The Pact

Mobilizing Access to the Sexual & Reproductive Rights of Women Living with HIV in Africa

By Oni Oluwfunmilayo

For over forty years, HIV has continued to be a nagging global public health issue. All this while, however, the sexual and reproductive health rights of women living with the virus have continuously been neglected.

In 2020, 37.7 million people were estimated to be living with HIV across the world, and 4.7 million of this number lived in West and Central Africa. In Sub-Saharan Africa, women and girls accounted for 63 per cent of all new HIV infections in 2020 and made up over half the people living with HIV.

Problems such as lack of access to higher education, poverty, rape, and gender-based violence have made women more than twice as likely as men to be infected. With this alarming figure, one would expect that women living with HIV/AIDS in Sub-Saharan Africa would have policies and inclusive care programmes suited for their needs and healthcare. But this is not the case. Important aspects of sexual and reproductive health include access to ante-natal, post-natal and newborn care; family planning and fertility services; access to safe abortions; combating sexually transmitted diseases; cervical cancer and other gynaecological morbidities; and promoting sexual health.

Access to the sexual and reproductive health rights of women living with HIV in the sub-region has been hindered by many factors, including poor policy formulation and implementation, poor funding, lack of skilled healthcare workers, the lack of societal recognition of the agency of women, and lack of HIV programming in the services provided by health centres. Most recently, the COVID-19 pandemic also made it harder for women to access their sexual and reproductive health rights.

Countries in sub-Saharan Africa allocate little funding for programmes aimed at supporting people living with HIV and depend largely on foreign aid. Between 2005 and 2018, about $6.2 billion dollars was spent to identify close to one million people living with HIV in Nigeria and place them on treatment. However, 80 per cent of this money came from international donors and development partners, only 18 per cent was contributed by the federal and state governments while 1 per cent came from the private sector. The conditions are the same in Cameroon, Senegal, and the Benin Republic.

Since countries in sub-Saharan Africa make available very little funding to fight HIV, minimal attention is paid to HIV programming. As a result, many of the countries lack the facilities needed to diversify the support offered to people living with HIV, especially women. Women then have to seek care from workers who may not be well-trained to support them adequately.

An example is Zainab (not real name), who lives in one of the slums in Lagos State, Nigeria. After she was diagnosed with HIV, she was advised to never have sex again and become an active member of a church in Nigeria. A well-trained health worker would have advised Zainab about her options rather than force her into celibacy. In other cases, some health care workers do not fully understand the best practices for pregnant women living with HIV. These women are, for instance, forced to have abortions because they fear that they may pass it on to their children.

Since 1997, Nigeria has consistently developed national policies on HIV/AIDS in order to reduce the spread and support people living with the virus. However, many of the strategic plans have been poorly implemented due to a lack of financing and efficient leadership.

The Nigerian government, through the National Agency for the Control of AIDS (NACA), released a strategic framework for 2019 – 2021 and the only objective that speaks specifically to women’s health rights is: “To eliminate mother-to-child transmission of HIV by 2030”. The objectives do not include specific issues that affect women such as training of healthcare workers to adequately support women living with HIV, disseminating information that will help reduce the stigma, and addressing gender inequality and practices that disempower women from accessing their rights such as the confidence to purchase condoms and seek HIV prevention methods or treatments without needing permission from their husbands.

In an interview with women in Makoko, popularly known as the world’s largest floating slum located in Lagos, eight in 10 women said their culture forbids them as “virtuous women” to purchase condoms or suggest using them to their husbands or boyfriends. Only men are allowed to make such suggestions. The women cannot also use contraceptives or treatments without permission from their husbands and this usually involves a long deliberation by the extended families.

As of 2019, approximately 7.5 million people in South Africa were living with HIV (the highest number in the world), including 26 per cent of women, compared to 15 per cent of men. Like in Nigeria, poverty and inequality have contributed significantly to the high infection rates among women, and many turn to transactional sex to sustain themselves. Because of this, the South African Government launched the She Conquers Campaign in 2016 to reduce sexual and gender-based violence amongst adolescent girls and young women, reduce new HIV infections in girls and young women, and reduce teenage pregnancies. But the programme had many problems that hindered its ability to support the target audience. Young women were left out of the decision-making process at crucial stages and the programme didn’t speak to their needs. To the campaign’s credit, it received massive coverage, which led to awareness and generated conversations about HIV and the rights of women. It also gave women and girls access to discrimination-free HIV prevention and treatment services and family planning, asked for feedback, and ensured that girls living with HIV had a safe space to thrive and achieve their full potential.

While many governments in Africa have set up programmes and policies to ensure that people living with HIV are able to access healthcare, it is also important for them to tailor services and policies that are specifically beneficial for women. Integrating participatory processes and training on the gender and the sexual and reproductive health rights of women and girls living with HIV will yield a fruitful outcome in ensuring that African women have access to comprehensive support.

Healthcare workers, policymakers, women living with HIV, members of their community, and their families must be involved in policy and decision-making processes, programme design and implementation, budgeting, and other important activities.

Like Zainab, many women in Africa have had to deal with hyper-religious and unskilled healthcare workers who are not keen on supporting them to get the necessary treatments but rather stigmatise them and urge/threaten them to find healing in religious activities that are often harmful. This is usually a problem in small and rural communities, and it can be tackled by engaging with health workers in those areas and ensuring that they have the necessary qualification, training, and skills.

Awareness campaigns about the rights of women should be carried out occasionally in all communities so that people can recognise and embrace the agency of women. By doing so, women living with HIV can ask for treatments, access psychosocial support, and leave abusive situations without needing and soliciting permission from their husbands and fathers. With this, women can make quick and lifesaving decisions that will improve their sexual health and general well-being in the long run.

The government also has a role to play. Inclusive policies such as ensuring women living with HIV, regardless of their socio-economic backgrounds, have access to antiretroviral therapy must be promoted. Firm government policies must be made regarding how healthcare workers treat women living with HIV. Metrics should be put in place to ensure that these policies are implemented and that stated goals are met. Key populations should be included in the monitoring and evaluating processes too so that they can give important feedback.

Governments across Africa need to increase their funding for fighting HIV as well as channel funding directly into specific issues that will make the lives of women easier.  Law enforcement must also clamp down on instances of retaliatory spreading of HIV through coercion, rape, and so on.

Although the scourge of HIV has been with us for over four decades, a lot has been done to get to where we are now in the fight against this deadly epidemic. Most of this work was done in the form of advocacy by activists since the early eighties till date. Their successes show how important coordinated, continuous, loud, and unfazed advocacy helps to complement medical and scientific efforts in combating this disease. This same tool – consistent advocacy – will see to the improved access of women living with HIV to their sexual and reproductive health rights, while we continue to wait for a cure.