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Africa: AIDS Struggle Continues

AfricaFocus Bulletin
June 22, 2015 (150622)
(Reposted from sources cited below)

Editor's Note

"Both globally and in Africa, there is good news. Our collective efforts to end the AIDS epidemic are paying off. Now more people living with HIV than ever before are accessing treatment, more people know their status, and AIDS-related deaths are declining. ... This progress, however, belies a dangerous reality: young African women and adolescent girls are especially vulnerable to HIV." - UNAIDS, June 2015

Progress in scientific research and in treatment for HIV/AIDS continues, with the most notable recent advance being the START (Strategic Timing of Antiretroviral Treatment) results released in May ( http://tinyurl.com/on9gsm4). This international study funded by the U.S. National Institute of Health showed that introducing treatment at the time of diagnosis instead of waiting until further damage to the immune system increases rates of survival by over 50%. Yet this news also highlights the gap between what is now possible and the results achieved (see latest data at http://tinyurl.com/nrexvjc).

A new UNAIDS report released this month, and excerpted below in this AfricaFocus Bulletin, makes it clear that those most vulnerable to the decades-long pandemic continue to be young women and adolescent girls in Africa. The response, the report stresses, must include not only providing additional resources for all aspects of the fight against HIV/AIDS but also addressing fundamental issues of gender inequality.

For talking points and previous AfricaFocus Bulletins on health issues, visit http://www.africafocus.org/intro-health.php

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Ebola Perspectives - Update

"The Other Ebola Battle: Fair Pay for Local Health Workers," June 2, 2105 http://tinyurl.com/o2yvf2j

"Ebola Cases Rise Again in West Africa," June 10, 2015 http://tinyurl.com/qcjfedr

"Turn on the taps to defeat the next Ebola," June 15, 2015 http://tinyurl.com/nhonhk2

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Empower Young Women and Adolescent Girls: Fast-Tracking the end Of the Aids Epidemic in Africa

UNAIDS

June 2015

[Excerpts only. Full formatted report, with references and graphs, available at http://www.unaids.org/en/resources/documents/2015/JC2746]

Foreword

Four decades into the HIV epidemic and response, we have made encouraging progress. More people living with HIV than ever before are accessing life-saving treatment; the number of deaths from AIDSrelated causes has declined; fewer babies are becoming infected with HIV; and new HIV infections have fallen. Africa's leadership commitments, the tireless efforts of civil society--including the women's movement and networks of women living with HIV--combined with scientific innovation and global solidarity have helped to achieve these great strides. The response will be strengthened further by the commitment from Africa's leadership to end the AIDS epidemic by 2030, while promoting shared responsibility and unity.

Yet, despite this progress, adolescent girls and young women are still being left behind and denied their full rights. They are often unable to enjoy the benefits of secondary education and formal paid employment under decent conditions, which would allow them to build skills, assets and resilience. The threat of violence is pervasive -- and not only in conflict and post-conflict situations. Many girls are married as children and assume adult roles of motherhood. Adolescent girls and young women are often prevented from seeking services and making decisions about their own health. This combination of factors drives both their risk of acquiring HIV and their vulnerability to HIV. The impact of HIV on young women and adolescent girls is acute: they account for one in five new HIV infections in Africa and are almost three times as likely as their male peers to be living with HIV in sub-Saharan Africa.

The variables and risks associated with sexual and reproductive health and HIV among adolescent girls and young women are tied to gender inequalities that are intricately woven into the sociocultural, economic and political fabric of society. Unleashing the potential of half the population of this region and tapping into the power of the largest youth populace in history will promote both sustainable progress in the HIV response and wider development outcomes.

In the words of Archbishop Desmond Tutu: "If we are to see any real development in the world, then our best investment is women." This holds true for the AIDS response, which needs greater attention, reaffirmed commitment and resourced action to ensure the health, rights and well-being of adolescent girls and young women throughout their life-cycle. The solutions engage all sectors of society and must embrace innovation.

The key message of advancing women's rights and gender equality in order to fast-track the end of the AIDS epidemic among adolescent girls and young women outlined in this report is an important contribution to the 2015 African Union theme "Year of women's empowerment and development towards Africa's agenda 2063". This will guide our blueprint for future action.

As the African community and the global community stand at the dawn of a new era of sustainable development, let us reaffirm our commitment to empowering girls and young women. A firm foundation of social justice, human rights and gender equality will make the AIDS response formidable and the end of the AIDS epidemic possible.

Michel Sidibé, Executive Director, UNAIDS

Nkosazana Dlamini-Zuma, Chair, African Union Commission


Introduction

With the platform provided by the post-2015 sustainable development goals, and leveraging the successes of the AIDS response so far, Africa has a historic opportunity to end the AIDS epidemic as a public health threat by 2030.

This requires adapting to the dynamism and opportunities of the continent and reaching people most vulnerable to HIV including young women and adolescent girls. It also requires taking action to target the root causes of vulnerability. The magnitude of young women's and adolescent girls' vulnerability to HIV cannot be explained by biology alone but lies in pervasive conditions of gender inequality and power imbalances as well as high levels of intimate partner violence.

Since the 1995 adoption of the Beijing Declaration and Platform for Action, the reality for most women and girls worldwide, including in Africa, is that the pace of change has been unacceptably slow. Women and girls are subject to multiple and intersecting forms of discrimination. These inequalities are even more acute for marginalized women, such as women with disabilities, migrant women, female sex workers and transgender women, who are also at heightened risk of discrimination and violence (1). There also remain other large disparities, such as fewer than one in three girls in subSaharan Africa being enrolled in secondary school, women having unequal access to economic opportunities, and women lacking decision-making power in the home and wider society (2, 3).

Within the context of HIV, this manifests in different ways. Young women and adolescent girls acquire HIV five to seven years earlier than young men, and in some countries HIV prevalence among young women and adolescent girls is as much as seven times that of their male counterparts(11, 54). Despite the availability of antiretroviral medicines, AIDS-related illnesses remain the leading cause of death among girls and women of reproductive age in Africa (4).

Many of these young women and girls are born and raised in communities where they are not treated as equal. Many cannot reduce their vulnerability to HIV because they are not permitted to make decisions on their own health care. They cannot reduce their vulnerability because they cannot choose at what age or who to marry, when to have sex, how to protect themselves or how many children to have.

The impacts of gender inequality are far-reaching. Gender equality matters intrinsically because the ability to make choices that affect a person's own life is a basic human right and should be equal for everyone, independent of whether person is male or female. But gender equality also matters instrumentally because it contributes to economies and key development outcomes (3).

To be effective, any health and development agenda needs to focus on the root causes of the gender gap, and the AIDS response is no different. But there is also good news on which to build. In the past 20 years the gender gap has closed in many areas with the most noticeable progress made in primary school enrolment and completion, in almost all countries. In addition, life expectancy of women in low-income countries is now 20 years longer on average than in 1960, and over the past 30 years women's participation in paid work has risen in most parts of the developing world (3).

There is also significant political commitment from Africa to gender equality and women's empowerment, with specific goals and targets for the response to HIV and sexual and reproductive health and rights. African leaders have enshrined the priorities of gender equality and rights in (among others) the African Union Agenda 2063; the Protocol to the African Charter on Human and Peoples' Rights on the Rights of Women in Africa (Maputo Declaration 2003); the Solemn Declaration on Gender Equality in Africa (2004); the Sexual and Reproductive Health Strategy for the Southern African Development Community Region (2006-2015); the 2013 Ministerial Commitment on Comprehensive Sexuality Education and Sexual and Reproductive Health and Rights in Eastern and Southern Africa; the Arab Strategic Framework on HIV and AIDS (2013-2015): and the Arab AIDS Initiative 2012; the Addis Ababa Declaration on Population and Development in Africa Beyond 2014; and the 2013 Declaration of the Special Summit of the African Union on HIV/AIDS, Tuberculosis and Malaria.

The depth and breadth of this political platform and the potential for action to transform the lives of young women and adolescent girls in Africa cannot be underestimated.

...

The Aids Response in Africa: Young Women and Adolescent Girls Left Behind

Both globally and in Africa, there is good news. Our collective efforts to end the AIDS epidemic are paying off. Now more people living with HIV than ever before are accessing treatment, more people know their status, and AIDS-related deaths are declining. New HIV infections among young people aged 15-24 years are also declining (460 000 new infections in 2013 compared with almost 715 000 new infections a decade earlier) (55). This progress, however, belies a dangerous reality: young African women and adolescent girls are especially vulnerable to HIV.

Globally in 2013, 15% of the approximately 16 million women aged 15 years and older living with HIV were young women; of these over 80% live in sub-Saharan Africa (55).

Despite declining HIV infection rates, in 2013 globally, there were approximately 250 000 new HIV infections among adolescent boys and girls, 64% of which are among adolescent girls (Figs 2 and 3). In Africa, 74% of new infections among adolescents were among adolescent girls (55). In addition, AIDS-related illnesses are the leading cause of death among adolescent girls and women of reproductive age in Africa, despite the availability of treatment (4).

...

Furthermore, young women and adolescent girls are missing out on the scale-up of antiretroviral treatment access for people living with HIV. Only 15% of young women and adolescent girls aged 15-24 years in sub-Saharan Africa know their HIV status (6). In the Middle East and North Africa, only one in five people living with HIV has access to treatment (55).

Young women and adolescent girls from socially marginalized groups are at increased risk of HIV because they face multiple challenges. Stigma, discrimination, punitive laws and a lack of social protection increase the risk of HIV, notably for young female sex workers, young transgender women, young migrants and young women who use drugs (7). In Kenya, HIV prevalence among female sex workers in Nairobi is 29% -- approximately three times the HIV prevalence among other women in Nairobi (8).

Eliminate mother-to-child transmission of HIV and keeping mothers alive

Progress to eliminate new HIV infections among children and keeping their mothers alive has been one of the most impressive achievements of the AIDS response to date. In 2013, for the first time since the 1990s, the number of new HIV infections among children in the 21 Global Plan 1 priority countries in sub-Saharan Africa dropped to under 200 000. This represents a 43% decline in the number of new HIV infections among children in these countries since 2009 (58).

Despite successes, progress among young women and adolescent mothers has been slow with many challenges. The average adolescent birth rate in Africa is 115 per 1000 girls, more than double the global average of 49 per 1000 girls (6). In western and central Africa, 28% of women aged 20-24 years have reported a birth before the age of 18 years, the highest percentage among developing regions. In Chad, Guinea, Mali, Mozambique and Niger, 1 in 10 girls has a child before the age of 15 years (9). In sub-Saharan Africa, an estimated 36 000 women and girls die each year from unsafe abortions, and millions more suffer long-term illness or disability (9).

Many young women who marry or enter into partnerships early do not have the knowledge or the personal agency that enables them to protect themselves from HIV -- for example, they cannot negotiate when to have sex or to use condoms.

A core strategy to eliminate mother-to-child transmission of HIV is to prevent pregnancy in young women and adolescent girls who do not want to have a child at that time. According to the United Nations Population Fund, 33 million women aged 15-24 years worldwide have an unmet need for contraception, with substantial regional variations. For married girls aged 15-19 years, the figures for an unmet need for contraception range from 8.6% in the Middle East and North Africa to 30.5% (one in three married girls) in western and central Africa (10). Among unmarried sexually active adolescent girls, the unmet need for contraception in sub-Saharan Africa is 46-49%; there are no data for North Africa (10).

According to 2013 data, in sub-Saharan Africa, only eight male condoms were available per year for each sexually active individual. Among young people, and particularly among young women, condom access and use remain low, despite offering dual protection against HIV and unwanted pregnancy (11). Sub-Saharan Africa accounts for 44% of all unsafe abortions among adolescent girls aged 15-19 years in low- and middle- income countries (excluding east Asia) (9).

Governments in Africa have already made important commitments in this area that can be leveraged. Among the strongest is the 2013 Ministerial Commitment for Comprehensive Sexuality Education and Sexual and Reproductive Health and Rights in Eastern and Southern Africa. This commitment includes action to "reduce early and unintended pregnancies among young people by 75%"(12).

Providing access to comprehensive sexuality education, keeping girls in school and implementing social protection programmes such as cash transfer programmes have all proven effective in reducing new infections among young women and adolescent girls.

Stopping child marriage and early pregnancy is also central to success. Across Africa, 41% of girls in western and central Africa, 34% of girls in eastern and southern Africa and 12% of girls in the Arab states are married as children (13). Child marriage has been associated with higher exposure to intimate partner violence and commercial sexual exploitation (13). Child marriage is a form of violence.

Intimate partner violence and the association with HIV

Over the past decade strong evidence has emerged on the relationship between intimate partner violence and HIV. There is equally strong evidence for and recognition of successful community strategies to prevent intimate partner violence and vulnerability to HIV (16, 29, 30, 57).

In high HIV prevalence settings, women who are exposed to intimate partner violence are 50% more likely to acquire HIV than those who are not exposed (16). Adolescent girls and young women also have the highest incidence of intimate partner violence (11). In Zimbabwe, for example, the prevalence of intimate partner violence among women aged 15-24 years is 35%, compared with 24% for women aged 25-49 years; and in Gabon, prevalence of intimate partner violence among young women is 42% compared with 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 (Fig. 4) (17). In addition, girls who marry before age 18 are more likely to experience violence within marriage than girls who marry later (14). According to the United Nations Children's Fund (UNICEF), globally 120 million girls -- 1 in 10 -- are raped or sexually attacked by the age of 20 years (15).

...

Women and girls also continue to experience unique risks and vulnerabilities to HIV during conflicts, emergencies and postconflict periods. In conflict situations, rape can be used as a weapon of war, increasing the risk of HIV transmission because rates of HIV among military personnel typically exceed those of the general population (18). Adolescent girls are particularly vulnerable and, in some cases, are abducted and used for sexual purposes by armed groups (15). The 2011 United Nations (UN) Security Council Resolution 1983 recognizes that the impact of HIV is felt most acutely by women and girls in conflict and post-conflict settings due to both sexual violence and reduced or no access to services (19). As highlighted by the resolution, however, there is also potential for peacekeeping operations to protect civilian populations through prevention of conflict-related sexual violence.

Core reasons why young women and adolescent girls are vulnerable to HIV

Every hour, around 34 young African women are newly infected with HIV. The reasons for relatively high rates of infection and low scale-up of services for young women in Africa are complex and interwoven. Changing the course of the epidemic requires addressing the root causes and understanding the core conditions that exacerbate vulnerability. Seven core conditions stand out:

  • inadequate access to good-quality sexual and reproductive health information, commodities and services, in some measure due to age of consent to access services;
  • low personal agency, meaning women are unable to make choices and take action on matters of their own health and well-being;
  • harmful gender norms, including child, early and forced marriage, resulting in early pregnancy;
  • transactional and unprotected age-disparate sex, often as a result of poverty, lack of opportunity or lack of material goods;
  • lack of access to secondary education and comprehensive ageappropriate sexuality education;
  • intimate partner violence, which impacts on risk and healthseeking behaviour;
  • violence in conflict and post-conflict settings.

Individually or in combination, these factors severely inhibit the ability of young women and adolescent girls to protect themselves from HIV, violence and unintended or unwanted pregnancy. Gender inequality and lack of women's empowerment or agency are key themes that cut across these drivers.

Women's agency or empowerment is the ability to make choices and to transform them into desired actions and outcomes. Across all countries and cultures there are differences between men's and women's ability to make these choices. Women's empowerment influences their ability to build their human capital. Greater control over household resources by women leads to more investment in children's human capital, shaping the opportunities for the next generation (3). In sub-Saharan African countries, more than half of married adolescent girls and young women do not have the final say regarding their own health care and play a low decision-making role in the household (20).

Poverty is another overarching factor. Poverty can push girls into age-disparate relationships, a driver of HIV risk for young women and adolescent girls. For example, in South Africa, 34% of sexually active adolescent girls report being in a relationship with a man at least five years their senior. Such relationships expose young woman and girls to unsafe sexual behaviours, low condom use and increased risk of sexually transmitted infections (57). The risk of trafficking and sexual exploitation is also higher for young women and adolescent girls living in poverty (21).

Poverty also increases the risk of child marriage, and girls in the poorest economic quintile are 2.5 times more likely to be married as children compared with girls in the richest quintile (21). In 2010, 67 million women aged 20-24 years had been married as girls, of which one-fifth were in Africa (14).

In May 2014, after numerous national and regional commitments to address child marriage (including the 2005 Maputo Protocol, Article 6c), the African Union Commission initiated a 2-year campaign, starting in 10 African countries 2 , to accelerate the end of child marriage on the continent by increasing awareness, influencing policy, advocating for the implementation of laws and ensuring accountability. Eliminating child marriage will decrease African girls' greater risk of experiencing domestic violence, premature pregnancies and related complications, and sexually transmitted diseases, including HIV.

There are promising solutions, but the solutions today are not the solutions of yesterday. Fast-tracking the response is about being flexible and taking account of the rapid transition taking place in Africa today, looking at the new risks but also at the new opportunities.


AfricaFocus Bulletin is an independent electronic publication providing reposted commentary and analysis on African issues, with a particular focus on U.S. and international policies. AfricaFocus Bulletin is edited by William Minter.

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