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 the United States 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 black men who have sex with men, and black women who have sex with men, HIV/AIDS rates continue to climb. In 2007 the US observed an increase in the number of new HIV infections—by as much as 50 percent—for the first time in over ten 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 appear to be slowing in the general population throughout the country, HIV transmission through highrisk heterosexual behavior is still on the rise among women, African Americans, and Latinas and Hispanics. Southern women experience the brunt of this reality.
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, it is at the forefront of every decision, relationship, and sexual encounter. More than three hundred thousand of those living with the disease in the US are women and girls. 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.
We now know that, among 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. Black and Latina women do not engage in risky sexual behaviors at different rates from their white 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.
Several key factors drive the 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 structural impediments must be addressed systemically by reducing violence against women and girls; ensuring universal access to quality education and healthcare; 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 socioeconomic status remain two principal drivers of infection. Yet, current HIV/AIDS responses fail 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 (PJ) offer a different, and potentially more successful, way to approach the issue.
Reproductive Justice, Prevention Justice, and 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 is 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 RJ 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 RJ 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 must be safe, affordable, and accessible; three minimal cornerstones of government support for all individual life decisions.
The HIV Prevention Justice Alliance is an emerging coalition of HIV/AIDS prevention advocates and activists who believe 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 PJ 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 that are most affected by the epidemic at the forefront of policy efforts.
To date, US HIV prevention efforts have focused on identifying and changing individual behaviors that can contribute to the virus’s 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 engaging in risky behaviors such as drug addiction or commercial sex work, as well as assessing the specific populations 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 PJ standpoint involves examining both community and structural conditions that increase infection risks for individuals and groups. The US prevention field has been relatively slow to create and implement strategies that specifically address the structural, social, and systemic problems that may increase an individual’s infection risks more than another’s. For example, PJ explores whether a resource-poor black mother is more susceptible to HIV because she prefers 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 in her life.
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 us 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 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 because of their status.5
Reproductive and prevention justice calls for, at a minimum, the following mechanisms to address the intersection of HIV risk and violence: collection and analysis of data on the relationship among sexually transmitted infections (including HIV/AIDS) and gender violence; the integration of HIV/AIDS prevention and/or treatment into care networks for victims of domestic and sexual violence; and education of 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 they can either independently control or 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 multisectoral approaches to HIV prevention. Behavior interventions, along with vaccines, microbicides, and other medicinal compounds, will have the best chance of causing 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 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 infections, and early or 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 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 make a real impact on HIV/AIDS, because women are most at-risk of contracting HIV/AIDS for economic reasons and 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, healthcare, 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 United States, 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 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 promote equitable representation of women at the highest levels in national political, executive, legislative, and judicial structures; ensure that organizations led by and serving women are more widely and meaningfully active in the forums where AIDS programs are designed, funded, and managed; 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 build partnerships between women’s rights organizations and groups working on HIV/AIDS to more effectively lobby for change.
SisterSong 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, a South Carolina–based HIV-positive activist who was on the management circle of SisterSong, when asked what she thinks the key roles are for HIV-positive women in the struggle for effective HIV/AIDS prevention strategies said,
Give [us] a voice and a platform for that voice. . . . Give [us] a safe place to let [our] 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?8
Notes
1. David Brown, “Estimate of AIDS Cases in U.S. Rises,” Washington Post, December 1, 2007, http://www.washingtonpost.com/wp-dyn/content/article/2007/11/30/AR2007113002535.html.
2. Centers for Disease Control and Prevention, “HIV Surveillance in Women,” June 2007, 4. http://www.cdc.gov/hiv/topics/surveillance/resources/slides/women/index.htm.
3. UNAIDS, UNFPA, and UNIFEM, “Women and HIV/AIDS: Confronting the Crisis,” 1. http://www.unfpa.org/sites/default/files/pub-pdf/women_aids.pdf.
4. Rickie Solinger and Loretta J. Ross, eds., Reproductive Justice Briefing Book: A Primer on Reproductive Justice and Social Change, last updated 2007, Pro-Choice Education Project/SisterSong Women of Color Reproductive Health Collective, http://protectchoice.org/downloads/Reproductive%20Justice%20Briefing%20Book.pdf.
5. Ibid.
6. Pan-American Health Organization (PAHO), “Propuesta de Proyecto sobre Las Redes de Atención a la Violencia Doméstica y Sexual como Punto de Entrada para el Tratamiento y Prevención del VIH/SIDA (Project proposal on the networks of attention to domestic and sexual violence as point of entry for the treatment and prevention of HIV/AIDS)” (Washington, DC: PAHO, June 2005), 2.
7. International Center for Research on Women, “Property Ownership for Women Enriches, Empowers and Protects,” 2005, https://www.icrw.org/wp-content/uploads/2016/10/Property-Ownership-for-Women-Enriches-Empowers-and-Protects-Toward-Achieving-the-Third-Millennium-Development-Goal-to-Promote-Gender-Equality-and-Empower-Women.pdf.
8. Juanita Williams, in Speak Up! Newsletter of the Positive Women’s Network, Spring/Summer (2011), 1.