Karesha, a 16-year-old girl in Jamaica, is thought by her family to be lucky because she has a Don -- an older man who buys her school books and uniforms -- in exchange for sex. Karesha is HIV-positive and lives in fear of becoming pregnant or contracting other sexually transmitted infections. "When the Don calls, you have to go."
Many of the social and economic barriers that stand in the way of effective HIV prevention, treatment, support and care for people living with HIV are the same barriers that impede access to comprehensive sexual and reproductive health programs and services. For instance, the circumstances that can lead to unintended pregnancies can also lead to infection with HIV and other STIs. Sex is the common denominator. In societies where cultural and gender norms tightly restrict the sexual and reproductive lives and choices of women and men, the risk for both unintended pregnancy and HIV infection is greatest.
These barriers have the greatest impact on the most marginalized in our communities. The poorest women, young women, sex workers, lesbian, gay and transgender persons, migrants, indigenous peoples are often the people most affected by HIV and have the least access to comprehensive sexual and reproductive health programs and services.
Gender inequities lie at the heart of these issues. What women wear, whether girls attend school, how many partners men have, and how they negotiate sex are all dictated by the cultural norms and values in their societies. These norms and values profoundly influence the ability of women and men to make healthy choices in their lives. When women and girls are coerced to engage in sex, with relatives, teachers, Dons or strangers, they have little choice over when and how that sex happens and no real ability to protect themselves or exercise their rights. Issues of power and control in gender relations that underlie family planning and sexual and reproductive health are closely linked to those affecting HIV prevention, treatment, care and support.
When we make progress in one field, it benefits the other. We know that education is a protective factor -- the longer girls stay in school and the more education they receive, the more likely they are to avoid unintended pregnancy and to remain HIV negative. Poverty, food insecurity and lack of economic opportunities are linked to increased vulnerability and restricted life choices.
Integrating family planning, maternal health, and HIV prevention, treatment and support services makes programmatic sense and is cost effective. Most importantly, this approach recognises that in the real world, multiple issues reside in a single person. It makes no sense for a woman to go to one place for contraceptives, another for anti-retroviral treatment and yet another for ante-natal care, especially when she has to travel long distances to access clinics that are open on different days of the week. Increasingly, service providers are collaborating to offer sensitive, comprehensive services. However, the funding for such services is offered in siloes -- creating competition for scarce resources and undercutting incentives to work together. We have a long way to go to make effective integration of services a reality.
But integration doesn't stop there. We also need to integrate our advocacy and policy work. For instance, the sexual and reproductive health and rights of HIV-positive people is a crucial area for joint action. Joining forces to address stigma and discrimination -- including negative attitudes of service providers -- is central. Women and men living with HIV report difficulties in getting the information, services and support they need to practice safe sex and many wishing to have children report hostile reactions from health workers. Growing documentation and litigation surrounding the forced and coerced sterilization of women living with HIV highlights the profound extent to which the human rights of HIV-positive women are being violated.
We also need to place more attention on methods that offer women enhanced control and choice in their sexual and reproductive decisions -- such as the female condom and microbicides. Currently, the female condom is the only available HIV-prevention and family-planning method that women can initiate themselves. With respect to microbicides, a clinical trial is now underway on a monthly vaginal ring to help prevent HIV infection in women and offers the option of combining contraception (or not). Women need access to a wide range of methods to protect themselves from HIV infection and plan their families.
Finally, collaborative work is needed to ensure that policies and programs aimed at preventing vertical transmission of HIV also ensure that anti-retroviral therapy is provided to women beyond childbirth -- women, as well as their children, must be kept free of HIV. The parents of those infants need to have access to the full range of choices to plan their families, receive quality education and have access to meaningful employment opportunities. Women and men need to become agents of their own lives with the ability to exercise choice.
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