Ringing the changes: choice and power for young women

By Georgina Caswell, Luisa Orza

Georgina Caswell is lead programmes and Luisa Orza is technical lead on HIV and gender, both at the Alliance.

Choice. We love this word. It’s about options, about possibilities. In sexual and reproductive health and rights, choice is an essential principle, strategy and goal if we want to see women and girls lead healthy lives.

And yet supporting all women and girls to enjoy their sexual and reproductive health and rights is an ongoing struggle. In the work we are doing to build resilient and empowered adolescents and young people we have learnt that the degree of choice young women have very much depend on their context: their home life, the opportunities they have to learn and gain employment, and the skills they develop over the years to make decisions and assert themselves, without fear and with encouragement from those around them.

Pheobe Kanana MalindiPheobe Kanana is a woman who sells sex in Watamu, a tourist hotspot on the Kenyan coast. Many young girls visit the coast in hope of finding a rich man to take care of them and then fall into drugs and sex work to pay for their drug use. © Corrie Wingate for the Alliance

Choice not a reality for many women

For many of the young women we work with, the idea of choice is a mirage. We hear difficult stories of young women’s first experiences of sex being coerced or forced; of getting pregnant before they are ready; of attending an antenatal clinic and learning they have contracted HIV; of getting married, often because they are pregnant and feel they have limited choices; of experiencing sexual, physical and emotional violence as a matter of course; and of being thrown onto the streets for saying no or speaking out.

“As young women, we must learn to break the silence. Let’s not be cornered by culture. For example, if a man slaps a woman, often the woman stays quiet. Sometimes a woman is even hurt but says nothing because of culture”, a familiar story shared by one young woman from the READY Teens project in Burundi.

As young women, we must learn to break the silence. Let’s not be cornered by culture.

Encouraging results of new HIV prevention tool

Given the world of limited choices within which many women live, we were excited this month to learn about the progress of a potential new female-initiated HIV prevention tool: the dapivirine ring. The silicone ring is inserted into the vagina, where it slowly delivers an ARV to reduce the woman’s risk of getting HIV, and is changed monthly.

On her initial clinic visit she is taught how to do it, but subsequently the idea is that she can easily replace the ring herself, and she has a choice as to whether she tells her male partner (unlike the use of male and female condoms which require both sexual partners to be on board).

The interim analyses of DREAM, the open-label study* led by the International Partnership for Microbicides (IPM), found that more than 90% of women used the ring at least some of the time during the trial, and overall HIV incidence among women was 54% lower than would be expected without use of the ring. HOPE, the parallel open-label study of the dapivirine ring, led by the Microbicide Trials Network (MTN), reported nearly identical findings. Although we need to be careful about reading too much into these findings since the data are preliminary and based on modelling (read more about that in IPM’s release), it is indeed encouraging.

This news builds on previous data that showed a reduced HIV risk of 30% overall in two large Phase III clinical trials – the Ring Study, conducted by IPM, and ASPIRE, conducted by MTN. In both studies, there was poor adherence amongst younger women (aged 18-21 years).

The final results of the follow-up open-label studies are expected in 2019, and another study to begin later this year will take a closer look at ring use among adolescent girls and young women.

Women need control of their bodies and a say in what’s on offer

However, we need to contextualise the encouraging news about the open-label studies in the realities of young women.

We cannot assume that women can access, or act on knowledge of, a ring or another HIV prevention tool. If women are living lives with limited choices, facing cultural, legal and financial barriers to accessing services, and experiencing violence, how would we support them to get hold of a ring each month or to store a supply safely somewhere and use them without fear?

Every time I try to access male condoms at the health facility, health workers call me an immoral young woman.

“Every time I try to access male condoms at the health facility, health workers call me an immoral young woman. So I send my male friends to pick me male condoms from the facility in fear of being judged,” said a young woman from Uganda.

Women - especially young women - will only be able to use the ring effectively if they have control over their bodies, consistent agency to make and enact the decision to use it, and confidence that they can do so safely.  And women – especially young women – will only want to use it if they have a say in what’s on offer to manage their sexual health, and how, where and when they are offered it.

Dreams, hopes and a lot of work lie ahead for all of us working in different aspects of sexual and reproductive health and rights, including HIV prevention, treatment and care. We are challenged to think through how the dapivirine ring could genuinely form part of a range of tools that women can choose from to reduce their risk of HIV in a world where they are also able to make broader life choices.

*Open-label extension studies follow on from clinical trials - the big difference being that in the open label studies there is no placebo arm, so women know that the product they are using contains dapivirine, the active ARV.