Worldwide, women constitute more than half of.Young women and adolescent girls account for one in every five new HIV infections in Africa and are nearly three times as likely as men of the same age group to be living with HIV in sub-Saharan Africa.
Adolescent girls and young women in sub-Saharan Africa acquire HIV five to seven years earlier than their male peers. Despite the availability of antiretroviral treatment (ART), AIDS-related illnesses remain the leading cause of death among African women of reproductive age.
These inequalities are more severe for marginalised women, including female sex workers,transgender women, migrant women and women with disabilities who are also at a heightened risk of discrimination and violence.
How does gender inequality increase women’s vulnerability to HIV?
HIV disproportionately affects women and adolescent girls because of their unequal cultural, social, and economic status in society.Gender inequality, intimate partner violence, and harmful traditional practices reinforce unequal power dynamics between men and women. This limits women’s choices, opportunities and access to information, health and social services, education and employment.
Stigma and discrimination, as well as inequitable laws and cultural practices, further exacerbate women’s vulnerability to HIV and undermine the response to the epidemic.
This makes tackling gender inequality key to ending the global HIV epidemic as well as achieving other, broader development outcomes.
Intimate partner violence and HIV
Over the past decade, strong evidence has emerged regarding the relationship between intimate partner violence (IPV) and HIV.
An estimated 30% of partnered women globally will experience physical or sexual abuse from a partner, rising to 37% in sub-Saharan Africa. In areas with a high HIV prevalence, women who are exposed to IPV are 50% more likely to acquire HIV compared to those who are not.Men who are violent towards their partners are more likely to have multiple partners than men who are not.
Adolescent girls and young women face the highest levels of IPV. For example, in Zimbabwe, 35% of 15 to 24 year old women face IPV, compared to 24% of 25 to 49 year olds. In Gabon, IPV among young women is 42% compared to 28% for older women.
In some settings, 45% of adolescent girls report that their first experience of sex was forced - another known risk factor for HIV. Additionally, girls who marry before age 18 are more likely to experience violence within marriage than girls who marry later. According to UNICEF, 120 million girls globally are raped or sexually abused by the age of 20.
Experience of IPV has also been shown to increase sexual risk taking behaviours among victims. In both developed and developing countries, past exposure to IPV and controlling behaviour from a sexual partner is associated with an increase in sexual partners, lower levels of condom use, increased substance use and sex while intoxicated, and increased participation in sex work – further increasing a woman’s risk of HIV.
Cultural and social norms
IPV is typically underpinned by dominant cultural and social norms about masculinity, femininity, and sexuality.Research shows that gender inequality results from the patriarchal nature of many societies, especially where control of women and male strength and power is highly valued.
Violence against women, including IPV and rape, is one consequence of gender inequality. However, such violence also reinforces and perpetuates gender inequality at both societal and relationship levels.
Educational factors
In many settings, cultural and social norms mean that girls in families affected by HIV are the ones who drop out of school to care for sick parents or generate income for the family. Less than one in three girls in sub-Saharan Africa are enrolled in secondary school.
Compared with girls who have had at least six years of schooling, girls with no education are twice as likely to acquire HIV and do not seek help in cases of intimate partner violence, which can increase the risk of HIV infection by 50%, according to one South African study.
Even those who remain in school do not receive adequate HIV and sex education. In sub-Saharan Africa, only 28% of young women reportedly know how to protect themselves from HIV.
Legal factors
In many places, discriminatory social and cultural norms are translated into laws which act as barriers to HIV services for women, increasing their vulnerability to HIV. Nine countries in 2014 reported laws that obstruct women and girls from accessing HIV services.
Mandatory parental consent has been shown to deter young women from accessing vital HIV and SRH services due to fear of disclosure or violence.
Age-restrictive laws, such as those that ban contraception under a certain age, act as barriers to healthcare for young women, while women belonging to other key affected populations are negatively affected by laws than ban drug use, sex work and homosexuality.
For example, one study of 77 countries reported that 18 countries had age restrictions for accessing needle and syringe programmes, and 29 had restrictions for accessing opioid substitution therapy. Most commonly, the age restriction was 18 years.
Poverty and gender inequal
Poverty is an overarching factor that increases vulnerability to HIV. It can push girls into relationships with older men for the promise of money or gifts.
For example, in South Africa, 34% of sexually active adolescent girls report being in a relationship with a man at least five years older than them. This is more likely to expose young women to unsafe sexual behaviours, low condom use and an increased risk of sexually transmitted infections.The risk of trafficking and sexual exploitation is also higher for young women and adolescent girls living in poverty.
Poverty also increases the risk of child marriage. Worldwide, girls belonging to the poorest 25% are 2.5 times more likely to be married as children compared with girls in the richest 25%. In 2010, 67 million women aged 20 to 24 years had been married as girls - one-fifth were in Africa.
Gender inequality and HIV in humanitarian emergencies
Women and girls also experience heightened vulnerability to HIV in conflicts, emergencies and post-conflict periods. For example, rape can be used as a weapon of war. In other cases, adolescent girls are abducted and used for sexual purposes by armed groups.
What is being done to tackle gender inequality?
There are a number of international commitments that recognise tackling gender inequality as vital to ending the global HIV epidemic and achieving wider development outcomes.
International commitments
For many years now, tackling gender inequality has been regarded as key to achieving a broad range of development goals. For example, Goal 3 of the Millennium Development Goals (MDGs) was to Promote Gender Equality and Empower Women. In 2015, the MDGs were replaced by the new Sustainable Development Goals (SDGs).
Many of the new SDG targets specifically recognise women’s equality and empowerment as both the objective, and as part of the solution. Target 5 in particular, is dedicated to achieving gender equality and contains a number of goals relating to gender inequality and HIV including:
End all forms of discrimination against all women and girls everywhere.
Ensure women’s full and effective participation and equal opportunities for leadership at all levels of decision making in political, economic and public life.
Ensure universal access to sexual and reproductive health and reproductive rights.
Adopt and strengthen sound policies and enforceable legislation for the promotion of gender equality and the empowerment of all women and girls at all levels.
Underneath these broad commitments sit a number of pledges to tackle gender inequality as a driver of the global HIV epidemic.
For example, the 2011 Political Declaration on HIV and AIDS recognised gender equality and the empowerment of women as fundamental to reducing women’s vulnerability to HIV. Specifically, it set a target to “meet the specific needs of women and girls and eliminate gender inequalities and gender-based abuse and violence” – which governments were required to report on every two years.
The UNAIDS Fast-Track Strategy, that calls for a dramatic scaling up of existing efforts in low- and middle- income countries to end the HIV epidemic by 2030, also identifies addressing gender inequality as crucial to achieving this aim. Under the ‘Zero discrimination’ target, the strategy calls for “increasing commitment to achieving gender equality and eliminating gender-based violence.”
In 2015, UNAIDS and the African Union outlined three commitments to advance the rights and empowerment of Africa’s young women and girls to enable a Fast-Track response to the HIV epidemic.
The commitments are to:
stop new HIV infections among young women and adolescent girls in order to ensure that AIDS is no longer the leading cause of death among adolescents
empower young women and adolescent girls through comprehensive sex education
prevent HIV infections among children and keep their mothers alive.
Translating international commitments into policy and practice
Despite political commitments to increase the capacity of women to protect themselves from HIV infection, the scale-up of interventions has not been fast enough. In 2014, a survey of 104 countries found that only 57% had an HIV strategy that included a specific budget for women.Indeed, translating these commitments into effective policies and programmes remains a challenge.
For example, the UNAIDS Global Plan towards the Elimination of New HIV Infections among Children by 2015 and Keeping Their Mothers Alive has seen significant progress in the prevention of mother-to-child transmission (PMTCT) to avert new HIV infections among children but has had a very limited impact in terms of the needs and priorities of women and girls.
Gender and social inequalities undermine prevention, treatment and care for this group, and make addressing structural issues essential to an effective HIV response.
The Greater Involvement of People Living with HIV and AIDS (GIPA) promotes the right of people living with HIV to “self-determination and participation in decision-making processes that affect their lives.”
However, women living with HIV face a number of barriers to meaningful participation in HIV policy and decision making. These include stigma and discrimination, economic insecurity, and a lack of access to information and resources, as well as insufficient opportunities for training and support.
There are also few institutional mechanisms to ensure women’s leadership or inclusion in the design, implementation, monitoring and evaluation of the HIV response. Even where opportunities exist, organisational and resource constraints hinder the participation of women living with HIV.
In fact, the evidence suggests that women and girls participation in national HIV planning processes is declining globally. In 2012, UNAIDS reported that 61% of women living with HIV participated in formal planning and review mechanisms where they are present, down from 66% in 2010.
Moreover, research by the Association for Women’s Rights in Development (AWID) discovered that while women and girls are recognised as key agents in development, a large majority of women’s organisations are underfunded.
Specifically, AWID mapped 170 initiatives that committed US$14.6 billion in total under the broad umbrella of ‘women and girls’, yet in 2010, the average income of over 740 women’s organisations around the world was just US$20,000.
“[To address gender inequality] we need the kind of holistic strategies that can tackle the interwoven aspects of women and girls' lives simultaneously.” – Michelle Bachelet, former Executive Director at UN Women
Programmes tackling gender inequality and HIV
A number of international recommendations and successful interventions to address gender inequality are outlined below.
Reducing intimate partner violence
Strategies to address IPV are critical to reducing young women's and adolescent girls’ vulnerability to HIV.
SASA! is a community mobilisation programme developed by Raising Voices in Kampala, Ugandato prevent violence against women and HIV. Community activists lead on a wide range of activities in their own neighbourhoods designed to decrease the social acceptability of violence by influencing knowledge, attitudes, skills and behaviours on gender, power and violence.
When implemented in four communities, the programme was associated with significantly lower incidence and acceptance of IPV among both men and women as well as more supportive community responses to women who experienced IPV. SASA! has been implemented by over 25 organisations in sub-Saharan Africa in diverse settings such as religious, rural, refugee, urban and pastoralist communities.
Scaling up and integrating HIV with sexual and reproductive health services
Scaling up comprehensive and youth-friendly sexual and reproductive health and HIV services for young women and adolescent girls is vital.
Condom programming designed to reach young people, such as through schools, can increase accessibility and confidence among those who are sexually active.Removing barriers like parental and spousal consent is critical for scaling up services and increasing access.
Keeping girls in school
Education allows girls to gain better knowledge about HIV and sexual and reproductive health and rights. It lowers exposure to IPV and increases their chances of becoming financially secure and independent.
In Africa, the most effective interventions that reduce the risk of HIV infection among adolescent girls, are the ones that keep them in school. These include making education free for girls, supporting orphans and other vulnerable children to stay in school, and conditional cash transfers that reward parents for keeping their daughters in school.
Offering comprehensive sex education
When young women and adolescent girls have access to comprehensive age-appropriate sex education before becoming sexually active, they are more likely to make informed decisions about their sexual health and approach relationships with more self-confidence.
School-based comprehensive age-appropriate sex education also increases condom use and voluntary HIV testing among young women as well as reducing adolescent pregnancy.
The 2013 Ministerial Commitment on Comprehensive Sexuality Education and Sexual and Reproductive Health and Rights in Eastern and Southern Africa confirmed Africa’s commitment to ensuring that all adolescents are equipped with “life skills-based HIV and sexuality education and youth-friendly sexual and reproductive health services”.
This demonstrates a clear dedication to addressing the specific needs of young people in the context of HIV and sexual and reproductive health.
Including women in the decision making process
In 2014, UN Women commissioned a global review of HIV treatment access for women to be led by women living with HIV. This is the first ever peer-led global study of treatment access for women living with HIV on this scale.
Known as the Global Reference Group (GRG), these women reside in 11 different countries and come from a diverse range of backgrounds. They have led the design and review of the programme as they are considered best place to identify and prioritise the issues that women face.
They were involved in setting the parameters of the literature review, identifying priority topics and questions for a discussion guide used for focus group discussions and one-to-one interviews. Some members are also involved in country case studies that investigate the issues and concerns that were raised.
"We know the critical steps that must be taken on the path to gender equality, and we must scale up and invest in what works for women and girls in the context of HIV and AIDS. This includes empowering women and girls, particularly those living with HIV, advancing their leadership; eliminating barriers and constraints to women’s access to prevention treatment and care services; eradicating gender-based violence; and ensuring adequate financing for women’s needs and priorities in the AIDS response.” – Phumzile Mlambo-Ngcuka, Executive Director, UN Women
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