Entrenched economic and gender inequities are the driving forces behind the globally expanding HIV/AIDS epidemic among women (1). Poverty and gender inequities operate in a vicious cycle: the many manifestations of poverty--insufficient income, limited access to education and jobs, and little autonomy for decision-making--are fueled by gender-based norms and values that reinforce women's lower social and economic status. This cycle is made worse by the spread of the HIV epidemic, which has increased poverty and further increased women's vulnerability to HIV (2).

Women and girls in many parts of the world are dependent upon their male partners and have limited access to sexual health information and tools, economic resources and education. This makes them extremely vulnerable to HIV infection (3). To date, the global spread of HIV has not declined significantly, at least in part because most prevention efforts assume a degree of individual control in decision-making that, in reality, many women and girls do not have. Efforts to decrease HIV transmission have overlooked the effects of this social environment--most notably poverty and gender inequities--on those most at risk.

Gender imbalances and poverty create several "structural pathways" to HIV risk for women (4). A structural pathway is something that shapes people's choices and their risk for illness. For vulnerable women and girls, this includes lack of access to educational and economic opportunities solely due to their gender.

Many women take part in high-risk behaviors in order to manage their economic situation. For example, many girls and women participate in "transactional sex," trading sex for food, clothing, or school fees. Often, they do this to survive or "get ahead," not only because their current options are limited, but because they can't imagine that a better life is possible.

Traditionally, HIV prevention has focused on giving women better access to information and health services. But such approaches--which include providing education and sometimes condoms--don't address the underlying drivers of HIV risk. However, when combined with strategies that promote gender equity and women's economic empowerment--for example, conditional cash transfers (CCT), microcredit, and training programs--they have a much better chance of success. These multi-component efforts also have the potential to help women gain more decision-making power in their lives and instill greater optimism for the future.

Research has also shown that giving girls a formal education helps reduce their risk of HIV/AIDS. Girls who are educated have a better knowledge and understanding of how HIV and AIDS is spread (5); are more likely to accept HIV counseling (6) and prevention messages (7), and have increased power in their relationships (8, 9). Studies have also found that girls who received more education started having sex at a later age; had higher levels of condom use; were less likely to be coerced into sex; were less likely to engage in transactional and/or intergenerational sex; and had lower odds of testing positive for at least one sexually transmitted illness (8, 10).Education is also likely to shape girls' perspective of the future, decreasing the "fatalism" that sometimes justifies engaging in risky behavior (6).

Unfortunately, poverty and gender inequity are part of the reason education is often withheld from girls. Numerous studies have shown that when families are stressed financially and cannot afford to educate all of their children, they often decide to keep male rather than female children in school (11). In other instances, girls are deliberately kept out of school because families would rather have their help at home (12) or because parents see it as a waste of resources when the girls will soon be married off to other families (13-14). This gender gap is widest in Africa, the Middle East, and South Asia (15). Cutting short girls' educational opportunities goes hand in hand with early marriage and sexual activity and with limited future economic opportunities, both of which only add to young women's poverty and lower status as well as their vulnerability to HIV. Thus, HIV prevention programs should include interventions to keep girls in school.

To date, few economic or educational interventions have yet targeted or been rigorously evaluated for reducing HIV infection. A recent study we conducted among teen-age female orphans in Zimbabwe found that combining vocational training and microgrants with HIV and gender education decreased rates of unintended pregnancy and experiences of physical and sexual violence--both outcomes related to HIV risk (16).

Such integrated approaches have the potential to create a win-win situation when it comes to disease prevention and women's lives: addressing poverty and gender inequities as well as reducing HIV in ways never before seen.

REFERENCES:

1. UNAIDS/UNFPA/UNIFEM. Women and HIV/AIDS: Confronting the Crisis. 2004.

2. Loewenson R, Whiteside A. HIV/AIDS: Implications for Poverty Reduction. New York: United Nations Development Programme. 2001.

3. Loewenson R. Exploring equity and inclusion in the responses to AIDS. AIDS Care. 2007;19:S2-S11.

4. Kabeer N. Resources, Agency, Achievements: Reflections on the Measurement of Women's Empowerment. Development and Change. 1999;30:435-64.

5. Hargreaves J, Boler T. Girl power: The impact of girls' education on HIV and sexual behaviour. Johannesberg: ActionAid International. 2006.

6. Kaufman CE, Clark S, Manzini N, May J. Communities, Opportunities, and Adolescents' Sexual Behavior in KwaZulu-Natal, South Africa. Studies in Family Planning. 2004;35(4):261-74.

7. Sherr L, Lopman B, Kakowa M, Dube S, Chawira G, Nyamukapa C, et al. Voluntary counselling and testing: uptake, impact on sexual behaviour, and HIV incidence in a rural Zimbabwean cohort.Aids. 2007 Apr;21(7):851-60.

8. Crosby R, DiClemente R, Wingood G, Salazar L, Rose E, Sales J. The protective value of school enrolment against sexually transmited disease: a study of high-risk African American. Sex Transm Infect. 2007;83:223-7.

9. DiClemente R SL, Crosby R, Rosenthal S. Prevention and control of sexually transmitted infection among adolescents: the importance of a soci-ecological perspective--a commentary. Public Health. 2005;119:825-36.

10. Kaufman C, Stavrous S. 'Bus fare please': the economics of sex and gifts among young people in urban South Africa. Culture, Health & Sexuality. 2004;6(5):377-91.

11. UNESCO. Education for All: Who is excluded and Why. 2004.

12. UNAIDS. Gender and HIV/AIDS: Taking stock of research and programmes. UNAIDS Best Practice Collection. 1999.

13. De Bruyn M. Women and AIDS in Developing Countries. Journal of Social Science and Medicine. 1992;34:249-63.

14. Hunter S. Orphans as a window on the AIDS epidemic in Sub-Saharan Africa: initial results and implications of a study in Uganda. Journal of Social Science and Medicine. 1990;31:681-90.

15. UNICEF. Gender Achievments and Prospects, 2005. Report No.: Part One.

16. Dunbar M, Kang M, Mudekunye I, Padian N. Economic Livelihoods and STI/HIV Prevention for Orphan Girls in Zimbabwe-SHAZ! Phase II. 18th International Society for STD Research Conference June 28, 2009 - July 1, 2009; London, England2009.

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Suneeta Krishnan, PhD, is an epidemiologist with the Women's Global Health Imperative, RTI International. She is also an adjunct assistant professor at the University of California, Berkeley, and adjunct associate professor at St. John's Research Institute, Bangalore, India.

Megan Dunbar, DrPH, is a public health scientist for the Women's Global Health Imperative, RTI International, and a prevention consultant for the Pangaea Global AIDS Foundation.

Alexandra Minnis, PhD, MPH, is an epidemiologist with the Women's Global Health Imperative, RTI International, and assistant adjunct professor in the School of Public Health, University of California, Berkeley.

Nancy Padian, PhD, is senior research fellow and director of the Women's Global Health Imperative, RTI International. She is also a professor in the School of Public Health, University of California, Berkeley, and a senior prevention consultant for the Pangaea Global AIDS Foundation.

This essay is based on the following article: Krishnan, S., Dunbar, M., Minnis, A., Gerdts, C., Medlin, C., & Padian, N. (2008). Poverty, gender inequities and women's risk of HIV/AIDS. In S. G. Kaler & O. M. Rennert (Eds.), Reducing the impact of poverty on health and human development: Scientific approaches. Special issue of the Annals of the New York Academy of Sciences, 1136.

The authors would like to acknowledge the contributions of Carol Medlin and Caitlin Gerdts with whom we have written a lengthier discussion on this topic. The following authors received research and salary support from the National Institute of Chile Health and Human Development: Krishnan (R01 HD41731 and the Presidential Early Career Award for Scientists and Engineers 2004), Minnis (K01 HD047434), and Dunbar and Padian (R01 HD045135-04). Dunbar and Padian also received support from the Office of AIDS Research, Office of the Director of the National Institutes of Health (R01 HD045135-04), and the Tides Foundation. Minnis and Padian received partial support from the National Institute of Allergies and Infectious Diseases (R01-AI48749). Minnis received additional research and salary support from the University of California Institute for Mexico and the U.S., California-Mexico Health Initiative, and the UC Office of the President. Padian received support from the NIH Roadmap Exploratory Centers for Interdisciplinary Research (P20 RR020817). The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of any of our sponsors, including the National Institutes of Health.