Chapter 7: Population-specific HIV/AIDS status report: Women - Conclusion
Chapter 7 - Conclusion
This is the first time PHAC has attempted to present evidence from a variety of sources in one document to better understand the impact of HIV/AIDS on women in Canada. This status report does not include an exhaustive list of program, policy and research gaps, nor does it prescribe solutions to address existing gaps. However, it is hoped that the evidence provided in the report will be useful to governments, non-governmental organizations, public health officials, researchers, communities and others in informing the development of programs and policies addressing HIV/AIDS and issues related to the determinants of health among women in Canada.
Canadian surveillance data presented in this report indicate that the proportion of women living with HIV/AIDS has increased over the last decade. Surveillance data show that the two most common exposure categories for women are heterosexual transmission and injection drug use. In the heterosexual exposure category, women are mainly infected through sexual contact with a person at risk. However, surveillance data do not explain why some women are more likely than others to engage in unprotected sex or share injection drug equipment. Complementary research is needed to better understand the complex interactions between the factors that make some women more likely to engage in risk behaviours. Research on these factors is conducted on the premise that if the root causes of the problem are better understood, the problem can be better addressed.
Research synthesized for this report shows that biology, gender, education, social status, employment and income, social environments and social support networks, physical environments, personal health practices and coping skills, healthy child development, health services, and culture and race, are all factors that influence women’s health and their vulnerability to HIV infection. For some of these factors, or determinants of health, the link between the determinant and women’s vulnerability to HIV infection is heavily supported by the evidence. For instance, research shows that poverty, housing insecurity, sexual violence and physical violence, sex work, and substance use are strongly associated with an increased risk of HIV infection in women. For other determinants, the link between the determinant and women’s vulnerability to HIV infection is less direct. However, less evidence does not necessarily reflect an absence of correlation, rather it highlights gaps where further research may be warranted.
a) Gender as a Key Determinant
While biology alone influences women’s risk of HIV transmission, treatment outcomes, disease progression and comorbidities, gender is recognized as a key determinant affecting women’s vulnerability to HIV/AIDS because of the way it interacts with and influences the other determinants. Research indicates that gendered roles of masculinity and femininity ultimately manifest as gender power imbalance, and it is this imbalance that lies at the heart of gender-based inequities and disparities. Gender power imbalance can directly affect risk behaviours as it translates into sexual interaction power imbalance, thereby limiting women’s ability to negotiate safer sex to protect against HIV infection.
Heterosexual women’s ability to negotiate safer sex (or to say no) with their partners may be compromised by gender power imbalance in a number of ways. For instance, condom use is predominantly male-controlled, placing women at a disadvantage for negotiating safer sex. This is especially true for sexual relationships involving casual partners or for women involved in sex work as condom negotiation in these situations can be difficult, especially if the security of the individual is jeopardized.
Gender power imbalance is also manifest in relationships in which male partners use physical violence or emotional abuse to obtain sex. Violence and abuse within heterosexual relationships are both causes and consequences of HIV infection in women. Injection drug use’s strong association with street-based sex work and among female youth at risk is also grounded in gender power imbalance, as evidenced by research which indicates that women’s injection-dependent relationships with men increase their vulnerability to HIV infection.
Culturally based attitudes about gender roles and sexual behaviour may also hinder women’s ability to negotiate safer sex. For example, social norms in some ethnocultural communities may have the effect of precluding condom usage between women and their regular partners, even in cases where a woman may be aware that her husband lives with HIV or has other sexual partners.
b) The Effects of Intersecting Discrimination
In addition to gender, determinants of race and culture, sexual orientation, and stigmatizing attitudes about HIV/AIDS play a significant role in influencing women’s vulnerability to HIV. This is especially true for women who are subject to multiple, compounding and intersecting forms of discrimination, such as women who live in poverty or women who are involved in sex work. For some women, several grounds of discrimination are piled one upon the other thereby increasing their vulnerability to HIV infection.
Intersecting discrimination is a contributing factor that helps explain why higher rates of HIV infection are seen among certain groups of women, including women from countries where HIV is endemic, Aboriginal women, and women who use injection drugs. As one example, research shows that the effects of intersecting discrimination are rampant in the lived experiences of Aboriginal women. For Aboriginal women, the historical trauma of colonialism and racism continue to adversely impact their socio-economic status, thereby increasing their likelihood of taking on risk behaviours, such as street-based sex work and injection drug use that increase their risk of HIV infection. Intersecting and stigmatizing attitudes about HIV/AIDS in the Aboriginal community further add to the challenges faced by Aboriginal women.
Because women’s lived experiences are so diverse, it is important that women-centred HIV/AIDS prevention projects continue to consider the underlying inequalities present in many women’s lives. Projects should also continue to emphasize the uniqueness and diversity of women’s HIV prevention experiences and needs.
c) The Importance of Empowering Women
Research and responses to HIV/AIDS and women in Canada presented herein highlight the importance of empowering women to redress gender power imbalances and discrimination. Research and evidence-based interventions show that women’s participation in the design and delivery of interventions is effective as it gives women a sense of ownership and direction to their lives. Research shows that including women as decision-makers and active participants in interventions enhances their ability to control their lives, increases their leadership skills, and provides them with the tools to negotiate safer sex.
d) Gaps in Research
Gaps in research on women and HIV/AIDS in Canada remain. While there is a significant body of research looking at HIV/AIDS among certain groups of women, such as Aboriginal women and women from countries where HIV is endemic, there remains a lack of research on certain cross-populations within these broader groups. For example, although Canadian research has examined HIV/AIDS among female youth at risk, no research has been undertaken to explore the disease among female youth from countries where HIV is endemic. Consequently, targeted interventions to address the needs of this cross-population proceed despite a lack of evidence about what works.
Other cross-populations that have not been studied include First Nations, Inuit and Métis female youth as populations independent from one another, and female youth who use injection drugs. The inventory of projects herein also failed to turn up any projects tailored to address HIV/AIDS among First Nations, Inuit and Métis women in prisons, in spite of demographic data showing that Aboriginal women are overrepresented in prison. Other groups of women overlooked by researchers include older women, who are increasingly being diagnosed with HIV, and women who are involved in sex work living and working in other areas of Canada outside of Vancouver’s DTES.
Research also shows that women continue to have problems accessing appropriate information and gender-sensitive health services. HIV/AIDS-related stigma and discrimination, including sexism, transphobia, classism, colonialism and racism, may limit women’s access to health services, including HIV testing, care and treatment. These factors may also complicate and limit the ability of women living with HIV/AIDS to access social and family support. Consequently, more research is needed to identify and analyze gender and culturally appropriate approaches to HIV/AIDS prevention, care, treatment and support, specific to the needs of certain groups of women, including female at-risk youth, women from countries where HIV is endemic, women who are involved in sex worker, lesbian, bisexual, transwomen, two-spirited women, Aboriginal women, women in prisons, women who use injection drugs and older women.
e) The Canadian Response
In reviewing the Canadian response to HIV/AIDS among women, the report found that many organizations provide distinct prevention strategies aimed at specific female populations. For example, some activities target women involved in sex work and focus on increasing their knowledge of HIV/AIDS, enhancing their capacity to empower themselves, and improving their access to health services. Several initiatives for women from countries where HIV is endemic provide support to women living with HIV/AIDS and endeavour to offer culturally specific services, including sexual health education workshops specifically designed to meet their cultural needs relating to health care. However, there is a continued need to evaluate these interventions to establish an evidence-based compendium of effective HIV prevention interventions for different groups of women. Further, more systemic evaluation is needed to identify what is working to improve the lives of women at risk and women living with HIV/AIDS.
Other initiatives delivered to women as part of the Canadian response to HIV/AIDS aim to address the root causes of HIV/AIDS among women. For instance, community-based organizations have worked to address key health needs of distinct female populations by offering culturally relevant services, peer support and counselling for women from countries where HIV is endemic and for Aboriginal women. Several of the projects have tried to address issues faced by women in prison and women living in disadvantaged urban environments and remote communities by supporting peer-led activities tailored for their particular environments. Other projects have also tried to tackle issues rooted in gender inequality, such as men’s violence against women (especially among Aboriginal women) and issues surrounding disclosure of HIV status, with interventions designed to empower women in heterosexual relationships.
However, there remain gapsFootnote 55 in the Canadian response to HIV/AIDS in women. For example, most projects treat Aboriginal women as a homogenous population, failing to recognize the differences between First Nations, Inuit and Métis women. Many projects overlook the effects of intersectional discrimination and its marginalization of certain groups of women. In addition, while several projects are designed to empower women in the hopes that empowerment will improve their ability to negotiate safer sex, it is not always clear whether these projects elicit the outcome desired.
f) The Importance of Partnership
Many of the projects reviewed as part of this report highlight the importance of partnerships among different sectors of society to affect change. The current Canadian response to HIV/AIDS in women involves a wide array of organizations and communities, which have built networks across the country to encourage knowledge exchange for gender-relevant approaches to HIV/AIDS. It is important to continue strengthening organizations’ capacity for evaluation and their capacity to collaborate with researchers to engage in community-based research to determine whether current programs, interventions and activities adequately meet the prevention, care, treatment, and support needs of this population. Consequently, cross-sectoral and cross-jurisdictional activities to share best practices, to increase partnerships among a wider range of stakeholders, and to better use evidence in the development of strategies and interventions should be fostered and encouraged.
g) Future Developments
In recent years, women's health advocates have asked scientists to intensify their research on female-controlled barrier method contraceptives. Barrier methods offer the advantage of protection against pregnancy and some types of sexually transmitted infections. Currently, the female condom remains the only available effective woman-controlled barrier against HIV infection, but it presents certain challenges for use. Ultimately, women need more affordable, more accessible, more reliable, more user-friendly and more easily hidden from a male partner (to protect women against abuse or violence) woman-controlled contraceptive barrier methods. There are several microbicides currently in the research pipeline which could one day improve women’s ability to protect themselves against the sexual transmission of HIV.
Canadian stakeholders involved in addressing HIV/AIDS among women have demonstrated a strong collective will to affect change. Their unwavering dedication to increase HIV/AIDS awareness and to reduce stigma and discrimination has contributed to a growing recognition that HIV/AIDS in women cannot be ignored. This report acknowledges the important role that stakeholders play in HIV/AIDS leadership, research, treatment and prevention. Stakeholders must continue to build on their successes and their ongoing quest to get ahead of, and reverse the impact of, HIV/AIDS among women in Canada.
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