Fix PEPFAR for Women and Girls

The HIV prevention paradigm given to us by the U.S. government -- abstain, be faithful and use condoms -- is irrelevant for many, even most, vulnerable women and girls. They cannot abstain, they are already faithful, and their partners refuse to use condoms.

We know, but it does not hurt to repeat, that just under half of all people living with HIV/AIDS worldwide are female, and in sub-Saharan Africa, far more than half are female, especially among those 15 to 24 years old. A major factor that fosters women's disproportionate vulnerability to HIV/AIDS is HIV/AIDS policy itself — and the funding priorities that go with it.

Prevention policy and programs have generally been driven by two paradigms. One says that we can contain HIV/AIDS by focusing on high risk populations such as sex workers, intravenous drug users, and men who have sex with men. This work is vitally important. But, it has also left vast numbers of girls and women unprotected.

The second dominant prevention paradigm — given to us by the U.S. government — is ABC: Abstain, Be Faithful, and use Condoms if you engage in risky behavior. Fortunately, more and more people recognize that this framework is irrelevant for many, even most, vulnerable women and girls. They cannot abstain, they are already faithful, and their partners refuse to use condoms. More than four-fifths of new HIV infections in women occur in marriage or long-term relationships with primary partners. In sub-Saharan Africa, an estimated 60 to 80 percent of HIV-positive women have been infected by their husbands or sole partner.

These are all fundamentally sexual and reproductive rights issues — issues that must become central to our HIV/AIDS prevention, treatment, and care paradigm.

First, imagine a pregnant woman seeking antenatal care. If the clinic she visits offers her HIV testing at all, it is likely for one of two purposes: either anonymous HIV surveillance or prevention of mother-to-child transmission (PMTCT) — typically not for the purpose of promoting her own health.

Imagine that she tests positive for HIV. It is still quite unlikely she will receive services to prevent transmission to her infant. Only 11 percent of pregnant women living with HIV/AIDS globally currently receive antiretroviral prophylaxis for the infant, and almost no PMTCT programs treat the mother herself. Furthermore, a pregnant woman who tests positive is often denied other reproductive health services outright, including skilled help during child birth.

Imagine, on the other hand, that the woman tests negative for HIV. She will receive inadequate antenatal care from overtaxed health workers, which will likely not include screening for sexually transmitted diseases or any information about how to protect herself from STDs, including HIV/AIDS. The health workers she sees will not have been trained to ask whether her husband or partner has other partners or visits sex workers, if she is forced to have sex against her will, or has been subjected to other violence. Nor will she be referred to support services that could help her in these circumstances and support her in asking her partner to be tested.

These policy and programmatic failures do not only affect pregnant women.

Imagine, now, a woman who seeks reproductive health services because she does not want to have a child. If she is unmarried, she may not even make it past the front door, because many countries have laws against services for unmarried people. Women who do get past the door will likely receive contraception, but not help for an STD or HIV counseling and testing.

Or imagine a woman who accesses the health system through HIV/AIDS services, such as a freestanding testing site. She almost certainly will not receive any family planning or other reproductive health services.

These gaps are not simply due to weak health systems or shortages of money. They are due to political divides, professional divides, and overall neglect of women. As Congress considers changes to the President's Emergency Plan for AIDS Relief (PEPFAR), it must stay focused on the real life needs of women and girls. Making the necessary investments in sexual and reproductive health services and protection of sexual and reproductive rights is an efficient and effective use of our tax dollars-and will save even more lives along the way.