Posted by Maria Codina on April 4, 2018 at 2:25 pm
HIV is not only driven by gender inequality, but it also entrenches gender inequality, leaving women more vulnerable to its impact. Providing sexual and reproductive health interventions for women living with HIV that are grounded in principles of gender equality and human rights can have a positive impact on their quality of life; it is also a step towards long-term improved health status and equity.
There were an estimated 17.8 million women aged 15 and older living with HIV in 2015, constituting 51% of all adults living with HIV. Adolescent girls and young women are particularly affected; in 2015 they constituted 60% of young people aged 15–24 years who were living with HIV, and they also accounted for 58% of newly acquired HIV infections among young persons in that age group. In many countries, women living with HIV do not have equitable access to good-quality health services and are also faced with multiple and intersecting forms of stigma and discrimination. Furthermore, women living with HIV are disproportionately vulnerable to violence, including violations of their sexual and reproductive rights.
Many signifcant changes in HIV-related policies, research and practice have occurred in the 10 years since the World Health Organization (WHO) published Sexual and reproductive health of women living with HIV/ AIDS: guidelines on care, treatment and support for women living with HIV/AIDS and their children in resource-constrained settings in 2006. These changes include the rapid expansion of antiretroviral therapy (ART) and the release in 2015 of WHO recommendations to offer immediate ART to all individuals living with HIV and to offer pre-exposure prophylaxis (PrEP) to individuals at substantial risk of HIV infection as an additional prevention choice. Given the signifcant difference in scope, this guideline was viewed as a new submission by the WHO Guidelines Review Committee, rather than an update of the 2006 guidelines. This guideline responds to requests from organizations, institutions and individuals for guidance which consolidates existing recommendations specific to women living with HIV along with new recommendations and good practice statements. It is expected to support front-line health-care providers, programme managers and public health policy-makers around the world to better address the sexual and reproductive health and rights (SRHR) of women living with HIV.
The starting point for this guideline is the point at which a woman has learnt that she is living with HIV, and it therefore covers key issues for providing comprehensive SRHR-related services and support for women living with HIV. As women living with HIV face unique challenges and human rights violations related to their sexuality and reproduction within their families and communities, as well as from the health-care institutions where they seek care, particular emphasis is placed on the creation of an enabling environment to support more effective health interventions and better health outcomes.
This guideline is meant to help countries to more effectively and efficiently plan, develop and monitor programmes and services that promote gender equality and human rights and hence are more acceptable and appropriate for women living with HIV, taking into account the national and local epidemiological context. It discusses implementation issues that health interventions and service delivery must address to achieve gender equality and support human rights.
This guideline aims to provide:
Woman-centred health services involve an approach to health care that consciously adopts the perspectives of women, their families and communities. This means that health services see women as active participants in, as well as beneficiaries of, trusted health systems that respond to women’s needs, rights and preferences in humane and holistic ways. Care is provided in ways that respect women’s autonomy in decision-making about their health, and services must include provision of information and options to enable women to make informed choices. The needs and perspectives of women, their families and communities are central to provision of care, and to the design and implementation of programmes and services. A woman-centred approach is underpinned by two guiding principles: promotion of human rights and gender equality.
Human rights: An integrated approach to health and human rights lies at the heart of ensuring the dignity and well-being of women living with HIV. This includes, but is not limited to, the right to the highest attainable standard of health; the right to life and physical integrity, including freedom from violence; the right to equality and non-discrimination on the basis of sex; and the right to freedom from torture or cruel, inhuman or degrading treatment. The right to SRH is an integral part of the right to health, enshrined in article 12 of the International Covenant on Economic, Social and Cultural Rights.
Gender equality: The promotion of gender equality is central to the achievement of SRHR of all women, including women living with HIV in all their diversity. This means recognizing and taking into account how unequal power in women’s intimate relationships, harmful gender norms and women’s lack of access to and control over resources affect their access to and experiences with health services.
The WHO Department of Reproductive Health and Research (RHR) led the development of this consolidated guideline, following WHO procedures and reporting standards laid out in the 2014 WHO handbook for guideline development. To help ensure that the guidance appropriately reflects the concerns of women living with HIV in all their diversity, WHO commissioned a global survey on the SRHR priorities of women living with HIV – the Global Values and Preferences Survey (GVPS)1. This process was placed at the heart of the development of this guideline and the findings of the survey are included throughout the guideline.
To develop the scope of this guideline, the WHO Guideline Steering Group (SG) mapped all existing WHO SRHR guidance for women living with HIV, then reviewed these documents to determine the relevance of existing recommendations that have undergone the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) for inclusion in this consolidated guideline. The SG identified the following eight topic areas for new recommendations or good practice statements: psychosocial support, ageing and healthy sexuality, economic empowerment and resource access (including food security), integration of SRHR and HIV services, empowerment and self-efficacy around safer sex and reproductive decision-making, facilitating safe disclosure for women living with HIV who fear or experience violence, modes of delivery for best maternal and perinatal outcomes (specifically caesarean section), and safe medical and surgical abortion. Development of the new recommendations and good practice statements to respond to these eight topic areas began with systematic and narrative reviews of the evidence. The Guideline Development Group (GDG) assessed the quality of the available evidence for the new recommendations and considered the bene ts and risks, values and preferences, human rights, equity, costs and feasibility of implementation to determine the strength of each recommendation.
Implementing comprehensive and integrated SRHR and HIV programmes to meet the health needs and rights of the diverse group of women living with HIV requires that interventions be put into place to overcome barriers to service uptake, use and continued engagement. In all epidemic contexts, these barriers occur at the individual, interpersonal, community and societal levels. They may include challenges such as social exclusion and marginalization, criminalization, stigma, gender-based violence and gender inequality, among others. Strategies are needed across health system building blocks to improve the accessibility, acceptability, affordability, uptake, equitable coverage, quality, effectiveness and efficiency of services for women living with HIV. If left unaddressed, such barriers undermine health interventions and the SRHR of women living with HIV.
Action on the recommendations in this guideline requires a strategy that is informed by evidence, appropriate to the local context, and responsive to the needs and rights of women living with HIV. In addition, programmes should aim to achieve equitable health outcomes, promote gender equality, and deliver the highest-quality care efficiently at all times. Effective implementation of the recommendations and good practice statements in this guideline will likely require reorganization of care and redistribution of health-care resources, particularly in low- and middle-income countries. Potential barriers are noted and a phased approach to adoption, adaptation and implementation of the guideline recommendations is advised.
During the guideline development process, the GDG identified important knowledge gaps that need to be addressed through primary research. This guideline will be updated ve years after publication unless significant new evidence emerges that necessitates earlier revision.
Tables 1 and 2 present the new and existing recommendations and good practice statements, respectively. Figure 2.1, at the end of Chapter 2, presents a visual framework that brings together all the elements of the guideline, with women living with HIV at the core.