Causes and Risk Factors
According to the World Health Organization (WHO), intimate partner violence and sexual violence against women have greatly contributed to women’s increased risk of HIV infection.  
 
Sexual violence can occur directly, through forced sex, and indirectly, through the powerlessness of women in negotiating the terms on which sexual encounters take place.  Regardless of the form sexual violence takes—whether it be human trafficking, prostitution, marital rape, or intimate partner violence—the cause of HIV infection in women stems from the reality that most “women lack control over their bodies and their daily lives, and the tools, resources, and support needed to change their situation.”[1] This vulnerability is affected by societal gender norms that place them in subordinate positions, by biological differences between men and women, and by structural and economic factors.[2]  Because sexual coercion has been associated with HIV risk factors, HIV transmission is likely to occur in the kinds of forced sexual encounters experienced by rape and trafficking victims.[3] 
 
As everywhere, violence against women (VAW) is a severe problem in Eastern Europe.  Reproductive health surveys show that between 15% and 29% of married women in Georgia, Russia, Ukraine, Moldova, and Romania have reported some kind of physical violence perpetrated against them. Although there is limited data on the extent of sexual assault, studies have shown a 2% to 8% lifetime prevalence rate in Moldova, Georgia, and Romania, with the first incident of assault occurring before the age of 25.[4]  
 
In a World Health Organization (WHO) publication focusing on the intersection of VAW and AIDS, Dr. Suzanne Maman identified the following four links between HIV/AIDS and VAW:
 
1.      Forced sex may directly increase women’s risk for HIV through physical trauma.
Women can be the victims of forced intercourse in a number of situations:  human trafficking, prostitution, and rape, including rape within a marriage or an intimate relationship.  There is a strong link between this type of violence and HIV infection, and several studies demonstrate that HIV-positive women have experienced more forced or coerced sexual encounters than HIV-negative women.  Biological differences between men and women also account for the increased likelihood that women will contract the virus during a forced sexual encounter.  The larger amount of exposed mucus membrane in women, the greater quantity of fluid transferred from men to women, and the vaginal or anal tears that might occur at penetration in these types of encounters increase the susceptibility of women.[5]  A European study on the health consequences of trafficking in women confirmed this link, as researchers found that sex trafficking victims are at a higher risk of contracting sexually transmitted infections because the tears and trauma to the vaginal lining that typically occur in coerced sexual encounters increase the likelihood of infection.  Particularly vulnerable are Eastern European and Asian women, who are becoming increasingly susceptible to sex trafficking, especially in the impoverished countries of the former Soviet Union.[6] 
 
2.      Violence, and threats of violence, may limit a woman’s ability to negotiate safe sexual behavior.
Women who are victims of abuse are frequently unable to negotiate safe sexual behavior, thus also increasing their risk of contracting HIV.  Studies show that women in violent relationships discuss and use condoms less.  Because insistence on condom use can subject a woman to further physical abuse, women suffering from physical or sexual abuse are essentially powerless to negotiate the terms under which their sexual activity occurs.
Some studies also suggest that marriage has become a risk factor for many women because: (a) it exposes them to more sexual encounters and (b) unprotected sex is more frequent and often expected.[7]  Insisting on condom use in marriage has been interpreted, particularly in relationships where there are power imbalances, as an expression of distrust. As a result, women in such relationships have tended to be afraid to insist on condom use for fear of violence against them.
 
3.      Sexual abuse in childhood may lead to coping behaviors that are associated with HIV infection.   
Maman asserts that individuals with a history of childhood sexual assault initiate sexual behavior earlier and engage in riskier sexual behavior in which they are more likely to contract HIV.  There is evidence that due to psychological factors, children who have been sexually abused have a tendency to participate in HIV risk behaviors such as alcohol and drug abuse in adolescence and adulthood; these behaviors, in turn, are associated with riskier sexual behaviors, such as unprotected sex, sex with multiple partners, and prostitution.[8]  As a result, women who were victims of sexual abuse as children are at a higher risk for contracting HIV.  And, one out of every five women in the world reports being sexually abused as a child.[9] 
 
4.      Women who test for HIV and share test results with partners may be at increased risk for violence.
The fourth link between VAW and HIV occurs after women have been diagnosed with HIV. Dr. C. Watts, of the London School of Hygiene and Tropical Medicine in the UK, asserts in Addressing violence against women in HIV testing and counselling  that VAW is both a cause and a result of the HIV epidemic; a cause in that a woman may not get tested due to fear of violence should she be diagnosed with the illness; and a result in that, as evidence suggests, disclosure of HIV infection may put women at risk of violence or abandonment by a partner, even if it is the partner who infected them. Studies have shown that up to 51% of women did not report their status to their partner due to fear of violence. Between 4% and 15% have reported disclosure-related violence in sub-Saharan Africa and Southeast Asia.[10]   Because of the stigma attached to HIV infection and the abuse inflicted on so many women, many conceal their true status or avoid getting tested altogether. About 71% of women in the developed world and only 52% of women in the developing world have shared their HIV status with their partners.[11]
 
Women who are partners of men who have sex with men are also particularly vulnerable to HIV infection.  Because of the stigma attached to homosexual behavior, some men who struggle with a homosexual identity will marry women to avoid it, while also continuing to have sex with other men.   In so doing, they put both their female and male partners at risk. This is especially the case in many parts of Eastern Europe where homosexual behavior is highly stigmatized.[12]
 
Another link between HIV/AIDS identified by The Global Coalition of Women and AIDS  is partnering with riskier or older men. Girls and women in impoverished parts of the world sometimes engage in transactional sex with older men in exchange for material goods that might range from their next meal to school fees to special items. Furthermore, as Florencia Aranda noted, in her work on the intersections between HIV and violence against young women, in some developing countries where the marriage of young girls to older men is common, the risk of these girls contracting HIV is high as older men tend to have had numerous previous sexual partners, and, in some cases, have current relationships with other women.[13]  
 
Lack of access to education is also a contributing factor in a girl or woman's risk of contracting HIV/AIDS.[14]   It is estimated that of the 115 million children worldwide who are not attending school, 57% are girls.  The result is that these girls lack the knowledge to protect themselves from HIV infection.  In its 2008 report on the global AIDS epidemic, UNAIDS noted that a survey of 64 countries revealed that only 55% of young women knew that condoms could help prevent HIV transmission, compared to 70% of males.  Also, there is evidence that knowledge of sex and reproductive health helps reduce the stigma associated with HIV/AIDS.[15]   Where access to education is not a factor, it appears the problem is underdeveloped sex education programs; this is the case among various Eastern European countries including Ukraine and Russia.  In other countries such as Bulgaria, Latvia, and Croatia, sex education may simply not be required in schools.[16] Women who are in prison are particularly vulnerable to HIV infection as they are often victimized by prison workers. Because of the unequal power relations between the two groups, women are often coerced to exchange sex for items like cigarettes.[17]  In Eastern Europe and Central Asia, (as is the case in the United States of America), the proportion of people in prisons who are infected with HIV is much higher than in the general population; this is attributed mainly to drug use both inside and outside of prison, as well as unsafe sexual practices within the prison.[18]  The European Union has reported that between 16% and 54% of prisoners, in general, use drugs and share unsterile equipment, but the numbers for women are reported to be much higher.[19] 
 

[1] Kathleen Cravero, UNAIDS Deputy Executive Director, in a 2004 speech.
[3] World Health Organization. Violence against women and HIV/AIDS: Setting the research agenda, 2009.
[4] World Health Organization. HIV/AIDS in Europe: Moving from death sentence to chronic disease management, 2006.
[5] United Nations Development Programme. Gender and HIV in Europe and CIS, 2009.
[6] Joint United Nations Programme on HIV/AIDS. Report on the global AIDS epidemic: Executive Summary, 2008.
[7] International Council of Aids Service Organizations. Gender, Sexuality, Rights and HIV: An overview for community sector organizations, 2007.
[9] World Bank. HIV/AIDS in ECA: Overview, 2009.
[10] Tools for change. Applying United Nations standards to secure women’s housing, land, and property rights in the context of HIV, UN Commission on the Status of Women, 2010.
[11] Tools for change. Applying United Nations standards to secure women’s housing, land, and property rights in the context of HIV, UN Commission on the Status of Women, 2010.
[16] World Health Organization. Progress on Implementing the Dublin Declaration on Partnership to Fight HIV/AIDS in Europe and Central Asia, 2008.