�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
Issues and Challenges
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
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.
Strengthening PEPFAR�s Approach to Gender
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.
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:
Taking Recommendations into Action
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.
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
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.
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 http://www.PEPFAR.gov/progress/.
Addressing Male Norms and Behaviors
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.
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
Increasing Women�s Access to Income and 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).
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.
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
|of this effort is that implementation of gender integrated approaches is critical to:
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.
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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