Heightened risks among adolescent girls and young women

Adolescent girls and young women (AGYW) are disproportionately affected by HIV and other sexual and reproductive health risks. Laws, policies and practices that perpetuate gender inequality, harmful gender norms and gender-based violence create barriers to access to sexual and reproductive health & rights. Moreover, gender inequality limits access to education, resources and services for AGYW, preventing AGYW from being able to make decisions about, control and access health care services.

Sexual and reproductive health and rights are essential to the well-being of each individual and to support the fulfilment of national responses to health risks, such as HIV. However, the GCHL 2018 Risks, Rights and Health Supplement recognizes that, in global efforts to reach SDG targets, adolescent girls and young women (AGYW) are being left further behind. This leaves them at risk of poor sexual and reproductive health. For instance:

• The Guttmacher Lancet Commission report Accelerate progress—sexual and reproductive health and rights for all found that “[c]ompared with young men, young women are more likely to acquire HIV, and the age of infection is 5-7 years earlier often coinciding with sexual debut. Other STIs, including HPV, are also commonly acquired in the early reproductive years—i.e., younger than 25 years.”
• The UNAIDS Global AIDS Update 2020 reports that in sub-Saharan Africa, adolescent girls and young women (aged 15–24 years) accounted for 24% – almost one in four – HIV infections in 2019 despite being just 10% of the population. Women and girls of all ages represented 59% of new infections among adults (aged 15 and older) in the region.

Factors that heighten the risk of HIV and sexual and reproductive health risks amongst AGYW include biological factors, as well as legal, social, economic and cultural factors relating to gender inequality, harmful gender norms, gender-based violence and other human rights barriers experienced by AGYW. For instance:

• The Guttmacher–Lancet Commission 2018 Report: Accelerate progress found that despite worldwide efforts to end child marriage, the practice remains common in developing regions, particularly in South Asia and sub-Saharan Africa. Child marriage increased sexual and reproductive health risks for adolescent girls for various reasons, including that “they are often socially isolated, tend to begin childbearing early, are vulnerable to STIs, including HIV, and are often unable to negotiate safer sex with their husbands, who are typically much older”. Research found that girls who marry before 18 years are at greater risk of intimate partner violence and forced sexual intercourse than those who marry at adulthood. The report also found that adolescents who give birth at 15 years or younger have increased risks of pregnancy-related complications and death.
• The report also found evidence that adolescents’ self-stigma and fear of health care workers was a barrier to access to sexual and reproductive health care services: “only a few of sexually active adolescent women who have an STI or who have symptoms seek care in a health facility. Many adolescents do not know where to seek STI services, and those who do might feel ashamed or afraid to get treatment from health-care providers.”

Laws and norms that limit women’s and girls’ autonomy

A wide range of laws, customs and practices – for instance laws and norms allowing young girls to be married below the age of 18 years, laws that fail to criminalize the rape of a wife by her husband, laws and practices that prohibit women from owning or inheriting property or to having autonomous decision-making power within their relationships, and laws, policies and practices limiting adolescent girls’ independent and confidential access to sexual and reproductive health services – perpetuate gender inequality. These laws, policies and practices limit the ability of women and young girls to control their lives, including their ability to protect themselves from HIV and other sexual and reproductive health risks.

The GCHL 2018 Risks, Rights and Health Supplement examined select legal, human rights and gender-related barriers to sexual and reproductive health for AGYW. It reported that criminalization, stigma, discrimination, violence and other legal and human rights barriers undermined women’s and girl’s ability to control their own bodies, choose their partners or to receive high-quality sexual and reproductive health care. For instance, it found that globally, laws and policies in more than 70 jurisdictions allow health-care providers to refuse to provide health services to girls and young women based on claims of “conscience,” preventing AGYW from accessing critical services such as contraception or abortion.

Increased vulnerability to HIV infection has also been linked to intimate partner violence, which is more common among younger women and women who are economically dependent on their male partners. Violence or the fear of violence can make it very difficult for women to insist on safer sex and to use and benefit from HIV and sexual and reproductive health services. Women living with HIV who experienced intimate partner violence were significantly less likely to start or adhere to antiretroviral therapy, and they had worse clinical outcomes than other HIV-positive women. Read more: GCHL (2012) Risks, Rights and Health

Recommendations for building enabling laws and policies

Enabling legal environments need to prioritise laws, policies and programmes that address the human rights and gender-related factors that cause heightened risk of HIV and other sexual and reproductive health risks amongst AGYW.

The GCHL Risks, Rights and Health Supplement recommends that governments must adopt and enforce laws that remove legal barriers to accessing the full range of sexual and reproductive health services and that protect and promote sexual and reproductive health and rights.

The Guttmacher-Lancet Commission report Accelerate progress—sexual and reproductive health and rights for all warns that a continuation of the status quo would mean that human rights violations, such as child marriage, female genital mutilation, intimate partner violence and sexual coercion and violence, will persist, along with major inequalities in health and access to health care. The report identifies high priority legal and policy reforms to support sexual and reproductive health and rights as outlawing child marriage, promoting gender equality and women’s autonomy, liberalizing abortion laws and prohibiting discrimination against people with diverse sexual orientations and gender identities and expression.

Gender-related risk factors for TB

Gender is an important determinant of risk and vulnerability to TB. The Global Fund Technical Brief: Tuberculosis, Gender and Human Rights identifies various gender-related risks and barriers to access to TB services, including:

• The negative impact of notions of masculinity on men’s health seeking behaviour, leading to delays in diagnosis and lower rates of treatment access and completion amongst men.
• Employment conditions (e.g. in the mining sector) impacting upon men.
• The deprioritization of women’s health needs in families, due to gender norms, child-care and family responsibilities or limited autonomy for health decision-making, leading to delays in diagnosis and lower rates of treatment access and completion amongst women.
• Higher rates of stigma against women with TB, leading to avoidance of health care by affected women.

Gender-responsive approaches to TB

A gender-responsive approach to TB requires integrating gender equality norms and principles in the design, implementation, monitoring and evaluation of TB programmes, as well as implementing various programmes to empower key and vulnerable populations to address their particular needs and ensure their participation in health decision-making.

The Political Declaration of the UN General Assembly High Level Meeting on the Fight Against TB commits Member States to recognising the various sociocultural barriers to TB prevention, diagnosis and treatment services, especially for those who are most vulnerable, ending TB-related stigma and discrimination and developing health service approaches that protect gender equality, amongst other things.

Gender-based risk factors for malaria

Gender-based constraints on access to malaria services have been identified as key factors in vulnerability to malaria. For instance:

• Women and girls may face malaria risks linked to gender norms where they are required to undertake tasks pre-dawn or in the early evening (e.g. preparing food, fetching water or working in fields) that expose them to mosquitoes. Similarly, men may be exposed due to migrant work, or work in forests, fields, mines or other high-exposure locations.
• Adolescent girls may have limited access to health services due to laws requiring parental consent for access to health care in a number of countries.
• Limited access to health information – e.g. due to low literacy – may impact on women more than men, limiting their acess to information on malaria prevention and treatment.
• In some circumstances, gender norms may dictate who receives long-lasting insecticidal nets; women may not have the autonomy to seek or receive nets, or purchase additional nets when needed.

Addressing gender-related barriers to malaria prevention and treatment

Health responses to malaria should be informed by a thorough analysis and understanding of all gender-related barriers to access to malaria prevention and treatment services and should seek to implement programmes to address these barriers.