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8 Gender MAIN MESSAGES • he scope and framing of PEPFAR’s gender-focused efforts have T evolved from a focus primarily on the HIV-related needs and vulner- abilities 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. • he available data on differences between enrollment of women and T 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 con- tinue to encounter barriers to accessing services. Men tend to have poorer health outcomes, in part due to enrollment in ART with later- stage illness. • EPFAR has placed a strong emphasis on addressing gender-based P 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. • ver time, PEPFAR has increasingly supported policy, data collec- O tion, 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 program- matic 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. 391
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392 EVALUATION OF PEPFAR • here are currently insufficient mechanisms and data to give either T the Office of the U.S. Global AIDS Coordinator (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 ap- proach, through both the program monitoring system and a coordi- nated 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. Overall Conclusion • s PEPFAR’s gender efforts have evolved and expanded, there have A 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 articu- lated 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 popula- tions 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 Coordina- tor (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: • he objectives and guidance should be informed by the available T 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, ex- pert consultation, and experiences from pilot programs in partner countries.
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GENDER 393 • GAC’s guidance on gender-focused efforts should encompass pro- O grams specific to addressing gender norms and inequities and efforts to incorporate gender-focused objectives within prevention, care, and treatment activities. • he development of guidance for gender-focused efforts should take T advantage of lessons learned from the processes used for PEPFAR’s recent updates to its guidance for prevention and orphans and vulner- able children (OVC) programs. • EPFAR U.S. mission teams should work with partner country stake- P holders and implementers to strategically plan, select, develop, imple- ment, and measure evidence-informed activities and programs to achieve the gender-focused objectives. • trategic implementation of gender-focused efforts will require strong S technical leadership, and as such additional capacity in gender exper- tise 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 incorpo- rated as part of the core competencies of mission team staff across PEPFAR’s programmatic areas. • s an engaged participant with other global and partner country A 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.)
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