The President's Emergency Plan for AIDS Relief (PEPFAR/Emergency Plan) recognizes that social inequalities between women and men, in conjunction with harmful gender-based cultural norms and practices, not only perpetuate women's vulnerability to HIV but also continue to fuel the HIV epidemic among both men and women. Strategies to address these issues, critical to achievement of the President's "2-7-10" goals in the focus countries, are highlighted in the U.S. Five-Year Global HIV/AIDS Strategy and incorporated in the Emergency Plan's prevention, treatment, and care efforts. Specifically, the Emergency Plan is supporting interventions to increase gender equity in HIV/AIDS programs and services, reduce violence and coercion, address male norms and behaviors, increase women's access to income and productive resources, and increase women's legal protection. Planned activities for fiscal year 2005, the first year for which data will be consistently available, already indicate that 32 percent of all Emergency Plan program activities will have a component addressing gender issues.
Issues and Challenges
The number of women and girls living with HIV is growing rapidly. In 1998, 41 percent of adults living with HIV were women; this number rose to 50 percent by 2004. Sixty percent of people living with HIV in sub-Saharan Africa are female. Girls and young women are especially at risk. In some of the worst-affected countries, girls between the ages of 15 and 19 are infected at rates three to six times higher than boys their age. This disproportionate impact is linked to biology and to harmful gender- based societal norms and practices. Women, especially young women, are biologically more susceptible to HIV infection than men; male-to-female transmission of HIV is estimated to be eight times more likely than female-tomale. Harmful social norms and practices include those that 1) restrict women's access to HIV/AIDS information and services; 2) severely limit women's control over their sexual lives, leaving them vulnerable to sexual violence and abuse as well as putting them at increased risk of HIV transmission; and 3) deprive them of economic resources and legal rights necessary to protect themselves from HIV/AIDS and contribute productively to caring for others affected by the disease. Some of the implications of these challenges are introduced in chapter 1, "Critical Intervention in the Focus Countries: Prevention."
Increasing gender equity in HIV/AIDS programs and services. Emergency Plan-supported programs are designed to provide equitable access to services for both women and men; ensure that women and girls are educated about HIV/AIDS; and meet the unique needs of women and girls, including orphans and victims of sex trafficking, rape, abuse, and exploitation. In focus countries where gender-specific data are available, during fiscal year 2004 approximately one-half of individuals in contact with community-based abstinence and faithfulness programs (more than 8 million women) were female, and more than half of those impacted by comprehensive community-based prevention programs were women (approximately 4 million). Approximately 52 percent of all those accessing counseling and testing services were women, and nearly 1.3 million pregnant women accessed prevention of mother-to-child transmission (PMTCT) services.
Women in Africa, who are disproportionately infected with HIV, in particular must be ensured access to quality antiretroviral treatment (ART). During the first reporting period, not all sites captured the number of women and girls receiving ART; however, among the sites reporting reporting such numbers, 56 percent of new clients receiving ART were female. Reporting by sex and age will improve significantly in the coming years.
In C�te d'Ivoire, a family-centered approach to care and treatment is reaching women and providing increased access to ART. The Emergency Plan supports PMTCTPlus services for pregnant women and their newborns, partners, and other children through two community-run maternal and child health clinics in the most densely populated areas of Abidjan. Since opening in August 2003, they have served 446 HIV-positive pregnant or delivering women. These women serve as an entry point to building a family care HIV program. To date, 192 HIV-infected women and 27 of their children have started ART. Among the women's partners, 116 have come for testing, with 64 testing HIV-positive and 33 starting ART. At the U.S. Government-supported HEART Project, which operates in a large government-run primary care center in Abidjan, a dedicated HIV clinic for adults and another for children have enrolled 2,217 people living with HIV/AIDS, including 1,177 women and 338 children, in the last six months. Of those, 966 are receiving ART, including 526 women and 213 children.
Another program in Haiti is geared to meet the needs of women in rural areas through mobile PMTCT and ART services. The Emergency Plan is funding a local Haitian health organization to provide HIV care and treatment to women with limited access to established health facilities. Since July 2003, more than 5,000 pregnant women at 26 monthly mobile clinic sites have been counseled and tested for HIV. HIV-positive women are provided nevirapine or triple-drug therapy to prevent mother-tochild transmission. They also receive antenatal care, counseling, family planning services, and food supplementation (with joint funding from USAID's Title II program). To date, 350 women who qualify also are enrolled in an ART program.
Reducing violence and coercion. A strong relationship exists between sexual and other forms of abuse against women and their risk of being HIV-infected. Additionally, fear of violence from community members as well as partners keeps women from seeking HIV information, getting HIV counseling and testing, and receiving care. The Emergency Plan is committed to reducing men's violence against women; supporting women in mitigating potential violence, especially in the context of disclosing their HIV status; and linking HIV programs with community and social services to prevent genderbased violence, strengthen conflict resolution skills, and protect and care for victims.
In order to prevent violence and coercion against women and girls, it is essential to target youth as well as adults. Emergency Plan-supported programs in Botswana and Kenya, for example, are working with youth to tackle issues of violence and sexual abuse, including messages in education-entertainment interventions, youth-focused newspapers and other publications, discussion forums, videos, Web sites, and negotiation skills workshops.
The "Lifeline Childline" program in Namibia is an example of a program addressing the roots of gender violence. It uses age-appropriate messages to teach girls and boys about HIV/AIDS, sexual abuse, domestic violence, and the resources available to vulnerable children through specialized counseling and other services. An estimated 16,000 children and teachers in more than 35 schools are benefiting from this program.
In Vietnam, the "Men in the Know" program provides training through workshops for men to promote safer sex within relationships and challenges the social norms prevalent in some communities that contribute to the sexual abuse of women.
Addressing male norms and behaviors. Practices such as multiple sex partners, cross-generational sex, and transactional sex increase vulnerability to HIV infection, particularly among women and girls. These risky practices are perpetuated by norms that reinforce such behaviors among men and leave women and girls with few options to avoid them. Emergency Plan prevention efforts recognize that these deep-seated norms must be addressed in order to achieve the widespread behavior change necessary to curb the HIV epidemic.
For example, the Emergency Plan is working with the Zambian Defense Force to train peer educators and commanding officers to raise awareness in the military about the threat posed by HIV/AIDS, and to enlist their support in addressing it. Training workshops cover basic facts about HIV/AIDS and its impact, including transmission, prevention, stigma, sexuality, gender, positive living, counseling and testing, and care. Due to the popularity of the workshops, they have been extended to include officers' spouses, dependents, daily employees, and nearby civilian communities.
In Kenya, outreach activities with Maasai communities supported by the Emergency Plan have led to changes in traditional practices that eliminate high-risk sexual behavior but preserve cultural heritage. For example, new cohorts of warriors are renouncing the practice of being honored by young women with sexual favors. At a recent ceremonial gathering, a polygamous Maasai man addressed his peers and said, "Now it is high time for us to go back to our families and come up with family-based resolutions on how to keep to our marriage vows."
With Emergency Plan support, several health centers in Rwanda's Gitarama and Byumba provinces have initiated highly successful programs to engage men in PMTCT services. Partners are invited discreetly (via letters from health facility staff) to accompany women to prenatal visits and receive voluntary counseling and testing. They participate in reproductive health services provided to their partners such as prenatal counseling. Associated community activities work to change male attitudes and behaviors that compromise their own health as well as the health of women and children. Partner involvement has grown dramatically as a result of these activities. At one clinic, 88 percent of partners are now coming for HIV counseling and testing, up from 10 percent in December 2002. In fact, the majority of women's partners now come to PMTCT counseling sessions without receiving the invitation letter.
The Emergency Plan also is addressing gender norms that govern caring for people with HIV. Although women traditionally bear the responsibilities of providing homebased care for people living with HIV/AIDS, the Emergency Plan aims to alleviate some of this burden by supporting innovative programs to help men play a more active role. In South Africa, for example, the Emergency Plan supports a very successful male involvement program known as "Men As Partners." In addition to dealing with HIV/AIDS prevention issues that include masculinity, stigma, and domestic violence, men are encouraged to assume a larger share of responsibilities for family and community care by spending more time with their children, mentoring young boys in the community, and visiting terminally ill AIDS patients.
Increasing women's access to income and productive resources. For many disadvantaged women and girls, transactional sex is one of the few options available to them for survival. The Emergency Plan recognizes that efforts must be undertaken to ensure more sustainable livelihoods for women and girls in order to enable them to escape prostitution, protect themselves from HIV/AIDS, and deal with its impact. Several programs are under way to address this critical issue and others, including public-private partnerships and linkages with U.S. Government-supported economic development and microfinance programs, are in development.
At a clinic in South Africa, for example, training in beadcraft skills, materials, and marketing assistance are available to HIV/AIDS patients to generate income. The clin- ic also supports a choir, which generates income for treatment drugs through the sale of music CDs. A local nongovernmental organization in Nigeria that offers care and support to people living with HIV/AIDS includes training for women in income-generating ventures such as soap-making, cooking, and fabric production. In Zambia, a drop-in center and "Care Club" for commercial sex workers has established links to the Department of Social Welfare, which offers support for education, an ideal mechanism for helping women move out of sex work.
Increasing women's legal protection. Many of the norms and practices that increase women's vulnerability to HIV/AIDS and limit their capacity to deal with its consequences are reinforced by policies, laws, and legal practices that discriminate against women. The Emergency Plan, therefore, is supporting efforts to review, revise, and enforce laws relating to sexual violence and women's property and inheritance rights; enhance women's access to legal assistance; and eliminate gender inequalities in civil and criminal codes.
Emergency Plan goals will not be attained until trends in infection rates among women and girls are reversed and women are guaranteed equal access to care and treatment services. The Emergency Plan has initiated a multitude of gender-focused programs to tackle critical gender issues during its first year. In the coming years, the Plan will intensify its efforts.
Country five-year strategies and fiscal year 2005 operational plans prepared this year include specific approaches that the Emergency Plan will take in each country to address the key gender issues outlined above. Reviews of the 2005 operational plans for the 15 focus countries indicate that 106 programs/activities are planned that address women's legal protection; 103 address women's access to income and productive resources; and 203 programs/ activities address reducing violence and coercion. Progress on these plans will be monitored, and new program approaches will continue to be developed and tested. Lessons learned will be shared and applied across countries, and successful programs will be taken to scale.