E-discussion on key HIV affected women and girls in Asia and the Pacific

[Facilitator's note: Below is a final message from the guest moderator of our e-discussion Vince Crisostomo, Executive Director, Coalition of Asia Pacific Regional Networks on HIV/AIDS (7 Sisters).]

Hello,

I just want to say a quick thank you to all who have posted. The dialogue generated will be compiled and this information shared. If there are topics that you think should be addressed in the forum please forward to me at vince@7sisters.org and I will bring to the attention of the Inter Agency Task Team (IATT) on Gender for future E-discussions. If we have enough interest perhaps we could even do a short survey to prioritize. So thanks again to all who have posted your contributions. I will look forward to the next one.

Always, 

Vince
 

Given that heterosexual transmission is the primary mode of HIV transmission in the country, the Indian HIV epidemic is expanding to non-high-risk groups that include adolescent girls (married and single); married women of reproductive age; sexually active single women; pregnant women; and women survivors of gender based violence, sexual abuse and rape. While statistically HIV prevalence is not high in these groups, recent trends point to their vulnerability to HIV and therefore highlight the need to consider these groups in any analysis of the barriers to accessing HIV services. According to the National AIDS Control Organisation (NACO), the HIV epidemic in the country is increasingly affecting women and young girls, more so in places where heterosexual sex is the main mode of transmission (NACO, 2007). Out of the estimated adults living with HIV in 2007, 38.4 percent were females (NACO, 2008) and this proportion has increased from approximately 27 percent in the year 2001.

Women bear a disproportionate impact of HIV due to socio-cultural-economic inequalities, discrimination, violence and lack of decision-making power in relationships.  A NACO-NCAER-UNDP study (2006) showed that discrimination prevented women living with HIV from accessing HIV services.  Even when they had access to prevention and treatment information, they could not act on it due to the socio-structural issues.  While government provides free ART to all PLHIV, the situation has not changed much for PLHIV, especially women and girls.  It is clear that there is a need to understand the barriers faced by women and girls in accessing services.

As a first step towards this understanding, UNDP conducted focused group discussions during 2010 with women living with HIV.  The women cited lack of privacy, fear of breach of confidentiality, constraints like time, child care, resources, distance, disabling factors like non-availability of female doctors, rudeness of hospital staff as some of the barriers to accessing treatment. The discussions clearly showed that women were not a homogenous group and that for effective programming, it was critical to have a comprehensive understanding of barriers to HIV prevention, testing and treatment services for women and girls in different settings of risk and vulnerability.  In 2011 UNDP partnered with ICRW to conduct a study on access issues and barriers faced by two groups of women – female sex workers in Pune, Maharashtra and wives of migrant men in Ganjam, Orissa. The study among the female sex workers highlights the higher vulnerability of ageing women, non-brothel based sex workers and younger women among the brothel-based workers.  It shows that awareness and access to services are directly proportionate to the income and decision making power of sex workers.  Sexual or gender based violence creates obstacles that prevent them from accessing appropriate and timely services.  The study shows that six out of every ten female sex workers have experienced some kind of violence.

Lack of voice, low risk perception, restricted mobility, distance to services, opportunity costs, stigma (including self/perceived), discrimination, indifferent counseling and incomplete services are common barriers faced by sex workers and wives of migrant men.  The low risk perception is echoed by service providers who sent only 37 percent of migrants’ wives for HIV testing during pregnancy. These, coupled with very low awareness of STIs, facilities, limited in come, cost of transportation, inequitable gender norms and low treatment seeking behaviour, create formidable barriers to information and services that these women find difficult to surmount.

Access can be facilitated by

- Empowerment and decision making of women (Better access to HIV and STI knowledge, prevention and treatment related to higher decision making of one’s health, higher education  income level)

- National AIDS Control Organisations should scale up coverage and saturation of most at risk and vulnerable women through targeted intervention

- While we do not have quantifiable data about female partners of MARPs but there is ample anecdotal evidence that female partners of MSM need  to be included in TI services.

- Gender-specific HIV testing and care services would directly address gender-specific HIV needs, including continuum of care and psychosocial support for women.

- Prevention programmes cannot succeed until women's health and rights are placed at the very center of HIV strategies and women’s realities actually inform programme design.

- Analysis of the legal aid clinics set up with UNDP support, showed that more than 50% of those seeking services are women and most cases were about issues of rights to property, custody of children etc. hence ccomprehensive and sustainable response to the epidemic must include the establishment of access to justice mechanism that acknowledges and addresses the different impact of the threat on men and women. Legal literacy and legal aid services are essential to promote and enforce women’s rights.

- Sensitization of law enforcement officials, police and the judiciary about the gender and legal dimensions of HIV is required to reduce women’s vulnerability.

- Enhanced social protection for women and girls living and affected by HIV, this can be done by widening the inclusion criteria of schemes to include women and girls living with HIV

- Improve women’s access to income and control over household assets through enforcement of existing legislations

- Integrating reproductive health, family planning and STI/HIV prevention and treatment services is critical for achieving universal access. Successful integration necessitates political commitment towards providing a comprehensive package of primary health care services and technical and financial support towards achieving this. Many attempts to integrate SRH services have encountered problems at the programme and service level. These include difficulties in: allocating and coordinating responsibilities; ensuring effective communication between staff in programmes; training staff with appropriate skills to meet a broader range of demands; strengthening referral services.

- Actively involving marginalised groups in decision making processes at all levels, and providing them with the opportunity to hold service providers and policy makers accountable for discriminatory practices, corruption or poor quality services.

Response by Alka Narang (Asst. Country Director – HIV and Development Unit) and Ernest Noronha (Programme Officer – HIV and Development Unit), UNDP India

I think that majority of women and girls in PNG who are affected most by HIV/AIDS, and issues related to gender equality and gender -based abuse and violence, are those uneducated women and girls in rural community settings. Such women and girls need to know about their rights and must be empowered to voice their concerns without fear.  From experiences that I have learned, most women and girls are deprived of their human rights and as free citizens of a democratic country to speak up for themselves. Since PNG is a traditionally oriented country, the majority of decisions made within family units are based on upholding traditional customs and beliefs, which see women and girls as second priority. Eg;Traditionally women are suppose to submit to their husbands and are seen as child bearers who take the resposibility to expand tribemenship within the clan. She does not take part in decision making processess, nor is she given opprtunutiy to air her concerns. 

I strongly feel that targets 1, 3 & 7 can be achieved through rural awareness on HIV/AIDS Prevention. Last years' World AIDS Day celebrations for PNG within NCD focused to the rural areas. This was a very good opprtunity organized by NACS through NCD PAC for many rural communities to learn about how they can reduce their risks of HIV/AIDS, STIs and unintended pregnancy, through safe sex practices. It is essential that HIV/AIDS Prevention inventerventions should be carried out in other rural communities throughout PNG, because that is where the bulk of the population lies.

For such interventions to be sucessful, we will need women who already have this knowledge and empowerment to take the lead in making a positive change for others.

Regards,

Bolalava Vaia

FHI 360, PNG

A briefing paper, published by Asia Pacific Coalition of AIDS Service Organizations (APCASO) in collaboration with the Asia Pacific Alliance for Sexual and Reproductive Health and Rights (APA) titled “Women and Girls: The 2011 Political Declaration on HIV/AIDS, Civil Society Perspectives on the 2011 HIV/AIDS High Level Meeting” was distributed at the last Asia Pacific High Level Intergovernmental Meeting on HIV/AIDS and MDGs. The paper looks at the 2011 Political Declaration made at the United Nations General Assembly High Level Meeting (HLM) on HIV/AIDS held in New York in 2011 and is a tool to hold stakholders accountable to their commitments and targets for women and girls.

I wish to share key recommendations of the factsheet.

The 2011 Declaration commit to comprehensively target populations at higher risk of HIV. This recognition is a step forward, however it is important to recognizethe needs of women and girls who work as sex workers, use drugs and/or transgendered. We need to comprehensively target these populations in national prevention strategies and ensure that gender sensitive services are available to them by removing punitive laws, policies, practices and stigma and discrimination that block access.

The 2011 Declaration calls for the elimination of all forms of violence against women and girls, and in particular “harmful traditional and customary practices, abuse, rape and other forms of sexual violence, battering and trafficking in women and girls”. Asia Pacific governments are called upon to undertake measures to address discrimination and legal barriers to effective HIV responses, in particular with regard to key affected populations. But scale up actions are needed for policies that address the rights of women and girls in the context of HIV, and the link between HIV and different forms of violence against all women and girls. Often stigma, discrimination and criminalization of behaviours prevent women from reporting acts of violence against them and seeking redress. This must be incorporated in national HIV response strategies and programs. Women's groups call for active involvement/ meaningful participation, especially key affected women and girls, in all aspects of HIV policies and programme development and decision-making.

Ensure access to comprehensive sexuality education for girls and boys both in and out of school. Also, only 34% of young people possess accurate knowledge of HIV. The 2011 Declaration strongly recognizes that young people are being excluded from information and services, and offers solutions by ensuring access of both GIRLS and boys to primary and secondary education, including HIV and AIDS, in curricula for adolescents, and ensuring safe environments especially for young girls. Civil society has stressed the need for equitable access to treatment literature especially for marginalized women who often have less access to education, putting them at greater risk. Equal opportunities for education should be guaranteed for women and men.

Ensure a comprehensive and rights based integrated response to HIV in ways that strengthen existing national health and social systems and strengthening linkages with sexual and reproductive health and maternal and child health services, programs and policies by 2015. In order to reduce sexual transmission of HIV by 50 per cent it is crucial that women and girls should be able to exercise their right over matters related to their sexual and reproductive health, without coercion, discrimination and violence. Also women have reported pressure by healthcare workers to have abortions or undergo sterilizations. Often coupled with lack of information about health risks, such forced decisions are violations of human rights. It is important that governments commit to redouble HIV prevention methods efforts by investing in facilitating female initiated prevention methods and access to rights based HIV and sexual and reproductive healthcare services.

Eliminating mother-to-child transmission of HIV by 2015 and substantially reducing AIDS-related maternal deaths is another time-bound commitment by governments. It is important that prevention of vertical HIV transmission should be part of a holistic HIV prevention, treatment, care and support package for women. To achieve this, the governments committed to ensure access for women of child-bearing age to HIV prevention-related services, access for pregnant women to antenatal care, counselling and other HIV services, and access for women and infants living with HIV to effective treatment. Laws and policies focused on key populations related to preventing vertical HIV transmission should adhere to principles of informed consent, confidentiality, pre and post-test counselling and proper referral to treatment, care and support services.

Migrants, especially female migrants, often experience conditions of high vulnerability, endure abuse, exploitation, violence, stigma and discrimination, and lack access to reproductive health services leading to sexually-transmitted infections, including HIV. This group is often forgotten, including in the 2011 Declaration and their needs and rights should be more comprehensively addressed.

Governments pledged to take all necessary measures for the empowerment of women to increase the capacity of women and adolescent girls to protect them from the risk of HIV infection. National responses should meet the specific needs of women and girls “through strengthening legal, policy, administrative and other measures for the promotion and protection of women's full enjoyment of all human rights”. Furthermore, the role and engagement of men and boys in the achievement of gender equality is crucial.

The 2011 Declaration has strong commitments and ways forward to make the response work for key affected women and girls. Now it is time to bring those commitments to live in the Asia and Pacific region. It is time to invest in women’s leadership, community capacity building, and eliminating gender based violence as critical enablers that are crucial to the success of HIV programmes and scale up action and resources for policies and programs that address the rights of women and girls in the context of HIV.

Rose Koenders

Executive Director, Asia Pacific Alliance for Sexual and Reproductive Health and Rights (APA)
www.asiapacificalliance.org

HIV, Gender and Human Rights especially with MARPs (Transgender, MSM, SW) is still a very sensitive and challenging topic in Papua New Guinea with contradictory laws that punishes individuals based on their sexuality. However, UN continues its dialogue with relevant senior authorities for decriminalization with examples of best practices with similar situations in other countries. Meanwhile, minimal targeted program activities are provided by very few NGOs and Faith based organization. There is still a long way away in sensitizing our leaders and the wider community in this crucial area.  

Recently, an annual film festival has been established and last year (its second year) since establishment, UNAIDS as part of the Word AIDS Day campaign, WAD twenty day of activism initiative sponsored a portion of the festival related to access to health care and rights to HIV treatment, care and prevention for all under the theme “Right to health and ending discrimination on the basis of sexual orientation and gender identity”. There were nine other themes showing a range of documentaries and featuring films followed by a panel discussion which I thought was an ice breaker for the attendees and panelist whom in their discussion highlighted that though such issues were happening right at their door steps, their own homes etc; there seems to be a denial embedded to societal cultures and taboos and there is no open discussion on these areas to understand and better support the HIV response.

Hence, I am in full support of this annual Human rights film festival to be accelerated by having the event in the provinces apart from the national one. The National Education Department has also reviewed its national HIV and gender equity policies integrating women, girls, gender and HIV having it incorporated into the school curriculum and learning materials with the aim of having related topics being taught to students as early as possible and at every learning level. 

Maria Towai Nepel
PSMO/Gender focal point
UNAIDS, Port Moresby
Papua New Guinea

For UNDP, gender equality is a core development objective.  It is indivisible from the UNDP human development goal of “real improvements in people’s lives and in the choices and opportunities open to them.”  This commitment to gender equality and women’s empowerment has most recently been clarified in “Empowered and Equal,” UNDP Gender Equality Strategy for 2008-2011. The Gender Equality Strategy notes that “by empowering women to claim their internationally-agreed rights in every development sphere, and supporting governments to be both pro-active and responsive in advancing the realization of these rights, UNDP will leverage the broadest possible expansion of choice and opportunity for all.” [1]

HIV thrives on stigma, discrimination and inequality.  When income inequality combines with other forms of marginalization, such as race, ethnicity, language, immigrant status, or gender, the impact becomes more pronounced.  Across the world, HIV epidemics occur in the context of high levels of poverty, unemployment, stigma, and gender and other inequalities—all of which can aid transmission of HIV, and hinder efforts to control its spread and mitigate its impact. Social exclusion and marginalization hamper access to health information and services, which in turn increases vulnerability to contracting illness and reduces the chances of adequate and sustained treatment.

While the association between HIV and inequality is gaining more attention, the specific interaction between gender, poverty and HIV is complex. Women in many parts of the world bear a disproportionate burden of the social and economic consequences of AIDS, including loss of property and inheritance and custody of children. Poverty and corresponding denial of inheritance rights to women and children gravely affect women’s ability to cope with the impact of AIDS and access health care.

Women and girls lacking economic resources are more vulnerable to coerced sex and the related risks.[2]  In a study of low-income women in long-term relationships in Mumbai, India, women believed that the economic consequences of leaving a relationship that they perceived as “risky” were far worse than the risk of contracting HIV/AIDS (Gupta, 2000).

In the context of the AIDS epidemic, understanding and responding to gender inequality is essential to delivering results.  The wide variation in patterns, resources and responses, in concentrated as well as generalized epidemics, points to the importance of understanding the role of gender inequality in driving epidemics, as well as the interaction between gender inequality and other social and structural factors—such as economic status, ethnicity and religion—that influence disease dynamics. Indeed, it can be said that gender norms[3]  drive and exacerbate HIV since “these gender norms strongly influence both men’s and women’s risk taking behaviour, expression of sexuality, and vulnerability to HIV infection and impact, including their ability to take up and use HIV prevention information and commodities, as well as HIV treatment, care and support.” [4]   

Prepared by Susana T. Fried, Senior Gender Advisor, UNDP, BDP, HIV/AIDS Practice

1  Empowered and Equal: gender equality strategy 2008-2011. UNDP, 2008. This commitment is further strengthened in conflict settings by the UNDP's Eight Point Agenda for Women's Empowerment and Gender Equality in Crisis Prevention and Recovery
2  Hallman, K and J Diers. “Social Isolation and Economic Vulnerability: Adolescent HIV and Pregnancy Risk Factors in South Africa.” Population Council, NY.
3  Gender norms can be defined as “learned and evolving beliefs and customs in a society that define what is “socially acceptable” in terms of roles, behaviours and status for both men and women…Gender norms can also be the basis of discrimination and violence against men who have sex with men, lesbians and trans-gendered people, placing them at higher risk of HIV infection and impact.”  UNAIDS/PCB(20)/07.11 dated 27 April 2007.
4  UNAIDS/PCB(20)/07.11 dated 27 April 2007.

In relation to the identification of the key affected women and girls in the region, and the priority actions for governments to take in order to achieve the three targets specifically relating to women and girls in the Political Declaration on HIV/AIDS (2011), I was pleased to see the following text in the draft Report of the ESCAP Asia-Pacific High Level Intergovernmental Meeting on the Assessment of Progress against Commitments in the Political Declaration on HIV/AIDS and the Millennium Development Goals (6-8 February 2012):

"The Meeting recognized that addressing gender norms and relations were crucial for reducing HIV vulnerability. For women, a major source of transmission of HIV was unprotected sex with their male partners, especially if those were the clients of sex workers, and the impact of the epidemic on monogamous women infected by their intimate partner across the region was highlighted by one delegation. The need to increase male involvement in reproductive health was noted."

I agree that addressing harmful gender norms is crucial to reducing HIV vulnerability of key affected women and girls in the region, including women vulnerable to HIV through sexual transmission from their spouses/intimate partners.  Addressing the rights and needs of key affected women and girls will not only enable progress towards the three targets specifically relating to women and girls in the Political Declaration 2011, it will also ensure progress on advancing human rights to eliminate stigma, discrimination and violence related to HIV (another of the 10 targets - which in fact impacts on countries' ability to achieve all targets).  It will also enable our efforts to address HIV to contribute to progress on broader development and human rights issues.  The Political Declaration contains commitments to implement a range of concrete programmes in order to achieve these targets, and governments should be held accountable to these commitments.  The United Nations, including UNAIDS, is supporting countries in their efforts.  And of course, civil society are invaluable partners for governments in achieving these targets. 

In terms of specific interventions that were raised at the ESCAP meeting and the side event:  The Gender Agenda:  Making HIV Responses Work for Key Affected Women and Girls, three that I would like to highlight for further consideration are:

1)  Advoacacy and partnership work with human rights organisations and women's rights organisations for increased attention to protecting and promoting the rights of ALL women, including those who engage in high risk behaviours, the spouses of men who engage in high risk behaviours, and women living with HIV.

2)  Increased, sustained investment in key affected women and girls to ensure that they can advocate for their needs and rights at the local, national and regional level;

2)  Working with men and boys - particularly mobile men with money - to integrate the notion of respect and responsibility for their own health, and that of their sexual partners into social norms relating to masculinity. 

Best,

Brianna Harrison 
Human Rights Programme Officer, UNAIDS Asia Pacific RST
Office: +66 2 680 4135; IP 96135;
Mobile:  +66 8307 202 07;
Fax:  +66 2 282 8199

SH&FPA works both nationally (Australia) and internationally (mainly in the Pacific). In our work we focus on family planning and sexual health. 

We think that governments and civil society should focus on:

• Recognition that access to safe and legal abortion services is a right for all women
• Support for integrated family planning/STI and HIV services to allow continuity of care
• Increased access to low cost versions of long acting reversible contraceptives
• Recognition that men are part of the solution to achieve gender equality, and support programs that focus on men and women working in partnership
• Decriminalizing sex work
• Support for comprehensive sexuality and respectful relationships education in schools 

Sarah Kirk
Senior Policy and Project Officer
Sexual Health and Family  Planning Australia (SH&FPA)
T: + 61 2 6232 4632
Mob:+ 61 478 513 135
Email: sarah.kirk@shfpa.org.au
Website: www.shfpa.org.au

From the perspective of the Asian Network of People who Use Drugs (ANPUD):

1) Key affected women and girls include women and girls who use drugs, spouses and sexual partners of people who use drugs, children of people who use drugs, and those people (who use drugs or who are sexual partners or children of people who use drugs) who, regardless of the sex they were born with, consider themselves women and girls.

2) Target 1: Implement all 9 interventions (as listed in the “WHO/UNODC/UNAIDS Technical Guide for Countries to set targets for universal access to HIV prevention, treatment, care for injecting drug users”) with sufficient coverage (at least 80 percent of the target population).

The nine interventions are:

1. Needle and Syringe Programmes (NSPs)
2. Opioid Substituition Therapy (OST) and other drug dependence treatment
3. HIV Testing and Counselling (T&C)
4. Antiretroviral Therapy (ART)
5. Prevention and treatment of sexually transmitted infections (STI)
6. Condom programs for IDUs and sexual partners
7. Targeted Information, Education and communication (IEC) for IDU and sexual partners
8. Vaccination, diagnosis and treatment of viral hepatitis
9. Prevention, diagnosis and treatment of Tuberculosis

Target 3: In addition to the nine interventions listed above, make available: community-sensitive, accessible, free, voluntary PMTCT services including testing and treatment for pregnant women who use drugs or who are sexual partners of people who use drugs. This would also include the provision of these services to pregnant women incarcerated in closed settings.

Target 7: Increase accessibility to male and female condoms and scale up the provision of sterile injecting equipment. Research and implement gender sensitive and culturally appropriate service provision of the nine interventions. Empower and educate both women and men.

Regional Coordinator
ANPUD
51/2 FL 3, Ruam Rudee Bldg III
Soi Ruam Rudee; Ploenchit Rd, Lumpini, Phatumwan
Bangkok 10330, Thailand
T:  +662 255-7477/78
F:  +662 255-7479
M: +66-891693108
E: dean.lewis@anpud.info
W: www.anpud.info
Skype: deanlewis_ind

Dear Gina Davis,

Thank you for e-mail. We will consider this content when making policies on social protection in Viet Nam.

Best,

TO DUC

Chief of Social Work Division, Social Protection Administration
Ministry of Labour, Invalid and Social Affairs
Office: 35 Tran Phu Str, Ba Dinh Dist, Ha Noi Capital, Viet Nam
Tel: (+84 4) 3747 5360; Cell phone: (+84) 986 42 6686
Fax: (+84 4) 3747 8674
E-mail: toduc@ymail.com & toduc@molisa.gov.vn

[Facilitator's note: Please find below our first comment of this e-discussion, from Gina Davis of WAPN+. Also, note that as a result of a technical issue the launch email did not reach a number of members with @undp.org email addresses. The issue has been fixed now, but for those members who missed the initial launch message it can be found on the e-discussion webpage at http://www.hivapcop.org/e-discussion/e-discussion-key-hiv-affected-women-and-girls-asia-and-pacific.] 

WAPN+ consider positive women and our children as a key affected population.

Governments should take action in addressing the needs of positive women, such as through social protection (which includes access to sexual and reproductive health services, social services and legal protection). Governments should put more effort in making sure that national policies are sensitive to the rights of women living with HIV  and are actually implemented. Many countries in the regions have had really good policies but they are not implemented, or they do not put aside any funding to implement. Governments needs to take responsibility and allocate funding to programs and activities at the national level. They have to stop relying on the international donors. Governments should increase their partnership with civil society, especially the communities, in responding to the needs of women and girls, particularly women's organizations and positive women's networks.

Civil society needs to reach out to positive women's groups and recognized positive women as partners in responding to HIV at the country level. Positive women's groups should be consulted in all program development that concerns positive women. All programs for positive women should be sensitive to the rights of women and girls infected and affected with HIV.  Above all, involve positive women in the service delivery of their programs. Train and employ positive women as educators, counselors, out-reach workers, etc. in reaching out to positive and non-positive women and girls.

I may have some more inputs later but for now, WAPN+ believes that the above are the priorities.

Best

Gina Davis
WAPN+ Coordinator
Women working group of APN+
51/2 Soi Ruam Rudee, Ploenchit Road
3rd Floor, Ruam Rudee Bldg. III
Bangkok, 10330 THAILAND
PH: +66 2 255 74 77 ext. 106
Mobile: +66845331423