PEPFAR: Addressing Gender and HIV/AIDS


March 7, 2014

Overview:

Addressing gender norms and inequities is essential to reducing HIV risk and increasing access to services for everyone. Gender-related disparities are the result of biological, structural, and cultural factors. Stigma and discrimination can also impede access to HIV services and hamper efforts to effectively control the epidemic. (See Box 1: Key Affected Populations)

This fact sheet describes the newly updated PEPFAR gender strategy, describes PEPFAR’s central gender initiatives, and highlights key results from PEPFAR activities to address gender and HIV/AIDS. .

To jump to each section of the fact sheet, click the links below:

Updated PEPFAR Gender Strategy:

PEPFAR’s Gender Strategy focuses on five key areas:

  1. Increasing gender equity in HIV/AIDS programs and services, including reproductive health services
  2. Preventing and responding to gender-based violence
  3. Engaging men and boys to address norms and behaviors around masculinity and sexuality
  4. Increasing gender-related policies and laws that increase legal protection
  5. Increasing gender equitable access to income and productive resources, including education

To respond to emerging evidence and programmatic needs, PEPFAR released an updated Gender Strategy in December 2013. The strategy is designed to help programs recognize the critical role gender norms and inequality play in the HIV epidemic, ensure equity in access to HIV programs and services, and take concrete steps to respond to the unique needs of different populations. It emphasizes the importance of understanding the needs of populations whose sex (women and girls), gender identity (transgender persons), sexual orientation (lesbian, gay and bi-sexual populations—LGBT), and/or sexual behavior (men who have sex with men, sex workers) make them vulnerable to HIV.

What’s New:

  • Gender Analysis required: Starting with March 2016, PEPFAR country teams will be required to conduct a gender analysis to inform the development of programs.
  • New Gender-Equality Indicators: PEPFAR programs are now required to report on two new Gender Equality indicators. These indicators measure changes in the power dynamics in how men and women, boys and girls, and those with other gender identities relate. One new indicator measures the number of people receiving post-GBV care, while the other tracks the number of people completing an activity pertaining to changing gender norms. In addition, all 26 of the new PEPFAR indicators now offer more refined age by sex disaggregated categories.

BOX 1: Key Affected Populations

Women and girls: 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 women age 15-24 years is three times higher than among men of the same age.ii

Men and boys: 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 tend to be lower among men compared to women.

LGBT populations: Gender norms around masculinity and sexuality put MSM and transgender persons at increased risk for both HIV and GBV. Globally, MSM are 19 times more likely to be HIV-positive compared to the general populationiii, and transgender women are 48 times more likely to have HIV compared to others of reproductive age.iv

 

PEPFAR Gender Initiatives:

In addition to incorporating gender issues in country programs, PEPFAR invests in a number of special initiatives to address the intersection between gender and HIV.
 
PEPFAR Gender-Based Violence and HIV Response: Gender-based violence is not only a violation of human rights, but also 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. Women and girls are disproportionately affected by violence and 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 A recent systematic review and meta-analysis of studies across different HIV epidemic settings by the WHO shows that intimate partner violence increases women’s risk for HIV infection by more than 50 percent, and in some instances by up to four-fold.vi

Sexual violence, which can directly lead to HIV infection, is alarmingly high among adolescents and pre-adolescents. To date, national Violence Against Children surveys in Swaziland, Tanzania, Zimbabwe, Kenya, and Haiti reveal that 28 to 38% of girls and 9 to 18% of boys report an unwanted sexual experience before the age of 18. Sexual violence against children can result in negative short- and long-term physical and mental health consequences, yet there is limited international guidance on provision of sexual assault services for children and adolescents. In response to this gap, PEPFAR Technical Working Groups and various partners developed Technical Considerations on post-rape care for persons under the age of 18 in primary health centers that also provide HIV care.
 

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.

 

PEPFAR Partnerships to Improve the Health and Lives of Women and Girls:

Saving Mothers, Giving Life (SMGL): A five-year public-private partnership to rapidly reduce maternal mortality in Sub-Saharan Africa, where many of these deaths occur. In its first year, SMGL districts in Uganda and Zambia reported significant decreases in the number of maternal deaths through the implementation of life-saving interventions that make high quality, safe childbirth services available and accessible to women and their newborns. In the first year of this initiative, the report found that maternal deaths dropped by 30 percent in the districts in Uganda and by 35 percent in the facilities in Zambia where the partnership has been implemented.

Together for Girls (TfG): A global public-private partnership dedicated to ending violence against children, with a focus on sexual violence against girls. TfG generates comprehensive national-level data, led by CDC, on the magnitude and consequences of emotional, physical and sexual abuse against children, which provides the foundation for action, mobilizing countries to lead a response and inform solutions that are evidence-based and supported by Together for Girls’ global partners.

Visit our page on Public Private Partnerships for more information about PEPFAR partnerships.

Impact of PEPFAR Gender Initiatives:

  • In FY2013, eight PEPFAR Gender Challenge Fund countries reached over 1.5 million people with individual, small group, or community-level interventions or services that addressed norms about masculinity related to HIV/AIDS.
  • In FY2013, 12 PEPFAR country programs reached 2.5 million people with individual, small group, or community-level interventions or services that addressed GBV and coercion.
  • In the past four years, PEPFAR reached over 114,000 individuals with post-exposure prophylaxis to prevent HIV for sexual violence survivors in 19 countries.
  • FY 2013, 800 health facilities reported that they now offer GBV screening and/or assessment and provide referrals to relevant services, four times as many as the previous year.
  • From FY2004–FY2013, PEPFAR procured nearly 75 million female condoms, making PEPFAR one of the largest procurers of female condoms worldwide.

BOX 2: Tanzania: A Comprehensive Gender-Based Violence (GBV) Response

In Tanzania, 27% of girls and 12% of boys experience sexual violence during childhood. PEPFAR is working closely with the government to integrate comprehensive GBV programming into existing HIV platforms. For example, the community home-based care program Tutunzane (“Let’s take care of each other”) works to sensitize communities about GBV and assist GBV survivors and people living with HIV with medical care and psychosocial support through regular home visitations. As of February 2012, Tutunzane was providing home-based care to nearly 30,000 people living with HIV/AIDSvii. Also, close to 2,000 people received post-exposure prophylaxis through PEPFAR supported programs in 2013, up from 187 the previous year.

In addition to addressing the negative health consequences of GBV, significant efforts are being made to move the GBV response beyond the health sector. With the support of Together for Girls, a PEPFAR-supported global public-private partnership, Tanzania has made impressive strides in developing a national child protection system. Following the completion of a Violence Against Children Survey, led by CDC, the government has launched a multi-sector national action plan and implementation is underway. To date an estimated 4,000 social welfare officers, community development officers, primary school teachers, health workers, police and district justice officials have been trained on child protection.

The impacts of these programs are being felt broadly. At a workshop in February 2014, Tanzanian Deputy Minister for Justice and Constitutional Affairs, Ms. Angela Kairuki, applauded PEPFAR for supporting the government efforts to address GBV. The Deputy Minister cited GBV’s impact on health outcomes for women and children and called upon the media to assist the public in understanding the laws and policies in place to protect people against GBVviii

 

New Tools to Integrate Gender Issues in PEPFAR

In collaboration with United Nations partners, the Global Fund to Fight AIDS, Tuberculosis and Malaria, civil society, government representatives, service providers, and USG implementing partners, PEPFAR is working to ensure that gender issues are addressed and integrated throughout all HIV programs. You can view a number of newly developed resources online, including a Compendium of Gender Equality and HIV Indicators.

_________

i World Health Organization. 2013. “Gender inequalities and HIV.” http://www.who.int/gender/hiv_aids/en/.

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

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.” http://www.unfpa.org/gender/violence.html.

vi WHO and UNAIDS. 2013. “16 Ideas for addressing violence against women in the context of the HIV epidemic: A programming tool.” http://apps.who.int/iris/bitstream/10665/95156/1/9789241506533_eng.pdf.

vii Fleischman, Janet. 2012 July. “Gender-Based Violence and HIV: Emerging Lessons From the PEPFAR Initiative in Tanzania”. http://csis.org/files/publication/120709_Fleischman_GenderBasedViolence_Web.pdf.

viii Athumani, R. 2014 February 12. Tanzania: 'Enlighten people on gender violence'. Retrieved from Tanzania Daily News website: http://allafrica.com/stories/201402120053.html

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