HIV and the Impact of Gender Imbalances

Understanding How Power Inequities Can Increase HIV Risk

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Artwork © Run Jane Fox

One of the primary concerns of public health officials is the impact of HIV on women and others who are disempowered within a sexual relationship, placing them at greater risk of infection. These dynamics can often dictate who makes decisions about certain sexual practices or, worse yet, who has the right to make decisions. It's a factor that continues to plague women around the world today.

Gender-based power imbalances, both economic and psychological, are seen to constrain a woman's ability to negotiate sexual practices.

According to research from the non-profit Primary Care Development Corporation, that one factor alone correlates to reduced condom usage—as little as 48% in the women surveyed. Physical, sexual, and emotional abuse only compounds the issue.

Sexual power inequities can often play out in more subtle forms, however, including:

  • Societal norms that dictate specific gender roles.
  • The promise or need of economic support.
  • Lack of literary or education (the rate of which is higher among women than men).
  • The general stigmatization of sexually active or unmarried women.
  • Cultural value systems that often place men above women.
  • Social acceptance of older men/younger women relationships (which, in some settings, correlates to higher rates of HIV infection ain women ages 15-24).

These stresses can greatly impact a woman's ability to negotiate safer sex, particularly when cultural demands for marriage, procreation, and motherhood are high.

HIV and Violence Against Women

The issue can be even further exacerbated by sexual, domestic, or emotional violence, with some studies suggesting that anywhere from 10% to 60% of women are affected worldwide.

So extreme is the problem today that, in some countries like South Africa, the annual rape statistic has been reported to be as high as 17% (or roughly one out of every six women).

In a 2009 sampling of 1,738 South African men in the provinces of KwaZulu Natal and the Eastern Cape, more than 25% admitted to having raped someone, while half of those acknowledged raping more than one woman.

The cycle of sexual and emotional violence against women increases the risk of HIV in several ways:

  • Forced penetrative sex can tear the fragile mucosal tissue of the vagina or anus, providing an easier route of access for the virus.
  • HIV itself often has a cause-and-effect relationship in violent relationships, wherein infection can occur as a result of violence, while violence is frequently enacted upon a woman with HIV (e.g., by a spouse or family member).
  • Destructive sexual behavior is frequently linked to an early sexual trauma.

Addressing Gender Inequities

According to the World Health Organization (WHO), only 52% of countries reported the implementation of women-focused HIV/AIDS programs as part of their national strategies, while little is being done to address the larger issues relating to inequities in economic opportunities and support; access to vocational and skills training; and the protection and promotion of inheritance rights.

Without the ability to redress these societal issues, the response from the perspective of HIV/AIDS is often muted. That’s not to say that HIV-specific strategies aren’t being explored or employed. Among the more promising options is a microbicidal intravaginal ring called the NuvaRing, which may be able to disable HIV at the time of sex and be kept in the vagina for up to 30 days.

Products like these are seen to be an advance on earlier preventative strategies, many of which didn’t provide women with the means for discreet self-protection or required too much in the way of daily adherence (something which is difficult to achieve in secrecy).

Meanwhile, a renewed push for the use of the female condom (or the "fem-dom") is being made in some sectors, with lighter, quieter, and less costly versions entering the mainstream. Among them are innovations such the Women’s Condom, which is inserted like a tampon and expands inside the vagina; and the silicon-based Origami Female Condom, which unfolds like an accordion and can provide stimulation to both the man and woman.

Gender Dynamics Can Affect Men, Too

On the flip side, societal dictates can also constrain how a man interacts in a sexual relationship. While women are often deemed to be the "communicators" in a relationship—not only with their partner, but with other women who share sexual advice—men are often expected to be knowledgeable and "experienced" about sex. Any gaps in a man's sexual education (including the failure to seek advice on proper condom use) can result in an increased risk for both he and his partner.

In a cross-sectional survey conducted by Emory University, heterosexual male college students were asked to recall their condom use over the previous three-month period. The study found that

  • 60% did not discuss condoms with their sexual partners;
  • 42% put condoms on only after starting sex;
  • 15% removed condoms before ending sex;
  • 40% did not leave space at the tip of the condom;
  • 30% placed the condom upside down on the penis;
  • 33% reported slipped or broken condoms during sex, and;
  • 42% wanted to use condoms, but did not have any available at the time.

Even among those who did use condoms, many reported to have done so at the request of their partner, which was sometimes perceived as a declaration of suspicion or infidelity.

These kinds of shortcomings suggest that greater focus needs to be placed on strategies that encourage a re-examination of perceived gender roles, focusing on shared communications and decision-making within a sexual relationship.


Pulerwitz, J.; Amaro, J.; De Jong, W.; et al. "Relationship power, condom use and HIV risk among women in the USA." AIDS Care. December 2002; 14(6):789-800.

Gollub, E. "Choice Is Empowering: Getting Strategic About Preventing HIV Infection in Women." International Family Planning Perspectives. December 2006; 32(4): 209-212.

Jewkes, R.; Sikweyiya, Y.; Morrell, R.; et al. "Understanding Men’s Health and Use of Violence: Interface of Rape and HIV in South Africa." Medical Research Council Policy Brief. Pretoria, South Africa; July 2009.

World Health Organization (WHO). "Gender inequities and HIV." Geneva, Switzerland; accessed May 13, 2014.

Higgins, A.; Hoffman, S.; and Dworkin, S. "Rethinking Gender, Heterosexual Men, and Women's Vulnerability to HIV/AIDS." American Journal of Public Health. March 2010; 100(3):435-445.

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