POLICY BRIEF STRENGTHENING PEPFAR FOR WOMEN AND GIRLS Globally, the HIV/AIDS infection is spreading most rapidly among young people between the ages of 15 and 24. Half of new infections worldwide, affecting 5,000 to 6,000 youth each day, occur in this age group.1 Women and girls now comprise 48 percent, or 17.7 million, of the nearly 40 million people living with HIV/AIDS. Especially vulnerable are young women and girls, who make up 75 percent of all new cases in sub-Saharan Africa, and a growing proportion of those infected in Asia, Eastern Europe and Latin America.2 Three-quarters of all women and girls with HIV and AIDS live in sub-Saharan Africa,3 many of them in the countries where the President’s Emergency Plan for AIDS Relief (PEPFAR)4 is working. In that region, young women and girls are at least three times more likely to be infected than their male cohorts.3
PEPFAR is now in year four of a $15 billion, five-year initiative to combat HIV/AIDS through prevention, care and treatment in 15 focus countries.5 PEPFAR has made strides in addressing the vulnerabilities of young women and girls: sex-disaggregated data is being collected to ensure that PEPFAR programs equitably incorporate women and girls; the gender content of PEPFAR’s current programs is being assessed; and a Gender Working Group is advising on future strategies. PEPFAR’s second report to Congress identifies hundreds of program activities whose aim is to address “the special vulnerability of women to HIV/AIDS.”5 While the Global AIDS Coordinator has signaled his strong endorsement of these efforts, an evaluation released in 2006 by the General Accounting Office6 indicates that PEPFAR restrictions and policies hamper maximum effectiveness in reversing the pandemic’s toll on young women and girls. PEPFAR must place reducing the vulnerability of young women and girls at the top of its agenda. As plans for reauthorization of the Act4 are developed, the opportunity to scale up and fully fund empirically-based strategies that are responsive to the needs of young women and girls should not be lost.
Why and How is HIV/AIDS Disproportionately Affecting Girls and Women? A Greater Biological Susceptibility Physiologically, women and girls are at a disadvantage: male-to-female transmission of the virus is twice as likely as female-to-male.7 Tears and lesions, resulting from forced sexual encounters, increase the likelihood of HIV transmission, especially among younger women and girls.8
Gender-Based Violence Forced and coerced sexual encounters are all too commonplace.9 The first sexual experience for 20-25 percent of young women in villages of Zambia, Kenya and South Africa was found to involve physical force or coercion.10 The inability to avoid sex without protection, even in ongoing partnerships, is increasingly recognized as a primary factor in the rise in HIV infections among young women and girls. Violence and
threats of violence further prevent women from seeking information, counseling and testing, treatment and care. Throughout the world, lack of legal recourse and financial dependence leave women who are in abusive relationships with little power.
Poverty and Lack of Economic Rights Gender-based social and economic inequities underlie the young, poor and female face of HIV and AIDS. Poor girls are often unable to access education and, consequently, the opportunity to learn skills for productive employment. While educated girls are more likely to delay sexual debut and marriage, and are better informed about HIV prevention, girls comprise two-thirds of the 113 million school-aged children worldwide who are not in school.11
Lacking economic self-sufficiency, women and girls are also often denied the protection of property and inheritance rights. A young woman’s HIV infection or the death of her husband from AIDS may leave her stripped of property and home, unable to support herself and her children. Even where civil laws protect the rights of women, contrary customary or traditional law may prevail.12 Destitution can lead unskilled women and girls to desperate acts, including transactional or commercial sex, greatly heightening the risk of contracting HIV.
Unsafe Schools Notwithstanding the critical benefits of education, the school environment itself can be a source of sexual coercion and exploitation of girls.13 Many girls are forced to leave school due to sexual harassment or impregnation by teachers.14 A study in South Africa found that a third of those who perpetrated rape on girls less than 15 years old were teachers.15 Girls are also vulnerable to sexual violence on the way to and from school.
Married Women and Female Heads of Household Are Not Protected The majority of young women in many developing countries marry and begin childbearing during adolescence. More than 50 million married girls are 17 years of age or younger. Because married girls more frequently have unprotected sex with men who are older and more sexually experienced,16 their risk of HIV infection is high, even if they themselves remain monogamous.17 Socially and economically dependent on their husbands, young women have little power to negotiate safe sex, and they widely report that even suggesting condom use can challenge the power of the male partner and lead to violence.18 In Southern Africa, one out of every three households with children is female-headed.19 Women and girls provide the greatest share of home-based care for HIV/AIDS-affected family members, a burden that further limits their ability to become educated, develop skills, and generate independent income. There are few sources of support for these women and girls, who are often desperately poor.
How Can PEPFAR Work More Effectively to Help Young Women and Girls?
End Counterproductive Policies Essential prevention interventions by U.S.-funded NGOs to reach female sex workers and their clients are hampered by the U.S. government’s “anti-prostitution clause.”20 The law stigmatizes both sex workers and young women and girls who may be forced by necessity to engage in transactional sex. These clauses should be rescinded.
Expand Evidence-Based Prevention Only 20 percent of PEPFAR funds can be spent on prevention, and a third of these must be spent on abstinenceuntil marriage programs.4,21 Yet, UNAIDS projections highlight that only by emphasizing prevention and a comprehensive evidence-based approach, can the upward trajectory of the epidemic be reversed.2 Without massive scale-up of successful prevention efforts, an estimated 60 million new infections will occur over the next 10 years22 and treatment programs will be unable to keep pace with the growing demand. PEPFAR’s requirement to spend a third of its limited prevention funds on abstinence-until-marriage programming constrains countries and communities from developing programs that best serve their own needs6 and limits the options for serving young women and girls who are married, sexually active, and/or victims of coerced sex. Rapid scale-up of proven prevention strategies is a sound investment that could prevent 30 million new infections in lowand middle-income countries in the coming decade.23 The abstinence earmark should be eliminated.
Support Female-Controlled Methods of HIV Prevention Female-controlled prevention measures, such as female condoms, enable women to better protect their own reproductive health. Integrating female condoms into core procurement packages, improving marketing to private providers and the public sector, and expanding information and training for women and providers on how to use them, would accelerate access and lower costs. Efforts to develop an effective microbicide and to determine the effectiveness of existing cervical barrier methods must be intensified through increased funding and collaboration.
Integrate/Improve Reproductive Health and HIV/AIDS Services HIV services should be integrated and coordinated with existing comprehensive reproductive, family planning and maternal health services already serving women and girls.24 Lack of privacy and confidentiality, and discriminatory and judgmental provider attitudes,25 prevent adolescents and young married women from accessing information and services to protect themselves. Such barriers must be eliminated and greater support is urgently needed for education and behavior-change programs to counteract the stigma and discrimination that many women and girls face in accessing voluntary counseling and testing.
Enable Universal Access to Prevention of Mother-to-Child Transmission (PMTCT) Failure to address stigma and gender discrimination contributes directly to preventable HIV infections among infants. Nearly nine in 10 women still lack access to services to prevent mother-to-child transmission of HIV, or
fail to use existing services, for fear that revealing their HIV status to their families and communities will lead them to be shunned or abandoned. Most of the half million new HIV infections among infants that occur each year26 can be prevented through PMTCT services that successfully address stigma, gender inequity and the vulnerabilities of young women and first-time mothers.
Ensure Safe, Universal Schooling for Girls To develop economic independence, as well as the knowledge and self-efficacy to protect themselves from HIV, girls need education beyond the primary level. Girls with secondary education have more than twice the level of comprehensive knowledge about HIV and AIDS as girls with primary education.2 Girls need a school environment that is safe, models gender-equitable behavior on the part of teachers, and offers a complete, evidence-based HIV prevention curriculum. School policies enforcing zero tolerance of sexual exploitation by male teachers and male students can provide girls with a safer learning environment.27
Support Female Caregivers Strengthening the ability of HIV-affected and femaleheaded households to remain economically viable is key to decreasing the vulnerability of women and girls. By supporting advocacy for and enforcement of laws that uphold women’s property and inheritance rights, microfinance programs and skills trainings, and providing stronger economic and practical support to female caregivers, PEPFAR programs can help break the transmis-
sion of poverty and vulnerability from poor mothers to their daughters.
Expand Programs Addressing Gender-Based Violence The link between GBV and HIV must be broken through targeted programs and funding. The inequitable beliefs and behaviors of men and boys must be challenged to enable women and girls to live free of violence. The development of strong public policies and legal frameworks protecting women and girls from violence, and punishing and rehabilitating perpetrators, should be furthered in each focus country. All PEPFAR programs should explicitly engage implementers in challenging social norms tolerating the sexual exploitation and abuse of women and girls and support the involvement of men and boys in constructive behavior change.
Collect Data that is Disaggregated by Age as well as Sex The ability to disaggregate data by age as well as sex is critical to understanding whether young women and girls are being reached and served by PEPFAR and other programs. Important differences in their experiences and vulnerabilities by age group can be missed. Girls under 15 are often completely invisible in the face of widespread evidence of sexual violence, often occurring in the home or school. Age-disaggregated data would also be useful in determining how to meet the specific needs of girls at different ages.
THE GLOBAL HEALTH COUNCIL SUPPORTS THE FOLLOWING MEASURES: The bipartisan Protection Against Transmission of HIV for Women and Youth (PATHWAY ) Act introduced by Rep. Barbara Lee, D-CA. This bill would require the Office of the Global AIDS Coordinator (OGAC) to establish a comprehensive and integrated HIV-prevention strategy aimed at stopping the rapid spread of HIV infection among women and girls, in part through integrating and coordinating HIV and reproductive health and family planning services. It would require that all prevention programs under PEPFAR address violence against women and would eliminate the abstinence-until-marriage earmark.*
The Microbicides Development Act introduced by former Sen. Jon Corzine, D-NJ. This bill would expand and coordinate microbicide activities at the National Institutes of Health; expedite the development and implementation of a federal strategic plan for microbicide research, and establish a Microbicide Research and Development Unit within the National Institute of Allergy and Infectious Diseases.* Increased U.S. funding for the purchase, international distribution, and program support needed to ensure access to and effective use of female condoms, as supported through the Prevention Now Campaign. * These three bills expired with the 109th Congress and are expected to be reintroduced in the 110th Congress.
The bipartisan HIV Prevention for Youth Act introduced by Sen. Dianne Feinstein, D-CA. In countries where the epidemic has “generalized” (more than one percent HIV prevalence), this bill would consider young people at high risk of contracting HIV and would provide additional assistance to combat HIV through medically accurate information on strategies
to reduce risk, including information about the correct and consistent use of condoms.*
References 1 Monasch, R and Mahy, M. Young People: The centre of the HIV epidemic, in
12 ICRW. Information Bulletin, Reducing women’s and girls’ vulnerability to
Ross, D, Dick, B and Ferguson, J Eds. Preventing HIV/AIDS in Young People, A
HIV/AIDS by strengthening their property and inheritance rights, ICRW:
systematic review of evidence from developing countries. WHO Technical Report
Washington D.C., 2006. 13 Save the Children. The power and promise of girls’ education, 2005.
Series 938. Geneva, 2006. 2 UNAIDS. Global summary of the AIDS epidemic, Geneva, December, 2006. 3 UNAIDS/UNFPA/UNIFEM. Women and HIV/AIDS: Confronting the crisis, 2004. 4 Authorized under Public Law 108-25 as the United States Leadership Against
14 Garcia-Moreno, C and Watts, C. Violence against women: its importance for HIV/AIDS. AIDS: 14 (suppl) S253-65. 2000. 15 Jewkes, R et al. Rape of girls in South Africa, Lancet, 359:319-20, Jan 26, 2002. 16 Mathur, S, Greene, M and Malhotra, A. Too young to wed, ICRW, 2003.
HIV/AIDS, Tuberculosis and Malaria Act of 2003. 5 Office of the Global AIDS Coordinator, The President’s Emergency Plan for
17 UNAIDS. India Fact Sheet: Women, girls, and HIV/AIDS in India, 2005.
AIDS Relief, Second annual report to Congress, 2006. The 15 PEPFAR focus
prevention, Global AIDSLink, Global Health Council, July/August 2006. 19 UNAIDS. Women and AIDS (An extract from the AIDS epidemic update),
countries are Botswana, Cote d’Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam and Zambia. 6 U.S. Government Accountability Office (GAO). Global Health: Spending requirement presents challenges for allocating prevention funding under the President’s Emergency Plan for AIDS Relief, April 2006. 7 The Global Coalition on Women and AIDS. HIV prevention and protection efforts are failing women and girls, Press release, London, 2004. 8 National Institute on Allergy and Infectious Diseases (NIAID). HIV infection
18 Gupta, GR (ICRW). Economic gains add up to large profits in HIV/AIDS
December 2004. 20 See the Global Health Council policy brief, “Anti-Prostitution Policy Requirement,” at www.globalhealth.org. 21 Although some countries received exemptions from this tight restriction, the GAO found that non-exempt countries made up the difference, resulting in 36 percent of prevention funds funding abstinence and faithfulness. 22 Stover, J et al. The global impact of scaling up HIV/AIDS prevention programs
in women, Fact sheet, 2004. Available at: www.niaid.nih.gov/ factsheets/women-
in low- and middle-income countries, Science Express, February, 2006. 23 See Global Health Council policy brief, “Prevention: Our chance to reverse the
hiv.htm. 9 Garcia-Moreno, C, Henrica, J, Watts, C, Ellsberg, M and Heise, L. WHO
HIV/AIDS pandemic,” at www.globalhealth.org. 24 See UNFPA, Sexual and reproductive health of women living with HIV/AIDS,
Multi-country study on women’s health and domestic violence against women,
2006. 25 Ensuring privacy and confidentiality in reproductive health services: A training
Geneva: WHO, 2006. 10 UNAIDS. Report on the global AIDS epidemic, Chapter 4 focus, HIV and young people: the threat for today’s youth, Geneva, 2004. 11World Bank. Education and HIV/AIDS: A window of hope, 2002.
module for providers, Washington D.C.: PATH and the Global Health Council, 2003. 26 AIDS Policy Law 2005 Dec 16:20 (22):1.
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