HIV is not only driven by gender inequality, but it also entrenches gender inequality, leaving women more vulnerable to its impact. It is the leading cause of death among women of reproductive age worldwide. In 2019, there were an estimated 38 million people living in HIV, and a majority of them are women of reproductive age. Women aged 15 years and up make up 51% of all adults living with HIV. Adolescent girls and young women are particularly affected; in 2019, they constituted 48% of all new HIV diagnoses and infections. In many countries, women living with HIV do not have equitable access to high quality health services and are also faced with multiple and intersecting forms of stigma and discrimination. They are disproportionately vulnerable to violence, including violations of their sexual and reproductive rights.
Injustices in Reproductive Care
HIV-positive women face violations of their sexual and reproductive rights, impacting their desire to have children, as well as their access to prevention, treatment, care, and support. They face stigma and discrimination when accessing HIV and reproductive services. For instance, they are often advised not to engage in sexual relationships and scolded when seeking healthcare when pregnant, which presents a barrier when accessing prevention of mother-to-child HIV transmission and safe delivery services.
Sexual and Reproductive Decisions
The sexual and reproductive decisions faced by women with HIV involve their desire for pregnancy, their contraceptive practices, their choices about an unintended pregnancy, and their prenatal and postnatal options to reduce the transmission of HIV. If a woman does not wish to become pregnant, she should be referred to family planning services. If she wishes to become pregnant, she should be educated about the local infertility and prenatal services to learn about how she can reduce the risks of transmission. If she is currently pregnant and wishes to continue her pregnancy, she should be offered the opportunity to obtain antiretroviral therapy to reduce transmission risks. If she is currently pregnant but does not wish to continue her pregnancy, she should be referred to safe abortion services. Postpartum contraception could be offered as an option for those who do not wish to become pregnant again.
The Right to Sexual Health as an “Integral Part of the Right to Health”
In 2016, the UN Committee on Economic, Social, and Cultural Rights defined the right to sexual and reproductive health as an “integral part of the right to health.” It outlined the measures to ensure the sexual and reproductive health and rights of women and girls living with HIV.
1. Human rights and gender equality must be placed at the center of a comprehensive approach to health and programming
2. Health systems must be responsive to the inequalities in access to health care and quality of care, which negatively affect women living with HIV
3. Women living with HIV should be empowered and engaged in the development of policies and programmes that affect them
4. Monitoring, evaluation, and accountability procedures must be strengthened to provide good-quality data, and to ensure remedies for violations of the rights of women living with HIV
Guide from World Health Organization (WHO)
In 2006, the WHO published a guide on how to support women living with HIV/AIDS and their children, but since then, many changes have occurred in medicine. Therefore, earlier this year, the organization released a new booklet that is viewed as a new submission by the WHO Guidelines Review Committee rather than as an update of the 2006 guidelines. It includes recommendations such as the following. In generalized epidemic settings, antiretroviral therapy should be initiated and maintained in eligible pregnant and postpartum women and in infants at maternal and child health care settings. Women who disclose any form of violence by an intimate partner or sexual assault by any perpetrator should be offered immediate support. Countries should work towards decriminalization of behaviors such as drug use, sex work, and same sex activity. To view the entire guide, click here.
The Centers for Disease Control and Prevention announced that HIV diagnoses among females in the United States declined by 49% from 2002 to 2011. As a result of effective treatment of HIV-positive pregnant women, mother-to-child transmission of HIV has been virtually eliminated in the United States. While this should be celebrated, there are still many disparities that exist and need to be resolved. While African American women represent just 13% of the female population, they constitute 64% of new HIV infections and are 14 times more likely to die from HIV-related causes than white women. Furthermore, the majority of all pregnant women living with HIV in the United States are not engaged in regular medical care. It is estimated 88% of them have been diagnosed, but only 45% are engaged in case and just 32% have achieved viral suppression. When virally suppressed as the result of effective, consistent therapy, transmission can be reduced as much as 96%.
The treatment of HIV-positive women in Chile stands as an example for many other countries around the world. They face the threat of coerced sterilization, stigmatization, and discriminatory treatment. This is largely due to social and cultural factors such as resistance to use of condoms, perception that women are somehow subordinate to men, and lack of education. Francisca, who is currently living in deep poverty, shared her experience in the country as an HIV-positive woman. She was sterilized without her consent during a C-section and said, “They treated me like I was less than a person. It was not my decision to end my fertility; they took it away from me.”
In 2019, U.S. global health funding was 10.9 billion USD. The U.S. government must be held accountable to its commitment.
The Sexual and Reproductive Health and Rights (SRHR) Index critically assesses the U.S. government’s global health policies and funding that impact SRHR and measures its performance by grading it annually.
Social and economic factors, especially poverty, affect access to health care, and disproportionately affect people with HIV. Pregnant women with HIV may face more barriers to accessing medical care and staying on treatment if they also inject drugs, use other substances, are experiencing homelessness, or are incarcerated, mentally ill, or uninsured.
Under the integrated HIV surveillance and prevention cooperative agreement, CDC awards around $400 million per year to health departments for HIV data collection and prevention efforts. This award directs resources to the populations and geographic areas of greatest need, while supporting core HIV surveillance and prevention efforts across the US.
CDC supports CityMatCH to convene a group of stakeholders including public health professionals and clinical care providers to implement the CDC framework.
CDC funds perinatal HIV prevention through the Integrated Human Immunodeficiency Virus Surveillance and Prevention Programs for Health Departments. Key partner activities include promoting HIV testing and ART for pregnant women; an HIV surveillance and birth registry match to identify mother-infant pairs in need of services; perinatal HIV exposure surveillance; and a community-based quality improvement process using case reviews, that is, the FIMR-HIV methodology, and perinatal HIV services coordination.
All graphics by Jaclyn Saik