PEPFAR Gender Strategy: Addressing gender norms and inequities is essential to reducing HIV risk and increasing access to HIV prevention, care and treatment services for women and men. In low and middle-income countries worldwide, HIV is the leading cause of death and disease in women in reproductive age. In sub-Saharan Africa, 60% of those living with HIV are women and in some of these countries, prevalence among young women aged 15-24 years is on average about three times higher than among men of the same age. Men and boys are also affected by gender expectations that may encourage risk-taking behavior, discourage accessing health services, and narrowly define their roles as partners and family members. Rates of HIV testing and treatment utilization are lower among men compared to women. Gender norms around masculinity and sexuality also put men who have sex with men (MSM) at increased risk for HIV by creating additional stigma and discrimination that can prevent them from seeking and accessing services. Globally, MSM are 19 times more likely to be infected with HIV compared to the general population. These disparities are the result of biological, structural, and cultural conditions that affect men and women differently such as gender norms that impact expectations and behaviors, as well as differences in access to resources that limit prevention and mitigation of the disease. PEPFAR proactively confronts the changing demographics of the HIV/AIDS epidemic, integrating gender throughout prevention, care, and treatment programs with a focus on:
• Increasing gender equity in HIV/AIDS programs and services, including access to reproductive health services
• Reducing violence and coercion
• Engaging men and boys to address norms and behaviors
• Increasing women and girls’ legal protection
• Increasing women and girls’ access to income and productive resources, including education
PEPFAR’s Role in Advocating for Women, Girls and Gender Equality: A central principle of the Global Health Initiative (GHI) is a focus on Women, Girls and Gender Equality (WGGE). PEPFAR is a key partner in implementing this principle which aims to redress gender imbalances related to health, including empowering women and girls, to improve health outcomes for individuals, families, and communities. PEPFAR aligns its efforts to focus on women, girls and gender equality across all U.S.-supported development efforts with the Secretary’s Office of Global Women’s Issues (S/GWI) and with key policies and frameworks across PEPFAR implementing agencies, including the newly released USAID Gender Equality and Female Empowerment Policy.
Gender-Based Violence (GBV): GBV fosters the spread of HIV/AIDS by limiting one’s ability to negotiate safe sexual practices, disclose HIV status and access services due to fear of GBV. Sexual violence can also directly lead to HIV infection. Country studies indicate that the risk of HIV among women who have experienced violence may be up to three times higher than among those who have not. Sexual violence among adolescents and pre-adolescents is alarmingly high. In 2010 the first nationally representative survey of violence against children in Tanzania found that nearly three in ten females and one in seven males experienced sexual violence prior to the age of 18. PEPFAR supports significant work in the field to mainstream GBV into existing HIV programs. In FY2010 PEPFAR Country Operational Plans provided an estimated $38 million for GBV activities in more than 28 countries; in FY2011 this increased to $57 million. Over the last two years, PEPFAR has invested a total of $155 million in GBV-related programming, making PEPFAR one of the largest investors worldwide.
Prevention of Mother-to-Child Transmission (PMTCT): In addition to meeting the comprehensive needs of women and girls, PMTCT is a key entry point to increase gender equity in HIV/AIDS programs and services. These programs prevent new infant HIV infections and provide antiretroviral treatment (ART) to HIV-infected mothers, which protects children from orphanhood and helps keep the family together. In FY2011, PEPFAR provided ARVs to over 660,000 HIV-infected pregnant women, effectively preventing over 200,000 infants from becoming HIV infected.
PEPFAR Gender Central Initiatives: In addition to incorporating gender in all country programs, PEPFAR has invested in special gender initiatives centrally—in order to pilot specific approaches, build our evidence base for investments and expand programming at the country level.
•PEPFAR GBV Response Initiative: Three countries—Mozambique, Tanzania, and the Democratic Republic of Congo—are in the first year of the GBV comprehensive programming, totaling over $48 million over three years. The Initiative also requires that countries report on three new PEPFAR GBV indicators that are currently being piloted in the field. Finally, in Tanzania, an in-depth evaluation project will be undertaken to examine the effectiveness & overall impact of the program.
• PEPFAR Gender Challenge Fund: The Gender Challenge Fund makes additional resources available to PEPFAR country programs, using central funds to match funds from country budgets totaling nearly $20 million. Current activities funded through the Gender Challenge Fund include addressing male norms to reduce GBV in Guyana, strengthening male engagement in HIV testing & PMTCT in the Dominican Republic, economic strengthening for vulnerable women in Swaziland & raising improved HIV surveillance for female partners of persons who inject drugs in the Central Asia Republics.
• S/GWI-PEPFAR GBV Small Grants: In order to support small, grass-roots civil society organizations that respond to GBV, PEPFAR and S/GWI have partnered to provide over $4.6 million in new small grants for countries with a PEPFAR presence.
Tools for Gender Integration in PEPFAR: PEPFAR, along with its partner AIDSTAR-One, has recently developed tools to integrate gender within HIV programs and platforms. These include:
• Gender-Based Violence and HIV: A Program Guide for integrating GBV Prevention and Response in PEPFAR Programs: An interactive implementation guide including recommended resources for addressing gender-based violence within each PEPFAR technical area.
• Integrating Gender Strategies in Concentrated HIV Epidemics Series: A series of nine case studies provide an in-depth look at HIV programs working with and those most-at-risk in South and Southeast Asia, Eastern Europe, Latin America, and the Middle East.
• Integrating Gender into Programs for Most-At-Risk Populations (MARPs): This brief explores the importance of incorporating gender into programming targeting most-at-risk populations.
• Africa Gender Compendium Case Study Series: A series of five case studies that describe how programs in Africa are using gender strategies to improve HIV services and reduce vulnerability to HIV infection. The programs were selected from a 31-program compendium developed by AIDSTAR-One.
Partnerships: Through the interagency Gender Technical Working Group, PEPFAR supports a range of activities to collaborate with partners to improve the lives of women and girls.
• Together for Girls (TfG): This unique partnership brings together public, private, U.N. and U.S. Government agencies to address sexual violence against children, particularly girls, but also boys. Working with governments and civil society, TfG is taking practical steps to tackle sexual violence against children. Current work is underway in Tanzania, Kenya, Swaziland, Zimbabwe, and Haiti with future work planned for Cambodia, Malawi, and Philippines.
• Pink Ribbon Red Ribbon® (PRRR): PRRR is an innovative public-private partnership to combat cervical and breast cancer – two of the leading causes of cancer death in women - in developing nations in Sub-Saharan Africa and Latin America. PRRR will expand the availability of vital cervical cancer screening and treatment—especially for high-risk HIV-positive women; expand access to human papillomavirus (HPV) vaccine; and promote breast cancer education.
• Indicators: With UN colleagues, PEPFAR has worked to harmonize indicators that track the status of women, gender equity and HIV, and – for the first time ever – helped to ensure that a new indicator on GBV was added to the 30 core indicators for UNAIDS progress reporting. We are now working with these partners to produce a compendium of indicators for monitoring gender in the context of an HIV response—this publication will be available in July 2012.
Impact: These investments and partnerships are having a major impact for women, girls and gender equity. For example:
• Six Gender Challenge Fund countries reported that over 29,000 people were reached by an individual, small group, or community-level intervention or service that explicitly addressed norms about masculinity related to HIV/AIDS.
• Five countries reported that over 102,000 people were reached by an individual, small group, or community-level intervention or service that explicitly addresses GBV and coercion.
•In FY2011, PEPFAR supported post-exposure prophylaxis (PEP) to prevent HIV infection for survivors of sexual violence to almost 47,061 people, 34% more than the year before. Close to 1,400 facilities provide PEP in 7 countries reporting data.
Finally, PEPFAR has invested significantly in new possibilities for female-controlled prevention technologies, including microbicides:
• In FY2010 and FY2011 PEPFAR invested $90 million in microbicides research. The results of the 2010 CAPRISA 004 microbicide trial have offered promising results for the future of female-controlled technologies.
• The trial of 1% Tenofovir gel, which was tested in 889 South African women, found that there were 39% fewer infections among women who received 1% Tenfovir gel compared to women who received placebo.
• From FY2004–FY2011, PEPFAR procured nearly 55 million female condoms, making PEPFAR one of the largest procurers of female condoms worldwide.
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