As World AIDS Day is marked this 1 December, tremendous gains have been made in the fight against HIV, with the number of annual AIDS-related deaths worldwide falling by more than a third from 1.2 million in 2010 to 770,000 last year.
Yet it remains an enduring problem: a disease rooted in poverty and inequality, it’s an epidemic that disproportionately affects women and young girls, health workers say.
Last year, 1.7 million people were newly infected with HIV, according to the Joint United Nations Programme on HIV/AIDS, known as UNAIDS.
But the prevalence is twice as high among young women aged 15 to 24 compared to men of the same age group.
In Gambia, South Africa, the Congo, and Gabon, HIV prevalence is three times higher among young women. In Angola, it is four times. And in eSwatini, a country with one of the highest prevalence rates in the world, young girls and women are five times more likely to be living with HIV compared to boys and young men.
There is concern that the HIV epidemic is falling from global public health agendas and, with it, financial investment.
Between 2017 and 2018, there was a $900 million decrease in HIV funding in low- and middle-income countries.
Jose Izazola, UNAIDS special adviser on resource tracking and finances, told The New Humanitarian this was driven primarily by: reduced disbursements from The Global Fund, a multilateral non-profit; reductions in contributions from donor governments such as the UK; and a stagnation in funding from the world’s largest donor – the United States.
Only about two percent of global funding for HIV is earmarked specifically for key populations such as girls and women – but that is changing.
An example is the DREAMs programme, a partnership with the US President’s Emergency Plan for AIDS Relief (PEPFAR) and the Bill and Melinda Gates Foundation, among other funders, to reduce new HIV infections in adolescent girls and young women in 10 sub-Saharan African countries.
“For the first time, we do have comprehensive programmes,” Chewe Luo, the associate director of UNICEF’s HIV/AIDS section, told TNH. “The DREAMs programme of PEPFAR is attempting to address exactly what we are talking about.”
The problem in eSwatini
There are particular reasons why the small southern African country formerly known as Swaziland, now officially the Kingdom of eSwatini, has so many women with HIV.
“The first thing to know is eSwatini is a patriarchal society. Women are considered children,” Albertina Zodwa Nyatsi, director of Swazi’s Africa Coalition on Tuberculosis chapter, told TNH on a trip around the northwestern countryside.
“Women have limited decision-making when it comes to family planning. Women cannot advocate for condom usage or they risk being viewed by their partner as a prostitute or as diseased,” said Nyatsi, who also founded Positive Women Together in Action, a support group for HIV-positive women.
“The first thing to know is eSwatini is a patriarchal society. Women are considered children.”
Swazi women cannot take steps to prevent the spread of HIV, and when they receive their diagnosis, they are often blamed, socially isolated, or face stigma and violence.
As a result of gender inequality and cultural practices, an estimated 16 percent of Swazi girls and young women were living with HIV in 2018, a reflection of the broader burden of HIV on girls and women.
Early sexual debut and child marriage – cultural practices that are normalised in many countries across sub-Saharan Africa – put girls at high risk of contracting HIV.
In some countries, it is estimated that 25 percent of adolescents are sexually active before the age of 15, and 12 million girls under the age of 18 are married each year.
“Many of those gender inequalities mean that women have less power. Girls have less power,” said Sarah Hand, CEO of Avert, a UK-based charity focused on spreading information about HIV.
“The cultural practices often mean that young girls, very young girls, are having sex early with male partners who are often themselves then in concurrent sexual partnerships.”
Lack of opportunities
Many challenges that young girls and women face stem from a lack of education and economic opportunities.
“We realise now, in terms of challenges among girls and young women, they go through multiple vulnerabilities as they grow,” said Luo.
“For example, we know that not keeping a girl in school increases risk of HIV acquisition because she is not empowered to negotiate for safer sex.”
“They go through multiple vulnerabilities as they grow.”
In eSwatini, only about 30 percent of adult women received some secondary education between 2010 and 2017. Limited education combined with widespread poverty creates an environment where transactional sex, often with multiple concurrent partners, and intergenerational sex are commonplace.
On top of that, gender-based violence, which is linked to higher rates of HIV transmission, is common. An estimated 48 percent of Swazi women experience sexual violence in their lifetime.
Harmful cultural practices such as polygamy and wife inheritance also persist and are frequently cited as factors contributing to high HIV rates.
In KaKhoza Township, an impoverished slum-like community in Manzini, eSwatini’s second largest city, TNH met with a support group for girls and young women living with HIV. Nearly every young woman was diagnosed with HIV in her late teens or early twenties – and only after seeking health services for pregnancy.
Stories of stigma and violence reverberated around the group.
“I was diagnosed with HIV when I went to the doctor for my pregnancy,” one girl, who asked not to be named, said. “When I told my partner, he beat me and forced me out of the home.
Today, she lives with her mother and her child in a one-room hut; she makes a small living selling fruits and vegetables in her town, but said her meagre income doesn’t even cover the medication for her baby.
“When the HIV came, my husband didn’t want to associate with me,” Dudu Manana, the support group’s leader said through a translator. “He sends a bit of money each month but doesn’t come to see me.” Like many HIV-positive women, Manana lives alone, socially isolated from her family and friends.
Stigma, violence, and the cultural expectation that Swazi women receive permission from their spouse or partner to access health services can prevent young girls and women from receiving proper medical treatment and social support.
“When you are diagnosed with HIV, you are seen as useless, depleted,” Tebeguni Nxumalo, a member of the Kakhoza support group said. “It is harder to become employed and you have to leave school.”
A grim employment outlook forces many young girls into the sex industry, said Florence, an HIV-positive sex worker living in Mbanane, the capital. “And then clients pay double for sex without a condom even when they know your HIV status,” she added.
Sex workers in eSwatini have the highest prevalence rate of HIV in the world, with 60 percent of sex workers living with the disease.
In eSwatini, antiretrovirals that suppress the virus are provided free of charge, but medications and diagnostic tests for illness caused by opportunistic pathogens are not, which drives up deaths from diseases such as tuberculosis and cryptococcal meningitis.
Food insecurity has been found to lower adherence to antiretroviral therapy.
“The [HIV] medicine makes you hungry, but there is no food,” said Hobsile Malambe, a resident in Mvembili, in the far north of eSwatini. “I wish they provided food, too.”