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Diplomacy in Action

Chapter 4: Gender and HIV/AIDS -- Responding to Critical Issues

The President's Emergency Plan for AIDS Relief: Second Annual Report to Congress
Office of the U.S. Global AIDS Coordinator
February 8, 2006

Through the National Muslim Council of Kenya, Muslim women gather to discuss the stigma and challenges of HIV/AIDS. The women provide support and empower each other to make positive impacts within their communities.

" There is a deep need for the empowerment of women, and that begins with education. Educated young women have lower rates of HIV/AIDS, healthier families, and higher rates of education for their own children... We must give more girls in Africa a real chance to avoid exploitation and to chart their own future. Another important aspect of empowerment and the fight against AIDS is the legal protection of women and girls against sexual violence and abuse." President George W. Bush June 30, 2005

Issues and Challenges
The President's Emergency Plan recognizes that social inequalities between women and men, which contribute to 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.

The number of women and girls living with HIV continues to grow rapidly. UNAIDS estimates that 46 percent of adults living with HIV worldwide now are women. In sub-Saharan Africa, the share is even higher - 57 percent. Adolescent girls continue to face especially high risks. In some countries, girls between the ages of 15 and 19 are infected at rates three to six times higher than boys their age. In addition to societal factors, another reason for this elevated risk is that 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-to-male. The interaction of this biological fact with the social fact of male behaviors and norms that put women at risk has proven to be deadly.

Among the harmful social norms and practices that increase the vulnerability of women and girls are 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 the chapter on Prevention.

As noted in the chapter on Care, women carry a disproportionate caregiving burden when family and community members become sick with AIDS or die. These burdens often fall on girls and young women, preventing them from obtaining education and the possibility of economic empowerment. In addition, women who provide care - or who become known to be infected themselves - often face severe stigma.

The societal issues around gender and HIV/AIDS are complex, and in some cases the issues vary from one country to another, requiring different approaches. Addressing these challenges successfully, however, is critical to the achievement of the Emergency Plan's ambitious prevention, treatment, and care goals, and remains a high priority for PEPFAR.

If the world is to succeed in the effort to defeat HIV/AIDS, the soaring infection rates among women and girls simply must be reversed, and it is impossible to do this without addressing these enormous challenges.

In fiscal year 2005, PEPFAR created an interagency Technical Working Group on gender, and it is providing technical assistance to field programs in order to assist them in conducting gender analysis and providing support to strengthen successful, evidence-based interventions.

Increasing gender equity in HIV/AIDS activities and services
The Emergency Plan is working to ensure that the activities it supports provide equitable access to services for both women and men and meet the unique needs of women and girls, including orphans and victims of sex trafficking, rape, abuse, and exploitation.

First Lady Laura Bush meets with women from the Mothers to Mothers-to-Be program in Cape Town, South Africa during her visit to Africa in July 2005.The Emergency Plan is the only international HIV/AIDS program that requires reporting of data disaggregated by gender. This is vitally important, because without knowing who is accessing services, it is difficult to effectively develop gender-sensitive programs. For fiscal year 2005 in the focus countries, the gender of over 90 percent of clients served at downstream sites (those sites for which disaggregation by gender is possible) is known. The statistics in the following paragraphs refer to data from these activities.

An encouraging fact is that approximately 60 percent of those receiving antiretroviral treatment were women and 40 percent were men. Given that most people on U.S. Government (USG)-supported treatment live in Africa, where 57 percent of infected adults are women, ensuring equitable access to treatment is essential, and the Emergency Plan is a leader in making equitable access a reality.

In terms of prevention, approximately 3.2 million pregnant women (including over 1.9 million in fiscal year 2005) have accessed PEPFAR-supported prevention of mother-to-child transmission (PMTCT) services in the 15 focus countries. PMTCT services include HIV counseling and testing, providing an important entry point to HIV care and treatment for women and their family members.

Approximately equal numbers of females and males were reached by ABC prevention programs. A variety of approaches are being undertaken in these programs, many of which tailor messages and behavior change interventions to specific needs of boys, girls, women, and men — and also tackle harmful social norms that perpetuate gender inequalities. Given the role of male behaviors and social norms in HIV transmission, it is important to note that prevention work with men is crucial for reducing the vulnerability of women. Harmful norms also can increase vulnerability of men and boys by creating expectations of early sexual initiation, multiple partners, risk taking, and use of aggression and control in relationships as signs of or to prove manhood.

Among all people who received PEPFAR-supported counseling and testing, approximately 69 percent were women, while approximately 31 were men. Of those who received HIV counseling and testing in downstream settings other than PMTCT, 53 percent were women, while 47 percent were men. (See the chapter on Care for further discussion of these figures.) The Emergency Plan is striving to ensure that women have equal access to counseling and testing services, not only through PMTCT services, but through a range of other PEPFAR-supported approaches, described in the chapter on Care. Among these approaches, the USG supports couples counseling and testing - an important strategy for reducing violence against women around their disclosure of their status. In order to promote a gender-sensitive approach, countries such as Uganda have worked to ensure that men receive their test results first in order to reduce the likelihood of men blaming women or acting out violently against them.

Among the orphans and vulnerable children (OVCs) served by PEPFAR activities, 52 percent were girls and 48 percent were boys. Ensuring that equal numbers of males and females have access to services does not by itself indicate that programming fully addresses gender issues, and therefore PEPFAR OVC programs are working towards including a greater focus on gender in their interventions. For example, in Zambia, Emergency Plan partners are working with the community to reduce potential violence towards OVCs, particularly adolescents, who are vulnerable and can fall victim to sexual coercion and rape.

One measure of equitable access is the extent to which men and women receive and access services. However, increasing availability of services for women and girls is just one component of the broader changes needed to reduce gender imbalance and promote gender equality. Programs must also address the barriers for women and men to receive information, access services, and adhere to treatment. Goals include improving hours of services and reducing costs of services to patients, ensuring greater gender equality in PEPFAR programming.

Reducing violence and coercion
Sexual and other forms of abuse against women fuel the spread of HIV in several ways. The practice or threat of sexual violence against women and girls puts them at increased risk of contracting HIV by creating situations in which women are unable to abstain or negotiate condom use. Fear of violence and rejection from partners, families, and communities keeps women from seeking HIV information, seeking counseling and testing for HIV, and receiving care and treatment. A woman can be at heightened risk of violence or rejection due to disclosing her positive status. The Emergency Plan supports activities to: change social norms and male violence against women; prevent violence resulting from HIV status disclosure through couples counseling and counseling on violence; strengthen policy and legal frameworks outlawing gender-based violence; and link HIV programs with community and social services, such as those to strengthen conflict resolution skills and to protect and care for victims.

In the focus countries during the reporting period, Emergency Plan implementing partners reported that 203 activities had a component that sought to address violence and coercion. Many of these activities are part of ABC efforts, as sexual coercion and violence create extreme challenges for girls and women to achieve these behaviors.

PEPFAR supports post-exposure prophylaxis (PEP) for rape victims in several countries, greatly reducing the risk of HIV infection. In Kenya, the Nairobi Women's Hospital Gender Violence Recovery Centre provides medical and psychosocial support for survivors of rape and sexual assault. In both Zambia and South Africa, USG partners are assisting women with concerted efforts to scale up sexual violence prevention services and PEP at both the local and national levels. Organizations are training healthcare providers in PEP provision, and the project has established a coordinated program with integrated post-rape services provided by pharmacists, police, and social workers. Furthermore, HIV-positive rape survivors are being referred to hospitals or clinics for ongoing clinical care and antiretroviral treatment (ART) assessment.

Alcohol contributes to sexual violence and assault against women, leading to HIV transmission. Emergency Plan activities focusing on alcohol abuse, discussed in the chapter on Prevention, are thus important for reducing both gender-based violence and HIV transmission.

Best Practices
Kenya: Education leads tribal elders to support women's inheritance rights

In the wake of the HIV/AIDS epidemic, problems related to women's rights to property and inheritance in Kenya have escalated as women are widowed by AIDS. Through activities supported by the Emergency Plan, this critical issue has been brought to the attention of leaders in Nyanza Province, the region with the highest HIV prevalence and highest number of AIDS deaths in Kenya. In this province many women are widowed and have little access to food or shelter. Supporting their property and inheritance rights addresses one of their greatest areas of vulnerability, providing the stability needed to raise children and take care of their own needs.

In 2005, the Emergency Plan, through USAID's POLICY project, supported a workshop with the Kenya National Commission for Human Rights to address the problem of women's inheritance and rights of property in the Luo ethnic group in Nyanza. The workshops provided an opportunity for the Luo Council of Elders, women leaders, political leaders, the provincial administration, and local and national organizations to explore the inheritance problem. Community women presented their personal experiences of the discriminatory practices in their culture, as well as those in Kenyan law. The project organized eight participatory community workshops, where widows and orphans vividly described the experience of losing land and other inheritances.

The community meetings resulted in immediate alleviation of inheritance issues through traditional and local government structures. Prior to this Emergency Plan-funded project, the 150 elders from this community had never focused on women's rights. The Council of Elders now wants to restructure their organization to better address the plight of women and orphans and property ownership and inheritance. This work has helped to fundamentally shift the power dynamics between the sexes and lessen the ignorance and distortion within the Luo community, leading to a strong partnership in addressing the plight of women and orphans and vulnerable children. As of September 2005, the Luo Council of Elders reported that they have resettled over 20 women and their children back on their family lands. One elder who had initially objected to this project now proudly reports that he has helped to resettle four women. "I am now converted, thanks to this project," he stated. This has indeed been a fundamental cultural change - one that the Emergency Plan is working to replicate in many other places.

Addressing male norms and behaviors
Emergency Plan prevention efforts recognize that deep-seated norms around male sexual behavior must be addressed in order to achieve the widespread behavior change necessary to curb the HIV epidemic. Practices such as multiple and concurrent 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. The Men as Partners program in South Africa trains non-governmental organizations (NGOs) in strategies for increasing male responsibility for HIV prevention, including working with traditional leaders to mobilize communities to challenge norms of masculinity that contribute to high-risk behavior.

To address these issues, PEPFAR implementing partners reported that 305 activities in the focus nations had a component specifically targeting men. Many of these activities target youth as well as adults, recognizing that
the seeds that lead to negative male behavior are often planted in youth.

In addition, the Emergency Plan supports PMTCT programs that encourage men's participation. For example, in Uganda, Kenya and South Africa, programs have begun to initiate partner testing within PMTCT settings.

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 supports 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. Implementing partners reported that 105 activities in the focus countries had such a component. In Kenya, the Federation for Women Lawyers helps people living with HIV/AIDS (PLWHA) on issues around property and inheritance as well as rape and sexual assault.

Empowering women to make healthy choices
The Emergency Plan supports interventions to enhance women's decision-making capacity in their personal lives and their capacity to provide leadership to community and national HIV/AIDS efforts. Support groups for women are valuable organizations that receive significant Emergency Plan support. For example, PEPFAR supports activities which link HIV-positive pregnant and postpartum women to psychosocial support groups run by peers. These support groups provide educational information on a range of topics from infant feeding to family planning, and provide a supportive space for women to talk with peers about coping with their HIV status.

A South African partner, Mothers To Mothers-To-Be (M2M2B), has created a support network with activities for pregnant women who have just learned their HIV status. The network helps to mentor, educate and encourage mothers to seek out ART, select the most appropriate feeding and family planning methods, and support women in their choice to disclose their HIV status and in coping with stigma. The Emergency Plan supports women's civil society organizations that provide leadership support for PLWHA - helping to build their organizational capacity to deliver services, and strengthening their linkages within broader health care networks.

Emergency Plan interventions are also linked to USGsupported family planning activities. For example, in Rwanda and Tanzania PMTCT programs train providers in family planning to help ensure that HIV-positive clients receive access to information and family planning services. The Emergency Plan also provides key support for expanding access to female-controlled methods of HIV/AIDS protection. PEPFAR-supported programs provide female condoms, and USG funding is contributing to research into microbicides, as noted in the chapter on Prevention.

Increasing women's access to income and productive resources
For many disadvantaged women and girls, transactional sex is one of the few options available for survival. The Emergency Plan supports efforts 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 the disease's impact. Programs also provide education and condoms to allow women who continue to engage in transactional sex to protect themselves. Several programs, including public-private partnerships, are under way to address this critical issue. Additionally, linkages between Emergency Plan and other USG-supported education, economic development, and microfinance programs are being strengthened.

The Emergency Plan supports income generation programs in India for women and girls infected and affected by HIV/AIDS.The USG supports activities targeting income generation development for women, helping women to mitigate the impact of HIV/AIDS on themselves and their families. The Emergency Plan also supports activities to help women develop alternatives to sex work, such as drop-in centers staffed by healthcare professionals and job placement and skill development support for women who wish to leave prostitution. These services are paired with male client interventions to reduce frequency of visits to commercial sex workers in a number of countries, such as Vietnam. Implementing partners reported 107 activities in the focus countries that addressed women's need for access to income and productive resources.

Future Directions
As programs mature and attention to quality of services grows, the need to focus on gender-related factors is becoming increasingly evident. The Emergency Plan's newly established Gender Technical Working Group will offer key technical assistance to field programs. PEPFAR will undertake expert consultations in order to expand its support for effective programs, developing evidencebased approaches to gender issues and taking them to scale. As part of this effort, the USG is refining its efforts to develop quantitative indicators and targets to ensure that the Emergency Plan is supporting effective approaches and to assess the contribution of such approaches to PEPFAR's goals.

Best Practices
Haiti: 'Other Choice' and 'Back to School' programs give women in prostitution new options

The Emergency Plan supports a growing range of programs and interventions in its fight against HIV/AIDS in Haiti. One of these programs, the Lakay Social Clubs, supports HIV/AIDS prevention services for commercial sex workers by offering income-generation and educational alternatives to prostitution. The Lakay project has two main objectives: reducing the incidence of sexually transmitted infections and HIV/AIDS among women in prostitution and their clients, and helping these women to abandon the sex trade.

To address the second objective, the "Other Choice" program provides commercial sex workers with socio-economic alternatives to prostitution. The program offers the women training courses in subjects such as cooking, sewing, computer skills, arts and cosmetology. With these new skills, the program assists women to find new jobs and abandon the sex trade. Former commercial sex workers are integrated into the "Other Choice" program as peer trainers, further enhancing the program's ability to reach other women who are still involved in prostitution.

Through September 2005, the Other Choice program trained more than 1,400 women, many of whom have partially or fully removed themselves from prostitution. In the coming year, PEPFAR will support evaluation of this and similar programs to determine the effectiveness of the training in helping women to leave prostitution.

The Other Choice program will also be extended to include a new strategy called "Back to School." This initiative will target young women who, often due to economic challenges at home, have abandoned school to enter prostitution. The program will support the reintegration of these adolescents into schools, and work to reduce the school-children-by-day/commercial sex worker-by-night phenomenon that has recently developed in many Haitian cities.

It remains clear that reversing trends in infection rates among women and girls and ensuring that women receive equitable access to care and treatment services are critical factors in PEPFAR's ability to meet its goals, including the 2-7-10 goals in the focus nations. The Emergency Plan has thus supported a wide variety of gender-focused activities to tackle critical gender issues, and will continue to intensify support for the gender-sensitive approaches to programming described above. These activities focus not only on access to services, but also on empowerment of women through strengthened individual, family and community-level interventions. In addition, programs that focus on men and boys will continue to grow as they are critical to achieving both successful gender programs and to slowing the tide of HIV transmission. Ongoing efforts will continue to address central issues such as gender-based violence.

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