The International Community of Women Living with HIV (ICW) is pleased to see that
much of our input into earlier drafts of the strategy especially those articulated
in the ICW Position Statement on UNAIDS 2016-2021 Strategy is reflected here;
particularly regarding the need to include a strong and comprehensive focus
on the needs of women and girls living with HIV.
We are very happy to see a section dedicated to women and girls, as well as language
about sexual reproductive health and rights (SRHR), engagement of women living
with HIV in all our diversities and gender equality more broadly and core actions
for the global response to achieve gender equality and empower women and girls.
We note that this strategy has come a very long way from women being mentioned
in a footnote and we applaud your efforts! We are hopeful to remain a strong
partner to UNAIDS as you finalize and refine this strategy and importantly
as you implement and work towards realizing this vision.
Given some of ICW the communities ongoing concerns about the lack of direct and
meaningful consultation with women living with HIV regarding this strategy
and other efforts by UNAIDS, we look forward to a more gender responsive UNAIDS
this document envisions.
ICW notes with particular positive interest that this version of the strategy has
included issues key for addressing HIV prevention and treatment among women
and girls. In particular ICW is pleased that components touching on SRHR, nutrition,
community involvement and capacity strengthening, aging and Non Communicable
Diseases (NCD’s) have been included. We feel that the strategy is much improved
but must be improved further, particularly regarding practical strategies for
implementation of the plan for women and girls living with HIV.
We are therefore pleased to share in a spirit of support for the progress shown
the following key observations and recommendations with the UNAIDS team.
Over Arching Concerns
- Increase focus on maternal health outcomes for women living with HIV is needed.
- Include practical steps to action SRHR, gender equality, human rights and issues
impacting women living with HIV at the regional level is needed.
- We reiterate the need for explicit focus on the engagement of women living
with HIV throughout these processes including and most importantly during
implementation. [Pg 30 #107]
- Ensure a strong and consistent focus throughout on women’s autonomy on their
lives and health beyond motherhood.
- Review the Strategic Development Goals (SDG’s) targets; although we understand
UNAIDS cannot prioritize all of them as cross-cutting targets- there are
many that could and should be references as support for different aspects
of UNAIDS programming that are not included throughout this document.
Violence Against Women Living with HIV
- We applaud the inclusion of a focus on eliminating all forms of violence against
women living with HIV [Pg32 #113 & Core Actions]
- We request that the institutional violence and violence in health care settings
including maternal health care settings be mentioned as a form of violence
experienced by women living with HIV.
- We suggest that Target 5.1 & 5.2 of the SDGs be used as a cross-cutting
target/issue for framing this strategy emphasis on ending all gender discrimination
(Target 5.1) and eliminating gender-based violence (5.2).
Keeping Mothers Alive-PMTCT & Maternal Health
- We note with concern the missing targets for maternal mortality and strategies
for ensuring PMTCT programs focus on keeping mothers alive. Maternal mortality
rates are 7-8 times as high among women living with HIV.
- To this end we suggest that target (3.1) under Goal 3 should be specifically
emphasized within the strategy as a cross-cutting/intersecting issue/target
for framing within the SDGs and contribute towards 3.1 By 2030, reduce
the global maternal mortality ratio to less than 70 per 100,000 live births.
- We note with positive interest section [Pg 27 #91] and recommend that although
the international community is called upon to sustain and strengthen efforts
to PMTCT, its implementation (HIV testing and treatment initiation) must
comply with basic human rights principles including informed consent which
must be explicitly referenced in the text; especially during HIV testing
and initiation to ART.
- It is also critical that efforts at partner involvement do not become mandatory
requirements for partner involvement which poses a significant barrier
for women living with HIV in seeking PMTCT services.
- We recommend a focus on ensuring existence of the focus towards keeping mother
alive beyond prevention of vertical transmission. This focus is currently
missing in the strategy.
- Regarding early infant diagnosis, mother s and women living with HIV should
be given adequate information and choices for early infant diagnosis. Furthermore
the strategy needs to ensure that implementation of testing complies with
basic human rights principles including informed consent. [Pg 22 #62 &
Pg 27 #90]
- We applaud the increased focus on protection and promotion of human rights
as a facilitator of the HIV response and recognition of the role of civil
society and particularly networks of people living with HIV to advance
the human rights of people living with HIV.
- We propose the inclusion of discriminatory and abusive treatment and attitudes
from health service providers in. [Pg 32 #112]
Sexual and Reproductive Health and Rights
- Although issues related to SRHR is a cross-cutting issue for us across regions,
not much is highlighted for specific regions among the gaps and challenges
and there are no specific interventions recommended as game changers to
respond to our SRHR related issues by regions. [Pg 40–58]
- The last sentence should state “urgent investment in adolescent and youth friendly
sexual and reproductive health services including HIV testing and treatment
is needed to close access gaps.” [Pg 27 #89]
- We must also include strong focus on support for women and mothers beyond preventing
vertical transmission and address women beyond motherhood particularly
we recommend focus on comprehensive SRHR services, which include family
planning, access to contraceptives, STI screening and treatment for Syphilis
and Cervical cancer among others.
Engagement of Women Living with HIV
- There is interchangeable use of the words Civil Society and Communities/Networks
of people living with HIV in the document. A definition is needed and explicit
reference to people and women living with HIV is suggested. [Section 21]
- We recommend clear definitions and roles for networks of people and particularly
women living with or affected by HIV including key population networks.
This is particularly helpful for articulating a vision as to how women
living with HIV will be engaged and involved in the roll out and implementation
of this strategy at global and regional and or country levels.
- We would like to see an explicit inclusion of indigenous women in this document.
- In the spirit of the Post-2015/SDG concept of “leaving no one behind” the strategy
needs to prioritize populations from rural settings and special groups
like indigenous populations who aren’t it seems this strategy focuses largely
on urban centres and does not mention much about the needs of those in
- The sentence ‘Priority-setting and focus: location and population more important
than ever before’ seems to replicate the PEPFAR programmatic shift with
a geographic and population focus in their countries of operation. The
challenge with this approach is that some countries/districts/cities may
report low HIV incidence which could be a result of poor model of service
delivery used by the implementing partner as opposed to actual lack or
need. [Pg 12 #25]
- We recommend that the decision on priority setting and focus in terms of location
and population should be based on accurate epidemiological data and also
should consider the HIV dynamics in various countries.
- Countries with a generalized epidemic and persistently high prevalence nationwide,
withdrawal of services has very different ramifications than in other countries
where the epidemic is more focused geographically.
- ICW welcomes the identification of core actions which we feel are well presented
however it is unclear how these core actions relate with regional goals
and strategies for achieving laid out with primary targets and game changers.
The strategy does not articulate how the UNAIDS will action the gender
equality/human rights goals in the regions and the regional focus sections
are missing any significant reference to gender related goals. It is critical
that UNAIDS explicitly outline how it intends to action its goals around
SRHR, Maternal health, gender equality, human rights, community engagement
at the regional level.
A Holistic Approach to Living with HIV
- ICW further recommends that the strategy encompasses a broader ‘systems thinking’
approach linking to women and girls across all our life cycle including
how HIV affects and is affected by all the SDG’s and not only those highlighted
in the draft.
Practical Actions on Trips
- The emphasis on this paragraph and other pages [Pg 31 #50] is on the impact
of intellectual property on access to treatment and supporting countries
to incorporate TRIPS flexibilities to reduce cost of antiretroviral medicines
and other commodities. However, the UNAIDS Strategy does not explicitly
show how it is going to support LDCs to achieve indefinite extension of
the 2002 pharmaceutical extension decision which expires 1 January 2016.
- The 2002 pharmaceutical extension decision explicitly states that with regard
to “pharmaceutical products” LDCs are not required “to implement or apply”
patents (Section 5 of the TRIPS Agreement) or to “enforce rights” provided
for under those Sections until 1 January 2016 which is not far from now.
Majority of people living with HIV are women and girls and majority of
the people living with HIV in LDCs who are initiated on ART, access generic
lifesaving commodities including ARVs. [Pg 13 #30, Pg 31 & Pg 50]
- We note with concern and seek justifications for the UNAIDS estimates that
one quarter of global HIV funds should be allocated to prevention efforts
other than antiretroviral therapy. We are in the era where HIV funding
is dwindling and there are still people who are eligible for HIV treatment
but are not yet on ART. [Pg 21 #51 (last sentence)]
- Food and nutrition interventions with a particular focus on cash transfers
should be implemented in such a way that it accommodates prevention with
positive adolescent girls and young women. We have concerns about the effectiveness
of cash transfer programs and concerns about their coercive nature. Current
cash transfer programs that focuses solely on those not living with HIV,
reinforce the already existing differential treatment, yet those who are
living with HIV and those who are not living with HIV do not live in isolation
from each other. [Pg 22 #59 and Pg 31 #110]
Tuberculosis (TB) & Women Living with HIV
- This paragraph needs to include a gender focus because TB affects women and
men differently. TB is particularly lethal for women living with HIV because
of the caring role but also because they have poor access to health services,
making them particularly vulnerable to poorer outcomes linked to undetected
or late detected TB disease. Women face acute risks of TB/HIV co-infection
and subsequent TB disease and TB is among the top killers of women of reproductive
age. [Pg 23 #68]
ICW remains committed to continued collaborative consultation with UNAIDS and other
stakeholders to ensure that the UNAIDS 2016–2021 Strategy meets the needs and
protects the rights of women and girls living with HIV.