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HIV prevention and reproductive justice: a framework for saving women's lives.

CHANGE WOMEN'S LIVES, CHANGE THE EPIDEMIC. The face of HIV/AIDS in America has gotten browner, younger, and more female. Rates of infection have diminished among some populations of those at greatest risk--such as men who have sex with men--but for others, particularly for young African American/Black men who have sex with men, and African American/Black women who have sex with men, HIV/AIDS rates continue to climb. There are some indications that, in 2007, the U.S. observed an increase in the number of new HIV infections--by as much as 50 percent--for the first time in over 10 years; this increase was centered largely among people of color. (1) The Centers for Disease Control and Prevention's (CDC) latest epidemiology on women and HIV suggests that, while infections throughout the country appear to be slowing in the general population, HIV transmission through high-risk heterosexual behavior is still on the rise among women, African American/Blacks, and Latinas/Hispanics. Southern women experience the brunt of this reality.

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HIV/AIDS is a problem that, while ever-present, is invisible to the naked eye. Most Americans are fortunate enough to go through life with the HIV/AIDS epidemic as a background issue. But, for the 1.2 million Americans living with HIV/AIDS, the infection is at the forefront of every decision, every relationship, and every sexual encounter. More than 300,000 of those who are living with the disease in the U.S. are women and girls, a population among which the proportion of AIDS cases has risen from 7 percent in 1985, to 27 percent in 2005. (2) Women and girls are increasingly at the center of the global pandemic and represent nearly half of the world's AIDS cases. (2) The vast majority of these women become infected through sex with HIV-positive men. (See the sidebar on page 3.)

We now know that, among all of the populations at greatest risk for sexual transmission of HIV, there are no indications that individual sexual behaviors are different or unique to the most-affected populations. African American/Black and Latina women do not engage in sexual risk-taking behaviors at different rates from their counterparts. Yet, because of the high HIV prevalence in their communities, these women are more likely to become infected with less exposure than White women are.

Several key factors drive women's HIV/AIDS crisis, factors that are both elusive and difficult to tackle. They include women's increased biological vulnerability to HIV transmission and lack of control over use of barrier methods of HIV prevention; and the political, cultural, and economic conditions that impede women's access to reproductive health education, treatment, and care. These impediments must be addressed systemically by: reducing violence against women and girls; ensuring universal access to quality education and health care; guaranteeing inclusive research and clinical trials; and alleviating the effects of poverty on women and children.

Almost three decades into the global AIDS epidemic, gender inequality and women's low socio-economic status remain two principal drivers of infection. Yet, current HIV/AIDS responses fail, as a whole, to tackle the social, cultural, and economic factors that not only increase women's risk for HIV, but also unduly burden them with the epidemic's consequences. (3) Reproductive Justice and Prevention Justice offer a different, and potentially more successful way, to approach the issue.

REPRODUCTIVE JUSTICE, PREVENTION JUSTICE, & HIV/AIDS PREVENTION

"Reproductive Justice" is defined as the complete physical, mental, spiritual, political, social, and economic well-being of women and girls, based on the full achievement and protection of women's human rights. Reproductive Justice maintains that, for Indigenous women and women of color, it's important to fight equally for the right to have a child; not to have a child; to parent one's children; and to control birthing options, such as midwifery. (4) The Reproductive Justice analysis offers a compelling framework for empowering women and girls that is relevant to every American family because it focuses on the ends--better lives for women, healthier families, and sustainable communities--rather than engaging in a divisive debate on abortion and birth control that neglects the real-life experiences of women and girls.

The Reproductive Justice framework analyzes how a woman's ability to determine her own reproductive destiny is directly linked to her community's conditions--conditions that are not merely a matter of individual choice and access. Reproductive Justice addresses the social reality of inequality, specifically inequalities in opportunities to control our reproductive destinies. Reproductive Justice moves beyond a demand for privacy and respect for individual decision-making, to include the social supports necessary for one's individual decisions to be optimally realized, and the government's obligations to protect women's human rights. Our options for making choices have to be safe, affordable and accessible: three minimal cornerstones of government support for all individual life decisions.

Prevention Justice Mobilization is an emerging coalition of HIV/AIDS prevention advocates and activists that believes that the best way to prevent HIV/AIDS is to ensure that all of us have the economic, social, and political power and resources to make healthy decisions about our bodies, sexuality, and reproduction for ourselves, our families, and our communities. The Prevention Justice framework acknowledges that HIV prevention cannot be separated from human rights, thereby changing both the way we look at HIV prevention and how we advocate for it. Prevention Justice places the people and communities most affected by the epidemic at the forefront of policy efforts.

To date, U.S. HIV prevention efforts have focused on identifying and changing individual behaviors that can contribute to the virus' spread (such as unprotected sex and unsafe drug injection). Traditional prevention efforts also involve exploring "risk factors", the behaviors and/or traits that increase the odds of an individual's engaging in risky behaviors (such as drug addiction or commercial sex work), as well as assessing specific populations that are most likely to engage in high-risk behaviors. This focus has, however, failed to accomplish the CDC's goal of halving HIV transmission rates. In fact, as noted, in some communities, HIV/ AIDS rates are rising once again.

Addressing HIV/AIDS from a Prevention Justice standpoint involves examining both community and structural conditions that increase infection risks for individuals and groups. The U.S. prevention field has been slow to create and implement strategies that specifically address the structural, social, and systemic problems that may increase some individuals' infection risks more than others'. For example, Prevention Justice asks whether a resource-poor African American/Black mother is more susceptible to HIV because she prefers to have intercourse without a condom, or because she "chooses" unprotected sex in order to keep the man who pays her bills, feeds her kids, and secures their housing?

Reproductive and Prevention Justice acknowledge the key issues that increase women and girls' vulnerability to HIV/AIDS, including violence against women, poverty and economic dependence, lack of prevention technology, and the marginalization of HIV-positive women in leadership. A Reproductive and Prevention Justice approach necessitates addressing these factors and changing our current approaches to reducing the incidence of HIV/AIDS among U.S. women and girls.

DANGEROUS INTERSECTIONS: VIOLENCE AGAINST WOMEN AND GENDER-BASED VIOLENCE

Violence against women plays a crucial and devastating role in increasing women's risk of contracting HIV. It is a key reason why women are more vulnerable to HIV infection than men. It is both a cause and a consequence of infection and, as such, is a driving force behind the epidemic.

Fear of violence prevents women from accessing HIV/AIDS information, being tested for the virus, disclosing their HIV status, accessing services to prevent HIV transmission from mother to child, and receiving treatment and counseling--even when they know they have been infected. Women who are victims of gender-based violence have. an increased risk of contracting HIV/AIDS because they experience diminished capacity to negotiate risk reduction with abusive partners. Women who are living with HIV/AIDS are at increased risk for being the victims of gender-based violence. (5)

Reproductive and Prevention Justice calls for, at a minimum, the following mechanisms to address the intersection of HIV risk and violence: 1) collection and analysis of data on the relationship among sexually transmitted infections (including HIV/AIDS) and gender-based violence; 2) integration of HIV/ AIDS prevention and/or treatment into care networks for victims of domestic and sexual violence; and 3) education of both staff in government and community-based service delivery, and of the general public.

IN WOMEN'S HANDS: PREVENTION RESEARCH AND TECHNOLOGY

Women and girls must have prevention tools that they either can independently control or that they can administer for themselves. The future of prevention is showing us that behavioral research must be coupled with biomedical and social science research as a means of identifying multi-sectoral approaches to HIV prevention. Behavior interventions, along with vaccines, microbicides, and other medicinal compounds, will have the best chance of affecting a positive reduction in the HIV epidemic, especially among women and girls who have almost no female-controlled options for safer sex practices.

The quest for a "magic bullet," solution, whether a single behavioral or biomedical intervention, is not likely to end the AIDS crisis. We urgently need theories, assessment tools, and hybrid prevention strategies that address risk in the context of vulnerability and that directly address the root causes of vulnerability.

HIV AND WOMEN'S DEVELOPMENT: SUSTAIN FAMILIES, REDUCE RISKS

Poverty and economic desperation are significant underlying causes of the HIV/AIDS pandemic. Women are particularly vulnerable to the disease for economic reasons: a woman's lack of livelihood increases her incidence of transactional sex (in exchange for food or basic life essentials), coerced sex, multiple partners, early sexual debut, untreated sexually transmitted diseases, and early/unplanned pregnancy. The use of microcredit programs in the developing world offers a clear example. Microcredit programs provide savings, credit, and insurance services to owners of tiny businesses in impoverished communities: many microcredit programs specifically target women for involvement, Microfinance services have significantly increased women's economic independence and decreased their vulnerability to disease and violence; the availability of microcredit is shown to lead to significant and rapid improvement of household income.

Targeting women with microfinance services is an effective and sustainable way to affect real impact on HIV/ AIDS, because women are most at-risk of contracting HIV/AIDS for economic reasons and also tend to be the primary caregivers of AIDS orphans and other vulnerable children. Women in the developing world tend to be self-employed and are already poised to utilize a loan to expand their small enterprises. Likewise, women tend to invest their increased income to improve their children's lives, including proper nutrition, health care, education and shelter, thereby reducing poverty levels for subsequent generations.

Where poverty, inequality, and AIDS are combined, they do disproportionate harm to women and girls. Research suggests that women who have access to, ownership of, and control over income, property, and other assets are better able to avoid relationships that threaten them with HIV, and to manage the impact of HIV/AIDS. In the U.S. increasing self-sufficiency and reducing economic dependency (especially among women in "developing communities") has also been proven effective. (6)

I AM NOT THE ENEMY, I AM THE ANSWER: HIV-POSITIVE WOMEN'S LEADERSHIP

In its Agenda for Action on Women and AIDS, the Global Coalition on Women and AIDS (GCWA) states that experience has shown that HIV/AIDS policies and programs will not work for women until women's organizations--especially those of, for, and by HIV-positive women--help shape their content and direction. (7)

Local and national networks of women living with HIV are being established in more and more countries. But, much more must be done to strengthen women's participation in the meetings, forums, and programs that influence and shape their lives. The GCWA calls on national governments to support efforts that: 1) promote equitable representation of women at the highest levels in national political, executive, legislative, and judicial structures; 2) ensure that organizations led by women and serving women are more widely and meaningfully active in the forums where AIDS programs are designed, funded and managed; 3) provide more funds to build the advocacy and leadership skills of women living with HIV so they can participate effectively in the processes that affect their lives; and 4) build partnerships between women's rights organizations and groups working on HIV/AIDS to more effectively lobby for change.

SisterSong National Women of Color Reproductive Health Collective is a membership organization that uses Reproductive Justice as an organizing framework to challenge inequalities; empower women and girls; and help them to transform both themselves and their communities. Juanita Williams, an Atlanta-based HIV-positive activist who sits on the Management Circle of SisterSong said, when asked what she thinks the key roles are for HIV-positive women in the struggle for effective HIV/AIDS prevention strategies, "Give [us] a voice and a platform for that voice ... Give a safe place to let their voices be heard and validate them. Positive people are not taken seriously, and positive women are taken even less seriously. People think positive people are way down on the totem pole. We need positive women's voices to continue to fight the stigma. How do we do that? We tell our stories and reflect each other. I am not the enemy, I am the answer. If you silence my voice, then what happens to my behavior?"

REFERENCES

(1) Brown, D, "Estimate of AIDS Cases in U.S. Rises," The Washington Post, Dec. 1, 2007, p. A01.

(2) U.S. Centers for Disease Control and Prevention (CDC) HIV Surveillance in Women, CDC: Atlanta, GA, June 2007, p. 4. Retrieved 9/27/07 from: http://www.cdc.gov/hiv/ topics/srveillance/resources/slides/women/index.htm.

(3) UNFPA, UNAIDS, and UNIFEM, Women and HIV/AIDS: Confronting the Crisis, UNAIDS: New York, NY, 2004, p. 1.

(4) SisterSong Women of Color Reproductive Health Collective, Reproductive justice Briefing Book: A Primer on Reproductive Justice and Social Change, SisterSong: Atlanta, GA, June, 2007, p. 1. Retrieved 9/29/07 from http://www.sistersong.net/documents/RJBriefingBook.pdf.

(5) Pan-American Health Organization (PAHO). "Propuesta de Proyecto sobre Las redes de atencion a la Violencia domestica y sexual como punto de entrada para el tratamiento y prevencion del VIH/SIDA" [Project proposal on the networks of attention to the domestic and sexual violence as point of entry for the treatment and prevention of the HIV/AIDS]. Washington, DC: PAHO, June 2005, p. 2.

(6) International Center for Research on Women (ICRW), Property Ownership for Women Enriches Empowers and Protects. Washington, DC: ICRW, 2005, p. 3. Retrieved 9/23/07 from http://www.icrw.org/docs/ 2005_brief_mdg-property.pdf.

(7) Global Women's Coalition on AIDS, the Promise: An Agenda for Action on Women and AIDS, UNAIDS: New York, NY: No date, pp. 24-25. Retrieved 9/8/07 from www.womenandaids.unaids.org.

ADDITIONAL RESOURCES

--International Community of Women Living with HIV/AIDS: www.icw.org

--The Women's Collective: www.womenscollective.org

--Global Campaign for Microbicides: www.global-campaign.org

--Action Aid USA: www.actionaidusa.org

--Women Organized to Respond to Life-threatening Diseases (WORLD): www.womenhiv.org

--US. Office of Women's Health: www.4women.gov

--National Women and AIDS Collective: www.msfoundation.org

--Center for Health and Gender Equity: www.genderhealth.org

--Kaiser Family Foundation: www.kff.org

--Women Won't Wait: www.womenwontwait.org

--Prevention Justice Mobilization: www.preventionjustice.org

RELATED ARTICLE: Keeping up with the numbers (2).

In 2005, for female adults and adolescents, the AIDS case rates (the number of infections among 100,000 individuals) for non-Hispanic Blacks was nearly 23 times higher than that for non-Hispanic Whites (45.5 infections per 100,000 individuals compared to 2 infections per 100,000 individuals). The estimated number of women's AIDS cases was more than five times higher for Hispanics than for non-Hispanic Whites (11.2/100,000 compared to 2/100,000).

The epidemic is disproportionately centered among women of color. In 2005, non-Hispanic Black females were 13% of the U.S. female population, but accounted for 66% of women's HIV/AIDS cases. Latina/ Hispanics were 11% of the female population, but accounted for 15% of women's HIV/AIDS cases. Non-Hispanic Whites made up 72% of the female population, but accounted for 17% of HIV/AIDS cases among females.

The CDC estimates that 71% of the 11,710 AIDS cases diagnosed among female adults and adolescents in 2005 were attributed to high-risk heterosexual contact: 59% from sex with bisexual men, or HIV-positive men with unidentified risk factors; and 12% from sex with injection drug users. Twenty-seven percent (27%) of infections were attributed to women's injection drug use, and the remaining 2% to "other or unidentified" risk factors.

An estimated 40% of adults and adolescents living with AIDS live in the South; 30% live in the Northeast; 20% live in the West; 10% live in the Midwest; and the remaining 3% live in U.S.-dependent areas.

Dazon Dixon Diallo, MPH, is the Founder and president of SisterLove, Inc. SisterLove, founded in 1989, is a reproductive justice organization with a human rights lens on HIV/AIDS. It is the oldest non-profit in Georgia dedicated specifically to the education, prevention, advocacy, and support needs of African American/Black and other women and girls at risk for, or living with, HIV infection and AIDS. The organization has locations in Atlanta, GA and Emalahleni, Mpumalanga, South Africa. See: www.sisterlove.org.
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Author:Diallo, Dazon Dixon
Publication:Women's Health Activist
Date:May 1, 2008
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