Gender inequalities explain why prevention is failing to contain HIV infection among young women in East and Southern Africa. UNAIDS calls for a major effort to reduce their risk of infection. Credit: Mercedes Sayagues/IPS

By Miriam Gathigah
NAIROBI, Nov 7 2014 (IPS)

Experts are raising alarm that years of HIV interventions throughout Africa have failed to stop infection among young women 15 to 24 years old.

“Prevention is failing for young women,” says Lillian Mworeko, HIV expert with International Community of Women Living with HIV in Eastern Africa, based in Uganda.

Among women in East and Southern Africa, four out of ten new HIV infections among women aged 15 years and over happen among  those aged 15 to 24, according to the Joint United Nations Programme on HIV/AIDS (UNAIDS).

Worryingly, HIV infection rates among young women are double or triple those of their male peers. In South Africa, the HIV prevalence of 18 percent among women aged 20-24 is three times higher than in men of the same age. 

Equally alarming are surveys showing that fewer than two in ten young women know their HIV status.

Experts attribute this high HIV prevalence to gender inequalities, violence against women, limited access to health care, education and jobs, and health systems that do not address the needs of youth.

Biology does not help. Teenage girls’ immature genital tract is more prone to abrasions during sex, opening entry points for the virus, Dr Milly Muchai told IPS.

Muchai, a reproductive health expert in Kenya, says it is not just sex that drives HIV infections among young women but the age of the male sexual partner.

“The risk increases steadily with male partners aged 20 years and over,” she explains.

Older men are more likely to have HIV than teenage boys. The Kenya AIDS Indicator Survey 2012 shows that male HIV prevalence remains low and stable until the age of 24, when it shoots up significantly.

Due to intergenerational sex, women in this region are acquiring HIV five to seven years earlier than men, says Muchai, because these relationships are characterised by multiple sexual partners and low condom use. In transactional sex, the young woman receiving gifts or money loses power to negotiate safe sex.

But Kenya is not a unique scenario.

Shocking figures

In Swaziland, Lesotho and Botswana, more than one in 10 females aged 15 to 24 are living with HIV, according to UNAIDS.

Dr Gang Sun, UNAIDS country director in Botswana, says that, in spite of the country’s remarkable progress in reduction of new infections and treatment, HIV is still a girls’ and women’s epidemic due to gender inequality and unequal power dynamics.

Among Batswana youth aged 20 to 24 years, HIV infection among women triples that of men, nearly 15 percent compared to 5 percent, he says.

Mary Pat Kieffer, senior director at Elizabeth Glaser Paediatric AIDS Foundation in Malawi, told IPS that as teenage girls become older, the risk of infection rises.

In Swaziland, HIV prevalence is six percent for girls aged 15 to 17 but rises to a whopping 43 percent by age 24.

Source: UNICEF

A package of interventions

Kieffer says that many of the issues – poverty, lack of secondary education, few jobs, rape and intimate partner violence – that underpin the unacceptably high HIV prevalence among young women are bigger than what HIV programs alone can address.

Mworeko observes major gaps in reproductive and sexual health services for young people, when they are neither children nor adults, in the region.

“Whether it is prevention, treatment, care and support services, young people do not have a youth friendly corner,” she says.

Paska Kinuthia, youth officer with UNAIDS in South Africa, told IPS that sexuality education needs to be strengthened in schools across the region.

“The regional average of comprehensive knowledge of HIV and AIDS stands at 41 percent for young men and 33 percent for young women,” he says.

Experts agree there is no one single solution to protect young women and a combination of interventions is needed.

Addressing restrictive laws on the age of consent for HIV testing and for access to sexual and reproductive health services would be a good place to start, experts say.

Promoting gender equality and providing jobs for young people are part of the solution, says Sun.

In Tanzania, HIV infection among girls more than triples between 15-19 and 20-24 years.

This fact, says Allison Jenkins, chief of HIV/AIDS with the United Nations Children’s Fund in Dar es Salaam, underlines “the importance of orienting HIV prevention and economic livelihoods interventions during her transition to adulthood.”

For all these reasons, UNAIDS is calling for “a major movement to protect adolescent girls and young women from HIV infection.”

Edited by: Mercedes Sayagues

With a new generation of HIV treatments available, mothers on Option B+ need only take one pill per day. Credit: Jennifer McKellar/IPS

By Wambi Michael
KAMPALA, Nov 27 2013 (IPS)

Uganda has gotten plenty of kudos and some criticism over its roll out of the new antiretroviral therapy for pregnant women and their babies, known as Option B +.

Recommended by the World Health Organisation in June 2012, Option B+ consists in life-long provision of ARV therapy to pregnant women regardless of their CD4 count. CD4s, or helper cells, fight infections in the body.

Before, under Options A and B, mother and baby were given ARVs during pregnancy and breastfeeding. Only women with CD4 counts under 350 were prescribed ARVs for life – but CD4-counting machines are expensive and scarce in Africa.

Uganda has done remarkably well. Over 70 percent of all health facilities offer Option B+ and it overshot its target of 35,000 women on treatment in the first year, reaching 50,000 by October 2013.

“We are overwhelmed by the roll out so far,” said Godfrey Esiru, national coordinator of prevention of mother-to-child transmission (PMTCT) at the Ministry of Health. “It is the cheapest option for a country with limited resources for the health sector.”

Uganda’s seroprevalence is seven percent, or some 1.5 million people, according to the Joint United Nations Programme on HIV/AIDS (UNAIDS).

AIDS activists welcomed the roll out but voiced some concerns.

“Option B+ denies a pregnant woman the right to decide whether to join the service or not,” said Dorothy Namutamba of the International Community of Women Living with HIV/AIDs in Eastern Africa (ICWEA).

This criticism featured prominently in the focus groups organised by ICWEA in 2012 to discuss the experiences of women with Option B+ in Uganda and Malawi.

“The names Option A, B and B+ imply that pregnant women who test positive for HIV are being given a range of options to choose from, whereas in reality it is the government that chooses which option to implement,” reads the ICWEA report on the focus groups.

Young HIV positive women may not want to start lifelong ARV treatment when they still feel healthy, although the regime is simplified to one pill a day. Over time, about two out of 10 people on treatment develop resistance to ARVs and must switch to more expensive second or third-line drugs.

Activist Mulani Birimumaso and his wife have lived with HIV for 15 years. Their two daughters are HIV negative thanks to PMTCT services available in Uganda since 2001.

He worries about couples sharing the pills at home. “They have initiated Option B+ without considering that there are other HIV positive people in homes other than mothers,” he told IPS. “The husbands also need those drugs.”

The focus groups noted the risk of domestic violence arising from the inequity in treatment access for husbands.

Another concern is ARV stock outs and dependence on donor funding. Uganda plans to put 240,000 people on treatment in 2014, Musa Bugundu, UNAIDS country coordinator, told IPS.

“Of these, 190,000 will be funded by the Americans and the remaining 50,000 by the Global Fund,” he said. “Is that the way to go? We have a serious problem.”

Proscovia Ayo, of the Tororo Forum of People Living with HIV Networks in eastern Uganda, points out that the roll out has ignored the need for family planning as part of PMTCT.

“You find a mother delivering every two years, yet she is on ARV treatment. We thought Option B+ would resolve that, but it has not,” she said.

Some critics say that Option B+ could be a potential incentive to get pregnant and gain access to the three-drugs-in-one-pill daily treatment.

Cellphones and men

Shafik Malende, a researcher in a study on implementation of Option B+ in northern Gulu district, found it requires strong family cooperation.

“Engagement of communities would greatly enhance Option B+ because they would ensure adherence and follow up,” said Malende.

A study at Mulago National Referrral Hospital in Kampala in late 2012 found that out of 190 women on Option B+, only 20 percent picked up their CD4 count results.

“High rates of loss to follow-up mean increased risk of treatment failure, drug resistance and disease progression for the woman,” Namutamba explained.

These concerns are being addressed as the program is implemented across the country, Godfrey Esiru told IPS. Now, each clinic is getting a cellphone to track mothers on treatment.

He admitted some weaknesses in male involvement, but added that increased use of village health teams and peer mothers groups will encourage men to support their wives.

One advantage of Option B+ is that HIV positive pregnant women are put on treatment without a CD4 count.  “We could not move this fast with the other options because we don’t have enough CD4 machines,” Esiru explained.

Yet, looking beyond birth, women on treatment will need regular CD4 counts and viral load tests to monitor their health. Activist Augustine Sebuma, who has lived with HIV for 20 years, wondered how health workers will monitor mothers on Option B+ when their clinics lack CD4 counting machines.

“We strongly support Option B+,” reads a statement by ICWEA. “But we are gravely concerned … about two major early challenges, loss to follow-up and weak engagement of communities, which will lead to weak demand for this service.”