This is not to say that at this stage of the epidemic, a shift in focus may not be required.  As a result of changes in the course of the epidemic, the focus must now be on who continues to become infected.  Of the 40 million people worldwide, who are estimated to be living with HIV infection, 17 million are women; half of all new cases being reported are now in women, and the heaviest burden of new infections is on young women between the ages of 15 and 49.  It must also be noted that globally, the epidemic evolved very differently for women as most become infected through heterosexual sex.  However, there are significant numbers of women in almost every part of the world, more so in the U.S. than other areas, who contract HIV through injecting drug use or high risk sex associated with drug use.   The sobering reality, regardless of the mode of transmission, is that mortality rates for women continue to rise worldwide.

Two questions immediately come to mind. Where do these women live?  Who are these women?  About two-thirds of all people living with HIV infection, live in sub-Saharan Africa.  In addition, the circum-Caribbean region has been assigned by the World Health Organization an HIV prevalence rate of 2% among adults 15-49 years of age, which is second only to the 8% prevalence rate among adults 15-49 in AIDS-ravaged sub-Saharan Africa.[i],[ii]   However, a recent study indicated that the Garifuna (slave descendants who live primarily in Central America: Honduras, Guatemala and Belize) have some of the highest HIV/AIDS (8% to 14% in Honduras) rates in Latin America.[iii]    In the U.S. where Afro-descendant women (also referred to as black or African American) are just 13% of the U.S. female population, they accounted for 63% of the newly reported cases among women in 1999.[iv]  In both regions: the U.S. and the circum-Caribbean, the majority of new cases are found predominantly in Afro-descendant women.   

The surge of new cases in women in general and in Afro descendant women in particular requires explanation.   With new knowledge about the disease, a better understanding has been gained, that anatomically, heterosexual transmission much more so than intravenous drug use and needle sharing is a greater problem for all women because physiologically, the rate of transmission from men to women is four times the rate from women to men,[v] as women have a much larger mucosal surface where micro-lesions can occur. 

For African descendant women specifically, where ever they are located, biology though significant is but one aspect of their higher vulnerability to the disease than other racial ethnic groups.  Of equal or greater importance than anatomy, are the societal structures that operate globally to determine individual social, political and economic power.  In addition there are defining forces also at work such as immigration status, class, social status and group history, all of which conspire to significantly increase HIV/AIDS rates among Afro-descendant women.

We now live in a world in which the globalization of work and wealth has had more than 500 years to firmly establish a well structured set of gradations of inequality that operate both within, and across nations.  These structural inequalities are felt in different degrees depending on one's status as an individual or nation.  As a result, irrespective of whether one happens to live in a wealthy nation or poor country, there exists for some individuals and subgroups an undue amount of suffering created largely by the processes in place to primarily pursue economic growth and development.  These processes are aptly described by Paul Farmer in his seminal treatise on new ways of waging war on the poor as "insidious assaults on individual dignity such as institutionalized racism, gender inequality and structural violence."[vi]  No other sub-group internationally, bears the burden of these structural inequalities than poor people of color in general and African descendant women in particular.

A vivid example of the ways in which undue suffering brought about by structural inequalities play out in people's lives, can be found in the dramatic increase of new HIV/AIDS cases among African descendant women in the Americas, especially in the U.S. and the circum Caribbean regions.   The geographic proximity of the two regions make them somewhat interdependent as the circum-Caribbean, which has been referred to by the Bush Administration and Caricom nations as the third border of the U.S.[vii], is also the primary vacation destination for residents of the U.S.   However, the AIDS epidemic in the Caribbean and Central America has begun to have negative consequences for economic and social development in the region.  In that regard, it must be noted that Latin Americans of African descent, who are thought to number 150 million, are among the Western Hemisphere's most impoverished citizens.[viii]    Unfortunately, there is wide spread recognition of the connection between poverty and HIV/AIDS

The entrenched poverty of Afro descendant populations throughout the Caribbean and Latin America has been oft cited as a primary "push force" in their migration to the U.S., of large numbers of women who come primarily in search of work and the ability to engage in "network" and "circular migration patterns."   Once in the U.S. Afro-descendant immigrants live among other people of color with whom they share some common characteristics such as socio-economic status, health status, and physical attributes.  At the same time these communities also have a marked degree of diversity in terms of nationality, culture, language, beliefs and values.   

The structural inequalities described above are accompanied by other defining forces, one of which is immigration status.  Women, especially those who are undocumented, (legal, politically approved permission to remain in the U.S. entry) often find themselves in the position of being totally dependent on men for housing, economic and social supports.  This dependence renders them powerless in terms of negotiating preventive behaviors such as condom use.  But, whether in the U.S or in their home country, immigration has an impact on women.  For example, U.S. policies on repatriation of migrant workers, foreign born ex-prisoners and other categories of persons do not include routine HIV testing and counseling, or sharing of HIV specific data on returnees, with the receiving home countries.  As a result the HIV/AIDS problematic for many developing nations now includes the fact that repatriated persons, sometimes unwittingly, take HIV home with them.[xiii]  

In 2005 the UN, UNAIDS and the World Health Organization issued guidelines to help all nations of the Americas set targets, conduct assessments and otherwise try to come into compliance with the earlier  recommendations for "Universal Access" to HIV/AIDS  prevention and treatment services.[xiv]  While this is an important step in the right direction there is also a need to focus on the transnational population of people who move between their home countries and the large metropolitan cities of the U.S. for purposes of work or repatriation.  Programs that focus on these populations will more likely demonstrate greater efficiency in helping to cultivate prevention thinking and behaviors thereby stemming the tide of new cases in women and girls as a result of heterosexual transmission.