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8 Gender Main Messages The scope and framing of PEPFAR’s gender-focused efforts have evolved from a focus primarily on the HIV-related needs and vulnerabilities of women and girls to an expanded focus that aims to also address the vulnerabilities of men and boys (including men who have sex with men) that arise as a result of social and cultural norms about gender and sexuality. PEPFAR’s efforts have also been scaled up over time from initial pilot programs to more central initiatives and country programming, with more financial and human resources devoted to them. This evolution is occurring in the context of a range of societal, cultural, economic, and other factors that affect gender norms in the countries in which PEPFAR is operating. The available data on differences between enrollment of women and men in antiretroviral therapy across countries indicate that there has been a successful scale-up of HIV treatment services for women as well as for men. Along with this success, both men and women continue to encounter barriers to accessing services. Men tend to have poorer health outcomes, in part due to enrollment in ART with later-stage illness. PEPFAR has placed a strong emphasis on addressing gender-based violence prevention and services. Continuing this focus is critical to changing one of the most important underlying structural drivers of vulnerability in the HIV epidemic. Over time PEPFAR has increasingly supported policy, data collection, and programming efforts for men who have sex with men that vary by country context and local need and are informed by available evidence. PEPFAR has only recently codified this support in programmatic guidance. Men who have sex with men continue to struggle with barriers to accessing care and treatment services and remain an important population at elevated risk for prevention programming. In addition, a more holistic and integrated approach to activities for men who have sex with men could be used in future programming given that their needs and challenges cut across the continuum of HIV-related services. There are currently insufficient mechanisms and data to give either OGAC or country programs an adequate assessment of the effectiveness of gender-focused programming and its impact on societal norms and health disparities. There is a need for PEPFAR to develop an adequate approach, through both the program monitoring system and a coordinated effort of periodic evaluation and other activities, to adequately assess what efforts are being implemented and the outcomes of these efforts across the full range of its programmatic portfolio for gender-focused activities. PREPUBLICATION COPY: UNCORRECTED PROOFS

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Overall Conclusion As PEPFAR’s gender efforts have evolved and expanded, there have been positive effects of these efforts. However, the approach for how PEPFAR engages with gender-related factors that influence the HIV epidemic and response has been ad hoc. Although PEPFAR has articulated its framing of gender vulnerabilities and inequities and its overarching aims in its Gender and HIV Factsheet, it has not articulated the objectives that would need to be met in order to achieve those aims or the outcomes that would reflect success in these efforts. In addition, it does not provide guidance on intervention effectiveness or on approaches to establishing priorities for gender-focused efforts in different country settings and to developing strategic country-specific portfolios. Activities supported by PEPFAR central initiatives and through country operational planning vary widely in type and intensity of focus across the articulated gender aims and the populations that are addressed. Recommendation Presented in This Chapter Recommendation 8-1: To achieve PEPFAR’s stated aim of addressing gender norms and inequities as a way to reduce HIV risk and increase access to HIV services, the Office of the U.S. Global AIDS Coordinator (OGAC) should develop and clearly state objectives and desired outcomes for gender-focused efforts. OGAC should issue guidance for how to operationalize, implement, monitor, and evaluate activities and interventions to achieve these objectives. Further considerations for implementation of this recommendation: The objectives and guidance should be informed by the available evidence on how gender dynamics influence both HIV outcomes and the implementation of activities and services as well as by evidence on intervention effectiveness from the existing knowledge base, expert consultation, and experiences from pilot programs in partner countries. OGAC’s guidance on gender-focused efforts should encompass programs specific to addressing gender norms and inequities and efforts to incorporate gender-focused objectives within prevention, care, and treatment activities. The development of guidance for gender-focused efforts should take advantage of lessons learned from the processes used for PEPFAR’s recent updates to its guidance for prevention and OVC programs. PEPFAR U.S. mission teams should work with partner country stakeholders and implementers to strategically plan, select, develop, implement, and measure evidence-informed activities and programs to achieve the gender-focused objectives. Strategic implementation of gender-focused efforts will require strong technical leadership, and as such additional capacity in gender expertise will be needed at both the OGAC and U.S. mission team levels. If gender efforts are to be appropriately integrated into all the aspects of service delivery and effectively implemented, this capacity cannot be limited to gender-specific experts but should also be incorporated as part of the core competencies of mission team staff across PEPFAR’s programmatic areas. As an engaged participant with other global and partner country stakeholders, through its implementation PEPFAR should contribute to generating evidence to inform gender-focused efforts through research and evaluation. (See also recommendations for PEPFAR’s knowledge management in Chapter 11). PREPUBLICATION COPY: UNCORRECTED PROOFS

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8 Gender INTRODUCTION The congressional charge for this evaluation, as laid out in the Lantos-Hyde Act of 2008, 1 requested that the Institute of Medicine (IOM), as part of its overall evaluation of PEPFAR, conduct an assessment of “efforts to address gender-specific aspects of HIV/AIDS, including gender-related constraints to accessing services and addressing underlying social and economic vulnerabilities of women and men.” 2 In response to this charge, this chapter begins with a brief background discussion of gender-related aspects of the HIV epidemic and response before presenting the committee’s assessment of PEPFAR’s efforts towards its stated aim of addressing gender norms and inequities as a way to reduce HIV risk and increase access to HIV services. The chapter reflects PEPFAR’s articulated gender strategy with discussions of the main gender-focused programming areas: equity in access to services, addressing gender norms, reducing gender-based violence, and increasing women’s access to economic resources and legal protections. This is followed by an assessment of PEPFAR’s activities for men who have sex with men (MSM); although these activities are organized under PEPFAR’s prevention portfolio, they must inherently be implemented in the context of cultural norms related to gender and sexuality and the resulting stigma and discrimination, which partly underlie the increased risk for HIV and barriers to accessing services experienced by this population. Finally, the chapter offers the committee’s conclusions and recommendation for improving PEPFAR’s gender-related efforts. BACKGROUND The AIDS epidemic always has been defined in part by issues of sex and gender. In the context of HIV, which remains primarily a sexually transmitted infection, sexual identity and sexual practices overlay sex and gender to influence how and which individuals and populations are affected. Fundamentally, then, HIV transmission, acquisition, and disease progression are 1 Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008, P.L. 110-293, 110th Cong., 2nd sess. (July 30, 2008), §101(c), 22 U.S.C. 7611(c)(1). 2 Ibid., §101(c), 22 U.S.C. 7611(c)(2)(B)(iii). PREPUBLICATION COPY: UNCORRECTED PROOFS 8-1

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8-2 EVALUATION OF PEPFAR simultaneously affected by physiological, behavioral, and social realities related to sex and gender which must be understood and addressed as part of the AIDS response in order to optimize prevention, treatment, care, and support efforts for women and men alike. Before the chapter presents the committee’s assessment of PEPFAR’s gender-related efforts, this section provides a very brief overview of some key factors in the interplay of sex and gender with the HIV epidemic and response, focusing on the areas of HIV transmission and acquisition, access to services, gender-based violence, and structural factors (e.g., social, economic, and political factors). These factors underlie the recognition by the public health community and PEPFAR, of the need to plan and implement programs from the perspective of gender as a social organizing principle for the creation of vulnerability; such an understanding of vulnerability must include the cultural and community norms and institutions that reflect and reinforce beliefs and practices that affect gender-associated differences in HIV risks and outcomes. This background section focuses primarily on the factors that influence differences between men and women; a subsequent section of this chapter provides a more in-depth background discussion on the factors affecting men who have sex with men in the HIV epidemic and response. While “sex” and “gender” are often contested terms, sex is generally understood to mean the biological and physiological characteristics that define males and females, while gender is generally understood to mean the socially constructed roles, expectations, behaviors, and attributes that are ascribed to males and females in various cultures. As WHO notes, “aspects of sex will not vary substantially between different human societies, while aspects of gender may vary greatly” (WHO, 2012). However, for many issues related to the HIV response, this distinction between sex and gender becomes blurred. For example, as described below, there are purely biological contributors to the differences between men and women in HIV infection risk and health outcomes, and, in general, epidemiological and clinical measures tend to be referred to in terms of sex differences. However, as will also be discussed below, differences in the risk infection and in clinical outcomes from care and treatment are often influenced as much by social and cultural factors as by biological factors. For purposes of simplicity, in this chapter, rather than broker specific decisions about when to use the term “sex” and when to use “gender,” the committee has chosen to have a low threshold for use of the term gender to refer to distinguishing between men and women for most issues discussed, recognizing that this choice does not apply to discussions of some specific populations, particularly transgendered persons. HIV Prevalence, Transmission, and Acquisition Globally, about half of all people living with HIV are women, and women continue to account for a disproportionate share of HIV-positive individuals in most key PEPFAR regions, making up an estimated 59 percent of people living with HIV in sub-Saharan Africa and 53 percent of people living with HIV in the Caribbean (WHO, 2011). There are exceptions to this however, as in Eastern Europe where the epidemic is driven by injection drug use and where men experience the greatest burden of disease and in other settings with concentrated epidemics where HIV has disproportionately affected men who have sex with men (WHO, 2011). There are biological factors that facilitate a higher rate of HIV transmission from men to women than from women to men during heterosexual vaginal sex (Karim et al., 2010), and a variety of social and cultural factors also contribute to gender differences in vulnerability to HIV infection. As documented in the literature and also emphasized by interviewees during the committee’s evaluation, cultural norms influence power dynamics between male and female PREPUBLICATION COPY: UNCORRECTED PROOFS

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GENDER 8-3 sexual partners, frequently limiting women’s abilities to negotiate safer sex practices such as condom use or enabling older men to engage in relationships with younger girls (116-24-USNGO; 240- 3 06-USNGO; 272-16-PCNGO) (International Council of AIDS Service Organizations (ICASO), 2007). On average, women become HIV infected five to seven years younger than men, which contributes to significant sex disparities in adolescent HIV infection rates; in sub-Saharan Africa this is driven in part by intergenerational relationships (Karim et al., 2010). Vulnerabilities associated with gender-based violence are also critical for understanding differential risks of HIV acquisition in women and men; these are discussed later in the chapter. Access to HIV Services and Other Health Services Access to and utilization of health services have important consequences for HIV-related outcomes, and can be influenced by gender-associated factors. However, limited data is available at the global level regarding the rates of access to HIV and other health services for women and men, especially for non-pregnant women. Some resources do provide this information at the country level, but the types of services measured and quality of data varies substantially by country and year (ICF International, 2012). Interviewees across countries identified access to health care as a challenge that was influenced by many varied cultural gender norms. Examples of challenges facing women included low health-seeking behaviors leading to less utilization of maternal care (240-19-USACA) and concern that for some services women were not comfortable using the same facilities as men (396-31-PCGOV). Women’s lack of access to income also leads to increased vulnerability in many countries, as their ability to pay for transportation or user fees may limit their access to HIV care and treatment (Karim et al., 2010). In several countries interviewees also described gender-related barriers that prevented men from using health services, such as the accepted masculine norm that going to a health facility is a sign of weakness or is unnecessary (636; 272; 166; 461; 272-12-USNGO); one interviewee observed that ‘men essentially do not go to health centers unless they are dying’ 4 (166-5-USG). Gender-related differences in enrollment in HIV care and treatment and in retention and outcomes are discussed briefly here and more detail in Chapter 6, Care and Treatment. Gender-Based Violence Sexual and physical violence and HIV risk are intricately linked. By some estimates women who are HIV positive are up to three times more likely to have ever experienced violence than women who are HIV negative (UN Trust Fund to End Violence Against Women, 2012). While, as noted above, the risk of HIV transmission during heterosexual vaginal sex is greater for women than for men (Karim et al., 2010), sexual violence can lead to female genital trauma, 3 Country Visit Exit Synthesis Key: Country # + ES Country Visit Interview Citation Key: Country # + Interview # + Organization Type Non-country Visit Interview Citation Key: “NCV” + Interview # + Organization Type Organization Types: United States: USG = US Government; USNGO = US Non-Governmental Organization; USPS = US Private Sector; USACA = US Academia; Partner Country: PCGOV = Partner Country Government; PCNGO = Partner Country NGO; PCPS = Partner Country Private Sector; PCACA = Partner Country Academia; Other: CCM = Country Coordinating Mechanism; ML = Multilateral Organization; OBL = Other (non-US and non-Partner Country) Bilateral; OGOV = Other Government; ONGO = Other Country NGO. 4 Single quotations denote an interviewee's perspective with wording extracted from transcribed notes written during the interview. Double quotations denote an exact quote from an interviewee either confirmed by listening to the audio-recording of the interview or extracted from a full transcript of the audio-recording. PREPUBLICATION COPY: UNCORRECTED PROOFS

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8-4 EVALUATION OF PEPFAR which can further increase a woman’s risk of HIV acquisition (UN Trust Fund to End Violence Against Women, 2012). The fear of violence can lead to intimidation and make women less able to negotiate condom use or other safer sex practices (Dunkle et al., 2004; Jewkes et al., 2003; UN Trust Fund to End Violence Against Women, 2012). A study published by the World Health Organization in 2005 found that, on average, between 13 percent and 26 percent of women had experienced at least one episode of “severe” violence (defined as violence that is highly likely to cause injury), and between 10 percent and 50 percent of women reported having experienced sexual abuse, including having been forced to have sex against their will (WHO, 2005). One of the most common forms of violence against women is violence perpetrated by an intimate partner. Rates of intimate partner violence vary greatly across developing countries, as do the factors influencing the likelihood of experiencing violence (Hindin et al., 2008). In a 2008 analysis of Demographic and Health Survey data, younger age of women at marriage and men’s alcohol use were found to significantly increase the rate of intimate partner violence in the majority of countries for which data were available (Hindin et al., 2008). Men and boys also experience physical and sexual partner violence and sexual abuse (Whetten et al., 2011); however, the data on these violence rates and health outcomes are more limited than those for women and girls. Interviewees also spoke of the challenges related to gender-based violence, including harassment and sexual coercion (240-22- PCNGO; 587-05- PCGOV; 636-02- USG; 272-17- USG); gender-based violence was specifically identified as one of the ‘underpinnings of the epidemic’ (272-17- USG). For example, women’s inability to negotiate the use of condoms in relationships where they experience intimate partner violence was described as both a social challenge and a contributor to HIV transmission (461-01-USG; 934-07- PCGOV). In one country an interviewee noted, ‘There is an expectation that girls would not say no to an older man and that men can be forceful if they want within the relationship’ (636- 02-USG). In addition, sexual violence against children has created further vulnerability within programs for orphans and vulnerable children (OVC) (587-21-PCNGO). Interviewees in several countries described the existence of legislation related to gender-based violence (331-19-USNGO; 587-5-PCGOV; 166-17-USG; 166-19-PCGOV; 272-17-USG; 636-6-USG 934-7-PCGOV); however, in general, where laws and policies existed related to gender vulnerabilities, interviewees reported that these laws and policies were not effectively implemented (240-22-PCNGO; 196-10-PCGOV; 196-23- USNGO; 636-6-USG; 166-17-USG; 272-17-USG; 461-18-USG; 934-7-PCGOV). Structural Factors Multiple studies have demonstrated the link between social, economic, political, and environmental elements, also called structural factors, and risks related to HIV (Coates et al., 2008; Gupta et al., 2008), and many of the inequities and barriers caused by structural factors are rooted in gender norms, such as a lack of access to education and income opportunities, the lack of legal protection, initiation rites for young girls and boys, and social norms that affect the power dynamics in sexual relationships. Data gathered during country site visits reinforced the important role that some of these structural factors play in the HIV epidemic. More broadly, interviewees in several countries identified discriminatory attitudes toward women and their roles in society as a challenge (240-6-USNGO; 331-9-PCNGO; 166-19-PCGOV; 636-2-USG): “The message to women is to be quiet” (331-9-PCNGO). As one interviewee stated: “The decision making is quite low. They can’t decide on anything. You’ll be surprised to get to a village and find that some women PREPUBLICATION COPY: UNCORRECTED PROOFS

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GENDER 8-5 are taking treatment without their husband’s knowing. And that makes it very much difficult for them; it’s quite a problem.” (636-11- PCNGO) Interviewees also described a contrast between cultural expectations related to women and their emerging role in professional and political environments, noting that despite the growing accomplishments of women, power differences continued to favor men (636-2-USG; 396-12- USG). There was an emphasis on the need to approach social norms not just by targeting women, but also by engaging men; this was exemplified by one interviewee’s comment that ‘women are not disempowered because of women, they are disempowered because of men’ (272-12-USNGO). The recognition of the important role that structural factors play in HIV-related vulnerability has led to the development of interventions targeted to this area, especially in the field of HIV prevention (Gupta et al., 2008). Such interventions typically aim to create an enabling environment that will allow individuals to act in their own and their partners’ best interests by effecting policy or legal changes, shifting harmful social norms through interventions targeting both men and women, catalyzing social and political change, and empowering communities and groups (Auerbach, 2009; Gupta et al., 2008). For example, in the IMAGE study which was a community randomized trial in South Africa, an intervention combining micro-credit, education, and community mobilization effectively reduced intra- partner violence, although the intervention was not effective in directly reducing HIV acquisition among women (Pronyk et al., 2006). A World Bank study in Malawi reported that a conditional cash transfer intervention resulted in a decrease in HIV and herpes simplex virus prevalence among young women (Baird et al., 2012). Examples of interventions to increase access to housing for HIV-positive persons, effect policy change regarding access to HIV prevention services, and empower community members at elevated risk of HIV have also been successfully implemented in developing countries, leading to reductions in HIV transmission (Gupta et al., 2008). These and other studies have contributed to the evidence that social and structural interventions can reduce the social determinants of HIV risk among women and girls (e.g., gender-based violence and economic dependence), sexual risk behaviors, and the rate of HIV infection. PEPFAR’S APPROACH TO GENDER Overview Legislation and Strategy The U.S. Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 highlighted the disproportionate impact that HIV/AIDS has had on women both as patients and as caregivers for those infected and affected by HIV. The legislation tasked PEPFAR with incorporating a focus on women into its planning, programming, and reporting. It required the establishment of and reporting on multiple strategies specifically aimed at addressing elements that could improve the lives of women living with or at risk of acquiring HIV. 5 These strategies 5 United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003, P. L. 108-25, 108th Cong., 1st sess. (May 27, 2003). PREPUBLICATION COPY: UNCORRECTED PROOFS

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8-6 EVALUATION OF PEPFAR included creating programs to educate women and girls about the spread of HIV/AIDS as well as developing specific strategies to: “meet the unique needs of women, including the empowerment of women in interpersonal situations, young people and children, including those orphaned by HIV/AIDS and those who are victims of the sex trade, rape, sexual abuse, assault, and exploitation” “encourage men to be responsible in their sexual behavior, child rearing and to respect women including the reduction of sexual violence and coercion” “increase women’s access to employment opportunities, income, productive resources, and microfinance programs” 6 In its second County Operational Plan Guidance PEPFAR listed five strategic areas to address the effects of gender norms on HIV: (1) increasing equity in services access, (2) addressing male norms, (3) reducing gender-based violence, (4) increasing women’s access to economic resources, and (5) increasing women’s legal rights and protections (OGAC, 2004b). The 2008 reauthorization legislation reaffirmed the important role of addressing gender as a part of PEPFAR’s HIV response, but it broadened the scope of PEPFAR in this area considerably. The legislation not only tasked the program to address gender-based violence and structural elements that contribute to the vulnerability of women and girls, but it also charged the program to develop a plan that addresses “the local factors that may put men and boys at elevated risk of contracting or transmitting HIV.” 7 In addition, PEPFAR was directed to provide “clear guidance to field missions to integrate gender across prevention, care, and treatment programs.” 8 Neither the authorizing nor the reauthorizing legislations, nor any of the subsequent guiding documents for gender-focused efforts, has laid out the sorts of programmatic targets or goals for gender that exist for PEPFAR’s prevention, treatment, care, or OVC programmatic areas. Thus, in the reauthorization legislation PEPFAR’s original directive to focus on women was expanded to incorporate the needs of men made vulnerable as a result of gender norms. PEPFAR has recently defined gender and its relationship to the HIV epidemic in the following way: Gender—refers to the attributes, constraints and opportunities associated with being a man and a woman. The social definition and expectations of what it means to be a man or a woman varies across cultures and varies over time. The transformation of gender-related power dynamics is a key guiding principle of the PEPFAR gender program framework. Differences in power between and among men and women are evident within couples, families, and communities and in their relationships with the healthcare system and other stakeholders and institutions. Gender influences individuals’ status within society, roles, norms, behavior, and access to resources—all of which influence dynamics of the HIV/AIDS epidemic and the success of programs to address it (OGAC, 2011d, p. 203). 6 Ibid., §101(b)(3)(E-F). 7 Supra., note 1 at §101(a), 22 U.S.C. 7611(a)(21)(A). 8 Supra., note 1 at §101(a), 22 U.S.C. 7611(a)(20)(C). PREPUBLICATION COPY: UNCORRECTED PROOFS

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GENDER 8-7 Consistent with this, the 2012 update to PEPFAR’s Gender and HIV Factsheet rearticulates the original five strategic areas and also captures PEPFAR’s more recent evolution to emphasize the gender expectations that affect HIV-related vulnerability and outcomes for men and boys. The 2012 update also emphasizes the reality that “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” (OGAC, 2012, p. 1). Finally, it is noteworthy that PEPFAR’s gender-focused programming has also been affected by its participation in the U.S. Global Health Initiative (GHI), announced in 2009 (US Global Health Initiative (GHI), 2010), which promotes a focus on women, girls, and gender equality within U.S. health and development programs. PEPFAR’s second Five-Year Strategy, covering 2009–2013, contained an appendix outlining the incorporation of the GHI principles into PEPFAR activities (OGAC, 2009d) and reiterated the central role of the existing five- strategies approach. The document enumerated four new areas of increased focus for gender: (1) increasing partner government commitment for gender equity, (2) ensuring access through linkages with other non-HIV gender programming, (3) operationalizing gender principles within PEPFAR and country programs, and (4) improving monitoring and evaluation of gender activities (OGAC, 2009d). Guidance PEPFAR does not issue programmatic guidance specific to gender efforts. Its Gender and HIV Factsheet provides an overview of PEPFAR’s aims, with some examples of activities (OGAC, 2012). Instructions to mission teams related to tracking gender efforts are provided as part of the annual Country Operational Plan (COP) guidance; these documents may also include information on how to implement gender activities, although this has varied over the history of PEPFAR, from negligible references to gender activities in FY 2004-FY 2006 to gradual increases in the acknowledgement and emphasis of the role of gender as an implementation consideration within the overarching programmatic areas of prevention, treatment, care, and strengthening health systems. In 2012, OGAC released a compilation of technical considerations in addition to its annual COP guidance that provided illustrative examples of gender-related activities that could be incorporated into country portfolios (OGAC, 2011d). However, neither the Factsheet nor the operational guidance provide information to country programs on how to select effective interventions and integration strategies, set priorities, develop strategic portfolios, or monitor and evaluate gender-focused efforts. Figure 8-1 summarizes how gender has been incorporated into PEPFAR guidance documents over the years. PREPUBLICATION COPY: UNCORRECTED PROOFS

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8-8 EVALUATION OF PEPFAR 2003 2004 2005 2006 2007 2008 COP First Five-Year COP Guidance ABC Guidance #1 COP Guidance COP Guidance COP Guidance Guidance Strategy Women Gender inequality The five-part gender The elevated risk of The five-part gender approach The five-part gender approach Gender is described as a are is noted within approach is acquiring HIV for women is included as a key legislative is included as a key legislative program priority area and mentioned prevention as introduced as a key and MSM is noted. Activities activity for tracking. The activity for tracking. The the five-part gender only as fueling the HIV legislative activity for that address the specific description of potential policy overlap between prevention approach is reiterated for targets for epidemic and tracking. The needs of women and activities includes gender. activities and gender is noted. tracking. The overlap PMTCT increasing women description of “vulnerable” populations Transgendered persons are The description of potential between prevention, services. and girls potential policy are encouraged. introduced as a target policy activities includes treatment, care, HSS, and vulnerability. GBV activities includes population. gender. policy activities and GBV is highlighted. gender. is noted. 2009 2010 2011 2012 Second Five-Year COP Guidance COP Guidance COP Guidance and Guidance for the Combination COP Guidance and Strategy (including Appendices Prevention of Sexually Prevention for Men Appendices annexes) Transmitted HIV Who Have Sex with (including technical Infections Men considerations) Addressing gender Gender is described as a Gender mainstreaming and Integrating a women- Gender is emphasized as This is the first and The technical issues and providing program priority area. For the five-part approach are and girls-centered an essential contextual only guidance considerations that services for vulnerable the first time countries are described as program policy approach is defined as element for document released accompany COP women are strongly instructed to write a considerations and are one of the core consideration across to specifically Guidance include emphasized within programmatic area identified as a key area for principles of the GHI, prevention interventions. address activities multiple lists of prevention. PEPFAR’s narrative for activities linking with other health and and addressing Addressing gender for MSM. It focuses illustrative gender contribution to the GHI addressing the five-part development programs. GBV gender issues is equality and GBV are on prevention and activities, broken is outlined describing gender approach. The is highlighted as a cross- described as a key defined and highlighted includes elements down by program how it will proceed with overlap between cutting budget attribution. program priority area. as an available structural on stigma and area. a women- and girls- prevention, treatment, The five-part gender prevention approach. discrimination and centered approach. care, HSS, and policy approach is reiterated MSM are only mentioned living with dignity. activities and GBV is noted. and gender-based as a population at violence is elevated risk. highlighted. FIGURE 8-1 Inclusion of gender in PEPFAR guidance documents over time, 2003-2012. NOTE: Descriptions have been summarized for space considerations. COP = country operational plan; GBV = Gender-based violence; GHI = Global Health Initiative; HSS = health systems strengthening; MSM = men who have sex with men; PMTCT = prevention of mother-to-child transmission. SOURCES: (OGAC, 2003, 2004a, c, 2005a, c, 2006b, 2007b, 2008b, 2009b, d, 2010b, 2011a, c, d, e). PREPUBLICATION COPY: UNCORRECTED PROOFS

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GENDER 8-9 In addition to the different forms of guidance released by OGAC summarized in Figure 8-1, the U.S. Agency for International Development (USAID) has recently issued technical documents focused on the integration of gender strategies into HIV programs for populations at elevated risk (USAID, 2011c) and on integrating multiple PEPFAR gender strategies to improve HIV interventions (USAID, 2011b), as well as a compendium of gender programs in Africa (USAID, 2009). The publications support the expansion of the scope of gender-related activities within PEPFAR and provide some recommendations for programming. USAID has also released specific policy guidance on Gender Equality and Female Empowerment (USAID, 2012a). The policy aims to guide the integration of gender equality and female empowerment into USAID’s existing work. Three outcomes goals are highlighted: reducing gender disparities in access to, control over, and benefit from resources, wealth, opportunities, and services; reducing gender- based violence and mitigating its harmful effects on individuals and communities; and increasing the capability of women and girls to realize their rights, determine their life outcomes, and influence decision making in households, communities, and societies (USAID, 2012a). Operational Approaches There are several operational approaches that PEPFAR uses to implement its gender programming. PEPFAR channels central funding into programs designed to address a specific gender-related component of HIV risk. Through this mechanism, PEPFAR has supported multiple gender central initiatives and, more recently, public–private partnerships, addressing either male norms or sexual and gender-based violence; these are described in greater detail in the relevant sections below. In addition there are gender-focused activities articulated as part of the country operational planning process that are managed by staff on the mission teams. In addition to managing PEPFAR-supported activities, interviewees in several countries noted that PEPFAR mission team members or implementing partners have worked directly to engage the national government or local organizations on topics related to gender; this work has included, for example, serving on or supporting national technical working groups (240-24-USG; 331-22-PCNGO; 196-18-PCNGO; 166-8-USG). In most countries there are not designated technical staff for gender, however, two country programs now have gender advisors as a part of their mission team. In support of all of these activities, one individual serves in the role of gender technical advisor at OGAC. PEPFAR also works closely with other U.S. development assistance efforts related to gender, such as the USAID Office of Gender Equality and Women’s Empowerment and the State Department Office of Global Women’s Issues (NCV-10-USG). The following sections present the committee’s limited assessment of PEPFAR’s gender- focused efforts in the different areas articulated in PEPFAR’s five-part gender strategy: equity in access to HIV services, gender norms, gender-based violence, and women’s access to income generation and legal protection. Most of this assessment is focused on an understanding of the activities that PEPFAR has supported and, in some cases, the effects of those activities documented through published evaluations and the interview data collected for this evaluation. Given the limited availability of data, the committee was unable to determine whether PEPFAR’s activities have had an impact on outcomes related to the aims laid out in PEPFAR’s gender strategy. PREPUBLICATION COPY: UNCORRECTED PROOFS

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8-18 EVALUATION OF PEPFAR generally, from the perspective of interviewees the presence of laws that criminalized homosexuality or homosexual activity and the experience of stigma and discrimination made working with MSM a challenge in multiple PEPFAR partner countries. Criminalization contributed to fear among MSM and exacerbated stigma and discrimination. With or without criminalization, stigma was described as leading to the challenge of having ‘hidden’ MSM who were difficult to reach with prevention and other efforts, and interviewees also reinforced the role of stigma and discrimination in affecting access to and the quality of health services for MSM. These issues were described as posing a similar and particularly difficult challenge for transgendered persons (196-25-PCNGO; 196-23-PCNGO; 116-28-USACA; 935-8-PCGOV; 331-22-PCNGO; 331-7-PCNGO; 331- 44-USNGO; 196-9-USNGO; 396-47-USNGO). Interviewees also described cultural expectations to marry and stigma against openly identifying as MSM as factors contributing to individuals having sexual partners who are both men and women and typically do not disclose this to their female partners (272-24-USG; 196-23-PCNGO), which limits their sexual partners’ knowledge of their risk of exposure to HIV. PEPFAR Efforts Related to MSM Guidance While activities for MSM have been supported to varying degrees in PEPFAR countries since the beginning of the program, organized primarily through the prevention portfolios in country programs, the creation of specific programmatic guidance for this population at elevated risk is only a recent development. In 2011 PEPFAR complemented its new prevention of sexual transmission guidance with the Technical Guidance on Combination HIV Prevention for Men who have Sex with Men (OGAC, 2011e). Derived from the UNAIDS Action Framework for MSM, this document described six core components that will be supported by PEPFAR as part of a “comprehensive package of integrated HIV prevention activities for MSM and their partners” (OGAC, 2011e, p. 5). • Community-based outreach • Distribution of condoms and condom-compatible lubricants • HIV counseling and testing • Active linkage to health care and antiretroviral therapy • Targeted information, education and communication • Prevention, screening, and treatment for sexually-transmitted infections The guidance also states that “PEPFAR supports efforts to further HIV prevention goals through laws, regulations and policies that improve the availability, accessibility and effectiveness of HIV prevention programs for MSM” (OGAC, 2011e, p. 9) and emphasizes the principles of equity, nondiscrimination, and confidentiality in each of the six core areas. PEPFAR Activities and the Effects of PEPFAR’s Support for Programming for MSM There were no required PEPFAR programmatic indicators for monitoring prevention of sexual transmission efforts specifically for MSM until 2010 when, as a part of the Next Generation Indicators process, a new required measure for the number of persons reached with individual or small-group level interventions was introduced that included disaggregation by the population at elevated risk. As a result, there are no longitudinal program monitoring data on PREPUBLICATION COPY: UNCORRECTED PROOFS

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GENDER 8-19 activities and outputs for this MSM available. However, data from semi-structured interviewees did provide insight into the types of activities supported by PEPFAR for MSM and into some of the effects of these activities. Most countries visited identified some set of activities for MSM that are supported by PEPFAR; similar activities for transgendered persons were also described (240-9-USG; 331-07-PCNGO; 331-14-USG; 331-18-USNGO; 331-22-PCNGO; 331-32-PCNGO; 196; 166-5-USG; 196-21-PCGOV; 196-23-PCNGO; 196-25-PCNGO; 272- 17-USG; 396-5-USNGO; 396-56-USNGO; 935-14-USG; 587-21-PCNGO; 542-3-USG; 461-1-USG). (The committee recognizes the distinction between MSM and transgendered persons, but PEPFAR’s efforts for these populations are discussed together here due to the overlap in both the supported activities and the effects of those activities.) Participants in multiple countries identified steps that were being taken by PEPFAR to address the challenge of access to services, such as establishing a connection with a specific, trusted service provider or health facility and then making referrals directly to that provider (331-07-PCNGO; 331-22-PCNGO; 196-23-PCNGO; 196-21-PCGOV); linking facility providers with MSM-led community groups (331-44-USNGO; 196-23-PCNGO); or supporting mobile clinics (196-25-PCNGO). Multiple interviewees also described general prevention efforts for MSM as important components of their programs (240-9-USG; 331-14-USG; 331-18-USNGO; 166-5-USG; 396-5-USNGO), including activities to increase access to condoms (331-14-USG; 196-25-PCNGO), behavior change campaigns (331-14-USG; 166-5-USG), and prevention programs for male sex workers (196-25-PCNGO). Using peer educators was a common mechanism for delivering messages for MSM in PEPFAR countries. These peer educators were often also MSM, which interviewees stated both enables the educators to better connect with outreach efforts and empowers the peer educators themselves (331-07-PCNGO; 196-25-PCNGO; 587-21-PCNGO). In addition to increasing condom distribution, the goals of MSM outreach activities also included encouraging HIV testing and addressing stigma in local communities (331-07-PCNGO; 196-25-PCNGO). Civil society organizations and local NGOs are key elements in the HIV response for MSM, and PEPFAR’s work with these organizations and populations in a variety of settings is an important success (AMFAR, 2010) (331-22-PCNGO; 331-32-PCNGO; 196-ES). One major challenge noted by interviewees is that there is very little data on this population. In response to this challenge, in several countries PEPFAR has either supported or is planning to support special studies, surveillance activities, and pilot studies to obtain better population size estimates and other country-specific information on MSM (331-ES; 240-ES; 396-ES; 196-3- USG; 240-09-USG; 166-5-USG; 166-20-USG; 166-26-USG 396-09-PCGOV; 396-24-USNGO; 935-14-USG). For example, in Ghana PEPFAR partnered with the University of California, San Francisco, to support the Ghana Men’s Study, and similar efforts are under consideration in Ethiopia (PEPFAR/Ethiopia, 2010; UCSF, 2012). These data collection activities, as well PEPFAR’s engagement with local government and nongovernment stakeholders, were also highlighted for their important role in increasing attention to MSM in the planning and implementation of the national HIV response (240-ES; 331-14-USG; 331-27-PCGOV; 331-ES; 166-ES; 196-3-USG). Despite notable improvements from PEPFAR’s work with MSM, supporting policy progress and scaling up prevention, treatment, and care services to meet the range of HIV-related needs for this population remains an enormous unmet need. Interviewees described PEPFAR’s MSM efforts as having variable coverage (542-5-USPS), and noted a rising HIV prevalence among MSM. One scale-up challenge identified by some interviewees was a divergence in the priorities of the national government and of PEPFAR (240-08-USG; 331-18-USNGO; 587-07-PCGOV; 587-12-USG), with the most common occurrence being that the country government wanted to focus on youth or the general population overall while PEPFAR mission teams and implementing partners identified and prioritized activities around populations at elevated risk, including MSM. In some cases this PREPUBLICATION COPY: UNCORRECTED PROOFS

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8-20 EVALUATION OF PEPFAR divergence was described as stemming from a lack of recognition by some in the government that MSM are present in the country (240-09-USG; 396-15-USNGO; 934-21-USG; 196-1-USG). One interviewee expressed concern for the future if PEPFAR’s presence in their country diminished: “[E]xpecting [the government] to pick up all of prevention particularly when it comes to target groups that have been so long stigmatized, there are still governments, parts of the provincial government partners who don’t even recognize MSM, for instance. It would be much harder to expect them to suddenly do innovative programming for that group.” (396-15-USNGO) Conclusion: Over time PEPFAR has increasingly supported policy, data collection, and programming efforts for men who have sex with men that vary by country context and local need and that are informed by available evidence. PEPFAR has only recently codified this support in programmatic guidance. Men who have sex with men continue to struggle with barriers to accessing care and treatment services and remain an important population at elevated risk for prevention programming. In addition, a more holistic and integrated approach to activities for men who have sex with men could be used in future programming, given that their needs and challenges cut across the continuum of HIV-related services. MEASUREMENT AND EVALUATION OF GENDER EFFORTS Tracking Gender-Focused Activities The mechanisms that PEPFAR uses to track the implementation of activities addressing one or more elements of its gender approach have varied over time. From 2005 to 2010 gender efforts were considered a cross-cutting activity and were tracked primarily through the use of a checkbox in each Country Operational Plan (OGAC, 2004b, 2005c, 2006b, 2007b, 2008b, 2009b), though the number of activities captured through this system are no longer regularly reported publicly. In 2009, following a reorganization of the program area narratives (which had previously been tied to individual budget codes), countries were for the first time instructed to provide a program area narrative for their gender activities as a part of the supporting documentation submitted with their Country Operational Plans (OGAC, 2008c). In 2010 the gender-specific narrative was eliminated, and gender was referred to as a “key issue” tracked via a checkbox. However, mission teams were also instructed to incorporate a description of the gender-related elements of any activity that was identified as having a gender component (OGAC, 2009b). In 2011, as part of an overall effort to streamline the country operational plan document, a narrative section for the adoption of the Global Health Initiative’s core principles was added, one section of which included providing greater detail on the types of gender activities underway and their expected effects related to each of the five components outlined in the gender strategy (OGAC, 2010b). These publicly available narratives provided a more organized, consistent view of country activities related to gender, although it is too early for the committee to assess if there will be any programmatic impact from their introduction. In 2012 PREPUBLICATION COPY: UNCORRECTED PROOFS

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GENDER 8-21 PEPFAR returned to a longer, more comprehensive country operational plan (intended to be submitted every two years), but the requirement to include a description of gender-specific efforts was maintained and incorporated into all technical area narratives (OGAC, 2011c). With respect to financial reporting, from FY 2004 to FY 2009 there were no budget codes specifically designed to track funding for gender-related efforts (OGAC, 2011f). However, one subcomponent of gender, gender-based violence, is currently considered one of seven “cross- cutting budget attributions” to be tracked, and estimated funding information was required to be reported to OGAC first in FY 2010 and again in FY 2012. In previous years this was referred to as a “cross-budget code,” but the data were not reported centrally (OGAC, 2008b). Program Monitoring Indicators Relevant to Gender-Focused Efforts One component of measuring progress in gender-related efforts is program monitoring; this includes monitoring to understand the differences between men and women as well as to follow specific populations, as a part of both overall program monitoring efforts and monitoring of gender-focused programs. PEPFAR states that it was the first international partner to disaggregate results data by sex (OGAC, 2006c), and the 2007–2008 PEPFAR program indicators included twelve measures with male/female sex disaggregation (Table 8-1) (OGAC, 2007c). These cut across the three major program areas of prevention, treatment, and care and were all intended to measure activities and outputs related to program implementation (OGAC, 2007c). In the Next Generation Indicators program monitoring guidance, five essential/reported measures require disaggregation by sex, and an additional indicator was added within prevention activities that requires disaggregation by populations at elevated risk, including men who have sex with men (OGAC, 2009c). Data with sex disaggregation are not collated centrally for annual reporting by PEPFAR to Congress in its public reporting mechanism (OGAC, 2005b, 2006a, 2007a, 2008a, 2009a, 2010a), although as described previously, a specific report on gender-based violence programs has been produced upon request (OGAC, 2006c). The indicator data that are not used for central analysis and reporting are available for use by country programs and implementing partners. TABLE 8-1 Sex-Disaggregated Indicators Routinely Reported to OGAC Routinely Reported Indicators, 2007 Next Generation Indicators (NGIs) – Essential/Reported Number of individuals reached through community Number of individuals who received testing and outreach that promotes HIV/AIDS prevention through counseling services for HIV and received their test abstinence and/or being faithful results Number of individuals reached through community Number of eligible adults and children provided with a outreach that promotes HIV/AIDS prevention through minimum of one care service abstinence Number of individuals reached through community Number of HIV positive adults and children receiving a outreach that promotes HIV/AIDS prevention through minimum of one clinical service other behavior change beyond abstinence and/or being faithful Total number of individuals provided with HIV-related Number of adults and children with advanced HIV palliative care (including TB/HIV) infection newly enrolled on ART PREPUBLICATION COPY: UNCORRECTED PROOFS

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8-22 EVALUATION OF PEPFAR Routinely Reported Indicators, 2007 Next Generation Indicators (NGIs) – Essential/Reported Total number of individuals provided with HIV-related Number of adults and children with advanced HIV palliative care (excluding TB/HIV) infection receiving antiretroviral therapy (current) Number of HIV-infected clients attending HIV care/treatment services that are receiving treatment for TB disease Number of registered TB patients who received HIV counseling, testing, and their test results at a USG- supported TB service outlet Number of OVC served by OVC programs Number of individuals who received counseling and testing for HIV and received their test results Number of individuals who received counseling and testing for HIV and received their test results Number of individuals newly initiating antiretroviral therapy during the reporting period Number of individuals who ever received antiretroviral therapy by the end of the reporting period Number of individuals receiving antiretroviral therapy at the end of the reporting period NOTE: ART = antiretroviral therapy; OVC = orphans and vulnerable children; TB = tuberculosis; USG = U.S. government SOURCES: (OGAC, 2007c, 2009c). Beyond the sex disaggregated indicators and the prevention indicator disaggregated by population, there are currently no indicators in the NGI guidance that are specific to outcomes for programs that address the five components of PEPFAR’s gender approach. The guidance does include descriptions for four process indicators that are recommended but not required to be reported to OGAC (OGAC, 2009c). One effort that PEPFAR staff members have supported at the international level is the development of an indicator to track the prevalence of gender-based violence as a part of the UNAIDS biannual reporting process. Data from interviews with OGAC headquarters staff noted the contributing role that PEPFAR played through multiple iterations of indicator development (NCV-2-USG; NCV-6-USG; NCV-10-USG). This indicator will ultimately contribute to the understanding of trends in gender-based violence over time at the national level, but it is just the first step in obtaining a comprehensive global picture of the factors that contribute to gender- based violence and the resulting health outcomes, including HIV. Perspectives from interviewees in partner countries varied on the use of and the need for PEPFAR indicators and other program data related to gender. While some interviewees cited examples of using data to track or inform gender programming (240-24-USG; 636-01-USG; 636-06-USG; 636-9- USACA; 116-1-USG; 331-43-USG), some also expressed a need for gender-specific program monitoring from PEPFAR (636-06-USG; 935-09-USG; 396-56-USNGO). Examples offered included a need to understand analytically how issues affect the sexes differently (636-6-USG) as well as the need to match their program activities by measuring changing norms, especially for young girls (935-9-USG). On the whole, interviewees indicated that sex disaggregation is not sufficient for gender program monitoring. As one interviewee noted, ‘The guidance is there from OGAC, but there is a lack of indicators; this has led to gender programs being developed in an ad hoc manner’ (935-17-USG). PREPUBLICATION COPY: UNCORRECTED PROOFS

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GENDER 8-23 The inclusion of sex disaggregation data and the participation in the development of the GBV indicator are elements of PEPFAR’s response to the reauthorization legislation’s mandate that the program develop a strategy that “includes specific goals and targets to address [gender] factors; …[and] sets forth gender-specific indicators to monitor progress on outcomes and impacts of gender programs.” 12 However, the current program monitoring indicators are insufficient to give either partner countries or OGAC an adequate picture of the effectiveness of their gender-focused programming and its impact on societal norms and health disparities. Beyond Program Monitoring Indicators The programmatic reporting process may not always be the most needed or the most appropriate means of measuring and assessing gender efforts. In particular, one measurement challenge in gender-related reporting is that there is often a lack of data about the need. Without population size estimates for key subpopulations, for example, it is difficult to determine the scope of the need, to plan the scale of programming, and to assess whether the demand for services is being met. In many countries PEPFAR is, as a part of its programming, supporting a variety of one-time or follow-up surveys to provide a better estimate of the size of various populations in need of services; these are often done for specific populations, such as men who have sex with men and sex workers, as described in the previous section and in Chapter 5, Prevention. Similarly, tools beyond program monitoring may be needed for PEPFAR to appropriately and sufficiently evaluate the effectiveness and impact of its gender activities going forward. PEPFAR has made efforts to share the lessons learned from some of its gender programming efforts. This is primarily accomplished through releasing various documents, such as the compendium of gender programs in Africa, as well as documents describing GBV, the integration of multiple PEPFAR gender strategies to improve HIV interventions, and populations at elevated HIV risk, which have been published through AIDStar-One (USAID, 2009, 2011a, b, c, d). PEPFAR also provides support for the website What Works for Women, which is a repository of information on a broad range of HIV interventions for women that is accessible to implementers worldwide (NCV-10-USG) (Gay et al., 2012). Chapter 11 on PEPFAR’s knowledge management contains a more detailed discussion of PEPFAR’s reporting and evaluation elements, including a committee recommendation regarding the utility of periodic special studies to be carried out across partner countries. Gender-related special studies will be an important consideration for PEPFAR to improve its ability to assess the full range of its programmatic portfolio. Conclusion: There are currently insufficient mechanisms and data to give either OGAC or country programs an adequate assessment of the effectiveness of gender-focused programming and its impact on societal norms and health disparities. There is a need for PEPFAR to develop an adequate approach, through both the program monitoring system and a coordinated effort of periodic evaluation and other activities, to adequately assess what efforts are being implemented and the outcomes of these efforts across the full range of its programmatic portfolio for gender-focused activities. 12 Supra., note 1 at §101(a), 22 U.S.C. 7611(a)(20)(B) and (D). PREPUBLICATION COPY: UNCORRECTED PROOFS

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8-24 EVALUATION OF PEPFAR SUMMATION PEPFAR’s gender efforts have evolved from an initial focus that was primarily on the HIV-related needs and vulnerabilities of women and girls to an expanded focus that includes the vulnerabilities of men and boys (including men who have sex with men) that arise as a result of social and cultural norms about gender and sexuality. PEPFAR’s efforts have also been scaled up over time from initial pilot programs to more central initiatives and country programming. There were limited data available to the committee concerning the scope, reach, effectiveness, and health impact of PEPFAR’s gender work, but the committee concluded that these efforts have had positive effects. However, the approach that PEPFAR uses to address the gender-related factors that influence the HIV epidemic and response has been ad hoc. Although PEPFAR has articulated its framing of gender vulnerabilities and inequities and its overarching aims in its Gender and HIV Factsheet, it has articulated neither the objectives that would need to be met in order to achieve those aims nor the outcomes that would reflect success in these efforts. In addition, it does not provide guidance on intervention effectiveness or on approaches to establishing priorities for gender-focused efforts in different country settings and to developing strategic country-specific portfolios. Activities supported by PEPFAR central initiatives and through country operational planning vary widely in type and intensity of focus across the articulated gender aims and the populations that are addressed. Based on the findings and conclusions presented in this chapter, the committee makes the following recommendation: Recommendation 8-1: To achieve PEPFAR’s stated aim of addressing gender norms and inequities as a way to reduce HIV risk and increase access to HIV services for women and men, OGAC should develop and clearly state objectives and desired outcomes for gender-focused efforts. OGAC should issue guidance for how to operationalize, implement, monitor, and evaluate activities and interventions to achieve these objectives. Further considerations for implementation of this recommendation: The objectives and guidance should be informed by the available evidence on how gender dynamics influence both HIV outcomes and the implementation of activities and services as well as by evidence on intervention effectiveness from the existing knowledge base, expert consultation, and experiences from pilot programs in partner countries. OGAC’s guidance on gender-focused efforts should encompass programs specific to addressing gender norms and inequities and efforts to incorporate gender-focused objectives within prevention, care, and treatment activities. The development of guidance for gender-focused efforts should take advantage of lessons learned from the processes used for PEPFAR’s recent updates to its guidance for prevention and OVC programs. PEPFAR U.S. mission teams should work with partner country stakeholders and implementers to strategically plan, select, develop, implement, and measure evidence-informed activities and programs to achieve the gender- focused objectives. PREPUBLICATION COPY: UNCORRECTED PROOFS

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GENDER 8-25 Strategic implementation of gender-focused efforts will require strong technical leadership, and as such additional capacity in gender expertise will be needed at both the OGAC and U.S. mission team levels. If gender efforts are to be appropriately integrated into all the aspects of service delivery and effectively implemented, this capacity cannot be limited to gender-specific experts but should also be incorporated as part of the core competencies of mission team staff across PEPFAR’s programmatic areas. As an engaged participant with other global and partner country stakeholders, through its implementation PEPFAR should contribute to generating evidence to inform gender-focused efforts through research and evaluation. (See also recommendations for PEPFAR’s knowledge management in Chapter 11). PREPUBLICATION COPY: UNCORRECTED PROOFS

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8-26 EVALUATION OF PEPFAR REFERENCES AMFAR. 2010. MSM and the Global HIV/AIDS Epidemic: Assessing PEPFAR and Looking Forward. Washington, DC: The Foundation for AIDS Research (amfar). Auerbach, J. 2009. Transforming social structures and environments to help in HIV prevention. Health Aff (Millwood) 28(6):1655-1665. Baird, S. J., R. S. Garfein, C. T. McIntosh, and B. Ozler. 2012. Effect of a cash transfer programme for schooling on prevalence of HIV and herpes simplex type 2 in Malawi: a cluster randomised trial. Lancet 379(9823):1320-1329. Beyrer, C., S. D. Baral, F. van Griensven, S. M. Goodreau, S. Chariyalertsak, A. L. Wirtz, and R. Brookmeyer. 2012. Global epidemiology of HIV infection in men who have sex with men. Lancet 380(9839):367-377. Coates, T. J., L. Richter, and C. Caceres. 2008. Behavioural strategies to reduce HIV transmission: how to make them work better. Lancet 372(9639):669-684. Dunkle, K. L., R. K. Jewkes, H. C. Brown, G. E. Gray, J. A. McIntryre, and S. D. Harlow. 2004. Gender- based violence, relationship power, and risk of HIV infection in women attending antenatal clinics in South Africa. Lancet 363(9419):1415-1421. Gay, J., M. Croce-Galis, and K. Hardee. 2012. What Works for Women and Girls: Evidence for HIV/AIDS Interventions (2nd). www.whatworksforwomen.org (accessed February 2, 2012). Grulich, A. E., and I. Zablotska. 2010. Commentary: probability of HIV transmission through anal intercourse. Int J Epidemiol 39(4):1064-1065. Gupta, G. R., J. O. Parkhurst, J. A. Ogden, P. Aggleton, and A. Mahal. 2008. Structural approaches to HIV prevention. Lancet 372(9640):764-775. Hindin, M., S. Kishor, and D. Ansara. 2008. Intimate Partner Violence among Couples in 10 DHS Countries: Predictors and Health Outcomes. Calverton, MD: Macro International Inc. ICF International. 2012. STATcompiler, edited by MeasureDHS and I. International. Calverton, MD. International Council of AIDS Service Organizations (ICASO). 2007. Gender, Sexuality, Rights and HIV: An Overview for Community Sector Organizations. Toronto, Ontario: International Council of AIDS Service Organizations (ICASO). Jewkes, R. K., J. B. Levin, and L. A. Penn-Kekana. 2003. Gender inequalities, intimate partner violence and HIV preventive practices: findings of a South African cross-sectional study. Soc Sci Med 56(1):125-134. Karim, A., S. Sibeko, and C. Baxter. 2010. Prevention HIV Infection in Women: A Global Health Imperative. Clinical Infectious Diseases 50(S3):S122-S129. Keesbury, J., and J. Thompson. 2010. A step-by-step guide to strengthening sexual violence services in public health facilities: Lessons and tools from sexual violence services in Africa. Lusaka: Population Council. OGAC. 2003. PEPFAR Country Operational Plan Guidelines for FYO4. ———. 2004a. The President's Emergency Plan for AIDS Relief: FY05 Country Operational Plan Guidance. Washington, DC: OGAC. ———. 2004b. The President's Emergency Plan for AIDS Relief: FY2005 Country Operational Plan Guidance. Washington, DC: OGAC. ———. 2004c. The President's Emergency Plan for AIDS Relief: U.S. Five-Year Global HIV/AIDS Strategy. Washington, DC: OGAC. ———. 2005a. ABC Guidance #1 For United States Government In-Country Staff and Implementing Partners Applying the ABC Approach To Preventing Sexually-Transmitted HIV Infections Within The President’s Emergency Plan for AIDS Relief. Washington, DC: OGAC. ———. 2005b. Engendering Bold Leadership: The President’s Emergency Plan for AIDS Relief. First Annual Report to Congress. Washington, DC: OGAC. PREPUBLICATION COPY: UNCORRECTED PROOFS

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