Integrating gender into HIV/AIDS programmes in the health sector: tool to improve responsiveness to women’s needs

Abstract

Half of all people living with HIV/AIDS worldwide are female and in sub-Saharan Africa it is far more than half, especially among those aged 15–24. Women living with or widowed by HIV/AIDS are commonly spurned by their families, beaten, lose their property, forced to marry a brother-in-law or cast out of their communities. They are the caretakers in the household and held solely responsible for getting pregnant and protecting the babies they bear. Girls’ and women’s vulnerability to HIV is fuelled by endemic sexual coercion and violence; early and forced marriage to much older men; and lack of access to HIV information, sexuality education and reproductive health services. Over a period of six years, WHO’s Department of Gender, Women and Health invested in field tests in five countries and painstaking reviews by diverse practitioners to produce this manual. As a result, HIV/AIDS programme managers and service providers now have a jargon-free guide, focused on action, with enough information on inequalities between women and men to persuade readers to act. Four sections for health-care providers focus on selected services that are not addressed in the other 187 resources listed in the excellent reference section: HIV testing and counselling, prevention of mother-to-child transmission, HIV treatment and care, and home-based care and support. An opening section explains the role that gender inequalities play in women’s vulnerability to HIV, in limiting women’s access to and effective utilization of HIV/AIDS services, and the steps required to deliver and monitor programmes that will reduce these problems. Each section of the manual, even the preface, is a gem, a terrific exposition of the investments that should be, but rarely are, made to produce a user-friendly tool. Although the authors suggest that the first section, on gender equality concepts, is most suitable for programme managers, service providers would also benefit from this clear and succinct clarification of “core” concepts. Each of the four service sections has examples of how to address the particular barriers, fears and challenges that women clients and patients are likely to face: at home, in the community and from health services. Examples from real life and materials from programmes provide additional energy to the already clear language and succinct presentations. Two of the best parts of the manual are presented as annexes but no reader should miss these. Each is constructed as a checklist for managers and service providers, respectively, to assess their progress. These lists are an additional way of presenting and reinforcing the actions needed, broken into useful subactions and presented in sequence. Sprinkled throughout the manual are special jewels, such as a clear and compelling list of reproductive rights interpreted for the HIV/AIDS context. There are also several pages on violence against women, its relationship to HIV exposure, its role in deterring effective HIV prevention, testing, disclosure and treatment, and examples of interventions specific to the health sector. This is also a compelling role-play for negotiating safer sex. Annex 3 invites users of the manual to submit suggestions for the expected revision of the manual in five years. This reviewer has a few suggestions, without which HIV/AIDS will persist, especially for girls and women. First, each section needs action steps to assist readers to integrate into their work ways to help women cope with stigma and discrimination outside the health system. Second, each section should emphasize supervision and other means to hold managers and providers accountable for improved performance. Third, the section on prevention of mother-to-child transmission does not include treatment for the woman herself. The reference in the treatment section is brief and phrased in negative terms rather than with the strong affirmation it deserves. Further, while addressing family planning, this section does not address women’s need and right to access safe, legal abortion should they want it. Fourth, references are inadequate on the importance of identifying and providing the comprehensive services women need, and to “linkages” between sexual and reproductive health services and HIV/AIDS programmes. All women need comprehensive reproductive health services. This has been agreed many times by governments since 1994 to include, at a minimum: family planning, safe abortion where legal, maternity care and diagnosis and treatment of sexually transmitted infections including HIV. Especially for women and young people, a paradigm shift is needed in HIV/AIDS programming to address HIV as a sexual and reproductive rights and health concern, including the services listed above as well as comprehensive sexuality education. This manual should be widely introduced, not simply disseminated, by WHO and all others engaged in the delivery and funding of HIV/AIDS services in the health sector. ■