The Social Determinants of Health

The Social Determinants of Health, Women & HIV

A brief overview of social factors that influence a woman’s experience with HIV

There are many factors that aren’t related to biological makeup that influence women’s health and well-being, and may put them at an elevated risk for HIV. These factors are commonly known as the social determinants of health.

There are many models of the social determinants of health that all differ slightly but the model that is recommended when considering HIV prevention includes the following:

1. Gender
2. Aboriginal status
3.  Disability
4. Early life
5. Education
6. Employment and working conditions
7. Food insecurity
8. Health services
9. Housing
10. Income
11. Race/ethnicity
12. Social exclusion
13. Social safety net
14. Unemployment and job security
15. Immigration
16. Sexual orientation
17. Gender identity


These factors can be more broadly described as the social and economic environment, the physical environment and a person’s individual characteristics and behaviours.  All of the factors listed in the box to the left can directly and indirectly impact women’s health and risk for HIV. These determinants are also highly intersectional, with all of the factors being tied together in a complex web. We will discuss the social determinants using these overarching terms to gather a broader understanding of the influence they have on a woman’s risk for HIV.  Gender is considered a key determinant influencing a woman’s health, and intersects with all the other determinants.

Gender

As referred to in Module 3, gender differs from sex in that it describes socially prescribed roles, whereas sex refers to the biological differentiation between men and women.

More and more research is revealing that women who are marginalized have more barriers to accessing social and health care systems and are therefore at a higher risk of contracting HIV. 

In addition to this, social norms surrounding gender tend to sexualize women, yet also vilify them for being sexual.  Furthermore, societal norms may approve of sexual promiscuity among men but not among women, and may discourage women from speaking openly about sex. This creates uneven sexual dynamics that can be harmful to women’s health.

Other barriers to accessing social services which are more likely to be experienced by women, such as lack of childcare, can also prevent them from accessing social services. For example, if a woman is unable to find someone to care for her child during appointments and does not feel comfortable bringing her child with her, she may opt out of attending. Furthermore, women could be afraid to access testing for fear of what a positive diagnosis could mean for their families.

Repeated physical and sexual violence is associated with a positive HIV diagnosis. While men can experience violence as well, women are disproportionately affected. Forced sex often involves trauma and tissue tearing, creating cuts or open sores that allow for easier entry of HIV. This is especially true for young females, whose reproductive tracts are less developed.  Violence, fear of violence, and fear of abandonment can also keep women, even those who are in a monogamous relationship, from insisting on condom use or saying no to unwanted sex, leaving women with no means of protecting themselves from HIV, or other STIs.  As mentioned, fear of sexual or physical violence, abandonment and stigma can also influence a woman’s willingness to be tested, or to disclose her status to her partner(s).

Sex workers are often at higher risk for HIV, and violence toward these women further increases their risk of infection. Sex work is highly stigmatized, and this often results in discriminatory treatment, including acts of violence. Many sex workers report being beaten, threatened or coerced into sex. Sex work is considered “immoral” and “deserving of punishment” by many people, and this makes women who engage in sex work easy targets for physical and sexual violence. Ambiguous laws regarding sex work contribute to an environment where violence towards sex workers is tolerated, and many sex workers consider violence to be a “part of the job”. Even if a sex worker was to report an act of sexual or physical violence, their claims are often dismissed. This tolerance of violence towards women in the sex trade increases the likelihood that acts of violence will occur, and increases their risk for HIV infection.

Lack of female-controlled prevention methods also plays a significant role in a woman’s HIV risk.  Using male condoms requires that a woman’s male partner(s) agrees to use them. In abusive or controlling situations, a woman may not be able to advocate for the use of male condoms. The female condom is worn by the woman during intercourse, and lines the vagina to help prevent pregnancy and STIs, including HIV. Many women find that their ability to negotiate safer sex with a male partner is enhanced by having access to female condoms because they can be in control of whether they are used or not. 

Microbicides are also a new type of prophylaxis that are being developed that could be used vaginally or internally in the rectum to protect against HIV and other STIs. Although not available yet, trials are underway to prove their safety and effectiveness. If made available, their use could be controlled by the woman, and even used covertly to avoid situations of confrontation with their partner(s) about safer sex.

Social, Economic & Physical Environment

Some women are socially and/or economically dependent on men and this can have a number of repercussions for women. Even though women have made a number of social and economic gains, more women than men work temporary and part time jobs. Recent reports reveal that 70% of individuals who work part time are women (Public Health Agency of Canada [PHAC], 2012). Women have a lower income then men on average, and income is directly associated with health status. Income impacts one’s ability to access to safe housing, and ability to buy healthy food. Both women who work part time and full time consistently earn a lower wage then men. The latest census revealed that women on average earn around $28, 000 a year, while their male counterparts earn almost $44,000 (PHAC, 2012). Women are unequally impacted by poverty and this may lead to participation in survival sex, or dependent relationships. Being economically dependent on their male partners can put women at an increased risk of HIV because they feel that negotiating safer sex practices, such as using a condoms, could put their relationship and financial security at risk. This may not be the case for all women, but those who fear domestic violence or abandonment may choose to protect their financial security before protecting themselves from HIV. Fear of domestic violence or abandonment can also prevent women from accessing support services, because they feel that reaching out for testing, treatment or care would jeopardize their safety and financial security.

Stigma is an issue that all individuals infected or affected by HIV must deal with. Due to societal norms that suggest women refrain from sexual behaviours that put them at risk for HIV, myths such as “only promiscuous women or sex workers are at risk of HIV” exist, even though this is not the case. This can create an even greater sense of stigma around women and HIV, further preventing women from accessing information about how to protect themselves or using support services.

Other issues that impact all individuals living with, affected by, or at risk of HIV include social isolation, lack of culturally appropriate services and knowledgeable service providers, language and cultural barriers.

Living and working conditions can also play a large role in risk for HIV.  Poverty and unemployment are more common amongst women, and these factors have a direct impact on health and well-being, including risk of HIV.  For example, there is a clear link between homelessness and housing insecurity and HIV risk behavior. If a woman is living in poverty and is financially dependent on her partner for housing, she may feel that she must choose between safer sex, and living on the streets.

Diversity amongst Women

Diversity amongst women in Ontario impacts women’s health and well-being, and their ability to access prevention resources. Different demographics or experiences can make a woman more or less likely to experience certain determinants that put them at a greater risk for HIV.

Women in prisons, female youth, Aboriginal women, Black, African and Caribbean women, women from countries where HIV is endemic, and trans-women are considered to be more vulnerable to HIV infection in Canada.  According to the most recent population specific report by the Public Health Agency of Canada, Aboriginal women are almost equally affected by HIV as Aboriginal men, with the average proportion of women among positive HIV reports in Aboriginal persons being 48.6% between 1998 and 2009. Amongst non-Aboriginal test reports, the proportion of positive tests amongst women was 20.4% (PHAC, 2012). Furthermore, women who come from countries where HIV is endemic account for over 50% of positive HIV tests amongst women in Canada. Women in prison also have a higher rate of HIV infection than men in prisons (4.7% compared to 1.7%) (PHAC, 2012).  

In 2009, African, Caribbean & Black women represented 56% of new infections among women in Ontario (AIDS Bureau, Ministry of Health and Long-Term Care, 2013). This includes African, Caribbean & Black women who were born in Canada.  There are several reasons why this community is disproportionally affected.  For example, racism and stereotypes may discourage women from accessing services. Stigma, fear, and gossip in small communities may make some people reluctant to access testing, treatment or support. Cultural norms about condom usage and gender norms may impact women’s ability to negotiate safer sex.  Religious beliefs, homophobia, cultural attitudes and stigma may contribute to denial of homosexuality and silence around important issues that affect sexual health. As well, African, Caribbean and Black women may already face stigma, discrimination and social determinants of health that impact their risk to HIV (ACCHO, 2006). Women of colour are more likely to experience unemployment and job insecurity and live in poverty which increases risk of HIV.  Racism experienced by women of colour has also been found to contribute to feelings of hopelessness, powerlessness and lower self-esteem (Leonard, 2007). This can lead to increased street involvement, homelessness/housing insecurity, and financial dependency on partners which means that they will likely place additional focus on maintaining basic survival needs such as food and shelter instead of concern for HIV prevention, putting them at an increased risk.

 

Gender norms and proscribed roles/expectations around women’s sexuality also play a part in contributing to stigma or making women less likely to access testing or other services. It is important to remember that women have a variety of sexual orientations and identities. They may have one partner or many, and may engage in a variety of sexual activities.  Not all sexual behaviours are embraced by societal or cultural norms and this can make it difficult for women to talk about their prevention needs. It may also make it difficult for women to access resources or advocate for their sexual rights.

It is important to understand that the social determinants of health form a complex web of intersecting factors that influence a woman’s health and well-being. Women in Ontario are a diverse population, and each woman will have her own experience with the social determinants of health. Understanding the complexity of these factors and that each woman’s situation is unique will be essential to improving health and well-being and meeting women’s HIV prevention needs.

 

Works Consulted

The African and Caribbean Council on HIV/AIDS in Ontario (ACCHO), and The HIV Social, Behavioural and Epidemiological Studies Unit, University of Toronto (2006). HIV/AIDS STIGMA, DENIAL, FEAR AND DISCRIMINATION: EXPERIENCES AND RESPONSES OF PEOPLE FROM AFRICAN AND CARIBBEAN COMMUNITIES IN TORONTO

 

AIDS Bureau, Ministry of Health & Long-Term Care, (2013). Women & HIV Fact Sheet 2011.

 

Leonard, L. (2007). Women and HIV prevention: A scoping review. Ottawa, ON: HIV Prevention Research Team.

Public Health Agency of Canada (2012). Population-specific HIV/AIDS status report: Women. Toronto, ON: Public Health Agency of Canada.

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