HIV and Women’s Rights

Session Goal To discuss why women are disproportionately affected by the HIV epidemic globally, and how public health programs and human rights doctrines address (or aim to address) this inequality.

Learning Objectives Understand the drivers of inequality that cause women and girls to be more vulnerable to HIV infection Understand how human rights relates to the prevention, treatment, and care of HIV Analyze the specific conditions in countries with high rates of HIV transmission among women Differentiate between a public health and human rights approach to addressing women’s HIV vulnerability and burden

Understanding the Epidemic What is HIV Current epidemiology Prevalence 36.7 million people living with HIV in 2016 (UNAIDS) Incidence In 2015 there were 0.3 new HIV infections per 1,000 uninfected people (people at risk) 1.8 million new infections in 2016 (UNAIDS) Source: http://www.unaids.org/en/resources/fact-sheet

Women and HIV 51% of people living with HIV (PLHIV) are women Women account for 60% of PLHIV in western and central Africa and 56% of new infections among adults in Sub-Saharan Africa. (UNAIDS, 2017) HIV is the leading cause of death among women aged 30-49

Young Women and HIV Young women are 2x as likely to acquire HIV as their male counterparts (UNAIDS, 2016) Sex workers are 10x more likely to acquire HIV than adults in the general pop. (Amin, 2015) Transgender women are 49x more likely to be living with HIV as compared to all adults of reproductive age groups (Amin, 2015) Intimate partner violence against women is associated with a 1.5-fold increase in risk of STIs or HIV in some regions (Amin, 2015)

Girls and HIV Source: When Women Lead Change Happens, UNAIDS 2017

This epidemic unfortunately remains an epidemic of women. Michel Sidibé, Executive Director of UNAIDS

Fishbone Diagram Activity How does gender inequality lead to increased risk for HIV? Causes/Drivers Socio-cultural Political Inequality Legal Protection Economic inequality Violence Biology

Human Rights and HIV Right to Health HIV is often framed within the context of the human right to health Noted in International Covenant on Economic, Social, and Cultural Rights and constitution of the World Health Organization (WHO) Sexual and Reproductive Health and Rights (SRHR) Women’s SRH is related to multiple human rights including the right to life, the right to be free from torture, the right to health, the right to privacy, the right to education, and the prohibition of discrimination. The OHCHR and CEDAW have both indicated that women’s right to health includes their SRH

Human Rights and HIV UN International Guidelines on HIV/AIDS and Human Rights, 1998 and 2006 UN Declaration of Commitment on HIV/AIDS, 2001 UN Political Declaration on HIV/AIDS, 2006 and 2011 Expressed concern for feminization of HIV, recognizing that gender inequalities and all forms of violence against women and girls increase their vulnerability to HIV Affirmed that full realization of all human rights is an essential element in the global response to HIV, including in the areas of prevention, treatment, care and support, and recognize that addressing stigma and discrimination is also a critical element in combating the pandemic

Human Rights and HIV UNAIDS has adopted a rights-based approach in its policies, programs and activities UNAIDS 2016–2021 Strategy is one of the first in the UN system to be aligned to the Sustainable Development Goals: SDG3: Good Health and Well-being SDG 10: Reduced Inequalities SDG 5: Gender Equality SDG 16: Peace Justice and Strong Institutions Source: http://www.unaids.org/en/goals/unaidsstrategy

Human Rights Violations Criminalization Sex workers HIV Transmission, exposure, and nondisclosure Discrimination In healthcare In the workplace HIV related travel and immigration restrictions Other Violations HIV testing without consent SRHR of WLHIV

The Global Commission on HIV and the Law Recommendations TED Talk: How to Fight An Epidemic of Bad Laws, Shereen El-Feki What recommendations address women’s HIV vulnerability and burden? (El-Feki pp 127-128)

The Global Commission on HIV and the Law Recommendations TED Talk: How to Fight An Epidemic of Bad Laws, Shereen El-Feki What recommendations address women’s HIV vulnerability and burden? (El-Feki pp 127-128) Decriminalize sex work Address issues of violence: domestic violence, rape, sexual assault, forced abortion and coerced sterilization of HIV positive women Address legal environment around early marriage, widow inheritance, widow cleansing Improve access SRH information and options Improve access to age-appropriate comprehensive sex education

Human Rights vs Public Health Framework Human Rights Approach Laws, treaties, political declarations and commitments that protect and promote fundamental rights such as health Guidelines may be vague as well as not legally binding or enforced How it can be applied: Influencing law and policy reform Monitoring and enforcement Addressing violations Implement harm reduction policies

Human Rights vs Public Health Framework Public Health Approach Surveillance and research on prevention, treatment and care of population health challenges Evidence-based interventions that promote and protect health including information, education, and services. Time bound and dependent upon funding How it can be applied: Effective delivery of prevention, treatment and care services to those at risk or affected addresses their right to health Public health programs can promote or violate human rights depending on how they are designed or implemented Can prioritize vulnerable populations

Integrated Framework Translating international human rights principles and legal obligations into practical public health programming at the country level. Incorporating human rights principles into HIV programs creates an environment where the most vulnerable have their rights fulfilled and and access the services they need. Key Principles Equality and non-discrimination Equal and full participation of all stakeholders Putting communities at the center of programs Capacity-building of rights holders and decision makers Accountability (AVERT, 2017) Source: https://www.avert.org/human-rights-and-hiv

Integrated Framework Examples of human rights-related HIV programs: Stigma and discrimination reduction Legal services Monitoring and reforming laws, regulations and policies relating to HIV Rights education for people living with HIV and key populations Sensitization of lawmakers and law enforcement officials Human rights training for healthcare workers Reducing gender-related discrimination Community responses to HIV and human rights. Source: https://www.avert.org/human-rights-and-hiv

Integrated Framework Examples: RCTs show male circumcision can prevent HIV transmission, but raises human rights concerns. In 2007 UNAIDS published a guidance for decision makers on human rights and legal considerations surrounding it. Treatment Action Campaign (TAC), a South African organization sued the government to provide ensuring mother-to-child-transmission (MTCT) prevention programs and access to antiretroviral therapy (ART) in public clinics US President's Emergency Plan for AIDS Relief (PEPFAR) used to exclude family planning in HIV/AIDS activities but now supports integration of SRH. In addition to gender mainstreaming in HIV programs, it supports human rights integration.

Discussion Questions 1. Pick a country from AVERT HIV Around the world page at https://www.avert.org/professionals/hiv-around-world 2. Why are women more vulnerable or disproportionately affected by HIV there? 3. What would be a more effective approach for addressing women’s HIV burden in the country? A Public Health or Human Rights approach?

Learning Objectives Recap Understand the structural drivers of inequality that cause women and girls to be more vulnerable to HIV infection Fishbone Diagram using UNAIDS, Amin, El-Feki readings Understand how human rights relates to the prevention, treatment and care of HIV Discussion of current human rights doctrine Discussion of El-Feki Recommendations Analyze the specific conditions in countries with high rates of HIV transmission among women AVERT research activity Differentiate between a public health and human rights approach to addressing women’s HIV vulnerability and burden AVERT research activity discussion question 3:10-3:20

-Michel Sidibé, Executive Director of UNAIDS “It’s incredible to see the progress that some countries have made over the past five years. They’ve taken important strides to protect the rights of women and people living with and vulnerable to HIV. But now is also the time to think of the way forward in addressing the persistent and new challenges that are leading to people being left behind in the response to HIV”. -Michel Sidibé, Executive Director of UNAIDS