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 the President’s Emergency Plan for AIDS Relief (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 toward 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 (GBV), and increasing women’s access to economic resources and legal protections (OGAC, 2011b). 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

__________________

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), img101(c), 22 U.S.C. 7611(c)(1).

2Ibid., img101(c), 22 U.S.C. 7611(c)(2)(B)(iii).



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 395
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 the President’s Emergency Plan for AIDS Relief (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 toward 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 discus- sions of the main gender-focused programming areas: equity in access to services, addressing gender norms, reducing gender-based violence (GBV), and increasing women’s access to economic resources and legal protections (OGAC, 2011b). This is followed by an assessment of PEPFAR’s activi- ties for men who have sex with men (MSM); although these activities are organized under PEPFAR’s prevention portfolio, they must inherently be 1  Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tu- berculosis, 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). 395

OCR for page 395
396 EVALUATION OF PEPFAR implemented in the context of cultural norms related to gender and sexual- ity 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 transmit- ted infection, sexual identity and sexual practices overlay sex and gender to influence how and which individuals and populations are affected. Funda- mentally, then, HIV transmission, acquisition, and disease progression are 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, GBV, and structural factors (e.g., social, economic, and political factors). These factors underlie the recognition by the public health com- munity 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. This vulnerability is influenced by 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 back- ground 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 (WHO, 2012). As the World Health Organization (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

OCR for page 395
GENDER 397 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 in- dividuals 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 disproportion- ately affected MSM (WHO, 2011). There are biological factors that facilitate a higher rate of HIV trans- mission 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 be- tween male and female sexual partners, frequently limiting women’s abili- ties to negotiate safer sex practices such as condom use or enabling older men to engage in relationships with younger girls (116-24-USNGO; 240-6-USNGO; 3 272-16-PCNGO) (ICASO, 2007). On average, women become HIV infected 5 to 7 years younger than men, which contributes to significant sex disparities in adolescent HIV infection rates; in sub-Saharan Africa this is driven in 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 = U.S. Government; USNGO = U.S. Nongovernmental Organization; USPS = U.S. Private Sector; USACA = U.S. 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-U.S. and non-Partner Coun- try) Bilateral; OGOV = Other Government; ONGO = Other Country NGO.

OCR for page 395
398 EVALUATION OF PEPFAR 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 (ICASO, 2007; Paul et al., 2001); these are discussed later in the chapter. Access to HIV Services and Other Health Services Access to and utilization of health services have important conse- quences for HIV-related outcomes (WHO, 2011) 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, because 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 (636-9-USACA; 166-5-USG; 461-17-PCNGO; 272-12-USNGO; 272-3235-PCNGO); 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 in 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, 2012). While, as noted above, the risk of HIV transmission during heterosexual vaginal sex is greater for women than for men (Karim 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.

OCR for page 395
GENDER 399 et al., 2010), sexual violence can lead to female genital trauma, which can further increase a woman’s risk of HIV acquisition (UN Trust Fund, 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, 2012). A study published by WHO 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 expe- riencing 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 (Tilbrook et al., 2010; 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 GBV, including harassment and sexual coercion (240-22-PCNGO; 587-5-PCGOV; 636-2-USG; 272-17-USG); GBV 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 (461-1-USG; 934-7-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’ (636-2-USG). In addition, sexual violence against children has created further vulnerability within programs for or- phans and vulnerable children (OVC) (587-21-PCNGO). Interviewees in several countries described the existence of legislation related to GBV (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, interview- ees 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, and many of the inequities and barriers caused by

OCR for page 395
400 EVALUATION OF PEPFAR structural factors are rooted in gender norms, such as a lack of access to education and income opportunities, the lack of legal protection, initia- tion rites for young girls and boys, and social norms that affect the power dynamics in sexual relationships (Coates et al., 2008; Gupta et al., 2008; Munthali and Zulu, 2007; Skinner et al., 2013). Data gathered during country site visits reinforced the important role that some of these struc- tural factors play in the HIV epidemic. More broadly, interviewees in sev- eral 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 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 en- vironments, 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 only by targeting women, but also by engaging men; this was exemplified by one interview- ee’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 tar- geted 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 in- terests 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 di- rectly 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 preva- lence 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

OCR for page 395
GENDER 401 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., GBV and economic dependence), sexual risk behaviors, and the rate of HIV infection. PEPFAR’S APPROACH TO GENDER Overview Legislation and Strategy The United States 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 incorpo- rating a focus on women into its planning, programming, and reporting. It required the establishment of and reporting on multiple strategies specifi- cally aimed at addressing elements that could improve the lives of women living with or at risk of acquiring HIV.5 These strategies 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 Country Operational Plan (COP) guidance, PEPFAR listed five strategic areas to address the effects of gender norms on HIV: (1) in- creasing equity in services access, (2) addressing male norms, (3) reducing GBV, (4) increasing women’s access to economic resources, and (5) increas- ing women’s legal rights and protections (OGAC, 2004a). 5  United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003, P.L. 108-25, 108th Cong., 1st sess. (May 27, 2003). 6  Supra, note 5 at §101(b)(3)(E-F).

OCR for page 395
402 EVALUATION OF PEPFAR 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 GBV and structural elements that contribute to the vulnerability of women and girls, but also it 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 docu- ments 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 as- sociated 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 indi- viduals’ status within society, roles, norms, behavior, and access to resources—all of which influence dynamics of the HIV/AIDS epi- demic and the success of programs to address it. (OGAC, 2011d, p. 203) 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). 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).

OCR for page 395
GENDER 403 Finally, it is noteworthy that PEPFAR’s gender-focused programming has also been affected by its participation in the U.S. Global Health Initia- tive (GHI), announced in 2009 (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, con- tained an appendix outlining the incorporation of the GHI principles into PEPFAR activities (OGAC, 2009d) and reiterated the central role of the ex- isting 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 ef- forts. Its Gender and HIV Factsheet provides an overview of PEPFAR’s aims, with some examples of activities (OGAC, 2012). Instructions to mis- sion teams related to tracking gender efforts are provided as part of the an- nual 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 pro- grammatic areas of prevention, treatment, care, and strengthening health systems. In 2012, the Office of the U.S. Global AIDS Coordinator (OGAC) released a compilation of technical considerations in addition to its annual COP guidance that provided illustrative examples of gender-related activi- ties that could be incorporated into country portfolios (OGAC, 2011d). However, neither the Factsheet nor the operational guidance provide infor- mation to country programs on how to select effective interventions and integration strategies, set priorities, develop strategic portfolios, or monitor and evaluate gender-focused efforts. Table 8-1 summarizes how gender has been incorporated into PEPFAR guidance documents over the years. In addition to the different forms of guidance released by OGAC summarized in Table 8-1, the U.S. Agency for International Development (USAID) has recently issued technical documents focused on the integra- tion 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 pro-

OCR for page 395
404 TABLE 8-1 Inclusion of Gender in PEPFAR Guidance Documents Over Time, 2003–2012 2003 2004 2005 2006 2007 2008 First Five-Year COP Guidance Strategy COP Guidance ABC Guidance #1 COP Guidance COP Guidance COP Guidance Women are Gender inequality The five-part The elevated risk The five-part The five-part Gender is described mentioned only is noted within gender approach of acquiring HIV gender approach gender approach as a program as targets for prevention is introduced as for women and is included as a is included as a priority area, PMTCT services. as fueling the a key legislative MSM is noted. key legislative key legislative and the five-part HIV epidemic activity for Activities that activity for activity for gender approach and increasing tracking. The address the tracking. The tracking. The is reiterated for women and girls description of specific needs description overlap between tracking. The vulnerability. GBV potential policy of women and of potential prevention overlap between is highlighted. activities includes “vulnerable” policy activities activities and prevention, gender. populations are includes gender. gender is noted. treatment, care, encouraged. Transgendered The description HSS, and policy persons are of potential activities and GBV introduced policy activities is noted. as a target includes gender. population.

OCR for page 395
2009 2010 2011 2012 Guidance for Second Five- the Prevention Combination COP Guidance Year Strategy of Sexually Prevention for and Appendices (including COP Guidance Transmitted HIV Men Who Have (including technical annexes) COP Guidance COP Guidance and Appendices Infections Sex with Men considerations) Addressing Gender is Gender Integrating a Gender is This is the The technical gender issues described as a mainstreaming women- and emphasized first and only considerations that and providing program priority and the five-part girls-centered as an essential guidance accompany COP services for area. For the first approach are approach is contextual document guidance include vulnerable time countries described as defined as one element for released to multiple lists of women are are instructed program policy of the core consideration specifically illustrative gender strongly to write a considerations principles of across prevention address activities activities, broken emphasized programmatic and are identified the GHI, and interventions. for MSM. It down by program within area narrative as a key area addressing Addressing focuses on area. prevention. for activities for linking with gender issues gender equality prevention PEPFAR’s addressing the other health and is described as and GBV are and includes contribution five-part gender development a key program defined and elements on to the GHI approach. The programs. GBV priority area. highlighted as stigma and is outlined, overlap between is highlighted The five-part an available discrimination describing how it prevention, as a cross- gender approach structural and living with will proceed with treatment, care, cutting budget is reiterated, prevention dignity. a women- and HSS, and policy attribution. and gender- approach. girls-centered activities and based violence is MSM are only approach. GBV is noted. highlighted. mentioned as a population at elevated risk. 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,b, 2005a,c, 2006b, 2007b, 2008b, 2009b,d, 2010b, 2011a,c,d,e. 405

OCR for page 395
420 EVALUATION OF PEPFAR an enormous unmet need. Interviewees described PEPFAR’s MSM efforts as having variable coverage (542-5-USPS), and noted continued high or increas- ing HIV prevalence among MSM (331-10-PCGOV; 331-14-USG; 196-8-ML; 196-11-USNGO; 396-6-PCGOV). One scale-up challenge identified by some interviewees was a divergence in the priorities of the national government and of PEPFAR (240-8-USG; 331-18-USNGO; 587-7-PCGOV; 587-12-USG), with the most common occurrence being that the country government wanted to focus on youth or the gen- eral population overall while PEPFAR mission teams and implementing partners identified and prioritized activities around populations at elevated risk, including MSM. In some cases this divergence was described as stem- ming from a lack of recognition by some in the government that MSM are present in the country (240-9-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 par- ticularly 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 codi- fied 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 MSM 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 var- ied 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 COP (OGAC, 2004a, 2005c, 2006b, 2007b, 2008b, 2009b), though

OCR for page 395
GENDER 421 the number of activities captured through this system are no longer regu- larly 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 nar- rative for their gender activities as a part of the supporting documentation submitted with their COPs (OGAC, 2008b). 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 COP document, a narrative sec- tion 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 under way 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 PEPFAR returned to a longer, more comprehensive COP (intended to be submitted every 2 years), but the requirement to include a description of gender-specific efforts was maintained and incor- porated 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 other years this has also been referred to as a “cross-budget code,” but the data were not reported centrally (OGAC, 2008b, 2009b, 2011c). Program Monitoring Indicators Relevant to Gender-Focused Efforts One component of measuring progress in gender-related efforts is pro- gram 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 13 measures with male/female sex disaggregation (Table 8-2) (OGAC, 2007c). These cut across the three major program areas of prevention, treatment, and care and were all intended to measure activities

OCR for page 395
422 EVALUATION OF PEPFAR 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 indi- cator 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 mecha- nism (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 may be available for use by country programs and implementing partners. 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 re- quired 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. Although some interviewees cited examples of using data to track or inform gender programming (240-24-USG; 636-1-USG; 636-6-USG; 636-9-USACA; 116-1-USG; 331-43-USG), some also expressed a need for gender-specific program monitor- ing from PEPFAR (636-6-USG; 935-9-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 measur- ing 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). The inclusion of sex disaggregation data and the participation in the development of the GBV indicator are elements of PEPFAR’s response

OCR for page 395
GENDER 423 TABLE 8-2 Sex-Disaggregated Indicators Routinely Reported to OGAC Next Generation Indicators Routinely Reported Indicators, 2007 (NGIs)—Essential/Reported Number of individuals reached through Number of individuals who received testing community outreach that promotes HIV/ and counseling services for HIV and received AIDS prevention through abstinence their test results and/or being faithful Number of individuals reached through Number of eligible adults and children community outreach that promotes HIV/ provided with a minimum of one care AIDS prevention through abstinence service Number of individuals reached through Number of HIV-positive adults and children community outreach that promotes HIV/ receiving a minimum of one clinical service AIDS prevention through other behavior change beyond abstinence and/or being faithful Total number of individuals provided Number of adults and children with with HIV-related palliative care (including advanced HIV infection newly enrolled on TB/HIV) ART Total number of individuals provided Number of adults and children with with HIV-related palliative care advanced HIV infection receiving (excluding TB/HIV) 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 (including TB) Number of individuals who received counseling and testing for HIV and received their test results (excluding TB) 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.

OCR for page 395
424 EVALUATION OF PEPFAR to the reauthorization legislation’s mandate that the program develop a strategy that “includes specific goals and targets to address [gender] fac- tors; [. . . and] sets forth gender-specific indicators to monitor progress on outcomes and impacts of gender programs.”12 However, the current pro- gram 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, includ- ing 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 abil- ity to assess the full range of its programmatic portfolio. 12  Supra, note 1 at §101(a), 22 U.S.C. 7611(a)(20)(B) and (D).

OCR for page 395
GENDER 425 Conclusion: There are currently insufficient mechanisms and data to give either OGAC or country programs an adequate assess- ment 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. 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 MSM) 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 program- ming. There was 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 effective- ness 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 com- mittee makes the following recommendation: Recommendation 8-1: To achieve PEPFAR’s stated aim of address- ing 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

OCR for page 395
426 EVALUATION OF PEPFAR 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 avail- able 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 program- matic areas. • As an engaged participant with other global and partner coun- try stakeholders, through its implementation PEPFAR should contribute to generating evidence to inform gender-focused efforts through research and evaluation. (See also recommen- dations for PEPFAR’s knowledge management in Chapter 11.)

OCR for page 395
GENDER 427 REFERENCES amfAR (American Foundation for AIDS Research). 2010. MSM and the global HIV/AIDS epidemic: Assessing PEPFAR and looking forward. Washington, DC: amfAR. Auerbach, J. 2009. Transforming social structures and environments to help in HIV preven- tion. Health Affairs 28(6):1655-1665. Baird, S. J., R. S. Garfein, C. T. McIntosh, and B. Ozler. 2012. Effect of a cash transfer pro- gramme 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 transmis- sion: How to make them work better. Lancet 372(9639):669-684. DoS (U.S. Department of State) and USAID. 2012. United States strategy to prevent and respond to gender-based violence globally. Washington, DC: U.S. Department of State and USAID. 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). GHI (Global Health Initiative). 2010. The United States Government Global Health Initiative. Washington, DC: U.S. Department of State. Grulich, A. E., and I. Zablotska. 2010. Commentary: Probability of HIV transmission through anal intercourse. International Journal of Epidemiology 39(4):1064-1065. Gupta, G. R., J. O. Parkhurst, J. A. Ogden, P. Aggleton, and A. Mahal. 2008. Structural ap- proaches 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. ICASO (International Council of AIDS Service Organizations). 2007. Gender, sexuality, rights and HIV: An overview for community sector organizations. Toronto, Ontario: Interna- tional Council of AIDS Service Organizations. ICF International. 2012. STATcompiler, edited by MeasureDHS and ICF International. Cal- verton, MD. 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. Social Science & Medicine 56(1):125-134. Karim, A., S. Sibeko, and C. Baxter. 2010. Prevention of 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. Munthali, A. C., and E. M. Zulu. 2007. The timing and role of initiation rites in preparing young people for adolescence and responsible sexual and reproductive behaviour in Malawi. African Journal of Reproductive Health 11(3):150-167. OGAC (Office of the U.S. Global AIDS Coordinator). 2003. PEPFAR country operational plan guidelines for FY04. Washington, DC: OGAC. OGAC. 2004a. FY05 country operational plan guidance. Washington, DC: OGAC.

OCR for page 395
428 EVALUATION OF PEPFAR OGAC. 2004b. The President’s Emergency Plan for AIDS Relief: U.S. five-year global HIV/ AIDS strategy. Washington, DC: OGAC. OGAC. 2005a. ABC guidance #1 for United States government in-country staff and imple- menting partners applying the ABC approach to preventing sexually-transmitted HIV infections within the President’s Emergency Plan for AIDS Relief. Washington, DC: OGAC. OGAC. 2005b. Engendering bold leadership: The President’s Emergency Plan for AIDS Relief. First annual report to Congress. Washington, DC: OGAC. OGAC. 2005c. President’s Emergency Plan for AIDS Relief: FY06 country operational plan final guidance. Washington, DC: OGAC. OGAC. 2006a. Action today, a foundation for tomorrow: The President’s Emergency Plan For AIDS Relief. Second annual report to Congress. Washington, DC: OGAC. OGAC. 2006b. The President’s Emergency Plan for AIDS Relief: FY2007 country operational plan guidance. Washington, DC: OGAC. OGAC. 2006c. The President’s Emergency Plan for AIDS Relief: Report on gender-based violence and HIV/AIDS. Washington, DC: U.S. Department of State. OGAC. 2007a. The power of partnerships: The President’s Emergency Plan for AIDS Relief. Third annual report to Congress. Washington, DC: OGAC. OGAC. 2007b. The President’s Emergency Plan for AIDS Relief: FY2008 Country Opera- tional Plan Guidance. Washington, DC: OGAC. OGAC. 2007c. The President’s Emergency Plan for AIDS Relief: Indicators, reporting require- ments, and guidelines. Indicators reference guide: FY 2007 reporting/FY 2008 planning. Washington, DC: OGAC. OGAC. 2008a. The power of partnerships: The U.S. President’s Emergency Plan for AIDS Relief 2008 annual report to Congress. Washington, DC: OGAC. OGAC. 2008b. The President’s Emergency Plan for AIDS Relief: FY 2009 country operational plan guidance. Washington, DC: OGAC. OGAC. 2009a. Celebrating life: The U.S. President’s Emergency Plan for AIDS Relief 2009 annual report to Congress. Washington, DC: OGAC. OGAC. 2009b. The President’s Emergency Plan for AIDS Relief: FY 2010 country operational plan guidance: Programmatic considerations. Washington, DC: OGAC. OGAC. 2009c. The President’s Emergency Plan for AIDS Relief: Next generation indicators reference guide. Version 1.1. Washington, DC: OGAC. OGAC. 2009d. The U.S. President’s Emergency Plan for AIDS Relief five-year strategy. An- nex: PEPFAR’s contribution to the Global Health Initiative. OGAC: Washington, DC. OGAC. 2010a. United States President’s Emergency Plan for AIDS Relief: 2009 annual report to Congress on PEPFAR program results. Washington, DC: OGAC. OGAC. 2010b. The President’s Emergency Plan for AIDS Relief: FY 2011 country operational plan guidance and appendices. Washington, DC: OGAC. OGAC. 2011a. Guidance for the prevention of sexually transmitted HIV infections. Wash- ington, DC: OGAC. OGAC. 2011b. PEPFAR: Addressing gender and HIV/AIDS. Washington, DC: OGAC. OGAC. 2011c. The President’s Emergency Plan for AIDS Relief: FY 2012 country operational plan guidance and appendices. Washington, DC: OGAC. OGAC. 2011d. The President’s Emergency Plan for AIDS Relief: FY 2012 country operational plan guidance technical considerations. Washington, DC: OGAC. OGAC. 2011e. Technical guidance on combination HIV prevention for men who have sex with men. Washington, DC: OGAC. OGAC. 2011f. The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) fiscal year 2011: PEPFAR operational plan. Washington, DC: OGAC. OGAC. 2012. PEPFAR: Addressing gender and HIV/AIDS. Washington, DC: OGAC.

OCR for page 395
GENDER 429 Paul, J. P., J. Catania, L. Pollack, and R. Stall. 2001. Understanding childhood sexual abuse as a predictor of sexual risk-taking among men who have sex with men: The urban men’s health study. Child Abuse & Neglect 25(4):557-584. PEPFAR (The President’s Emergency Plan for AIDS Relief). 2012. PEPFAR announces $5 mil- lion for Together for Girls partnership. http://www.state.gov/r/pa/prs/ps/2012/07/195509. htm (accessed August 14, 2012). PEPFAR/Ethiopia. 2010. PEPFAR country operational plan FY 2011. Washington, DC: OGAC. PEPFAR/Mozambique. 2011. Mozambique FY 2011 COP executive summary. Washington, DC: OGAC. Pronyk, P. M., J. R. Hargreaves, J. C. Kim, L. A. Morison, G. Phetla, C. Watts, J. Busza, and J. D. Porter. 2006. Effect of a structural intervention for the prevention of intimate- partner violence and HIV in rural South Africa: A cluster randomised trial. Lancet 368(9551):1973-1983. Pulerwitz, J., S. Martin, M. Mehta, T. Castillo, A. Kidanu, F. Verani, and S. Tewolde. 2010a. Promoting gender equity for HIV and violence prevention: Results from the male norms initiative evaluation in Ethiopia. Washington, DC: PATH. Pulerwitz, J., M. Widyono, M. Mehta, J. Shityuwete, F. Verani, and C. Keulder. 2010b. Pro- moting gender equity for HIV and violence prevention: Results from the PEPFAR male norms initiative evaluation in Namibia. Washington, DC: PATH. Skinner, J., C. Underwood, H. Schwandt, and A. Magombo. 2013. Transitions to adulthood: Examining the influence of initiation rites on the HIV risk of adolescent girls in Mangochi and Thyolo districts of Malawi. AIDS Care 25(3):296-301. Tilbrook, E., A. Allan, and G. Dear. 2010. Intimate partner abuse of men. Perth, Western Australia: Men’s Advisory Network. UCSF (University of California, San Francisco). 2012. Ghana—global research at UCSF. http://globalresearch.ucsf.edu/ghana.html (accessed December 4, 2012). UN Trust Fund (United Nations Trust Fund to End Violence Against Women). 2012. Effective approaches to addressing the intersection of violence against women and HIV/AIDS: Findings from programmes supported by the UN Trust Fund to End Violence Against Women. New York: UN Women (United Nations Entity for Gender Equality and the Empowerment of Women). USAID (U.S. Agency for International Develoment). 2009. Integrating multiple gender strate- gies to improve HIV and AIDS interventions: A compendium of programs in Africa. Washington, DC: International Center for Research on Women. USAID. 2011a. Gender-based violence and HIV: A program guide for integrating gender-based violence prevention and response in PEPFAR programs. Washington, DC: USAID. USAID. 2011b. Integrating multiple PEPFAR gender strategies to improve HIV interventions: Recommendations from five case studies of programs in Africa. Washington, DC: USAID. USAID. 2011c. Integrating PEPFAR gender strategies into HIV programs for most-at-risk populations. Washington, DC: USAID. USAID. 2011d. Scaling up the response to gender-based violence in PEPFAR: PEPFAR con- sultation on gender-based violence, Washington, DC, May 6-7, 2010. Washington, DC: USAID. USAID. 2012a. Gender equality and female empowerment policy. Washington, DC: USAID. USAID. 2012b. PEPFAR gender special initiative: Go Girls! Initiative. http://www.aidstar- one.com/pepfar_gender_special_initiative_go_girls_initiative_0 (accessed November 30, 2012). USAID. 2012c. PEPFAR gender special initiative: Male Gender Norms Initiative. http://www. aidstar-one.com/focus_areas/gender/pepfar_gender_special_ initiatives/male_norms_ initiative (accessed October, 22, 2012).

OCR for page 395
430 EVALUATION OF PEPFAR USAID. 2012d. PEPFAR gender technical working group gender special initiatives. http:// www.aidstarone.com/focus_areas/gender/pepfar_gender_special_initiatives (accessed Au- gust 14, 2010). Whetten, K., J. Ostermann, R. Whetten, K. O’Donnell, N. Thielman, and Positive Outcomes for Orphans Research Team. 2011. More than the loss of a parent: Potentially trau- matic events among orphaned and abandoned children. Journal of Traumatic Stress 24(2):174-182. WHO (World Health Organization). 2005. WHO multi-country study on women’s health and domestic violence against women. Geneva: WHO. WHO. 2011. Global HIV/AIDS response: Epidemic update and health sector progress to- wards universal access. Progress report 2011. Geneva: UNAIDS (Joint United Nations Program on HIV/AIDS). WHO. 2012. What do we mean by “sex” and “gender”? http://www.who.int/gender/whatis gender/en (accessed October, 22, 2012).