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.


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

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