Advancing Upstream: The Effect of Laws Discrimination on Gender Inequality in Health Outcomes Related to HIV/AIDS

Background: Globally, AIDS-related deaths are the leading cause of mortality in women aged 15 to 49 years. According to data from UNAIDS, adolescent girls and young women aged 15 to 24 are more than three times as likely to contract HIV compared to their male counterparts. Gender inequality and discrimination not only heighten the risk of HIV infection among women, especially young women and adolescent girls, but also limit their access to treatment opportunities, particularly in middle- and lower-income countries. The impact of social determinants on health disparities cannot be ignored. This study explored whether institutional discrimination against women, as manifested in laws, is relevant to HIV mortality. It also examined which types of discriminatory laws are associated with HIV mortality in different income-level countries.

Methods: Scores on laws discriminating against women, across 163 countries, were obtained from the Gender, Institutions and Development Database 2019. Female-to-male HIV mortality rate ratios (F/M ratios) were the index of gender inequality of HIV mortality, which data from the Global Burden of Disease. Mediation analysis was employed to test whether the Gender Inequality Index (GII) mediates the relationship between legal discrimination and the F/M ratios, with subgroup analyses conducted separately for low-income and high-income countries.

Results: Preliminary analyses revealed that F/M ratios varied significantly across different countries, with the highest ratios found in African and Southeast Asian countries, and the lowest in European countries. The countries with the highest levels of discrimination against women are mostly located in Africa, Southeast Asia, and to a lesser extent, in some European countries, Canada, and Australia. Mediation analysis results showed that in the full sample, the total effect of legal discrimination on F/M ratios was significant, and the GII fully mediated the relationship between certain dimensions of legal discrimination and F/M ratios.

In high-income countries, the relationship between legal discrimination and F/M ratios was fully mediated by the GII, while in low-income countries, the indirect effects were significant only in the path of the laws of restricted access to productive and financial resources.

Implications: The study provides a comprehensive examination of the role of gender inequality in shaping health outcomes related to HIV/AIDS, and underscores the need for structural interventions to address these disparities. It is crucial to break down legal barriers and prioritize political interventions that aim to reduce gender inequalities. Moreover, countries’ income-level disparity should be considered when developing policy interventions. Future research should incorporate more macro factors, cause law is just one dimension of social determinants. It is also necessary to examine the impact of structural factors on the health outcomes related to HIV/AIDS from specific aspects such as testing, treatment, and adherence.