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Evaluation of PEPFAR (2013)

Chapter: 8 Gender

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Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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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 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

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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).

Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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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 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 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. 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 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 (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

Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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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 MSM (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 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; 240-6-USNGO; 272-16-PCNGO) (ICASO, 2007).3 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

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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 Country) Bilateral; OGOV = Other Government; ONGO = Other Country NGO.

Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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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 consequences 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 dying4(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

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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.

Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
×

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 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 (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 orphans 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, 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, and many of the inequities and barriers caused by

Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
×

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 (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 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 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 only 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

Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
×

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 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 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) increasing equity in services access, (2) addressing male norms, (3) reducing GBV, (4) increasing women’s access to economic resources, and (5) increasing women’s legal rights and protections (OGAC, 2004a).

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5 United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003, P.L. 108-25, 108th Cong., 1st sess. (May 27, 2003).

6Supra, note 5 at img101(b)(3)(E-F).

Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
×

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 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)

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).

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7Supra, note 1 at img101(a), 22 U.S.C. 7611(a)(21)(A).

8Supra, note 1 at img101(a), 22 U.S.C. 7611(a)(20)(C).

Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
×

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 (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 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, 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 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. 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 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 pro-

Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
×

TABLE 8-1 Inclusion of Gender in PEPFAR Guidance Documents Over Time, 2003–2012

2003 2004 2005 2006   2007 2008
COP Guidance First Five-Year Strategy COP Guidance ABC Guidance #1 COP Guidance COP Guidance COP Guidance
Women are mentioned only as targets for PMTCT services. Gender inequality is noted within prevention as fueling the HIV epidemic and increasing women and girls vulnerability. GBV is highlighted. The five-part gender approach is introduced as a key legislative activity for tracking. The description of potential policy activities includes gender. The elevated risk of acquiring HIV for women and MSM is noted. Activities that address the specific needs of women and ‘vulnerable’ populations are encouraged. The five-part gender approach is included as a key legislative activity for tracking. The description of potential policy activities includes gender. Transgendered persons are introduced as a target population. The five-part gender approach is included as a key legislative activity for tracking. The overlap between prevention activities and gender is noted. The description of potential policy activities includes gender. Gender is described as a program priority area, and the five-part gender approach is reiterated for tracking. The overlap between prevention, treatment, care, HSS, and policy activities and GBV is noted.
Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
×
2009   2010 2011     2012
Second Five-Year Strategy (including annexes) COP Guidance COP Guidance COP Guidance and Appendices Guidance for the Prevention of Sexually Transmitted HIV Infections Combination Prevention for Men Who Have Sex with Men COP Guidance and Appendices (including technical considerations)
Addressing gender issues and providing services for vulnerable women are strongly emphasized within prevention. PEPFAR's contribution to the GHI is outlined, describing how it will proceed with a women- and girls-centered approach. Gender is described as a program priority area. For the first time countries are instructed to write a programmatic area narrative for activities addressing the five-part gender approach. The overlap between prevention, treatment, care, HSS, and policy activities and GBV is noted. Gender mainstreaming and the five-part approach are described as program policy considerations and are identified as a key area for linking with other health and development programs. GBV is highlighted as a crosscutting budget attribution. Integrating a women- and girls-centered approach is defined as one of the core principles of the GHI, and addressing gender issues is described as a key program priority area. The five-part gender approach is reiterated, and genderbased violence is highlighted. Gender is emphasized as an essential contextual element for consideration across prevention interventions. Addressing gender equality and GBV are defined and highlighted as an available structural prevention approach. MSM are only mentioned as a population at elevated risk. This is the first and only guidance document released to specifically address activities for MSM. It focuses on prevention and includes elements on stigma and discrimination and living with dignity. The technical considerations that accompany COP guidance include multiple lists of illustrative gender activities, broken down by program area.

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.

Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
×

vide some recommendations for programming. The U.S. government has also released specific policy guidance on GBV (DoS and USAID, 2012) and USAID on Gender Equality and Female Empowerment (USAID, 2012a). The USAID policy aims to guide the integration of gender equality and female empowerment into USAID’s existing work. Three outcomes goals are highlighted: (1) reducing gender disparities in access to, control over, and benefit from resources, wealth, opportunities, and services; (2) reducing GBV and mitigating its harmful effects on individuals and communities; and (3) 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 Department of State Office of Global Women’s Issues (NCV-10-USG) (OGAC, 2012; DoS and USAID, 2012).

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 (OGAC, 2011b). 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

Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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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.

PEPFAR’s Efforts to Address Equity in Access to HIV Services

There are few specific activities specified in PEPFAR’s gender strategies that are designed to address inequity in service access, and PEPFAR’s gender documents do not articulate what standards might be applied to define equitable access. Interviewees in multiple countries described outreach efforts to increase the utilization of health services; most of these were aimed at women, although as described, previously cultural norms also affect men’s seeking of health services, and PEPFAR has also supported some efforts in this regard.

Interviewees stated that PEPFAR has increased women’s access to health services (331-9-PCNGO; 636-6-USG; 396-21-USG; 240-13-PCGOV; 240-2-USG). These health services include HIV treatment, including antiretroviral therapy (ART) (240-2-USG; 240-15-USG), HIV testing (240-24-USG), antenatal care, and increased access to and integration of family planning services, which is further discussed in the services integration section of the service delivery building block in the health systems strengthening chapter (Chapter 9). Examples of mechanisms used to increase access included reducing fees for antiretroviral drugs (240-2-USG), increasing the number of female health workers through the development of a community health worker cadre (240-13-PCGOV), better integrating prevention of mother-to-child transmission (PMTCT) programs with other women’s health needs and social services (587-5-PCGOV; 166-19-PCGOV), and creating mother-in-law groups to help support women who choose to go for treatment (636-11-PCNGO). However, women seeking services still face access challenges (240-13-PCGOV; 542-16-PCGOV; 331-5-ML; 272-14-PCNGO; 396-37-USNGO), and participants pointed to family planning and cervical cancer screening as existing gaps in service availability (587-3-USG; 272-20-PCNGO; 396-12-USG; 542-16-PCGOV).

Increasing coverage and utilization rates of PMTCT services is also an important component of PEPFAR’s gender work because antenatal clinics are not only the entry point for many women into the health care system but are also where counseling and testing frequently occurs. PMTCT services should thus serve as an entry point not only for the prevention of vertical transmission but also HIV care and treatment, including antiretroviral therapy, for the mother who is HIV-positive. A detailed discussion on service access successes and challenges specifically associated with PMTCT and linkages to care and treatment for women can be found in Chapter 5, “Prevention,” as well as in Chapter 6, “Care and Treatment.”

Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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Programmatic data from Track 1.0 partners9 provided by the U.S. Centers for Disease Control and Prevention (CDC) indicated that the proportion of individuals newly enrolled in antiretroviral therapy was consistently about 65 percent female and 35 percent male from 2005 to 2011.10 These data represent the subset of patients enrolled during this time period in HIV care and treatment programs supported through four large PEPFAR implementing partners. The data are aggregated from programs in 13 countries and thus are not matched to country-specific information on the relative disease burden between men and women in these settings; they are also not matched to estimates of the need for antiretroviral therapy in men and women, which vary by country. However, given that women make up an estimated 59 percent of people living with HIV in sub-Saharan Africa (WHO, 2011), these treatment enrollment figures are broadly in line with the disparity of HIV infection rates between men and women in the largest generalized epidemics and the key PEPFAR-supported regions where these implementing partners are operating. Thus, within the limitations of interpreting this aggregated subset of the total population served by PEPFAR, the data do provide a sense that PEPFAR-supported provision of treatment services reflect the disproportionate burden experienced by women and that PEPFAR is supporting access to care and treatment programs for women.

Indeed, the programmatic data from Track 1.0 partners provided by CDC show that health care for men lags behind in these programs; men enter treatment at later stages of disease progression and have worse outcomes on average after starting ART regimens. One contributor to this discrepancy in health outcomes may be the influence of social-cultural norms that affect how men access and interact with the health system. Interviewees in multiple countries visited expressed an awareness of these challenges for men and indicated a goal of addressing them (636-6-USG; 272-12-USNGO; 461-17-PCNGO; 166-5-USG). As one interviewee noted, ‘There is a bias towards women that PEPFAR is trying to balance, which is explained through the prevalence data that shows women are more vulnerable to HIV infection(636-6-USG). PEPFAR, through its implementing partners, has supported such activities as offering mobile counseling and testing and other services for men (272-12-USNGO; 461-17-PCNGO), providing technical assistance to train community workers to conduct health promotion services with men (272-12-USNGO), campaigns to encourage men to go for counseling and testing (166-5-USG), and ef-

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9 Track 1.0 partners in this report refers to four partners that were the primary large-scale implementers of ART in PEPFAR’s centrally funded Track 1.0 program (for more information, see Appendix C, Methods). These partners also implemented other HIV services and programs, and there were also other centrally funded Track 1.0 partners in other program areas.

10 The presentation of these data and a more comprehensive discussion can be found in Chapter 6, “Care and Treatment.” Additional information on data requests and the methods used by the committee can be found in Appendix C.

Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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forts to engage men who accompany women to PMTCT services (636-9-USACA). In one country an interviewee described care and treatment programs that were focused on men in order to ensure that they received ART (636-6-USG). To some extent, addressing health-seeking behavior is also a part of PEPFAR’s activities to respond to this and other HIV-related challenges influenced by gender norms, which are described further in the following section.

Conclusion: 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’s Efforts to Address Gender Norms

As previously described, cultural norms concerning gender underlie HIV-related experiences (e.g., vulnerability to infection; availability, access and utilization of services; and legal and human rights protections) in all countries. These norms are variable within and across country settings and govern social institutions (e.g., family, law, religion, politics, and media) that affect HIV epidemics and the responses to them. Thus, PEPFAR—and, by extension, OGAC—has an important and delicate role to play working in local communities and with partner country governments in undertaking activities to mitigate the harmful elements of cultural norms about gender. As outlined in its five-part gender strategy, PEPFAR’s activities in this area are primarily defined in terms of addressing male norms (OGAC, 2011b). While addressing both the positive and negative consequences of male norms has received less attention within PEPFAR than other gender-associated factors that affect the HIV epidemic and response, there are several activities in these areas that are ongoing in partner countries, some of which are supported centrally from OGAC headquarters.

The PEPFAR Male Norms Central Initiative lasted for 3 years and came to a close in 2010. It was implemented through different, independent programs in Ethiopia, Namibia, and Tanzania; all of these programs attempted to build on knowledge gained from existing PEPFAR-funded gender activities in countries such as South Africa (Pulerwitz et al., 2010b; USAID, 2012c). In 2010 an evaluation of the initiative’s work in Namibian prisons failed to identify significant changes based on a survey conducted on self-reported behaviors, but follow-up in-depth interviews found that intervention participants did perceive changes in their behaviors and an awareness of gender dynamics (Pulerwitz et al., 2010b). In Ethiopia par-

Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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ticipants receiving interactive group education combined with community engagement activities had a lower risk of HIV than those who received community engagement activities alone; they also had partners who reported positive changes in their relationships, including increased sharing of household responsibilities (Pulerwitz et al., 2010a). There is no similar outcome evaluation available for the initiative in Tanzania.

PEPFAR activities to address male norms also include country-level programming, and partner country implementers identified two primary categories of effort: changing perceptions about gender roles and responsibilities (240-6-USNGO; 166-17-USG; 166-23-USG; 934-30-USNGO; 272-12-USNGO) and increasing male involvement in existing HIV and health care services (636-11-PCNGO; 636-6-USG; 461-21-ONGO; 935-20-PCNGO), including their engagement with their partners in PMTCT (331-27-PCGOV; 587-9-USG; 636-9-USACA; 116-15-USNGO). Although a few programs were well established and had been supported by PEPFAR for several years, many of the male-norms programs were described as being in the initial stages of development, either planned for implementation or recently started. Thus, there is limited information on outcomes. However, interview data show that PEPFAR-supported efforts have led to some observable changes in gender roles related to care giving and responsibility for household chores in partner country settings (240-6-USNGO; 934-30-USNGO). Despite these gains, the relatively narrow focus of PEPFAR’s activities for shaping the cultural norms of men is not sufficient to comprehensively address the dynamic ways in which gender norms interact with and influence multiple aspects of prevention, treatment, and care in the HIV response.

PEPFAR’s Work on Gender-Based Violence

PEPFAR identified the unique contribution of gender-based violence to the transmission of HIV early in its priority setting (OGAC, 2004b). The authorizing legislation for the program specifically required that the first comprehensive Five-Year Strategy include information related to reducing violence and coercion experienced by women.11 As a result, activities in this area have received a large proportion of the focus and effort within the program’s five-part gender strategy. In 2010–2011, PEPFAR invested approximately $155 million in activities related to gender-based violence, which makes it one of the largest investors in this area worldwide (OGAC, 2012).

OGAC’s understanding of the contribution of GBV to HIV-related outcomes is presented in Figure 8-1.

Over time PEPFAR services to address gender-based violence have included prevention activities such as providing post-exposure prophylaxis

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11Supra, note 5 at img101(b)(3)(F).

Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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img

FIGURE 8-1 Gender-based violence and HIV.
SOURCE: USAID, 2011d.

to survivors of sexual assault and violence, behavior change communication and community mobilization, and the integration of services for survivors of gender-based violence into existing facilities or programs (OGAC, 2007b, 2008b, 2009b, 2011d). In 2006 PEPFAR released a congressionally requested report on GBV and HIV/AIDS, outlining the efforts under way at the time and the progress that had been made to that point on scaling up services (OGAC, 2006c). The report was produced too early in the program to identify outcomes of GBV activities, but it did provide several early benchmarks of GBV programming expansion, including as a part of country programs. The report noted that across the 15 focus countries, mission teams had identified 243 different activities that included at least one component designed to address GBV and that in FY 2005 activities that contained a GBV element represented just less than one-third of all funded activities that reported addressing at least one of the five gender components (OGAC, 2006c).

PEPFAR Central Initiatives to Address Gender-Based Violence

PEPFAR also supports several central initiatives to address GBV (USAID, 2012d), including one that has recently come to an end.

The Sexual and Gender-Based Violence Initiative The Sexual and Gender-Based Violence Initiative (SGBV), which began in 2007 in Rwanda and Uganda, was a 3-year effort to expand the available evidence base on

Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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interventions for sexual violence. The initiative highlighted the technical assistance needs of SGBV activities as well as the potential for country-to-country collaborations to be used in addressing violence. IT ultimately resulted in the development of “A Step-by-Step Guide to Strengthening Sexual Violence Services in Public Health Facilities” (Keesbury and Thompson, 2010).

Currently PEPFAR is in the middle of scaling up three new central initiatives aimed at combating violence against women and girls, which not only continue to elevate the profile of GBV efforts in PEPFAR, but also increase the available central funding available for GBV activities.

The Gender-Based Violence Response Scale-Up The Gender-Based Violence Response Scale-Up is an effort in three countries (Mozambique, Tanzania, and the Democratic Republic of the Congo) to build on existing GBV pilot programs. Within these countries the initiative attempts to provide comprehensive care to GBV victims, including post-rape services, and to support multisectoral GBV prevention efforts by working with law enforcement, education, and social services and addressing existing policy barriers within each of the three countries (OGAC, 2011b; USAID, 2011d).

The Gender Challenge Fund The Gender Challenge Fund provides matching resources from headquarters to those designated by participating mission teams in their budgets for GBV activities (OGAC, 2012). As of 2011, 15 countries had received additional funding through this program (OGAC, 2011b).

Together for Girls Together for Girls is a public–private partnership created to reduce sexual violence against girls through raising awareness of the problem and supporting increased data collection at the national level, as well as supporting policy and legal reforms for GBV at both the national and community levels (OGAC, 2011b, 2012). In the summer of 2012, in coordination with the 21st meeting of the International AIDS Society in Washington, DC, the program announced an additional $5 million for the Together for Girls partnership (PEPFAR, 2012).

Country Program Activities to Address Gender-Based Violence

Interview participants from several countries identified multiple types of PEPFAR activities under way to address gender-based violence. These included efforts supporting female empowerment, education, and awareness (240-24-USG; 331-19-USNGO; 196-18-PCNGO; 636-6-USG; 272-17-USG; 166-17-USG); addressing alcohol use (240-24-USG); providing post-exposure prophylaxis to victims of rape (166-17-USG; 196-22-PCGOV; 935-17-USG); training health care workers in providing GBV

Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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services (166-17-USG); working with law enforcement (542-11-PCNGO; 166-17-PCNGO); helping women access the legal system after they have been victims of violence (166-17-PCNGO); and conducting surveys on populations with elevated risk and assessments of PEPFAR’s in-country programmatic structure for gender (331-15-USG; 272-17-USG; 166-17-USG). There were also a number of GBV activities targeted at reaching men, including a “male network program” (587-21-PCNGO), a focus on male leadership and role models (636-6-USG), and a focus on partnership and addressing negative stereotypes about expected male norms in relationships with women (272-12-USNGO). While no interviewees explicitly identified a reduction in the prevalence of GBV, several described other successes resulting from PEPFAR-supported GBV programs. These included increased knowledge among women and girls regarding what to do if they experience violence (240-6-USNGO), an appreciation of the value of having a GBV program as part of their portfolio (166-3-USG), and successfully increasing the availability of post-exposure prophylaxis (166-17-USG).

Conclusion: PEPFAR has placed a strong emphasis on addressing GBV prevention and services. Continuing this focus is critical to changing one of the most important underlying structural drivers of vulnerability in the HIV epidemic.

Women’s Access to Income Generation and Legal Protections

The final two elements of PEPFAR’s five key strategic approaches for gender are increasing women’s access to income-generating activities and legal protections. These topics are important structural mechanisms to reduce women and girl’s vulnerability, but they have received relatively limited attention in PEPFAR’s programming over time (NCV-10-USG). However, one central initiative, while it had broader goals than just these two elements of PEPFAR’s gender approach, did include an economic-strengthening component.

The Gender Special Initiative on Girls’ Vulnerability to HIV (also called Go Girls!) was a 3.5-year central initiative that used a multilevel intervention approach, including mass media communication, life-skills building, training of school personnel, and economic empowerment, to reduce the risk of HIV infection among adolescent girls. The program was implemented in Botswana, Malawi, and Mozambique, and an assessment of the initiative conducted following its completion in 2011 showed that while addressing the economic needs of girls was key to reducing their vulnerability, it remains difficult to achieve in practice (USAID, 2012b).

Numerous interviewees emphasized that economic motivations and constraints are key drivers of gender imbalances. PEPFAR partners and staff described support for income-generating or employment activities

Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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for women in a number of countries visited (240-14-USPS; 196-9-USNGO; 166-27-PCNGO; 116-15-USNGO; 934-31-USNGO; 636-6-USG). Examples included supporting small-scale savings and loan programs (116-15-USNGO), providing life-skills training for young girls who were victims of abuse (934-31-PCNGO), and supporting programs to offer vocational training for women engaged in sex work to find alternate sources of income (196-9-USNGO; 166-27-PCNGO; 935-16-USNGO). (For more information on PEPFAR-supported activities for sex workers, see Chapter 5, “Prevention.”) In one country an interviewee described how income-generation activities at the household and village levels had resulted in positive changes in women’s lives, with local women subsequently running small-scale businesses (116-15-USNGO), whereas in another country these were described as not effective (240-24-USG). There were also examples of activities designed to increase women’s access to legal resources, but these were scarcer (166-27-PCNGO; 636-6-USG; 166-23-USG). Such activities included working to ensure that families understood the legal resources available to respond to sexual coercion (636-6-USG), helping young boys and girls with inheritance laws (166-23-USG), and supporting legal defense for victims of violence (166-27-PCNGO). Outside of PEPFAR’s efforts to provide comprehensive services to survivors of gender-based violence, there are no central initiatives for legal protection. From the limited data available, it seemed to the committee that increasing women and girl’s access to income-generating activities and legal protections are the least developed elements of PEPFAR’s articulated five-part approach to gender programming.

Integration of Gender in Prevention, Care, and Treatment Programs

The previous sections have described efforts that, for the most part, seek to accomplish gender-focused outcomes through specific programs and activities that are designed to address one or more of the five aims of the gender strategy. Following the reauthorization legislation, PEPFAR has also identified an overarching aim of its gender efforts as “integrating gender throughout prevention, care, and treatment programs,” with a focus on the same five aims (OGAC, 2012, p. 1). PEPFAR sometimes applies the term “mainstreaming” to efforts in partner countries to integrate gender considerations into prevention, treatment, and care activities. Some interviewees identified “mainstreaming” of gender into other programmatic areas as an element of their implementation approach (240-24-USG; 636-6-USG; 272-12-USNGO); one described mainstreaming as expecting ‘women to benefit equally with men’ from services and that ‘every technical person should be gender-sensitive’ and include gender assessments and gender concerns in proposals and programs in other technical areas (240-24-USG). However, it was difficult for the committee to make any assessment of this approach, given the difficulty of

Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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determining the specific objectives of these efforts or how they are currently operationalized within PEPFAR programs in partner countries.

Effects of PEPFAR’s Gender Efforts Overall

As presented in the preceding sections on PEPFAR’s gender-related work, the majority of data offered by in-country interviewees concerned inputs and activities for gender planning and programming; some limited information on the outcomes and impact of PEPFAR’s gender efforts was also provided. Many of these outcomes were specific to one of the five gender focus areas articulated in PEPFAR’s gender documentation, such as several positive changes in gender norms that occurred in two countries following efforts by PEPFAR implementing partners (240-6-USNGO; 934-30-USNGO), including an example where local religious leaders ceased blessing early marriages for young girls (240-24-USG), or the successful scale-up of care and treatment access and coverage for women in multiple PEPFAR countries. In addition to these focus-area-specific successes described above, interviewees in multiple countries described more cross-cutting gender outcomes, most notably an increased feeling of empowerment for women (240-6-USNGO; 116-15-USNGO; 331-9-PCNGO; 331-32-PCNGO; 636-6-USG), especially for girls (240-6-USNGO; 116-15-USNGO) as a result of participating in PEPFAR-supported programs. One implementer noted that they had ‘seen changes where the girls start expressing themselves and have a vision of the future(240-6-USNGO), while another stated, ‘Historically it has been a taboo to talk about sex. Now women can sit in a group and discuss sex issues and protection against HIV(636-6-USG). Finally, in several countries the positive benefits were expressed by organization staff members on behalf of the communities they served, as a result of being a part of PEPFAR’s implementation across gender programming (331-22-PCNGO; 196-23-PCNGO). As one interviewee articulated:

The [organization] would like to extend its appreciation to the [. . .] USG because through their support they feel as though they have been treated as humans and are able to be appreciated.’ (196-23-PCNGO)

One of the most common overarching challenges identified by interviewees was the need for longer project periods for gender initiatives in order to fully assess and address gender issues (240-24-USG; 636-6-USG) and have time to see the program’s effects.

Conclusion: 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

Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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aims to also address 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 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.

MEN WHO HAVE SEX WITH MEN

Background

From the first identification and diagnosis of AIDS in the United States, men who have sex with men have been significantly affected by the HIV epidemic. Work by Beyrer and colleagues (2012) has shown that, even where MSM constitute a small proportion of a country’s population, they bear a disproportionate burden of HIV disease. HIV prevalence for men who have sex with men is significantly higher than that of the general population in all regions of the world. In sub-Saharan Africa, approximately 18 percent of MSM are HIV-positive, compared with approximately 5 percent of the general adult population (see Figure 8-2) (Beyrer et al., 2012).

There are several factors that contribute to the increased rate of HIV infection in MSM. Biologically, there is an 18-fold increase in probability of HIV acquisition per sexual event through unprotected receptive anal intercourse as compared to unprotected vaginal intercourse (Grulich and Zablotska, 2010). Structurally, stigma and discrimination and criminalization of homosexuality or homosexual activity continue to prevent many MSM from accessing health services, including HIV testing, treatment, and care (amfAR, 2010; Beyrer et al., 2012). More 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

Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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img

FIGURE 8-2 HIV prevalence in MSM compared to HIV prevalence in all adults in 2010.
NOTE: MSM = men who have sex with men.
SOURCE: Beyrer et al., 2012. Used with permission.

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

Although PEPFAR-supported activities for MSM have been organized primarily through the prevention portfolios in country programs (see also Chapter 5, “Prevention”), the needs of this population, as for all populations, cut across multiple categories of services and activities. As described previously in this chapter, PEPFAR has recently included MSM in its comprehensive framing for understanding the role of gender in the HIV epidemic and response, recognizing 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).

Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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Guidance

While activities for MSM have been supported to varying degrees in PEPFAR countries since the beginning of the program, 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 Joint United Nations Programme on HIV/AIDS (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):

1. Community-based outreach

2. Distribution of condoms and condom-compatible lubricants

3. HIV counseling and testing

4. Active linkage to health care and antiretroviral therapy

5. Targeted information, education and communication

6. 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 (NGIs) 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 (OGAC, 2009c). As a result, there are no longitudinal program monitoring data on 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; 331-7-PCNGO; 331-14-USG; 331-18-USNGO; 331-22-PCNGO; 166-5-

Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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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 because of 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 (331-7-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 (331-7-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 (331-7-PCNGO; 196-25-PCNGO). Civil society organizations and local nongovernmental organizations 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 (331-22-PCNGO; 196-ES) (amfAR, 2010).

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; 240-9-USG; 166-5-USG; 166-20-USG; 166-26-USG; 396-9-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 and Mozambique (PEPFAR/Ethiopia, 2010; PEPFAR/Mozambique, 2011; UCSF, 2012). 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

Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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an enormous unmet need. Interviewees described PEPFAR’s MSM efforts as having variable coverage (542-5-USPS), and noted continued high or increasing 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 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 divergence was described as stemming 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 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 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 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 COP (OGAC, 2004a, 2005c, 2006b, 2007b, 2008b, 2009b), though

Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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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 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 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 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 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 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 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 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

Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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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 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 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. 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 monitoring 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 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).

The inclusion of sex disaggregation data and the participation in the development of the GBV indicator are elements of PEPFAR’s response

Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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TABLE 8-2 Sex-Disaggregated Indicators Routinely Reported to OGAC

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

Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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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.

__________________

12Supra, note 1 at img101(a), 22 U.S.C. 7611(a)(20)(B) and (D).

Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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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.

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 programming. 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 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, 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

Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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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.)

Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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Suggested Citation:"8 Gender." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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The U.S. government supports programs to combat global HIV/AIDS through an initiative that is known as the President's Emergency Plan for AIDS Relief (PEPFAR). This initiative was originally authorized in the U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 and focused on an emergency response to the HIV/AIDS pandemic to deliver lifesaving care and treatment in low- and middle-income countries (LMICs) with the highest burdens of disease. It was subsequently reauthorized in the Tom Lantos and Henry J. Hyde U.S. Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (the Lantos-Hyde Act).

Evaluation of PEPFAR makes recommendations for improving the U.S. government's bilateral programs as part of the U.S. response to global HIV/AIDS. The overall aim of this evaluation is a forward-looking approach to track and anticipate the evolution of the U.S. response to global HIV to be positioned to inform the ability of the U.S. government to address key issues under consideration at the time of the report release.

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