Why Women and Girls Need an AIDS Vaccine
Sustainable change for girls and women, especially in Sub-Saharan Africa, and a true end to HIV/AIDS requires more choice and improved prevention. Given the complex web of biological, physiological and socioeconomic factors increasing women’s vulnerability to HIV infection, a comprehensive response to HIV/AIDS today requires new prevention approaches to complement existing prevention and treatment options. An AIDS vaccine would help girls and women to independently protect themselves and their children from HIV infection, strengthen their power over their lives, and ultimately offer a long-term solution to the epidemic.
While the number of new HIV infections and AIDS-related deaths is declining globally, this progress eludes severalgroups of people, including adolescent girls and young women in eastern and southern Africa who are infected at rates two to five times higher than boys and men their age. According to the latest joint report from the United Nations and the African Union young women and adolescent girls in Africa “are still being left behind” particularly in cultures that limit women’s knowledge about HIV and their ability to protect themselves and negotiate safer sex.1 These failures are most acute in poor countries and among the poorest women in all countries. Globally, half of all adults living with HIV are women. In Africa this rate is even higher where women represent 60% of people living with HIV. This percentage is even higher among young Africans. Currently, 82% of all adolescents (ages 10-19) with HIV reside in Africa, and the majority of them (58%) are girls and young women. Among newly infected adolescents in eastern and southern Africa, 71% are female where approximately 850 girls and young women between 15-24 are now acquiring HIV each day.2
AIDS is the number one cause of death among women of reproductive age in Sub-Saharan Africa and worldwide. These grim statistics have ramifications for the broader social fabric of affected communities since a mother’s death greatly impacts her entire family. According to UNICEF, children are 10 times more likely to die within two years of their mothers' death.3
Women and girls’ increased biological vulnerability to HIV infection, coupled with a lethal mix of legal, social and economic inequities, fuel the epidemic in resource-poor nations. Entrenched gender norms and inequalities result in power imbalances in relationships, affecting women’s ability to control or negotiate the terms of sexual relations and condom use. Poverty and reliance on men for economic support also
limit women’s power to protect themselves and force some to turn to transactional sex for survival. Cultural norms that preclude girls’ and women’s access to knowledge about sexuality and HIV, and the threat of violence or loss of economic support can impede their ability to communicate with their partners about HIV prevention. In addition to the impact of the disease itself on HIV-positive women, the burden of caring for those with HIV-related illnesses and for children orphaned by AIDS typically falls on women and girls. HIV-affected women and families are increasingly impoverished, further exacerbating their vulnerability to infectious diseases. Stigma and discrimination remain acute for many HIV positive people, but because of their low social standing, women are especially vulnerable to ostracism, abuse, and even destitution.
Findings from studies done in Kenya4, South Africa5, and Tanzania6 showed that women living with HIV had consistently higher rates of intimate partner violence. In 2014, UNAIDS published a collection of essays written by women living with and affected by HIV about their experiences of violence by intimate partners and health-care institutions. In some settings, up to 45% of adolescent girls report that their first sexual experience was forced7; young women who experience intimate partner violence are 50% more likely to acquire HIV than women who have not and young women are more likely to experience gender-based violence than older women. Fear of violence can also affect whether or not a woman feels able to use counseling and testing services. Among girls aged 15–19 years who reported having multiple sexual partners in the past 12 months, only 36% said they used a condom the last time they had sex.8
The gap in addressing women and girls in HIV/AIDS responses is not a new discovery, but recent data has raised the profile of this issue and demands a new and more aggressive approach to this population. While women and girls in developing countries may be among those most vulnerable to HIV, they also are effective agents against the epidemic’s further spread. Many women in poor, rural villages are leading efforts to address how their communities take care of families and children affected by HIV/AIDS. And, in all responses to the epidemic – whether at the village or national level – it is imperative that women’s unique vulnerabilities to HIV are integrated into prevention, support and treatment programs, as well as into the research and development efforts toward new options for them. (For more on how to better align HIV prevention R&D agendas with the needs of women and girls in Sub-Saharan Africa, see our Policy Brief, Research and Development of New Biomedical HIV Prevention Tools for Women and Girls.)
A comprehensive response to HIV/AIDS today requires a scaling up and strengthening of existing prevention and treatment approaches as well as the research and development of new options. Current interventions include access to HIV and sexual and reproductive health education, particularly for young people; efforts to positively shift gender norms and combat sexual coercion and violence; initiatives to increase access and availability of male and female condoms; promotion of mutual fidelity and abstinence, where feasible; increasing access to voluntary HIV counseling and testing with referrals to appropriate treatment, care, and support; and programs for the prevention of mother-to-child transmission.
Recent initiatives like Determined, Resilient, AIDS-free, Mentored and Safe (DREAMS) recognize that urgent and bold action is imperative to better address girls and women and ultimately avoid a rebound of the epidemic. The two-year, $210 million pilot program launched jointly by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the Bill & Melinda Gates Foundation and the Nike Foundation focuses on “hot spots” in 10 countries where HIV incidence is highest among girls and young women. This innovative, groundbreaking program offers a long overdue critical focus on girls and women. Even with this heightened focus, we may still fall behind as millions of women and girls will still be newly infected with HIV and die from AIDS in the decades to come. Sustainable change for girls and women and a true end to HIV/AIDS will also need to build on the DREAMS momentum to demand more choice and improved prevention including new and better long-term prevention tools—especially methods that women can initiate or control.
An AIDS vaccine would help girls and women redress lethal imbalances and serve as a truly transformative tool by helping to circumvent gender-power and behavioral obstacles to HIV prevention and protect women’s health. An effective vaccine, as part of a comprehensive response, offers a long-term solution to the epidemic. Women would be able to access and use a vaccine with or without their partners’ knowledge. Adolescent girls, who are particularly vulnerable to infection, could potentially be vaccinated as pre-adolescents before the onset of sexual activity. Delivered confidentially, before exposure to the virus and invisible to partners and peers, a vaccine could help empower women to protect themselves — and their families and societies.
A vaccine is also likely to reduce dependence on behavioral change and adherence. While the use of anti-retroviral drugs for Pre-Exposure Prophylaxis (PrEP) has proven highly effective in preventing infection if regularly used, studies demonstrated high dependence on adherence among young, unmarried South African women for oral or vaginal products. A holistic approach that also includes longer-acting tools that can be used confidentially, such as long-acting injectable anti-retroviral drugs, implants and vaccines, and finding ways to engage with girls and young women will support greater adherence. Our ability to end the AIDS epidemic will depend on a combination of powerful approaches and a vaccine will greatly bolster the full spectrum of prevention, treatment and care. No infectious disease in history has ever been eradicated or effectively controlled without a vaccine, and AIDS is no exception. Current data modeling suggests, that under reasonable assumptions, a vaccine could reduce annual infections by 78-85% by 2070 depending on how effectively other interventions have been implemented, and would be cost-effective in low-income countries under any background scenario.9
The International Aids Vaccine Initiative (IAVI) vaccine work extends to women around the globe. IAVI works diligently with its partners in Africa and elsewhere to ensure that women are involved in the research and development of vaccine candidates, and in the clinical testing of such candidates and makes efforts to engage women’s health stakeholders globally, and in other countries where IAVI works. Gender work initiated in India has served as a foundation for IAVI’s gender efforts globally. IAVI adapted its well-received India gender training curriculum for clinical trial staff for use in East Africa and has conducted social research in Kenya on gender-related barriers to women’s and men’s participation in vaccine research and social impact of participation. IAVI-led efforts also ensure women can make voluntary, independent decisions to participate and receive the drugs and health services they need. Local scientists, including many women, play a crucial role in research, and local Community Advisory Boards (CABs) to help educate the community on vaccine development and other issues including gender sensitivity. Through a partnership with International Community of Women Living with HIV (ICW), IAVI is also helping to build the capacity of a core group of advocates to mobilize and educate more women to increase participation in HIV research, policy and advocacy to ensure equitable access to products by women and girls and enhance the understanding of the specific needs of girls and women for new products among researchers.
A well-implemented AIDS vaccination program could prevent millions of potential new infections with HIV– millions of men, women and children would then have a greater opportunity for a healthy, productive life. In its latest report, the UNAIDS-Lancet Commission calls for the world to urgently step up efforts to expand access to HIV/AIDS treatment particularly among vulnerable and marginalized people like women and girls and to “get serious” about prevention, including supporting development of an AIDS vaccine or face more HIV infections and deaths than five years ago. Preventing HIV infection in women secures families and economies. By protecting women and young girls from HIV, a vaccine will help unleash their potential and protect their development. Healthy girls are more likely to be able to finish school, healthy women can continue to work and provide for their families, and HIV negative mothers can be freed from the fear of passing the virus on to their children.
IAVI continues to work hand-in-hand with people and communities who need a vaccine the most by conducting and supporting groundbreaking research that will bring girls, women and the world an AIDS vaccine and help meet other global health challenges for many years to come.
1 UNAIDS/African Union. “Empower Young Women and adolescent girls: Fast-Tracking the End of the AIDS Epidemic in Africa.” 2015. Available at: http://www.unaids.org/sites/default/files/media_asset/JC2746_en.pdf
2 Fleischman J, Peck K. Addressing HIV Risk in Adolescent Girls and Young Women. Center for Strategic and International Studies. 2015. Available from: http://csis.org/files/publication/150410_Fleischman_HIVAdolescentGirls_Web.pdf
3 UNICEF Millennium Development Goals, Available from: http://www.unicef.org/mdg/maternal.html
4 Increased risk of HIV in women experiencing physical partner violence in Nairobi, Kenya. Fonck K, Leye E, Kidula N, Ndinya-Achola J, Temmerman M AIDS Behav. 2005 Sep; 9(3):335-9.
5 Gender-based violence, relationship power, and risk of HIV infection in women attending antenatal clinics in South Africa. Dunkle KL, Jewkes RK, Brown HC, Gray GE, McIntryre JA, Harlow SD Lancet. 2004 May 1; 363(9419):1415-21.
6 Maman S, Mbwambo J, Hogan N, Kilonzo G, Campbell JC, Weiss E. HIV-positive women report more lifetime partner violence: findings from a voluntary counseling and testing clinic in Dar es Salaam, Tanzania. American Journal of Public Health. 2002;92(8):1331–1337.
7 UNAIDS. “The Gap Report 2014: Adolescent Women and Girls.” 2014. Available from: http://www.unaids.org/sites/default/files/media_asset/02_Adolescentgirlsandyoungwomen.pdf
8 Joint United Nations Programme on HIV/AIDS (UNAIDS). Fast-Track: ending the AIDS epidemic by 2030. UNAIDS. 2014. Available from: http://www.unaids.org/sites/default/files/media_asset/JC2686_WAD2014report_en.pdf
9 Exploring the impact and cost-effectiveness of a vaccine as part of the Enhanced UNAIDS Investment Framework to end AIDS Available from: http://www.epostersonline.com/hivr4p2014/node/4521