Technical Issue Brief: Gender and HIV/AIDS
Introduction
| |
 |
| |
Women participating in a skills-building and empowerment workshop in Tamil Nadu, India.
Source: Anna Williams |
Gender influences the vulnerability of women, girls, men, and boys
to HIV and its effects. It also influences how societies respond to
the epidemic. Gender refers to the cultural, economic, and political
attributes, constraints, and opportunities associated with being a
man or a woman. It is a social construct that defines roles, responsibilities,
and behaviors of women, men, girls, and boys. Differences
in behavior and power between and among men and women are
evident within couples, families, and communities. They are also evident
within the health care system and among other stakeholders
and institutions. These power dynamics, along with gender norms
and inequalities, influence behavior, societal status, and access to resources
– all of which impact the global HIV/AIDS epidemic.
Integrating gender across HIV/AIDS prevention, treatment, and
care programs with an emphasis on transformative interventions is
a key guiding principle in the HIV/AIDS work of the U.S. Agency
for International Development (USAID) in partnership with the
U.S. President’s Emergency Plan for AIDS Relief (PEPFAR).
Gender and HIV/AIDS Overview
Gender constructs and issues vary by age, religion, ethnicity, region,
etc. However, there are several ways that gender affects HIV risk
and how women and men cope with and respond to the disease
across countries and communities.
For example, gender norms may discourage women from asserting
control over the timing and circumstances of sex, including negotiating
protection against HIV and other sexually transmitted infections
(STIs). This is coupled with social norms, held by men and women,
related to masculinity that may encourage male control in sexual
decision making, and discrimination against male same-sex behavior.
In some cases, expectations about exerting power and control over
others may result in sexual and/or physical violence, which may be
overlooked in health services and can be aggravated by justice and
legal systems that do not adequately protect vulnerable groups.
In some settings in Southern Africa, where norms that promote
age-mixing, concurrence of sexual partners, and transactional sex
influence the spread of HIV, prevalence levels peak among women
at much younger ages than men. Adolescent girls make up two-thirds of new infections among young people aged 15 to 24 years.
Where injecting drug use is a primary driver of the epidemic in Eastern Europe and Asia, female and male injecting drug users may
face HIV risks and unmet reproductive and other health needs.
Gender and socio-economic inequalities underpin the high levels
of violence, stigma, and HIV faced by sex workers. Expectations of
masculine behavior contribute to stigma and other difficulties faced
by men who have sex with men and transgenders for behaving
outside the norm.
There are also inequalities that limit women’s and girls’ access to
land, education, credit, and employment. In addition, women’s rights
to own, sell, and inherit land are not legally protected in many settings.
These factors further contribute to women’s vulnerability to
HIV by reinforcing their economic dependence and their inability to
negotiate safe practices or address their health needs.
Gender norms can also prevent men and women from seeking
HIV testing, counseling, and treatment, as well as disclosing their
HIV status. Women may be reluctant to be tested, disclose a positive
diagnosis, or access treatment for fear of violence or abandonment.
At the same time, men may have more limited access to
these services because many are provided most commonly to
pregnant women through antenatal services. Gender norms surrounding
masculinity can also discourage men’s use of HIV testing and
other health services.
Gender norms also affect how women and men cope with the effects of the HIV/AIDS epidemic both personally and publicly as well as the ways their families and communities cope. Since women and girls are culturally assigned roles as caregivers, they bear a disproportionate burden in caring for family members who are ill as a result of AIDS, and they typically do so with very few material resources at their disposal.
USAID: Well Equipped to Support Gender
and HIV/AIDS Programming
USAID understands the many links between gender and the global
HIV/AIDS epidemic. Recognizing that gender is a cross-cutting
issue, USAID, in partnership with the Emergency Plan/PEPFAR, works to integrate gender
into HIV prevention, treatment, and care and support programs
around the world, with emphasis on five strategic areas:
- Increasing gender equity in HIV/AIDS programs and services
- Reducing violence and coercion
- Addressing male norms and behavior
- Increasing women’s legal protection
- Increasing women’s access to income and productive resources
To help support these strategies, USAID provides leadership for
and is actively involved in PEPFAR’s Interagency Gender Technical
Working Group (G/TWG), which includes members from USAID;
the Office of the Global AIDS Coordinator; the Department of
Health and Human Services, Centers for Disease Control and Prevention;
the Department of Defense; and the Peace Corps.
The goals of the G/TWG are to facilitate the achievement of program
goals for HIV/AIDS treatment, prevention, and care;
strengthen program quality and sustainability; guarantee women’s
and men’s equitable access to programs; and prevent program outcomes
that may unintentionally and differentially harm men and
women. The G/TWG supports the implementation of the Emergency Plan/PEPFAR’s
gender framework, identifies promising practices in gender and
HIV/AIDS programs and policies, and provides gender technical assistance
and training for the field.
The G/TWG coordinates three Emergency Plan/PEPFAR gender special programming
initiatives:
- The Vulnerable Girls Initiative seeks to address adolescent girls’
vulnerability to HIV at multiple levels: structural, community, and
family/peer/individual. It is implemented in Botswana, Malawi, and
Mozambique.
- The Male Norms Initiative builds the capacity of organizations
and institutions to implement programs that address gender norms
affecting HIV/AIDS prevention, care, and treatment. An evaluation
has been carried out using the Gender Equitable Men (GEM) Scale
in Ethiopia and Namibia.
- The Sexual and Gender-Based Violence Initiative seeks to strengthen health services for survivors of sexual violence, increase referrals from health facilities to other support services, and facilitate access to services by expanding linkages between communities and health services. It is being implemented in South Africa, Uganda, and Rwanda.
Evidence of Effectiveness
of Gender-Integrated Programming
Social and cultural notions of gender can be difficult to measure.
However, a number of tools and methods designed to capture
norm change and its links to behaviors that place people at risk of
HIV infection have been developed and applied. These tools and
methods contribute to the growing evidence base on the importance
of explicit integration of gender transformative approaches
as a measurable component of HIV/AIDS programs.
With USAID support, the Gender Equitable Men (GEM) Scale was
developed and tested in Rio de Janeiro, Brazil. It is a multi-faceted
tool that measures multiple domains within the construct of gender
norms, with a focus on men’s support of equitable and inequitable
norms in the context of sexual relationships, sexual and reproductive
health, and disease prevention. The GEM Scale has also been applied
in India and sub-Saharan Africa. Results have shown that men who
decreased their support for inequitable gender norms were more
likely to report condom use with primary partners and a reduction
of physical violence against their partners.
Other initiatives have applied rigorous evaluation methods to capture
gender norm change over time. An evaluation of the Stepping
Stones intervention, an HIV prevention program that aims to
improve sexual health by building stronger, more gender-equitable
relationships in Eastern Cape, South Africa, found some evidence
of program success in reducing sexually-transmitted infections in women and in changing
men’s sexual risk-taking behavior and use of violence. While no reduction
in HIV incidence was found, the evaluation documented an
impact on several HIV risk factors – notably herpes simplex virus
type 2, and male perpetration of intimate partner violence.
A cluster randomized trial explored changes in HIV vulnerability
among women exposed to the Intervention with Microfinance for
AIDS and Gender Equity project, which links gender and HIV/AIDS
awareness to microfinance. Results from this trial indicate that the
intervention improved participants’ economic wellbeing, social capital,
and empowerment. After two years of involvement in the initiative,
participants’ past-year risk of physical and sexual violence
was reduced by 55 percent. When compared with controls, young
participants had higher levels of HIV-related communication, were
more likely to have accessed voluntary counseling and testing, and
less likely to have had unprotected sex at last intercourse with a
non-spousal partner.
USAID-Supported Programs
Addressing Gender and HIV/AIDS
Mulheres Primero (Women First)
The Mulheres Primero program, implemented by the International
Relief and Development Agency, combines health and HIV prevention
activities with entrepreneurial training for rural women in
Mozambique. Through these integrated activities, the program aims to promote healthy behaviors and increase women’s access to income
by giving them the skills to develop sustainable businesses
and manage their financial resources. Initially, Mulheres Primero focused
exclusively on health education and economic empowerment
activities. However, program participants identified
gender-based violence (GBV) as a barrier to managing their income
and practicing healthy behaviors, so the program incorporated
community theater, interactive discussions, and group dialogue to
change norms around violence and develop strategies to deal with
violence, including issues that come up in the context of HIV testing
and disclosure. Program evaluation has demonstrated the value of
implementing multiple interventions to address various factors affecting
women’s lives, rather than any one intervention alone to
achieve health outcomes. Participants reported higher levels of HIV
knowledge and condom use. The program has also received financial
support from the Canadian International Development Agency
and the United Nations Development Programme.
 |
|
| Men engaging in a discussion at a Men as Partners gender equality workshop in South Africa. Source: Oscar Gutierrez/EngenderHealth |
|
| |
|
Men As Partners
Established in 1996, the Men as Partners (MAP) program, implemented
by EngenderHealth, has been at the forefront of innovative
work with men to enhance their role in promoting gender equity
and health. MAP works to address men’s health needs and to
reach them with health services; promote the constructive role of
men as supportive partners and fathers; and build men’s skills to
become benefactors of positive change in their communities. The
MAP program implements its approach through skills-building
workshops that confront harmful stereotypes of masculinity; training
of health care providers to offer male-friendly services, use
of street theater and art; support for local and national public education
campaigns; and building national and international advocacy
networks. MAP has been replicated and implemented in over 15
countries in Africa, Asia, and Latin America. In South Africa, the
MAP program is focusing on HIV and GBV prevention as well as
working with men to assume a larger share of caretaking responsibilities
for their children and people living with HIV/AIDS. In
Ethiopia, the program has led to increased involvement of men in
the prevention of mother-to-child transmission services. In Mozambique
and Tanzania, efforts include bringing about policy change by
engaging stakeholders at the national level.
Biruh Tesfa (Bright Future)
Biruh Tesfa, implemented by Population Council together with several
local organizations, addresses the vulnerabilities of migrant
adolescent girls aged 10 to 19 years who have relocated to urban
areas in Ethiopia. Away from their families and socially isolated,
these girls are at risk of coerced sex, transactional sex, and economic
exploitation, all of which contribute to their vulnerability to
HIV. The mentorship program is a central component of Biruh
Tesfa. Through mentors – local women leaders, who receive training
– the girls have access to HIV prevention information, social
support, financial literacy and savings skills, and services for sexual
exploitation and abuse. The program has established linkages with
government health centers to help support the girls’ health, including
care in the case of rape. Biruh Tesfa has also partnered with the
Nia Foundation, a local nongovernmental organization that provides
vocational training and job placement for the girls. The program
currently reaches 10,000 girls. The Population Council is in
the process of completing end-line data collection and analysis on
several health and gender outcomes using qualitative and quantitative
methods. The program has also received financial support
from the UK Department for International Development, the
United Nations Population Fund, and the Nike Foundation.
Children First
Children First is USAID/Zimbabwe’s lead mechanism to improve
the lives of orphans and vulnerable children affected by and infected
with HIV/AIDS. With operations in Umzingwane district
(Matabeleland South Province) and Harare, Children First aims to
mitigate the impact of HIV/AIDS on children in Zimbabwe by improving
access to quality care and support services. The project, implemented by World Education and John Snow, Inc.,
undertakes specific training and outreach related to child protection
with particular attention to gender-based violence. In doing so,
it ensures the full inclusion and protection of young girls. Through
its partners, Children First facilitates access to post-exposure prophylaxis
(PEP) to survivors of rape and sexual abuse by offering
them transport reimbursements to clinics. Working through community
volunteers, the project is able to have children access PEP
within 72 hours of abuse. The community volunteers also play an
important role in raising awareness about child protection against
gender-based violence in their various communities. By establishing
a community-based reporting mechanism and raising awareness in
communities through volunteers, Children First experienced a dramatic
increase of over 50 pecent in the number of abuse cases reported
within six months after commencement of the initiative.
Children First has been able to increase the number of children accessing
clinical services and reduce possible contraction of HIV.
Gender Based Violence
Gender Based Violence (GBV) is a pervasive public health and human rights issue throughout the world. Globally, at least
one out of every four women is beaten, coerced into sex, or otherwise abused during her lifetime. Based on data from
more than 30 countries, 10 to 50 percent of women who have ever had partners have been hit or otherwise physically assaulted;
between 7 percent and 48 percent of adolescent girls and between 2 and 32 percent of adolescent boys report
that their first experience of sexual intercourse was forced. Men may also experience GBV, stigma, and shame associated
with disclosing and seeking assistance; however, women, girls, and boys are most often the victims.
GBV consists of sexual, physical, emotional and/or financial abuse and is manifested throughout the life cycle. Forms of
GBV include sex-selective abortion; female infanticide; child sexual abuse; forced marriage; intimate partner violence; abuse
during pregnancy; sexual coercion within and outside of relationships; and honor killings. GBV also includes structural discriminations
that result in disparities or stigmatization in services; state-sponsored violence such as abuse of commercial
sex workers or men who have sex with men; and trafficking of women and girls.
GBV is deeply embedded in norms that accept violence as normal and expected by men and women and dictate how
men and women are expected to behave in relationships as well as in the community, including expectations of men’s use
of aggression and control. This violence is manifested in the context of women’s and girls’ low relative status; it is based
on power imbalances between and among women and men, girls and boys, and serves to maintain the unequal balance of
power.
GBV and HIV/AIDS
There are myriad negative health consequences linked to GBV. The associations between GBV and HIV/AIDS play out in
different ways: violence may limit the ability to negotiate HIV preventative behaviors or access tools and services; women
who experience early physical and/or sexual abuse are more likely to engage in risky behaviors; actual or fear of violence
and abandonment may affect uptake of HIV testing, willingness to disclose status, and adherence to treatment; and women
who experience violence are more likely to be in partnerships with men who are at elevated risk for HIV infection.
Recent data from South Africa found that women who were physically and sexually abused or experienced frequent violence
were 50 percent more likely to be HIV positive. In India, women who experience intimate partner violence are
seven times more likely to be infected with HIV. In addition, the use of violence against partners is correlated with behaviors
that place individuals at high risk of infection, such as multiple sexual partners, use and abuse of alcohol, and transactional
and commercial sex.
USAID Response
USAID is fully committed to preventing and responding to gender-based violence. Following an ecological framework,
there are several factors at the individual/relationship, community, and society levels that increase risk for and perpetuate
violence. GBV interventions need to work with both men and women to address these multiple factors at various levels.
They should also focus on gradually influencing beliefs and attitudes as well as actual behaviors, and respond to the needs
of those experiencing violence.
There are several entry points to address GBV across HIV/AIDS prevention, treatment, and care programs. Current
USAID activities include:
- Addressing root causes of violence, such as those mentioned above, in GBV and HIV prevention activities through behavior
change communication and community mobilization
- Supporting efforts to engage men to take a stand against violence in their communities and empower women to access
services against violence and make healthy decisions for themselves
- Screening and counseling for GBV within HIV/AIDS programs, as well as strengthening referrals between HIV/AIDS
services and GBV services
- Integrating GBV services for victims/survivors into health programs
- Strengthening linkages between health, legal, law enforcement, and judicial services and the capacity of these sectors
to prevent and mitigate gender-based violence
More program evaluation and research is needed to better understand how GBV impacts HIV/AIDS in different contexts
and types of epidemics, as well as the most effective strategies and interventions available to confront this issue. Current
USAID programming reflects promising practices to date. |
November 2009
|
