Putting women in the centre of the global HIV response is key to achieving epidemic control
As we celebrated International Women’s Day and applauded the many successes that women have, and continue to achieve globally, we are also reminded of the many challenges that remain. HIV/AIDS continues to be one such challenge.
According to UNAIDS, in 2018, there were about 38 million people living with HIV, 770,000 AIDS-related deaths and 1.7 million new HIV infections – a startling reminder that HIV remains a major pandemic and that we have miles to go in sustaining our current treatment successes, strengthen our prevention efforts, and address continued human rights violations and research gaps before we achieve control of this devastating virus.
Women across their lifespan fulfil many and multiple roles in society including being caretakers and educators in formal and informal settings, which largely goes unrecognized and is unrewarded.
Moving towards the UN 2030 goal of ending AIDS as a public health threat calls for new and concerted efforts to ensure that:
1) innovation in prevention and treatment efforts include women across their lifespan,
2) HIV prevention efforts in adolescent girls and young women (AGYW) address the underlying gender-power differences at the root cause of their vulnerability,
3) investments in research and care for all women of all ages to prevent or treat HIV are increased, and
4) innovation for less user-dependent women-initiated HIV prevention technologies continues.
A nuanced and granular understanding is critical for the development of effective responses to reduce their vulnerability and societal impediments to empowerment and gender equality.
Sub-Saharan Africa bears a disproportionate 70% of the global burden of HIV that is spread predominantly through sex with a concomitant epidemic in infants born to mothers living with HIV. A unique characteristic of this generalized epidemic is the high rate of HIV in AGYW aged 15 to 24 years, who are up to six times more likely to have HIV compared to their male peers.
This early acquisition of HIV in young women, often from men who are five or more years older than them, is central to the continued spread of HIV in this region. Four out of five of all infections occurring among adolescents in sub-Saharan Africa are in girls aged 15 to 19 years.
UNAIDS estimates that in South Africa, which is home to one in five of the world’s people living with HIV, 1500 AGYW acquire HIV every week. Overall, AGYW are twice as likely to be living with HIV and experience higher rates of morbidity and mortality compared to their male peers.
Behavioural and biological factors such as age-disparate sexual coupling between young women and older men, genital inflammation and vaginal dysbiosis contribute to a young woman’s vulnerability for acquiring HIV. These factors are difficult to mitigate against the backdrop of structural challenges of poverty, social incohesion due to migration and conflict, gender-based violence and gender-power dynamics, including a woman’s limited ability to negotiate safer sex with prevention technologies that depend on male co-operation.
When adolescent girls become pregnant, they are more likely to drop out of school and not complete high school. This limits their employment opportunities, leading to vicious cycles of dependency on older men, and increases their risk of having a repeat pregnancy within a year and of acquiring HIV if not already living with HIV. Preventing new infections in this group is therefore a high priority to alter the current epidemic trajectory in sub-Saharan Africa and get it on the path of epidemic control.
The PEPFAR-funded DREAMS Project is an excellent example of an intervention targeting behavioural, biological and structural drivers of adolescent vulnerability, underscoring the importance of completing schooling, avoiding unplanned pregnancies and graduating from high school HIV-free. These investments will strengthen social cohesion and realize the continent’s full potential of youth as its demographic dividend.
Transgender women are among the most marginalized in society due to the general lack of legal gender recognition and criminalization of their gender identity. Stigma, discrimination, and unavailability of transgender-competent health care are key barriers for transgender women to
address their basic health needs. Meeting their health needs together with strengthening legal protections and advocacy around their human rights is critical.
Millions of women worldwide over the age of 50 are living with HIV – but their successes, challenges and future prospects are rarely heard. The majority reside in sub-Saharan Africa, but there are hundreds of thousands living in high-, low- or middle-income regions around the world. Congruent with expanded antiretroviral treatment access, their numbers will continue to increase over the next decade. We have been complacent about understanding the biomedical changes and societal barriers for these women; and research investment is lacking.
Women, like men, are at increased risk for cardiac disease, malignancies and bone disease as they age; some conditions such as bone disease are amplified among peri- or post-menopausal women. Knowledge of the consequences of the extraordinary weight gains associated with dolutegravir are unknown, but differentially affect women.
There are enormous unmet behavioural health needs for women throughout life, particularly associated with ageing, where depression and loneliness, coupled with cognitive decline, can lead to a downhill spiral and premature death. The health and wellbeing of women ageing with HIV is also particularly affected by cultural norms that violate their fundamental human rights.
Lack of property ownership and gender-based violence can precipitate or exacerbate poverty, food security and access to care. Women in polygamous marriages may lose stature and resources as they age.
Around the world, women over 50 who do not have HIV are often not considered “at risk” to acquire HIV, are tested less frequently than men, and are less likely to seek PrEP. In 2018 alone, 22,000 women over the age of 50 acquired HIV in southern and eastern Africa.
By ensuring that no women – from birth to death – experience barriers to access to the full range of HIV prevention and care services or violation of their basic human rights, all of society benefits.
* This is an edited version of the open access article titled: Putting women in the centre of the global HIV response is key to achieving epidemic control! Abdool Karim Q et al, published in the Journal of the International AIDS Society 2020
** Professor Quarraisha Abdool Karim is the Associate Scientific Director of CAPRISA and the UNAIDS Special Ambassador for Adolescents and HIV.