In Women’s Eyes

There is rightly a huge global effort to enable women living with HIV to have long productive lives, through treatment access. However, many women living with HIV experience violence against women (VAW), in both domestic and health care settings. The ways in which VAW might prevent treatment access and adherence for women has not to date been reviewed coherently at the global level, from Luisa Orza, MA, is SRHR Technical Lead at the International HIV/AIDS Alliance. Emily Bass is director of strategy and content at AVAC. Emma Bell is an independent consultant, Sophia Forum trustee, and senior associate at Social Development Direct. E. Tyler Crone, MPH, JD, is co-founder and director of ATHENA. Nazneen Damji, MSc, is policy advisor for Gender Equality, HIV, and Health at UN Women. Sophie Dilmitis is an independent consultant based in Zimbabwe. Liz Tremlett is an independent consultant based in Kathmandu, Nepal. Nasra Aidarus supported this project while working at AVAC: Global Advocacy for HIV Prevention in New York City. Jacqui Stevenson is lead for research and analysis at the ATHENA Initiative and a PhD candidate at the University of Greenwich, UK Souhaila Bensaid is living with HIV in Tunisia. She is founder of the Tunisian Association of Positive Prevention for women and girls, sex workers, and MSM living with HIV. Calorine Kenkem is a woman living with HIV from Cameroon, who used to work with the Cameroonian Network of Positive Women. Gracia Violeta Ross is a Bolivian advocate and social anthropologist with expertise in gender, sexual and reproductive health. Elena Kudravtseva, MA, is policy specialist on gender equality and HIV at UN Women. Alice Welbourn, PhD, FRCOG (Hon), is a woman living with HIV and is founding director of the Salamander Trust. Competing interests: Sophie Dilmitis, Liz Tremlett, Souhaila Bensaid, Calorine Kenkem, Gracia Violeta Ross, and Alice Welbourn are all women living with HIV. Disclaimer: The views expressed here are of the authors and may not necessarily reflect those of UN Women. Please address correspondence to Alice Welbourn. Email: [email protected]. Copyright © Orza, Bass, Bell, Crone, Damji, Dilmitis, Tremlett, Aidarus, Stevenson, Bensaid, Kenkem, Ross, Kudravtseva, Welbourn. This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original author and source are credited. Health and Human Rights Journal HHr HHR_final_logo_alone.indd 1 10/19/15 10:53 AM l. orza, e. bass, e. bell, e. t. crone, n. damji, s. dilmitis, l., n. aidarus, j. stevenson, s. bensaid, c. kenkem, g. v. ross, e. kudravtseva, a. welbourn / HIV and Human Rights, 155-168 156 D E C E M B E R 2 0 1 7 V O L U M E 1 9 N U M B E R 2 Health and Human Rights Journal Introductory overview Since 2016, the World Health Organization (WHO) has recommended life-long anti-retroviral therapy (ART) for all people with HIV, from their diagnosis date, regardless of CD4 count or clinical stage.1 Efforts are needed for ensuring that all people living with HIV have access to life-saving medication that can turn HIV into a manageable chronic condition. ART is central to the Sustainable Development Goal (SDG) of ending AIDS by 2030 and to UNAIDS’ “90-90-90” targets aimed at ensuring that, by 2020, 90% of all people living with HIV will know their HIV status; 90% of all people with diagnosed HIV will access treatment; and 90% of all people receiving ART will achieve viral suppression.2 Meanwhile, women living with HIV continue to face widespread violence, both at home and in health care settings after their diagnosis.3 Policy makers are increasingly aware that this violence may act as a barrier to treatment access and adherence.4 To date, however, there has been scant formal evidence, from women’s own perspectives, regarding if and how this violence affects women’s ability to start and continue with treatment.5 Further, funding for HIV, and global health, is shrinking.6 While there is continued focus on strategic investments in biomedical approaches, psychosocial programs and complementary community initiatives remain under-resourced.7 Thus, to maximize women’s health in this highly constrained funding context, it would be beneficial for policy and program makers to understand more about facilitators and barriers to treatment access and adherence, for women living with HIV, from women’s own perspectives. Indeed, as this review reveals, the very manner in which women are tested for HIV and start ART can be a barrier, if based on compulsion, instead of informed choice as a fundamental principle of human rights.8 We describe a global review of HIV treatment access which has explored facilitators and barriers, through the normative framework of the human right to health, as established by relevant United Nations treaties and commitments relating to women, the Committee on the Elimination of Discrimination Against Women (CEDAW Committee), the Global Commission on HIV and the Law, and the recent WHO woman-centered guideline on the sexual and reproductive health and human rights (SRHR) of women living with HIV.9 ATHENA, AVAC, and Salamander Trust—three civil society organizations—undertook this review effort in three phases: a qualitative and quantitative literature review (phase one); focus group discussions and one to one interviews (phase two); and three country case studies (phase three). The review was commissioned and funded by UN Women. women’s own perspectives. Meanwhile, funding for global health care, including HIV treatment, is shrinking. To optimize women’s health and know how best to optimize facilitators and minimize barriers to access and adherence, especially in this shrinking funding context, we need to understand more about these issues from women’s own perspectives. In response, we conducted a three-phase review: (1) a literature review (phase one); (2) focus group discussions and interviews with nearly 200 women living with HIV from 17 countries (phase two); and (3) three country case studies (phase three). The results presented here are based predominantly on women’s own experiences and are coherent across all three phases. Recommendations are proposed regarding laws, policies, and programs which are rights-based, gendered, and embrace diversity, to maximize women’s voluntary, informed, confidential, and safe access to and adherence to medication, and optimize their long-term sexual and reproductive health. l. orza, e. bass, e. bell, e. t. crone, n. damji, s. dilmitis, l., n. aidarus, j. stevenson, s. bensaid, c. kenkem, g. v. ross, e. kudravtseva, a. welbourn / HIV and Human Rights, 155-168 D E C E M B E R 2 0 1 7 V O L U M E 1 9 N U M B E R 2 Health and Human Rights Journal 157 This is the first peer-led global study to date that looks at HIV care and treatment access for women living with HIV.