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Women and HIV: The Challenge of Sub-Saharan Africa

Over the past 15 years, the number of people with HIV getting treatment has risen steadily, but incidence rates have flat-lined. Julie Pulerwitz, HIV expert with the Population Council, explains why reaching young women and girls is key to beating the epidemic.

Written by Christine Chung Published on Read time Approx. 5 minutes
Civil rights activists march in Durban, South Africa at the start of the 21st International Aids Conference, July 18, 2016. AP

This week in Durban, South Africa, over 18,000 scientists, policymakers, political leaders and people living with HIV are gathered for the 21st International AIDS Conference.

Organized by the International AIDS Society and its partners, the conference brings together participants from July 18-22 to discuss current global epidemic trends, best practices and new strategies for the treatment and prevention of HIV.

One of those participants is Julie Pulerwitz, director of social and operations research for the Population Council’s HIV and AIDS program, who has been working on HIV programs and services for over 20 years, focusing on gender and male engagement, behavior change communication and HIV-related stigma. From the Durban conference, she spoke to Women & Girls Hub about why young women and girls in sub-Saharan Africa are particularly vulnerable to the virus.

Women & Girls Hub: You’ve been working for many years in the HIV field. What broad trends have you witnessed?

Julie Pulerwitz: The International AIDS Conference has been happening every two years for almost 30 years now. In 2000, when an earlier conference was here in Durban, and I was in attendance then, there was no access to treatment. Treatment had just become available in the sense that we were aware that it was effective, but almost no one had access to it. The big push at that time was to get people who needed treatment, who were dying, on treatment. Over these ensuing years, there have been many successes in the treatment area, where 17 million people are now on treatment. South Africa has the largest treatment program in the world with almost 4 million people on antiretroviral treatment.

We’re now seeing that the prevention messages that we had always been saying have essentially stalled. Almost 2 million people have acquired HIV each year for the last five years, and it’s not going down. We need to revive this prevention focus and bring all our new biomedical technologies, of which there are a few, as well as different strategies, to try to break the cycle of continuing incidents.

One example would be PrEP – pre-exposure prophylaxis – as a new technology where people who are particularly at risk are able to take antiretroviral medications to prevent acquiring HIV. That’s a big topic and a shift in the field now.

Women & Girls Hub: What other highlights from the conference can you share?

Pulerwitz: A theme throughout the years and probably the issue that we’ve been least successful at tackling is stigma and discrimination experienced by people who live with HIV, as well as people who are associated with HIV risk behavior – what we call key populations, including sex workers, injecting drug users and men who have sex with men.

More recently, we’ve been talking about adolescent girls and young women as they have much higher rates of acquiring HIV and are particularly vulnerable and are often ostracized and stigmatized. We really need to change our understanding and have people who are at risk in this way live with dignity and be able to access prevention technologies.

Women & Girls Hub: You mention that adolescent girls and young women make up a key population. Can you explain why?

Pulerwitz: There are particular countries in sub-Saharan Africa where you see much higher rates of HIV acquisition among girls than boys. This is due to a variety of reasons, including the fact that girls lead pretty disempowered lives. They often do not have access to education or to health systems and services, while norms and dynamics happen in a society where they don’t have a lot of control about their sexual lives and behaviors.

There is a lot of sexual violence and “transactional sex,” where women need to trade sex for goods and money. This leads to the situation where about 7,000 girls a week are acquiring HIV. While we’ve been very successful globally in having people access treatment, we are still seeing flat-lined incidence rates, meaning that people are still not effectively preventing HIV. And, in particular, girls in sub-Saharan Africa are at risk.

One flagship strategy to address the challenges that these young women and girls are facing is the DREAMS initiative that’s being funded and led by the U.S. government through PEPFAR [the President’s Emergency Plan for AIDS Relief]. The research around DREAMS, the implementation science to understand more about what’s working in life, is being met by the Population Council with Bill and Melinda Gates Foundation funding.

Women & Girls Hub: Could you tell us more about the initiative?

Pulerwitz: It includes the 10 countries in sub-Saharan Africa where you see the most disparity in infection rates between young women and young men. We’re working with communities to try to change norms about what’s appropriate around sexual behaviors, for example, to try to dismantle the common relationships between older men and younger girls because they are getting exposed to HIV this way. Also literacy, working with parents, access to mentors and social networks in the community where they know they can find a safe space if they’re at risk of violence. This whole package is being implemented by different combinations of local and international partners.

Are we reaching the right girls? Are they staying in programs? Are they being affected by these different attempts to reduce incidents for them? That’s one set of questions. The second set relates to the male partners of these girls, and this is very important because we don’t know enough about that dynamic. In several countries, we are trying to actually reach out to these older men to get them tested and into services. Then having them access treatment and care when they need it and thereby not continuing the cycle to transmit to young women.

Very exciting results are coming out of the conference on this new pre-exposure prophylaxis (PrEP) technology that I mentioned, showing that it’s a new tool we can use with groups that are particularly at risk. They’re starting to put that into the DREAMS package to see how to offer it as part of a comprehensive HIV program that gives those people choices. Now, in addition to condoms, treatment and testing, we want to be able to offer them something that would prevent them from acquiring HIV, through antiretroviral medication.

We don’t yet know how best to do this with adolescent girls and young women so that they’re safe, so that they are not exposed to violence, and we don’t further stigmatize them for being known to be sexually active. That’s an important set of questions that we hope to answer and inform both DREAMS and PEPFAR, but also the global field.

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