Time to Address the Intersecting Crises of Covid-19, HIV, and Gender Inequality
On World AIDS day in 2014, the U.S. Global AIDS coordinator, Ambassador Deborah Birx, sounded the alarm on HIV infections in adolescent girls and young women (AGYW) and launched an ambitious initiative called DREAMS—Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe—to significantly reduce new HIV cases in the highest-burden countries. After five years and over $900 million invested, DREAMS is now at an inflection point, with Covid-19 threatening to reverse its impact, along with decades of health and development gains for women and girls.
Faced with the intersecting crises of HIV, Covid-19, and gender inequality, the Biden-Harris administration should advance a strategic vision around securing a healthy future for this growing population of young women as key to the Covid-19 response and to the prosperity and stability of their countries—all central to U.S. national interests. While Covid-19 and vaccine distribution will dominate U.S. global health policy in the near term, these issues do not exist in a vacuum: in countries battling HIV epidemics, efforts to tackle the health and economic impacts of Covid-19 will not succeed without also addressing the fundamental challenges of HIV and gender inequality, which increase risk and vulnerability, especially for AGYW. To launch such a timely and targeted response, the incoming administration should build on the existing platform of DREAMS, adapting and amplifying its focus on AGYW as a priority health and development initiative.
DREAMS, led by the President's Emergency Plan for AIDS Relief (PEPFAR), is a unique health program in that it focuses on a combination of structural, behavioral, and biomedical interventions to reduce HIV incidence, including gender-based violence prevention and response, economic skills strengthening, and education support in 15 countries. It was created as a multisectoral, public-private partnership—with the Bill & Melinda Gates Foundation, Gilead Sciences, Girl Effect, Johnson & Johnson, and ViiV Healthcare—to address the social and economic drivers that directly and indirectly increase HIV risk for AGYW, resulting in infection rates that are between 2 and 14 times higher than boys their age in Southern and Eastern Africa. PEPFAR’s Country Operational Plan guidance for 2020 outlined a plan to double its investments in DREAMS, with a particular expansion in two areas: increasing access to pre-exposure prophylaxis (PrEP), an antiretroviral drug that dramatically reduces HIV acquisition; and promoting economic strengthening programs.
Yet Covid-19 is now forcing those involved in programming for women and girls and for HIV prevention more broadly to adapt their approaches to the age of Covid-19. This is an urgent moment to find new ways to maintain the momentum around AGYW programs, to generate new evidence to identify gaps and needs, and to build on what has worked. As Linda-Gail Bekker, deputy director of the Desmond Tutu HIV Centre in South Africa, put it: “What if any of those [lessons from DREAMS] need to be adapted because of Covid . . . what do we do differently now that we’ve got Covid on board, but still have the inherent successful ingredients that we’ve learned from DREAMS?”
Over the past six months, the CSIS Global Health Policy Center has conducted scores of interviews with experts, implementers, and AGYW themselves in Kenya, South Africa, and Zambia. Through these interviews, it became clear that Covid-19 is severely affecting AGYW programs, threatening the momentum on AGYW and HIV prevention and on development goals, such as education for girls and gender equality. Lockdowns and social distancing regulations due to Covid-19 have undermined access to information and services for all vulnerable populations, but the toll on AGYW has been particularly harsh. This is evident in the emerging data: sharp declines in access to services for sexual and reproductive health, HIV testing and PrEP uptake/continuation, safe spaces, and post-rape care; rising rates of gender-based violence, intimate partner violence, and unintended pregnancies; and economic hardships fueling transactional sex, food insecurity, and school drop outs. Maurine Murenga, executive director of the Lean on Me Foundation in Kenya, called the rise in gender-based violence, new HIV infections, and rising teenage pregnancy a “shadow epidemic.”
This is an opportunity to learn from and build upon the lessons from DREAMS to enhance the global health response.
A “Layered” Approach
DREAMS is well-positioned to adapt its programming to the new realities and challenges presented by Covid-19. From its inception, DREAMS has implemented a “layered” approach, meaning that since no single intervention has been shown to avert new HIV infections on its own, it provides the AGYW with a package of interventions across different sectors to address the risks and vulnerabilities that put them at risk of HIV. These include gender-based violence prevention and response, access to sexual and reproductive health services, education support, economic strengthening, and social welfare. The DREAMS approach will be especially important in order to address the heightened challenges impacting AGYW during the Covid-19 pandemic.
In response to Covid, PEPFAR has outlined the need to follow local guidelines for gatherings, which particularly impacts DREAMS safe spaces and mentorship activities. PEPFAR has emphasized that maintaining contact with AGYW is a priority during this time and that mentors and facilitators who work with DREAMS should have access to cellphone airtime so they can continue activities through digital platforms to keep AGYW engaged. Delivery platforms are already being adapted to respond to the Covid-19 crisis, including expanding digital and social media outreach, shifting to community delivery, and providing multi-month drug dispensing. PEPFAR has recommended that PrEP services be moved out of health clinics and that implementers use virtual options when possible.
Sexual and Reproductive Health-HIV integration
The Covid crisis has also elevated the importance of sexual and reproductive health-HIV integration for AGYW. With the lockdowns, clinics and hospitals reduced their services, significantly limiting access to sexual and reproductive health and HIV services. This, in turn, has contributed to the rise in teenage pregnancy, and though data is still scarce, we will likely see a similar rise in sexually transmitted infections and mother-to-child transmission of HIV, as well as rising rates of HIV infection. Many observers noted that countries will have to look at how to better integrate sexual and reproductive health-HIV programs at clinics, in schools, and in communities, along with Covid programs. The importance of sexual and reproductive health services in HIV prevention was summarized by Dr. Ruth Laibon-Masha, the CEO of the National AIDS Control Council in Kenya: “It’s a fallacy to actually imagine that we cannot address sexual and reproductive health and still get impact on HIV prevention.”
Integrated services are also important entry points for PrEP. Increasingly, evidence shows that PrEP continuation is improved when AGYW are also using family planning methods and access PrEP through integrated platforms. Providing PrEP through health services not associated with HIV treatment, like ART clinics, reduces stigma and increases uptake by AGYW. Successful programs also require trained healthcare providers and peer educators to avoid the provider bias and judgmental attitudes that are too often associated with services for sexually active AGYW. These shifts and innovations can help fuel further integration of services.
Before Covid, DREAMS provided education support that helped some 132,000 AGYW to enroll in and stay in school and to transition to and complete secondary school. With the Covid lockdowns, school as a protective factor was taken away, and the increased economic stress on families has compelled many AGYW to take on more roles in the household and to try to find work to support the family. Researchers and implementers are concerned about the increased social, emotional, educational, and physical impacts on AGYW stuck at home, as well as increases in unhealthy coping mechanisms such as transactional sex and alcohol or drug abuse.
School-based programs have been affected by the shutdowns, and not all AGYW have been able to access online education platforms, putting them even further behind. Many key informants expressed concern that vulnerable AGYW may not return to school due to economic hardships, early marriage, and rising teenage pregnancy. According to Hasina Subedar, who heads the South African government’s She Conquers campaign on AGYW and HIV: “Covid has really interrupted the education system, and young women will be much more disadvantaged as we go forward. We should pay very special attention about how to make sure that these young women are supported or reintegrated.”
A Digital Divide
In response to the Covid pandemic, organizations and institutions around the world attempted to shift activities to online or virtual forums, and sub-Saharan Africa was no exception. According to Saiqa Mullick, director of implementation science at the Wits Reproductive Health Institute in South Africa, these digital innovations became critical since partners were relying on them for demand creation and client support. This meant increased use of cell phones, online services, chatbots, mobile apps, and social media. “If we’re going to live in an era of Covid and work with young people, these are digital interventions that we need to ensure access to,” Mullick said. The South African government also updated its B-Wise site, which provides information for young people about sexual health, HIV, sexually transmitted infections unintended pregnancy, and relationships, to include information about Covid.
This shift in programming further exposed the digital divide for AGYW. Too often, at-risk AGYW do not have smartphones or cell phones to participate in such virtual programs, or cannot afford airtime or data, or they rely on the phones of their families or boyfriends, which raises important privacy and confidentiality concerns. Accordingly, efforts by mentors and peer educators to stay connected with the AGYW participants become more challenging and require redoubled efforts to maintain those connections and ensure that the AGYW can access available services. “Technology is a double-edged sword,” Daniel Were, a project director with JHPIEGO in Kenya, explained. “Not all AGYW have access to phones, many use their partners’ or their mother’s phone, which is a huge challenge for programs . . . We push to be tech savvy, but it might also be a risk driver.”
The Way Forward
The Covid-19 pandemic has revealed and exacerbated inequities faced by AGYW, a situation made even more acute in the DREAMS countries with high HIV burdens. As countries and communities struggle to address the intersecting crises of Covid-19, HIV, and gender inequality, the Biden-Harris administration should prioritize the need for a comprehensive response that builds on existing platforms. Indeed, this is a critical opportunity for the new administration to work with Congress to ensure that adolescent girls and young women are central to U.S. global health policy, including responses to Covid-19. To do so effectively, it should ensure that young women are at the table, involved in decision-making, and engaged in the design and implementation of programs. The new administration should make the development of an innovative and ambitious agenda on the health and development of AGYW a signature priority.
In the words of Esther, a young woman we spoke to in Kenya, “If you empower a girl child, you empower the whole community.” On this World AIDS Day, President-elect Biden and Vice President-elect Harris should heed her advice.
Janet Fleischman is a senior associate (non-resident) with the Global Health Policy Center at the Center for Strategic and International Studies (CSIS) in Washington, D.C.
This commentary is part of a project about the achievements, challenges, and next steps for DREAMS and other AGYW programs, made possible by the generous support of ViiV Healthcare.
Commentary is produced by the Center for Strategic and International Studies (CSIS), a private, tax-exempt institution focusing on international public policy issues. Its research is nonpartisan and nonproprietary. CSIS does not take specific policy positions. Accordingly, all views, positions, and conclusions expressed in this publication should be understood to be solely those of the author(s).
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