This document from The Joint United Nations Programme on HIV/AIDS (UNAIDS) examines one aspect of HIV transmission in Asia: women at risk of acquiring HIV because they are intimate partners of men with high-risk behaviours. As stated here, the term ‘HIV transmission in intimate partner relationships’ is used to describe the transmission of HIV to women from their long-term male partners who inject drugs, have sex with other men, or are clients of sex workers.

Data on HIV among women in Asia infected by their intimate sexual partners are limited. The pattern of HIV infection among women in countries across the region varies according to the phase of the country’s HIV epidemic. For example, in epidemics that started in the early 1980s, the proportion of infected women has increased remarkably. By 2007, women constituted 35% of all adult HIV infections in Asia, up from 17% in 1990. It is estimated that more than 90% of women living with HIV acquired the virus from their husbands or from their boyfriends while in long-term relationships. Further, it is estimated that at least 50 million women are at risk of acquiring HIV from their intimate partners.

The rate of serodiscordancy in couples - one of the pair testing positive for HIV - underscores the fact that the risk behaviours of men put their monogamous partners at risk of HIV. "This is exemplified by data from the National Family Health Survey (NFHS-3) in India, which reveal that in one in every 200 married couples in the country at least one or both partners are infected with HIV." Extrapolated data show that "[w]omen are HIV negative in about 0.76 million couples and men are HIV negative in about 0.16 million couples. Only 6% of serodiscordant couples in India use condoms consistently. Representative surveys of sexual behaviour in the region have found that very few women report more than one lifetime sexual partner. These findings also highlight that there is a need to carry out better research in order to understand the underlying mechanisms of HIV transmission in Asian countries."

Interventions for prevention of HIV transmission include:

• scaling-up HIV prevention among sex workers, men who have sex with men, and injecting drug users, including a strong additional component reaching out to their long-term intimate sexual partners.
• preventing intimate partner violence, including sexual violence.
• promoting gender equality.
• reducing economic inequities.
• promoting property rights.
• reducing vulnerability conditions associated with migration.
• reducing stigma and discrimination.
• improving disclosure within serodiscordant couples.

Factors accounting for women's prevention needs include: patriarchal gender norms preventing women from having information on protection and supporting male multiple partner relationships; exposure to intimate partner violence from husbands (raising married women's risk of HIV infection in some countries 7 times higher than the norm); mobility and migration of populations in the region; and stigma surrounding testing and disclosure. Men who migrate, as found by the 'Report of the Commission on AIDS in Asia', generally have disposable income and provide the demand for commercial sex. Migrant women, however, often must engage in paid sex. The female partners of migrant workers have been shown to be at an increased risk of infection when the latter return from working in countries with a high HIV prevalence. "Rural women left behind in China are economically dependent on their migrant husbands and have a poor understanding of HIV transmission. They are usually under societal pressure to give birth and do not use condoms, while those who have already given birth use long-term contraceptives instead of condoms, which poses a risk of HIV if the migrant husband is infected."

Vulnerabilities of migrants and their sexual partners leading to an increased risk of acquiring HIV are:

1. Social vulnerability, which includes poverty, lack of legal protection, exploitation, harassment, discrimination against migrants, xenophobia, gender discrimination, and a lack of power.
2. Individual vulnerability, lack of negotiating power; separation from families, partners, communities, and norms; loneliness, alienation, despair, and willingness to take risks.
3. Programme vulnerability, which includes lack of access to prevention, treatment, care, and support. Scaling interventions must include both migrant populations and their partners.

Ignorance about one’s HIV status increases the person’s and their intimate partners’ vulnerability to HIV infection. It is often fear of stigma and discrimination that affects the ability and willingness of people to undergo testing and disclose their HIV test results to others.

The document concludes with a call for:

• scaling up health services for men whose risky behaviours put their partners at risk;
• increasing sexual and reproductive health services for men and women, including prevention and treatment programmes and training the rural workforce in programme provision;
• integrating treatment programmes for AIDS-related illnesses and programmes addressing mother-to-child transmission into rural health systems;
• promoting condom use;
• encouraging government involvement in provision of life-skills education, including sexual and reproductive health/HIV counselling for young people;
• addressing male behaviour and issues of masculinity;
•  reducing stigma and discrimination surrounding HIV status;
• developing indicators and monitoring for gender sensitivity of sexual and reproductive health and HIV services;
• developing cross-border dialogues to promote policies to protect rights of migrants and provide them consistent prevention and treatment for sexual and reproductive health, including pre- and post-departure programmes that include intimate partners;
• orienting key stakeholders such as immigration officials, social welfare policy-makers, and health service providers on HIV transmission and migration; and
• providing for research on: the impact of migration on HIV intimate partner transmission, the magnitude of serodiscordance, linkages between risk behaviours of men and the infection of their partners, and the challenges of supporting high-risk populations of men to disclose to and protect intimate partners.

UNAIDS website on October 28 2009