Why women’s agency matters in the fight against HIV

The theme for this year’s International Women’s Day is #EachforEqual — recognising that an equal world is an enabled world and that to achieve this we must challenge stereotypes, fight bias, broaden perceptions, improve situations and celebrate women’s achievements.

To celebrate International Women’s Day, we caught up with Dr Nevilene Slingers, Executive Manager at the South African Medical Research Council (SAMRC), and a prominent HIV clinical specialist, to learn more about how HIV affects young women in South Africa and what can be done about it.

Social Finance has been working with the SAMRC to develop a social impact bond (SIB) that improves HIV and pregnancy outcomes for young women, due to launch later this year.

How did you first start working in HIV in South Africa?

My journey working with HIV and young women is a long one — I am a medical doctor, specialised in Family Medicine and then did an Executive MBA. I first started out in HIV programme design and implementation whilst working as a doctor at a local district level before moving to the provincial level to focus on the design and implementation of a programme to provide antiretroviral therapy. This started my journey where I then became more and more interested in improving health outcomes, focusing on evidence based programming, cost-effective use of resources, as well as active citizenship. It became increasingly apparent to me that all of the above is necessary in order to achieve sustainable outcomes.

Since 2003, I’ve worked specifically on HIV and TB. During my time as a medical doctor in the early 2000s, HIV was at crisis point in South Africa; antiretroviral treatment was not available, policies and guidelines were not in place to make sure products were available at the primary healthcare clinics and hospitals were overwhelmed with HIV positive patients. In the hospital I worked in, there where people arriving in the tens and hundreds, with end stage complications of HIV and we had no treatment to offer them! At this point I realised that the primary healthcare level was just not being heard at the provincial and the policy setting level.

How does HIV impact women in South Africa?

In the last few years, the South African health surveys have started to show that about a third of new HIV infections are in young women and adolescent girls. This translates to around 2,000 new cases among women aged 15–24 every week.

The difference in infection rates between men and women in that age group is stark: young women and girls in South Africa are eight times more likely to be living with HIV than young men of the same age. So, we tried to understand exactly why women are impacted in this way.

A cycle of transmission has been identified and this shows that adolescents and young women are having unprotected sex with older HIV infected men. This cycle can be explained by the prevalence of transactional sex and the wider challenging circumstances many young women face in South Africa. Where there is poverty, girls are more likely to engage in different forms of transactional sex, often with older men. Many of these men may have multiple sexual partners and may not be tested for HIV. Furthermore, if the men do not have a source of regular income, they may also engage in violence and alcohol abuse, and may also be unable to access healthcare — which further complicates the situation.

Ultimately, the high prevalence of HIV among women is intrinsically linked to the wider societal issues they face, such as unemployment and social inequality. These societal issues also undermine women’s agency, and, without agency, young women are unable to negotiate safe sex or access services. It’s also important to mention that within the context of South Africa, the after effect of apartheid adds another layer to these already complex social issues and further underlines the need for an intersectional approach when tackling HIV.

How do gender inequality and the broader societal issues you described affect women in the different stages of HIV care and treatment?

In South Africa, women are often the primary caregivers and are not always able to prioritise their own health, which is often seen as secondary to the health needs of their partners and their children. In some communities, women have to explain to their partners why they are going to health facilities and why they are on medication. Taking anti-retrovirals can be seen as a sign that women don’t trust their husband or partner. There is an imbalance between what you are allowed to negotiate as a woman, versus what men expect. As a society, we need to empower women to be able to say ​“I will go to the clinic and I will take contraception”.

How can HIV programmes and policy promote female agency?

HIV programmes and policies tend to focus on making sure people have accurate information and knowledge, as well as ensuring that services are available and accessible. But without agency, women won’t even be able to leave the house, let alone get to a health facility. Generically, improving agency is spoken about in terms of resilience and self-confidence, but this can’t be measured in the short term, and donors are reluctant to fund programmes that build agency in the long term.

I really believe that this issue of agency is a gap, but we can’t only address it from the HIV side, and this is why we should be looking at other approaches like social impact bonds, where we are making a link to a more sustainable and deeper change. This issue needs to be tackled creatively with government providing the necessary funding and policy environment, supported by the private sector, for innovative solutions that understand and respond to the needs of adolescents and young women and broader communities. This is my feeling of how you bring about that change.

What potential solutions does an impact bond have to offer to this issue?

In using the impact bond approach, we are trying to bring in new sources of funding, because resource mobilization to tackle this issue area remains a challenge. The focus on performance and the use of performance management is essential in driving continuous improvement, as is the greater use of data and analysis to inform changes and decision-making. We are also looking at the evidence base from a slightly different perspective than those before us, whilst building on lessons learnt, and we have carried out extensive research to inform the ​“how” of delivering the package of services to young women. An impact bond pulls together all of this, shifts the focus towards outcomes and means that the outcomes funder (in this case the Government of South Africa) will only pay for what works.

Focusing on outcomes, rather than inputs, allows for flexibility. Typically, programmes are set out according to pre-agreed inputs and processes and have a fixed budget so there is a lot of focus on doing what you said you were going to do. In a bond, we can change the programme to respond to feedback from young women, implementing organisations and from other stakeholders. This kind of drive to continuously learn and improve is what sets the SIB apart, and we are hoping that this will allow us to build a better intervention in a shorter amount of time, whilst also being cost-effective.

We also plan on implementing economic modelling and a pragmatic randomized cluster-controlled study, to be able to demonstrate the impact of this package of interventions, to understand what makes it work and its cost-effectiveness. This will mean the government has a clear indication of the programme’s impact, its cost and cost savings, and the details of how it should be implemented for success.

What does success look like?

If the SIB is successful, we would work with government departments to scale it up. Reducing HIV incidence, improving continued access to HIV care and treatment, and reducing teenage pregnancy are key issues for the government of South Africa and, if we have an intervention that shows it can improve the outcomes in these areas, the programme could then be rolled out in schools all over the country.

The challenge of HIV is one we can’t ignore. It forces people to collaborate and think in different ways. By working with the social investors, we can leverage more resources and involve the private sector in a more meaningful way. We must have hope for young women for the next generation and whilst we can’t underestimate the challenge, we must continue to learn and improve if we are to have an impact!