PEPFAR: Addressing Gender and HIV/AIDS

March 7, 2013



“HIV/AIDS is not just a health issue.  It’s a social issue that impacts men and women differently, and it’s an issue linked with and affected by gender inequality.  Our success in fighting this epidemic is tied to our ability to recognize and respond to this reality.”

Ambassador Eric Goosby, U.S. Global AIDS Coordinator


PEPFAR Gender Strategy:

Addressing gender norms and inequities is essential to reducing HIV risk and increasing access to services for everyone. In low and middle-income countries worldwide, HIV is the leading cause of death and disease in women of reproductive age. In sub-Saharan Africa, 60% of people living with HIV are women.[i] In some countries, prevalence among young woDate: 03/07/2013 Description: Courtesy of © PEPFAR Photomen aged 15-24 years is on average three times higher than men of the same age.[ii] Men and boys are 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 are lower among men compared to women. Gender norms around masculinity and sexuality also put men who have sex with men (MSM) and transgender persons at increased risk for HIV. Globally, MSM are 19 times more likely to be HIV-positive compared to the general population[iii], and transgender women are 48 times more likely to have HIV compared to others of reproductive age.[iv] These disparities are the result of biological, structural, and cultural conditions, as well as stigma and discrimination that affect men, women, and transgender persons differently and impede access to resources that can prevent and mitigate HIV. As a result, PEPFAR, through the interagency Gender Technical Working Group, encourages all of its programs to address gender norms and inequities, with PEPFAR's Gender Strategy focusing on five key areas:

  • Increasing gender equity in HIV/AIDS programs and services, including access to reproductive health services

  • Preventing and responding to gender-based violence

  • 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 Commitment to Women, Girls and Gender Equality:

This Administration has made great strides in its commitment to women, girls, and gender equality, with progress reflected in President Obama’s historic signing of a January 2013 Presidential Memorandum, which ensures that advancing the rights of women and girls remains central to U.S. diplomacy and development around the world. PEPFAR plays a critical role in implementing programs that advance gender equality in order to improve health outcomes for individuals, families, and communities. PEPFAR also aligns its focus on these critical issues across all U.S.-supported development efforts and with key policies and frameworks, including the Secretary of State Policy Guidance on Promoting Gender Equality to Achieve our National Security and Foreign Policy Objectives, and USAID’s Gender Equality and Female Empowerment Policy, both released in 2012.

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 reprisal. An estimated one in three women worldwide has been beaten, coerced into sex, or otherwise abused in her lifetime, with intimate partner violence as the most common form of violence experienced by women globally.[v] 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.[vi] Sexual violence can also directly lead to HIV infection. Sexual violence among adolescents and pre-adolescents is alarmingly high. To date, national Violence Against Children surveys in Swaziland, Tanzania, Zimbabwe, and Kenya reveal that 28 to 38% of girls and 9 to 18% of boys report an unwanted sexual experience before the age of 18. In August 2012, the U.S. government released the first ever U.S. Strategy to Prevent and Respond to Gender-based Violence, and an accompanying Presidential Executive Order directing implementation of the strategy. In line with these efforts, PEPFAR supports significant work in the field to integrate GBV into existing HIV programs. Over the last three years, PEPFAR has invested more than $215 million in GBV-related programming, making PEPFAR one of the largest investors worldwide.

PEPFAR Gender Central Initiatives:

In addition to incorporating gender issues across country programs, PEPFAR has invested in special gender initiatives centrally in order to 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 second year of implementing GBV comprehensive programming, totaling more than $60 million over three years. The Initiative also requires that countries report on three pilot PEPFAR GBV indicators. In Tanzania, an in-depth evaluation is examining the effectiveness and overall impact of the GBV health response and prevention interventions in the Mbeya Region.

  • PEPFAR Gender Challenge Fund (GCF): Through two rounds of funding, GCF has leveraged nearly $20 million of central and matching funds from 18 PEPFAR countries throughout Africa, Asia, Central America, and the Caribbean to advance strategic gender priorities across PEPFAR programs. Current activities include support for One Stop Centers to prevent and respond to GBV in Rwanda; addressing gender norms, stigma and discrimination, and violence among key populations in the Caribbean region; economic strengthening for vulnerable women in Swaziland; and improving 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. These grants address a range of GBV issues, such as strengthening legal and judicial systems, reducing stigma, and enhancing prevention efforts—all of which work to address the drivers of both GBV and HIV.


Date: 03/07/2013 Description: Courtesy of © PEPFAR Photo






Tools to Integrate Gender Issues in PEPFAR:

In collaboration with civil society, government representatives, services providers, and USG implementing partners, including AIDSTAR-One Project, PEPFAR has developed a number of resources to address gender issues across HIV programs. These include:

  • Gender-based Violence and HIV: PEPFAR funded the re-launch of this website, which provides strategies and evidence on a wide range of HIV prevention, care, and treatment interventions for women and girls

  • Integrating Gender Strategies in Concentrated HIV Epidemics Series: Nine case studies provide an in-depth look at HIV programs for key populations in South and Southeast Asia, Eastern Europe, Latin America, and the Middle East

  • Africa Gender Compendium Case Study Series: A series of five case studies, selected from a 31-program compendium, describe how programs use gender strategies to improve HIV services and reduce risk to HIV infection

  • PEPFAR Gender Technical Consultation: 26 PEPFAR country delegations convened in October 2012 to build global capacity to use gender integration tools and improve addressing gender issues in country programming.

Date: 03/07/2013 Description: Courtesy of Still Life Projects © PEPFAR Photo






PEPFAR supports a range of partners to improve the health and lives of women and girls. For example:

  • Together for Girls: A global public-private partnership, Together for Girls (TfG) works to eliminate violence against children, with a focus on ending sexual violence against girls. Working with governments and civil society, TfG builds on existing platforms to integrate the issue of violence against children into social welfare, gender, health, education, and justice programs. TfG is active in Tanzania, Kenya, Swaziland, Zimbabwe, and Haiti with work underway in Cambodia, Malawi, and Indonesia. In July 2012, PEPFAR announced an additional $5 million for TfG to support violence against children interventions in response to TfG’s Violence Against Children surveys.
  • Empowering Adolescent Girls to Lead through Education (EAGLE): A five-year $15 million PEPFAR and USAID joint initiative, EAGLE seeks to improve the number of girls transitioning from primary to secondary school, and reduce their vulnerability to HIV, by tackling many of the barriers keeping girls from continuing their post-primary educations—including cost and school safety—thus improving knowledge, attitudes, and practices regarding GBV prevention and response, and gender equality within schools.
  • Pink Ribbon Red Ribbon® (PRRR): PRRR is a public-private partnership to address 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 builds on the PEPFAR platform to expand the availability of vital cervical cancer screening and treatment, especially for high-risk HIV-positive women; expand access to the HPV vaccine; and promote breast cancer education. 

Date: 03/07/2013 Description: Courtesy of Still Life Projects © PEPFAR Photo








These investments and partnerships are having a major impact for women, girls and gender equity. For example:

  • In FY2012, seven Gender Challenge Fund countries reported that over 1.3 million people were reached by an individual, small group, or community-level intervention or service that explicitly addressed norms about masculinity related to HIV/AIDS.

  • In FY2012, 11 countries reported that 720,000 people were reached by an individual, small group, or community-level intervention or service that explicitly addressed GBV and coercion.

  • Over the past 3 years, PEPFAR has reached almost 85,000 individuals with post-exposure prophylaxis to prevent HIV for sexual violence survivors in 19 countries.

  • From FY2004–FY2012, PEPFAR procured nearly 67 million female condoms, making PEPFAR one of the largest procurers of female condoms worldwide.


[i] World Health Organization. 2013. “Gender inequalities and HIV.”

[ii] UNICEF. 2009. Actions for children: The greater vulnerability of girls and young women to HIV infection.”

[iii] Baral S, Sifakis F, Cleghorn F, et al. “Elevated risk for HIV infection among men who have sex with men in low- and middle-income countries 2000-2006: A systematic review.” PLoS Med. 2007 December 1;4(12):e339.

[iv] Baral S, Poteat T, Strömdahl S, Wirtz A, Guadamuz, T, Beyrer, C. “Worldwide burden of HIV in transgender women: a systematic review and meta-analysis.” The Lancet Infectious Diseases. 2013 March ( Vol. 13, Issue 3, Pages 214-222 )
DOI: 10.1016/S1473-3099(12)70315-8.

[v] UNFPA. “Ending widespread violence against women.”

[vi] The Global Coalition on Women and AIDS, WHO. “Violence against women and HIV/AIDS: Critical intersections, intimate partner violence and HIV/AIDS,” 2004.

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