Drug use is more common among men, with women accounting for just one in three people who use drugs and one in five people who inject drugs. However, women who use drugs face special health risks.

Although few countries report sex-disaggregated data to UNAIDS on people who inject drugs, the majority of publicly available data suggest that women who inject drugs have a greater vulnerability than men to HIV, hepatitis C and other blood-borne infections. In 16 of the 21 countries that reported such data since 2013, women who inject drugs were more likely to be living with HIV than their male peers. In Germany, Uganda and Uzbekistan, HIV prevalence among women who inject drugs was almost twice as high as among their male peers.

It has been 25 years since the groundbreaking International Conference on Population and Development, held in Cairo, Egypt, in 1994. Since then, significant progress has been made in the area of sexual and reproductive health and the rights of young women and adolescent girls. Voluntary access to modern contraception has increased by 25% since 1994, and the quality of sexual health and HIV services has also vastly improved.

So why are around 7000 young women and girls still becoming infected with HIV every week? And why, in sub-Saharan Africa, are girls aged 15–19 years three times as likely to become infected with HIV than boys the same age?

“We cannot wait another 25 years. We need to push for accountability to make sufficient progress in addressing the current government deficit to deliver on the sexual and reproductive health and rights commitments for women and girls,” said Gogontlejang Phaladi, from the Pillar of Hope Project in Botswana.

Her comments set the tone at an event organized by the Global HIV Prevention Coalition, during the Women Deliver conference in Vancouver, Canada. The event, co-convened by UNAIDS and the United Nations Population Fund (UNFPA) and held on 3 June, put the spotlight on why young women and adolescent girls are being left behind and why they continue to bear the brunt of poor sexual and reproductive health and HIV.

“We are facing an HIV prevention crisis,” said Shannon Hader, UNAIDS Deputy Executive Director, Programme. “While the target was to reduce new HIV infections among adolescent girls and young women to fewer than 100 000, an estimated 340 000 became newly infected with HIV in 2017. We have a huge task ahead of us.”

Speakers at the event discussed the critical importance of engaging young people as leaders of change. “We need to call out policy-makers, traditional and religious leaders, even parents,” said Monica Geingos, First Lady of Namibia. “We must never tell you what to say. Generations before, you were shamed and silenced. Never lower your voices.” She also added that the lack of progress for women and girls is being fuelled by gender discrimination, violence and denial of fundamental freedoms.

UNFPA’s Regional Director for Eastern and Southern Africa, Julitta Onabanjo, also stressed that more needs to be done. “I see a dynamic young women warrior generation here to take the agenda forward—so that by 2030 every young person can fulfil their best potential and nothing is going to hold them back,” she said, while noting that the recommendations of the event should be fed into a summit being held in Nairobi, Kenya, later in 2019.

A major issue preventing young women and girls from accessing HIV services is the requirement by many countries that young people have to be over the age of 18 before they can access health services, including sexual and reproductive health and HIV services, without parental consent. UNAIDS estimates that 78 countries have some form of restrictive laws or policies that prevent young people from accessing sexual health services without the consent of their parents.

As part of efforts to remove these barriers to young people accessing timely and effective HIV prevention, testing and care, during the youth-led Generation Now: Our Health, Our Rights preconference meeting on 2 June, UNAIDS committed to tackle parental consent laws, and their implementation, in five countries in eastern and southern Africa—Lesotho, Malawi, Namibia, Uganda and Zambia. This includes working with young people to ensure that youth are driving change and co-creating the quality services they want and need to have bright and healthy futures.

To advance progress, the participants agreed that investing in community organizations will be critical, as will taking small projects that work to the national level. Nyasha Sithole, from the Athena Network said, “People are watering the leaves, but not the roots. We need to move away from paper and pen to implementation on the ground.”

UNAIDS is a co-convener of the Global HIV Prevention Coalition, which works with countries with a high incidence of HIV to accelerate access to combination HIV prevention services. The coalition seeks to ensure accountability for delivering HIV prevention services at scale in order to achieve the targets of the 2016 United Nations Political Declaration on Ending AIDS, including a 75% reduction in HIV infections towards fewer than 500 000 new infections by 2020. The work of the coalition includes a particular focus on young women and their male partners.

One of the 11 UNAIDS Cosponsors, UN Women is working closely with UNAIDS to improve the lives of women and girls worldwide. In Malawi, for example, UNAIDS and UN Women have partnered to reduce the impact of gender-based violence and mitigate the risk of HIV infection among women and girls.

“UN Women is the youngest of the UNAIDS Cosponsors, and we are delighted to work closely with UNAIDS and other partners under the UNAIDS Unified Budget, Results and Accountability Framework 2016–2021,” says Clara M.W. Anyangwe, the representative of UN Women in Malawi. The Unified Budget, Results and Accountability Framework (UBRAF) is a UNAIDS instrument that maximizes the coherence, coordination and impact of the United Nations response to HIV by combining the efforts of the UNAIDS Cosponsors and UNAIDS Secretariat. Its principal aim is to allocate financial resources to catalyse country-level action in the AIDS response.

With UBRAF funding, UN Women in Malawi has teamed up with an impressive number of partners, including UNAIDS, the Ministry of Gender, Children, Disability and Social Welfare, the National AIDS Commission, the National Law Commission, the United Nations Development Programme, the Malawi Network of AIDS Service Organizations and civil society to implement a project that aims to enhance the national response to sexual and gender-based violence, harmful practices, sexual and reproductive health and rights and HIV.

“Working together as UNAIDS Cosponsors is just a better approach,” says Ms Anyangwe. “There is no single agency that can help the country to achieve the UNAIDS 90–90–90 targets. Instead, each agency has a comparative advantage that they bring to the table. In this case, UN Women brings in the gender dimension and UNAIDS its expertise in the HIV response.”

Malawi has made great progress in reducing new HIV infections. In 2017, there were 39 000 new HIV infections, a 40% reduction since 2010, but 9500 of those were among adolescent girls and young women between the ages of 15 and 24 years. That is more than double the number among men of the same age group.

The project has produced a perception study on the prevailing gender norms that increase violence against women and girls and their risk of HIV infection in Malawi, such as rite of passage practices, sexual cleansing, child marriage, marriage by proxy and transactional sex. An indicator framework has been developed from the findings that will be used to track progress of Malawi’s National Strategic Plan for HIV and AIDS.

An important part of the project is to engage with traditional leaders, including those who facilitate rite of passage practices, and mother and father groups. As a result of the engagements, a framework has been developed that links partners in the local HIV, sexual and reproductive health and rights and sexual and gender-based violence response to monitor and address harmful cultural practices that occur during local rites of passage ceremonies.

A series of intergenerational dialogues that brought together young people, people living with HIV and traditional and faith-based leaders revealed that issues such as lack of access to youth-friendly HIV and sexual and reproductive health and rights services, peer pressure, stigma and discrimination and gender-based violence need to be addressed in order to increase young people’s resilience and empower them to protect themselves against HIV infection.

“We also leveraged UN Women’s global He for She campaign to engage men and boys as partners of women and girls. We were looking particularly to foster a positive masculinity. How can we use masculinity to protect women and girls against harmful practices?” said Ms Anyangwe.

During the dialogues, more than 100 men and boys took the pledge to be He for She champions to promote gender equality and reduce HIV and sexual and gender-based violence. The human rights approach embedded in the project has seen laws and policies that relate to HIV and gender translated into local languages and widely disseminated in affected communities.  

Ms Anyangwe insists that leveraging the specific expertise of partners under the UBRAF umbrella is reaping rewards in Malawi.

“It has also been great to have UNAIDS as a member of the Country Coordinating Mechanism of the Global Fund to Fight AIDS, Tuberculosis and Malaria. UNAIDS’ involvement in these mechanisms benefits us all,” she says.

“We really value UN Women’s continued support and partnership in ending HIV and gender-based violence in Malawi,” says Thérèse Poirier, UNAIDS Country Director for Malawi. “It has been beneficial to work as One UN so we don’t confuse our national counterparts by coming in and working separately on different areas of these interconnected and multilayered epidemics,” she said.

When the family and neighbours of Salma Karim (not her real name) found out that she was living with HIV they chased her out of her home. With nowhere to go, she was forced to leave her two young children behind. This is not an uncommon story in Egypt. One in five people living with HIV report being forced to leave their homes by their landlords, family or neighbours.

High levels of stigma and discrimination are one of the key factors driving new HIV infections in the country, which doubled between 2010 and 2016. Women and adolescent girls are often the most vulnerable. Societal norms, gender inequality, economic dependence, legal discrimination and harmful practices affect them disproportionately, making them more vulnerable to HIV and facing greater levels of stigma and discrimination in the event of HIV infection.

In 2016, UNAIDS in partnership with the Egyptian Ministry of Health and Population joined efforts towards a gender-transformative response to the HIV epidemic. With funding from the Dutch government, a pilot project called Enhancing Sexual and Reproductive Health of Women Living with and Affected by HIV was launched. Three years later, the pilot has reached double its intended beneficiaries with stigma-free quality sexual and reproductive health services.

“I lost my first child as I didn’t know I had HIV,” explains Nour Tarek (not her real name). It was in one of the pilot project sites in Giza that she received the support to realize her reproductive rights free from discrimination. “I followed up with the doctor in the hospital and I became pregnant again.”

Thanks to the antiretroviral medicine she received while pregnant, her baby Mona (not her real name) was born HIV-negative. “I still have to test again until she is older to make sure she is fine,” explains Ms Tarek.  

Having proved its success, the pilot project is now being scaled up to a third of the country’s governorates. The aim is to deliver high-quality sexual and reproductive health and HIV services for 1300 women living with HIV and 3000 women at higher risk of acquiring HIV. Its focus on building the capacity of health-care providers and civil society organizations will be key to avoiding future stigma and discrimination, which is reported to lead one in four people living with HIV in Egypt not to disclose their HIV status when seeking care.

During his visit to Cairo on 9 April, the Executive Director of UNAIDS, Michel Sidibé, and the Ambassador of the Netherlands to Egypt, Laurens Westhoff, discussed the expansion of the project. Implemented through a new three-year Dutch grant, the scaled-up services will complement national efforts to achieve Egypt’s ambitious new National AIDS Strategy 2018–2022 and the Sustainable Development Goals.

“Without our voice, you are doing it for you, not for us”, said Winny Obure, a youth leader and women’s rights defender from Kenya, at the United Nations in New York, United States of America.

She was joined by other young women demanding the removal of barriers to their sexual and reproductive rights and for adolescent girls to be empowered. The event—Step It Up!—was a call to action for the most left behind adolescent girls and was convened by UNAIDS, the ATHENA Network, the Governments of Australia and Namibia, and UN Women, with 25 partners from the United Nations and civil society.

Adolescent girls and young women are still disproportionally affected by HIV. One million adolescent girls live with HIV globally and every week 7000 adolescent girls and young women become infected with HIV. Comprehensive sexuality education is so limited that levels of knowledge about HIV prevention among young people have remained flat over the past 20 years.

“We will not reach the Sustainable Development Goals if the voices and aspirations of adolescent girls are oppressed,” said Gunilla Carlsson, UNAIDS Deputy Executive Director, Management and Governance.“Where is the accountability for the millions of adolescent girls being left behind?”

All too often, adolescent girls remain invisible to decision-makers, especially if they belong to groups that are discriminated against, criminalized or stigmatized. As many of the participants pointed out, they are subjected to human rights violations, including violence and harmful practices, and denial of their sexual and reproductive health and rights.

“We need to move away from these meeting rooms and go to communities to talk to adolescent girls and young women. We need to address the uniqueness of specific groups of girls, of their specific needs .We have the solutions, it’s just a matter of including us in the discussion,” said Maximina Jokonya, a young woman from Zimbabwe.

“Teenage girls are often out of sight and out of mind and they are not where the power is, it’s still with men,” said Sharman Stone, Australia’s Ambassador for Women and Girls. She highlighted the barriers that girls face in the Pacific, where they are denied contraception and subjected to high levels of violence. She said that a key priority for Australia during humanitarian crises is to ensure access to sexual and reproductive health services.

The Minister of Gender Equality and Child Welfare of Namibia, Doreen Sioka, spoke about championing the rights of adolescent girls and young women, comprehensive sexuality education and integrated sexual and reproductive health and HIV services. She outlined major achievements in fulfilling international HIV targets. A new law in Namibia enshrines the right of all children to access critical services—at 14 years of age, children can now be tested for HIV without permission from their parents or guardians.

The young women at the event underscored their realities and restricted opportunities, as well as what works to improve their lives. Deneka Thomas, from Trinidad and Tobago, described how she uses art in schools to interact with lesbian, gay, bisexual and transgender young people and girls traumatized by bullying, rape and other forms of violence.

Raouf Kamel of AIDS Algérie spoke about the first-ever initiative in the Middle East and North Africa to hear the voices and experiences of especially marginalized groups of women. They had all experienced violence, pointing to adolescence as a crucial point in life when the risks to their health and safety, and of HIV infection, are especially marked.

The participants concluded that much more needs to be done to address the needs and rights of adolescent. Investing in inclusive, quality education, in HIV, sexual and reproductive health services and in mental health is key. Other important actions include preventing and responding to gender-based violence, promoting women’s rights, engaging boys and investing in youth organizations and community-based initiatives led by, and for, young women.

The event was held on 13 March on the margins of the sixty-third session of the Commission on the Status of Women.

Quotes

The UNAIDS Executive Director, Michel Sidibé, celebrated International Women’s Day in Addis Ababa, Ethiopia, at an event organized by the Ministry for Women, Youth and Children Affairs and supported by UNAIDS. The event brought together female leaders and representatives of women’s associations from all over the country. Addressing the meeting, the Prime Minister of Ethiopia, Abiy Ahmed, emphasized that women are the “pillars of the nation.”

Yalem Tsegaye, the Minister of Women, Children and Youth Affairs, outlined the Jegnit initiative. Jegnit means “heroine” and is an innovative movement led by the Government of Ethiopia to empower and bring more women to leadership positions, both at the community and political levels.

During the event Mr Sidibé congratulated the Prime Minister and the Government of Ethiopia for its bold reforms in addressing the gender gap by appointing women to leadership positions in all sectors. He commended the Prime Minister for ensuring gender parity in his Cabinet.

“It is time to empower women and girls, because ending AIDS is as much about righting power imbalances as it is about health. This means prioritizing girls and young women in true partnership with them. It means providing adolescents girls and young women with more options and real choices,” said Mr Sidibé.

While in Addis Ababa, Mr Sidibé met with Vera Songwe, Executive Secretary of the United Nations Economic Commission for Africa, the first woman to hold the post in 60 years, to discuss ongoing collaboration on sustainable AIDS responses across the African continent.

Mr Sidibé also met with Amira Elfadil of the Department of Social Affairs of the African Union. In 2019, UNAIDS and the African Union are celebrating 20 years of a partnership focused on ending the AIDS epidemic across Africa.