With COVID-19 taking up all the news, it is easy to forget that we are already at the centre of a global pandemic: HIV and AIDS. In South Africa – which has the highest number of people living with HIV in the world – the face of HIV is largely young and female, with adolescent girls and young women between 15 and 24 over three times more likely to acquire HIV than their male peers.
What President Ramaphosa called South Africa’s ‘second pandemic’ of gender based violence is also young and female: three quarters of sexual violence survivors reached with services in the post-rape care centres where we work are under the age of 24. These two pandemics are closely interlinked and co-dependent with an estimated 20 to 25% of new HIV infections attributable to gender based violence.
And then there is the ‘forgotten’ pandemic: tuberculosis. In high TB transmission settings like South Africa (one of just eight countries that account for two thirds of the global TB burden), the rate of tuberculosis increases rapidly during adolescence to peak in early adulthood. Again, this disease is intertwined with HIV. Over 60% of people with active TB are living with HIV. Some of the same factors that make young women vulnerable to HIV (like poverty and inequality), also put them at greater risk of TB: there are more female than male cases notified up to the age of 25 years in South Africa.
We are working at the intersection of HIV, GBV, TB and now COVID-19.
Why are girls and women more at risk? Sibongile Sondi, a supervisor on one of our programmes aimed at keeping girls in school sums it up: "In my community, children are under a lot of stress, especially the girls. There is often an unhealthy home background and many are orphans, live with their extended family, and experience alcoholism and abuse within the home environment. Often, they're the primary caregivers in a home. I have so much respect for them."
An evaluation of our Global Fund Young Women and Girls programme, published by the South African Medical Research Council in 2019 as part of the Her Story Study, identified the following drivers of HIV risk in young women: poverty and a lack of educational and economic opportunities, poor access to sexual and reproductive health services, gender inequality and violence, stigmatisation and the widespread availability of alcohol.
This validates and echoes our own experience of working with vulnerable girls and young women in communities across the country. We have discovered a general lack of awareness about sexual and reproductive health, as well as the self-efficacy and confidence to change behaviour and avoid the risks. Extremely high rates of gender based violence – and in particular intimate partner violence – are further disempowering young women and preventing them from seeking care and help.
Finally, poverty and lack of access to work and training opportunities are making young women vulnerable to transactional sex: where they exchange sex for basics like food, air time and clothing, often with older men.
The new pandemic
When COVID-19 hit South Africa in March, the risks for young women accelerated. Lockdown meant there was a rapid reduction in the uptake of HIV testing services, TB screening and HIV and TB treatment. The post-rape care centres where we work also saw a dramatic drop in victims reporting in – even though we knew that rates of sexual and gender based violence were increasing in the community.
Young women and girls dropped out of the programmes our partner organisations run to engage them and keep them safe. Out of school and locked down at home, girls were isolated and more vulnerable than ever before. The worry is that COVID-19 will roll back any progress we have made in tackling HIV, TB and GBV in one of the most vulnerable groups: young women.
We have found that the best way to engage young women and girls is to focus on empowering them to build coping ability and the self-efficacy to make healthy choices. With the support of the Global Fund, NACOSA has been able to mobilise existing networks and structures to provide extra support for adolescent girls and young women like information and counselling using WhatsApp, online training, journals to inform, inspire and track their progress, and homework support while schools were closed.
In the longer term, we will use IMpower – empowerment self-defense sessions – to give girls the confidence, verbal and physical skills to prevent assaults. Mobile clinics, equipped with multimedia communication capabilities, will provide comprehensive sexual and reproductive health advice and services to young women and girls in the most rural and isolated of communities.
Radio and social media campaigns will encourage young women to access care and treatment for all the four pandemics – HIV, GBV, TB and COVID-19. If we can increase testing, reporting of sexual assault and access to treatment, we can reduce the risks for young women and radically improve their health outcomes.
But perhaps the most critical intervention of all is empowerment. “When you get girls together and talk with them, they begin to see value in themselves," says Sibongile Sondi. As a society, we need to see value in young women and empower them to build a better, safer and healthier future for themselves.