Evaluation of PEPFAR (2013) / Chapter Skim
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8 Gender
8 Gender
Pages 395-430
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From page 395... ...
, conduct an assessment of "efforts to address gender-specific aspects of HIV/AIDS, including gender-related constraints to accessing services and addressing underlying social and economic vulnerabilities of women and men."2 In response to this charge, this chapter begins with a brief background discussion of gender-related aspects of the HIV epidemic and response before presenting the committee's assessment of PEPFAR's efforts toward its stated aim of addressing gender norms and inequities as a way to reduce HIV risk and increase access to HIV services. The chapter reflects PEPFAR's articulated gender strategy with discussions of the main gender-focused programming areas: equity in access to services, addressing gender norms, reducing gender-based violence (GBV)
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From page 396... ...
Fundamentally, then, HIV transmission, acquisition, and disease progression are simultaneously affected by physiological, behavioral, and social realities related to sex and gender, which must be understood and addressed as part of the AIDS response in order to optimize prevention, treatment, care, and support efforts for women and men alike. Before the chapter presents the committee's assessment of PEPFAR's gender-related efforts, this section provides a very brief overview of some key factors in the interplay of sex and gender with the HIV epidemic and response, focusing on the areas of HIV transmission and acquisition, access to services, GBV, and structural factors (e.g., social, economic, and political factors)
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From page 397... ...
, and a variety of social and cultural factors also contribute to gender differences in vulnerability to HIV infection. As documented in the literature and also emphasized by interviewees during the committee's evaluation, cultural norms influence power dynamics between male and female sexual partners, frequently limiting women's abilities to negotiate safer sex practices such as condom use or enabling older men to engage in relationships with younger girls (116-24-USNGO; 240-6-USNGO; 3 272-16-PCNGO)
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From page 398... ...
. Interviewees across countries identified access to health care as a challenge that was influenced by many varied cultural gender norms.
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. For example, women's inability to negotiate the use of condoms in relationships where they experience intimate partner violence was described as both a social challenge and a contributor to HIV transmission (461-1-USG; 934-7-PCGOV)
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. Examples of interventions to increase access to housing for HIV-positive persons, effect policy change regarding access to HIV prevention services, and empower community members at elevated risk of HIV have also been successfully implemented
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The legislation tasked PEPFAR with incorporating a focus on women into its planning, programming, and reporting. It required the establishment of and reporting on multiple strategies specifically aimed at addressing elements that could improve the lives of women living with or at risk of acquiring HIV.5 These strategies included creating programs to educate women and girls about the spread of HIV/AIDS as well as developing specific strategies to • "meet the unique needs of women, including the empowerment of women in interpersonal situations, young people and children, including those orphaned by HIV/AIDS and those who are victims of the sex trade, rape, sexual abuse, assault, and exploitation" • "encourage men to be responsible in their sexual behavior, child rearing and to respect women including the reduction of sexual violence and coercion" • "increase women's access to employment opportunities, income, productive resources, and microfinance programs"6 In its second Country Operational Plan (COP)
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From page 402... ...
Thus, in the reauthorization legislation PEPFAR's original directive to focus on women was expanded to incorporate the needs of men made vulnerable as a result of gender norms. PEPFAR has recently defined gender and its relationship to the HIV epidemic in the following way: Gender -- refers to the attributes, constraints and opportunities as sociated with being a man and a woman.
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From page 403... ...
. Instructions to mission teams related to tracking gender efforts are provided as part of the annual COP guidance; these documents may also include information on how to implement gender activities, although this has varied over the history of PEPFAR, from negligible references to gender activities in FY 2004–FY 2006 to gradual increases in the acknowledgement and emphasis of the role of gender as an implementation consideration within the overarching programmatic areas of prevention, treatment, care, and strengthening health systems.
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key legislative key legislative and the five-part HIV epidemic activity for Activities that activity for activity for gender approach and increasing tracking. The address the tracking.
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COP = country operational plan; GBV = gender-based violence; GHI = Global Health Initiative; HSS = health systems strengthening; MSM = men who have sex with men; PMTCT = prevention of mother-to-child transmission.
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From page 406... ...
In addition there are genderfocused activities articulated as part of the country operational planning process that are managed by staff on the mission teams. In addition to managing PEPFAR-supported activities, interviewees in several countries noted that PEPFAR mission team members or implementing partners have worked directly to engage the national government or local organizations on topics related to gender; this work has included, for example, serving on or supporting national technical working groups (240-24-USG; 331-22-PCNGO; 196-18-PCNGO; 1668-USG)
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From page 407... ...
PEPFAR's Efforts to Address Equity in Access to HIV Services There are few specific activities specified in PEPFAR's gender strategies that are designed to address inequity in service access, and PEPFAR's gender documents do not articulate what standards might be applied to define equitable access. Interviewees in multiple countries described outreach efforts to increase the utilization of health services; most of these were aimed at women, although as described, previously cultural norms also affect men's seeking of health services, and PEPFAR has also supported some efforts in this regard.
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From page 408... ...
indicated that the proportion of individuals newly enrolled in antiretroviral therapy was consistently about 65 percent female and 35 percent male from 2005 to 2011.10 These data represent the subset of patients enrolled during this time period in HIV care and treatment programs supported through four large PEPFAR implementing partners. The data are aggregated from programs in 13 countries and thus are not matched to country-specific information on the relative disease burden between men and women in these settings; they are also not matched to estimates of the need for antiretroviral therapy in men and women, which vary by country.
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From page 409... ...
that affect HIV epidemics and the responses to them. Thus, PEPFAR -- and, by extension, OGAC -- has an important and delicate role to play working in local communities and with partner country governments in undertaking activities to mitigate the harmful elements of cultural norms about gender.
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From page 410... ...
. Despite these gains, the relatively narrow focus of PEPFAR's activities for shaping the cultural norms of men is not sufficient to comprehensively address the dynamic ways in which gender norms interact with and influence multiple aspects of prevention, treatment, and care in the HIV response.
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From page 411... ...
. PEPFAR Central Initiatives to Address Gender-Based Violence PEPFAR also supports several central initiatives to address GBV (USAID, 2012d)
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. Currently PEPFAR is in the middle of scaling up three new central initiatives aimed at combating violence against women and girls, which not only continue to elevate the profile of GBV efforts in PEPFAR, but also increase the available central funding available for GBV activities.
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From page 413... ...
Continuing this focus is critical to changing one of the most important underlying structural drivers of vulnerability in the HIV epidemic. Women's Access to Income Generation and Legal Protections The final two elements of PEPFAR's five key strategic approaches for gender are increasing women's access to income-generating activities and legal protections.
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From page 414... ...
From the limited data available, it seemed to the committee that increasing women and girl's access to income-generating activities and legal protections are the least developed elements of PEPFAR's articulated five-part approach to gender programming. Integration of Gender in Prevention, Care, and Treatment Programs The previous sections have described efforts that, for the most part, seek to accomplish gender-focused outcomes through specific programs and activities that are designed to address one or more of the five aims of the gender strategy.
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From page 415... ...
Many of these outcomes were specific to one of the five gender focus areas articulated in PEPFAR's gender documentation, such as several positive changes in gender norms that occurred in two countries following efforts by PEPFAR implementing partners (240-6-USNGO; 934-30-USNGO) , including an example where local religious leaders ceased blessing early marriages for young girls (240-24-USG)
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PEPFAR's efforts have also been scaled up over time from initial pilot programs to more central initiatives and country programming, with more financial and human resources devoted to them. This evolution is occurring in the context of a range of societal, cultural, economic, and other factors that affect gender norms in the countries in which PEPFAR is operating.
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From page 417... ...
, the needs of this population, as for all populations, cut across multiple categories of services and activities. As described previously in this chapter, PEPFAR has recently included MSM in its comprehensive framing for understanding the role of gender in the HIV epidemic and response, recognizing that "gender norms around masculinity and sexuality also put men who have sex with men (MSM)
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PEPFAR Activities and the Effects of PEPFAR's Support for Programming for MSM There were no required PEPFAR programmatic indicators for monitoring prevention of sexual transmission efforts specifically for MSM until 2010 when, as a part of the Next Generation Indicators (NGIs) process, a new required measure for the number of persons reached with individualor small group–level interventions was introduced that included disaggregation by the population at elevated risk (OGAC, 2009c)
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From page 419... ...
Participants in multiple countries identified steps that were being taken by PEPFAR to address the challenge of access to services, such as establishing a connection with a specific, trusted service provider or health facility and then making referrals directly to that provider (331-7-PCNGO; 331-22-PCNGO; 196-23-PCNGO; 196-21-PCGOV) ; linking facility providers with MSM-led community groups (331-44-USNGO; 196-23-PCNGO)
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, with the most common occurrence being that the country government wanted to focus on youth or the general population overall while PEPFAR mission teams and implementing partners identified and prioritized activities around populations at elevated risk, including MSM. In some cases this divergence was described as stemming from a lack of recognition by some in the government that MSM are present in the country (240-9-USG; 396-15-USNGO; 934-21-USG; 196-1-USG)
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. In 2011, as part of an overall effort to streamline the COP document, a narrative section for the adoption of the Global Health Initiative's core principles was added, one section of which included providing greater detail on the types of gender activities under way and their expected effects related to each of the five components outlined in the gender strategy (OGAC, 2010b)
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From page 422... ...
. In the Next Generation Indicators program monitoring guidance, five essential/ reported measures require disaggregation by sex, and an additional indicator was added within prevention activities that requires disaggregation by populations at elevated risk, including men who have sex with men (OGAC, 2009c)
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ART Total number of individuals provided Number of adults and children with with HIV-related palliative care advanced HIV infection receiving (excluding TB/HIV) antiretroviral therapy (current)
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PEPFAR has made efforts to share the lessons learned from some of its gender programming efforts. This is primarily accomplished through releasing various documents, such as the compendium of gender programs in Africa, as well as documents describing GBV, the integration of multiple PEPFAR gender strategies to improve HIV interventions, and populations at elevated HIV risk, which have been published through AIDStar-One (USAID, 2009, 2011a,b,c,d)
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Based on the findings and conclusions presented in this chapter, the committee makes the following recommendation: Recommendation 8-1: To achieve PEPFAR's stated aim of address ing gender norms and inequities as a way to reduce HIV risk and increase access to HIV services, the Office of the U.S. Global AIDS Coordinator (OGAC)
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From page 426... ...
• OGAC's guidance on gender-focused efforts should encompass programs specific to addressing gender norms and inequities and efforts to incorporate gender-focused objectives within prevention, care, and treatment activities. • The development of guidance for gender-focused efforts should take advantage of lessons learned from the processes used for PEPFAR's recent updates to its guidance for prevention and OVC programs.
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2004a. FY05 country operational plan guidance.
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2011d. The President's Emergency Plan for AIDS Relief: FY 2012 country operational plan guidance technical considerations.
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2012c. PEPFAR gender special initiative: Male Gender Norms Initiative.
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2012d. PEPFAR gender technical working group gender special initiatives.
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