Structural and cultural conditions at the country level contribute to these disparities. By working to change these conditions, both PEPFAR and the larger GHI will assist countries in improving overall health outcomes for women and girls. For example, PEPFAR’s prevention programs work to reduce cultural acceptance of crossgenerational sex with older, more sexually experienced, and potentially high-risk male partners. Research supported by the USG is helping to spur development of microbicides, a woman-controlled prevention method. In programs with women, law enforcement and community leaders, PEPFAR strengthens awareness of reporting, treatment services, and systems that address sexual and gender-based violence. Finally, PEPFAR’s work with peer education programs assist women in making decisions about their own health and relationships, and assist communities in supporting this role for women.

Gender inequities limit women’s power over family and sexual relationships. They contribute to economic, legal, and educational inequities that place women and girls in situations where they cannot protect themselves from HIV. Unequal land tenure laws may mean that widows cannot gain ownership of land following the death of their husbands, leading them to poverty and homelessness. Women who lack access to other economic opportunities may engage in transactional sex for motivations ranging from survival to obtaining status-enhancing material goods. Women and girls who are denied the opportunity to attend school miss important opportunities to learn about HIV and the ways it is transmitted.

The negative impacts of culturally-driven gender norms may be most apparent for women, but have a significant impact on men as well. For example, prevention efforts cannot work if men face pressure to engage in behavior that is risky for themselves and their partners. Cultural expectations around gender norms further stigmatize men who have sex with men (MSM) and transgender individuals, making it harder for these populations to access health services. PEPFAR’s behavior change communication efforts must work to reduce risky behavior, such as procuring commercial sex or abusing alcohol, and create broader support for men who engage in positive behavior. In addition, men are essential partners in efforts to engage in national and community-level changes that address the impact of gender norms. Male leaders are often the ones with the power and platform to convince others to change behavior, policies, and cultural norms.

Addressing gender in the health sector involves activities beyond providing health services to women. The benefits of helping women access care, legal rights, and economic opportunity are clear for both men and women. Through its gender efforts, PEPFAR is facilitating participation of women and men in work that helps their families and communities. PEPFAR’s gender work will be linked to efforts to strengthen health systems and engage greater involvement of women as leaders, health care workers and decision makers.

PEPFAR is committed to ensuring gender equity in its prevention, care, and treatment services. This concept of gender equity is one that PEPFAR strives to integrate within all of its programming, taking into account the ways in which gender norms and barriers contribute to epidemics at the country context. In addition to integrating gender throughout its prevention, care, and treatment activities, PEPFAR’s gender strategy focuses on five crosscutting areas:

• Increasing gender equity in HIV/AIDS programs and services;
• Reducing violence and coercion;
• Addressing male norms and behaviors;
• Increasing women’s legal protection; and
• Increasing women’s access to income and productive resources.

Through its existing gender strategy PEPFAR has demonstrated, and will continue, its commitment to gender equity at the highest levels of leadership. What must now occur is a robust, country-specific gender response in its programs.

Despite the range of successes in recent years, gender disparities in HIV prevalence persist in most PEPFAR countries. Country-level programming and investments do not always meet the needs that exist at the community level. In addition, PEPFAR’s programs to address cross-cutting gender issues have not always successfully translated priorities into practice. Assessing gender equity in HIV/ AIDS programs and services requires careful analysis of gender disparities and programming to address those disparities. To date, data have been lacking to help PEPFAR and other programs assess the quality and true scope of gender programming.

Over the next phase of PEPFAR, and in conjunction with the GHI, the program is expanding, assessing, and improving its programming to target gender inequity and the needs of women and girls. Its work includes the following:

Increasing partner government commitment to supporting gender equity through bilateral and multilateral mechanisms
Through Partnership Frameworks and other bilateral discussions, PEPFAR is working to expand country government engagement regarding the impact of gender upon the HIV response. Partnership Frameworks allow PEPFAR to leverage policy reform to address the vulnerability of women and girls and eliminate barriers to women’s full realization of their rights. For example, in generalized epidemics, this could mean that Partnership Frameworks address employment or inheritance laws that limit women’s ability to achieve economic equality. In addition to Partnership Frameworks, PEPFAR’s focus on creating government capacity increases the ability of national, provincial and district governments to plan, implement, and evaluate gender-focused programs and services. PEPFAR is supporting country-level efforts to develop gender strategies as a component of national AIDS strategies. PEPFAR is also continuing its efforts with civil society to ensure that organizations are able to hold governments accountable to their commitments. Finally, through its multilateral partners, including the Global Fund and UNAIDS, PEPFAR supports and encourages governments in making and expanding country- level commitments to gender equity.

Ensuring gender-equitable access to prevention, care, and treatment programming under PEPFAR, as well as PEPFAR’s linkages to broader development programming
In its next phase, PEPFAR is maintaining and promoting gender-equitable access to essential prevention, care, and treatment services across the lifespan. PEPFAR supports governments both in establishing such gender-equitable access and eradicating gender-defined structural barriers. As part of the GHI, PEPFAR will work to address the immediate and ongoing HIV/AIDS needs of women and girls, and strengthen linkages with reproductive health, family planning, and other maternal and child health services. In particular need are women who experience gender-based violence or who are unable to negotiate use of protection with partners. Wraparound programming, such as efforts to keep girls in school or address land tenure rights, will address structural drivers and social determinants of the epidemic.

PEPFAR programs also address the detrimental impacts of negative gender norms upon men and boys. During its next phase, PEPFAR is working with countries to change cultural expectations that associate masculinity with behaviors, such as multiple concurrent partnerships, that put individuals at increased risk for HIV.

Helping countries and programs translate gender principles into operational programs
PEPFAR is working to integrate gender concerns within all its prevention, treatment, and care programs and support countries to do the same. In its next phase, PEPFAR is also working to ensure that its headquarters and country staff have the skills and capacity to provide technical assistance to countries as they implement gender-equitable programming.

Expanding monitoring and evaluation, and increasing impact measurement
PEPFAR’s reporting of sex-disaggregated data represents progress in HIV data collection and reporting, but the program is doing more to expand monitoring and evaluation. PEPFAR will work with countries to establish measurable goals, targets, and reporting systems to track outcomes in gender work. As in the other areas of PEPFAR, country-level efforts to identify and map needs are necessary in order to ensure that women and girls are being reached by appropriate and responsive prevention, care, and treatment services. In addition, the program is placing a greater emphasis on highlighting gender-related research. The effectiveness and impact of new and scaledup programs should not limited by country-level gender dynamics. PEPFAR is also continuing efforts to work with other donors and bilateral partners to identify and introduce harmonized gender indicators.

Scaling up national programs to address gender-based violence
GBV contributes to increased risk of HIV. Those who experience GBV also face difficulty in disclosing this abuse to health care providers, and may be unable to access critical medical and support services. PEPFAR supports a number of programs addressing the linkages between GBV and HIV. However, efforts to date have been small compared to high rates of sexual and gender violence within the countries where PEPFAR operates. To expand the reach and scope of sexual and GBV services, PEPFAR will work with countries that have high HIV and GBV rates to develop and bring to scale a comprehensive public sector response to gender violence. In its next phase, PEPFAR is expanding services for survivors of sexual violence, including the provision of post-exposure prophylaxis, treatment of sexually transmitted infections, and reproductive health counseling and services. PEPFAR’s investments also enable expanded linkages with law enforcement and judicial systems and mobilization of communities in support of GBV prevention.

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