# Presentation: 896278

## Women’s Empowerment and Containing the HIV Epidemic

- ©Jonathan Wallen

## Kathryn Anastos MD Professor of Medicine, Epidemiology and Population HealthAlbert Einstein College of MedicineMontefiore Medical Center

- Executive Director
- Women’s Equity in Access to Care and Treatment
- WE-ACTx

## WE-ACTxWomen’s Equity in Access to Care and Treatment 

- www.we-actx.org

## In all countries, many/most women are responsible for:

- All childcare
- All care of others
- In family
- In community
- Of orphans
- Food preparation
- Health care
- Agriculture (many, not all, countries)

## Stephen Lewis:

- “Women carry the entire burden of care and sustaining the entire society.”

## ©Jonathan Wallen

## In all countries, many/most/some women cannot control their, and their children’s:

- Risk of HIV infection
- Access to care
- Economic stability, family finances and Food security
- Fertility
- Physical safety

## In many countries, ALL women are unable to control their, and their children’s:

- Risk of HIV infection
- Access to care
- Economic stability, family finances and Food security
- Fertility
- Physical safety

## In all countries, many/most/some women cannot control their, and their children’s:

- Risk of HIV infection
- Access to care
- Economic stability, family finances and Food security
- Fertility
- Physical safety

## Burden of HIV infection in Women Globally

- UNAIDS 2007 AIDS Epidemic Update

## HIV prevalence by sex in sub-Saharan 

- African Countries through 2005

- Women/girls **50-300%** higher prevalence

## Trends in Annual Rates of Death Due to Leading Causes of Death Among Persons 25-44 Years Old, USA, 1987-2001

**Trends in Annual Rates of Death Due to Leading Causes of Death Among Persons 25-44 Years Old, USA, 1987-2001**

- For comparison with 1999-2001 data, 1987-1998 data were modified to account for ICD-10 rules instead of ICD-9 rules for selecting the underlying cause of death. 2001 data are preliminary.

**Mortality (per 100,000 population)**

- CDC, HIV Statistics 2003

## Trends in Rates of Death From HIV Among White Men 25-44 Years Old, 1987-2001

- For comparison with 1999-2001 data, 1987-1998 data were modified to account for ICD-10 rules instead of ICD-9 rules for selecting the underlying cause of death. 2001 data are preliminary.

**Mortality (per 100,000 population)**

- CDC, HIV Statistics 2003

## Trends in Rates of Death From HIV Among Black Men 25-44 Years Old, 1987-2001

- For comparison with 1999-2001 data, 1987-1998 data were modified to account for ICD-10 rules instead of ICD-9 rules for selecting the underlying cause of death. 2001 data are preliminary.

**Mortality (per 100,000 population)**

- CDC, HIV Statistics 2003

## Trends in Rates of Death From HIV Among Black Women 25-44 Years Old, 1987-2001

- For comparison with 1999-2001 data, 1987-1998 data were modified to account for ICD-10 rules instead of ICD-9 rules for selecting the underlying cause of death. 2001 data are preliminary.

**Mortality (per 100,000 population)**

- CDC, HIV Statistics 2003

## In Africa, HIV infection in women is:

- Overwhelmingly heterosexually transmitted
- More likely at higher incomes
- Highly likely to be transmitted by her husband
- Transmitted to younger women by older men
- Transmitted to children by pregnancy, delivery and breastfeeding--**and 99% preventable**

## Disappointing news on the prevention front

- Circumcision does not protect women from HIV infection (although some protection from other STDs)
- Suppressing Herpes Simplex infection does not decrease HIV transmission (although it does decrease ulcers)
- Microbicides- need new safety assessment (some are increasing HIV transmission)
- Vaccines not protective

## One known mechanism by which Nonoxynol-9

**Disrupted epithelium allows HIV to migrate across the barrier and  infect target cells**

- Mucosal
- epithelium

- T-cells

- HIV-1

- Disruptive microbicide (N-9)

**One known mechanism by which Nonoxynol-9**
** ****enhances HIV transmission**

## Therefore, other forms of prevention are critical

- Barrier Protection: condoms, condoms, condoms
- Abstinence--not achievable for women if they do not have control in the bedroom
- Be faithful--man needs to be faithful also; none of us knows for certain that our partner is faithful
- Women cannot prevent HIV-infection until
- They can control their risk
- The sexual behavior of men changes

## In all countries, many/most women cannot control their, and their chldren’s:

- Risk of HIV infection
- Access to care
- Economic stability, family finances and Food security
- Fertility
- Physical safety

## Scale up of antiretroviral therapy worldwide in ART-LINC sites

- Keiser, ART-LINC, unpublished data (submitted)

## Time trend in number of patients initiating ART by site

- Keiser, ART-LINC, unpublished data (submitted)

## Proportion of women among patients initiating ART

- Keiser, ART-LINC, CROI 2008

## Women more likely to access care for themselves and their children 

- Worldwide, in all groups of equal socioeconomic status --same degree of barriers to care
- For themselves and their children
- Three examples in Rwanda and Uganda
- HIV testing and care
- Childhood vaccinations
- Cervical cancer screening

## In all countries, many/most/some women cannot control their, and their children’s:

- Risk of HIV infection
- Access to care
- Economic stability, family finances and Food security
- Fertility
- Physical safety

- Low or absent ability to earn money
- Other activities by men in the family, especially alcohol
- Many families are hungry
- Yet, this does NOT impair adherence

## Ability to create income

- Immediately changes the family dynamic-shifts the balance of power
- She becomes a source of hope for the community and the family
- Women and girls become more valuable
- Downstream social effects for:
- Daughters--see different scope of opportunity
- Sons--see women differently, and their own role

## Example-Business for Peace (Bpeace), in Afghanistan

- Bpeace develops entrepreneurial talent in women
- “Rangina”-one woman’s business, now employs 400 women creating beaded products for export
- One family, nine daughters, father angry and disappointed, abusive
- Now mother and all daughters working--father is proud, no longer abusive

- www.bpeace.org

## Entrepreneurship and Small Business

- Have been the fuel for economic development in every successful economy
- To foster this: Find and nurture talent through
- Access to capital--micro or not so micro-credit
- Training and development in specific skills
- Finding a market
- Choosing product according to available markets
- Choose local market if possible--more sustainable
- Understand trend, duty, what the customer wants
- Marketing, signage etc.

## In all countries, many/most/some women cannot control their, and their children’s:

- Risk of HIV infection
- Access to care
- Economic stability, family finances and Food security
- Fertility
- Physical safety

## Control of Fertility

- Fewer children spaced further apart
- Decreases maternal mortality
- Decreases infant and child mortality
- Improves family circumstances and health
- Important for community and nation, not only the individual and family
- Overpopulation extends poverty, especially in settings of limited resources

## Family Planning Services

- Need broad reach
- More effective if highly community based
- Bring the service to the patients when possible
- Make it a community value
- Make all methods available
- Hormonal
- IUD
- Barrier protection--also prevent HIV-infection

## THIS IS ACHIEVABLE

- Change paradigm of care
- Community based primary care--mobile teams
- HIV counseling and testing, HIV Care, PMTCT
- Family planning
- Cervical cancer screening and prevention
- Leverage information technology
- Make services cost effective

## In all countries, many/most/some women cannot control their, and their children’s:

- Risk of HIV infection
- Access to care
- Economic stability, family finances and Food security
- Fertility
- Physical safety

## In all countries

- Violence from men is tolerated to a greater or lesser degree
- Women at risk of violence
- Within the family
- Within the community
- From strangers

## Domestic and sexual violence

- In RWISA (Rwanda) prevalence of any history of
- Domestic violence is ~20% in both HIV+ and negative women
- Of sexual violence is ~5%
- In United States, in Women’s Interagency HIV Study Prevalence of any history of
- Domestic Violence is 72% in both the HIV+ and HIV-negative women
- Sexual violence is 35%

## Is there a solution?OF COURSE

- Stephen Lewis, UN Ambassador for AIDS in Africa, until 2006:
- “We must zero in on the inappropriate male behavior and put them in jail for long periods when they engage in rape and sexual violence, and change the laws that give them the free run of the land. There just has to be very firm dealing with the men who are making such a dreadful hash of gender equality.”

## Legal Solutions	

- Equality can be legislated--and then quantum leaps occur generationally
- Key parameters:
- Property rights
- Inheritance rights
- Children
- Fertility control

- www.we-actx.org

## Rwanda

- Paradigm shift for women after the genocide
- Embedded in the constitution
- Part of “Never Again”
- Previously property, now in nearly all positions of power
- Very successful PEPFAR program
- Best in world?

## Rwanda’s PEPFAR EvaluationJanuary 2008

- 92% of adults and 93% of children retained in care at 12 mnths;
- of those not retained, 2.6% of children and 4.4% of adults were known dead.
-  Estimate the one-third to one-half of others are have in fact died, so very very low lost to follow up rates
- Have set goal of “zero transmission”, needs Prevention with Positive

## Primary Care Services

- We should develop and assess models that are:
- Community/village based, family centered
- Mobile services--bring the services closer to the patient
- Combine services that utilize same infrastructure, and have high impact on leading causes of death:
- HIV counseling, testing and care
- PMTCT
- Family planning
- Prenatal care
- Cervical cancer screening/prevention incl. vaccination

## The HIV Epidemic is fueled by:

- Women’s lack of control of
- Risk of HIV infection
- Access to care
- Economic stability, family finances and Food security
- Fertility
- Physical safety

## And for each of these there are clear and achievable solutions

## ©Jonathan Wallen