Intimate partner violence, child sexual assault, forced first intercourse and adult sexual assault by non-partners were generally associated with increased HIV risk behaviors, as were mid or high scores on the Sexual Relationship Power Scale (SRPS) which measured women’s power in her relationship. Overall, of participants reported transactional sex, which we defined as sex with a non-primary male partner in exchange for material goods or money. Women who reported intimate partner violence, problematic substance use, urban residence, ever [having worked], or living in substandard housing were more likely to report transactional sex, while women who delayed first coitus, were married, or had a post-secondary education were less likely to do so. Transactional sex was associated with increased risk of HIV

Harmful traditional practices

A number of practices increasing a woman’s risk of HIV infection are often justified in the name of cultural values and traditions. Some of these are discussed under themes of sexual rights and economic independence. The three practices discussed here are: early marriage, wife inheritance and genital mutilation.



Early marriage

The Convention on the Rights of the Child does not set a fixed minimum legal age of marriage. However, other treaties do specify a minimum legal age for marriage. Although data is incomplete it appears that, in practice around the world, girls marry earlier than boys. Child marriage involves a number of factors which increase a young woman’s risk of HIV infection. The following factors increase potential exposure to the virus: lack of awareness of measures required for self-protection; lack of power within the marital relationship; family pressure to obey a husband; and pressure to start a family which militates against the use of condoms. Some studies have found a higher prevalence of HIV in young married women compared to unmarried women in the same age group, particularly where the husband is significantly older than the wife. Researchers have suggested that the increased risk is linked to older men’s increased sexual experience and exposure to HIV, young wives Inability to make demands on older husbands, and less use of means of protection.
Child marriage impedes a girl’s access to education with all that implies for managing her relationships, gaining employment and negotiating sexual behaviour. In
Ethiopia , for example, some 80% of married young women have had no education and are unable to read.

Wife inheritance

Wife inheritance is the practice of the transfer of the widow of a deceased man to that man’s brother she is "inherited", sometimes into a polygamous family. Subsequent sexual activity is often coerced and unsafe. The possibility that either the wife or the new husband will already be living with HIV increases the risk of transmission and thus facilitates the spread of the virus. In some traditions the woman must consent to the new marriage but if she refuses she will not receive any of the property associated with her previous married life and will lose her home. Either decision is likely to have an unwelcome outcome for the woman.

Female genital mutilation or cutting (FGM or FGC)

Cutting of the female genitalia as a cultural practice is widespread in parts of Africa and the
Middle East . Female genital mutilation can involve excision of the clitoral hood, with or without excision of part or all of the clitoris; excision of the clitoris with partial or total excision of the labia minora; or removal of part or all of the external genitalia and stitching/narrowing of the vaginal opening. The practice places girls and women at increased risk to HIV infection through several routes. Firstly, the use of unspecialized razors or knives to carry out the procedure among a number of girls risks passing the virus from one girl to the next should one of them be HIV-positive. Secondly, FGM renders the genitals more likely to tear during intercourse. In cases of infibulations or sewing up of the vaginal entrance, penetration is bound to lead to bleeding, which in turn makes sexual transmission of the virus from an HIV-positive partner much more likely. Thirdly, difficulties with intercourse may make a woman less likely to welcome the partner’s advances and lead him to a more violent approach to sex; or to engage in sexual practices with his wife (such as unprotected anal intercourse) which might place her at increased risk of HIV infection

Women must not be regarded as victims. They are, in many places, leading the way forward. In communities scattered around the globe, women and men are taking action to increase knowledge about the disease, expand access to sexual and reproductive health and educational services, increase women's ability to negotiate safer sexual relations, combat gender discrimination and violence and increase access to female-controlled prevention methods such as the female condom.

Confronting the Crisis.

Women are fighting both a virus and systemic discrimination in trying to overcome the threat of HIV&AIDS. Across the world, they face a number of circumstances which increase their risk of HIV infection in gender-specific ways. Many women are exposed to sexual violence and coerced sex inside and outside marriage, including through harmful traditional practices such as genital mutilation, early marriage, and wife inheritance. They frequently lack information on and access to HIV prevention measures and to health care as well as to support and medication after infection. They are denied property and inheritance rights, employment and access to finance. Denials which make them dependent on men. And are frequently excluded from participation in policy-making and implementation, including on issues which primarily affect them.

However women are increasingly campaigning effectively for their rights. Grassroots activism by women, including in particular women living with HIV&AIDS, has grown for years with some striking successes. And in the face of a multitude of impediments.

The HIV pandemic is increasingly viewed as a strongly gendered health, development and human rights issue. It is a preventable disease yet millions of people live with the virus and the proportion of women affected is increasing. Gender-specific factors which put women at risk of contracting HIV&AIDS and of the consequences of contracting HIV&AIDS which women face are:
Violence against women and other forms of gender-based discrimination increase women’s likelihood of contracting HIV.
Gender-based discrimination also hinders women’s access to prevention methods and to treatment.
A comprehensive rights-based approach is needed to effectively tackle the pandemic, its causes and consequences.
Agendas for an effective response to HIV&AIDS agreed by the international community including UNAIDS human rights guidelines. the Cairo Programme of Action, the Beijing Declaration and Platform for Action, the Millennium Development Goals and others have yet to be implemented effectively.


The scale of the pandemic and its impact on women

HIV affects not only those living with the virus but others who depend on, or are related to, them. It affects:
Women living with the virus who face stigma, discrimination, violence, and unequal access to medication
Women at particular risk through gender-based violence, unsafe sex, injecting drug use or living with people who are injecting drug users, as sex workers, and through discriminatory traditional practices.
Women caring for affected family members or others.

Women's gender-specific susceptibility to the virus

Women face gender-specific risks from HIV in a number of ways. The growing proportion of women affected by HIV arises from a mix of physiological, social and human rights factors. Women and girls appear to have a higher inherent risk of being infected via heterosexual activity (compared to men) because semen contains higher levels of HIV than vaginal fluids. Moreover the vagina offers a larger area of mucosal tissue subject to micro-injuries through which the virus can enter the bloodstream. Women are thus more likely than men to contract HIV through a single heterosexual encounter.

However the differential levels of infection seen in southern Africa and elsewhere, where four to five times more young women than young men in the same age group are infected each year, do not reflect solely or even mainly biological differences between males and females but rather social and human rights factors. For many women the most common risk factor they face is living with an HIV-positive husband or partner (whether he is aware of his status or not). Other risk factors include the level of violence to which women are subjected, harmful traditional practices which put women at higher risk, and socio-economic factors which limit women’s capacity to protect themselves.

Although physiology affects women’s greater risk of HIV transmission, it is women and girls relative lack of power over their bodies and their sexual lives, supported and reinforced by their social and economic inequality, that make them such a vulnerable group in contracting, and living with, HIV&AIDS. The stereotypical gender roles that underpin sexual inequality and sexual violence are confirmed and reproduced by social, cultural and religious norms. This lends an aura of naturalness and inevitability to these roles and can make them particularly difficult to contest and change.

Gender-based violence

Women face an epidemic of violence every day. Violence against women includes, but is not limited to:
Violence in the family. This includes battering by intimate partners, sexual abuse of female children in the household, dowry-related violence, marital rape and female genital mutilation and other traditional practices harmful to women. Abuse of domestic workers including involuntary confinement, physical brutality, slavery-like conditions and sexual assault can also be considered in this category.

Violence against women in the community.

This includes rape, sexual abuse, sexual harassment and assault at work, in educational institutions and elsewhere. Trafficking, forced prostitution and forced labor fall into this category, which also covers rape and other abuses by armed groups.
Gender-based violence perpetrated or condoned by the state, or by "state actors” police, prison guards, soldiers, border guards, immigration officials and so on. This includes, for example, rape by government forces during armed conflict, forced sterilization, torture in custody and violence by officials against refugee women.
Violence is a key factor in increasing women’s risk of contracting the virus. Studies suggest that the first sexual experience of a girl will often be forced. Women are two to four times more likely to contract HIV during unprotected vaginal intercourse than men both because their sexual physiology places them at higher risk of injury (especially in the case of young women) and because they are more likely to be at the receiving end of violent or coerced sexual intercourse.

Rape

One of the most pervasive and damaging forms of gender-based violence is rape. The psychological and physical trauma inflicted by rape is well-documented. However, increasingly, the transmission of HIV is an additional consequence of rape. Because it is by definition non-consensual, rape has a higher risk of leading to HIV infection by virtue of physical injury to the woman’s genitalia or anus. Even in the absence of apparent physical injury, rape can cause micro-lesions in the vagina which can be a route of infection for the virus.
Protecting women (and men) from rape, and thus from the potential exposure to HIV caused by rape, requires a number of measures. Amnesty International has documented rape in police custody, in prisons, in the community and in areas of conflict or war. While each situation requires some particular reform, what is common to all is that there needs to be political will to make clear that rape is an unacceptable crime and will be punished; that there must be public education to encourage greater gender-awareness; that police and medical professionals should be provided with more training on sensitive investigation and documentation of rape; that medico-legal and trauma services be strengthened and that laws on rape and other sexual offences be reformed to adequately address the nature and seriousness of rape. The gravity of rape has been recognized at the highest international level. The International Criminal Court, under article 7(1) (g) of the Rome Statute of the ICC, considers rape (and similarly grave forms of sexual abuse) as crimes against humanity when committed as part of a widespread or systematic attack against any civilian population. When committed in the context of an international or non-international armed conflict, these offences also constitute war crimes.
Addressing the crime of rape requires support and protection for witnesses before, during and after the trial. The obstacles posed to effective justice in rape cases are considerable and supporting complainants effectively is essential if justice is to be done and to be seen to be done.

Violence in the family and community

Intimate partner violence

Domestic violence or intimate partner violence places a significant health burden on women and on society. Intimate partner violence occurs in all countries and within all social, economic, religious or cultural groups. The overwhelming burden of partner violence is borne by women at the hands of men, although men can also be victims of violence at the hands of female partners, violence can be inter-generational, and same-sex relationships can also be characterized by violence. Intimate partner violence comprises verbal/psychological, physical and sexual violence and affects millions of women worldwide.

Women who live with violent partners face not only psychological trauma and physical injury but also experience difficulties time protecting themselves from unwanted pregnancy or disease, including sexually transmitted infections. Physical or sexual violence by a man living with HIV can contribute directly to the transmission of the virus to a partner and the longer the violence continues the higher will be the risk of this happening. A woman is also at risk when she is in a sexual relationship with an HIV-positive man who is unwilling to take preventive measures such as using a condom (whether he is aware of being HIV-positive or not). However women are also at risk more indirectly by;
Being unable to negotiate the use of contraceptives including condoms.

Commencing to abuse alcohol or illegal drugs which can lead to undertaking higher risk sexual or drug-injecting behaviour.
Intimate partner violence, child sexual assault, forced first intercourse and adult sexual assault by non-partners were generally associated with increased HIV risk behaviors.

What is the female condom?
A female condom is a device that is used during sexual intercourse. The female condom is a thin sheath or pouch worn internally by the receptive partner. It entirely lines the vagina and physically blocks ejaculated semen from entering that person's body and thus helps to prevent pregnancy and sexually transmitted diseases (STDs) including HIV. Two types of female condom are available.

The FC / FC2 female condom
The FC female condom has been available in Europe since 1992 and was approved by the US Food and Drug Administration (FDA) in 1993. It is available in many countries, at least in limited quantities, throughout the world. This female condom carries various brand names in different countries including Reality, Femidom, Dominique, Femy, Myfemy, Protectiv’ and Care.



The FC female condom is a polyurethane sheath or pouch about 17 cm (6.5 inches) in length. At each end there is a flexible ring. At the closed end of the sheath, the flexible ring is inserted into the vagina to hold the female condom in place. At the other open end of the sheath, the ring stays outside the vulva at the entrance to the vagina. This ring acts as a guide during penetration and it also stops the sheath bunching up inside the vagina.



There is silicone-based lubricant on the inside of the condom, but additional lubrication can be used. The condom does not contain spermicide.



In 2005 the makers of the FC female condom announced a new product called FC2. This has the same design as the original version but is made of nitrile, which may make it cheaper to produce. The FC2 began large-scale production in 2007.

The VA w.o.w. Condom Feminine


Like most male condoms, the VA is made of latex. When not stretched it is much shorter than the FC – around 9 cm (3.5 inches) – though it is highly elastic. It has a rounded triangular frame at the open end and a sponge inside the closed end, which helps to anchor it inside the vagina.



The VA is lubricated and does not contain spermicide. Oil-based lubricants should not be used with this female condom as they can damage latex.

How do you use the female condom?
Open the package carefully. Choose a position that is comfortable for insertion - squat, raise one leg, sit or lie down. Make sure the condom is lubricated enough.



If you are using the FC or FC2 female condom, make sure the inner ring is at the closed end of the sheath, and hold the sheath with the open end hanging down. Squeeze the inner ring with thumb and middle finger (so it becomes long and narrow), and then insert the inner ring and sheath into the vaginal opening. Gently insert the inner ring into the vagina and feel it go up. Place the index finger inside the condom and push the inner ring as far as it will go. Make sure the condom is inserted straight, and is not twisted inside the vagina. The outer ring should remain on the outside of the vagina.

To begin inserting the VA, hold the sponge and frame close together and place the closed end in front of the vagina. Use two fingers to push the closed end containing the sponge inside the vagina as far as it will go. Make sure the sponge is opened up flat once it has been inserted. The frame should remain on the outside of the vagina.

The penis should be guided into the condom in order to ensure that the penis does not slip into the vagina outside the condom. Use enough lubricant so that the condom stays in place during sex. The female condom should not be used at the same time as a male condom because the friction between the two condoms may cause the condoms to break.

If the condom slips during intercourse, or if it enters the vagina, then you should stop immediately and take the female condom out. Then insert a new one and add extra lubricant to the opening of the sheath or on the penis.

To remove the condom, twist the outer ring or frame gently and then pull the condom out keeping the sperm inside. Wrap the condom in the package or in tissue and throw it away. Do not put it into the toilet. It is generally recommended that the female condom should not be reused.

The female condom may feel unfamiliar at first. The female condom may feel different and some people find it difficult to insert. Some women find that with time and practice using the female condom becomes easier and easier.

What are the benefits?
Opportunity for women to share the responsibility for the condoms with their partners
A woman may be able to use the female condom if her partner refuses to use the male condom
The female condom will protect against most STDs and pregnancy if used correctly
The FC or FC2 female condom can be inserted up to 8 hours before intercourse so as not to interfere with the moment
The FC and FC2 female condoms are made of polyurethane and nitrile, which are less likely to cause an allergic reaction than latex. These materials can be used with oil-based as well as water-based lubricants. No special storage requirements are needed because polyurethane and nitrile are not affected by changes in temperature and dampness. In addition, these materials are thin and conduct heat well, so sensation is preserved.
What are the disadvantages?
The outer ring or frame is visible outside the vagina, which can make some women feel self-conscious
The FC and FC2 female condoms can make noises during intercourse (adding more lubricant can lessen this problem)
Some women find the female condom hard to insert and to remove
It has a higher failure rate in preventing pregnancy than non-barrier methods such as the pill
It is relatively expensive and relatively limited in availability in some countries
It is recommended that the female condom be used only once
Reuse of the female condom?
It is believed that limited availability and high cost have led some women to reuse female condoms in some countries. The World Health Organisation (WHO) recommends use of a new male or female condom for every act of intercourse for those people who use condoms for pregnancy prevention and/or STD/HIV prevention.

WHO does not recommend or promote reuse of female condoms but has released a document together with guidelines and advice for programme managers who may consider reuse of FC female condoms in local settings. There are no guidelines for reusing VA and FC2 female condoms.

Using the female condom for anal sex
Some people use the female condom for anal sex. Although it can work effectively, it is difficult to use and can be painful. There is also the risk of rectal bleeding which increases the risk of contracting HIV. So it’s better to use the male condom for anal sex.

Support for the female condom
WHO and UNAIDS are encouraging wider access to the female condom as a method of preventing both pregnancy and sexually transmitted infections. Many governments and non-governmental organisations provide female condoms for free or at subsidised prices as part of their HIV prevention and family planning programmes.

Worldwide use and availability
The female condom is used in public health programmes in more than 90 countries and is commercially marketed directly to consumers in ten countries. It is quite widely used in some places where it is actively promoted, such as South Africa , Zimbabwe and Brazil . However in many parts of the world it is hardly available at all.