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What is the Impact of HIV/AIDS on Women?


This dissertation will outline the major issues surrounding HIV/AIDS infection as it relates to women, with specific reference to women in Zimbabwe and the United Kingdom (UK). It will explore the reasons why women are increasingly at greater risk of infection than males. Underpinned by a feminist analysis of women’s oppression, it will include a discussion of how biological, social, sexual, economic and cultural inequalities contribute to women’s vulnerability. It will also look at the impact of HIV/AIDS on women and how these factors can influence them to seek services. The differences in what is deemed “social work” in terms of both definition and practice as well as the differences in the health systems and the healthcare workers involved in delivering services in both countries will also be explored.


AIDS stands for acquired immunodeficiency syndrome, a disease that makes it difficult for the body to fight off infectious diseases. The human immunodeficiency virus known as HIV causes AIDS by infecting and damaging part of the body’s defences – its lymphocytes – against infection. Lymphocytes are a type of white blood cell in the body’s immune system and are supposed to fight off invading germs. People may be infected (HIV positive) for many years before full AIDS develops, and they may be unaware of their status. HIV can only be passed on if infected blood, semen, vaginal fluids or breast milk gets inside another person’s body. HIV and AIDS can be treated, but there are no vaccines or cures for them (WHO, 2003).


Increasingly, “the face of HIV/AIDS is a woman’s face” (UNAIDS, 2004). AIDS is now the leading cause of death in Sub-Saharan Africa and the fourth-highest cause of death globally (UNAIDS, 2002). AIDS is a profound human tragedy and has been referred to as the “world’s most deadly undeclared war” (Richardson, 1987). Women and girls are especially vulnerable to HIV infection due to a host of biological, social, cultural and economic factors, including women’s entrenched social and economic inequality within sexual relationships and marriage. HIV/AIDS continue their devastating spread, affecting the lives of 16,000 people each day, with women, babies and young people being increasingly affected. The number of people living with HIV/AIDS has now reached almost 40 million globally (UNAIDS and WHO, 2006), and of these an estimated two-thirds live in Sub-Saharan Africa, Zimbabwe included.

Zimbabwe is experiencing one of the harshest AIDS epidemics in the world. The HIV prevalence rate in Zimbabwe is among the highest in the world, although recent evidence suggests that prevalence may be starting to decline. In Zimbabwe 1.8 million adults and children are living with HIV/AIDS, with 24.6% of adults infected: women represent 58% of those infected among the 20- to 49-year-old age range. (Consortium on AIDS and International Development, 2006) In a country with such a tense political and social climate, it has been difficult to respond to the crisis. President Robert Mugabe and his government have been widely criticised by the international community, and Zimbabwe has become increasingly isolated, both politically and economically. The country has had to confront a number of severe crises in the past few years, including an unprecedented rise in inflation (in January 2008 it reached 100,000%), a severe cholera epidemic, high rates of unemployment, political violence, and a near-total collapse of the health system (AIDS and HIV Information, 2009).

In Britain, HIV prevalence is relatively low and currently stands at 0.2% of the population. Statistics show that at the end of 2008 there were an estimated 88,300 people living with HIV, of whom over a quarter (22,400, or 27%) were unaware of their infection. This compares to the 77,000 people estimated to be living with HIV in 2007, of whom 28% were estimated to be unaware of their HIV infection. Of all diagnoses to the end of 2008, 45% resulted from sex between men and 42% from heterosexual sex, with black Africans representing 35% of newly diagnosed infections (HPA, 2009). According to the Health Protection Agency (2009), there has also been a dramatic increase in the number of women diagnosed with HIV. In the years up to and including 1992, females accounted for 12% of HIV diagnoses, but in 2008 that was 37%.

Therefore, as HIV/AIDS is a global pandemic, the eradication of this health issue represents one of humanity’s greatest challenges – one that requires co-operation and comprehensive collaboration between scientific disciplines, governments, social institutions, the media, social work and healthcare professionals, and the general public (IFSW, 2009). Social workers, by virtue of their training, their commitment to human rights, and the fact that they are uniquely placed within a wide variety of health and welfare settings, can play a very effective role in the global effort to address the HIV/AIDS epidemic (IFSW, 2009).



While women are battling for equal rights throughout the international community, the existing power imbalance between men and women renders women particularly vulnerable to contracting HIV. Women’s subordinate position places them at a considerable disadvantage with respect to their fundamental human right to control their own sexuality, and to access prevention, care, treatment, and support services and information. This subordination of women is mainly caused by the socially-constructed relations between men and women – or, in other words, the patriarchal structure which is oppressive to women. (Walby, 1990, cited in Richardson, 2000) defines patriarchy as the “system of social structures and practices that men use to dominate, oppress and exploit women”, thus giving them greater opportunities to access services compared to females. Although the World Health Organization (WHO) and many governments are implementing educational programmes to teach women about protecting their health, traditional and cultural practices continue to perpetuate discrimination against women, in turn forcing women into high-risk situations. Unless proactive human-rights policies are enacted to empower, educate, and protect women with regard to their sexual autonomy, HIV/AIDS will continue to spread at an alarming rate and will have a devastating impact on all aspects of society. Even though the root of women’s vulnerability lies in the imbalance in power between men and women, biological and sexual practices have an important role to play and mean that HIV transmission is unfortunately more efficient in women than in men.


Women are more biologically vulnerable to HIV than men; research has shown that women are at greater risk than men of contracting HIV both from an individual act of intercourse and from each sexual partnership. This “biological sexism” applies not only to HIV but to most other sexually transmitted diseases (Hatcher, et al, 1989). A woman has a 50 per cent chance of acquiring gonorrhoea from an infected male partner while a man has a 25 per cent chance if he has sex with an infected woman (Doyal et al., 1994). This is because the vaginal tissue absorbs fluids more easily, including the sperm, which has a higher concentration of the HIV virus than female vaginal secretions and may remain in the vagina for hours following intercourse, thus increasing women’s vulnerability to infection.

Not only are women more vulnerable to STIs than men, but “untreated genital infections, especially genital ulcer disease, syphilis and genital herpes, all predispose to HIV infection” (Doyal, 1994). While STDs are not necessarily gender specific, it is likely that women with STDs will remain undiagnosed and untreated for longer, increasing their risk of infection (Finnegan, et al, 1993). This is largely because women tend to remain symptomless for longer than men (Doyal, 1994). Even though much is known about the transmission of HIV to women through unprotected sex with men, less is known about the manifestations, progression, treatment and care of HIV/AIDS in women. Due to the lack of research we can at best speculate on the reasons for this. One reason may be the failure of medical professionals to pick up on possible symptoms which are often present in women:

“…existing diagnostic guidelines pay little attention to symptoms such as thrush, herpes, menstrual problems and cervical cell abnormalities that seem to characterise the early stages of the disease process in many women. Indeed a significant number are diagnosed only during pregnancy or when their child is found to be HIV positive”. (Doyal, 1994, p13)

Therefore, if researchers persist in ignoring the biological differences, then the realities of the risks of infection and the disease progression in women will remain unacknowledged. As a consequence of this, women will continue to be diagnosed later than men, which ultimately leads to an earlier death. (Gorst, 2001,) Further research into biological differences and the effects of HIV on women’s bodies is urgently needed.


Traditional and customary practices play a part in the vulnerability of women to HIV infection. Practices such as early marriage and the payment of lobola in marriages make women and girls more vulnerable to HIV infection. Marriages among black women in Zimbabwe include bride wealth “lobola” if the couple is to be socially approved. Bride wealth is increasingly becoming big business in Zimbabwe, with some parents charging as much as US$2,500 plus five or more cattle for an educated girl. (IRIN NEWS, 2009) The insistence on bride wealth as the basis of validating a marriage makes female sexuality a commodity and reduces women to sexual objects, with limited rights and privileges compared to their husbands, who pay in order to marry them, thus leaving them without a say in their relationship.

Patriarchal attitudes are also found in Christianity and these have strengthened the traditional customs that men use to control women’s sexuality. (Human Rights Monitor, 2001) For example, Eve’s alleged creation from Adam’s rib has made women occupy a subordinate position in the Church as well as in the family. Women are therefore viewed merely as second-class citizens who were created as an afterthought. This is to say that if God had seen it fit for Adam to stay alone, then Eve would never have been created and hence women would not exist in this world. Such patriarchal attitudes have seen women being forced to be submissive to males. To make matters worse, once Eve was created she wreaked havoc by giving in to the Devil’s temptation and pulling Adam into sin. This portrayal of women as the weaker sex has made men treat women as people who have to be kept under constant supervision. St Paul’s letter to the Colossians is one example of the letters which Zimbabwean men quote as a justification of their control over women. The woman is expected “to submit to her husband” (Colossians 3:18) whilst the husband has to love his wife (Colossians 3:19). Therefore, because of these beliefs, women will remain passive and powerless in relation to sexual health, making them more vulnerable to HIV/AIDS.


Migration or displacement as a result of civil strife, natural disasters, drought, famine and political oppression has a greater impact on women’s vulnerability to HIV infection compared to men. About 75 per cent of all refugees and displaced people are women and children. The political and economic crisis in many African and Asian countries has caused many women to come to the UK in search of safer lives and employment (Freedman, 2003).

The World Health Organization (WHO, 2003) states that female immigrant workers are more vulnerable to sexual barter as they try to negotiate for necessary documentation, employment and housing, which further increases their risk of HIV/AIDS infection. In addition, because of the lack of legal documentation these women will experience limited options, receive low status, receive low pay and are often isolated in their work, including marriage, domestic, factory and sex work. These situations place women in vulnerable and powerless positions, with little ability to refuse or negotiate safe sex, thereby increasing their risk to HIV/AIDS.

Despite the risks associated with the migration process it is important to recognise the right to ‘freedom of movement and travel irrespective of HIV status’ (ICW 12 Statement and the Barcelona Bill of Rights, 2002). This was a focal point during the Barcelona HIV/AIDS conference in 2002, because the Spanish authorities denied visas to numerous people from the South – many of whom were open about their HIV status. Some countries do have discriminatory policies regarding travel of people living with HIV/AIDS (PLHA) and others are instituting stricter controls. For example, Canada has recently introduced the need for an HIV test for people emigrating to Canada and Australia. Whilst they say it will not affect the final decision it is not clear why they need the information (Tallis, 2002).


Women and men experience poverty differently because of gender inequality:

The causes and outcomes of poverty are heavily engendered and yet traditional conceptualisations consistently fail to delineate poverty’s gender dimensions resulting in policies and programmes which fail to improve the lives of poor women and their families (Beneria and Bisnath, 1998).

Despite worldwide attention to existing inequalities and the way these violate a socially-just society, there is no society in the world in which women are treated as equals with men (Doyal, 2001). Major inequalities between men and women still exist in many places – from opportunities in education and employment to choices in relationships. Gender and social inequalities make women more vulnerable to HIV infection, especially in societies which afford women a lower status than men.

Worldwide, women and girls are disproportionately impacted by poverty, representing 70 per cent of the 1.2 billion people who live in poverty worldwide (Amnesty International, 2005), a phenomenon commonly referred to as the “feminisation of poverty”. Worldwide, women receive an average of 30-40 per cent less pay than men for the same work (Card et al, 2007). This economic inequality may influence women’s ability to control the timing and safety of sexual intercourse. Specifically, economic dependence on men, especially those who are not educated and do not have good jobs, forces women to remain silent about HIV risk issues and to stay with partners who refuse to engage in safe-sex practices.

Poverty also leads to greater HIV risk among women by leading them to barter sex for economic gain or survival (Weiss et al, 1996). Commercial sex work is the most well-known way for women to exchange sex for money, food, shelter or other necessities. Most of this sex will be unsafe as women will be at risk of losing economic support from men by insisting on safer sex. Where substance abuse is a factor, the means for obtaining clean needles may be traded for other essentials. Trading or sharing needles is a way to reduce drug-addiction costs. Risk behaviours and disease potential are predictable under such compromised circumstances (Albertyn, 2000, cited in Card, 2007).

Educational inequality also contributes to a woman’s HIV risk directly, by making information on HIV/AIDS less accessible to her, and indirectly, by increasing her economic dependence on a male partner. In particular, studies show that more-educated women are more likely to know how to prevent HIV transmission, delay sexual activity, use healthcare services, and take other steps to prevent the spread of HIV (UNIFEM, 2004). Because many cultures value ignorance about sex as a feature of femininity, many young women are prevented by husbands, fathers, or other family members from obtaining information about HIV/AIDS. Others decline to seek such information out of fear for their reputations. Lack of education about the causes, prevention, and treatment of HIV/AIDS will increase these women’s vulnerability to infection.

Legal systems and cultural norms in many countries reinforce gender inequality by giving men control over productive resources such as land, through marriage laws that subordinate wives to their husbands and inheritance customs that make males the principal beneficiaries of family property (Baylies, 2000). For example, Zimbabwe has a dual legal system, recognising both common and customary law in marriage. This creates inequalities for many women upon divorce or their husband’s death. Women in customary marriages, especially those who are not educated and who live in rural areas, make up approximately 80% of marriages in Zimbabwe, and are not entitled to the same rights as those married under common law; this means that they are often barred from inheriting property and land, or getting custody of their children, thus making them more vulnerable to male dominance and increasing their risk of getting infected with STIs (Womankind, 2002).


Power inequalities at social, economic, biological, political and cultural levels mean that women continue to be increasingly more at risk from HIV infection. It is therefore critical that social workers and other healthcare professionals make sure that HIV/AIDS prevention and care programmes address the most immediate perceived barriers to accessing HIV/AIDS prevention and care services. Measures could include vocational training, employment, micro-finance programmes, legal support, safe housing and childcare services. Such measures would empower these women to have options and to take voluntary and informed decisions regarding the adoption of safer practices to prevent the transmission of HIV/AIDS (UNODC, 2006). There is also the need for a female-controlled form of protection which women can use to protect themselves, for example microbicides, which women can use without the consent or even the knowledge of their partner, thus enabling them to protect themselves if they are forced to engage in unprotected sex.



Although there is a vast literature on HIV/AIDS, relatively little has been written about how HIV/AIDS affects women, and what constitutes a high-risk group. In part, this reflects the way AIDS was initially perceived in the West as a “men’s disease”, so much so that until a few years ago a common response to the topic of women and AIDS was “Do women get AIDS?”, the assumption being that women were at little or no risk (Doyal, et al, 1994). This has never been true of Africa, where the appallingly pervasive epidemic has always been a heterosexual disease and where 55 per cent of those who have been infected were women. In recent years it has become increasingly clear that women can both become infected with HIV and transmit the virus. A study conducted by AWARE (Association for Women’s AIDS Research and Education) in America found that women who inject and share needles, have sexual contact with or are artificially inseminated by a man, lesbians, sex workers and those from an ethnic minority, especially black women, were at increased risk of HIV infection (Richardson, 1987). The study also found that most people in these groups are underrepresented in prevention or treatment interventions, and often suffer social stigma, isolation, poverty and marginalisation, which place them at higher risk. Therefore, in this chapter I am going to discuss how some of these groups are vulnerable to infection, and what can be done to prevent and treat infection in these vulnerable groups without inadvertently increasing their stigmatisation.


There is a substantial body of research on the correlation between HIV/AIDS infection and female prostitution. Studies worldwide have revealed cause-and-effect relationships between AIDS and prostitution in a number of areas, including the use of alcohol and/or psychoactive drugs, and have revealed variance in the rate and circumstance of infection from one country to another (O’Leary et al, 1996). For example, researchers have found the high rate of AIDS in Africa to be largely a reflection of exposure through sexual activity only, while in the US and Europe, transmission of the AIDS virus is more likely to come from prostitutes or customers who are also IV drug users.

Many writers have pointed out that real social concern about HIV infection did not materialise until its potential “spread to heterosexuals” was recognised. What is less often pointed out is that concern for the “spread to heterosexuals” has mostly been manifest in concern for the spread to heterosexual men, not heterosexual women (Flowers, 1998). The expressed fear is that HIV will spread from women to men, allegedly through prostitution. In the press and the international scientific literature on AIDS, often the light cast upon Women in Prostitution (WIP) has been a harsh one. WIP have been identified as a “risk group”, a “reservoir of infection”, and a “bridge” for the HIV epidemic. Such technical, epidemiological language has depicted WIP as vectors of HIV infection (Scharf and Toole, 1992). Rather than presenting WIP as links in broader networks of heterosexual HIV transmission, women categorised as prostitutes have been described as “infecting” their unborn infants, their clients and indirectly their clients’ other female sexual partners, as though HIV originated among WIP (Scharf and Toole, 1992). Like posters from WWI and WWII which aimed to warn armed servicemen in Europe of the danger of contracting gonorrhoea and syphilis (Brandt, 1985, cited in Flowers et al, 1998), some AIDS-prevention posters have caricatured WIP as evil sirens ready to entice men to their deaths (New African, 1987, cited in Larson, 1988). Interestingly, there is evidence that some HIV-positive men may be inclined to claim that their infection came from a female prostitute, in order to cover up its real origins: sex with a man, or IV drug use.


There are many reasons why women engage in prostitution in Zimbabwe. Studies show that poverty and deviance are the main causes. Other studies have shown that many women engage themselves in prostitution by their own choice – and see it as a career path – whilst others might be forced into it (Chudakov, 1995). In Zimbabwe prostitution is illegal, and many women and young girls, especially orphans who engage in prostitution, are driven to it by poverty and economic dislocation, which is being caused by the current economic and political crisis the country is experiencing. According to the United Nations Children’s Fund (UNICEF), the hunger and disease-ridden conditions in much of Zimbabwe have forced many children into prostitution in order to feed themselves (UNICEF, 2008). Save the Children, a non-governmental organisation working to create positive changes for disadvantaged children in the country, estimate that girls as young as 12 are now selling their bodies for even the most meagre of meals, such as biscuits and chips. They also state that the issue is further complicated by the growing presence of child traffickers in the region, looking for young girls to abduct and take to South Africa for the use of potential clients at the 2010 World Cup (Mediaglobal, 2009).

Combating child prostitution and trafficking is complicated, but prioritising the alleviation of poverty – with particular emphasis on fighting poverty from a child’s perspective; prioritising education for all, with emphasis on improving access for girls; and provision of information to victims and survivors of child prostitution and/or trafficking, including information about available counselling and legislative services – would be helpful (WHO, 2003).


Prostitution in the UK is different from that in Zimbabwe. The laws around prostitution in England and Wales are far from straight-forward. The act of prostitution is not in itself illegal – but a string of laws criminalises activities around it. Under the Sexual Offences Act 2003, it is an offence to cause or incite prostitution or control it for personal gain. The 1956 Sexual Offences Act bans running a brothel and it’s against the law to loiter or solicit sex on the street. Kerb-crawling is also banned, providing it can be shown that the individual was causing a persistent annoyance (BBC NEWS, 2008).

Though actual s are scarce, it has been estimated that at least 2 million women are selling sexual favours in Britain. The bulk of these are brothel prostitutes working in parlours, saunas or private health clubs. According to The First Post published on 18/08/08, prostitution was viewed as “the new profession”. The article stated that prostitution in Britain is booming, and that thousands of young women have chosen prostitution for independence and financial security. The key factor which has led to a huge rise in this kind of prostitution is the influx of girls from Poland and other Eastern European countries which acceded to the EU in 2000.

A strong relationship also exists between UK prostitutes and substance abuse, which drives many into the sex business. Intravenous-drug-using prostitutes are particularly prominent in Scottish cities such as Glasgow (O’Leary et al, 1996). According to researchers, 70 per cent of the city’s streetwalkers are IV drug addicts, injecting heroin, temazepam and tengesic. In Edinburgh, which has the highest rate of HIV-seropositive IV drug addicts of all cities in Britain, a significant number of those addicts testing HIV positive have been identified as prostitutes.

Even though sex workers can transmit HIV/AIDS, blaming them encourages stigma and discrimination against all women. It allows the men who infect sex workers and their own wives to deny that they are infecting others. Wives too can infect their husbands, who can in turn infect sex workers. It is therefore important to note that sex workers and their clients are not serving as a “bridge” for HIV transmission into the rest of the population.


Can women transmit the disease to other women through sexual activity? The answer to this question is crucial for a community that knows that HIV is within it even though the question might be difficult to answer as there is “very little” information on this subject (Richardson, 1987). Lesbians were seen as least likely to be infected, as there was an understanding of HIV as a disease which existed in specific groups of people, for example gay males and intravenous-drug users. Because of these biased attitudes toward people, rather than risk behaviours, no data was systematically gathered. This understanding prevented the healthcare system from defining sexual risk behaviours: it stressed people, not sexual behaviours.

It has therefore been noted that most lesbians have been in “risk situations” or engaged in what would be considered as “risky behaviour” at some stage. Some lesbians inject drugs and may share needles. Also, a significant number of lesbians have had sex with men before coming out, and many will have had unprotected vaginal or anal intercourse Some may still have sex with men for reproductive purposes (Gorna, 1996). Some may be prostitutes who, for economic reasons or through pressure from a pimp, may have had unprotected sex with clients (Richardson, 1989). According to records from a London sexual health clinic for lesbians, 35 per cent of the lesbians who attended had had sex with a man in the previous six months (Gorna, 1996). As Gorna puts it, this emphasises the fact that “activity is not always consistent with identity”. In other words, “we are put at risk by what we do, not by how we define ourselves or who we are” (Bury, 1994, p32).

Although the risk of HIV infection from sex between women is very small, it is important for lesbians to look at what they do, how they do it and with whom they do it, just like everyone else, as, “Low risk isn’t no risk” (Richardson, D, 2004). However, they may find it difficult to access services and, if they become ill, they may experience special problems, given that the healthcare system is designed for and administered by a predominantly heterosexual population. There may be a lack of recognition of their relationships, which could lead to isolation and depression. For example in Zimbabwe homosexuality is illegal and punishable by imprisonment of up to 10 years. The President of Zimbabwe, Robert Mugabe, views lesbians and gays as “sexual perverts” who are “lower than dogs and pigs” (BBC NEWS, 1998). In 1995 he ordered the Zimbabwe International Book Fair to ban an exhibit by the civil-rights group Gays and Lesbians in Zimbabwe (GALZ). He followed this ban with warnings that homosexuals should leave the country “voluntarily” or face “dire consequences”. Soon afterwards Mugabe urged the public to track down and arrest lesbians and gays. Since these incitements, homosexuals have been fire-bombed, arrested, interrogated and threatened with death (Tatchell, 2001). This makes it difficult for lesbians in Zimbabwe to access information and other services, thus increasing their vulnerability to HIV infection.


The number of older people (older than 50 years) with HIV/AIDS is growing fast. Older adults are infected through the same high-risk behaviours as young adults, though they may be unaware that they are at risk of HIV/AIDS. However, when assessing the impact of the HIV/AIDS epidemic upon the world’s population, older people are often overlooked. HIV-prevention measures rarely target the older generation, despite the fact that many older people are sexually active and therefore still at risk of being exposed to HIV. The older population is steadily growing larger with the maturing of the “baby-boomer” generation as well as the availability of antiretroviral drugs which extend people’s life expectancy. Social norms about divorce, sex, and dating are changing, and drugs such as Viagra are facilitating a more active sex life for older adults (NAHOF, 2007, cited in Lundy et al, 2009). Heterosexual women aged 50 and older are most in need of the HIV-prevention message.

The Joint United Nations Programme on HIV/AIDS (UNAIDS, 2006) estimates that around 2.8 million adults aged 50 years and over are living with HIV, representing 7 per cent of all cases. In the UK, the Health Protection Agency reported that almost 4,000 HIV-infected people who were accessing care in 2006 were aged 55 years or over. Data on this subject from low-income countries like Zimbabwe is fairly patchy. This is because HIV/AIDS surveillance is commonly conducted in antenatal clinics, as many people have little other direct contact with medical services. Data from antenatal clinics does not provide information about people who are above child-bearing age, thus making it difficult for healthcare and service providers to make policies that will impact on the elderly who are infected.

Firstly, it has been noted that elderly women can be exposed to HIV via non-consensual sexual contact or rape. Research has shown that some criminals appear to target older women for sexual crimes because they appear to be, and often are, vulnerable to attack (Muram et al, 1992). Elderly women in institutional settings such as nursing homes may also be at greater risk. Some estimates suggest that up to 15 per cent of elderly nursing-home residents have been victims of either sexual or physical abuse, thus increasing their vulnerability to HIV infection (Collins, 2002).

Exposure to blood tainted with HIV may also occur when an older woman provides care to adult children who may be suffering from AIDS (Levine-Perkell, 1996). Allers (1990) revealed that more than one-third of all adults who contract A

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