Securing health as a normative social goal and addressing gender inequalities that undermine womenās opportunities to be healthyāthese challenges, formidable on their own, comprise disparate yet interwoven threads that are inextricably bound together within the ongoing problem of human immunodeficiency virus (HIV) acquisition and the disproportionate burden of HIV illness among women.
Worldwide, 36.7 million people are living with HIV (UNAIDS, 2016a). Globally, HIV remains the leading cause of death in women of reproductive age (18ā44 years) (World Health Organization [WHO], 2014a).1 Ongoing HIV risk , prevalence and premature HIV-related deaths, particularly for key populations of women, continue to raise core questions for governments, societies and the international community, concerning not just āhealth as social justiceā but āhealth and gender as social justiceā . Justice is about fairness. Questions of justice in relation to HIV rush to the fore because HIV is fully preventable and treatable, and because HIV transmission is driven, in part, by social factors and processes (UNAIDS, 2014a, 2014b). These social factors are particularly salient for women in high HIV prevalence settings, such as South Africa, which represents over 18% of the global population living with HIV (UNAIDS, 2014b, see pp. 17ā18). South Africa is one of 19 countries with the highest (and increasing) HIV incidence in young women (aged 15ā24), globally. Seventeen others are also located in sub-Saharan Africa (SSA) (UNAIDS, 2016a, 2016b). The number of new HIV infections recorded in women (aged 15ā24) in those countries totalled 450,000 in 2015: equivalent to 8600 new HIV infections in women per week (UNAIDS, 2016a, 2016b). Among these 19 countries, South Africa is the indisputable leader, owing, in part, to its large population size (e.g. relative to neighbouring Lesotho, Swaziland and Botswana). In this work, I use a health equity lens to investigate the opportunities to be healthy, or capabilities (Sen, 1999) of black South African women who are living with HIV. Based on the findings, I address a companion question: what more, if anything, does justice require of the South African government?
Today, HIV can be managed as a chronic condition, provided people have access to essential HIV medication or combination antiretroviral therapy (cART) . Indeed, the survival and improvements in the quality of life of millions of people living with the virus can be attributed to cART (Marins et al., 2003; UNAIDS, 2014b, 2016c; Walensky, Paltiel, & Losina, 2006). In settings in the developing world, this very possibility exists as a result of a victorious global social justice campaign led primarily by civil society. Access to affordable HIV medicine has been the chief battleground for the global HIV community (comprising activists, researchers and other stakeholders), to press for health to be viewed as a public good and a social justice claim (Heywood, 2009). With pivotal leadership from the Global South, including from South Africa and Brazil , this global justice movement was also successful in garnering greater recognition of the right to health as a primary aspect of ensuring well-being in ways that reshaped the global health discourse (GalvĆ£o, 2005; Rosenberg, 2001). Global health can refer to the interacting, single system affecting health worldwide, and to the health of the world population. Indeed, there is no accepted definition of global health, but rather, a set of dominant features that characterise the evolving field, including the types of problems engaged, and levels and units of analysis. Nonetheless, there is agreement on several core principles, such as the need to value health as a public good and an appropriate social justice goal and to focus particularly on populations in the developing world, where 80% of the global population resides (see Frenk & Moon, 2013; Fried, Piot, Spencer, & Parker, 2012; Koplan et al., 2009; Merson, Black, & Mills, 2011). Health equity considerations associated with the HIV epidemic among women have increasing relevance for global and national health across the domains of research, policy and practice. They promise to refashion debates over global health justice, or greater equity in health, once again by bringing gender-based considerations, typically pushed to the sidelines, to the centre.
Health equity, the ability of diverse groups in society to achieve a certain standard of health, is a chief objective of social justice (Sen, 2002). While inequality and poverty are empirical notions that are measurable, judgements of equity require that normative social assessments be undertaken, largely within national, social contexts. Research and related work on equity in health thus take intuitive notions about fairness and then seek to make them explicit (Evans, Whitehead, Diderichsen, Bhuiya, & Wirth, 2001). By definition, health inequities have a social basis āor some degree of social causation (Braveman, 2006; Diderichsen, Evans, & Whitehead, 2001; Whitehead, 1990, 1992). Because health inequities are agreed to be socially produced to some extent, they are also viewed as modifiable, through particular social policies and interventions implemented over the long term, through approaches such as āhealth in all policiesā (HiAP) (Braveman & Gruskin, 2003; Koivusalo, 2010; Leppo, Ollla, Pena, Wismar, & Cook, 2013). Thus, and significantly, the use of the term health equity recognises the active role and the obligation of states to ameliorate inequities in groups and populations (Braveman & Gruskin, 2003).
Within the current HIV epidemic among women, research indicates, and this work affirms, that the battleground of justice in health has now shifted from ājust health careā (or justice in health care) to social or structural determinants of health (SDHs), including gender-related factors, as a key location on which greater equity in health for women depends. Significantly, for women (particularly, but not only) in high HIV prevalence locations, both improved HIV outcomes for those living with the virus and prevention of new HIV infections in women at risk of contracting HIV rest on moving the structural drivers that foster HIV risk and transmission from the periphery to the very core of the HIV response.
This is not to say that justice in health care, or ensuring HIV testing and treatment provision in health systems, should cease (UNAIDS, 2014a). Roughly 50% of Africans living with HIV still do not have access to cART, which underscores the continuing importance of health care and systems. On the contrary, it would be more accurate to envisage social structure and health systems as multiple, connected locations that affect peopleās opportunities to be healthy in ways that are relational, as this work demonstrates. These concentric spheres are perhaps most visible for women in the geographical location where the majority of people, 71%, are living with HIV and acquired immune deficiency syndrome (AIDS): SSA. When it comes to gender, HIV and advancing health equity, as ever, place matters, as does social context. In SSA, HIV transmission occurs primarily through heterosexual contact, and women comprise 58% of those living with HIV (UNAIDS, 2016a). That statistic not only reveals a feminised epidemic, but also points to the influential social health determinants, including the leading role of gender-related factors in continuing to foster HIV transmission, particularly for women in the high HIV prevalence setting of Southern Africa (Leclerc-Madlala, 2008a, 2008b; UNAIDS, 2016a, 2016b, 2016c).
Gender, a social concept, is influenced by sociocultural factors, rather than anatomical ones, and refers to characteristics, such as norms, behaviours and roles, that are not located in the person but are socially constructed (Butler, 2004; Moynihan, 1998). Gender norms refer to the beliefs and actions that define social relations and the expected roles and behaviours between individuals, according to their gender categories (see Connell, 1987, 1995). Adverse gender and sociocultural norms and practices play a crucial role in generating individual or group susceptibility to disease or health conditions, and in determining access to the enabling conditions and factors that protect and promote human health and development (Sen , Ćstlin, & George, 2007). Gender relations are ultimately about power and influence, and gender inequality undermines health and health-seeking opportunities, also influencing vulnerability and exposure to injury, abuse ...