WOMEN AND HIV IN SUB-SAHARAN AFRICA
Christian DjokoArticle Type:
Article Number: 7
ABSTRACT This article highlights the socio-political factors that disproportionately expose women and girls to HIV in West and Central Africa. It outlines some of the available solutions to overcome this particularly deadly pandemic and its unequal impact on women and girls compared to men and boys.
Let’s imagine the situation of Chaïdana, a young HIV-positive Katamalanasian woman from a socially disadvantaged background, who died in 2015 at the age of 19. Despite doing really well in school, at age 16 she was forced to drop out of school and give up on the idea of having a romantic relationship, as she was forced to marry a man 20 years her senior whom she barely knew. This forced marriage was an extremely painful moment for Chaïdama.
Some months after marrying, Chaïdana found out that her husband had been unfaithful on multiple occasions. She was also subjected to domestic violence. Her husband, Kamga, would hit her simply for saying yes or no. This threat of violence meant Chaïdana could not ask him to practice safe sex. Then at the age of 18, during her first antenatal check-up, she discovered that she was HIV-positive. Worried and frightened about the prejudice, discrimination and stigma experienced by HIV-positive women in her community, Chaïdana decided not to reveal her HIV status to anyone. She knew nothing about her rights and the lack of community legal and para-legal services was all the more disempowering. Moreover, she also didn’t start antiretroviral treatment because she was scared of making her husband suspicious.
Then a month before she was due to give birth, a health worker at the hospital Chaïdana visited for antenatal care revealed Chaïdana’s HIV status to some people from Chaïdana’s neighborhood. In a matter of days, the news spread like wildfire. When Kamga heard the news, he accused Chaïdana of having infected him. Chaïdana was terrified of her husband’s words and of him hitting her, so one morning she escaped and went to her parents’ house in the village. But the glimmer of hope she had was extinguished as soon as she entered their house. Her parents insisted that all marriages have their problems and ordered her to return to her husband’s house. A few days after she returned, Chaïdana (and her unborn child) died after she was beaten up yet again.
Chaïdana’s story is a fictional one, but one that nevertheless reflects the tragic end that many African women and girls are exposed to on a daily basis.
Although adolescent girls and young women (aged 15-24) represent just 10% of the population in sub-Saharan Africa, UNAIDS’s 2021 Global AIDS Update says that they accounted for 25% of HIV infections in 2020.
Figure 1. Distribution of new HIV infections by sex and of the population by age and sex, sub-Saharan Africa
Source: Global AIDS Update 2021, UNAIDS
The data are even more alarming in West and Central Africa. In 2020, women and girls (aged 15-49) in these two regions accounted for 65% of new HIV infections. And HIV incidence among young women aged 15 to 24 is 60% higher than among young men of the same age.
Figure 2. Distribution of new HIV infections by sex (aged 15–49 years), Western and Central Africa, 2020
Source: Global AIDS Update 2021, UNAIDS
HIV thrives on inequality and gender-based violence
Regular and continually improving data gathering has shown that the increased and disproportionate exposure of women to HIV is due to several converging factors: gender inequality, women’s economic and political subordination, gender-based violence (GBV), punitive laws and policies, abusive practices by law enforcement officials, and the persistence of certain discriminatory and stigmatizing gender norms (religious beliefs, cultural practices, etc.). Differences in the response to HIV, the resulting infections and mortality rates from opportunistic diseases very often correlate with rates of GBV and gender inequalities.
In some African countries, up to 45% of adolescent girls report that their first sexual experience was forced. Like Chaïdana, many of these women and girls cannot negotiate safe sex with their partners or are not able to freely and independently make decisions about contraceptive use. Many girls are married before they turn eighteen and have very limited access to HIV prevention information. At the regional level, only three out of ten adolescent girls and young women aged 15-24 have comprehensive and accurate knowledge of HIV. According to UN Women, “the lack of information on HIV prevention and the power to use this information in sexual relationships, including in the context of marriage, undermines women’s ability to negotiate condom use and engage in safer sex practices”.
The Global Fund launched the Breaking Down Barriers (BDB) initiative with a view to combating systemic injustices of this kind. The aim is to provide “catalytic matching funds and technical support to drive development and implementation of country-owned national programs to address the injustices that continue to threaten progress against HIV, TB, and malaria”. Despite many obstacles related to COVID-19 in particular, the initiative remains full of promise. The BDB mid-term assessment report provides a strong barometer of the program and valuable insight into inspiring practices.
Women’s lives matter
Drawing on data from the 20 countries where BDB is being conducted, the report shows that greater human rights protection is essential for the HIV response to be successful. At a practical level, this involves combating stigma and discrimination, as well as overcoming other legal and social barriers and barriers linked to rights and gender, which make certain populations vulnerable and prevent them from accessing HIV prevention, treatment and care services.
The report gives the example of the Viva+ program and its enlightening approach, which could serve as a model for other countries. The Viva+ project, supported by the Global Fund, reached 100,000 women, girls, transgender women, and men who have sex with men, with human rights education sessions that included modules focused on sexual and reproductive health and GBV. This was hailed as a critical part of Mozambique’s broad and sustained efforts to reduce the disproportionate burden of HIV on young women and girls, including female sex workers.
The report also presents other interesting measures to break this particularly deadly cycle for women and girls.
Involving those who are affected
The BDB initiative shows that there are efficiency gains each time through the empowerment of “people living with HIV and TB, TB survivors and other key populations and when they have been mobilized as peer paralegals and as monitors of human rights violations“. In fact, BDB implicitly assumes that decisions taken following this participatory approach will be much more effective if those affected are consulted, in this case women and girls. More broadly, the term “participatory” takes a much more specific, inclusive and engaging outreach approach. This approach makes it possible to enhance motivation and to put women’s empowerment in the driver’s seat with a view to making the HIV response more sustainable.
The report also tells us what we already know; that money remains the critical component of pandemic responses. In order to end HIV, funding for prevention, testing and treatment must be increased. At the global level, raising at least $18 billion at the Global Fund’s Seventh Global Replenishment would help to address the structural determinants that make certain groups particularly vulnerable to the disease and prevent them from accessing the health services they need.
In conclusion, it is worth remembering that mobilizing funds to respond to HIV, TB and malaria is not an expense, but a necessary and crucial investment that can, according to the Global Fund Strategy (2023-2028), reduce health inequalities, including human rights and gender-related barriers that hinder access to services. The lives of millions of African women and girls depend on it.