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Elizabeth Futrell is an associate technical officer at FHI, where she works on activities related to community-based family planning and youth sexual and reproductive health.
In recent years, campaigns like the The Girl Effect and publications such as Half the Sky have called attention to the key role of women and girls in combating poverty and its many challenges, including HIV/AIDS. At a recent talk in Chicago titled, “Transmitting Hope for Women in the HIV/AIDS Pandemic,” Geeta Rao Gupta, former president of the International Center for Research on Women (ICRW), elaborated on why and how the global health community must focus on girls and women.
Geeta began her focus on HIV prevention among women in sub-Saharan Africa in 1990, when a USAID colleague noticed that although most efforts to prevent HIV among women were targeted at women who sell sex, they were not the only women becoming infected with HIV. A team of researchers embarked on a 15-country research program to learn more about the realities of women’s sexual health and found that three key factors made women and girls disproportionately susceptible to HIV: (1) economic vulnerability, (2) harmful gender norms, and (3) disparities in access to health information and services. Compounding these challenges was the fact that, in many cases, even if women and girls did have access to HIV prevention information and services, unequal power dynamics left them unable to negotiate safer sexual practices with their partners. Further, many women felt unable to leave risky sexual relationships because of economic dependence or threat of violence. For these women, the immediate threats of physical harm and extreme poverty posed far greater risks than the possibility of dying of AIDS 10 years down the road. Public health messages about abstinence, faithfulness, and condom use did no good for the women who lacked power to negotiate these practices.
Therefore, Geeta argues that HIV prevention efforts must address not only individual risk behaviors, but also the societal structures that make women and girls vulnerable to HIV and other health threats. How do we do this? She says we must start with the understanding that broad generalizations about what works do not ring true for every context. While promising, single approaches like microfinance are not a magic bullet but just one of many tools to be used in creating long-term, structural solutions. Central to the wellbeing of women and girls is the creation of an enabling environment in which women and girls can apply their empowerment. The development, implementation, and enforcement of supportive laws and policy regarding education, land and inheritance rights, age of marriage, and gender-based violence are critical to this endeavor. So is legal literacy—women need to know what their rights are and how to obtain them. Educating women and girls on their rights, training judges and law enforcement to uphold and enforce protective laws, and deploying community legal workers to help women and girls navigate the legal system are important strategies for upholding the rights of women and girls.
Effective, evidence-based programming borne from context-specific research is also necessary. In other words, implementing organizations need to get the facts, understand the context, and mobilize resources for each unique setting rather than rushing to quick solutions. These organizations also must focus on building local capacity to sustain and scale up effective programs. Geeta notes that successful scale-up does not mean giving a local organization that has successfully implemented a program more money and telling it to reach an additional 10,000 people, but rather finding other organizations that can effectively replicate the program and asking them to help reach new audiences.
Just before the talk closed, an audience member asked whether any of the Millennium Development Goals are achievable. “Absolutely,” Geeta asserted. Some of these goals, including elimination of mother-to-child transmission of HIV by 2015 are within reach. We have the tools and the cost is low—all it will take is good partnerships, capacity building, and a critical mass of support to overcome the stigma still associated with HIV, another challenge faced disproportionately by women and girls.
This post originally appeared on USAID’s blog “Frontlines” and can be accessed here.
The exchange of sex for money remains a major driver of the spread of HIV/AIDS throughout Southeast Asia, but the karaoke bars, massage parlors, beer gardens, and other settings where these transactions are brokered remain some of the most viable employment venues for vulnerable women.
In Cambodia—where more than 10 percent of female entertainment workers are infected with HIV, and more than 25 percent of these women and girls report having no education—USAID programming supported by the U.S. President’s Emergency Plan for HIV/AIDS Relief (PEPFAR) is implementing a new approach to reducing HIV risk by focusing on the central principle of the Global Health Initiative: that the health and well-being of women is key to the health of all.
Instead of exclusively focusing on distributing condoms and conducting risk-reduction education for high-risk women, the SmartGirl program aims to improve the sexual and reproductive health of its beneficiaries more broadly through linkages to personal counseling, voluntary family planning services, clinical care, savings schemes, and legal services.
Late last year, the program received a PEPFAR Heroes award from the Office of the U.S. Global AIDS Coordinator for its efforts to reduce the risks associated with entertainment work, while also supporting women in the pursuit of other employment.
“We’re committed to having women in the driver’s seat,” said Michael Cassell, the coordinator of the PEPFAR initiative in Cambodia. “SmartGirl is largely designed and run by entertainment workers to address their own felt needs. And the skills they acquire in the process help many of them to consider and pursue other careers, including ones in HIV and reproductive health service delivery.”
Avoiding “Message Fatigue”
Previous HIV/AIDS programs have focused on raising awareness of HIV, and educating people about how to avoid getting infected. But by demonstrating that staying healthy is key to the pursuit of education, wealth, happiness, and other personal objectives, SmartGirl strives to engage beneficiaries while sidestepping some of the “message fatigue” and monotony associated with more didactic approaches. Education sessions are run by peers, cover a broad range of topics that are updated regularly, and offer referrals to free HIV testing, family planning, and other services.
During a recent visit to a SmartGirl club in Phnom Penh, U.S. Rep. Laura Richardson (D-Calif.) was inspired to join program beneficiaries in a rousing karaoke rendition of Gloria Gaynor’s “I Will Survive,” noting her appreciation for the leadership of club members in providing health education and referrals to health care, vocational training, and legal services to other entertainment workers.
“I am so proud of you,” Richardson told the club members.
The SmartGirl program, which is implemented by USAID-partner Family Health International, currently provides services to 12,600 of the estimated 35,000 women working in clubs and night spots in Cambodia. The program is funded by PEPFAR but is consistent with the overarching objectives of the Global Health Initiative, the U.S. government’s six-year, $63 billion commitment to help partner countries strengthen their health systems, with a particular focus on improving the health of women, newborns, and children.
“Almost 30 percent of entertainment workers in Cambodia report having an abortion in the past year, suggesting inconsistent condom use and unmet needs for family planning,” said Cassell. “By linking these women to sexual and reproductive health services, we stand to prevent new HIV infections while also reducing maternal mortality—the latter arguably being Cambodia’s biggest public health challenge.”
A Model Approach
Cambodia is home to one of the most renowned national success stories in the fight against HIV/AIDS. Late last year, the country received international recognition in the form of a Millennium Development Goals country award for cutting adult HIV prevalence in half, from 2 percent to 0.9 percent between 1998 and 2006, while extending HIV-related care to more than 70 percent of HIV-infected adults, and HIV treatment to more than 90 percent of eligible individuals.
The estimated proportion of sex workers infected with HIV is down to around 10 percent from over 21 percent in 2003, according to the 2006 HIV Sentinel Surveillance (HSS). However, the maternal mortality ratio in Cambodia remains the second highest in East Asia.
“We’re particularly excited about the potential of this program to serve as a model for the scale up of higher quality and more holistic approaches to address the needs of populations at high risk for HIV infection,” said Cassell. “Many of the service delivery and referral protocols pioneered through SmartGirl are now being implemented as part of Cambodia’s national program with support from the Global Fund to Fight AIDS, Tuberculosis and Malaria.”
In the past decade, the U.S. government has invested more than $150 million in HIV/AIDS programs in the Southeast Asian nation, providing almost 40 percent of the resources available to the national response.
Robyn Dayton is a Technical Officer at FHI where she works on the research utilization portfolio of youth reproductive and sexual health activities.
I recently traveled with an FHI colleague, Allison Prickett, to Kenya and Botswana to test a new set of activities that were designed to prevent multiple and concurrent partnerships (MCPs) among youth. For more information on our trip and the health impact of these sorts of partnerships see Allison’s blog entry from March 7, 2011.
What struck me most in the field tests is just how common these kinds of partnerships are and how complex and difficult it will be to change this behavior. Even as they acknowledged how dangerous MCPs can be, the youth we spoke to described the need for having multiple sexual partners at one time. We heard often that young people believe it’s impossible to get what one needs from just one sexual partner. For example, young women talked about having one financially supportive partner, commonly called a sugar daddy, and a partner who is closer to her age—someone with whom she has a romantic connection. Young men reported that having two or more sexual partners is a symbol of status. Furthermore, both young men and women see additional partners as a way to deal with the loneliness that results from being in long-distance relationships, which are quite common. And even when a couple lives together, the perception is that having additional partners means greater sexual satisfaction.
So, what to do? Should we encourage youth to reassess need versus desire, even if this means attempting to change culture (especially those cultures that have historically promoted polygamy or that continue to)? Do we teach youth to focus on finding new ways to get their needs met without additional partners? If so, maybe we should work on income-generating activities to help alleviate the need for sugar daddies, or teach communication skills so that youth can talk to their main partner about their sexual desires instead of going outside the relationship when they want to try something new. Should we try to help youth have safer concurrent partnerships—ones in which they use a condom 100% of the time with every partner, even those they have been with for years?
Luckily, the power of field testing activities comes not only from learning what the fundamental questions are, but also from learning who might have the answers. The youth in the field tests were actively engaged in answering the questions above for themselves. And ultimately, it won’t be up to curriculum developers to determine the best way for youth to deal with these fundamental issues—the answers have to come from the youth themselves. Otherwise, how relevant and acceptable could these answers be?
Today marks the 100th anniversary of International Women’s Day, a day for celebrating and honoring the achievements of all women, past and present. We would also like to take the opportunity on International Women’s Day to focus on how we can improve the lives of girls and adolescents, who are the women of our future.
The global population of females ages 10-24 is currently the largest in history and is expected to peak in the next decade; over 600 million girls currently live in developing countries. One out of seven girls in developing countries is married before age 15, and 38 percent are married before age 18. Approximately 16 million girls between the ages of 15 and 19 give birth each year, accounting for 11% of all births worldwide. Between one-quarter and one-half of girls in developing countries become mothers before age 18. Out of the world’s 130 million out-of-school youth, 70 percent are girls. It is estimated that one-quarter of girls in developing countries are not in school. Adolescent girls who are married or become pregnant are more likely than their peers to drop out of school.
Young girls are future mothers and leaders, yet they face a multitude of challenges. Promoting girls’ education and enabling young women to postpone childbirth results in healthier families, leads to higher incomes among females, and gives girls a brighter future. So this International Women’s Day, let’s not forget our “future women.” Let’s do all we can to ensure that young women across the globe stay in school longer, delay pregnancy and marriage, and receive greater opportunities.
- Watch the Girl Effect video:
- Learn how reproductive health care is changing the lives of millions of girls and women on Pathfinder International’s Web site.
- Host an International Women’s Day party.
- Encourage young women to take the Girl Scouts’ “The Power of Girls Pledge.”
- Leave a comment! Let us know how you are celebrating International Women’s Day and what you can do to help girls and young women around the world.
Allison Prickett, MPH is a Global Health Research Fellow at FHI.
At Stepping Stones International (SSI), located just outside of Gaborone, Botswana, children gather every day for an after-school program that includes activities such as tutoring, life skills lessons, and a meal. In Botswana, 17 percent of the population is living with HIV and 64 percent of children ages 10-18 have been left orphaned by the epidemic. SSI provides a safe and nurturing environment where orphaned and vulnerable children can gain the skills they need for a bright future.
Just a few weeks ago, I had the opportunity to work with FHI colleagues from North Carolina and Botswana as we partnered with SSI to pilot-test educational activities pertaining to HIV. Much of the HIV epidemic in Botswana is attributed to the social norm of having multiple and concurrent sexual partnerships (MCPs), locally known as having “a small house.” MCPs are particularly dangerous for a couple of reasons. When someone first becomes infected with HIV, that person has a high viral load, meaning they are highly infectious and are much more likely to rapidly spread the disease to their partners. And secondly, by their nature, MCPs create a large sexual network through which the virus navigates. The government of Botswana recently initiated a campaign, O Icheke, designed to raise awareness and change behavior related to MCPs. However, most HIV programs worldwide do not currently address MCPs as a key driver in the spread of the virus.
Given the high prevalence of HIV and the active role the country’s government has taken in HIV prevention, Botswana made for a prime location to pilot-test seven activities that are geared toward informing youth about the dangers of MCPs. These activities were collaboratively created by ETR’s Doug Kirby and by FHI. The activities are meant to supplement an existing HIV educational program, because they focus specifically on building knowledge, values, and skills that youth need to make healthy decisions about sexual partnerships.
Pilot-testing at SSI proved to be not only beneficial for improving the MCP activities, but also a great deal of fun with the participatory lessons, discussions, and role-plays. The participants were intrigued and eager to share their newly acquired knowledge with their peers. With input from SSI’s staff, we hope to refine these innovative educational activities on MCPs to help combat the spread of HIV.
For more information, check out the links below:
The O Icheke Campaign, Botswana (707 KB)