Women and girls

Community-based organizations in Dar es Salaam, United Republic of Tanzania, with assistance from UNAIDS, are supporting women who use drugs and their families to survive during these difficult times.

“Before the pandemic, life was simple and better. I used to do activities at the beach, such as cleaning fish, helping people load and clean their boats, and they would pay me. I would help my daughter wash her clothes; I would escort her to school and cook food for her. Life was simple,” said Doroth Hassan as she sits in the office of SALVAGE, a sister organization of the Tanzania Network for People who Use Drugs (TaNPUD), in Kigamboni, Dar es Salaam.

Ms Hassan would normally provide for herself and her daughter by doing sex work and other informal jobs, such as the work on the beach. But this has become a challenge since the onset of the COVID-19 pandemic.

“Now life has changed. I live in fear and worry. People who I worked for don’t want to pay, with the excuse that they have no cash because of the coronavirus. Everything changed. Life is tough. Clients disappeared, vanished. And the few who are still coming cheat; they pay less for sex,” said Ms Hassan.

She is not alone in her worry. Most of the women who use drugs in Dar es Salaam survive in the same way as Ms Hassan does, by doing sex work, trading and doing other jobs in the informal sector. They live in camps for people who use drugs or in informal and densely populated settlements.

With support from UNAIDS and other partners, local community-based organizations, including TaNPUD and SALVAGE, have been able to provide some relief to women in the camps and settlements in Dar es Salaam.

“TaNPUD raised awareness and SALVAGE provided buckets, soap and food with other hygiene materials to us and other women in the community. TaNPUD always advocates for our health rights,” said Oliver Kinanda, a person who previously used drugs and is now on opioid substitution therapy.

Ms Kinanda also volunteers at the Medication-Assisted Treatment (MAT) clinic in Temeke, where she lives. Here, she informs people on prevention of tuberculosis (TB) and takes samples from clients for TB screening. With the onset of COVID-19, however, her tasks have shifted.

“As a peer educator I have knowledge of prevention of COVID-19 and provide education and awareness. Together with other people who use drugs I also got help; for example, face masks,” said Ms Kinanda. She has also received information and support from other local community-based organizations, including donations to the community and the clients she works with in the Temeke MAT clinic.

Ms Hassan received the same support.

“TaNPUD is raising a voice on our behalf, and SALVAGE, as the sister organization of TaNPUD, supporting women, has been linking us to care and treatment with other services and providing shelter, food and hygiene support to us,” she said.

The support, distributed with financial and material assistance from UNAIDS, will help to alleviate some of the consequences of the global pandemic, even as the effects of COVID-19 are slowly wearing off in the United Republic of Tanzania.

Happy Assan, the Coordinator of TaNPUD, said this support has so far reached 55 families of women who use drugs in Dar es Salaam.

“The support covered food and hygiene needs. It also provided women with the ability to stay at home instead of going out, for example to do sex work, and to negotiate less risky sex. The support reduced fear and worry about meeting the food needs of families with children,” said Ms Assan.

Many of the women who use drugs are living with or at risk of HIV infection and depend on reliable access to treatment and care, including harm reduction services. Despite the support in the community, some services that the women who use drugs depend on have been halted.

“Harm reduction services have been interrupted; they are less. No condom distribution or other commodities, only needle and syringes distribution. At least now SALVAGE is helping with sanitary items. At hospital there is no other support; HIV treatment only,” explained Ms Hassan.

Ms Hassan and Ms Kinanda both recount facing increased stigma during the pandemic—some derived from unintended consequences of the support, since the face masks they received were a certain colour, making the wearer identifiable in the local community as a person who uses drugs. Stigma and discrimination at hospitals is also reportedly high, adding to the difficulties of accessing services. But most difficult is the financial loss because of the pandemic.

As Ms Kinanda puts it, “No clients, no pay. Financially it is hard because my clients say they have no cash because the coronavirus has affected their jobs. I continue providing awareness and education to the community and my family too. I financially suffer, but what can I do other than continue pushing on?”

In nearly all regions, women living with HIV are more likely to access HIV testing and antiretroviral therapy than men, in part due to better health-seeking behaviour among women and the existence of HIV-related services designed specifically to reach women (such as services to prevent mother-to-child HIV transmission that are provided during antenatal care).

In 2019, treatment coverage globally was 12 percentage points higher among women living with HIV than among men living with HIV, and viral suppression was 10 percentage points higher. This treatment gap among men living with HIV contributes to the higher number of new HIV infections among women in sub-Saharan Africa. Recent longitudinal studies have shown how closing these gaps accelerates declines in the incidence of HIV among women, especially young women.

Lola Makhmudova (not her real name) grew up in a close-knit family, but her parents were afraid to tell her about her HIV-positive status for a long time, even though they both work in the health sector. She found out about it by chance, after hearing nurses talking in the hospital when she was 10 years old.

“Once, a few years later, when I already knew a lot about HIV infection and treatment, I was in the hospital with one boy, he also had HIV,” Ms Makhmudova said. “But his parents refused to give him antiretroviral therapy for religious reasons. I told them about myself, that therapy helps you to remain healthy, that I feel good and live a full life. I am happy that I managed to convince them. We are still friends with this boy.”

Ms Makhmudova is now 18 years old and has been a peer counsellor and volunteer at the Day Center for HIV Affected Families in Tashkent, Uzbekistan, for several years. She communicates with children and adolescents living with HIV, helps them to accept their diagnosis and explains the need for treatment.

Ms Makhmudova has not yet decided precisely what she will become when she is an adult, but she is sure that she wants to help people. She became one of three young people living with HIV to join the new United Nations Youth Advisory Board in Uzbekistan.

She takes her work on the Board for Youth Affairs seriously. “I was scared at first,” she said. “Everyone there is so grown up and smart. But I decided that I would study, I would learn languages ​​so that I could be heard, and I could influence decisions that concern young people.”

The Board for Youth Affairs includes 15 young people from different regions in Uzbekistan, representing various social groups and interests, including the most disadvantaged and marginalized.

“Uzbekistan has agreed to be a fast-track country for implementing the Global United Nations Youth 2030 Strategy. The United Nations Board for Youth Affairs is part of the initiative. Currently, the board works with partners to ensure that the views of young people are taken into account in the development and implementation of United Nations strategies and programmes as well as the State Youth Policy in the country,” said Charos Maksudova, UNAIDS Country Manager for Uzbekistan.

Guzal Akhmedova (not her real name) is a young woman who has been living with HIV for eight years. She is a second-year student at the University of World Economy and Diplomacy and speaks Uzbek, English and Russian and is learning Chinese.

“I have been working as a peer educator for five years, and it is giving me a lot of opportunities. I’m a delegate of the International AIDS Society. In 2018, I was selected to go to the Netherlands to participate in the conference. And this year, I got a scholarship to take part in the virtual AIDS 2020 conference. My life and my story of living with HIV are unique because I love myself, my illness, my body and everything that I have. This all started when I accepted myself as I am. I suggest my simple motto to everyone: positive mind, positive life!”

Shirin Botirova (not her real name) found out that she was living with HIV five years ago, when she was 15 years old. Like many of her peers, she had to go through all the stages of accepting her HIV status. And this, according to her, was not easy. “After a while, I decided to start a new life without self-stigma. And from that day, my activism began. I started going to a self-help group, studying all the information about HIV.”

She also began studying law to know her rights and how to protect people living with HIV.

Since 2015 Ms Botirova has been actively participating in various trainings for peer counsellors.

“Today, I am a national trainer, and I try to share the knowledge and skills that I have. We conduct training throughout the country, and even in other countries, talk about peer self-help groups and consultations, give general concepts about HIV.”

Ms Botirova is doing everything to ensure that the world accepts people living with HIV without stigma. “I want to contribute to creating a world without stigma and discrimination. I set myself the goal of changing the attitude of people towards us, people who are living with HIV, since this is one of the most urgent tasks in our region. I believe that everything depends on ourselves, and I believe that together we can create a world without borders.”

The socioeconomic impact of COVID-19 is clear. People have lost incomes. Children are out of school. Food and housing insecurity are on the rise. And there has been an increase in domestic violence.

But for many women living with HIV in Jamaica, there are added layers of stress. According to the Jamaica Community of Positive Women (JCW+), many of their clients reported having received only one month’s supply of HIV treatment, although they were hoping for the recommended three months. New screening protocols at certain clinics have made some people feel exposed to unfamiliar health-care staff and unexpected disclosure of their HIV status. A few women report not having been able to access contraception on time.

According to the Coordinator of JCW+, Olive Edwards, the pressure of dealing with both pandemics has had a huge mental health impact on women living with HIV.

“Uncertainty is taking a toll,” she said. “It has disrupted life and people are worried. Some are struggling to cope with these feelings of constant uncertainty.

JCW+’s main objective for 2020 was to provide community support for women living with HIV in order to improve treatment adherence and reach viral suppression. When COVID-19 hit in March, they were presented with an added challenge. How would they address women’s new needs?

UNAIDS Jamaica’s COVID-19 emergency response contributed hygiene supplies to care packages. JCW+ used these as an entry point for connecting with clients. Women were provided with soap, household disinfectant and bleach and were shown during peer-share sessions how to use those products, along with masks made by a community mobilizer.

From there, the organization linked women to the Positive Health and Dignity Movement and treatment adherence projects. JCW+ participants prepared personal development plans with a focus on treatment adherence, education, job training and certification goals, where necessary. They keep in contact with the care teams in order to ensure access to optimal health and social support services. They have conversations to keep hope alive and send text reminders to reinforce key health and well-being messages.

“Community needs to be engaged at this time. Managing COVID-19 is about physical distance, not social distance. We felt women needed to meet and talk,” Ms Edwards said. They’ve limited support group sessions to eight people at a time.

According to the UNAIDS Country Director for Jamaica, Manoela Manova, the AIDS response must now strike a delicate balance.

“We must address standing health-care and human rights priorities as well as the immediate physical needs triggered by the COVID-19 response,” Ms Manova said.

Going forward, Ms Edwards says JCW+’s advocacy priorities are ensuring that the HIV response is not neglected because of COVID-19 and ensuring the most marginalized people are caught by state social safety nets. 

Ms Edwards asked that UNAIDS continue to “feel the pulse of what is taking place” and support community outreach strategies that are relevant to Jamaican culture.

GENEVA, 3 August 2020—Tlaleng Mofokeng, a South African medical doctor and a women's rights and sexual and reproductive health rights activist, has been appointed as the new United Nations Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.

"I congratulate Tlaleng Mofokeng on her appointment as the United Nations Special Rapporteur on the Right to Health—the first African women to be appointed to this important role," said Winnie Byanyima, Executive Director of UNAIDS. "I know that she will fight for human rights and for everyone, everywhere to be able to get the health care they need. We both share a vision: that health care should not be just for the rich, but a right for all."

Appointed by the United Nations Human Rights Council, the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health monitors the right to health around the world. The post-holder studies national practices and experiences related to the right to health, identifies trends and challenges in the process and makes recommendations on how to ensure the protection of the right to health. The Special Rapporteur also receives individual complaints of alleged violations of the right to health.

The right to health is a fundamental human right enshrined in international law and countries have basic human rights obligations to respect, protect and fulfil the right to health.

"I look forward to working with Dr Mofokeng," Ms Byanyima added. "Only by ensuring that the right to health is a reality for all will AIDS be ended by 2030."

UNAIDS

The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNESCO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals. Learn more at unaids.org and connect with us on Facebook, Twitter, Instagram and YouTube.

The European Medicines Agency has adopted a positive opinion of the dapivirine ring, a monthly vaginal ring that reduces the vulnerability of women to HIV

GENEVA, 28 July 2020—UNAIDS congratulates the International Partnership for Microbicides (IPM) on obtaining a positive opinion from the European Medicines Agency (EMA) on the dapivirine vaginal ring. The monthly ring adapts a medical technology commonly used as a contraceptive device to deliver the antiretroviral medicine dapivirine to prevent HIV.

“UNAIDS welcomes the advances made to make the dapivirine ring available to women in sub-Saharan Africa where around 4500 adolescent girls and young women become infected with HIV every week,” said Winnie Byanyima, Executive Director of UNAIDS. “Continued investment in research is needed to fill the HIV prevention gap for women and give them the options they need to protect themselves from HIV.”

Two phase III studies evaluated use of the monthly ring among nearly 4600 women between the ages of 18 years and 45 years in Malawi, South Africa, Uganda and Zimbabwe. The Ring Study, led by IPM, found that the ring reduced overall risk by 35%, and the ASPIRE study, conducted by IPM’s clinical trial partner the National Institutes of Health-funded Microbicide Trials Network, found that the ring reduced overall risk by 27%. More recent data from two open-label extension studies suggested a greater risk reduction—of more than 50%.

IPM will now seek regulatory approvals in sub-Saharan Africa, the region most affected by HIV, were many countries recognize the EMA’s opinion. If approved by African regulators, the ring could offer women over the age of 18 years the first long-acting tool they could use on their own terms to reduce the risk of contracting HIV. IPM estimates that given the urgency for women, with strong political will and funding the ring could begin to become available in 2021 in some communities in Africa.

UNAIDS

The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNESCO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals. Learn more at unaids.org and connect with us on Facebook, Twitter, Instagram and YouTube.

The AIDS response has taught the world the importance of protecting human rights and promoting gender equality when fighting a disease. COVID-19 has amplified that lesson.

Since the start of the COVID-19 pandemic, UNAIDS has repeated the call that governments must protect human rights and prevent and address gender-based violence—an issue that is even more vital now that lockdowns are putting women and girls at an even higher risk of intimate partner and sexual violence. Equally, UNAIDS has made it clear that sexual and reproductive health services should be recognized as the essential services they are. 

To drive those messages to decision-making tables and to the front lines of the response, a new UNAIDS report shows how governments can confront the gendered and discriminatory impacts of COVID-19. Presenting six areas as imperatives to address the needs, and protect the rights, of women and girls during the pandemic, the report highlights the needs of women and girls in all their diversity, particularly the most marginalized, and the importance of access to essential health services. The neglected epidemic of gender-based violence, the misuse of criminal and punitive laws, the importance of education, health and well-being and the value of women’s work and making unpaid care work everybody’s work are also showcased.

“Just as HIV has held up a mirror to inequalities and injustices, the COVID-19 pandemic has put a spotlight on the discrimination that women and girls battle against every day of their lives,” said Winnie Byanyima, Executive Director of UNAIDS. “Many of the drivers of inequality in the HIV epidemic are the same as those driving inequality and injustice in the COVID-19 pandemic—both epidemics can only be successfully fought by putting gender equality at the centre of the response.” 

The report underscores that sexual and reproductive health and rights are often the first to be sacrificed during epidemics and that the gains of the past decade must be protected. The report also makes it clear that scarce resources must be focused on the most marginalized women and girls, including sex workers, gender diverse people, women in prison and migrants and others without proof of employment or residence.

A selection of practical steps that UNAIDS has been taking with partners in countries to maintain essential health-care services, mobilize emergency legal protection and support populations facing human rights violations during the COVID-19 outbreak are presented.

For example, in Nigeria and Côte d’Ivoire UNAIDS is partnering with the International Community of Women Living with HIV to facilitate women living with HIV to work as community pharmacists, who help with the collection and home delivery of antiretroviral therapy and other medicines for people who were unable to access their treatment owing to COVID-19 restrictions.

In Latin America, the United Nations Population Fund and UNAIDS are offering contraceptives and HIV testing, as well as hygiene kits and information on gender-based violence and HIV, to women who are in compulsory quarantine after fleeing the Bolivarian Republic of Venezuela because of COVID-19. 

In Morocco, UNAIDS, in partnership with the Ministry of Health, the Global Fund to Fight AIDS, Tuberculosis and Malaria and civil society, is mobilizing self-help groups, medical and psychosocial support and family mediation services for populations at higher risk of HIV. Collaborations between the government and civil society have helped to ensure continued access to antiretroviral therapy, opioid substitution therapy and food aid during the pandemic. 

Above all, the report has the message that health, safety, dignity and rights, especially for women and girls, in all their diversity, must not be compromised and women should lead the call for change. 

“Get out there and fight, use your voice to demand and take action for your communities,” added Ms Byanyima.

In 2019, the ECHO trial reminded the world of the very high HIV incidence among women in parts of southern Africa. Those high levels of HIV, and of sexually transmitted infections, were found among women accessing routine contraceptive services.

A new joint report by the World Health Organization (WHO) and UNAIDS sets out the steps needed to improve and integrate HIV prevention and contraceptive services in order to reduce new HIV infections among women.

“We need to reflect on the diverse needs of women, including adolescent girls, women with lower levels of education and key populations, who have often been neglected in contraceptive and broader sexual and reproductive health and rights programming. The new approach means more contraceptive choices, additional HIV prevention choices and complementary community activities beyond facilities,” said Paula Munderi, Coordinator of the Global HIV Prevention Coalition at UNAIDS. 

The report clearly states that women at the highest risk of HIV and sexually transmitted infections in southern Africa and women from key populations should be the focus for the most urgent action.

Different approaches in places with different levels of HIV risk are suggested. For example, where there is a high incidence of HIV and sexually transmitted infections, HIV prevention choices, including male and female condoms, and prevention counselling need to be essential elements of contraceptive services and actively promoted. In settings with extremely high HIV incidence in southern Africa, the rapid introduction of pre-exposure prophylaxis (PrEP) within contraceptive services should be considered.

“Sexual and reproductive health and rights and HIV integration have been promoted for more than a decade, yet progress remains limited. Supporting women living with HIV to access contraception in HIV treatment clinics and providing HIV services in contraception services is a critical priority requiring committed funding for concrete action,” said Rachel Baggaley, Unit Head, Testing, Prevention and Populations, Global HIV, Hepatitis and STI programmes at WHO.

In order to understand what women need and want, the report suggests that women be at the centre of decision-making. “HIV prevention and contraceptive choices for women and girls are still not widely available. We need to ensure that the agency and choice of girls and women are promoted by making available a wide range of HIV prevention commodities, ranging from PrEP and microbicides to user-friendly condoms. Women and girls thrive when they are given an opportunity to choose,” said Nyasha Sithole, an advocate for the rights of girls and women from Zimbabwe.

Although people living with HIV who are on antiretroviral therapy and are virally suppressed cannot transmit HIV to their sexual partners, millions of women accessing contraception continue to have unprotected sex with men who do not know their HIV status. As the PopART trial showed, high HIV incidence among young women is also the result of men not accessing treatment. The report proposes concrete steps to strengthen partner prevention, testing and treatment services, including HIV self-tests for men combined with community outreach and gender-transformative prevention approaches.

“Effective integration requires multilayered prevention that can—and should—encompass both sexual and reproductive health and HIV services, including multipurpose prevention technologies. Siloed care, stock-outs and too little input from women themselves are among the long-standing barriers to women’s health care, and COVID-19 exacerbates these difficulties,” said Mitchell Warren, Executive Director of AVAC.

With the physical distancing necessary as a result of the COVID-19 pandemic reducing contact with health services, it will be essential that interactions with health-care providers be optimized through integrating services. “Prevention of HIV and sexually transmitted infections should be the standard of care for contraception information and services provided to women at a high risk of acquiring HIV,” said James Kiarie, Unit Lead, Contraception and Fertility Care, Department of Sexual and Reproductive Health, WHO.