2008</td><td align="center" rowspan="1" colspan="1">1743</td><td align="left" rowspan="1" colspan="1">Cluster survey in Lugufu refugee camp, Tanzania</td><td align="left" rowspan="1" colspan="1">Factors that may increase the risk of HIV<xref ref-type="table-fn" rid="T000F1">*</xref> infections among refugees compared to the population in the surrounding villages include young age of sexual initiation among males, high-risk sex partners in the 15-24 year age group, limited access to income, and the vulnerability of refugee women totransactional sex</td></tr><tr><td align="left" rowspan="1" colspan="1">Silverman <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2007</td><td align="center" rowspan="1" colspan="1">287</td><td align="left" rowspan="1" colspan="1">Retrospective analytical study of sex-trafficked Nepali women</td><td align="left" rowspan="1" colspan="1">Repatriated Nepalese sex-trafficked girls and women were found to have a high prevalence of HIV<xref ref-type="table-fn" rid="T000F1">*</xref> infection, with increased risk among those trafficked prior to the age of 15 years</td></tr><tr><td align="left" rowspan="1" colspan="1">Sarkar <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2008</td><td align="center" rowspan="1" colspan="1">580</td><td align="left" rowspan="1" colspan="1">Community-based cross-sectional survey of sex workers in Eastern India</td><td align="left" rowspan="1" colspan="1">The seroprevalence of HIV<xref ref-type="table-fn" rid="T000F1">*</xref> was strikingly higher among Nepalese (43%) than among Bangladeshis (7%) and Indians (9%).</td></tr><tr><td align="left" rowspan="1" colspan="1">Lau <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2009</td><td align="center" rowspan="1" colspan="1">728</td><td align="left" rowspan="1" colspan="1">Two point cross-sectional analysis of clients of female sex workers in China following an intervention safe sex</td><td align="left" rowspan="1" colspan="1">Condom use and service utilization behaviors changed in the study population over a time period, when an enhanced intervention program was implemented</td></tr><tr><td align="left" rowspan="1" colspan="1">Subramanian <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2008</td><td align="center" rowspan="1" colspan="1">4821</td><td align="left" rowspan="1" colspan="1">Cross-sectional survey of clients of female sex workers in Andhra Pradesh, India</td><td align="left" rowspan="1" colspan="1">The prevalence of HIV<xref ref-type="table-fn" rid="T000F1">*</xref> ranged from 2.0 to 10.9%, syphilis ranged from 3.1 to 10.1%; gonorrhea and Chlamydia ranged between 0 and 4.5%</td></tr><tr><td align="left" rowspan="1" colspan="1">Patterson <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2009</td><td align="center" rowspan="1" colspan="1">400</td><td align="left" rowspan="1" colspan="1">Cross-sectional survey of clients of female sex workers in Mexico</td><td align="left" rowspan="1" colspan="1">Although sexually transmitted infection prevalence was lower than among female sex workers, HIV<xref ref-type="table-fn" rid="T000F1">*</xref> prevalence was comparable, suggesting the need for interventions among clients</td></tr><tr><td align="left" rowspan="1" colspan="1">Cohen <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2000</td><td align="center" rowspan="1" colspan="1">1645</td><td align="left" rowspan="1" colspan="1">Survey of women with HIV<xref ref-type="table-fn" rid="T000F1">*</xref> or at risk of HIV<xref ref-type="table-fn" rid="T000F1">*</xref></td><td align="left" rowspan="1" colspan="1">A continuum of risk, with early childhood abuse leading to later domestic violence, may increase the risk of behaviors leading to HIV<xref ref-type="table-fn" rid="T000F1">*</xref> infection</td></tr><tr><td align="left" rowspan="1" colspan="1">McDonnell <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2003</td><td align="center" rowspan="1" colspan="1">611</td><td align="left" rowspan="1" colspan="1">Quantitative and qualitative assessment of HIV<xref ref-type="table-fn" rid="T000F1">*</xref> positive and demographically similar HIV<xref ref-type="table-fn" rid="T000F1">*</xref> negative women</td><td align="left" rowspan="1" colspan="1">Significant differences were found between HIV<xref ref-type="table-fn" rid="T000F1">*</xref>-positive women and HIV<xref ref-type="table-fn" rid="T000F1">*</xref>-negative women in the pattern of abuse experienced as children, the frequency of abuse as an adult, and the involvement of women's drinking before or during a violent episode</td></tr><tr><td align="left" rowspan="1" colspan="1">McDonnell <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2005</td><td align="center" rowspan="1" colspan="1">445 (188 HIV<xref ref-type="table-fn" rid="T000F1">*</xref> + 257 HIV<xref ref-type="table-fn" rid="T000F1">*</xref> -)</td><td align="left" rowspan="1" colspan="1">Quantitative and qualitative assessment</td><td align="left" rowspan="1" colspan="1">Living with HIV<xref ref-type="table-fn" rid="T000F1">*</xref> or having experienced inter-partner violence in the past year was significantly associated with poorer levels of the health-related quality of life</td></tr><tr><td align="left" rowspan="1" colspan="1">Gielen <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2000</td><td align="center" rowspan="1" colspan="1">310</td><td align="left" rowspan="1" colspan="1">Quantitative and qualitative assessment of HIV<xref ref-type="table-fn" rid="T000F1">*</xref> positive women in the United States of America</td><td align="left" rowspan="1" colspan="1">Although 4% reported physical abuse following a disclosure event, 45% reported experiencing emotional, physical, or sexual abuse some time after their diagnosis</td></tr><tr><td align="left" rowspan="1" colspan="1">Maman <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2002</td><td align="center" rowspan="1" colspan="1">245</td><td align="left" rowspan="1" colspan="1">Follow-up study of HIV<xref ref-type="table-fn" rid="T000F1">*</xref> positive and negative women for three months after HIV<xref ref-type="table-fn" rid="T000F1">*</xref> testing</td><td align="left" rowspan="1" colspan="1">The odds of reporting at least one violent event was significantly higher among HIV<xref ref-type="table-fn" rid="T000F1">*</xref>-positive women than among HIV-negative women (OR<sup>‡</sup>-2.63)</td></tr></tbody></table><table-wrap-foot><fn id="T000F1"><label>*</label><p>HIV-Human immunodeficiency virus</p></fn><fn id="T000F2"><label>†</label><p>STD-Sexually transmitted diseases, OR-Odds ratio</p></fn></table-wrap-foot></table-wrap><table-wrap id="T0002" position="float"><label>Table 2</label><caption><p>HIV and women; a look into the nonbiological factors complicating the picture. A brief summary of studies quoted in text (in order of citation, continued from <xref ref-type="table" rid="T0001">Table 1</xref>)</p></caption><table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="1" colspan="1">Author</th><th align="center" rowspan="1" colspan="1">Year published</th><th align="center" rowspan="1" colspan="1">Sample size</th><th align="left" rowspan="1" colspan="1">Study design</th><th align="left" rowspan="1" colspan="1">Conclusions</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">Gaillard <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2002</td><td align="center" rowspan="1" colspan="1">290</td><td align="left" rowspan="1" colspan="1">Intervention study of HIV<xref ref-type="table-fn" rid="T000F3">*</xref>-positive women in Kenya</td><td align="left" rowspan="1" colspan="1">Despite careful counseling, 10% subsequently experienced violence or disruption of their relationship</td></tr><tr><td align="left" rowspan="1" colspan="1">Talbott <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2007</td><td rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1">Analytical study of UNAIDS<xref ref-type="table-fn" rid="T000F5">§</xref> data for 77 countries</td><td align="left" rowspan="1" colspan="1">Significant correlation exists between a countries' HIV<xref ref-type="table-fn" rid="T000F3">*</xref> prevalence and income inequality, but not with wealth</td></tr><tr><td align="left" rowspan="1" colspan="1">Adimora <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2006</td><td align="center" rowspan="1" colspan="1">493 cases, 1063 controls</td><td align="left" rowspan="1" colspan="1">Population-based case-control study of black men and women, aged between 18 and 61 years in North Carolina</td><td align="left" rowspan="1" colspan="1">Poverty may be an underlying determinant of high risk behaviors and a contributor to infection risk even in people who do not have high-risk behaviors</td></tr><tr><td align="left" rowspan="1" colspan="1">Dunkle <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2004</td><td align="center" rowspan="1" colspan="1">1366</td><td align="left" rowspan="1" colspan="1">Cross-sectional study of women seeking antenatal care in Soweto, South Africa</td><td align="left" rowspan="1" colspan="1">Transactional sex may place women at an increased risk of HIV<xref ref-type="table-fn" rid="T000F3">*</xref>, and is associated with gender-based violence, substance use, and socio-economic disadvantage</td></tr><tr><td align="left" rowspan="1" colspan="1">Hargreaves <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2002</td><td align="center" rowspan="1" colspan="1">1000 men, 1000 women</td><td align="left" rowspan="1" colspan="1">Cross-sectional population survey of adults from an urban population, Kenya</td><td align="left" rowspan="1" colspan="1">Risk profiles suggested that men and women of lower socioeconomic status may be at a greater risk of newly acquired HIV<xref ref-type="table-fn" rid="T000F3">*</xref> infection</td></tr><tr><td align="left" rowspan="1" colspan="1">Gavin <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2006</td><td align="center" rowspan="1" colspan="1">1807</td><td align="left" rowspan="1" colspan="1">Cross-sectional analysis combined with HIV<xref ref-type="table-fn" rid="T000F3">*</xref> testing for females aged between 15 and 19 years in Zimbabwe</td><td align="left" rowspan="1" colspan="1">Adolescent females in Zimbabwe who are married, not attending school and/or are unemployed, are at a higher risk of HIV<xref ref-type="table-fn" rid="T000F3">*</xref> infection</td></tr><tr><td align="left" rowspan="1" colspan="1">Weiser <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2007</td><td align="center" rowspan="1" colspan="1">2051</td><td align="left" rowspan="1" colspan="1">Cross-sectional population-based study of adults in Botswana and Swaziland</td><td align="left" rowspan="1" colspan="1">Food insufficiency was associated with inconsistent condom use with a non-primary partner, sex exchange, intergenerational sexual relationships, and lack of control in sexual relationships.</td></tr><tr><td align="left" rowspan="1" colspan="1">Oyefara <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2005</td><td align="center" rowspan="1" colspan="1">320</td><td align="left" rowspan="1" colspan="1">Cross-sectional survey and qualitative interviews of female sex workers in Lagos, Nigeria</td><td align="left" rowspan="1" colspan="1">There is a significant relationship between poverty, food insecurity, and use of condoms by sex workers at a <italic>P</italic> < 0.01</td></tr><tr><td align="left" rowspan="1" colspan="1">Seib <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2009</td><td align="center" rowspan="1" colspan="1">247 sex workers, 185 clients</td><td align="left" rowspan="1" colspan="1">Cross-sectional analysis of sex workers and clients in Australia</td><td align="left" rowspan="1" colspan="1">There was little variation in self-reported lifetime STD<xref ref-type="table-fn" rid="T000F4">†</xref> prevalence of licensed brothel, private and illegal (predominantly street-based) sex workers, although licensed brothel workers have been less likely to report ever being diagnosed with gonorrhea or pubic lice in the past (<italic>P</italic> = 0.035 and 0.004, respectively).</td></tr><tr><td align="left" rowspan="1" colspan="1">Mercer <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2007</td><td align="center" rowspan="1" colspan="1">1175 women, 703 men</td><td align="left" rowspan="1" colspan="1">Cross-sectional survey of rural married adults in Bangladesh</td><td align="left" rowspan="1" colspan="1">The proportions of men who reported sex with a female sex worker or with another male, while living away, were double the proportions reporting they had done so before living away or among men who had not lived away (<italic>P</italic> < 0.05).</td></tr><tr><td align="left" rowspan="1" colspan="1">Go <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2003</td><td align="center" rowspan="1" colspan="1">84</td><td align="left" rowspan="1" colspan="1">In-depth interviews and focus group discussions with adult men and women from slum communities of Chennai, India</td><td align="left" rowspan="1" colspan="1">Given the choice between the immediate threat of violence and the relatively hypothetical risk of HIV<xref ref-type="table-fn" rid="T000F3">*</xref>, women often resign themselves to sexual demands and indiscretions that may increase their risk of HIV<xref ref-type="table-fn" rid="T000F3">*</xref> acquisition</td></tr><tr><td align="left" rowspan="1" colspan="1">Luginaah <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2005</td><td align="center" rowspan="1" colspan="1">Two focus groups</td><td align="left" rowspan="1" colspan="1">In-depth interviews and focus group discussions with widows and community leaders in Nyanza, Kenya</td><td align="left" rowspan="1" colspan="1">Wife inheritance, emerged as an outstanding issue forthe widows in the context of HIV<xref ref-type="table-fn" rid="T000F3">*</xref> transmission</td></tr><tr><td align="left" rowspan="1" colspan="1">Voisin <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2006</td><td align="center" rowspan="1" colspan="1">280</td><td align="left" rowspan="1" colspan="1">Survey among detained female adolescents in the United States of America</td><td align="left" rowspan="1" colspan="1">Greater substance use, stronger risk-taking attitudes, lower perceived parental monitoring, and familial support, gender roles supporting male dominance, risky peer norms, and lower student-teacher connectedness, were independently associated with increased STD<xref ref-type="table-fn" rid="T000F4">†</xref> risk behaviors</td></tr><tr><td align="left" rowspan="1" colspan="1">Harrison <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2006</td><td align="center" rowspan="1" colspan="1">101 male, 199 female adolescents</td><td align="left" rowspan="1" colspan="1">Survey on adolescents aged between 18 and 24 years in South Africa</td><td align="left" rowspan="1" colspan="1">For men, more frequent condom use was not only associated with higher levels of partner attachment, but also with stronger approval of relationship violence and dominant behavior. In contrast, for women, more frequent condom use was correlated with a lower endorsement of relationship violence</td></tr><tr><td align="left" rowspan="1" colspan="1">Kaufman <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2008</td><td align="center" rowspan="1" colspan="1">309 males</td><td align="left" rowspan="1" colspan="1">Survey of men attending STD<xref ref-type="table-fn" rid="T000F4">†</xref> services clinic in Cape Town, South Africa</td><td align="left" rowspan="1" colspan="1">A negative attitude toward women was significantly positively associated with a high level of HIV<xref ref-type="table-fn" rid="T000F3">*</xref> risk behavior, and that endorsement of traditional male roles was negatively associated with HIV<xref ref-type="table-fn" rid="T000F3">*</xref> risk behavior</td></tr><tr><td align="left" rowspan="1" colspan="1">Hebling <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2004</td><td align="center" rowspan="1" colspan="1">Six focus groups</td><td align="left" rowspan="1" colspan="1">Qualitative study with focus group discussions associated with a prospective interventional study</td><td align="left" rowspan="1" colspan="1">Although women had information about HIV<xref ref-type="table-fn" rid="T000F3">*</xref>, they did not use preventive measures in steady relationships because they did not wield their decision-making power. Gender inequality and fidelity were two significant issues related to the increase in HIV<xref ref-type="table-fn" rid="T000F3">*</xref> among women</td></tr><tr><td align="left" rowspan="1" colspan="1">Kerrigan <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2007</td><td align="center" rowspan="1" colspan="1">50</td><td align="left" rowspan="1" colspan="1">In-depth interviews with African American adolescents in Boston, United States of America</td><td align="left" rowspan="1" colspan="1">Stronger adherence to female gender ideologies related to emotional strength and caretaking may be linked to a heightened desire for male intimacy and tolerance of male sexual risk behavior, with increased risk of HIV<xref ref-type="table-fn" rid="T000F3">*</xref> transmission</td></tr><tr><td align="left" rowspan="1" colspan="1">Stephenson <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2009</td><td align="center" rowspan="1" colspan="1">11,410</td><td align="left" rowspan="1" colspan="1">Analysisof demographic health survey data for men and women aged between 15 and 24 years, in Ghana, Burkina Faso, and Zambia</td><td align="left" rowspan="1" colspan="1">For young women, residence in communities with demographic and behavioral patterns that are indicative of greater opportunities are associated with increased knowledge of HIV</td></tr><tr><td align="left" rowspan="1" colspan="1">Smith <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2004</td><td align="center" rowspan="1" colspan="1">863</td><td align="left" rowspan="1" colspan="1">Cross-sectional analysis combined with in-depth interviews of adolescents and unmarried young adults</td><td align="left" rowspan="1" colspan="1">Assessments of current and potential partners, choices about whether or not to have sex, and decisions about whether or not to use condoms are influenced by shared cultural values regarding the importance of parenthood. These are gender-specific and put men and women in different negotiating positions with regard to sex and contraception</td></tr><tr><td align="left" rowspan="1" colspan="1">Jarama <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2007</td><td align="center" rowspan="1" colspan="1">51</td><td align="left" rowspan="1" colspan="1">Qualitative study among African American women</td><td align="left" rowspan="1" colspan="1">Despite having risk behaviors, all women in the sample perceived their risk of infection to be nonexistent</td></tr><tr><td align="left" rowspan="1" colspan="1">Prata <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2005</td><td align="center" rowspan="1" colspan="1">1995</td><td align="left" rowspan="1" colspan="1">Knowledge, attitudes and practices survey in Luanda, Angola among youth aged between 15 and 24 years</td><td align="left" rowspan="1" colspan="1">Urban residence, higher education, being in school and not equating condom use with lack of trust were important predictors of use at last intercourse in regular and casual relationships, whereas, access to condoms was the most important factor in spousal relationships</td></tr><tr><td align="left" rowspan="1" colspan="1">de Walque <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2005</td><td align="center" rowspan="1" colspan="1">Round 1 Females: 1627 Males: 1388 Round 2 Females: 2271 Males: 1876</td><td align="left" rowspan="1" colspan="1">Cohort study in Uganda with follow-up for 11 years</td><td align="left" rowspan="1" colspan="1">In 1989-1990, higher educational attainment was associated with higher risk of HIV<xref ref-type="table-fn" rid="T000F3">*</xref>-1 infection, especially among males, but once odds ratios were adjusted for age, no significant relation remained. In 1999-2000, there was, for females aged 18 – 29 years, a significant relationship between higher educational attainment and lower HIV<xref ref-type="table-fn" rid="T000F3">*</xref> prevalence. (<italic>P</italic> for trend 0.01)</td></tr><tr><td align="left" rowspan="1" colspan="1">Barden-O'Fallon <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2004</td><td align="center" rowspan="1" colspan="1">1601</td><td align="left" rowspan="1" colspan="1">Community-based survey in rural Malawi</td><td align="left" rowspan="1" colspan="1">Knowledge of HIV does not necessarily translate into perceived risk. In addition, there appears to be a gender difference where men assess risk in a relationship to their own behavior, while women do so in relation to their partner's behavior</td></tr></tbody></table><table-wrap-foot><fn id="T000F3"><label>*</label><p>HIV-Human immunodeficiency virus</p></fn><fn id="T000F4"><label>†</label><p>STD- Sexually transmitted diseases</p></fn><fn id="T000F5"><label>§</label><p>UNAIDS- United Nations Joint Programme on HIV/AIDS</p></fn></table-wrap-foot></table-wrap><table-wrap id="T0003" position="float"><label>Table 3</label><caption><p>HIV and women; a look in to the nonbiological factors complicating the picture. A brief summary of studies quoted in text (in order of citation, continued from <xref ref-type="table" rid="T0001">Table 2</xref>)</p></caption><table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="1" colspan="1">Author</th><th align="center" rowspan="1" colspan="1">Year published</th><th align="center" rowspan="1" colspan="1">Sample size</th><th align="left" rowspan="1" colspan="1">Study design</th><th align="left" rowspan="1" colspan="1">Conclusions</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">Mansoor <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2008</td><td align="center" rowspan="1" colspan="1">1054</td><td align="left" rowspan="1" colspan="1">Survey among First year students in Afghan Universities</td><td align="left" rowspan="1" colspan="1">Females were statistically more knowledgeable than males, and high-risk behaviors were significantly more prevalent among males; <italic>P</italic> = 0.01 and <italic>P</italic> = 0.001, respectively</td></tr><tr><td align="left" rowspan="1" colspan="1">Li <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2004</td><td align="center" rowspan="1" colspan="1">1081</td><td align="left" rowspan="1" colspan="1">Survey on Chinese College students</td><td align="left" rowspan="1" colspan="1">Males were more knowledgeable than females overall (<italic>P</italic> < 0.0001)</td></tr><tr><td align="left" rowspan="1" colspan="1">McManus <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2008</td><td align="center" rowspan="1" colspan="1">251</td><td align="left" rowspan="1" colspan="1">Cross-sectional survey on girls in secondary schools in New Delhi, India</td><td align="left" rowspan="1" colspan="1">About 30% of respondents considered HIV<xref ref-type="table-fn" rid="T000F6">*</xref>/AIDS<xref ref-type="table-fn" rid="T000F9">‖</xref> could be cured, 49% felt that condoms should not be available to youth, 41% were confused about whether the contraceptive pill could protect against HIV<xref ref-type="table-fn" rid="T000F6">*</xref> infection and 32%thought it should only betaken by married women</td></tr><tr><td align="left" rowspan="1" colspan="1">DiClemente <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2004</td><td align="center" rowspan="1" colspan="1">522</td><td align="left" rowspan="1" colspan="1">Randomized controlled trial of African American girls aged between 14 and 18 years. The intervention group underwent a comprehensive education programme</td><td align="left" rowspan="1" colspan="1">Over the 12-month follow-up, adolescents in the intervention were more likely to use a condom at the last intercourse, less likely to have a new vaginal sex partner in the prior 30 days, and more likely to apply condoms to sex partners and they had better condom application skills, a higher percentage of condom-protected sexacts, and fewer unprotected vaginal sex acts</td></tr><tr><td align="left" rowspan="1" colspan="1">Hirsl-Hećej <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2006</td><td align="center" rowspan="1" colspan="1">2070 in first round, 1972 in second round</td><td align="left" rowspan="1" colspan="1">Two-wave cross-sectional analysis of Croatian adolescents in a four-year interval</td><td align="left" rowspan="1" colspan="1">Statistically significant increases in knowledge of HIV<xref ref-type="table-fn" rid="T000F6">*</xref> and condom use. Both changes were more substantial among female students</td></tr><tr><td align="left" rowspan="1" colspan="1">Chhabra <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2008</td><td align="center" rowspan="1" colspan="1">1846</td><td align="left" rowspan="1" colspan="1">Interventional study to assess school-based educational program in Mumbai, India</td><td align="left" rowspan="1" colspan="1">Both boys and girls significantly improved their knowledge, attitudes, and beliefs regarding HIV<xref ref-type="table-fn" rid="T000F6">*</xref>/AIDS<xref ref-type="table-fn" rid="T000F9">‖</xref> and in their confidence level in dealing with risky behavior. However girls showed significantly better results on comparison</td></tr><tr><td align="left" rowspan="1" colspan="1">Di <italic>Noia <italic>et al.</italic></italic></td><td align="center" rowspan="1" colspan="1">2007</td><td align="center" rowspan="1" colspan="1">204</td><td align="left" rowspan="1" colspan="1">Interventional study to assess an educational program on HIV<xref ref-type="table-fn" rid="T000F6">*</xref> prevention</td><td align="left" rowspan="1" colspan="1">Improved HIV<xref ref-type="table-fn" rid="T000F6">*</xref> knowledge and understanding of avoidance of risk behavior compared to controls</td></tr><tr><td align="left" rowspan="1" colspan="1">Ndiaye <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2009</td><td align="center" rowspan="1" colspan="1">318</td><td align="left" rowspan="1" colspan="1">Cross-sectional analysis of HIV<xref ref-type="table-fn" rid="T000F6">*</xref>-positive males and females in Mali and Burkina Faso on the sero status disclosure</td><td align="left" rowspan="1" colspan="1">Cohabiting with the partner was strongly associated with disclosure in both men and women. In men only, older age, literacy, and having good communication with the treating doctor were significantly associated with disclosure. Among women, having children and high self-reported importance of religion was associated with disclosure</td></tr><tr><td align="left" rowspan="1" colspan="1">Arrington-Sanders <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2008</td><td align="center" rowspan="1" colspan="1">369</td><td align="left" rowspan="1" colspan="1">Prevalence of HIV<xref ref-type="table-fn" rid="T000F6">*</xref> testing among sexually active African Americans</td><td align="left" rowspan="1" colspan="1">The adjusted odds of HIV<xref ref-type="table-fn" rid="T000F6">*</xref> testing was 2.7 times higher for female adolescents than males</td></tr><tr><td align="left" rowspan="1" colspan="1">Jarrin <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2008</td><td align="center" rowspan="1" colspan="1">6923</td><td align="left" rowspan="1" colspan="1">Retrospective analysis of 23 HIV<xref ref-type="table-fn" rid="T000F6">*</xref> seroconverter cohort studies from Europe, Australia, and Canada</td><td align="left" rowspan="1" colspan="1">From 1997 onward, women had a lower risk of AIDS<xref ref-type="table-fn" rid="T000F9">‖</xref> (adjusted cumulative relative risk = 0.76) and death (adjusted hazard ratio = 0.68) than men</td></tr><tr><td align="left" rowspan="1" colspan="1">Moore <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2002</td><td align="center" rowspan="1" colspan="1">497 males, 146 females</td><td align="left" rowspan="1" colspan="1">Prospective cohort study after initiation of HAART<sup>¶</sup></td><td align="left" rowspan="1" colspan="1">A possible benefit in women compared to men, in the rate of outcomes after HAART<sup>¶</sup></td></tr><tr><td align="left" rowspan="1" colspan="1">Chen <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2008</td><td align="center" rowspan="1" colspan="1">2838</td><td align="left" rowspan="1" colspan="1">Retrospective cohort study</td><td align="left" rowspan="1" colspan="1">Significantly higher survival rates among females than males in WHO<xref ref-type="table-fn" rid="T000F10">**</xref> stages 1, 2, and 3 (both <italic>P</italic> < 0.0001) and borderline in stage 4 (<italic>P</italic> = 0.076)</td></tr><tr><td align="left" rowspan="1" colspan="1">Chandra <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2009</td><td align="center" rowspan="1" colspan="1">log</td><td align="left" rowspan="1" colspan="1">Cross-sectional analysis of quality of life using WHO<xref ref-type="table-fn" rid="T000F10">**</xref> quality of life instrument for HIV<xref ref-type="table-fn" rid="T000F6">*</xref> in men and women, living with HIV<xref ref-type="table-fn" rid="T000F6">*</xref>, in South India</td><td align="left" rowspan="1" colspan="1">Men reported significantly higher quality of life in the following facets — positive feeling, sexual activity, financial resources, and transport, while women reported significantly higher quality of life on the forgiveness and blame facet</td></tr><tr><td align="left" rowspan="1" colspan="1">Braitstein <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2008</td><td align="center" rowspan="1" colspan="1">33,164</td><td align="left" rowspan="1" colspan="1">A comparison of UN AIDS<xref ref-type="table-fn" rid="T000F8">§</xref> data on the gender distribution of HIV<xref ref-type="table-fn" rid="T000F6">*</xref> infection with the proportions of women and men receiving HAART<sup>¶</sup> in the ART-LINC Collaboration (Clinic network in Asia, Africa, and Latin America)</td><td align="left" rowspan="1" colspan="1">Women in resource-constrained settings are not necessarily disadvantaged in their access to HAART<sup>¶</sup></td></tr><tr><td align="left" rowspan="1" colspan="1">Cook <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2007</td><td align="center" rowspan="1" colspan="1">1710</td><td align="left" rowspan="1" colspan="1">Prospective cohort study on HIV<xref ref-type="table-fn" rid="T000F6">*</xref> positive women in the United States of America</td><td align="left" rowspan="1" colspan="1">There were interactive effects of drug use and depressive symptoms on reduced likelihood of HAART<sup>¶</sup></td></tr><tr><td align="left" rowspan="1" colspan="1">Mathews <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2002</td><td align="center" rowspan="1" colspan="1">235</td><td align="left" rowspan="1" colspan="1">Prospective cohort study on predictors of adherence and outcome after initiation of HAAR<sup>¶</sup></td><td align="left" rowspan="1" colspan="1">Males were more adherent than females (<italic>P</italic> < 0.05) to HAART<sup>¶</sup> regimes</td></tr><tr><td align="left" rowspan="1" colspan="1">Turner <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2003</td><td align="center" rowspan="1" colspan="1">5073</td><td align="left" rowspan="1" colspan="1">Prospective cohort study on HIV<xref ref-type="table-fn" rid="T000F6">*</xref> positive individuals on HAAR<sup>¶</sup> in the United States of America</td><td align="left" rowspan="1" colspan="1">Women were less adherent than men (18 vs. 25%, respectively, <italic>P</italic> < 0.001) and more likely to be diagnosed with depression (34 vs. 29%)</td></tr><tr><td align="left" rowspan="1" colspan="1">Berg <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2004</td><td align="center" rowspan="1" colspan="1">113</td><td align="left" rowspan="1" colspan="1">Prospective cohort study on HIV<xref ref-type="table-fn" rid="T000F6">*</xref> positive current or former opioid users</td><td align="left" rowspan="1" colspan="1">Median adherence among women was 27% lower than among men (46 vs. 73%; <italic>P</italic> < 0.05)</td></tr><tr><td align="left" rowspan="1" colspan="1">Applebaum <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2009</td><td align="center" rowspan="1" colspan="1">67</td><td align="left" rowspan="1" colspan="1">Analysis of adherence to treatment regimes in HIV<xref ref-type="table-fn" rid="T000F6">*</xref>-positive individuals</td><td align="left" rowspan="1" colspan="1">No significant difference in adherence was observed between men and women</td></tr><tr><td align="left" rowspan="1" colspan="1">Solomon <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2008</td><td align="center" rowspan="1" colspan="1">356</td><td align="left" rowspan="1" colspan="1">Cross-sectional analysis of HIV<xref ref-type="table-fn" rid="T000F6">*</xref>-positive people in South India</td><td align="left" rowspan="1" colspan="1">Men and women reported similar scores in physical well-being, satisfaction with healthcare, and relationship with partner from the period prior to care, at enrollment, and at 6 months. Women scored significantly lower than men in psychosocial well-being from the period prior to care, at enrollment, and at six months (<italic>P</italic> < 0.05)</td></tr><tr><td align="left" rowspan="1" colspan="1">Shor-Posner <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2000</td><td align="center" rowspan="1" colspan="1">75</td><td align="left" rowspan="1" colspan="1">Prospective cohort study of intravenous drug using HIV<xref ref-type="table-fn" rid="T000F6">*</xref> positive individuals</td><td align="left" rowspan="1" colspan="1">Significant gender differences were observed in activity assessment. Independent of disease status, women had significantly lower activity scores (<italic>P</italic> = 0.0038)</td></tr><tr><td align="left" rowspan="1" colspan="1">Strebel <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2006</td><td rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1">Qualitative study with in-depth interviews and focus group discussions</td><td align="left" rowspan="1" colspan="1">The familiar issues of stigma, denial, and disclosure emerged in both interviews and focus groups. Use of condoms was difficult. HIV<xref ref-type="table-fn" rid="T000F6">*</xref> positive women suffered differently from stigma compared to men</td></tr><tr><td align="left" rowspan="1" colspan="1">Mantell <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2009</td><td align="center" rowspan="1" colspan="1">10 semi-structured focus group discussions</td><td align="left" rowspan="1" colspan="1">Qualitative study among tertiary institution students in South Africa</td><td align="left" rowspan="1" colspan="1">Significant changes in the post-apartheid era, particularly for emerging gender norms that promote women's protection against unintended pregnancy and HIV<xref ref-type="table-fn" rid="T000F6">*</xref>/STDs<xref ref-type="table-fn" rid="T000F7">†</xref> were observed.</td></tr><tr><td align="left" rowspan="1" colspan="1">Molla <italic>et al.</italic></td><td align="center" rowspan="1" colspan="1">2008</td><td align="center" rowspan="1" colspan="1">3743</td><td align="left" rowspan="1" colspan="1">Cross-sectional survey among Ethiopian youth</td><td align="left" rowspan="1" colspan="1">Those who did not believe in traditional values of preserving virginity (adjusted hazard ratio = 2.91), were more likely to have premarital sex than their counterparts</td></tr></tbody></table><table-wrap-foot><fn id="T000F6"><label>*</label><p>HIV = Human Immunodeficiency Virus</p></fn><fn id="T000F7"><label>†</label><p>STD = Sexually Transmitted Diseases, OR = Odds Ratio</p></fn><fn id="T000F8"><label>§</label><p>UNAIDS = United Nations Joint Program on HIV/AIDS</p></fn><fn id="T000F9"><label>‖</label><p>AIDS = Acquired Immuno deficiency Syndrome, HAART = Highly active antiretroviral therapy</p></fn><fn id="T000F10"><label>**</label><p>WHO = World Health Organization</p></fn><fn><p>††AOR = Adjusted odds ratio</p></fn></table-wrap-foot></table-wrap><sec id="sec2-1"><title>Violence</title><p>Violence against women can occur in different settings including civil wars, communal disputes, and domestic violence.[<xref ref-type="bibr" rid="CIT4">4</xref><xref ref-type="bibr" rid="CIT5">5</xref>] The gender based violence (GBV) defined in this article includes all forms of physical, sexual, and emotional abuse against women. A cross-sectional survey in eight African countries revealed that 18% of the women had experienced GBV within one year.[<xref ref-type="bibr" rid="CIT6">6</xref>] Another multicenter study in ten countries (n-24,097) reported the lifetime risk of inter-partner violence (IPV) to be in the range of 15-71%, indicating a wide range of variation in communities.[<xref ref-type="bibr" rid="CIT7">7</xref>]</p><p>It is established that HIV is more likely to be transmitted in an act of forced penetration rather than during voluntary sex, due to factors such as inability to negotiate on safer sex and breach of epithelial barriers (with trauma) making it easier for the virus to enter the blood stream.[<xref ref-type="bibr" rid="CIT8">8</xref>] Forced sex increases the woman's chances of contracting a sexually transmitted disease (STD) four-fold.[<xref ref-type="bibr" rid="CIT8">8</xref>]</p><sec id="sec3-1"><title>Violence makes women vulnerable to HIV</title><p>A population-based survey in Tanzania concluded that women had a significantly higher risk of HIV [Odds ratio(OR)-2.0] if they had experienced coerced sex before 18 years of age.[<xref ref-type="bibr" rid="CIT9">9</xref>] Fonck <italic>et al.</italic>[<xref ref-type="bibr" rid="CIT10">10</xref>] reports a two-fold higher risk of lifetime intimate partner violence for HIV positive women. A cross-sectional survey by Dunkle <italic>et al.</italic>[<xref ref-type="bibr" rid="CIT11">11</xref>] in South Africa has shown that intimate partner violence (OR-1.48) and high level of male control in a relationship (OR-1.52) was associated with HIV infection.</p><p>However, Jewkes <italic>et al.</italic>[<xref ref-type="bibr" rid="CIT12">12</xref>] has shown that while IPV is strongly associated with many HIV risk factors, it was not directly or significantly correlated with HIV positivity when corrected for other risk behaviors. A similar conclusion of an indirect relationship between IPV and HIV is suggested by Pettifor <italic>et al.</italic> and Langen <italic>et al.</italic>[<xref ref-type="bibr" rid="CIT13">13</xref><xref ref-type="bibr" rid="CIT14">14</xref>] This difference can be partly explained by the sample selection (general population vs. at-risk population). Many risk factors having a direct association with HIV, such as, age gap between the partners, frequency of intercourse, and number of sexual partners in the past year can be linked to IPV as well. In fact, Jewkes <italic>et al.</italic>[<xref ref-type="bibr" rid="CIT12">12</xref>] have demonstrated an association between such HIV risk factors and IPV, although a direct association has not been seen between IPV and HIV positivity.</p><p>An interventional prospective study in South Africa, by Pronyk <italic>et al.</italic>,[<xref ref-type="bibr" rid="CIT15">15</xref>] showed that economic empowerment and skill development of women reduced IPV by 55% in the intervention group. The microfinance initiative was linked with an HIV awareness program. However, neither the risk behaviors nor the HIV prevalence showed a significant difference at the end of follow up (after three years) between groups.</p><p>Studies outside Africa report a strong association between violence and HIV risk. In a cross-sectional survey of adolescents in USA, Viosin <italic>et al.</italic>[<xref ref-type="bibr" rid="CIT16">16</xref>] have reported that those exposed to family or community violence are three to four times more likely than their peers to engage in HIV risk behaviors. However, this association was more common in boys than in girls. In a survey of Hispanic women in Boston, USA, Raj <italic>et al.</italic>[<xref ref-type="bibr" rid="CIT17">17</xref>] have reported increased HIV risk for abused women than non-abused women. In India, a systematic multistage survey delineated a close relationship between IPV and risk behavior [men with extramarital affairs and STD symptoms were more likely to abuse their wives (OR-6.22 and 2.43, respectively)].[<xref ref-type="bibr" rid="CIT18">18</xref>]</p><p>In addition to IPV, women are victimized by other means, especially in times of war and civil unrest. Rape of women is well-documented in many civil wars in Africa (Rwanda, Sierra Leone, and Liberia). In some situations women were deliberately raped by HIV positive individuals to inflict psychological trauma and a ‘painful’ death.[<xref ref-type="bibr" rid="CIT5">5</xref>] In Nepal, at the beginning of the Maoist insurgency (1999), the HIV prevalence in Kathmandu stood at 2.7%. Three years later it had shot up to 17%.[<xref ref-type="bibr" rid="CIT19">19</xref>] Vulnerability of refugee women for transactional sex was identified as a risk factor for HIV in a survey of the Lugufu refugee camp (Tanzania) by Rowley <italic>et al.</italic>[<xref ref-type="bibr" rid="CIT20">20</xref>] A significant proportion of refugees reported forced sex (<italic>P</italic> < 0.001) compared to the villagers outside the camp. Many instances of forced sex had occurred after the displacement. Younger age of sexual initiation for boys, poverty and high-risk partners in the 15-24 age group were identified as risk factors for HIV among refugees (compared to villagers), in addition to vulnerability of women. Interplay of these risk factors may result in an increased rate of unprotected intercourse (by force or by consent) within the camps. In this sample, 20% of the refugees admitted to transactional sex (92% of instances since displacement) as opposed to 4% among villagers. However 82% of these encounters were with a fellow refugee rather than an outsider. Similarly, although the incidence of forced sex was high among refugees (10 vs. 4%), in many instances (64%) the perpetrator was the intimate sexual partner.</p><p>Sex trade is another form of female exploitation and HIV spread. Child sex and trafficking of women for prostitution is a burden for many countries. The Indo-Nepal border is notorious for such activity and it is estimated that 5000-7000 Nepali women are taken across the border to India annually in sex trafficking.[<xref ref-type="bibr" rid="CIT21">21</xref>] Subsequent analysis of the sero-status of such sex-trafficked Nepali women have shown disproportionately higher rates of HIV infection compared to native Indian sex workers.[<xref ref-type="bibr" rid="CIT22">22</xref><xref ref-type="bibr" rid="CIT23">23</xref>] While many studies and interventions have targeted female sex workers (FSWs), few have observed the STD profile and HIV risk of male clients of FSWs. They are an important source of spreading the infection via heterosexual intercourse. Recent studies in Mexico, China, and India have all shown high risk behaviors and fairly high rates of HIV and other STDs in this group.[<xref ref-type="bibr" rid="CIT24">24</xref>–<xref ref-type="bibr" rid="CIT26">26</xref>]</p></sec><sec id="sec3-2"><title>HIV positivity makes women vulnerable to violence</title><p>Violence following disclosure of the sero-status is not a universal phenomenon. It depends on the locality studied. Studies in United States have failed to demonstrate a higher rate of domestic violence against HIV-positive women when compared to sero-negative women.[<xref ref-type="bibr" rid="CIT27">27</xref>–<xref ref-type="bibr" rid="CIT29">29</xref>] In a study by Gielen <italic>et al.</italic>[<xref ref-type="bibr" rid="CIT30">30</xref>], only 4% of the sample reported physical abuse immediately following disclosure. Still 45% reported some form of abuse since the time of disclosure.</p><p>A study in Tanzania showed that HIV-positive women had a higher risk of physical and sexual violence than HIV-negative women.[<xref ref-type="bibr" rid="CIT31">31</xref>] Violence was more likely to occur when the sero-status of the partner was unknown. In a prospective study in Kenya, 10% of the women experienced violence or disruption of the relationship following disclosure.[<xref ref-type="bibr" rid="CIT32">32</xref>]</p></sec></sec><sec id="sec2-2"><title>Poverty</title><p>In a statistical analysis of UNAIDS data from 77 countries, Talbott <italic>et al.</italic>[<xref ref-type="bibr" rid="CIT33">33</xref>] have identified that income inequality within a country has a positive correlation with HIV prevalence. Several studies reporting a link between violence and HIV also report a correlation between poverty and HIV.[<xref ref-type="bibr" rid="CIT9">9</xref><xref ref-type="bibr" rid="CIT20">20</xref><xref ref-type="bibr" rid="CIT34">34</xref>] Limited financial power limits autonomy in sex for women. Langen <italic>et al.</italic>[<xref ref-type="bibr" rid="CIT14">14</xref>] reports that women who are economically dependent on their partners are less likely to insist on condoms during sex. There are several other studies conducted in Sub Saharan Africa that correlates low socioeconomic status with a high HIV risk.[<xref ref-type="bibr" rid="CIT35">35</xref>–<xref ref-type="bibr" rid="CIT37">37</xref>]</p><p>Food insufficiency is a marker of poverty that places women at a significant disadvantage to acquire HIV. In a population-based, cross-sectional study in Swaziland and Botswana, Weiser <italic>et al.</italic>[<xref ref-type="bibr" rid="CIT38">38</xref>] report that food insufficiency is associated with many risk behaviors for HIV (inconsistent condom use with a non-primary partner [Adjusted odds ratio (AOR) -1.73], intergenerational sexual relationships (AOR-1.46), sex exchange (AOR-1.84), and lack of control in a sexual relationship (AOR-1.68)). Interestingly, men reported fewer instances of food insufficiency and a lesser correlation between that and risk behaviors. Dunkle <italic>et al.</italic>[<xref ref-type="bibr" rid="CIT35">35</xref>] and Oyefara[<xref ref-type="bibr" rid="CIT39">39</xref>] have independently confirmed some of these associations with food insufficiency.</p><p>Several studies outside Africa, have demonstrated a positive correlation between HIV risk and poverty, for women. A study in China on FSWs has shown that some entered the trade voluntarily.[<xref ref-type="bibr" rid="CIT40">40</xref>] However, the driving force for selling sex was poverty. If social poverty was avoided it is assumed that these women would not sell sex and will not be at risk of acquiring HIV. Many ‘low end’ FSWs in India (streetwalkers) are unable to negotiate with the client to minimize risk behaviors. Unfortunately they account for a larger proportion of all FSWs.[<xref ref-type="bibr" rid="CIT41">41</xref>] Interestingly in Australia, a wealthier country, no difference in lifetime self-reported STDs have been observed in streetwalkers, private and brothel based sex workers.[<xref ref-type="bibr" rid="CIT42">42</xref>]</p><p>Migration for economic reasons is another risk factor for HIV in both sexes.[<xref ref-type="bibr" rid="CIT43">43</xref>] Women have become a sizable proportion of the migrant population, which may have a significance in the feminization of the epidemic.[<xref ref-type="bibr" rid="CIT44">44</xref><xref ref-type="bibr" rid="CIT45">45</xref>] Migrant male workers’ risk of acquiring an STD has been linked to the time spent in the host country.[<xref ref-type="bibr" rid="CIT46">46</xref>] In the South Asian context, these men are an important source of infection for women (both spousal and non-spousal partners).[<xref ref-type="bibr" rid="CIT46">46</xref><xref ref-type="bibr" rid="CIT47">47</xref>]</p><p>The studies by Oyefara[<xref ref-type="bibr" rid="CIT39">39</xref>], Dunkle <italic>et al.</italic>[<xref ref-type="bibr" rid="CIT35">35</xref>] and Weiser <italic>et al.</italic>[<xref ref-type="bibr" rid="CIT38">38</xref>] need special mention as they have not restricted the measures of poverty to family income. There may be differences in the way income is distributed in a family, which may be disadvantageous to the women. This phenomenon may create a state of ‘relative poverty’ for women and female children (depending on the gender norms of the society) although the family income is reasonable. Pronyck <italic>et al.</italic>[<xref ref-type="bibr" rid="CIT15">15</xref>] in their interventional study failed to show a reduction in HIV incidence or risk behaviors in the intervention group, despite the upliftment of economic standing, which may be a result of the above phenomena. The study in Botswana and Swaziland showed little correlation between low socioeconomic status and HIV risk, while there was a significant risk correlation for food insufficiency.[<xref ref-type="bibr" rid="CIT38">38</xref>] In fact food insufficiency may be a better marker of poverty as it represents a final common pathway of poverty than income. It is important to identify similar markers of poverty in different societies that might better correlate with HIV risk than wealth.</p></sec><sec id="sec2-3"><title>Gender norms and culture</title><p>Gender norms can be defined as appropriate behaviors, beliefs, attitudes and conduct per gender as directed by society. It is a learnt behavior. In assigning gender roles, the phenotypical differences of genders are redefined as feminine and masculine with different capabilities in societal functioning (e.g., division of labor, power sharing, economic responsibility, dominance and submission).[<xref ref-type="bibr" rid="CIT48">48</xref>] Such gender norms are different in various societies and subject to change with time.[<xref ref-type="bibr" rid="CIT49">49</xref>] Yet, in many countries, especially in the developing world where HIV is spreading fast, females serve a subservient role to men as dictated by gender norms and culture.[<xref ref-type="bibr" rid="CIT50">50</xref><xref ref-type="bibr" rid="CIT51">51</xref>] These traditional norms place women at an increased risk as they have less freedom in choosing their partners, initiating and pacing sexual activity and negotiating on safer sex.[<xref ref-type="bibr" rid="CIT50">50</xref><xref ref-type="bibr" rid="CIT51">51</xref>] In addition, some traditions, customs and beliefs are also harmful to women (wife inheritance, having sex with a virgin as a cure for HIV).[<xref ref-type="bibr" rid="CIT52">52</xref><xref ref-type="bibr" rid="CIT53">53</xref>]</p><p>In our review, we have identified several studies linking gender roles to risk behavior. In a cross sectional analysis of females in detention in Georgia, USA, Voisin <italic>et al.</italic>[<xref ref-type="bibr" rid="CIT54">54</xref>] concludes that gender norms favoring male dominance as well as high-risk peer norms were significantly associated with STD risk (<italic>P</italic> < 0.05). A cross-sectional analysis by Harrison <italic>et al.</italic>[<xref ref-type="bibr" rid="CIT55">55</xref>] in South Africa gives an insight on changing gender roles and their impact on HIV. Their results were different to what was expected. Among men, hyper-romanticism and favoring of male dominance were associated with more consistent condom use (especially with the primary partner). More open sexual ideology was associated with less consistent condom use. Interestingly, more open sexual norms and hyper-romanticism in women was significantly associated with more partners. Similar unexpected findings were reported by Kaufman <italic>et al.</italic>[<xref ref-type="bibr" rid="CIT56">56</xref>] They showed that endorsement of traditional male dominant gender norms were associated with less HIV risk behavior for men. However, a negative attitude toward women showed (as expected) a positive correlation with risk behavior.</p><p>Qualitative studies may be a better tool to assess the complex interactions between gender norms and HIV, although the generalizability of findings remains doubtful. The interference of prevalent gender norms with HIV-prevention strategies is delineated by Go <italic>et al.</italic>[<xref ref-type="bibr" rid="CIT50">50</xref>] in a qualitative study in slum communities of Chennai, India. Risk behaviors such as multiple partners for men were ‘acceptable’ by the prevalent norms. Using condoms with regular partners was rare even when women were aware of its protection (as it would imply questioning a man's fidelity). Refusal of sex with husband was not an option even when the wife perceived a risk of infection. Similar findings were reported by Hebling <italic>et al.</italic>[<xref ref-type="bibr" rid="CIT57">57</xref>] Despite being educated on HIV transmission risks, women were unable to take precautionary measures due to prevalent gender norms and male dominance. In a study on African American adolescents in USA, Kerrigan <italic>et al.</italic>[<xref ref-type="bibr" rid="CIT58">58</xref>] explain how the female gender ideologies of care taking and emotional strength (standing by the man) can make them value relationship intimacy more than protection against HIV/STDs.</p><p>Despite their obvious negative impact on AIDS control, the traditional norms may have served a protective role against HIV too. In many developing nations, premarital sex is discouraged by tradition and is highly stigmatized. The ‘virginity’ of a female is still expected till marriage in many Asian and African societies.[<xref ref-type="bibr" rid="CIT49">49</xref><xref ref-type="bibr" rid="CIT59">59</xref><xref ref-type="bibr" rid="CIT60">60</xref>] Though it is a marker of discrimination against women, the fear of such discrimination may have discouraged premarital sex among adolescents helping to keep the epidemic at bay. It is interesting to note how the changing gender norms have made an impact on premarital sex, virginity norms, and HIV prevalence.</p></sec><sec id="sec2-4"><title>Gender differences in adherence to prevention and treatment measures</title><p>It is a commonly held view that women have less access to HIV/STD prevention programs, especially in developing nations. In three high prevalence African countries (Burkina Faso, Ghana, Zambia), a better knowledge of HIV in females was associated with living in a community with more opportunities (better education, higher age in marriage and initiation of sex).[<xref ref-type="bibr" rid="CIT61">61</xref>] A positive association between HIV knowledge and education has been reported in several other studies in Africa.[<xref ref-type="bibr" rid="CIT37">37</xref><xref ref-type="bibr" rid="CIT62">62</xref>–<xref ref-type="bibr" rid="CIT65">65</xref>] A community-based study in rural Malawi has shown that while both sexes had a good knowledge of transmission of HIV/AIDS, men were more knowledgeable than women. Age, education, occupations other than farming, and childhood residency in a city were associated with better knowledge.[<xref ref-type="bibr" rid="CIT66">66</xref>]</p><p>The few studies conducted outside Africa (within our search limitations) showed conflicting results. A cross-sectional analysis among university students in Afghanistan showed that only 28.3% of students had a good knowledge of AIDS and the scores were better in females.[<xref ref-type="bibr" rid="CIT67">67</xref>] A similar study in China has shown that the overall knowledge scores were significantly high in males compared to females (<italic>P</italic> < 0.0001) and a better awareness was associated with the number of years spent in the university and coming from an urban area.[<xref ref-type="bibr" rid="CIT68">68</xref>] Yet, the level of education had a minimal impact in certain situations. A survey among secondary school girls in New Delhi, India has shown gross inadequacy of HIV- and STD-related knowledge (30% thought HIV can be cured, 21% thought oral contraceptive pills (OCP) would protect against HIV).[<xref ref-type="bibr" rid="CIT69">69</xref>]</p><p>The importance of educational interventions for women has been underscored in several studies.[<xref ref-type="bibr" rid="CIT37">37</xref><xref ref-type="bibr" rid="CIT70">70</xref>–<xref ref-type="bibr" rid="CIT73">73</xref>] Diclemente <italic>et al.</italic>[<xref ref-type="bibr" rid="CIT70">70</xref>] in a randomized controlled trial demonstrated that adolescent girls who underwent a comprehensive educational package on HIV/AIDS had significantly less risk behaviors in a 12-month follow-up period. Gavin <italic>et al.</italic>[<xref ref-type="bibr" rid="CIT37">37</xref>] in their study on adolescent females in Zimbabwe have shown that those who had sex education in schools had a decreased risk of HIV (OR-0.43). Chhabra <italic>et al.</italic>[<xref ref-type="bibr" rid="CIT72">72</xref>] and Hecej <italic>et al.</italic>[<xref ref-type="bibr" rid="CIT71">71</xref>] have reported better risk reduction practices in adolescent females compared to males following an educational program in India and Croatia, respectively. Interestingly a similar program targeting a different high-risk group in China (clients of FSWs) has shown promising results, with a significant increase in those using prevention services (OR-2.2).[<xref ref-type="bibr" rid="CIT24">24</xref>]</p><p>HIV testing, risk perception, and disclosure of sero-status are also reported to show a gender difference. Age, literacy, good doctor-patient relationship were associated with disclosure for men while having children, and being religious were associations for disclosure in women.[<xref ref-type="bibr" rid="CIT74">74</xref>] A cross-sectional survey among African American adolescents in the US has shown that females were significantly more likely to undergo voluntary HIV testing (OR-2.4 to 2.7) than males.[<xref ref-type="bibr" rid="CIT75">75</xref>]</p><p>However, several studies involving sexually active females have shown that a good knowledge of HIV is not synonymous with avoiding risk behavior.[<xref ref-type="bibr" rid="CIT62">62</xref><xref ref-type="bibr" rid="CIT63">63</xref><xref ref-type="bibr" rid="CIT66">66</xref>] In other words the knowledge is not put to practice. There are two main reasons for this paradox, impaired risk perception[<xref ref-type="bibr" rid="CIT62">62</xref><xref ref-type="bibr" rid="CIT63">63</xref>] and social barriers, that limits sexual autonomy for women. Some authors suggest a gender difference in risk perception as well.[<xref ref-type="bibr" rid="CIT66">66</xref>]</p><p>The paradoxical impact of education on HIV in the early 1990s in Africa is worth mentioning. HIV was associated with a better education in the early days of the epidemic in Africa. Some authors explain this phenomenon by the hypothesis that better educated had better jobs, more money, and more access to paid sex and IV drug use.[<xref ref-type="bibr" rid="CIT76">76</xref>] Education without an effective sex education component may have a minimal role in countering the epidemic. Asia today, may be in the state Africa was two decades ago.</p></sec><sec id="sec2-5"><title>Highly active antiretroviral therapy</title><p>In this section we discuss the results of studies that have looked into a gendered difference in HAART-related issues (availability, accessibility, and adherence), excluding those related to the biological differences of sexes (side effects and clinical and viral response).</p><p>An analytical study of 23 sero-converter cohorts from Europe, Australia, and Canada have shown that women fared better after HAART was introduced. Comparing the pre-HAART (before 1997) period and the HAART era, authors have reported a lesser risk of AIDS and death in women compared to men (OR-0.76 and 0.68, respectively).[<xref ref-type="bibr" rid="CIT77">77</xref>] Moore <italic>et al.</italic> and Chen <italic>et al.</italic> have both reported a better outcome for females in two cohorts on HAART.[<xref ref-type="bibr" rid="CIT78">78</xref>–<xref ref-type="bibr" rid="CIT79">79</xref>]</p><p>It is speculated that women in resource-limited settings may have restricted access to treatment due to socioeconomic constraints and gender norms.[<xref ref-type="bibr" rid="CIT80">80</xref>] However, the evidence is contrary to this. Chandra <italic>et al.</italic>[<xref ref-type="bibr" rid="CIT81">81</xref>], Muula <italic>et al.</italic>,[<xref ref-type="bibr" rid="CIT82">82</xref>] and Braitstein <italic>et al.</italic>[<xref ref-type="bibr" rid="CIT83">83</xref>] have all shown that women are not at a disadvantage in access to HAART, in resource-limited settings. The epidemiology update of UNAIDS for 2008 confirm these findings. In 45 developing countries (with the exception of Chile and Belize) the coverage was better for females with HIV. Still, it is important to note that the overall coverage of HAART in these settings was low. In many countries, coverage of the HIV-positive population with HAART was less than 40% for both men and women. Only 35% of pregnant women had access to the therapy in 2008.[<xref ref-type="bibr" rid="CIT1">1</xref>]</p><p>Adherence to therapy is another dimension of interest. Several authors have reported women to be less adherent to HAART.[<xref ref-type="bibr" rid="CIT84">84</xref>–<xref ref-type="bibr" rid="CIT88">88</xref>] Several possible associations with this observation are depression,[<xref ref-type="bibr" rid="CIT84">84</xref><xref ref-type="bibr" rid="CIT85">85</xref>] alcohol dependence,[<xref ref-type="bibr" rid="CIT88">88</xref><xref ref-type="bibr" rid="CIT89">89</xref>] other substance misuse,[<xref ref-type="bibr" rid="CIT85">85</xref><xref ref-type="bibr" rid="CIT90">90</xref>] and increased side effects in women.[<xref ref-type="bibr" rid="CIT91">91</xref>]</p></sec></sec><sec sec-type="discussion" id="sec1-3"><title>DISCUSSION</title><p>In summary, as expected, violence, gender norms, and poverty placed women at a disadvantage with regard to HIV/AIDS (increased risk of contracting HIV and increasing the burden of those living with the disease). However, regarding access to HAART, females fared better than males in many parts of the world.</p><p>In interpretation of the available evidence, the following issues need attention:</p><p>The vulnerability of sex-trafficked women, prostitutes, and victims of rape to HIV is obvious. However, the rise in the rate of infections at times of war and displacement is simply not a case of women being raped by the ‘enemy'. It may be the result of a complex interaction of several risk factors like, transactional sex, poverty, lack of opportunities, breakdown of civil order, and less rigid sexual norms.</p><p>Many studies only demonstrate that HIV positive women were significantly subjected to violence compared to the HIV-negative population. It is not clear whether the violence increased or began after sero-status disclosure. More studies are needed to identify which comes first; violence or HIV, or is it a vicious cycle.</p><p>Poverty and its relation to HIV is simply not an issue that can be reduced to the availability of money. Low income countries obviously may have many risk factors for HIV spread such as illiteracy, unemployment, and lack of opportunities for women. Yet, countries with a better income also have their own risk factors (fast life style, overcrowding in cities, and prostitution). Even in the affluent countries there may be microenvironments that are disadvantaged and not any different from the developing world with regard to HIV risk. When the data are generalized to the whole country, these significances go unnoticed. This argument is further supported by the findings of Talbott <italic>et al.</italic>[<xref ref-type="bibr" rid="CIT33">33</xref>] who showed that while the gross domestic product (GDP) of a country shows little or no relation to HIV/AIDS prevalence, the income inequality shows a positive correlation.</p><p>Regarding gender norms, there is the obvious need to discuss the conflicting or rather unexpected findings of some studies,[<xref ref-type="bibr" rid="CIT55">55</xref><xref ref-type="bibr" rid="CIT56">56</xref>] which do not collaborate with the view of high HIV transmission risk and traditional gender norms. This may be partly explained by the theory that traditional gender roles are changing in contemporary societies. Evidence for such change has been documented in the educated younger generations of South Africa.[<xref ref-type="bibr" rid="CIT92">92</xref><xref ref-type="bibr" rid="CIT93">93</xref>] Such contrasts may also be influenced by the improved awareness of the transmission of HIV. The more consistent use of condoms by dominant males may be an expression of responsibility or a measure for their own protection as they are likely to have multiple partners. More open sexual ideology being associated with less condom use may be an indicator of trust and selection of an educated and similar partner. Still the association of hyper-romanticism and open sexual ideology with more partners, in females, is difficult to explain. However some weaknesses in the study methodology may have influenced the outcome. The samples were not representative of the general population (Harrison <italic>et al.</italic>[<xref ref-type="bibr" rid="CIT55">55</xref>] used a sample with a disproportionate number of females in the ratio of 2:1, while Kaufman <italic>et al.</italic>[<xref ref-type="bibr" rid="CIT56">56</xref>] used a sample of high-risk males only). The sample sizes were limited to generalize the findings to a larger community.</p><p>On educational interventions and their gender implications, many studies have demonstrated a positive link between living in urban communities, education, and better HIV knowledge for women.[<xref ref-type="bibr" rid="CIT32">32</xref><xref ref-type="bibr" rid="CIT61">61</xref>–<xref ref-type="bibr" rid="CIT64">64</xref>] Faced with the epidemic, many Sub Saharan countries have initiated educational campaigns for the public, with funding from global agencies. The positive impact of such interventions are clearly visible, specially with regard to females.[<xref ref-type="bibr" rid="CIT76">76</xref><xref ref-type="bibr" rid="CIT94">94</xref>] However, the picture in the Asian context is less promising. Although many countries in Asia are still considered to be low prevalence, this can be a false state of complacency. Despite the fact that cultural barriers may prevent effective sex education at schools; the risk behaviors are high even among those having access to education.[<xref ref-type="bibr" rid="CIT67">67</xref><xref ref-type="bibr" rid="CIT69">69</xref>] Male dominance and gender norms limit a woman's ability to protect herself from infection despite being educated about HIV/AIDS. Therefore, we propose that a successful education program must concentrate on both sexes equally and be sensitive to prevalent gender norms in the society.</p><p>The evidence does not support the commonly held belief that women are at a disadvantage with access to HAART in resource-limited settings. This may be explained by the fact that women have two motives to enter a treatment plan to treat themselves and to prevent mother-to-child transmission.</p><p>There were several limitations in our review; it was limited to articles published in English only, and it is possible that important studies published in other languages were missed. Most of the data was from African and Asian countries; data from Latin American and Eastern European countries was minimal. Data on response to HAART was predominantly available from cohorts in developed countries. Such gaps in the available data affect the validity and generalizability of our conclusions.</p><p>We have recognized the following as areas with ‘gaps in knowledge’. These issues should be explored with further research.</p><list list-type="order"><list-item><p>Incidence and form of violence against HIV-positive women by intimate partner and others, following disclosure of sero-status in developing countries is not well explored.</p></list-item><list-item><p>Specific markers of poverty that may reflect the relationship between HIV and women better than wealth itself, needs to be investigated. Such markers may be different in each community (as food insufficiency was an indicator in some African countries).</p></list-item><list-item><p>Changing gender norms and their impact on women and HIV has been inadequately explored in Asia. The protective role (if any) of traditional gender norms and virginity norms needs to be identified.</p></list-item><list-item><p>Specific issues in different societies that cause discordance between knowledge and practice has to be analyzed as this has a direct impact in policy design on prevention.</p></list-item><list-item><p>Why do women have better access to HAART (as shown by statistics) despite the commonly held belief to the contrary? It is important to keep track of sex ratios on HAART as more people gain access to it, to avoid discrimination of women.</p></list-item><list-item><p>Identification of culturally appropriate educational tools to impart sex education for adolescents is a need of the hour.</p></list-item></list></sec><sec sec-type="conclusions" id="sec1-4"><title>CONCLUSION</title><p>The gendered implications of many aspects of HIV are apparent. The traditionally held view that women are at a disadvantage is true with regard to several issues such as violence, poverty, and gender norms. In treatment-related issues, women (at least in Africa) have made significant gains with better awareness. The access to HAART was better for females in many resource-limited settings, although the overall coverage was unsatisfactory.</p><p>Much of the work done in the last decade has focused on the Sub Saharan Africa, which is the hub of infection with large numbers of patients. However, the social and cultural dynamics of Asia and Africa are quite different. Although many Asian countries (India, China) are considered to be low prevalence ones for HIV, the disease burden may actually be considerable in Asia for two reasons; the large population (even a smaller percentage equates to a large number of infections) and under-reporting. 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