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

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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

+++++++++++++++++++++++++++++++++++

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

++++++++++++++++++++++end editor’s note+++++++++++++++++

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 AIDS-
related 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 sub-
Saharan 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 post-
conflict 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 age-
appropriate sexuality education;

* intimate partner violence, which impacts on risk and health-
seeking 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.

*****************************************************

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providing reposted commentary and analysis on African issues, with a
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