Chapter 5 - Responding to Critical Issues: Gender and HIV/AIDS


Mrs. Laura Bush visits with representatives from the Mothers to Mothers-To-Be program of South Africa on March 13, 2006 in the private residence at the White House. From left to right are Babalwa Mbono, Aunt Manyongo �Kunene� Mosima Tantoh and Gloria Ncanywa. White House photo by Kimberlee Hewitt

�When we talk about respect for women, we are referring to a moral truth. Women are free by nature, equal in dignity and entitled the same rights, the same protections and the same opportunities as men.�

Secretary of State Condoleezza Rice
Remarks at the Independent Women�s Forum
upon Receiving Woman of Valor Award
May 10, 2006

Issues and Challenges
Over the past year, the President�s Emergency Plan for AIDS Relief (Emergency Plan/PEPFAR) has played an important role in responding to the growing feminization of the HIV/AIDS epidemic. As highlighted during the U.N. General Assembly High Level Meeting on HIV/AIDS, it is essential that HIV/AIDS programming be responsive to gender disparities. The Emergency Plan is proactively confronting the changing demographics of the disease; working to reduce gender inequalities and gender-based abuse and violence; expanding priority gender activities; and integrating gender considerations throughout all programming areas.

The number of women and girls living with HIV continues to grow rapidly. The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that there are more than 17.7 million women living with HIV worldwide � more than a million more than in 2003. In sub-Saharan Africa, approximately 58 percent of all people living with HIV are female. The United Nations estimates that every day more than 4,000 young people aged 15 to 24 become infected with HIV around the world. By some estimates, a staggering two-thirds of these new infections are among women. In some countries, girls between the ages of 15 and 19 are infected at rates that are three to six times higher than among boys their age.

Among the harmful social norms and practices that increase the vulnerability of women and girls are those that: restrict women�s access to HIV/AIDS information and services; severely limit women�s control over their sexual lives, leaving them vulnerable to sexual violence and abuse and putting them at increased risk of HIV transmission; and deprive them of economic resources and legal rights necessary to protect themselves from HIV/AIDS and contribute productively to caring for others affected by the disease. It is also important to note that harmful social norms and practices can also increase vulnerability of boys and men, such as pressure from peers or others to have multiple sexual partners or to seek transactional sex. Some of the implications of these challenges are introduced in the chapters on Prevention, Care, and Children.

As noted in the chapter on Care, women carry a disproportionate care-giving burden when family and community members become sick with AIDS or die. These burdens often fall on girls and young women, preventing them from obtaining an education and losing the potential for economic empowerment which an education can provide. In addition, women who provide care � or who become HIV-positive themselves � often face severe stigma.

The societal issues around gender and HIV/AIDS are complex, and in some cases the issues vary from one country to another, requiring different approaches. Addressing these challenges successfully, however, is critical to the achievement of the Emergency Plan�s ambitious prevention, treatment, and care goals.

Priority Gender Strategies
The authorizing legislation for PEPFAR (Public Law 108- 25) specifies that PEPFAR will support five high-priority gender strategies:

  1. Increasing gender equity in HIV/AIDS activities and services;
  2. Reducing violence and coercion;
  3. Addressing male norms and behaviors;
  4. Increasing women�s legal protection; and
  5. Increasing women�s access to income and productive resources.

These five priority gender strategies of the Emergency Plan are monitored annually during the Country Operational Plan (COP) review process. In fiscal year 2006, a total of $442 million supported more than 830 interventions that included one or more of these gender strategies. Highlights of these activities are summarized in table 5.1 and presented in greater detail throughout this chapter.

Table 5.1: Gender: Number of activities per Gender Strategic Focus Area in FY2006

Strengthening PEPFAR�s Approach to Gender
On June 1, 2006, PEPFAR convened a wide range of gender experts for a one-day meeting to facilitate discussion among key stakeholders on issues and priorities for gender and HIV/AIDS prevention, treatment, and care programming. More than 120 participants attended the �President�s Emergency Plan for AIDS Relief: Gender and HIV/AIDS Consultation,� including Congressional staff, researchers, and program staff from U.S. Government (USG) agencies, multilateral agencies, and HIV/AIDS implementers, including from non-U.S. funded organizations. Objectives of the meeting were to review the state of knowledge and the latest findings on gender and global HIV/AIDS; to examine innovative programs currently being implemented under PEPFAR; to identify program opportunities and gaps for innovation and scale-up; and to inform PEPFAR�s gender programming priorities for the coming year.

The meeting was organized around panels and small-group discussions and featured presentations by leading experts on gender issues and strategies related to HIV/AIDS; illustrative examples of how PEPFAR is programmatically addressing gender issues; and recommendations for strengthening gender and HIV/AIDS programming.

Men, such as those pictured here from Kenya, play an important role in addressing gender issues and the Emergency Plan supports community-based prevention programs and media messages to change male norms and behavior.

Outcomes of the Consultation were summarized and presented for feedback at the HIV/AIDS Implementers� Meeting on June 13, 2006, in Durban, South Africa. Based on this feedback, three high-priority topic areas were identified:

  • Creating positive change in male norms, roles, and behaviors;
  • Strengthening services for gender-based violence within the health setting; and
  • Addressing HIV vulnerabilities among young girls and women.

Taking Recommendations into Action
In August 2006, PEPFAR allocated an initial $8 million in central funding to launch gender-specific initiatives that were designed based on the priority topics identified through the Gender Consultation process. These initiatives represent an opportunity to develop innovative approaches and test implementation across several countries. Robust assessments of each approach will result in greater opportunity for expansive scale-up of effective gender programming in the context of HIV/AIDS.

  • Changing male norms � This project aims to scale up coordinated, evidence-based interventions by providing technical resources and support in order to develop and implement a strategic, intensive, and coordinated approach to changing male norms and behaviors. The program scale-up will be evaluated by assessing changes in social/community norms and individual behavior.
  • Responding to gender-based violence � This project aims to increase access for survivors of sexual violence to comprehensive treatment services, including HIV post-exposure prophylaxis (PEP), by: implementing sexual violence service delivery models and strengthening the capacity of local partners and institutions to deliver high-quality health care services, including PEP, to survivors of sexual violence; establishing and improving linkages among the health, law enforcement, legal, and community service sectors for delivery of a coordinated response to sexual violence survivors; fostering South-to-South exchange of programmatic experience, protocols, and tools; and measuring the costs and outcomes of implementing these services.
  • Addressing adolescent vulnerability � This project aims to prevent HIV infection among 13 to 19-year-old orphaned girls, by developing innovative program interventions to successfully modify contextual factors (such as economic and social vulnerabilities) associated with increased sexual risk behavior and rates of HIV infection among these adolescents; and assessing the feasibility and effectiveness of these interventions and their potential for sustainability, scale-up, and transferability to other settings.

Programming of these funds is planned to begin in fiscal year 2007, and will be supplemented with country funds to expand implementation. The Gender Technical Working Group (discussed further later in this chapter) will oversee implementation of the initiatives and continue to support field programs in these and other critical gender areas.

Increasing Gender Equity in HIV/AIDS Activities and Services

The Emergency Plan was the first international HIV/AIDS program to disaggregate results data by gender. This disaggregation is critical to understanding the extent to which women and men are reached by life-saving interventions, and helps implementers to better understand whether programs are achieving gender equity. Utilizing gender-equitable strategies supported by this growing evidence base allows the Emergency Plan to reduce vulnerabilities that contribute to the significant gender disparities of the HIV/AIDS epidemic. An important part of this effort involves working with men to change norms and behaviors through HIV prevention, treatment, and care services with efforts such as male-partner testing activities within prevention of mother-to-child transmission (PMTCT).

The Emergency Plan is committed to ensuring that all the activities it supports provide equitable access to services and meet the unique needs of women, girls, men and boys, including orphans and victims of sex trafficking, rape, abuse, and exploitation. In fiscal year 2006 in the focus countries, gender-disaggregated data were available for more than 90 percent of service statistics at downstream sites.

An encouraging fact is that an estimated 61 percent of those receiving antiretroviral treatment through downstream USG support in fiscal year 2006 were women; of these, nearly seven percent were under the age of 15. Given that most people on USG-supported treatment live in Africa � where 58 percent of infected adults are women � ensuring equitable access to treatment is essential, and the Emergency Plan is a leader in making equitable access a reality. Moving forward, PEPFAR programs will build on this success by identifying gender-related barriers that women and men may face in accessing and adhering to treatment and staying healthy. Goals include improving hours of services to meet patients� needs, facilitating linkages among different types of services, and reducing the costs of services � recognizing that ART costs can be especially prohibitive to women, due to their economic disadvantages within the family and society.

PMTCT programs serve as an important entry point for women to access HIV treatment and care services. Approximately six million pregnant women (including more than 2.8 million in fiscal year 2006) have accessed Emergency Plan-supported PMTCT services in the 15 focus countries. Innovative programs in Kenya, Uganda, Zambia, and elsewhere reach out to the male partners of PMTCT clients, encouraging them and other family members to be counseled and tested, and linking them to follow- up HIV services.

Approximately equal numbers of females and males were reached by ABC prevention programs in fiscal year 2006. These programs include a wide range of gender components that tailor messages and behavior change interventions to the specific needs of boys, girls, women, and men. For example, in Mozambique and Rwanda, the Emergency Plan supports faith-based programs that encourage youth to either abstain or practice healthy sexual behaviors. These programs, working in partnership with churches, schools, and community clubs, are designed to be developmentally appropriate with age-specific, gender-sensitive curricula; they also work to reach girls through �girl-friendly� clubs, activities, and small groups. In Botswana, the Emergency Plan supports the Ministry of Education�s HIV/AIDS life skills curriculum, which was designed for use in all Botswana primary and secondary schools in an effort to reach young people with HIV prevention information and provide appropriate skill-building to assist students in reducing the behaviors that put them at risk of contracting HIV/AIDS (see story Botswana: Teaching Students Life Skills in the chapter on Prevention).

Emergency Plan programs recognize that gender norms can present barriers to prevention for men as well as women. Expectations that men are self-reliant, sexually experienced, and knowledgeable can inhibit them from seeking information about HIV and participating in behavior change programs.

Women represented approximately 71 percent of all people who received downstream PEPFAR-supported counseling and testing in fiscal year 2006. Of those who received HIV counseling and testing in downstream settings other than PMTCT, 56 percent were women (for further discussion of these figures and PMTCT, see the chapter on Care). Emergency Plan programs in many countries are addressing gender relations among men and women by offering couples counseling and testing services. For example, during couples counseling in Uganda, men receive their test results first and are counseled on violence prevention, in order to reduce the likelihood of men blaming their partners for their test results.

Among the orphans and vulnerable children (OVCs) served by Emergency Plan activities, 51 percent are girls and 49 percent are boys. A large number of gender issues have an impact upon access to and delivery of HIV services, including the extreme vulnerabilities of many young female OVCs, who often are the first to drop out of school and provide care for sick or bedridden family members. PEPFAR partners work with rural OVCs to provide care, while also ensuring that girls and boys have equal access to education and other support services.

A key strategy for promoting gender equity across all program areas is enhancing women�s personal decision-making capacity and their capacity to provide leadership to community and national HIV/AIDS efforts. Emergency Plan support to women�s non-governmental organizations (NGOs) through training and financial support helps to strengthen health care networks. Women�s NGOs often play a vital role in linking health care clients to community services to ensure comprehensiveness and continuity of care. In Kenya, South Africa, and Uganda, for example, women�s NGOs help to link HIV-positive pregnant and postpartum women to psychosocial support groups run by peers.

Finally, the Emergency Plan supports expanded access to female-controlled methods of HIV/AIDS protection, including social marketing of female condoms in many countries and support for microbicide research, as noted in the chapter on Prevention.

Reducing Violence and Coercion
Gender-based violence (GBV) is a pervasive public health and development problem throughout the world that severely increases women�s vulnerability to contracting HIV/AIDS. Globally, as many as 69 percent of women report physical abuse by an intimate partner at least once in their lives, and up to one in four women experience sexual violence by an intimate partner in their lifetimes. Sexual and other forms of abuse against women fuel the spread of HIV in several ways. The practice or threat of sexual violence against women and girls places them at increased risk of contracting HIV, by creating situations in which women are unable to abstain from intercourse or negotiate condom use. Fear of violence and rejection from partners, families, and communities keeps women from seeking HIV information, seeking counseling, being tested for HIV, and receiving treatment and care. A woman also can be at heightened risk of violence or rejection by disclosing her HIV-positive status. For further information please see PEPFAR�s 2006 Congressional Report on Gender- Based Violence and HIV/AIDS located at

Concern about gender-based violence in the context of HIV/AIDS continues to grow, and in response, the Emergency Plan has intensified its programming in this area. In fiscal year 2005, the Emergency Plan dedicated $98 million to support GBV activities in the 15 focus countries. In fiscal year 2006, an additional $104 million supported a total of 243 activities to address GBV and sexual coercion.

Emergency Plan-supported GBV programs include those whose primary objective is to prevent violence or enhance care for survivors, as well as those that incorporate violence- related activities indirectly as part of a spectrum of HIV/AIDS-related efforts. Typically, Emergency Plan activities are coordinated and leveraged with broader, more comprehensive programs within countries, acknowledging that multi-sectoral, multi-pronged approaches are critical to stemming the practice of gender-based violence and addressing its consequences.

In fiscal year 2006, the Emergency Plan established important linkages with the President�s Women�s Justice and Empowerment Initiative (WJEI). This $55 million, three-year program is designed to support the existing efforts of four African countries (Benin, Kenya, South Africa, and Zambia) to strengthen the capacity of legal systems to protect women and punish perpetrators; improve health, counseling, and shelter services for survivors; and raise awareness of the need for action to improve women�s justice and empowerment.

Strengthening post-exposure prophylaxis (PEP) services for survivors of sexual assault is a critical Emergency Plan intervention. In most countries, PEP services currently are offered only in urban and peri-urban settings. Due to a number of barriers, including cost of transportation, fear, lack of PEP services, and a lack of knowledge regarding where the services are available, a majority of survivors of rape and sexual assault do not receive PEP � particularly those living in rural areas. In Kenya, the Emergency Plan supports the Nairobi Women�s Hospital Gender Violence Recovery Centre to expand its medical and psychosocial support for survivors of rape and sexual assault (see accompanying story). In both Zambia and South Africa, USG partners are assisting women through concerted efforts to scale up sexual violence prevention services, with availability of PEP services at both the local and national levels. Organizations are training health care providers in PEP provision, and projects have established coordinated programs with integrated post-rape services provided by pharmacists, police, and social workers. Furthermore, HIV-positive rape survivors are being referred to hospitals or clinics for ongoing clinical care and antiretroviral treatment assessment.

Kenya: Supporting Survivors of Violence and Coercion

In Kenya, PEPFAR supports the Gender Violence Recovery Centre, a program the Nairobi Women�s Hospital launched in 2001. The Centre provides specialized medical services, including post-exposure prophylaxis (PEP) and psychological treatment to survivors of domestic violence and sexual abuse, as well as HIV counseling and testing and medical care for rape survivors. The Emergency Plan supports the cost of PEP for the Centre. The Centre also works with the community to raise awareness of the problem of gender-based violence, assists the police in apprehension of perpetrators, and makes appropriate referrals for survivors. With Emergency Plan support, additional activities include increasing the number of health facilities to institutionalize PEP; supporting awareness- raising activities on gender-based violence and rape management; and establishing rape desks in Rift Valley and Coast Provinces.

Other types of GBV activities that the Emergency Plan supports include: changing social norms that condone or encourage male violence against women; preventing violence resulting from HIV status disclosure, through couples counseling and counseling on violence; strengthening policy and legal frameworks outlawing GBV; and linking HIV programs with community and social services, such as programs to strengthen conflict resolution skills and protect and care for victims of violence.

In Rwanda, a program has been launched to determine the feasibility of including GBV screening at selected PMTCT sites. In response to the findings that sexual violence and abuse are much higher among both male and female OVCs than among children in the general population, South Africa and Zambia have developed specific programs for adolescent OVCs that incorporate interventions such as violence prevention. The Emergency Plan also supports special programs designed to respond to the heightened violence faced by refugees. For example, Kenya and Uganda have initiated GBV and HIV prevention services in refugee camps and border areas.

Emergency Plan-supported activities in conflict areas acknowledge the urgency of GBV issues. In Uganda, the Emergency Plan works in conflict areas to address GBV, sexual assault, and alcohol abuse. The refugee HIV/AIDS services in Kyaka II Settlement leverage a wraparound community sensitization project on sexual exploitation and GBV. For further information on PEPFAR�s support for refugees and internally displaced persons, please see the 2006 Congressional Report on Refugees and Internally Displaced Persons located at

Addressing Male Norms and Behaviors
Emergency Plan prevention efforts recognize that deep-seated norms revolving around male sexual behavior must be changed in order to curb the HIV epidemic. Practices such as multiple and concurrent sex partners, cross-generational sex, and transactional sex increase vulnerability to HIV infection, particularly among women and girls. These risky practices are perpetuated by norms that reinforce such behaviors among men and leave women and girls with few options to avoid them. In generalized epidemics, most new infections result from chains of concurrent sexual partnerships among adults in the general population. As noted in the chapter on Prevention, successful prevention programs target the general population by heightening risk perception about multiple, concurrent sexual partners. Although these partnerships are often regular and trusted, they lead to most new infections in high-prevalence epidemics. Prevention programs must address gender vulnerabilities and the social norms that can be barriers to adopting �ABC� behaviors (Abstain, Be faithful, correct and consistent use of Condoms).

In Mozambique, the JOMA Project aims to reduce the spread of HIV/AIDS by teaching young men to think critically about gender roles and healthy behavior (see accompanying story). In South Africa, the USG-supported Men as Partners (MAP) program works with men to challenge gender-related attitudes, address norms of masculinity, and discuss the risks of having multiple sex partners. Through workshops, community education, media advocacy, and public policy, MAP supports ABC prevention approaches to reducing the risks of HIV infection for men and their partners. MAP also coordinates a network of communitybased, faith-based, and non-governmental organizations to collaborate for the social change needed to prevent the spread of HIV/AIDS.

Mozambique: Challenging Gender Roles to Promote Healthy Behavior

The JOMA Project aims to reduce the spread of HIV/AIDS in Mozambique by teaching young men to think critically about gender roles and healthy behavior. The Project began in April 2006 with a training conference for teachers and students. Participants debated the definition of a �real Mozambican man,� and discussed the impact of men�s behavior on society as a whole. They were also trained to communicate HIV prevention messages to their peers.

In the months following the training conference, groups carried out micro-projects in schools with support from PEPFAR. These efforts help to examine male stereotypes steeped in history and social norms. Several groups produced �wall newspapers� with student-authored articles exploring the social impact of HIV/AIDS. Students also created murals that raise awareness of gender inequalities and held public debates during the inaugurations of the murals.

A group at an agricultural school brought students together to practice sustainable farming techniques, and used the opportunity to also discuss the importance of healthy behavior and the social pressures faced by young Mozambican men. Theater groups created performance pieces examining gender roles by considering the community realities: fathers traveling to work in the mines, parents arranging early marriages for their daughters, and sexual relationships between teachers and students.

In fiscal year 2006, Emergency Plan implementing partners in the focus countries reported that 348 of their activities had a component specifically targeting men. Many of these activities target youth as well as adults, recognizing that the seeds of negative male behavior often are planted in youth.

Increasing Women�s Legal Protection
Many of the norms and practices that increase women�s vulnerability to HIV/AIDS and limit their capacity to deal with its consequences are reinforced by policies, laws, and legal practices that discriminate against women. Discrimination against women with regard to property and inheritance rights is especially harmful. Since land and housing serve as collateral for credit; land can be used to grow food, both for sustenance and as a source of livelihood; and housing not only provides physical shelter but also protects women by creating a source of assets � economic empowerment can foster the ability to avoid high-risk sexual behavior. The Emergency Plan therefore supports efforts to review, revise, and enforce laws relating to both sexual violence and women�s property and inheritance rights. PEPFAR also supports efforts to eliminate gender inequalities in civil and criminal codes and enhance women�s access to legal assistance. In fiscal year 2006, implementing partners reported that 80 activities in the focus countries have such a component. For example, the Orongo Widows and Orphans Group in Kenya (see accompanying story) offer legal and support services to women.

Kenya: The Women of Orongo

�Had I not joined the Orongo Widows and Orphans Group, I would be dead by now,� says Betty Atieno, a 28 year-old mother of three.

Shortly after her husband died, Betty�s parents-in-law said she would be inherited by their other son. She refused, but her brother-in-law often came home drunk and abused her. Each time, Betty would run away to friends. He gave Betty an ultimatum: become his wife or be thrown out of her marital home.

Betty, who had already lost her parents to AIDS, lost hope. Then a friend told her about the Orongo Widows and Orphans Group. �I now know I have rights and I will not run away the next time he assaults me,� Betty says.

The Orongo Widows and Orphans Group was founded by Florence Gundo in 1999. She formed the group because, in addition to the practice of wife inheritance, Florence noticed that �widows were resorting to selling illicit liquor, and orphans were being used as herdsboys and maids.�

  Betty Atieno, a 28-year-old mother of three, is a member of the Orongo Widows and Orphans Group.

�When you are inherited by your brother-in-law, it�s almost impossible to ask him to get tested for HIV,� Florence explains.

After attending a women�s property rights workshop� Florence mobilized widows to teach them about their rights. �We started teaching women in churches, schools, even during funerals, and gradually their attitude started changing,� Florence says.

The group has successfully reclaimed land snatched from widows and orphans. Moreover, the project has encouraged members to learn their HIV status, leading to greater acceptance of people living with HIV. Some members have even been trained to provide home-based care for those affected by HIV/AIDS.

The group still faces challenges. It cares for more than 300 orphans. Providing them food, support, and education is a monumental task. The group is also teaching women to be self-reliant by providing training in tailoring, horticulture, and other income-generating activities.

Written by Anne Waithera, a journalist for Citizen Radio based in Nairobi, Kenya. Anne was trained in responsible HIV/AIDS reporting through a PEPFAR-supported project.

Increasing Women�s Access to Income and Resources
For many disadvantaged women and girls, transactional sex can seem like one of the few options available for survival. The Emergency Plan supports efforts to ensure more empowering and sustainable livelihoods for women and girls which enable them to avoid prostitution, protect themselves from HIV/AIDS, and mitigate the impact of HIV/AIDS on themselves and their families. Implementing partners reported 97 activities in the focus countries that provide support for increasing women�s access to income and productive resources.

In Haiti, the �Other Choice� program provides women in prostitution with socio-economic alternatives. Women formerly in prostitution serve as peer trainers, helping other women who are still in prostitution and wish to seek alternative forms of income. These peer trainers help women gain access to vocational training resources, ranging from computer training to arts and cosmetology. In Namibia, a micro-credit program gives OVC caregivers start-up capital for income-generating projects (see accompanying story).

Namibia: Grandmother Supports Orphaned Grandchildren through Micro-Credit

Josephine Nuuyoma, age 65, and her husband, Frans Shiimi, have lived in the Omusati region of Namibia for more than 51 years. She gave birth to nine children, six of whom died from HIV/AIDS-related illnesses. Thanks to a micro-credit program supported by PEPFAR, Josephine has become a self-employed businesswoman, selling bread and marula oil to support her extended family. She received start-up capital of US$100 (approximately $15) through a loan from the Village Health Fund Project run by a PEPFAR partner organization. Earning a profit of nearly N$90 per week has allowed her to support six of her grandsons who were left orphaned by AIDS. She pays their school fees, buys books and clothes, and covers hospital expenses. A shrewd money manager, Josephine is even able to put some money away for the future.

Josephine recently took out her third loan of N$300 (approximately $43) to expand her business. She used the loan to purchase materials for her business, which is located near the local school. She sells bread to students every day when school lets out. �My bread is so tasty that it only takes them a few minutes before they are finished,� she said. Josephine also supplies bread for weddings, funerals and other occasions.

This year, the Emergency Plan has launched several programs, including public-private partnerships (PPPs), that address this critical issue. For example, in Tanzania and Zambia, the activities of the PlayPump Alliance, discussed in the Building Capacity: Partnerships for Sustainability chapter, include a specific gender component. Without the daily burden of water collection, girls may be more likely to attend school, and women can focus on other productive activities, building stronger families and healthier communities. Additionally, linkages between Emergency Plan and other USG-supported education, economic development, and microfinance programs are being strengthened.

Guyana: Microfinance Project Is a Source of Empowerment

With support from the Emergency Plan, a partner organization in Guyana is helping people living with HIV/AIDS become more productive and economically independent by providing small loans through a microfinance program. The program empowers HIV-positive men and women by providing loans, ranging from US$375 to US$1,750, which enable recipients to expand their small businesses and support their families.

The loans are made possible by a public-private partnership among the Institute of Private Enterprise Development, the Guyana Telephone and Telegraph Company, and the Guyana Lotto Company. Many people living with HIV/AIDS who receive loans under the project are unable to obtain them through traditional means, either because of their economic status or because of discrimination.

For female beneficiaries, the grants are a source of empowerment. In July 2006, Samantha Brown received a loan to expand her and her husband�s business producing cooking utensils. Before obtaining the loan, the couple worked long hours, but could not produce enough each week to meet demand. They used the loan to purchase materials that enabled them to increase production. Now the couple employs several family members in the business.

�This is truly the best thing that has happened to me since learning I had HIV,� Samantha said. �I am able to make ends meet and give my daughter, who was born HIV-positive, more nutritious food.�

  Samantha Brown obtained a small loan to expand her and her husband�s business producing and selling tin products. Andrea Rohlehr-McAdam

Karungi Grace receives free antiretroviral medicine from the Finlays Tea Mulenge Clinic in Uganda. Her health has improved and she is able to earn a small income through hair braiding.

Multilateral Collaborations
The Emergency Plan is proud to join the many local, international, and bilateral organizations that are committed to addressing gender disparities in the HIV/AIDS epidemic. At the 2006 United Nations General Assembly High Level Meeting on AIDS, the United States joined all other member states of the United Nations to pledge to �eliminate gender inequalities, gender-based abuse and violence.� To follow up on this new commitment, the United States led gender-related discussions at the 18th UNAIDS Board Meeting, held in June 2006, which adopted a decision that �requests UNAIDS, in partnership with national governments, to conduct gender assessment of three to five national AIDS plans � in response to the increased feminization of the epidemic.� These assessments provide the U.N. system with a concrete opportunity to introduce coherent and comprehensive gender approaches to its work in the fight against HIV/AIDS.

During the 19th UNAIDS Board Meeting, held in December 2006, the United States supported civil society in pushing a gender-related decision, adopted under the heading of �AIDS, Security and Humanitarian Response.� This decision �Calls on UNAIDS to intensify programmatic efforts on the intersection between gender-based violence and HIV, including but not limited to situations of conflict, particularly acknowledging the unique contributions of women survivors and those affected by violence.� The Emergency Plan will explore, along with UNAIDS and others, possible actions involved in implementing this decision as part of the ongoing global effort to respond to the increasing feminization of the HIV/AIDS epidemic.

Mainstreaming Gender into Prevention, Treatment, and Care Programs
The USG interagency Gender Technical Working Group was established in 2005 and currently has more than 30 members, representing all the USG agencies that implement PEPFAR. PEPFAR supports host countries� implementation of evidence-based, gender-sensitive approaches, in order to meet legislative requirements and program goals. An underlying principle

of this effort is that implementation of gender integrated approaches is critical to:
  • Achieving PEPFAR�s �2-7-10� goals for treatment (support antiretroviral treatment for 2 million people); prevention (support prevention of 7 million infections); and care (support care for 10 million people);
  • Strengthening program quality and sustainability;
  • Guaranteeing women�s and men�s equitable access to programs; and
  • Preventing or ameliorating program outcomes that may unintentionally and differentially harm women and men.

Gender-focused technical reviews of the fiscal year 2006 COPs for the 15 focus countries, and the strategies and mini-COPs for the five largest other bilateral program countries, offered an opportunity to comprehensively examine gender issues and HIV programming within the Emergency Plan. These reviews indicated considerable variation within the various program areas and across countries, with regard to the articulation and quality of gender-integrated approaches. Based the fiscal year 2006 findings, PEPFAR began offering gender-related technical resources and program assistance, in order to strengthen the integration of gender-related issues across prevention, treatment, and care programs. Technical resources include a technical considerations guide and an accompanying gender assessment tool. The tool, which was piloted in Nigeria and subsequently introduced at the 2006 HIV/AIDS Implementers� Meeting in Durban, South Africa, will be implemented in all focus countries during fiscal year 2007.

Future Directions
As programs mature and attention to quality of services continues to grow, the need to focus on gender-related factors is increasingly evident. The Emergency Plan Gender Technical Working Group will continue to offer technical assistance to field programs, including supporting countries as they conduct gender assessments to help mainstream gender-related issues across all program areas. PEPFAR also will expand its support for effective programming by documenting evidence-based approaches to gender issues and taking them to scale, through implementation of the recommendations from the Gender and HIV/AIDS Consultation. The addition of central resources will enable PEPFAR to further enhance the global understanding of gender and HIV/AIDS programming.

It remains clear that attention to gender issues is critical to Emergency Plan success in achieving its prevention, treatment, and care goals. Thus, the Emergency Plan has supported a wide variety of gender-focused activities and will continue to intensify support for the gender-sensitive approaches to programming described above. These activities focus not only on access to services, but also on the empowerment of women through strengthened individual, family, and community-level interventions. Ongoing efforts will continue to address central issues, such as GBV and the expansion of violence prevention services. In addition, programs that focus on men and boys will continue to grow, as they are critical to achieving both successful gender programs and to slowing the tide of HIV transmission.

The Emergency Plan�s gender strategy is making an important contribution to the global effort to turn the tide against HIV/AIDS. The Emergency Plan is continuing to develop plans to work closely with local, national, and international partners, to identify concrete actions to address gender issues within the context of the HIV/AIDS epidemic. The Emergency Plan recognizes that in order for the global community to succeed in this critical area, it is essential that it leverage its own resources to build synergies and continue to work together effectively.

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