If asked to imagine someone living with HIV, most people would envision a gay man, or maybe a transgender woman. Most cisgender women don’t think about the possibility of getting HIV, which—while strange to state—isn’t too surprising. Since the inception of the HIV epidemic, gay men and trans women have had a disproportionate number of people become HIV positive and die as a result of AIDS. Over time, being deemed “at higher risk” has been warped to infer only men who have sex with men and trans women can get HIV, which is far from the truth. In 2018, one in five new HIV infections were among women, yet women make up less than 10% of pre-exposure prophylaxis (PrEP) prescriptions nationwide. In fact, since the approval of PrEP in 2012, there’s been a steady decline nationwide in the number of women taking it.
Several factors contribute to the low number of cisgender women on PrEP and getting tested for HIV. Most sexual-health education aimed toward cisgender women centers around two things: not getting pregnant and what to do once you are pregnant. Studies have also shown that unless a conversation surrounding HIV and sexually transmitted infections (STI) testing is initiated by a medical provider, women are significantly less inclined to ask for an HIV test, and often medical providers don’t initiate. By acknowledging the impact clinical bias has, restructuring the present media portrayal of who benefits from HIV prevention, and reframing sexual health education, we can dismantle stereotypes surrounding HIV risk and cisgender women. While this article is focusing on the experience of cisgender women, several barriers mentioned are applicable to transgender women as well. In addition to other systemic barriers caused by racism and toxic masculinity, trans women have to deal with the violence and barriers to care that come with transphobia. The resources highlighted throughout this piece provide services to women of all backgrounds and experience.
Risk Perceptions in Clinical Spaces
Cisgender women are the most likely population to go to the doctor for routine prevention screenings and procedures. Even when excluding visits for pregnancy check-ups, women are 33% more likely to go to a medical provider than men. The only area in which this doesn’t stand true is when it comes to sexual health—specifically, HIV-related care. Many medical providers, namely those with limited experience discussing HIV, expect a “high risk” patient to present as a gay man or a transgender woman. When the person asking for PrEP or an HIV test doesn’t fit this box, providers hesitate to write a PrEP prescription or even start a conversation around the patient’s sexual practices. “We’ve heard from patients if they go in and ask, they get turned away or told, ‘Oh, that’s not for someone like you,’” says Ashlee Wimberly, program manager of D.C. PrEP for Women. Among some medical providers, being at risk for HIV is only possible for cisgender women who are sex workers or IV drug users. While these populations are important to reach, making them synonymous with high risk is problematic, and it results in unsatisfactory care to other women coming in for a check-up. A cisgender woman having receptive anal sex is at the same level of risk as a gay man or trans woman who participates in these same sexual activities. Women diagnosed with an STI are also more likely to contract HIV than a man diagnosed with an STI. A medical provider who doesn’t take the time to have a conversation about what kinds of sexual activities their patients are engaging in misses a huge intervention opportunity. Conversations can also be had with pregnant women about PrEP and HIV testing, but they often don’t happen. “All women are tested for HIV during labor, but a lot of places avoid talking to pregnant women about PrEP,” says Jasmine Pope, HIV program coordinator at the University of Maryland’s STAR TRACK Clinic. “Even if [they say] no, this should still be offered.”
Sexual Health Education and Women
Many of the misconceptions surrounding HIV risk stem from larger gaps in sexual-health education. Growing up in a rural, more conservative part of Maryland, I was given conversations about abstinence more than I was about sex. A core component of the sexual health education for high schoolers in this area consisted of viewing pictures of what genitals of folks with an STI looked like. This was used to scare teenagers out of sex, as opposed to discussing ways to healthily engage in sexual practices. When early conversations around safe sex and healthy sexual dynamics are inconsistent or avoided, you get adults who are uncomfortable or unable to discuss what their protection needs are. This is further detrimental for women, who are both hypersexualized while also chastised for having sex and assumed not to have sexual desires. Women, especially women of color, are taught not to prioritize their needs, and sexual needs are treated no differently. This, paired with implicit bias from medical providers, results in limited spaces for cisgender women to talk about their sexual-health questions. “We need well-rounded education that goes into a wide range of topics, and how you see PrEP fitting into your [health] toolkit. Women need the opportunity to talk about their own understanding of their sexuality and how they make [sexual health] decisions,” states Wimberly. Lack of spaces results in cisgender women not understanding components of sexual health and not knowing how to talk about what they don’t understand.
Portrayal of HIV Risk in the Media
Public news reports, television content, and film play a massive role in what people visualize when they hear “HIV.” This in turn has a huge impact on which people are presumed to be HIV positive, and how folks with HIV are treated. News and television content during the onset of the epidemic often portrayed folks living with HIV in a negative light. This has changed in the past few years, and television media has become a key player in actively challenging stigma surrounding HIV prevention and treatment. Digital public-health campaigns like Baltimore’s #PeopleWhoLookLikeMe and the rise in HIV prevention commercials from companies like Gilead, along with films like How to Survive a Plague and We Were Here, have been crucial in portraying the narratives and experiences of the folks primarily impacted by the epidemic: gay men and transgender women. While some cisgender women’s narratives have been included, they were often present in a smaller facet, and were mostly from the perspective of sex workers or injection drug users. Despite the rising number of HIV transmissions happening among those having heterosexual intercourse, most HIV-related advertisements continue to market to gay men and women of trans experience. Wimberly comments, “Cis women felt they were being left behind, and in a sense they were.” Historically speaking, this makes sense, as much damage was done by allowing homophobia and transphobia to silence those most impacted by the HIV/AIDS epidemic. But being at a lower level of risk does not equal zero risk, and including people of all experiences is essential. It also decreases the sincerity of including gay men and trans women by automatically blanketing them as risky by default of existing. Companies are gradually incorporating more women of all experiences in HIV-related public health campaigns and prevention commercials, but there is still a long way to go. “You cannot just coat something in pink and think women will take it,” states Wimberly. “Do focus groups, find out what they want, be more intentional in your inclusion of women.”
Changing Current Dynamics
There are individuals working hard to change this present dynamic. Digital spaces for cisgender women to talk about their experiences are opening up, and folks like sex educator Shan Boodram and groups like Afrosexology have been instrumental in opening up sexual-health conversations. Additionally, groups like D.C. PrEP for Women have done insurmountable work in making sure cisgender women are being asked about and connected to PrEP. They do so through providing funding and educational opportunities for medical providers at clinics like Mary’s Center and Planned Parenthood of Metropolitan Washington. More women are also being reached through integrating sexual-health care with primary health, a connection that isn’t always obvious for medical providers. Through funding from D.C. PrEP for Women and the Center for AIDS Research, more places are able to add PrEP as an option for primary care patients. The folks at D.C. PrEP for Women also facilitated community health education events
and trainings to help providers talk to patients. Wimberly comments, “We’ve taken the approach of being sex positive and try to talk about PrEP without using scare tactics, which surprises some folks. We emphasize that we are here to give information, not just to push PrEP.” Sisters Together and Reaching, a faith-based, women-led nonprofit organization with roots in Baltimore City, has also taken on trying to connect more women to HIV prevention and treatment. They offer HIV testing and provide linkage-to-care services, while also allowing room for folks to freely talk about sex and their health in group settings.
Individuals discriminate, but HIV doesn’t. It is a disservice to everyone to have filters on as to who should and who shouldn’t be getting HIV-related services. This type-casting, both in clinical spaces and in media and educational content, negatively contributes to the health of cisgender women and the population at large. We can all work towards challenging the idea that prevention is only for folks of a certain background. Through challenging the stereotypes on who is at risk for HIV, we can better attack the HIV epidemic and decrease its impact on persons of all experiences.