House of Commons - International Development

Select Committee on International Development Twelfth Report

5 Women

The 'feminisation' of HIV/AIDS

59. A key characteristic of the HIV/AIDS epidemic in recent years has been the disproportionate impact on women—which DFID describes as the 'feminisation' of the disease.[115] As ActionAid told us, 60% of all adults living with HIV/AIDS are women and three-quarters of young people who are HIV-positive are female.[116]Whilst the proportion of women among people living with HIV globally has remained stable for several years, women's share of infections has increased in many regions.[117]

60. Multiple factors have driven this. Firstly, women can far more easily become infected through sex than men due to biological factors. Secondly, socio-economic factors put women and girls at higher risk of the infection. In many developing countries, pervasive gender inequalities disadvantage women and girls—especially those living in poverty—in multiple ways. For example, cultural norms and lack of economic empowerment mean that women often struggle to negotiate their rights to safe sex and some are led into sex work. Women also struggle to access adequate treatment once they are infected: written evidence from ActionAid cited lack of money for treatment and travel, dependence on male partners for money, inability to take time off work to access health treatments, distance to facilities and lack of confidentiality as the main barriers women face when trying to access HIV/AIDS treatment.[118]

61. The disproportionate impact of the epidemic on females also reflects the fact that the needs of women and girls are not being adequately addressed in national and international responses to HIV.[119] For example, the 'ABC' (Abstinence, Be Faithful and Condomise) strategies promoted in many developing countries tend to focus on 'high risk' groups (for instance, sex workers and drug users). In some countries, this has helped popularise the mistaken assumption that marriage protects against HIV. In South Africa married women are identified as the group most at risk of HIV infection and more than four-fifths of new infections in women result from sex with their husbands or primary partners.[120]

62. Addressing gender inequalities should be at the heart of effective prevention and treatment of HIV/AIDS. Specially tailored policies that focus on education and socio-economic empowerment of women and girls are needed to help reverse the current trend of high levels of infection amongst women. We believe that efforts should be made to target these strategies beyond traditional high risk groups such as sex workers to include young people and married couples.

DFID's Strategy and women

63. DFID's new Strategy highlights that medical approaches towards preventing and treating the virus will never be fully effective unless the social and behavioural actions that drive the epidemic are addressed.[121]The Strategy underlines the close relationship between HIV and violence, and the link with harmful traditional practices such as child marriage and female genital mutilation.[122]It supports a holistic approach to women and HIV that recognises the need for a broad-ranging approach encompassing working with men and boys, with the justice and education sectors, and through the provision of social protection measures (to support people, often women, who are caring for relatives suffering from AIDS).[123]We support the holistic approach towards women and HIV that DFID advocates in its new Strategy. Addressing embedded gender inequalities will rely on wide-ranging strategies that bring together health, education, justice and social protection agendas.

64. The new Strategy makes several commitments to address the impact of HIV on women, including:

support for female-controlled HIV prevention—a pledge to increase by at least 50% DFID funding for research and development of AIDS vaccines and microbicides between 2008-2013;[124]
a recognition of the importance of integrating HIV with sexual and reproductive health services (see paragraphs 76-82);
a pledge to train DFID staff on women's rights (in line with the Department's Gender Equality Action Plan); and
attention to the burden of care on women with £200 million funding over the next three years for social protection programmes.[125]

65. However, welcome as these commitments are, few have practical strategies attached to them and details as to how they will be implemented are lacking. The UK Consortium on AIDS Gender Working Group told us:

There are mentions of gender throughout the strategy and recognition of the need to address gender as a key driver of the pandemic. However it does not detail how this will be achieved or what might be done differently.[126]

Fionnuala Murphy of ActionAid emphasised to us that the challenge regarding the Strategy's "important first steps" on gender lies in their implementation:

They are very top-line promises and they are actually talking about very complex cultural and structural issues, so the real challenge is what action does DFID propose to take and how will DFID measure success and make sure [...] that we have delivered real benefits for women and girls.[127]

She highlighted four specific requirements that ActionAid believes DFID needs to fulfil to have a meaningful impact on HIV/AIDS amongst women and girls:

a breakdown showing what proportion of DFID's £6 billion health systems funding will go towards addressing the impact of HIV/AIDS on women;
a commitment to greater international leadership on the feminisation of HIV/AIDS, including the development of a "long-term global advocacy plan that identifies key moments and key opportunities to influence these issues" and highlights "strategic activities that DFID will undertake";
a comprehensive training programme for DFID staff on the linkages between women's rights and HIV; and
the development of an action plan on violence against women, with associated funding.

This could include using DFID funds to train health workers to recognise signs of violence and understand the particular support needed to address it.[128]

66. We commend the emphasis in the new DFID Strategy on the disproportionate impact of HIV/AIDS on women and girls. However, we are concerned by the lack of concrete and country-specific policies within the document. The Strategy does more to describe the impact of HIV/AIDS on women and girls rather than to indicate how DFID will tackle it. Beyond an important but limited set of commitments on HIV prevention and social protection, gender-specific policies and funding pledges are lacking. We recommend the development of a global action plan, linked to the AIDS Strategy, which sets out the actions DFID will take to support women-specific approaches to the epidemic over a specified timescale.

Gender-based violence

67. Sexual and/or gender-based violence (GBV) is closely linked to the spread of HIV. Studies from southern Africa show up to threefold increases in HIV risk among women who have experienced violence compared to those who have not.[129] Violence-related factors that increase women's risk to HIV include:

exposure to blood and direct transmission through sexual violence;
sexual abuse during childhood and forced sexual initiation during adolescence (including sex with higher risk/older men); and
constraints on women's ability to negotiate condom use.[130]

68. No concrete actions aimed at addressing gender-based violence are included in the Strategy commitments.[131]In our Report on Maternal Health published earlier this year, we highlighted successful DFID-funded projects addressing gender-based violence (GBV) in Nepal, Bangladesh and South Africa and recommended that DFID seek to replicate these approaches elsewhere.[132] However, no such strategies or approaches are included in DFID's new Strategy.

69. We are concerned about DFID's lack of dedicated strategies and funding to address gender-based violence (GBV), which is closely linked to the spread of HIV. We highlighted successful DFID-funded approaches to addressing GBV in Nepal, Bangladesh and South Africa in our Maternal Health Report earlier this year and were disappointed not to see information on scaling up or replicating these initiatives included in the new Strategy. We recommend that, in its Response, DFID provides us with a policy update which sets out details of the specific approaches it will take to address GBV, including the necessary funding commitments.

Prevention of mother-to-child transmission of HIV/AIDS

70. A further Strategy commitment in relation to women living with HIV is the pledge to "intensify international efforts to increase to 80% by 2010 the percentage of HIV-infected pregnant women who receive anti-retroviral treatments (ARVs) to reduce the risk of mother-to-child transmission" of the infection.[133]

71. The prevention of mother-to-child transmission (PMTCT) is a central platform within international strategies to prevent the spread of HIV. 90% of paediatric HIV is due to mother-to-child transmission. Without access to services to prevent transmission, about 35% of infants born to HIV-positive mothers will acquire the virus during pregnancy, labour, delivery or breast-feeding.[134] As Stuart Kean of the UK Consortium on AIDS told us, developed countries such as the UK have virtually eliminated paediatric HIV cases through a package of care that includes the provision of ARVs.[135] Yet worldwide only 34% of women currently have access to PMTCT services.[136]Of the 21 countries on track to meet the 80% ARV provision target by 2010, only four are from the eight "hyper endemic" southern African countries listed in DFID's Strategy.[137]

72. Witnesses welcomed DFID's pledge to help increase access to PMTCT.[138]However, Interact Worldwide was concerned that DFID's commitment focused exclusively on ARV provision rather than a fuller strategy that included other aspects of the care package needed to protect against transmission. Interact stated:

According to the World Health Organisation, comprehensive PMTCT also includes: delivery and post-partum care; HIV treatment for women, infants and their families as appropriate; SRH [sexual and reproductive health] services, including family planning; and dual protection advice for women and their partners.[139]

Alvaro Bermejo of the International HIV/AIDS Alliance emphasised the importance of making a full package of integrated services, including family planning, available. He stated that the "the most cost-effective way of preventing mother-to-child transmission is investing in preventing unwanted pregnancies and making sure that the general population has access to good sexual and reproductive health services."[140]

73. World Vision's evidence highlighted the concern that DFID's commitment to "work with others to intensify international efforts" on PMTCT is couched in terms of a contribution to global efforts. Disaggregating the Department's specific contribution and setting out ways of measuring it are therefore of increased importance.[141]

74. We welcome DFID's pledge to support an increase in the percentage of HIV-infected pregnant women who receive anti-retroviral treatments (ARVs) to 80% by 2010, and thereby reduce mother-to-child transmission of HIV. However, ARV provision is only one of a number of interventions to prevent transmission recommended by the World Health Organisation. We recommend that DFID works to ensure ARV provision forms one, critical, part of a care package for HIV positive mothers that also includes the full range of required interventions.

75. We note the ambitious level of percentage increase needed to meet DFID's commitment to increasing ARV coverage for HIV-infected pregnant women: from the current rate of 34% to 80% in just two years' time. We expect to see a clear commitment on how progress towards this ambitious and short-term target will be measured in DFID's Monitoring and Evaluation Framework which is due to be published on 1 December 2008. We recommend that the Framework includes an indication of the level of DFID's specific projected contribution to the international efforts to reach this target.

Integration with sexual and reproductive health

76. There are close intersections between sexual, reproductive and maternal health and HIV/AIDS. As Interact Worldwide stated:

Causes of poor sexual and reproductive health (SRH) and HIV and AIDS are intimately related and have common drivers: poverty, gender inequity, marginalisation and stigma, discrimination and denial. To separate the responses is therefore to divorce them from the reality in which sexual and reproductive behaviour takes place and is, in turn, contributing towards the lack of progress being made to address issues such as maternal mortality, unintended pregnancies and HIV and AIDS.[142]

77. Yet in many national health systems, sexual and reproductive health (SRH) and HIV/AIDS treatment and care are administered and funded separately, with poor collaboration between the sectors.[143] Integrated responses help avoid the creation of parallel systems and bring policy and programming for HIV and SRH closer together. It can be confusing, expensive and time-consuming for people to visit different facilities for HIV, sexually transmitted infections and other SRH treatment and care. Integrated delivery can also reduce the costs for providers of services.[144]As DFID points out in its Strategy, women's first interaction with the health system is often their use of maternal health services, and thus integration of AIDS services offers an important opportunity to engage women in HIV prevention and care.[145]According to the World Health Organisation, integrated interventions that address HIV and SRH, along with maternal health, might include:

counselling on reproductive choices including protecting against unwanted pregnancies;
condom provision (male and female);
screening and treatment programmes for sexually transmitted infections (STIs) including HIV;
prevention of mother-to-child transmission of HIV;
provision of anti-retroviral therapy and treatment for STIs; and
programmes for adolescents and young people focusing on their particular SRH needs.[146]

78. We explored the issue of integrating SRH with HIV and maternal health services in our Report on Maternal Health, published in February 2008. We drew attention to the importance of making screening and treatment for sexually transmitted infections including HIV available at family planning clinics, because attendance at such clinics is often routine for women, thereby helping to remove the stigma attached to HIV testing.[147] We highlighted that witnesses to our inquiry believed that the Global Fund should do more to support integrated HIV, maternal, and sexual and reproductive health interventions, for instance through the training of skilled birth attendants.[148]

79. DFID's Strategy includes closer integration of HIV/AIDS and SRH, as well as maternal and child health services, TB and malaria as a Priority for Action.[149]It highlights efforts it is making to improve integration, for example its provision of £52.8 million over seven years to promote SRH services for HIV prevention in Nigeria.[150]

80. Witnesses were broadly impressed with the Strategy's emphasis on integration. Interact Worldwide considered DFID to have a comparative advantage amongst donors in strengthening the linkages between SRH and HIV/AIDS.[151] The UK Consortium on AIDS and International Development agreed that DFID's leadership in integrating HIV/AIDS and SRH agendas and services is 'essential'.[152] However, as we have noted, Médecins sans Frontières cautioned against trying to integrate services prematurely in contexts where primary health care is not yet operational or of sufficient quality. MSF stated:

Much work needs to be done before HIV/AIDS care can be integrated without compromising on quality and access, and premature integration could cause a setback in AIDS care delivery. The emphasis on integration therefore needs to be handled with care. 'Achieving Universal Access' refers to service delivery that is effective as well as integrated—in many cases these objectives will be at cross purposes and a trade-off will be required.[153]

DFID's perspective was that governments and agencies working with health systems that were not set up to integrate services were "missing opportunities to deliver more effective services."[154] However, its Strategy does note that "integration needs to recognise the stage of the epidemic and the needs of specific groups."[155]

81. A key route towards ensuring national health systems are ready and willing to better integrate responses will be advocacy work by donors such as DFID to promote a broader integration agenda. As Interact Worldwide stated, "Countries need to want and to be in a position to implement integrated services."[156] Interact suggested that DFID should target its advocacy not just at national governments but at the Global Fund, the World Bank, the World Health Organisation, the UN Population Fund (UNFPA) and UNAIDS who all potentially play a key role in the integration of health services.[157] It also suggested that DFID's support for health sector-wide approaches (SWAps) offered an opportunity for different funding partners to support comprehensive health sector responses to SRH and HIV.[158]

82. We welcome the focus in the Strategy on closer integration of HIV/AIDS and sexual and reproductive health services (SRH), together with maternal and child health, TB and malaria. SRH and HIV/AIDS cannot be separated as health issues and accordingly DFID is right to include better integrated responses as a priority action. We believe that integration will be more effective where it is prioritised by health systems that are ready and willing to implement it. Accordingly, we recommend that DFID presses both national governments and multilateral donors—particularly the Global Fund, the World Bank and the relevant UN agencies—to do more to support the integration of services.

115 Achieving Universal Access, see pp 2 and 9 Back

116 Ev 45 Back

117 UNAIDS, 2008 Global Report, p 30 Back

118 Ev 49 Back

119 UNAIDS, Statement to the Fifty-first session of the Commission on the Status of Women 2007, online at http://data.unaids.org/pub

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120 HIV/AIDS and the Media Project, University of the Witwatersrand, online at http://www.journaids.org/gender.php Back

121 Achieving Universal Access, p 16 Back

122 Achieving Universal Access, p 25 Back

123 Achieving Universal Access, p 25 Back

124 Microbicides are gels and creams which women can use to protect themselves from HIV, and offer a female-controlled route to protection (for example where a woman is unable to persuade her partner to wear a condom). DFID currently contributes over £9 million each year to research and development (Achieving Universal Access, p 19).

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