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Understanding the contribution of vaginal bacteria to HIV risk will be a key target of future research.67 Adolescent girls may be at further increased risk due to the existence of greater proportions of genital mucosa, which are present in an immature cervix.
Adolescent girls are also susceptible to relatively high levels of genital inflammation, which may also increase the risk of HIV acquisition.68 Due to the lower uptake of ART among men, in most countries it is likely that fewer men than women are virally suppressed, which means men are more likely to pass the virus on to others.
This can lead to HIV-positive women choosing to have an abortion because they are misinformed about their options and how to protect their health, as well as their child's.17 Additionally, in 29 countries women require the consent of a spouse or partner to access SRH services.18 A lack of access to comprehensive HIV and SRH services means that women are less able to look after their sexual and reproductive health and rights (SRHR) and reduce their risk of HIV infection.
A review of evidence from Latin America and Caribbean relating to HIV-positive women’s use of, and access to, SRH services found women living with HIV experienced more unplanned pregnancies, more induced abortions, a higher risk of immediate sterilisation after birth and higher exposure to sexual and institutional violence, compared to HIV-negative women.19 In many settings, where SRH and HIV services exist, they are primarily for married women with children and do not meet the specific needs of unmarried young women and adolescent girls.
As minors, child brides are rarely able to assert their wishes, and are less likely than their peers to be aware of how to protect themselves from HIV and other STIs.64 These factors all increase HIV risk.
The risk of HIV acquisition during vaginal sex has been found to be higher for women than for men in most (but not all) biological-based studies.65 This high susceptibility can be explained by a number of factors including the ability of HIV to pass through the cells of the vaginal lining and the larger surface area of the vagina.66 A study published in 2018 has provided further insight into the specific biological conditions that increase HIV risk in women.
Today, women constitute more than half of all people living with HIV1 and AIDS-related illnesses remain the leading cause of death for women aged between 15 and 49.2 Young women (aged 15-24), and adolescent girls (aged 10-19) in particular, account for a disproportionate number of new HIV infections.
In 2017, 7,000 adolescent girls and young women became HIV-positive.
Researchers found that older men had consistently higher HIV prevalence than younger men, thus exposing young women to an increased risk of HIV infection – particularly given the generally low levels of condom use which were also associated with this age difference.61However, a study into age-disparate relationships between young women and older men in South Africa found HIV risk to be similar across all age gaps once the disparity reached five years and above.62 Every year, around 12 million girls are married before the age of 18.63 Girls who marry as children are more likely to be beaten or threatened by their husbands than girls who marry later, and are more likely to describe their first sexual experience as forced.This assumption arises from harmful gendered expectations of intimate relationships; namely, that men are responsible for providing material resources and women are responsible for providing sexual and domestic services.Many of these relationships include shared emotional intimacy, with people referring to themselves as boyfriends, girlfriends or lovers.58 Research indicates that in sub-Saharan Africa, transactional sex is one of the key factors in women’s heightened vulnerability to HIV and other STIs.A lack of privacy was also cited as a reason for not adhering to treatment, with no safe space at home or work to take medications without others seeing.55 A study in the regions of Brazil with the highest rates of gender-based violence and highest prevalence of HIV (São Paulo in the South-eastern region and Porto Alegre in the Southern region) found women were at increasingly more likely to experience gender-based violence during their lifetime if they were HIV-positive.56 Overall, in Brazil, 98% of women living with HIV reported a lifetime history of violence and 79% reported violence prior to an HIV diagnosis.57 Age-disparate sexual relationships between young women and older men are common in many parts of the world, with particularly high levels in both east and southern Africa and west and central Africa.In many instances, these relationships are transactional in nature, in that they are non-commercial, non-marital sexual relationships motivated by the implicit assumption that sex will be exchanged for material support or other benefits.
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10 HIV disproportionately affects women and girls because of their unequal cultural, social and economic status in society.11 12 Intimate partner violence, inequitable laws and harmful traditional practices reinforce unequal power dynamics between men and women, with young women particularly disadvantaged.