Why climate change’s impact on women in sub-Saharan Africa needs to be treated as the health crisis that it is

By Edith Magak

When the HIV pandemic emerged in the 1980s, men were more likely than women to acquire the disease. But today, women are the face of the virus. In sub-Saharan Africa, over 60% of people living with HIV are female. This feminization of HIV was confirmed in the latest UNAID’s update, which revealed that around 4200 adolescent girls and young women in sub-Saharan Africa acquire HIV every week. In 2020, six in seven adolescents aged between 15-19 years acquiring HIV in the region were girls.

Women and girls are disproportionately affected by HIV because of vulnerabilities, including gender inequality and cultural norms that put them at a higher risk of exposure. Because of stricter gender roles, they are also the main household managers. As such, they carry the primary burden of providing food, collecting water and firewood, and being the guardians of household food security. 

They are also on the frontlines of climate change. In 2019, women in agriculture represented about 50% of sub-Saharan Africa’s female labor participation, but climate change has increased heat waves and changed rainfall patterns, leading to an increased frequency of droughts across the continent. Lack of rainfall has severely impacted crop yields in this region which is heavily dependent on subsistence agriculture for food and income, leading to intensified food insecurity. Hunger has more than doubled in the past year, with tens of millions suffering from food insecurity

Food insecurity in sub-Saharan Africa has a significant gender dimension. Women, who are particularly vulnerable to income and environmental shocks, are at more risk of severe hunger and suffer more consequences due to limited coping strategies. This leads to different coping mechanism and societal behaviors, such as engaging in transactional condom-less sex for money or food, early sexual debut for girls, and gender-based violence, thereby increasing HIV transmission. Food insecurity among women living with HIV has also been associated with decreased adherence, as many refuse to take the treatment on an empty stomach due to side effects. Malnutrition and risky infant-feeding practices, such as early introduction of solids and fluids,  among food-insecure mothers also elevate the risk of vertical mother-to-child transmission.

In regions around Lake Victoria, the largest lake in Africa, lack of rainfall made worse by climate change has increased women’s risk of contracting HIV. Increased droughts have caused a decline in water levels, reducing the quantity of tilapia and Nile perch, which the communities depend on as a source of income and food.  In Kenya, men go fishing, and women purchase fish from them to sell at the market. Even if a woman has money, fish is in such short supply there is little to buy. The fishermen require sex in addition to cash. When approached, a woman will accompany a fisherman to a shanty to meet her part of the transaction and then return to the shore to pick up her allotment. The risk of contracting HIV is elevated for these women as HIV prevalence among fishing communities of Kenya is 32%. 

Many studies have shown the connection between drought and HIV prevalence.  A population-based survey study by Dr Andrea Low of ICAP at Columbia and colleagues conducted in Lesotho between 2016 and 2017 aimed to find the association between drought and HIV-related outcomes after the severe drought of 2014–2016. The findings revealed that among young females (15-24 years) residing in urban areas, drought was linked with an almost 5-fold increase in transactional sex and a 3-fold increase in those forced into sexual relations. 

Food insecurity, a prime outcome of drought, has also been linked to higher rates of HIV. In another study published in the July 2022 volume of BMJ, Dr Low and colleagues conducted a survey in six sub-Saharan countries to determine the relationship between food insecurity and HIV incidence. The investigators found that food insecurity among women who recently acquired HIV had doubled their risk of contracting the virus . In contrast, no significant risk was noted in men. Women with severe food insecurity also reported early sexual debut (occurring before 15 years), more forced sex and condom-less sex with a partner of unknown or positive HIV status. 

In another paper, Dr Kelly Austin of Lehigh University and colleagues explored how drought creates food insecurity, which contributes to the feminization of the HIV burden. Women are the first to sacrifice their food to ensure their children and others have enough to eat during drought. Therefore, they were more malnourished, which weakened their immune defenses against HIV. Additionally, food insecurity indirectly intensified gendered inequalities that limited women’s access to education and healthcare, including birth control services, which could protect females against HIV. 

Interestingly, the study revealed that economic development in communities had no significant improvement in health disparities like HIV or alleviating suffering from drought or food insecurity. Rather investments in public health resources like drinking water, doctors, and schooling, protected people from drought and reduced gendered vulnerabilities to disease.

Given the likelihood of future droughts, addressing the impact of food insecurity on HIV prevention and treatment outcomes for women is essential to achieving the UNAIDS 95-95-95 goals, which aims for 95% of those living with HIV to know their status, 95% of those who know their status to be on treatment, and 95% of those on treatment to be virally suppressed. 

Some programs are now trying to address this; 

In Kenya, the Women in Climate Change program is helping women living with HIV establish climate-friendly kitchen gardens using locally available biodegradable materials, training them to construct energy-saving devices, and establishing tree nurseries. In South Africa, the FRESH (Females Rising through Education, Support, and Health) program is operating in KwaZulu-Natal, a province with one of the highest rates of HIV in the world, to empower women. Women visit the mall twice weekly to participate in a nine-month program that provides life and job skills training. Participants are also provided with HIV prevention medication and HIV treatment should they be diagnosed with HIV.

UN Women has also embarked on a program called Women Empowerment through Climate-Resilient Agriculture, which helps women farmers use new techniques and technologies, particularly resilient seeds, to ensure that agriculture can withstand erratic drought and flood cycles. And on July 18 2022, leaders meeting at the African Union summit in Zambia launched the Education Plus initiative, aimed at taking action to keep adolescent girls in school, which will reduce their vulnerability to HIV. 

But more immediate support, like food assistance, is urgently needed. Dr Andrea Low’s study found that receipt of food assistance was associated with a 64% lower risk of recent HIV infection in women. This suggests that hunger alleviation interrupts the cycle of vulnerability and high-risk behaviors to obtain food. Cash transfers, provided in times of food shortage, encourage rural families to keep girls in school and avoid early marriages, as seen in Kenya. Additionally, biomedical prevention modalities such as pre-exposure prophylaxis (PrEP) to women might disrupt this pathway. 

But most importantly, the upcoming COP27 in Egypt in November, dubbed ‘the African COP’, allows African leaders to address this. As stakeholders will be demanding wealthier, polluting nations to give them more money for adaptation projects and compensation for climate change-linked losses, they must also focus on integrating actionable and measurable risk reduction policies for African women and girls in the context of climate change.