Why Health Equity is the Way to End HIV

Studies show that educating girls is one of the most powerful weapons in the fight to eliminate AIDS. But on the African continent, an estimated 34 million girls of secondary school age are not in school. And adolescent girls in the region face disproportionately high HIV rates: of the 4,000 adolescent girls and young women aged 15-24 years living with HIV around the world every week, 3,100 are in sub-Saharan Africa. These statistics frustrate Winnie Byanyima, Executive Director of the Joint United Nations Programme on HIV/AIDS (UNAIDS).

How does completing secondary education lower the risk of HIV infection among adolescent girls and young women?

Byanyima: Gender-based inequalities are a consequence of and also continue to drive the HIV pandemic. Girls in sub-Saharan Africa are not completing secondary education due to poverty, inequality, and harmful societal norms that push them into child marriage, forced unions or exploitative relationships where there’s unequal power and transactional sex. Safe school environments not only give girls the education and life skills they need to protect themselves outside of school, they also provide them with a protective cover from exploitative relationships that put them at risk of violence and HIV. For instance, if adolescent girls and boys are able to access comprehensive sexuality education (CSE) before becoming sexually active, they are more likely to make informed decisions about their sexuality and approach relationships with more self-confidence. We know that just one additional year of secondary education can increase a girl’s potential earnings by up to 18% and can reduce new HIV infections by between 50% and 87% annually.

What are the main obstacles that prevent girls in sub-Saharan Africa from completing secondary education?

Byanyima: I’ll focus on two Rs: resources and rights. For years, the right for girls to attend primary school has been almost universally achieved in Africa and globally. Now, we’re working toward free quality secondary education for girls.

Policies and legal frameworks around school re-entry and eliminating discriminatory policies and stigma against pregnant learners and teenaged parents are key. For instance, Sierra Leone, an Education Plus champion country^[1], has introduced a radical inclusion policy and abolished a former policy that prohibited pregnant girls from attending school. That has gone a long way to securing girls’ rights, which, in turn, removes some of the factors that make them vulnerable to acquiring or spreading HIV.

We also need to work on changing the gender norms surrounding girls’ bodily autonomy, such as the power to decide and negotiate safe sex. Gender norms influence who the family or community sends to school and who drops out when families face economic hardships. Gender norms drive gender-based violence, and in places with high HIV prevalence, women and adolescent girls who experience intimate partner violence are 50% more likely to acquire HIV than women who do not. Violence or the fear of it can block young women’s access to treatment services, their ability to negotiate condom use with perpetrators, to disclose their HIV status, and to stay on HIV treatment.

We know that education alone is often not enough for adolescent girls and young women to overcome the obstacles imposed by gender inequality – including for preventing HIV – without additional concerted efforts to change attitudes, behaviors, institutions, and systems rooted in gender discrimination and unequal power dynamics.

In one example, Malawi, another Education Plus champion country, launched the Male Engagement Strategy in 2023 to bring men into the conversation. The government published a training manual to support community gatekeepers in fighting harmful masculinity norms and promoting positive ones. These kinds of initiatives are critical to reducing the disproportionate risk of HIV that girls in Africa face.

Can you tell us about some of the other countries in the initiative that have made progress on increasing girls’ access to secondary school and lowering their HIV risks?

Byanyima: In Kenya, Education Plus was taken on by the National Syndemic Diseases Control Council and incorporated into a “Triple Threat” campaign, which tackles adolescent pregnancies, HIV infections, and sexual and gender-based violence.

Zambia’s government has done something remarkable: they’ve recruited 30,000 new teachers and brought 80,000 girls back into secondary school. What struck me was how they’ve integrated health into education. They’ve introduced adolescent health clubs where girls can learn life skills and get vital information on HIV prevention. It’s holistic, addressing both the education and health needs of young women.

Then there’s Lesotho. They’ve taken a different, but equally impactful, approach. They’ve revamped their entire education curriculum to include vocational and technical streams alongside academics, making education more inclusive and practical.

And let’s not forget Cameroon, which reviewed its school curriculum to include comprehensive sexuality education and is implementing a new policy on addressing school-related gender-based violence. They’ve also launched scholarships and school feeding programs to keep girls in school, especially those from vulnerable backgrounds.

We have come so far in the HIV response: the end of AIDS as a public health threat is achievable by 2030 – but only if everyone’s rights are protected. The progress that has been made in the HIV response has been driven by advances that have been won in the protection of human rights.

But big gaps in the protection of rights are keeping the world from getting on the path that ends AIDS. And the surge in attacks on rights is even endangering the gains that have been made.

Only rights can fix these wrongs. We urgently need to remove laws that harm people’s rights, we need to enact laws and approaches that protect the human rights of everyone, and we need to foster societal respect for everyone’s human rights. Acceptance, respect and care are vital for HIV programs to work.

The HIV response is at a crossroads. If we take the ‘rights’ path, we will end AIDS. Let us walk it together.

Health rights are key to this year’s World AIDS Day campaign. Credit: WHO

Patience Ndlovu believes it is time to change the conversation around HIV prevention. As the Regional Director for Southern Africa for JSI, a global nonprofit, she wants the world to recognize that ending the HIV epidemic requires addressing the factors that drive its spread, not just treating the condition itself. And having formerly led Bantwana, a girls’ and young people’s empowerment initiative implemented by World Education under JSI, she knows that educating and economically empowering adolescent girls and young women is essential to reaching that goal.

“We have been making a lot of noise about this over the years and not being heard because the attention is being placed more on the biomedical and clinical supports,” Ndlovu said. “We also need to be looking at the social and structural challenges that hinder the education of adolescent girls and young women and stop their successful transition to employment and sustainable livelihoods.”

Established in 2006, around the height of the HIV pandemic, the Bantwana initiative focuses on keeping adolescent girls in school and helping them develop sustainable livelihoods, two critical drivers for reducing vulnerability to HIV.

Ndlovu spoke with the WHO Foundation about the initiative, the immense challenges that girls in sub-Saharan Africa face as they try to finish their schooling, and the crucial role of family and community in helping them do that.

Why focus on education as one of the main interventions within Bantwana to help bring down HIV rates?

Ndlovu: It’s important to note that this is about keeping girls in school – not just enrolling them, but ensuring they stay and progress. Research shows that higher completion rates significantly reduce HIV infections among adolescent girls and young women. In countries such as South Africa, Eswatini, and Zimbabwe, completion rates above 50% at lower secondary level are associated with a 70% reduction in new HIV infections. That’s how powerful it is to keep girls in school. We need to combine education with interventions like economic strengthening to address risks such as transactional sex and gender-based violence. Education, when layered with vocational training and economic opportunities, empowers girls with agency and independence – both of which are crucial for making informed decisions about HIV prevention. Data from Eastern and Southern Africa shows a positive correlation between educational attainment and condom use, underscoring the importance of education in HIV prevention.

One of Bantwana’s flagship programs is the Siyakha Girls Economic Empowerment Initiative, which aims to equip young women with skills they can use to develop sustainable livelihoods once they are out of school. How does this help tackle the spread of HIV?

Ndlovu: “Siyakha” means “building up” in Ndebele, so we are building up girls. It’s an evidence-based initiative funded with support from PEPFAR [U.S. President’s Emergency Plan for AIDS Relief], targeting adolescent girls and young women who are HIV-negative to keep them negative. We provide education, HIV prevention information, and economic empowerment through skills training. Girls also gain soft skills and the agency to make informed decisions about their health, including negotiating safe sex.

Since we piloted the program in 2018, we’ve adapted it to include HIV-positive girls, focusing on health education, economic empowerment, and vocational skills. For these girls, the goal is viral suppression to prevent mother-to-child HIV transmission, contributing to the global target of eliminating vertical HIV transmission by 2030.

At the school level, we work with ministries of education to train teachers, develop curricula, and integrate comprehensive sexuality education (CSE) into schools. Research shows that in countries where CSE has been implemented, girls are better equipped with sexual and reproductive health knowledge.

We train teachers to look for early-warning indicators, such as absenteeism, poor performance, or risks such as early marriage and gender-based violence, to identify and support at-risk girls. But because dropout often stems from issues at the household level, we also employ community workers who are attached to schools. If a teacher notices a girl is not attending school, the community worker follows up with the family to understand the situation. For instance, they might uncover cases of early marriage, a lack of value placed on education, or other household challenges. Community workers are trained to engage with both the family and community leaders to encourage the girl to return to school.

For out-of-school girls, we provide safe spaces where they receive HIV prevention education, sexual and reproductive health resources, and we link them up to services like free condoms, PrEP [pre-exposure prophylaxis], and contraceptives.

At the household level, we engage parents through community-based parental groups, which provide culturally appropriate information and skills to help parents discuss education and health topics, which are often taboo in many sub-Saharan African contexts.

And at the community level, we address harmful norms around girls’ education and gender roles by engaging champions, including traditional leaders. These efforts aim to change perceptions, increase the value placed on girls’ education, and reduce risks related to HIV and early marriage.

As part of its holistic approach, the Siyakha program directly involves families and communities in the process of empowering young women. Why is that important?

Ndlovu: We ask families or partners to sign a “social contract” committing to support the girl in our program. We explain that investing in a girl benefits her family and community, as women reinvest 90% of their earnings back into their families. This helps shift perceptions and creates buy-in.

The program then provides girls with technical and vocational training for three months, tailored to local economic opportunities – such as cosmetology, tailoring, or motor mechanics. Alongside this, they receive life skills training, including confidence building and understanding their rights. After training, they are placed in internships, either in formal businesses or with local artisans who mentor them. Even in rural areas, local mechanics or salon owners often open their spaces to train these girls, even letting them bring their babies with them. And we’ve had girls from rural areas move to cities to intern at five-star hotels.

These companies understand that investing in their future labor force benefits them. If they train these girls, they’re likely to retain them, and they see tangible returns. For example, Amaryllis, a five-star hotel in Malawi, has been a fantastic partner. They’ve worked so well with us that the Malawi Institute of Tourism now has a tripartite memorandum of understanding with them and us. The school provides theoretical training, and the hotel handles the practical internships. It’s an excellent example of how private-sector engagement can really work.

After these internships, girls can pursue entrepreneurship or formal employment. We’ve had girls open their own salons, save money, and return to school. The results are inspiring.

^[1] Making secondary school free for every girl in the region is one of the key goals of Education Plus, an initiative that UNAIDS co-leads along with UNESCO, UNFPA, UNICEF, and UN Women to empower girls and young women and, eventually, achieve gender equality in sub-Saharan Africa.