On the Brink of Sweeping Change for Women, Girls, Gender Equality and HIV

Honourable Chair, Delegates, Colleagues, and Friends,

I like to think that we are on the brink of sweeping change for women and girls. ‘Bleak’ no longer conveys where we are today in the AIDS epidemic, nor does it capture the progress or promising trajectory for women and girls. Gains are evident in treatment coverage, drug safety and effectiveness. The pace of new infections has slackened. Health systems strengthening and ‘combination’ prevention are rightfully taking hold. In recent years, a vibrant movement of people living with HIV has taken charge of shaping the rights and sexual and reproductive health agenda. Recognizing that HIV is the leading cause of death among women of reproductive age, groundbreaking support is finally being galvanized for implementing all four components of PMTCT – ramping up long-term treatment alongside primary prevention and family planning. And finally, achieving gender equality has taken its rightful place as an accepted HIV strategy. The recently launched Agenda for Women and Girls has already harnessed considerable international, and, increasingly, national support.

Of course, the litmus test of our resolve is what happens at country level. GESTOS, through a South-South project has been monitoring national progress in addressing the gender dimensions of the epidemic for women and girls.

My remarks today draw upon this insightful 2010 GESTOS report reviewing how well sexual and reproductive health and rights are integrated into the national AIDS plans of 12 countries in Africa, Latin America and the Caribbean, Southeast Asia, and Eastern Europe. I am also using the rich findings covering the same issues contained in several of the Report Cards on HIV Prevention for Girls and Young Women, which were jointly developed by UNFPA, IPPF, Young Positives, and the Global Coalition on Women and AIDS in these countries.
I will address four key issues that consistently arose:

1. sexuality education;
2. the right to SRH and HIV prevention for young women;
3. sexual and reproductive health for women living with HIV; and
4. strategies to eliminate gender-based violence against women.

Without comprehensive sexuality education, women and girls will continue to be sequestered in a shroud of ignorance – and consequently disempowered. Understanding one’s sexuality is fundamental to self-awareness and fulfillment of the ICPD promise of reproductive rights, including to a satisfying and safe sex life. Yet countries are reticent to implement comprehensive sexuality education. Time and again, studies have demonstrated that young people need a combination of knowledge and skills both in and out of school to overcome their vulnerability – vulnerability to unintended pregnancies; to STIs including HIV, and to exploitation as they transit from puberty to adulthood. Age appropriate guidance on sexuality education now exists, such as the International Technical Guidance on Sexuality Education. However, opposition continues. And not surprisingly, both the content and delivery of sexuality education are sub-optimal - often over-medicalized, judgemental, and out of touch with the realities of young people. As one interviewer from Uganda admitted, “Today, schools are talking about sex education in a defensive way and not giving the whole package.”

Not surprisingly, what limited outreach exists to out of school youth is mostly provided by NGOs and not fully owned by national programmes. Overall, despite its great potential, comprehensive sexuality education is falling short.

Young women face significant obstacles to fulfilling their right to sexual and reproductive health. Legal and policy barriers loom, such as those limiting the age of consent for HIV counselling and testing and for SRH services. As an interviewer in Peru explained,“How can we expect that adolescents go with their parents to SRH services if they don´t even talk with them about sexual relationships?” Young women and girls are usually not even aware they have rights, let alone offered the skills or legal support required to realise them. Accessing youth friendly SRH and HIV services, and securing commodities such as condoms, is impeded by judgmental health providers, opposition from parents, cost, fear, distance, stigma, lack of confidentiality and privacy, and low quality of services. And despite international recognition of the value of ‘knowing your epidemic’, most national plans do not adequately differentiate among ‘young people’ resulting in programmes that do not meet their wide-ranging needs – a girl at risk of forced marriage; an unemployed young woman who uses drugs; a pregnant sex worker; a young person living with HIV since birth, or a young woman in a relationship with an older more established man. Nor have young people’s capacity been developed or their engagement truly sought. If young people were better involved they would insist that not all of their concerns can be addressed through health systems alone but through income generation, negotiation skills, education, entertainment, and a chance to have their voices heard and respected.

Women living with HIV in all regions have been unjustly and consistently denied their rights, especially their reproductive rights – forced sterilisation and abortion, judgmental attitudes against sexual activity, and lack of support for conception. PMTCT has been slow to address the needs of women for optimal antiretroviral therapy for their own health. Universal access to sexual and reproductive health means just that – access for everyone. Yet most countries have been slow to tailor their programmes to people living with HIV, especially those young people who have been living with HIV since birth. As these young people enter their sexually active years they must contend not only with the challenges of puberty, but with concerns such as potential disclosure of HIV status and related stigma and discrimination. As one network of people living with HIV in Peru has stressed, “We don´t need the ABC but the A to the Z.”

Legislation is essential to protect rights regarding HIV testing, family planning, property and inheritance, marriage, discrimination, and criminalization of sexual activity. These laws and policies must be enforced by establishing mechanisms for people living with HIV to document and redress rights violations, and through capacity building of health providers and teachers to foster accepting attitudes. Otherwise, as was pointed out during one interview, if women are not accorded the respect they deserve, they will avoid services, thinking “… if I am going to be treated like that I prefer to not return.” Engagement of people living with HIV – as with young people and key populations - is a paramount condition of effective rights-based programming. Yet, in most of the countries studied, there was a lack of adherence to this essential principle with significant consequences. As a recent guidance document has suggested “active participation … tends to diminish stigma and empower HIV-positive people to seek the support that they need.”

Most countries are still falling short of translating their agendas for women and girls into concrete budgeted action. Technical capacity to address the gender dimensions of HIV, including gender-based violence, is often in short supply. Despite being a flagrant human rights violation, gender-based violence against women is insufficiently addressed. Although most of the countries studied had established laws against rape, and some had passed laws against domestic violence, actual enforcement lags behind. As one youth coordinator in Thailand admitted, “… These laws are meaningless, if our gender biased social values do not change”.

As we have seen, many countries have clearly set themselves on a course toward gender equality and empowering women as they respond to their diverse and dynamic HIV epidemics. Linking HIV and SRH policies, systems, and services is essential, as part of the wider agenda to strengthen health systems. But health centred approaches alone will not be sufficient. Better coordination is required with other sectors, such as education, and finance, alongside community mobilization, and engaging men and boys to transform their attitudes and practices.

Women and girls need to be empowered to shape their own destinies, claim their rights, and access comprehensive SRH and HIV services free of stigma and discrimination. As we move toward 2015, when progress in reaching the MDGs will be measured, we find ourselves poised on the brink of hope or despair. Failure would be an unacceptable option.

Thank you.