Suffer not the vulnerable

The most vulnerable around the world are often the hardest hit by HIV. Lilian Anekwe investigates the plight of women and children in an Aids pandemic

Until now HIV prevention efforts have focused on groups seen as most at risk, such as sex workers, men who have sex with other men, and intravenous drug users. But many argue it’s time the focus shifted to women, adolescent and young girls and children – groups that have often been overlooked.

In South Africa, for example, rates of HIV infection are highest among younger people. Some 17.8 per cent of adults, aged 15 to 49, are HIV-positive, UNAIDS estimates. But a breakdown of these statistics shows a disproportionate number of infections in younger women. A 2008 study in South Africa found that among 15 to 24 year olds, 3.7 per cent of the male population were HIV-positive, compared with 15.9 per cent of women. And in those aged 20 to 29, 15.7 per cent of men were HIV-positive compared with 32.7 per cent of women.

The delicacy of vaginal tissues, which are prone to abrasions through which the HIV virus can enter the body, means females are biologically more susceptible to HIV infection. But Dr Brian Brink, the Johannesburg-based chairman of the International Women’s Health Coalition (IWHC) and chief medical officer of mining giant Anglo American, says the biggest contributors to infection are social and cultural. “There’s a whole array of conditions that work systematically against girls and young women – inequalities in education, violence and sexual exploitation of girls because of poverty and desperation, inadequate health services and family planning, and many cultural traditions that deprive them of their rights,” he says.

It’s easy to give out condoms or antiretroviral drugs, but this does nothing to address women’s rights

The IWHC promotes and protects the sexual and reproductive rights and health of women and young people in Africa, Asia and Latin America. Alexandra Garita, IWHC’s international policy programme officer, says: “I’m optimistic about the potential and possibility for change because I see it happening all the time, but it’s not easy. These are transformational programmes and it takes time to change attitudes. That’s part of the reason why these programmes have received so little funding and attention – they are not quick fixes or short-term solutions.

“It’s comparatively easy to give out condoms or antiretroviral drugs, and those schemes have their place, but they don’t do anything to address women’s rights, or help understand how to negotiate sex and relationships. These issues go much deeper, take longer to address, but the benefits would be so much wider than just HIV.”

There’s evidence that healthy, educated women provide a high return on investment. Just one extra year of secondary school raises a girl’s lifetime wages by up to 25 per cent, while increasing female education by 10 per cent raises a country’s average GDP (gross domestic product) by 3 per cent. And, in turn, women with greater access to education and economic resources are better able to protect themselves from HIV infection, and their children benefit from higher rates of survival and health.

Ilze Melngailis, who runs GBCHealth’s Healthy Women, Healthy Economies programme, which encourages investment in health, education and economic empowerment for women, and constructive engagement of men and boys, says an holistic approach is critical. “This includes working with men, who may just be an untapped resource in this fight,” she says. “We will reduce women’s vulnerability to HIV and other health issues much more quickly if we engage men, as well as women, in challenging their societies’ underlying, limiting and harmful gender norms.”

Women in Muslim cultures are also put at risk by a lack of sexual rights and infection rates are rising in these countries. UNAIDS estimates the number of new HIV infections in the Middle East and North Africa increased from 36,000 in 2001 to 75,000 in 2009.

In 2008, the United Nations Development Programme reported on the issues facing women who migrated in search of work from Bangladesh, Sri Lanka, the Philippines and Pakistan to Bahrain, Lebanon and the United Arab Emirates. Many of the issues affecting women are heightened by their migrant status. They lack a voice in their communities, are economically vulnerable and disempowered, and so have nowhere to turn if they are diagnosed HIV-positive.

Shakirul Islam, one of the UN report’s authors, says: “The situation has not changed. We conducted an assessment in January 2011 which revealed many women migrant workers were forced to engage in sex or became victims of sexual exploitation; they were beaten and tortured if they resisted or refused.”

Aids among children has been virtually eliminated in some Western countries. Half of HIV-positive pregnant women in low and middleincome countries now receive medicines to help prevent transmission of HIV to their babies. But according to a 2010 UNAIDS report, of the 33.3 million people living with HIV globally, 2.5 million (7.5 per cent) are under 15 years old and an estimated 370,000 children were newly infected with HIV in 2009.

This issue has been given fresh impetus by US Secretary of State Hilary Clinton, who recently pledged “to change the course of this pandemic and usher in an Aids-free generation… one where virtually no children are born with the virus”. The goal has been widely applauded but Chip Lyons, president of the Elizabeth Glaser Pediatric Aids Foundation, who says there’s no room for complacency. “While these commitments signify remarkable progress, they are simply not enough,” he says.

“Ending paediatric Aids, a goal that once seemed unattainable, would be a fight worth winning.”

PREVENTING MOTHER-TO-CHILD TRANSMISSION

More than 1,000 children are infected with HIV every day. Unless they are diagnosed and treated, one third of infected infants will die before the age of one, and almost a half before their second birthday.

More than 90 per cent of HIV infections in children result from motherto- child transmission, where the virus is passed from a mother living with HIV to her baby during pregnancy, childbirth or breastfeeding. While the precise mechanisms for viral transmission during pregnancy are not completely understood, the risk of this form of transmission increases in direct relation to the severity of the mother’s HIV infection.

The most effective method of preventing transmission is, where possible, giving HIV-positive pregnant women antiretroviral therapy (ART) as early as possible. If a woman is not suitable for ART, or ART is not available, a simple course of antiretroviral (ARV) drugs can be given to the mother, starting early in pregnancy, and to her infant immediately following delivery. ARVs decrease the amount of virus in the mother’s bloodstream and reduce the risk that the infection will be transmitted to her infant. These drugs also have a protective effect on the child before and after birth, helping its body resist infection. Continuing to give ARVs through the breastfeeding period also decreases the likelihood of HIV transmission via breast milk.