Problem Analysis Final Paper

Gender Inequality and HIV in Developing Countries

Problem Landscape

The issue I have chosen to examine is HIV in developing countries, specifically how gender inequality exacerbates the epidemic. In June 2001, the United Nations General Assembly declared HIV/AIDS a global emergency. Today, HIV remains a global epidemic. At the end of 2016, there were approximately 36.7 million people living with HIV. More than 95% of HIV infections are in developing countries, and two-thirds of them are in sub-Saharan Africa (HIV/AIDS).

Since the beginning of the global HIV epidemic, women have been disproportionately affected. In sub-Saharan Africa, young women are 8 times more likely than men to be HIV positive. “In 2016, 360,000 adolescent girls and young women were infected with HIV – almost 1,000 a day” (Adolescent). Findings from a recent World Health Organization report claim that for women in their reproductive years (15-44), HIV/AIDS is the leading cause of death (HIV/AIDS). Such increasing feminization of the HIV pandemic reflects the vulnerability of women and young girls to HIV.

HIV is part of a harmful cycle in which gender inequality both drives HIV and is entrenched by it. There are many factors rooted in gender inequality that make women more vulnerable to HIV, including lack of access to healthcare services, lack of access to education, lack of economic opportunities, sugar daddy culture and transactional sex, and gender-based violence.

Women’s lack of access to healthcare services, particularly sexual and reproductive health services, leaves them less able to protect themselves against HIV infection. In 29 countries, women require the consent of a spouse or partner to access sexual and reproductive health services. The Global Fund to Fight AIDS, Tuberculosis, and Malaria released a statement claiming, “Because power is distributed unequally in most societies, women typically have less access to and control over health information, care, and services, and resources to protect their health.”  Another main factor in women’s vulnerability to HIV is women’s lack of access to education. Research has shown a direct correlation between girls’ education and HIV risk. In Botswana, UNAIDS reports that every additional year of school a girl completes has been shown to reduce her risk of HIV infection by 11.6% (WHEN). Despite conclusive evidence that a girl who has a basic education is three times less likely to contract HIV, a shocking ninety-eight million girls around the world are not in school (WHEN).

Women in extreme poverty are more at risk of HIV infection because they are more pressured to engage in transactional and intergenerational sex, as well as relationships that expose them to gender-based violence. Sugar daddy culture in many areas of poverty promotes transactional sexual relationships, which often expose young women to unsafe sexual behaviors, low condom use, and increased risk of HIV. “A long-term study of age-disparate sex and HIV risk for young women took place between 2002 to 2012 in South Africa, where a third of sexually active adolescent girls will experience a relationship with a man at least five years older than them. The study found a cycle of transmission, whereby high HIV prevalence in young women was driven by sex with older men who themselves had female partners with HIV, many of whom had acquired HIV as young women” (Transactional). Additionally, gender-based violence, a physical manifestation of gender inequality, prevents many women from being able to protect themselves against HIV.  “Gender-based violence is not only a violation of human rights, but also fosters the spread of HIV/AIDS by limiting one’s ability to negotiate safe sexual practices, disclose HIV status, and access services due to fear of reprisal” (Adolescent). Research shows that in regions with high HIV prevalence, women who are victims of gender-based violence are 50% more likely to acquire HIV than women who are not.


Solutions Landscape

Initial HIV prevention programs primarily focused on the prevention of HIV transmission through behavioral interventions.  One of the first programs was the ABC approach, which stood for “Abstinence, Be Faithful, Use a Condom”. As the complexity of the global HIV epidemic was realized, HIV interventions were developed that addressed factors beyond the scope of behavioral interventions. Today, a “combination prevention” approach is utilized, which focuses on preventing the transmission of HIV through the combination of behavioral, biomedical, and structural strategies.

Behavioral interventions are still an important factor in the combination prevention strategy and include the provision of information, such as sex education, HIV counseling, and programs aimed at reducing the stigma of HIV. The provision of information is particularly important because many young people lack the knowledge needed to protect themselves from HIV. As of 2015, in sub-Saharan Africa only 36% of young men and 30% of young women correctly identified ways of preventing the sexual transmission of HIV and rejected major misconceptions about HIV transmission (HIV). Biomedical interventions are another element of the combination prevention strategy and include male and female condoms, voluntary medical male circumcision, antiretroviral drugs, pre-exposure prophylaxis, and post-exposure prophylaxis.

The last element of the combination prevention strategy is structural interventions, which address the upstream barriers, such as gender inequality, that undermine biomedical and behavioral interventions. The importance of structural interventions is demonstrated by a study that focused on fishing communities in Southern Malawi. The results of this study suggested that unequal gender power relations increase women’s vulnerability to HIV by causing economic vulnerability, which is a key motivation for women to engage in transactional sexual relationships. Both females and males in these communities showed a good understanding of the HIV risk, suggesting that HIV prevention messages were being effectively communicated. Despite this, men and women still engaged in transactional sexual relationships. This lack of behavioral change despite effective behavioral interventions highlights the importance of changing the structural environment. The focus of this problem analysis paper is the structural issue of gender inequality because it is the primary factor that exacerbates women and girls’ vulnerability to HIV and blocks their access to HIV services. A basic example of this is that a woman’s unequal status (a structural issue) can affect her ability to negotiate condom use, thereby preventing her from utilizing both a biomedical intervention (availability of condoms) as well as a behavioral intervention (knowledge about safe sex practices).

In 2003, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) was launched to address the HIV/AIDS epidemic. PEPFAR has recognized that one area where progress had not been achieved is among adolescent girls and young women. According to PEPFAR, “No greater action is needed right now to control the HIV/AIDS epidemic than empowering adolescent girls and young women” (Adolescent). PEPFAR has deepened its focus on women and girls with its “Gender Strategy”, which focuses on increasing gender equity in HIV/AIDS programs and services, preventing and responding to gender-based violence, and increasing women and girls’ access to income and productive resources. According to the latest results for the year 2017, PEPFAR supported HIV testing services for more than 85.5 million people, prevented 2.2 million babies from being born with HIV, who would have otherwise been infected, and supported the lifesaving antiretroviral treatment for more than 13.3 million people (2017).

In 2009, the Obama Administration proposed as a six-year, $63 billion effort to develop the US Global Health initiative (GHI), a comprehensive USG strategy seeking to increase the efficiency of U.S. global health programs. One principle of the GHI is the “Women, Girls, and Gender Equality” (WGGE) principal. This principle was designed “to redress gender imbalances related to health, promote the empowerment of women and girls, and improve health outcomes for individuals, families, and communities”. One component of this the strategy for the WGGE principle is “gender analysis”, which involves “an assessment of the priority needs of women and girls in the health sector as well as the broader structural factors, roles, and norms that affect women and girls and should inform the design of GHI projects and activities”.

In 2014, PEPFAR introduced DREAMS, an effort supported by private companies that is focused on HIV prevention for adolescent girls and young women in sub-Saharan Africa. The aim of DREAMS is to help girls develop into “Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe” women. DREAMS employs an evidence-based comprehensive, multisectoral approach that extends beyond biomedical interventions to address the structural drivers of HIV that increase the vulnerability of women and girls to HIV, including poverty, gender inequality, sexual violence, and lack of education. According to a recent report, through DREAMS, there has been a 25-40% decline in new HIV diagnoses among adolescent girls and young women (New).


Lessons Learned & Levers for Change

Future interventions should continue to build upon the efforts of PEPFAR and DREAMS in expanding the USG’s gender-focused combination prevention approach to the HIV epidemic. In order for structural interventions to continue to be an emphasis in HIV programming while also scaling up existing biomedical and behavioral interventions, a co-financing budget should be adopted in order to increase funding. Because a structural approach includes intervening upstream, its benefits extend across multiple sectors, including education and economic development. This creates synergies between HIV prevention and other development areas, thus making structural measures the most efficient strategies. Such potential synergies were demonstrated in a trial in rural Malawi that found that cash transfers to young girls reduced HIV infection by 64%, and also reduced school drop-out, teen pregnancies, and risk of other sexually transmitted infections (Heise). If analyzed with a co-financing approach, the cost would be shared across sectors and the intervention would be seen as cost-effective. The current measures used to analyze HIV-specific cost-effectiveness do not recognize the multi-sectoral benefits of structural interventions. Due to this silo approach to budgeting, structural approaches are often unattractive to policy makers and thus underfinanced.

From researching this issue, I have learned that HIV/AIDS is inherently a gender-based issue. Future interventions should focus on one of the four primary structural intervention objectives detailed below. These objectives address the remove the structural barriers that continue to undermine effective biomedical and behavioral interventions.

  1. Strengthen legislation, law enforcement, and programs to end intimate partner violence.
  1. Increase girls’ access to secondary education.
  1. Use cash transfers to empower women economically, to keep them in school and to enable them to make healthy partner choices.
  2. Remove third-party authorization requirements and other barriers to women and young people’s access to HIV and sexual and reproductive health services.


Potential Next Steps

In order to gain a deeper understanding of this issue, I would like to focus on the fourth structural object listed above: remove third-party authorization requirements and other barriers to women and young people’s access to HIV and sexual and reproductive health services. Women need healthcare solutions that are discreet, do not need their partner’s consent to use, and convenient enough for correct use and constant adherence.

One example of where human-centered design (HCD) is currently being used for such a solution is with USAID’s “Project EMOTION”. This project uses HCD to inform HIV product development to increase young South African women’s uptake of and adherence to PrEP, a daily pill to prevent HIV infection. Project EMOTION conducted qualitative interviews and focus groups with young South African women to determine the best PrEp packaging. Although the researchers initially believed that inconspicuous packaging would best, the women’s feedback suggested that plain packaging would stand out among other brightly colored products women commonly own. Thus, HCD revealed that plain packaging would make a woman’s use of PrEp more obvious to a partner, decreasing the likelihood of uptake and adherence.

I would like to develop a similar innovation solution by using a HCD approach to create program that supports women in correct and constant use of Dapivirine (DPV) Rings. I could start by conducting interviews and focus groups with young women in developing countries to understand how the DPV ring could function within their lives.  Key initial questions to focus on would be: What is the best way to teach young women about the DPV ring? What concerns would prevent young women from using the DPV ring? What do you think are the greatest challenges to consistent and sustained ring use? After gaining insight into these questions, I could design potential solutions and conduct another round of interviews to gain further feedback. For example, suppose the initial interviews revealed that the lack of transportation is a concern for sustained use of the DPV ring, because transportation is needed to pick up DPV ring refills. I might then focus on designing a solution to this barrier. For the second round of questions, I might ask: Would you prefer to pick up your DPV ring refills yourself if transportation was available, as opposed to having them delivered? What is the best way to make DPV ring deliveries discrete? By collaborating with the young women who would be impacted by such a program, I would gain better understanding. This understanding would inform the iterative development of concepts designed to address DPV ring uptake and adherence.


Works Cited

“2017 PEPFAR Latest Global Results.”, The President’s Emergency Plan For

AIDS Relief , Nov. 2017,

“Adolescent Girls & Women.” The United States President’s Emergency Plan for AIDS Relief,

“Dapivirine Ring Design Guide.” U.S. Agency for International Development,

“Focus OnHuman-Centered Design.” U.S. Agency for International Development,

Https://, May 2017,

Heise, Lori et al. “Cash Transfers for HIV Prevention: Considering Their Potential.” Journal of

the International AIDS Society 16.1 (2013): 18615. PMC. Web. 11 Dec. 2017.

“HIV and AIDS in Kenya.” AVERT, AVERT, 14 Sept. 2017,


“HIV/AIDS Factsheet.” World Health Organization, World Health Organization, Nov. 2017,

“New PEPFAR Results Reach Historic Highs in HIV Prevention and Treatment.” The United

States President’s Emergency Plan for AIDS Relief, The United States President’s Emergency Plan for AIDS Relief, 2017,

Russell, Elizabeth, and Emily Harris. “’But What If It Falls out?’ Using Human-Centered Design

to Answer Questions about the Dapivirine Ring.” U.S. Agency for International Development, 11 July 2017,

“Transactional and Age Disparate Sex in Hyperendemic Countries.” AIDSFree, USAID,

“WHEN WOMEN LEAD CHANGE HAPPENS.” U.S. Agency for International Development,, 2017,