Hillary's AIDS Plan Missed a Key Idea: Women

Thursday, December 1, 2011

It's an odd question to ask Hillary Clinton, the Obama administration's champion for global women's reproductive rights. But where were the women in her "AIDS-free generation" speech two weeks ago? World AIDS Day is a good time to ask.

(WOMENSENEWS)--Two weeks ago, Secretary of State Hillary Clinton gave a speech that outlined a new course of action in the fight against HIV that sidelined women and reproductive health.

Have no doubt we will lose this fight if we follow the plan without considering the consequences.

Any complete, effective response to HIV is contingent upon woman-centered interventions and unfettered access to comprehensive sexual and reproductive health services. Women account for more than half of the world's population living with HIV, and sexual intercourse is still the No. 1 mode of transmission. Increasingly, women are the face of this pandemic, and our sexual and reproductive health and rights are the crux.

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Clinton's "AIDS-free generation" theme was ambitious, along with her 2015 target date for ending vertical (mother-to-child) transmission. Her focus on evidence-based interventions was broadly welcomed, but anyone familiar with the demographics of the pandemic had reason to be disheartened. While references to women and gender inequality decorated her speech, nominal mention of gender-based violence and discrimination do not make a woman-centered policy.

On World AIDS Day, meant to raise collective awareness and concern about the pandemic, there's no better time to focus on what Clinton should have emphasized, but didn't.

Overlooked Points

  1. Female and male condoms: These are the only existing dual-protection methods that when used correctly and consistently protect against HIV and allow women to plan their families. They have to be part of every program to prevent and treat HIV and care for those infected.
  2. Integrating sexual and reproductive health services: HIV and reproductive health are inextricably linked; addressing them independently causes critical health gaps that fuel the pandemic. Women living with HIV may go untreated because their family planning provider does not test for HIV. Others may receive treatment at an HIV clinic, yet face stigma if they seek contraception or prenatal care because of widespread perceptions that women living with HIV should not have sex.
  3. Women's rights: HIV thrives on gender inequalities that keep women from controlling our sexual activity. Women's rights need to be recognized and respected if we are going to negotiate condom use, extract ourselves from abusive relationships, say no to unwanted sex, reject child marriage and combat rape.

Clinton instead identified three interventions as the new focal points of U.S. HIV policy: male circumcision, treatment as prevention and prevention of vertical transmission. Each intervention is critical, but without integrated reproductive health services and an emphasis on women's rights, they are nowhere near enough.

'Eventually' Not Good Enough

Male circumcision is a one-time intervention that can decrease a man's risk of contracting HIV during heterosexual sex from anywhere between 44 and 71 percent. Eventually, if fewer men contract HIV, fewer women will contract it as well. But "eventually" isn't good enough, and a decreased risk of 71 percent at best isn't good enough, either.

Women are the majority of this pandemic and we need our own protection now. Any and all male circumcision efforts need to be integrated with female and male condom programs, so women can initiate their own protection and men can understand that circumcision's partial protection requires backup -- and is not a license to go condom-free and have sex without consent.

"Treatment as prevention" is based on evidence showing that when people with HIV are receiving treatment, their viral load decreases. This lowers their risk of transmitting the virus to others. It's essential, but it's not enough. HIV was responsible for approximately 60,000 maternal deaths in 2009, and pregnancy alone can further compromise the immune system of a woman living with HIV. We must integrate voluntary family planning and other reproductive health interventions so women living with HIV can maintain their health.

Prevention of vertical transmission protects infants and is key, of course. But the first opportunity to prevent infections in children is preventing infections in women. And the second opportunity is to provide women living with HIV who don't wish to have children access to contraception. In fact, prevention for women and voluntary family planning programs are two of the four core components of comprehensive vertical transmission prevention. Yet these critical components are not typically the focus of U.S.-funded programming.

And what about women who are not infected? What tools does the new course of action offer them? When did protecting women from infection in the first place become an afterthought?

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The analysis is very helpful where it says we need to have a focus on women, family planning and sexual and reproductive rights, program integration, and male and female condoms; it's less helpful in its implied criticisms of treatment as prevention, prevention of vertical transmission, and male circumcision:

-Treatment-as-prevention treats women equally meaning it specifically reaches the disproportionate number of women infected in Africa (60+%)
-Treatment-as-prevention reduces women's risk of infection by 96%, equal to or better than consistent and correct use of condoms
-Prevention of vertical transmission is to be promoted primarily based on Option B or Option B+ which means that long-term maternal health and survival are prioritized not just infant health
-Prevention of vertical transmission is pro-women – women don't want their babies to be infected with a life-threatening disease or to bear the psychological scars of not having taken measures to reduce the risk of transmission
-Prevention of vertical transmission reaches infant girls (and of course we are not only concerned about adult women)
-Male circumcision provides primary protection for men, but secondary protection for women which is equally important (fewer infected male partners, fewer exposures for women, though we do, as the article says have to guard against disinhibition)
-No one argues that microbicides, which will provide primary protection for women, shouldn't be emphasized because they don't address primary protection for men (there is a secondary benefit for men just like circumcision has secondary benefits women)

I hope our collective advocacy for the importance to woman-centered advocacy and for sexual and reproductive health can support both/and thinking. Secretary of State Clinton's speech was mostly about the US finally responding to the new science of treatment-as-prevention both for horizontal and vertical transmission. The speech would have been better, more balanced, and more scientifically accurate if it had included more on programming for women and girls and SRH. And the author may well be right that Clinton's retreat from discussing those issues is because of an anti-SRH backlash in Congress. But when the article asks "what about women who are not infected?" and "what tools does the new course of action offer?" it seems to trivialize the important implications of treatment-as-prevention and other synergistic prevention activities.