The AIDS epidemic showed the world that HIV was highly gendered, and COVID-19 underlined the message.
The COVID-19 pandemic highlighted how women and girls are most vulnerable in health emergencies with sobering statistics on the rise in domestic violence or avoidable health complications from a lack of adequate essential maternal and reproductive healthcare, including HIV prevention in lockdowns around the world.
Equity and social determinants and their impact on health at home and around the world are critical issues for the global community. On November 17th, the Yale Institute for Global Health (YIGH) hosted UNAIDS Executive Director Winnie Byanyima for a conversation on HIV, COVID-19 and gender inequalities driving these pandemics. Luke Davis, Associate Professor of Epidemiology (Microbial Diseases) and of Medicine (Pulmonary), chaired the wide-ranging conversation which included discussion on the global economic injustices leading to health inequalities, peer-led interventions that support displaced women and girls,and other issues.
“Today HIV is an injustice because we have the tools, maybe not a vaccine yet, but we have the tools for prevention and testing and yet people are dying preventable deaths,” said Byanyima. “Last year we had 1.5 million new infections and 650,000 people dying from related illnesses, most of them in Africa. So, in spite of what we have, what science provides, we still have people newly infected, people dying. When we peel that back and see who is dying, we see the inequalitiesdriving the deaths.”
Byanyima emphasized the gendered dimensions of HIV by saying, “In Sub-Saharan Africa, adolescent girls and young women are three times as likely to acquire HIV as adolescent boys and young men.” These numbers are driven by gender inequalities including unequal opportunity to education or sexual information, lack ofaccess to services, or increased risk of sexual violence. As a result, gender equality is pivotal in fighting any epidemic.
“Inequalities of every kind, gender, income, racial and then where they intersect is where you have the highest vulnerability,” added Byanyima. Byanyima noted that inthe United States, African Americans are eight and a half times more likely to be diagnosed with HIV than white people. Given the population, that translates to roughly one in two people at risk of contracting HIV across their lifetime, which Byanyima pointed out was a higher lifetime risk than the average in her home country of Uganda.
Still, when the problem is complex, the solution needs to be creative and multifaceted. Cutting through the web of social determinants that lead to health inequalities requires innovative approaches beyond just the health sector. For example, in Malaysia, there is a concentrated epidemic in areas where same-sex relations are criminalized. Men who have sex with men are 72 times more likely than other men to be living with HIV where same-sex relations are criminalized. “So just removing the law that hunts down gay men reduces their vulnerability,” says Byanyima. On February 25, 2021, Malaysia’s Federal Court ruled that a state law banning consensual same-sex conduct was unconstitutional.
A sharp critique of the USAID approach to the AIDS epidemic has been its reliance on a biomedical model rather than focusing on the social determinants and the structural barriers to healthcare. Byanyima noted that this is something UNAIDS is working to correct but admittedthat more data is needed to make the linkage betweeneconomic inequality and vulnerability to HIV. UNAIDS is making strides in this area. She added that decriminalizing is not the only way to address stigma and said that by “making the goal of equalizing, we can end AIDS.”
In her closing remarks, Byanyima offered some advice for World Aids Day and what she hopes for the future. “Young people, girls and boys today need more information on HIV and AIDS, and sexuality education which is critical for life,” she said She urged for more nuance and free academic debate on gender, health rights, and human rights. On Yale’s role in the epidemics, she added that universities can spur the movement and challenge stigma from the top-down. “We need to give our children the space to challenge these old traditions and stigmas and teach every student about human rights.”