Written responses to International Development Committee

following Oral Evidence Session on Tuesday 4 July 2023

Provided by:

Alice Welbourn, Salamander Trust

Fionnuala Murphy, Frontline AIDS

●        What issues do lower-income countries have in diagnosing, preventing, and treating HIV/AIDS and other sexually transmitted infections?

Alice Welbourn:

Below I offer some examples of the challenges hampering successful prevention, diagnosis, and treatment of HIV in LMICs. These examples are by no means exhaustive. The overall gist of what I describe is the critical importance of involving those affected by these issues as much as possible, in order to learn from their experiences and build on these. Their meaningful involvement throughout policy and programme research, development, implementation and evaluation is both a human right (Article 27,1) and also aligns with what is recommended by the WHO Guideline on the SRHR of women living with HIV (section 6.2.1). In addition, it supports the recovery of those most affected by enabling them to feel useful, valued, respected and supported, rather than marginalised, rejected and ostracised by society. All responses also need to be holistic, 360 degrees, integrated, comprehensive, placing the person / survivor at the center of the response, using the Lancet-Guttmacher definition of SRHR as a valuable baseline[1].

PREVENTION:

1)               Lived experience.

Most global and in-country analysis of why people acquire HIV is over-simplistic and has not taken on board the lived experiences of women (or others) living with HIV[2]. This often increases the stigma and discrimination experienced by people living with HIV and also makes it harder for people to apply prevention messages to their own lives.

2)              Dual protection.

For example, in order for women to be able to use condoms during sex, to protect themselves from HIV or other STIs, there is a need for them – and their sexual partners - to be trained in the importance of condom use to protect themselves, combined with condom negotiation and wider communication and relationship skills. Such skills are critical to avoid violence and to maintain their bodily autonomy. (Removing a condom during sex without consent is seen as rape in UK law[3]). There is still much to be done to advance condom demand and condom negotiation skills globally[4].

HIV prevention is also hampered by lack of any attention to dual protection in contraception programmes, such as WISH. Without condoms and related negotiation skills, even if they avoid unplanned pregnancy, they are still highly vulnerable to acquiring HIV or other STIs, through unprotected penetrative sex. Young women practising cross-generational transactional sex (ie with older men), girls and young women in early childhood marriages, and older married women who may well want to have a baby, as well as sex workers or lesbian / bi women or women who use drugs are all vulnerable to HIV and other STIs if they cannot negotiate condom use with their sex partner.  Even if they try to use condoms, this can result in violence. WHO has reported that VAWG increases their vulnerability to acquiring HIV or other STIs by a factor of 1.5 (this figure may be even higher in some areas – see Kuchukhidze et al below)[5].

3)              Gender-transformative policies and programmes.

The UN Global AIDS Strategy[6] and the Global Fund[7] strategy do now have a more nuanced understanding of the complexity of the gendered physical, sexual, reproductive, psycho-social, material, financial and legal power dimensions that need to be addressed in effective HIV (and other STI) prevention programming. These include the need for gender-transformative social norms change programming[8].

However, there is still limited recognition - and extremely limited funding available - for this sort of ‘invisible’ programming, since such responses fall outside the conventional bio-medical response to addressing viruses. Data are often still undisaggregated by gender or age, and results cannot be seen or measured down a microscope. As What Works 1 established, working with both women and girls and men and boys in gender-transformative ways can and does mean that violence is preventable. This is also the case for HIV prevention work, since global experts are agreed that the drivers for VAWG, HIV, other STIs, ECM, unplanned pregnancy, and many more SRHR challenges are all so closely aligned and would best be addressed from a person-centred (ie women / girls / survivors) perspective rather than from a disease/event focus[9],[10].

4)  Pleasure.

Prevention programmes are often seen as very negative and punitive in their messaging – ie ‘don’t have sex – or else’. By contrast the Pleasure Project has demonstrated[11] that programmes which advocate for everyone’s right to have pleasurable sex has shown a significant increase in readiness to listen to the messaging around condom use. “Our meta-analysis provides evidence about the positive impact of pleasure-incorporating interventions on condom use which has direct implications for reductions in HIV and STIs.”

5) Children.

In the context of schools-based prevention programmes, (comprehensive sexuality education), attention is rarely given to those children who may have acquired HIV at birth who feel they have to keep their HIV a secret at school. Students are regularly informed that HIV is acquired through sex. Therefore, if they are found to have HIV – or if some staff or students already know this, they are thought to have already been sexually active and are ostracised. It is really important for CSE programming to paint the whole picture of transmission roots – and to do so in a way which affords top priority to safety, support and respect for all with HIV – and eschews any blame of students - or of their mothers.

6)  Drug use.

HIV prevention amongst people who use drugs requires laws which promote the clear evidence around harm reduction[12] and which stop criminalisation of drug use.  Effective policies include meaningful involvement of people in all their diversity who use drugs (up to 50% of whom are women), needle exchange programmes, safe spaces for injection and – once more – condom negotiation skills to minimise HIV and/or other STI transmission. Portugal is a lead country in promoting harm reduction in its HIV prevention strategy. Most other countries have highly punitive laws against drug use[13]. The WHRIN site offers a mine of valuable information.

7)              Sexual Orientation, Gender Identity and Expression.

Punitive laws also exist in many countries, which criminalise LGBTI+ communities. These undermine effective HIV (or other STI) prevention programming amongst these communities. In contrast, those countries such as South Africa, which have a much more supportive constitution, are more effective in supporting LGBTI+ communities in prevention strategies which are created, shaped and led by community members themselves.

8)              Sex work.

Sex workers in many countries are criminalised even for carrying condoms, so whilst sex worker communities have often been at the forefront of HIV prevention strategies, they are also often persecuted for doing so. The NSWP website contains a wealth of detailed information about the inclusive, holistic, rights-based work of many of its member associations around the world[14].

DIAGNOSIS:

1)               Pregnant women.

HIV is most often diagnosed when women are attending ante-natal clinic – ie during pregnancy. Unfortunately, if diagnosed at this time, the main focus continues to be on the role of the woman as a potential transmitter of HIV to her partner and her child, rather than focusing on her own health. Women are regularly exposed to structural violence in healthcare settings as a consequence. Sometimes this can even lead to women being forcibly sterilised. The result is that women prefer to vote with their feet and avoid coming to clinic. This means that they also miss out on accessing ARVs which would keep them safe and well during pregnancy.

As Martha Tholanah (who is a member of the International Advisory Board of What Works 2) put it some years back “am I lost to follow-up or bullied out of care?” By contrast, the 4M Mentor Mothers Programme offers voluntary peer mentoring support to pregnant women living with HIV. It has proposed a paradigm shift away from “eMTCT” programmes to “eSRHR” programmes[15], where the primary focus is on ‘ensuring the SRHR’ of women living with HIV throughout the pregnancy journey – ie ensuring safety, support and respect from before conception through delivery to breastfeeding and beyond.

2)              Children and adolescents.

Diagnosis among children and adolescents: an HIV diagnosis of a child or young adolescent is often undertaken without the child’s knowledge and children are often started on treatment without the child being told the real reason for their medication. This is often to keep HIV a secret in the family, for fear a child will tell others. Whilst well-intentioned, this brings challenges for the children. Children living with HIV may often also be orphaned and living with aunts or grandmothers – or older siblings. The complex adverse childhood experiences (ACEs) they face (eg sickness, death, grief, secrecy, self-blame, anger, …) can often result in life-long health problems. These can often mean that, as adolescents, and once they guess or are insensitively told the reason for taking medication, they often disengage from healthcare, and stop taking their ARVs. Children and adolescents can often also start and/or continue drug or alcohol use to ease the pain of the traumas that they have faced. Adolescents are naturally curious. Many want to experiment as they grow developmentally - and need to be supported to do so as safely as possible. When things go wrong for them, they also need support and respect, in order for them to learn from their experiences and stay connected with significant adults, rather than feel further rejected and ostracised. Yet, even when supportive adolescent-centred SRH services try to exist, adolescents are often unable to access them, or have to attend them with a carer, because of legal age restrictions. This often renders the services unusable.

Many experts working with adolescents now recognise the critical importance of starting young with children (ie 5-9 or so), and with their adult carers (who often themselves feel bereft and overwhelmed by responsibilities), to build trusting supportive relationships, in order to minimise the life-long effects of the ACEs. This is also why holistic age-appropriate comprehensive sexuality education (CSE) - with fundamental building blocks of trust, mutual respect, kindness etc. - is so important with this age group, to ensure that children feel wanted and loved. The younger that children can feel this support, the more likely they are able to navigate their teenage years safely. However, there is little awareness or understanding of the existence or role of ACEs among children affected by HIV: and almost no funding for programming with children between 5 and 9.

3)              Younger / older men.

There has been so much focus on diagnosis of women and children that younger and older men have often been missed out. There has been routine testing of men in the police and armed forces, but these statistics are often kept as state secrets. So the myth has grown that HIV is essentially a disease affecting men who have sex with men and has nothing to do with other men – who, thanks to homophobia, fear any association with HIV. Lack of knowledge of an issue frequently produces fears about it which, in turn, lead to anger and violence if people feel threatened by the issue. This is the case for many men who have been violent towards their wives/partners if they are found to have HIV. Recent efforts to create testing services which are more supportive to men are welcome – provided there is recognition that women’s services also need to be made more supportive of women. In addition, we have already seen how gender-transformative social norms change programmes, which include both men and women, girls and boys, have successfully supported men to learn more about HIV, stop being angry and violent towards their partners, get tested and start on treatment – which in turn has greatly improved the quality of life of their partners and children also. Male-focused testing clinics (ie a bio-medical approach) alone will not be able to shift men’s attitudes and experiences and need the community work also. Yet currently, funding for the community element is not forthcoming[16].

TREATMENT OF HIV and OTHER STIs:

1)               Trauma-aware care.

People often feel reluctant to access care and treatment for HIV and other STIs if they have experienced or heard of negative past experiences from healthcare workers. If people living with HIV (and/or other STIs) feel safe, supported and respected by healthcare providers, they are much more likely to access services.

This requires training of healthcare providers in trauma-aware care. This means the need for recognition that an HIV (or other STI) diagnosis can often be a traumatic experience for someone who may also have experienced other adversity in their lives (eg sexual abuse, other adverse childhood experiences, intimate partner violence, poverty, alcohol and/or drug use, issues around sexual orientation and/or gender identity.) Alternatively, they may have experienced none of these, and ‘just’ experience an HIV or (other STI) diagnosis during pregnancy, which can come out of the blue. This can also be devastating[17] if they were unaware until then that they had been exposed to HIV (or other STIs) in their relationship.

2)              Peer support.

In addition, provision of peer support services working alongside healthcare professionals has been seen to greatly increase clients’ ability to engage with and stay in healthcare. Yet peer support services are, once more, invisible and are therefore often unfunded.

By contrast, the global ‘eMTCT’ programme still focuses primarily on viewing women living with HIV as vectors and vessels of disease, rather than active agents of change, who need to have their own rights to SRH upheld; and who would then also additionally be best placed to look after their babies’ health if their own holistic SRHR is ensured.

Continued engagement in care is especially important in the context of women living with HIV after they have given birth. This is a vulnerable time both for the women themselves, who are coping with the usual challenges of having a new baby and possible infant feeding challenges. It is also be a crucial time for the baby. Again, this is why peer support programmes like the women-led 4M programme can be so vital in ensuring that women living with HIV themselves are able and supported to remain in the best of physical and psycho-social well-being, as their own intrinsic right. There are also instrumental benefits to this: they are then best placed to ensure that their babies can remain HIV-free and grow up in the best of health.

3)              Drug use.

For treatment of people who use drugs, a positive harm reduction approach is essential. See for example https://whrin.site/. One report on the site also highlights the challenges faced by young women living with HIV who use drugs in accessing SRHR services if they are considered to be minors[18].

4)              Sex work.

Again, the NSWP site provides a wealth of information about the challenges sex workers face in accessing treatment for HIV and other STIs: and the punitive approach of many states to sex workers’ efforts to look after their own and their clients’ health[19].

5) Ageing and HIV / ARV -related side effects.

As more people living with HIV access ARVs, to keep them healthy and productive, there are also age- and/or ARV-related issues which affect them. For example, as more women living with HIV stay alive and well, it is becoming clearer that we often experience the menopause earlier; and that the menopause in the context of HIV can have additional challenges. In addition, many women are finding that some ARVs are causing excess weight gain, which can lead to diabetes and mobility problems (and mental health issues related to body dysmorphia). There is much more research needed on care, treatment and support in the context of these additional dimensions of women’s SRHR.

[1] Lancet-Guttmacher Commission 2018 Accelerate progress—sexual and reproductive health and rights for all https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(18)30293-9.pdf

[2] Dunaway K et al. 2022 What will it take to achieve the SRHR of women living with HIV? Journal of Women’s Health doi: 10.1177/17455057221080361  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8891932/

[3] https://nottssvss.org.uk/consent-coalition/campaigns/removing-a-condom/

[4] See eg Cele et al Determining the level of condom use and associated factors among married people in Tshwane District of South Africa. Pan Afr Med J. 2021 Sep 3;40:11. doi: 10.11604/pamj.2021.40.11.26681. PMID: 34733379; PMCID: PMC8531972.

[5] See https://vaw-data.srhr.org/map for a visual map of VAW globally.

[6] UN Global AIDS Strategy 2021-2026 https://www.unaids.org/sites/default/files/media_asset/global-AIDS-strategy-2021-2026_en.pdf

[7] See eg Global Fund for ATM Key Performance Indicators (KPIs) Handbook for the 2023-2028 Strategy   slide 13 - 48 KPIs adopted… https://www.theglobalfund.org/media/12681/strategy_globalfund2023-2028-kpi_handbook_en.pdf

[8] Two evidence-based VAWG reduction programmes, which align with UKAid’s What Works 1 analyses[8] (Stepping Stones and SASA!) are recommended in the Global Fund’s modular framework handbook[8]. Stepping Stones has received some funding from DfID in the past, and was adapted in different ways as part of WW1; and SASA! is created by Raising Voices, who are part of the UKAid What Works 2 consortium.

[9] See eg Petroni S et al Understanding the Relationships Between HIV and Child Marriage: Conclusions From an Expert Consultation

  https://www.jahonline.org/article/S1054-139X(19)30109-0/fulltext

[10] Jewkes, Flood and Lang 2014, From work with men and boys to changes of social norms and reduction of inequities in gender relations: a conceptual shift in prevention of violence against women and girls

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61683-4/fulltext

[11] https://thepleasureproject.org/wp-content/uploads/2022/06/journal.pone_.0261034-1-1.pdf

[12] WHRIN Global Mapping of Harm Reduction Services for Women Who Use Drugs https://drive.google.com/file/d/1F6c38cHwmVf7fLYkZtF2oEjPfk45R8W8/view?pli=1

[13] WHRIN Gender Sensitive Harm Reduction Programming https://whrin.site/ourpublication/gender-sensitive-harm-reduction-programming/

[14] See for example https://www.nswp.org/members/asia-and-the-pacific/sangram-sampada-grameen-mahila-sanstha

[15] 4M Mentor Mothers Network 2020 From eMTCT to eSRHR. https://4mmm.org/wp-content/uploads/2020/12/4M_July2020_Advocacy_Brief_combinedbriefs_final.pdf

[16] The Dunaway et al article cited above explains more about this.

[17] NB it is not the responsibility of individuals to tell health workers about these other issues in their lives. This is why we call it ‘trauma-aware’ rather than ‘trauma-informed’ care here. Instead, health workers should be trained to ask themselves why clients may be reluctant to attend their services, rather than to blame and shame clients for non-attendance or to violate their confidentiality.

[18] https://whrin.site/wp-content/uploads/2019/07/Ain%E2%80%99t-I-a-woman-Recognising-and-protecting-the-rights-of-young-women-affected-by-HIV-and-drug-use.pdf

[19] See for example https://www.nswp.org/resource/nswp-smart-guides/smart-sex-workers-guide-the-who-consolidated-guidelines-hiv-viral

Fionnuala Murphy:

1. Impact of COVID-19

In many countries with high HIV prevalence, health systems are still struggling with the impacts of Covid-19, alongside newer shocks, and this has an impact on their capacity to respond to HIV and to deliver wider SRH services. Covid-19, and the lockdowns in particular, brought an increase in many of the drivers of HIV among women and girls.  Women lost their income, faced fuel and food shortages and saw an increase in gender-based violence.  Covid also shut down health services so women were unable to access vital HIV prevention and SRHR at a time when these were desperately needed.  Many of Frontline AIDS’ partners can describe what they have seen since that time, from an increase in teenage pregnancies to a growing number of people being diagnosed with HIV very late, when their immune systems are already severely compromised.  We have also heard partners talk about higher than normal numbers of young mothers missing out on antenatal care and services to prevent parent to child transmission of HIV, with dire consequences for them and their babies.

2. Inequitable access to health technologies

Covid has had a profound impact on health systems, health workers and health financing, especially in settings where vaccines were not widely available.  The reason for this fundamentally is inequitable access to health technologies - drug company monopolies afforded by international patent rules limited the number of Covid vaccines that could be reduced and kept the prices high, with most stocks quickly bought up by countries in the global north, including the UK.  While a number of these same countries supported what was called a TRIPS waiver, which would have enabled low- and middle-income countries to produce their own generic versions of the COVID vaccine, the UK opposed this and has also not supported the WHO’s MRNA hubs, which would enable the know-how relating to essential health technologies to be transferred to countries like South Africa, which could then manufacture them in large numbers.  These moves have had a significant impact on countries’ ability to get their Covid epidemics under control, with dire consequences for their ability to then manage the other health needs of their populations.

The delayed roll-out of COVID vaccines to countries with high levels of HIV prevalence, including untreated HIV or HIV that was only diagnosed at a late stage when the immune system was already compromised, has also had a severe impact on the health and lives of people living with HIV, who statistically are disproportionately affected by COVID-related mortality.  In South Africa, this combination of untreated HIV and slow roll out of COVID vaccines also led to the development of the Delta variant and could see further dangerous variants emerge in future.  This outlines one of the many reasons why the UK and other northern countries need a rethink of their current approach to research and development of health technologies, so that we move towards a system which favours access rather than monopolies.

We are now seeing the same issues play out in relation to CAB-LA, a new form of antiretroviral treatment which needs to be injected every two months.  It is a gamechanger for both treating HIV and for preventing it - it can be used prophylactically and reduces a person’s chances of contracting HIV by 98%.  Yet it will not be available in most countries with high HIV prevalence for several years.  Cost is also a barrier, albeit to a lesser extent, for another new HIV prevention technology, the Dapivirie vaginal ring, as well as for other key commodities needed for diagnosing and treating HIV and STIs - including the vaccine for m-pox.  

When it comes to essential health technologies, changes are needed to the research and development system so that it moves away from intellectual property restrictions and monopolies, towards a significant increase in generic production and a resultant increase in access.  In relation to STIs in particular, there are growing concerns about drug resistant forms of both gonorrhea and chlamydia, which again will require new drug development in order to prevent against future public health threats, as well as investment in integrated SRHR, STI and HIV service provision, with a scale up in condom programming in order to prevent STI transmission.

3. Restrictive social and legal environments

Legal and social barriers also pose a major challenge for health systems in many countries.  Some legal barriers of significance include age restrictions which prevent adolescents from accessing HIV and STI testing, as well as HIV prevention and other key SRHR services, without their parents consent.  These legal barriers are often reinforced by social norms which prevent open conversations about topics like sexuality, sexual and reproductive health and HIV, and which can mean that teachers and the education system as a whole is resistant to providing comprehensive sexuality education. 

Additional legal barriers include the criminalisation of some of the key populations most affected by HIV - for example people who use drugs, sex workers and LGBT people.  There is ample evidence to show that when these communities are criminalised, they are much less likely to access HIV prevention, testing and treatment, and are multiple times more likely to be living with HIV.  For gay men and other men who have sex with men, there are also barriers to accessing STI care, particularly where an STI is presenting anally and to seek healthcare for this would expose them not only to stigma and discrimination, but potentially also to forced outing, violence and even arrest and imprisonment. 

As a final point, health systems can also come up against social barriers in the form of gender norms - and sometimes health systems and health workers can be responsible for reinforcing these.  As noted above, in many countries there is a strong perception that young people should not be sexually active, and this both prevents young people from accessing services, and can mean that services are delivered in a way that is not youth friendly and can be judgemental or stigmatising.  Young women and adolescent girls in particular report stigmatising and discriminatory experiences in health settings, and the HIV statistics show us that they are not getting the care that they need.  Every week, a staggering 4,900 adolescent girls and young women ages 15-24 are infected with HIV in sub-Saharan Africa. While women in this age group are 10% of the population in sub-Saharan Africa, they represent 25% of new HIV infection. With the 15- to 24-year-old population expected to increase by 40% over the next decade in sub-Saharan Africa, failure to act decisively will lead to a significant resurgence of HIV. 

The UK’s Global Fund investments are helping to turn the tide on these shocking numbers, and between 2018 and 2020, Global Fund investments in HIV prevention and testing for this group increased by 107% in priority countries, leading to a 56% drop in HIV incidence since 2010.  Alongside Global Fund support, it’s important that the UK’s other SRHR investments, including its bilateral funding and initiatives like WISH, are promoting an integrated approach to HIV and SRHR.  We need to be ensuring that when young women come for family planning, UK funded programmes are not sending them off without a conversation on their HIV risk.  In fact, with exciting new HIV prevention technologies like oral PREP, CAB-LA and the Dapivirine ring already available or coming onto the market, there is an incredible opportunity and one that I think the UK has not yet taken advantage of.  Again with a new WISH funding call due, it’s critical that the UK builds in the inclusion of innovative HIV prevention technologies,

In terms of gender norms, there can also be specific barriers for men and boys who tend to be diagnosed late, which has negative consequences for their health and survival chances, and also has a correlation to the high rates of infection among adolescent girls, as men and boys who are not diagnosed or on treatment will have a higher viral load, and therefore a higher chance of passing HIV on to the (often younger) women that they have sexual relations with.  Men and boys are often missed out of SRHR strategies, and this is a particular risk with the UK government approach to SRHR, which is explicitly framed with the Women and Girls strategy. 

These points hgihlight the need to address legal barriers and to overcome the societal drivers of HIV, alongside investing in SRHR and HIV services.  There is also a need for investments in advocacy to change laws and policies, as well as hearts and minds, led by women and girls themselves and by communities most affected by HIV.

4. The anti-rights movement

Over the last two to three years, we have also seen the rise of a well organised and very well resourced anti-rights movement, which is actively mobilising against SRHR as a concept, as well as specific components of SRHR including safe abortion, comprehensive sexuality education, youth friendly services, LGBT rights and even HIV prevention.  These activities are ideological in motivation but are having a direct impact on what SRHR services and information are available, as well as who can access them.

For example, in recent months, anti-rights actors such as the US-based group Family Watch International have played a key role in persuading Ugandan law makers to introduce and vote for a new anti-gay law which sees some same sex relations punished by the death penalty, as well as banning the provision of healthcare and other services to LGBT people, and prohibiting any activities that fit under the vague definition of “promoting homosexuality”, sounding the death knoll for effective HIV prevention for LGBT people in the country.  A Frontline AIDS partner in Uganda (who cannot be named for security reasons) has reported a substantial drop in the number of people attending its clinics to access HIV treatment since the Bill was tabled.  Five peer educators working for this partner have also been arrested, while another partner with a key role in health delivery has received visits from government officials and been made the subject of an investigation of its activities.

A similar bill is soon to be tabled in Kenya, while a further one has been sitting on the books for some time in the parliament of Ghana, with rumblings that it is now going to be revived.  Frontline AIDS partners in other countries are also reporting signs of anti-gay mobilisation - from more conservative states like Tanzania to countries that have already decriminalised same sex relations like Botswana. 

These developments follow recent activism aimed at blocking or rolling back on comprehensive sexuality education in multiple countries, and a coordinated and effective effort to deter countries in East and Southern Africa from signing onto a new regional commitment on Adolescent SRHR - which in turn will have an impact on funding for and availability of youth-friendly services, as well as driving further restrictions in the wider legal and social environment, which will in turn deter health workers and facilities from providing essential HIV, STI and SRHR services to young people. 

Anti-rights activity is also acutely visible at the international level, where SRHR, CSE and other related areas have been left out of key global documents, most recently including the outcome document from the annual UN Commission on Population and Development, which did not include CSE.  Faced with an opposition of this scale, it is critical that the UK and other countries that are strongly committed to SRHR goals sustain and scale up their SRHR funding, in order to meet the threats that we face and prevent roll back on the progress that UK investments have made over recent years.

●        What burden do sexually transmitted infections place on healthcare systems in lower-income countries?

Alice Welbourn:

1)   Diagnosis in LMICs.

The WHO webpage on STIs provides a valuable summary of STIs and their effects on people[1].  As the page explains, many STIs can initially be asymptomatic and only get picked up once symptoms develop, when damage may have already been done to the individual. There is need for more lab testing to improve diagnosis and to reduce reliance on ‘syndromic management’ alone, and to improve health outcomes for patients. However, this inevitably has cost implications for healthcare systems.

2)   Partner tracing.

Partner tracing and testing is also key – however this has to be treated sensitively. Healthcare systems, in the context of HIV tracing, often expose women living with HIV to breaches of confidentiality, which often result in violence against them.

3)   Violence and links to HIV….

Violence against women living with HIV globally is widespread[2]. A recent study of 30 countries in sub-Saharan Africa has found that: “women who had experienced physical or sexual IPV in the past year were 3·22 times as likely to acquire a recent HIV infection as those who had not experienced past-year IPV.”[3] .

4) …. and STIs

Since most of the women are likely to have acquired HIV through unprotected sex, they are also likely to have acquired other STIs. Unfortunately, however, the article does not mention STIs at all – another example of the lack of integrated research on policies and programming which we highlighted in the oral session. This is another challenge facing women living with HIV – if they are being screened for HIV but not for other STIs.

Apart from the usual challenges of STIs for everyone (eg chlamydia causing infertility), some are especially damaging for women living with HIV. One example is the development of HPV which, if undiagnosed and untreated, can cause 70% of cases of cervical cancer, which is usually fatal. This is because in many countries, women are told to go for free pap smears (to screen for HPV); but for those women who have a positive result, only private treatment is available[4]. Women living with HIV are 4-5 times more vulnerable to cervical cancer than other women[5].

Another STI linked to HIV for women is hepatitis C. Women who inject drugs can acquire hepatitis C through sharing unsterilised needles as well as through unprotected sex. Whereas in the Global North, women with hepatitis C can now be treated and cured, diagnosis and treatment elsewhere is still rare and expensive[6]. Hepatitis C untreated leads to liver cirrhosis and cancer[7].

In sum, STIs are widespread and largely go undiagnosed and untreated. There is little integrated management of STIs and the consequences of STIs, especially when combined with other conditions such as HIV, can make both worse. The consequences for the SRHR of women living with HIV, for example, and their dependents, can be devastating. Again, we recommend a move away from siloed, top-down bio-medical policies to comprehensive, equitable, integrated person-centred research, policies and programming, which include, learn, from and build on the lived experiences of people living with HIV (and/or other STIs) in all their diversity.

One final point to add here: the significant ‘brain drain’ of qualified health staff from the Global South countries to the Global North, including the UK NHS, has had a significant and lasting overall effect on the healthcare systems of many LMICs. A recent editorial in the Lancet about Decolonising global health spells this out[8]. 

An additional final point: it also goes without saying that COVID-19 has had a devastating effect on all aspects of HIV-related work. In addition to all that Fionnuala has stated above, the significant contributions that women living with HIV have made organising responses in their own communities to support their peers and others around them, need to be understood, recognised and funded[9]. Future pandemic preparedness work also needs to ensure that it has the lived experiences of communities and CS in general at its core, in order to form the basis of a sound, sustainable strategy, in a syndemic approach.

[1] https://www.who.int/news-room/fact-sheets/detail/sexually-transmitted-infections-(stis)

[2] https://vaw-data.srhr.org/map

[3] Kuchukhidze et al.  The effects of intimate partner violence on women's risk of HIV acquisition and engagement in the HIV treatment and care cascade: a pooled analysis of nationally representative surveys in sub-Saharan Africa.  2022 DOI: https://doi.org/10.1016/S2352-3018(22)00305-8

[4] https://salamandertrust.net/podcast/podcast-episode-no-6/

[5] https://www.unaids.org/en/resources/presscentre/featurestories/2018/february/20180208_Tanzania_cancerday

[6] https://www.who.int/news-room/fact-sheets/detail/hepatitis-c

[7] WHO states: “Globally, an estimated 58 million people have chronic hepatitis C virus infection, with about 1.5 million new infections occurring per year. There are an estimated 3.2 million adolescents and children with chronic hepatitis C infection.”

[8] https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(23)00275-9/fulltext

[9] ITPC et al. 2022 Are the sexual and reproductive health and rights of women living with HIV still confined by COVID-19? https://itpcglobal.org/wp-content/uploads/2022/10/SRHR-Women-Still-Confined_20221027.pdf

●        What role is antimicrobial resistance playing in limiting the ability to treat sexually transmitted infections?

Alice Welbourn:

This is not my area.

Fionnuala Murphy:

Similarly this is not an area of expertise for me, although as noted above there have been documented outbreaks of drug resistant gonorrhea and chlamydia, pointing to a need to tackle drug resistance and to develop new medications in order to prevent against future public health threats.  Investment in integrated SRHR, STI and HIV service provision is also a key part of the solution, with a scale up in condom programming in order to prevent STI transmission.

●        Is the UK engaged enough in countering the threat of antimicrobial resistance globally?

Alice Welbourn:

This is not my area.

Fionnuala Murphy:

This is not my area but please see comments in the question above.

●        Were any groups disproportionately affected by the UK’s reduction in ODA spending?

Alice Welbourn:

I think you have already heard about several programmes that have been suddenly, severely and deeply affected by the UK’s reduction in ODA spending. I would like to add a couple of personal examples in here.

1)               WHO-commissioned toolkit on the SRHR of women living with HIV

I described in the oral session an image of a tree to depict our SRHR. This image comes from a toolkit on the SRHR of women living with HIV. This was commissioned by the WHO Human Reproductive Programme (HRP), as a follow-up to our global values and preferences survey, which fed into and informed WHO’s 2017 Guideline on the SRHR of women living with HIV. The budget was $64,000 (an average of less than $210 per woman per 17 weeks of work).

18 of us women living with HIV (and a few colleagues) in all our diversity (ie old and young, cis- and trans-, from the LB community, and straight, sex workers, women who use drugs, married and single, with children and without, and women with other disabilities, , urban and rural, Indigenous and migrant, from across the world) worked together over 4 months from November 2021 – March 2022. All of the women, who are renowned and inspiring leaders in their respective countries, met weekly by zoom to create the content for this toolkit. We designed it to become an interactive live (ie regularly updateable) digital app which would be highly appealing and accessible - especially to younger women living with HIV, many of whom nowadays access most of their information on their mobile phones. This information can often be inaccurate, and also misogynistic or stigmatising. The design varies according to geographic context: so the oak tree described in the oral hearing becomes a palm tree for those in tropical areas, or a pine tree for those in Eastern Europe. Together we learnt so much from one another and created comprehensive content linking all the branches of our shared tree, based on our collective lived experiences and recommendations. We submitted all our work to WHO in March 2022. WHO has greatly appreciated our work However, since then no further funds have been available. WHO staff members have stated: “The UK is a consistent funder of HRP and the commitment of the program teams we work with in DFID and now FCDO is not in doubt...... However, the size of the envelope has indeed suffered from the changes in policy which has resulted in our inability to pursue as comprehensive an agenda as is needed.”  Meanwhile all our months of collective work is gathering dust on a proverbial virtual shelf, with no prospect of all our collective practical and emotional efforts to bring SRHR to a global audience of women living with HIV to reality. 

© Salamander Trust et al 2021

2) Feminist Scaling of gender-transformative social norms change programmes

Another example I would like to share is of Lucy Wanjiku Njenga[1], whom I described in the oral hearing. Last November, Lucy, as Director of Positive Women’s Voices in Nairobi, hosted a meeting of 42 women living with HIV and trainers in an evidence-based gender-transformative social norms change programme which, when properly adapted, can end violence against women and girls, and against children, and promote, advance and uphold their SRHR in communities. The meeting (budget $50,000) was funded by UNAIDS and launched the STREAM Network[2], designed to promote feminist scaling of this programme through training women (and men) living with HIV and its facilitators in their own communities: and then rolling the program out through their networks (feminist scaling)[3]. The objectives of the STREAM Network align closely with the UN Gender AIDS Strategy. One UNAIDS staff member described the proposal behind this meeting and the STREAM Network as the best one that he had ever read. However, since then, because of severe cuts in UNAIDS’ budget, further funding for the STREAM Network or for in-country planned roll-out of its strategic plan have been halted. Lucy is now hoping for 1/3 ($25,000) of the requested budget to support the process to move forward for this year in 7 countries: but over half way through 2023, this is yet to be confirmed. 

These are two personal examples. The budgets are modest (and also less than really needed – a lot of background voluntary effort went into both.) However, I am aware from colleagues around the world that these are two relatively minor examples of the crushing effects of these and other organisations’ cuts on women’s efforts to improve our SRHR.

3) UNAIDS MENA Region

Meanwhile, we have just learnt that UNAIDS has had to close its MENA office entirely. Our colleagues at MENA Rosa, who have created powerful material documenting systematic structural violence against women living with HIV in healthcare settings[4] (with Robert Carr funding) depend on UNAIDS to support and uphold their SRHR across the region. They are deeply shocked by this closure and are at a loss to know how they can move forward without UNAIDS’ support.

Fionnuala Murphy:

1. Bilateral funding cuts

STOPAIDS, Frontline AIDS and the APPG on HIV and AIDS 2021 joint report ‘Jeopardising Progress’ highlights the significant impact that the cuts to multilateral, bilateral and Research & Development spending had on sexual and reproductive health programming. From reduced access to contraceptives to driving more people into poverty, the report explores how cutting ODA will increase the number of HIV transmissions and AIDS related deaths.  As explored in the Jeopardising Progress report, marginalised communities (including women and girls living with and affected by HIV) have been disproportionately affected by the UK’s reduction in ODA spending.

At Frontline AIDS, we saw two programmes that we were contributing to cut to zero at short notice.  One of these, ACCESS, was providing HIV, STI and SRHR services to the most marginalised people, including people in humanitarian settings.  Another, ECID, was working with marginalised communities such as people in prison and LGBT people.  A third, Zero Violence, was discontinued at the end of its six month inception phase, putting an end to work to stop violence against womena and girls and against LGBT people.

These were all strong examples of what high quality, holistic approaches to SRHR can look like – explicitly recognising HIV and STIs as essential parts of the SRHR continuum, and encompassing work on violence as a sexual rights issue, and on the people and communities most left behind, as well as looking beyond approaches that focus on family planning or safe motherhood alone.

With a new funding call due to go out under the Women’s Integrated Sexual Health (WISH) programme there is a renewed (and very important) opportunity for the FCDO to ensure that future UK funded programmes are also making these kinds of links – bringing real life benefits for women and girls, and value for money benefits for the UK tax payer.  As Frontline AIDS, we would strongly encourage the FCDO to ensure that it explicitly includes integration with HIV and STIs into this funding call, as well as FGS.

Additionally, it is welcome that the Women and Girls strategy committed to targeting 80% of FDCO’s bilateral aid programmes to gender equality programming by 2030 and renewed funding to the Women's Integrated Sexual Health, or WISH, program. However the commitment funding to WISH represent a large cut compared to funding levels prior to the 2021 ODA cuts. In 2021, the same year as the UK Government’s ODA cuts, WISH programs in 10 countries closed, and services were suspended in another five. It is also disappointing that the strategy did not reassert the UK’s commitment to restoring the women and girls’ budget in full. 

Additionally, the FCDO has recently put out a new LGBT equality funding call and again, it’s important that the FCDO ensures that that call does support work on access to HIV and STI services – recognising the astronomically high rates of HIV infection and AIDS related death among MSM and trans people globally, and especially in environments of criminalisation and repression.  Additionally it would be good to see work on a broader SRHR remit integrated w LGBT equality, explicitly including eg HIV, sexual and gender-based violence, drug use/ harm reduction, mental health, family plannign and STI care, reflecting the fuller range of SRHR interventions included under the Lancet-Guttmacher definition. 

2. Reduced UK support to the Global Fund

Recent ODA reductions include the UK Government making a pledge of £1 billion to the Global Fund’s seventh replenishment. Whilst this funding will still have significant impact, this is an almost 30% cut from its 2019 pledge at the sixth replenishment. The UK was the only G7 member to cut funding to the Global Fund in 2022. The US, Japan, Canada, Germany, the EC and several Global Fund grant implementing countries met the Global Fund’s request for a 30% increase. Largely due to the UK’s significantly reduced pledge, The Global Fund is over $2 billion short of reaching their seventh replenishment target of raising at least US$18 billion.

Analysis from CSOs suggest that this cut in funding, rather than reaching the Global Fund’s funding target, risks 1.54 million potential lives lost and over 34.5 million new transmissions across the three diseases, setting back years of progress. It also estimated that it could lead to 222,317 pregnant women not having medicines to support their own healthcare - or to prevent transmitting HIV to their babies.

A recent example of the impact of the UK’s reduction in ODA spending is the Global Fund’s available resources for Catalytic Investments. The majority of the monies raised by the Global Fund are invested through country grants, but it is well documented that they can leave critical gaps. Catalytic Investments were allocated over US$800 million during the 2020-2022 Allocation Period, and played an essential role in the Global Fund efforts to leave no one behind.

However, with the Global Fund unable to reach their replenishment target, Catalytic Investments were cut from US$890 million to US$400 million. As explored within technical briefing from the Global Fund Advocates Network, has meant that catalytic investments supporting adolescent girls and young women, human rights and key populations has been cut significantly. For example, Matching Funds for Adolescent Girls and Young Women (AGYW) are decreasing by 86%, with no new countries eligible. 7 out of 13 countries eligible in the grant cycle 5 and 6 have zero AGYW matching funds in GC7 – again raising the question of how to ensure that countries will prioritise the need of AGYW, who represent half of all new HIV infections.

As noted within our written submission, the UK Government should return to being a leading investor to the Global Fund and make a supplementary allocation in funding for the Fund’s seventh replenishment. For every additional pound the UK contributes, the US will provide a 50% match. The US has already committed these funds, but the match is required by U.S law. Additional UK funds will produce a direct, significant, and immediate multiplier effect. Without additional funds a large amount of US money will be left on the table. For the 7th Replenishment, Canada, Germany, Japan, the US, and the European Commission all increased by 30% over the 6th Replenishment. If the UK did the same by increasing its pledge from £1 billion to £1.8 billion, then the US would provide an additional £400 million.

3. ODA levels

In the context of the profound level of need in relation to HIV and SRHR - a need that has been worsened by the long-term impact of Covid-19 as well as by the rising anti-rights movement, I would like to take this opportunity to emphasise the importance of the UK returning to its pledge of spending 0.7% of GDP on ODA as soon as possible.  It is also critical that the UK moves away from reallocating the aid budget to activities taking place within the UK and ensures that overseas development assistance is benefitting health and development goals in low- and middle-income countries.

●        Does the FCDO advocate an integrated approach to sexual and reproductive healthcare in its aid programming?

Alice Welbourn:

We are disappointed to see repeated examples of FCDO continuing to promote a top-down, bio-medical, siloed approach to its policies and programming, instead of an integrated approach. The examples given above – including lack of mention of HIV in the Women and Girls’ Strategy, when AIDS is the leading cause of death amongst women; and the lack of mention of male or female condoms to protect against most STIs (including HIV) in the WISH Strategy, are two recent examples.

Again, we would recommend that FCDO explicitly adopts the Lancet-Guttmacher[5] “positive, progressive, evidence-based” umbrella definition of SRHR as a working definition in all its policy documents; and that it seeks to ensure that all its funding streams promote person/women/survivor-centred care, treatment and support.

As women living with HIV in all our diversity have stated repeatedly:

“There is no future for top-down, siloed, one-size-fits-all processes. Instead, principles of women-centred, rights-based, holistic, informed, non-judgmental, voluntary, confidential choice should be core to all new guidance. We radically reject public-health-only approaches that “harmonise” treatment, with a vertical HIV-prevention-specific focus that prioritises numbers over quality. These have undermined and failed many women repeatedly, fostering violence in health-care settings, damaging our mental health and adding further challenges to our treatment adherence. Some women do not “fail to adhere” to treatment. It is bad health policies and programmes that fail to understand our challenges.”[6]

[1] Lucy Wanjiku Njenga. 2023. Hope made a way https://www.amazon.co.uk/HOPE-MADE-Lucy-Wanjiku-Njenga/dp/9914491820/ref=tmm_pap_swatch_0?_encoding=UTF8&qid=1689148542&sr=8-2

[2] STREAM Network Strategic Plan 2022 https://pywv.org/static/documents/stream-plan.pdf

[3] Htun and Weldon 2012, in a review of 70 countries over 40 years, concluded that the one single factor to reduce violence against women in a country is a vibrant independent women’s rights movement. This is another reason why we place so much emphasis on the importance of funding networks of women living with HIV, to achieve an effective, ethical and sustainable response to the ‘syndemics’ of VAWG and HIV, in order to achiever their SRHR. Htun and Weldon (2012). The Civic Origins of Progressive Policy Change: Combating Violence against Women in Global Perspective, 1975–2005. American Political Science Review,106, pp 548569 doi:10.1017/

S0003055412000226

[4] https://menarosa.org/discrimination-against-hiv-women-in-healthcare/

[5] Lancet Guttmacher 2018 https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(18)30293-9.pdf

[6] Anam et al 2018 https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(18)30352-8/fulltext

Fionnuala Murphy:

AIDS-related illness remains the leading cause of death for women of reproductive age in Africa, but it is not explicitly mentioned in the FDCO’s Women and Girls strategy. 

It also receives just one reference in the Ending Preventable Deaths strategy, where the FCDO mentions its contribution to the Global Fund for AIDS, TB and Malaria. 

The UK’s contribution to the Global Fund makes a realy significant contribution towards the goal of ending AIDS, and to wider SRHR goals.  Global Fund investments include key elements of comprehensive SRHR: treatment and prevention programs, prevention of mother-to-child transmission of HIV, integrated services for antenatal and postnatal care, prevention of malaria during pregnancy and targeted screening, screening and testing of sexually transmitted infections, PrEP, self-testing, prevention of cervical cancer, post-violence care, and comprehensive information and education on sexual health for in-school and out-of-school youth. In Global Fund-supported countries, the percentage of mothers receiving treatment to prevent transmission of HIV to their babies reached 85% in 2020, compared to 44% in 2010.

These are impressive results from really vital investments, and I would reiterate my recommendation for the UK to make a supplementary allocation to the Global Fund, in order to ensure that it is fully funded and fully able to deliver on its mission.  To give one example of what that could mean, there are still approximately 180,000 pregnant women left out who are not receiving treatment to protect their babies and themselves. Among the women who do receive treatment during pregnancy, many may not continue through breastfeeding, putting themselves and their infants at risk. In 2020 there were 150,000 new HIV cases among children – that’s approximately 410 children infected with HIV every day.

Alongside increasing its Global Fund support, I would love to see the UK increasing its bilateral SRHR funding and ensuring that that funding is intentionally directed towards programming which explicitly includes HIV, STIs and FGS alongside other SRHR interventions.  As I note above in my comments relating to WISH, it is critical that these three areas are explciitly included in FCDO funding calls, and that attention to HIV, STIs and FGS are included in the criteria that are used to assess applicants and consortiums and to make funding awards.

I would also reiterate my comment here about the importance of the UK returning ODA levels to 0.7% of GDP and ensuring that the aid budget is not being spent here in the UK.

●        The UK funds several multilateral organisations that work on tackling STIs in lower-income countries.  Do you think there is a sound rationale for the FCDO prioritising funding to multilateral organisations, such as the Global Fund, over bilateral programmes?

Alice Welbourn:

We consider it important for FCDO to fund both multilateral and bilateral organisations.  We also request that UK ODA is reinstated at 0.7% GNI as soon as possible; and that no ODA funds are used to support migrants in the UK.

For example, both the Global Fund and UNAIDS are very much valued by my colleagues in GNP+, ICW and YP+.

1)               The Global Fund

The Global Fund has supported Svitlana Moroz and her colleagues at the Eurasian Women’s Network on AIDS to conduct a gendered survey across 15 Eurasian countries to assess barriers to accessing services by women living with HIV, women who use drugs and sex workers. In this harsh political and legal environment, 52% of women living with HIV have reported physical violence after an HIV diagnosis. This report, which will be published shortly, will provide invaluable baseline data to hold their respective governments to account. So often, data are not disaggregated and, without an evidence base, donors and governments do not accept women’s reports of the inequities they experience. It is good that the Global Fund now has KPIs in place in relation to Communities, Gender and Rights. However, it is impossible to get the work needed to meet them off the ground in a meaningful way. My colleagues at YP+ described how important the Global Fund Her Voice fund is to their ability to support young women like the girls having to get funds for food through transactional sex to feed their younger siblings on the shores of Lake Victoria. However, the significant cut in UK funds to the Global Fund has meant that its programming to countries specifically to support adolescent girls and young women has had to be cut instead of being expanded.

Some Global Fund grantees are front-loading their 3-year grants just to cover the costs of the 1st 2 years - with no prospect of further funds for year 3. They are facing a very worrying situation. Funds are also reported to be arriving late.

My colleagues at Women for the Global Fund also describe how the significant grant cuts at the Global Fund (and elsewhere) are having a severely detrimental effect on civil society in general, with discrete organisations and communities having to compete fiercely with one another for ever scarcer funding in a highly competitive environment. As my colleagues at ICW describe, many women’s rights organisations doing excellent work have had to close, for lack of funding. We are not on track to achieve the SDGs.

2)              UNAIDS

UNAIDS has been a long-term ally of networks of women living with HIV. It has a critical key role to play in countries, advocating for their rights and supporting them with leverage to engage in highly complex Global Fund grant application processes and to advocate for transformative gender-equitable funds. The 30-60-80 and 10-10-10 markers are now in place for meaningful community engagement and an end to stigma and discrimination. However, UNAIDS can no longer give core support to networks of women living with HIV because of lack of systematic funding. Only small, short-term grants are now available. This means that it is now unable to develop or maintain serious partnerships with these women’s networks; and these markers will not be achieved.

There is a threat to capacity at all levels here. A UNAIDS colleague has described how DfID was so good at recognising how change takes 2-3 or 5 years and longer, and the need to ensure that sustained funds are provided over time. However, all of this has now changed. Stop / start funding is crippling us all. I mentioned above the effects of the cuts on the MENA Region office, which has had to close – and on the WROs across the region who are left reeling. My colleague at MENA-Rosa states: “Now that the regional UNAIDS office is closing we, & others, are deeply concerned about the potential for a deadly backward slide on the progress around HIV in the region and the erosion of regional attention and support for HIV related issues and the unique concerns of Women Living with HIV."

Fionnuala Murphy:

For an effective response tackling STIs in lower-income countries, there are benefits to both bilateral and multilateral programmes. However it should not need to be a choice between either if the UK Government was to urgently return to its commitment to spend 0.7% GNI on ODA.

However, with the multilateral organisations that the UK Government supports (with leading funding and representation on boards), it is able to ensure UK Government strategies are implemented at scale, value for money and closer partnership with LMIC Governments and affected communities.

For example, The Global Fund is the 2nd largest international funder for HIV (after PEPFAR) and it plays a key role in supporting comprehensive SRHR programs, as well as their strengthened integration with HIV services for women in all their diversity and their partners. In line with UK priorities and enabled through the UK’s ODA investments, between 2018 and 2020, Global Fund investments in HIV prevention and testing for adolescent girls and young women increased by 107% in priority countries. This led to a 56% drop in HIV incidence since 2010.

The alignment to UK priorities and value for money is also seen within the UK’s support for Unitaid. As noted by Minister Andrew Mitchell in Parliament, Unitaid has become a significant actor within the global health landscape. Over their last strategic period (2017-2021), Unitaid contributed to saving 758,000 lives, averted 133 million cases of mortality from HIV, tuberculosis (TB) and malaria, and $2.3 billion in economic savings. Unitaid also works in coordination in bilateral programmes and UK institutions. For example, Unitaid invests in more than a dozen UK based organisations – predominantly research and academia – to combine the best of British innovation with other global leaders in high, middle and low-income countries.

Given the pioneering nature of Unitaid’s work, it is essential that it has predictability over its financial flows.  For this reason, it is imperative that the UK confirms its intent to honour its funding commitment and provides a schedule for its funding between now and 2026. In the absence of a schedule, Unitaid is withholding investments in promising innovations that seek to improve the health of pregnant women and their unborn children.

Given the transformational impact of multilateral organisations supported by the UK Government and the need to ensure value-for-money within ODA resource limited settings, the UK Government should reconsider the target within its International Development Strategy to reduce spending to multilaterals to just 25% by 2025. Working to advance this target would lead to continued huge cuts to life-saving programming and hold back the UK Government from realising their development priorities, including the Women & Girl’s Strategy.

SOME FINAL COMMENTS (Alice Welbourn)

I would like to add a few final comments.

Thank you again for inviting me to take part in the oral hearing. I have found the process very valuable and appreciate the opportunity to share my thoughts.

As I mentioned in the hearing, we cannot discuss all this without looking at the wider backdrop of climate change (which drives increasing violence against women, through extreme weather events, severe food insecurity, poverty and migration); the international financing structure within which we all operate; the urgent need to decolonise and reform global north/south power imbalances, and a growing recognition amongst global health advocates that ‘business as usual’ is no longer fit for purpose.

I would like to share a few relevant documents that I have found inspiring:

a)              Chater, N. & Loewenstein, G. The i-frame and the s-frame: How focusing on individual-level solutions has led behavioral public policy astray. Behavioral and Brain Sciences. DOI: https://doi.org/10.1017&am               This article, written by 2 long-term academic policy researchers, explains how they have realised the need to move from individual level behaviour change to systems-based thinking about effecting lasting sustainable change. I suggest that this applies to the FCDO’s approach to effective SRHR also. We all need to address the bigger picture together.

b)              Alternative funding models to international financing structures exist and are gaining considerable interest. For example:

i)               African Feminist Macroeconomic Academy et al. nd. The Audacity to Disrupt https://static1.squarespace.com/static/536c4ee8e4b0b60bc6ca7c74/t/5fd8257f50dc481b78961e12/1608000898730/The+Audacity+to+Disrupt+2020+-+E-version.pdf

ii)              Kate Raworh Doughnut Economics https://doughnuteconomics.org/about-doughnut-economics 

iii)            Hickel et al. 2022  Imperialist appropriation in the world economy: Drain from the global South through unequal exchange, 1990–2015: “we find that the South’s losses due to unequal exchange outstrip their total aid receipts over the period by a factor of 30. Our analysis confirms that unequal exchange is a significant driver of global inequality, uneven development, and ecological breakdown.”

iv)            Michelle Bachelet (OHCHR) 2022 speech: Feminist Economics and the Fight for Human Rights https://www.ohchr.org/en/statements/2022/06/feminist-economics-and-fight-human-rights 

c)    Some documents about decolonising aid and global health:

i)               Peace Direct et al 2021 Time to decolonise aid https://www.peacedirect.org/wp-content/uploads/2021/05/PD-Decolonising-Aid_Second-Edition.pdf

ii)              Pai, Forbes Magazine, 2021, Decolonizing Global Health – a moment to reflect on a movement https://www.forbes.com/sites/madhukarpai/2021/07/22/decolonizing-global-health-a-moment-to-reflect-on-a-movement/?sh=47d842ab5386

iii)            (Also mentioned earlier): Lancet July 2023 Adhikari et al The way forward in decolonising global health https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(23)00275-9/fulltext