GENDER GUIDANCE FOR
GENDER GUIDANCE FOR NATIONAL AIDS RESPONSES
TABLE OF CONTENTS Page
Executive Summary……………………………………………………………… 3 I. Introduction…………………………………………………………………… 5 II. Gender and AIDS……………………………………………………………. 8 III. Objectives and Recommendations………………………………………… 13 IV. Actions, Roles and Responsibilities……………………………………….. 15 V. Programme Priorities……………………………………………………….. 25 Annex 1: Glossary………………………………………………………………. 29 Annex 2: Key Tools and Resources…………………………………………… 30
1. HIV is most often transmitted sexually. As a result, it has long been recognized that unequal relationships between men and women and societal norms of femininity and masculinity are important influences on HIV epidemics. Gender inequality and harmful gender norms are not only associated with the spread of HIV but also with its consequences. For example, women and girls often bear a disproportionate burden of responsibility for families affected by HIV. Gender norms and expectations also make men vulnerable to HIV— including by influencing male sexuality and risk-taking, and making men and boys less likely to seek medical care when ill.
2. The purpose of this guidance is to promote increased and improved action on the intersecting issues of AIDS and gender inequality at country level, emphasizing three cross-cutting key principles: know your epidemic; ensure that responses are evidence-informed; and root strategies, policies and programmes in human rights. The guidance complements existing gender guidelines and tools by emphasizing the process of
strengthening action to address gender equality in AIDS responses. It does not attempt to describe in detail how to intervene in specific thematic areas or sectors, as a wide variety of training materials and tools are already available to guide and support specific interventions.
3. The guidance encourages countries to understand how harmful gender norms and gender inequality contribute to the spread of HIV, and how HIV differentially affects women, men, girls and boys. It also points to the specific impact of gender norms on HIV amongst men who have sex with men, which affect this population directly as well as contributing to the broader epidemic, because many men have sex with both men and women.
4. The guidance emphasises that setting gender and AIDS programme priorities will vary according to a country‘s epidemic situation and local contexts. For example, in
generalized and hyper-endemic settings, effective and sustainable action for HIV prevention requires concerted and far-reaching action to challenge and change harmful gender norms and inequalities between women and men, as well as focused action to make community environments safer, especially for young women and girls. For countries facing low-level or concentrated epidemics, a key priority is for HIV prevention to address gender dynamics influencing key populations and their regular partners, including sex workers, men who have sex with men, and women and men who inject drugs. Identifying and supporting discordant couples is important in both contexts, as is paying attention to the differential impact of HIV on women and men, either as people living with HIV or as care-givers or family members.
5. The guidance focuses on three broad objectives with seven corresponding recommendations for stakeholders, to expand and strengthen action on gender equality within national AIDS responses.
Objective 1: Know your country’s epidemic and current response in gender terms.
Recommendations for national stakeholders:
a. Ensure that HIV monitoring, surveillance and evaluation fully capture information
about the gender dimensions of the HIV epidemic, and periodically conduct stand-
alone gender assessments to gather essential supplementary data.
b. Assess the current response to AIDS to see if and how it is addressing the gender
dimensions of the epidemic.
Objective 2: Plan, implement and evaluate specific actions to advance gender equality, and ensure that appropriate attention be given to gender across your multisectoral AIDS programmes.
Recommendations for national stakeholders:
c. Integrate gender analysis and action into the national AIDS strategy, annual action
plans and sector plans, with special attention being given to dedicated budgeting and
allocation of funds.
d. Implement and scale up specific interventions to address the gender dynamics of the
epidemic in your country in terms of HIV prevention, treatment, care and impact
e. Develop and track targets and indicators to measure gender-related outcomes and
impacts of AIDS programmes.
Objective 3: Build capacity and mutually reinforce links between action on AIDS and broader action to achieve gender-equality goals.
Recommendations for national stakeholders:
f. Promote reciprocal capacity-building to increase the gender competence of those
involved in AIDS-related initiatives and the HIV competence of those involved in
g. Ensure the implementation of essential gender-related actions that promote the
achievement of both AIDS-related goals and broader gender-equality goals.
1. HIV is most often transmitted sexually. As a result, it has long been recognized that
unequal relationships between men and women and societal norms of femininity and
masculinity are important influences on HIV epidemics. Power imbalances between
women and men cover all aspects of personal, social and economic relations – from
access to education and property rights to the negotiation of condom use.
2. Gender inequality and harmful gender norms are not only associated with the spread of
HIV but also with its consequences. For example, women and girls often bear a
disproportionate burden of responsibility for families affected by HIV. In many contexts,
orphaned girls are more vulnerable to mistreatment than orphaned boys. Women
widowed as a result of AIDS are more likely to suffer economic exploitation and less
likely to be able to replace lost family income. Gender norms and expectations also
make men vulnerable to HIV—for example, by influencing male sexuality and risk-taking,
and making men and boys less likely to seek medical care when ill.
3. From the beginning of HIV prevention efforts, many interventions used different
messages and approaches to separately reach and motivate women and men, and girls
and boys. Sometimes this led to ineffective or counterproductive approaches, such as
campaigns in some countries that portrayed women as dangerous vectors of disease.
Fortunately, some early sex-specific campaigns were more gender-sensitive, leading to
successes such as the ‗zero grazing‘ prevention messages in Uganda, which promoted
male faithfulness to sexual partners. It was not long before some of the most effective
prevention programming also began to specifically address the relationships between
women and men, and younger and older people. However, these initiatives have tended
to be limited in scale and number, and are often weakly integrated into national AIDS
4. It is clear that gender inequality and harmful gender norms are major barriers to 1achieving universal access to HIV prevention, treatment, care and support by 2010. At
the 2006 High Level Meeting on AIDS, United Nations Member States pledged ―to 2eliminate gender inequalities, gender-based abuse and violence‖. Taking this into
account, in June 2006, the Programme Coordinating Board requested the development
of practical, user-friendly guidance to respond to the critical gender dimensions of AIDS.
This document was developed in response to that request.
35. Anchored within the ‗Three Ones‘ principles for coordination of national AIDS responses,
the guidance is intended to encourage and assist country-level stakeholders to increase
attention to gender in the coordination, strategic planning, funding, and monitoring and
evaluation of country AIDS programmes. The guidance complements existing gender
guidelines and tools by emphasizing the process of strengthening action to address
gender equality in AIDS responses. It does not attempt to describe in detail how to
intervene in specific thematic areas or sectors, as a wide variety of training materials and
tools are already available to guide and support specific interventions (please see Annex
1 United Nations. Scaling up HIV Prevention, Treatment, Care and Support. Note by the Secretary-General. 24 March 2006. 2 Ibid. 3 ‗Three Ones‘ principles: (1) one agreed AIDS action framework that provides the basis for coordinating the work of all partners; (2) one national AIDS coordinating authority, with a broad-based multisectoral mandate; and (3) one agreed country-level monitoring and evaluation system (UNAIDS, May 2005).
6. In addition to benefiting from the wealth of literature on gender inequality and AIDS, this
guidance document responds to key findings from a number of gender and AIDS
assessments and a review of progress made in countries participating in the United
Nations Secretary-General‘s Task Force on Women, Girls and HIV/AIDS in Southern 4,5Africa. Through a consultation process jointly led by UNDP, UNIFEM and the UNAIDS
Secretariat, a diverse range of stakeholders including governments, donors, civil society
representatives, and UN agencies also contributed to the development of this guidance
7. In consultation processes during the development and pre-testing of the guidance, one
of the issues discussed extensively was the degree to which the guidance should include
attention to men who have sex with men and to transgender populations, given the direct
relevance of gender norms and gender inequality to these groups. Many respondents
asked for a full integration of these issues and populations, important in and of
themselves as well as because many men have sex with both men and women. This
would also align the guidance with a Board decision of the Global Fund to Fight AIDS,
Tuberculosis and Malaria, which requested increased action on gender issues with
particular attention to women, girls and sexual minorities. However, others expressed
concern that attention to men who have sex with men detracts from the importance of
focusing on women and girls and their unequal relationships with men and boys, and
suggested that it would be more appropriate to keep the guidance focused on the needs
of girls and women and to develop separate guidance documents addressing sexual
8. Feedback from national AIDS programme managers pointed to the wisdom of both
perspectives. Several of the consulted programme managers called for at least some
attention to the need to provide a tool to help resolve local debates in concentrated
epidemics regarding how to strike the right balance in addressing increasing
heterosexual transmission alongside sustained epidemics among men who have sex
9. Three key principles are therefore echoed repeatedly throughout the guidance: (1) know
your epidemic; (2) ensure responses are informed by evidence; and (3) root strategies,
policies and programmes in human rights. With these three principles in mind, it is clear
that countries must address not only how HIV differentially affects women and men, but
also the degree to which there may be cross-over between HIV epidemics amongst men
who have sex with men and heterosexual populations. Programme investments must be
proportionate to need, with an emphasis on prevention for those most likely to be
infected in the immediate future. In addition, all affected populations must participate in
shaping policies and programmes, with special attention to the voices and perspectives
of the most vulnerable.
10. The guidance describes objectives, recommendations and actions for more effectively
addressing gender issues in national AIDS responses. It is organized as follows:
4th UNAIDS. 20 Meeting of the UNAIDS Programme Coordinating Board. Conference Room Paper. Assessing Gender Equality and Equity as Critical Elements in National Responses to HIV: Cambodia, Honduras and Ukraine. Geneva, Switzerland. 25–27 June 2007. 5th UNAIDS. 20 Meeting of the UNAIDS Programme Coordinating Board Conference Room Paper. Review of Progress–Secretary-General‘s Task Force on Women, Girls and HIV/AIDS in Southern Africa, 2003–2007.
Working Draft. Summary Report. Geneva, Switzerland, 25–27 June 2007. The Secretary-General‘s Task Force
on Women, Girls and HIV/AIDS in Southern Africa brought together senior officials in government, the UN and civil society organizations in 2003 to focus on improving the AIDS response for women and girls in the nine most affected countries of southern Africa (Botswana, Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Zambia and Zimbabwe).
; Section II provides an overview of some key gender dimensions of the HIV
; Section III outlines the objectives of the guidance with corresponding
; Section IV details actions for key stakeholders to operationalize each of the
recommendations in Section III;
; Section V provides examples of programming priorities in different epidemic settings; ; Annex 1 includes a glossary of key terms used in the guidance document; and
; Annex 2 provides a summary list of tools and resources to support programme
11. The core intention of the guidance is to promote increased and improved action on the intersecting issues of AIDS and gender inequality at country level. The document points to the important role of many key stakeholders, including National AIDS Coordinating Authorities and their government partners, civil society, the donor community, and the UN system. It is essential however that National AIDS Authorities provide the central vision, leadership and actions on gender that are required for effective and sustainable responses to AIDS.
12. Rollout of the guidance will proceed according to a detailed action plan, which emphasizes a focused number of priority activities to further dissemination of the document and implementation of its recommendations (see page 34). With the aim of strengthening and expanding action on gender and AIDS at the country level, the UNAIDS action plan includes:
a. direct efforts to strengthen gender action in selected national AIDS responses;
b. promotion and refinement of the gender guidance and related tools and resources to
support implementation; and
c. coordination and alignment of policy advice and support to countries.
II. GENDER AND AIDS
Sex Differences in HIV Epidemiology
1. When HIV began to spread around the world, the majority of infections were among
males. However, the 1990s witnessed a rapid increase in the number of women living
with HIV in sub-Saharan Africa. There was also an increase in infections among females
in other parts of the world, albeit at a slower pace and from a smaller base. By 2001,
nearly half of all adults living with HIV were women. Since that time, approximately equal
numbers of females and males have been infected around the world, although such
global averages mask important differences among and within countries.
2. In sub-Saharan Africa, women are disproportionately affected by HIV and make up about 661% of all adults with HIV. In younger age groups, girls and young women are
particularly vulnerable and represent an even larger proportion of people living with HIV.
This reflects patterns in some settings of intergenerational sex most often involving older
men and younger women, earlier age of sexual debut for females and sexual violence.
Despite the fact that the majority of people with HIV in Africa are women, a study of
serodiscordant couples from five countries showed that only the male partner was HIV-7positive in 60–70% of couples. This may reflect men‘s greater tendency to abandon
their wives when they are found to have HIV than vice versa, as well as a higher
likelihood for men to have sex outside of marriage. Nevertheless, the fact that 30–40% of
serodiscordant couples in these countries are made up of a seropositive woman and a
seronegative man calls for a nuanced analysis of HIV and steady relationships. For
example, with women on average being infected at a younger age than men, pre-marital
testing and counselling is more likely to reveal HIV-positive diagnoses for young women,
who are marrying men close to their own age, than it is for men.
3. Outside sub-Saharan Africa, the majority of HIV infections in most countries continue to
be among males, although females account for a slowly increasing proportion of new
HIV infections in many settings. Depending upon the country, key risk factors for men
include paying for sex, having sex with other men, injecting drugs or some combination
of the three. In most countries outside Africa, the most significant risk factors for women
are relationships with men involved in these risky activities, or direct participation in
selling sex or injecting drugs.
4. In the small number of countries that have managed to prevent or reverse HIV epidemics
on a national scale, the proportion of new infections among women can rise considerably,
even as the absolute number of infections in both women and men is declining
dramatically. For example, in Cambodia, new infections reached a peak in 1994, when it
is estimated that around 18,500 men and 9,300 women contracted HIV—a ratio of two
males for every female. By 2007, the ratio of male to female infections was almost
exactly one to one, with just over 500 new infections in each of the sexes. Cambodia
thus benefited from a 95% reduction in new infections among women—a success
sometimes obscured by the increasing ratio of women to men.
6 UNAIDS, 2007 AIDS Epidemic Update. Geneva, UNAIDS, 2007. 7 DeWalque D, Discordant Couples: HIV Infection Among Couples in Burkina Faso, Cameroon, Ghana, Kenya and Tanzania. 2006. [Paper provided by The World Bank in its series Policy Research Working Paper Series,
5. Gender inequality and power relations between women and men often create dynamics
where women are more vulnerable to HIV infection and less able to negotiate or insist on
safer sex in heterosexual relations. This is true in and out of marriage, in shorter- and
longer-term relationships and in commercial as well as non-commercial sex. It is
important to note the disproportionate vulnerability of younger women in relationships
with older men, as well as in many marriages or long-term relationships, where women
may have particular difficulty discussing or negotiating risk reduction with their partners,
who may be engaging in risky behaviour outside the relationship. Similarly, in many
settings, norms around femininity and masculinity create an expectation for women to be
monogamous and have limited knowledge of sexual issues, while encouraging multiple
relationships for men. Such norms also mean that women are less likely to disclose
extramarital relations, for example to health care providers or counsellors. These norms
and unequal power relations increase the risks faced by both men and women.
6. Around the world, there is also a strong association between gender-based violence and
vulnerability to HIV. For example, in South Africa, women who experience violence from
their partners have been found to be 50% more likely to be living with HIV than other 8women. In the United Republic of Tanzania, the odds of reporting violence are 10 times 9higher for young HIV-positive women compared to young HIV-negative women. In
Uganda‘s Rakai district, almost 35% of women report having experienced sexual
coercion, and HIV incidence among women whose first sexual experience was coerced
is double that of women who have never experienced sexual violence. Many individuals
also face violence because of their real or perceived HIV-positive status. For example,
women who disclose their HIV-positive status have often faced greater stigma and
suffered more extreme negative reactions than men.
7. Gender-based violence and the associated risk of HIV are of particular concern at times
of humanitarian crisis, emergencies and recovery, as well as for people on the move. In
situations of natural disasters and conflict, large groups of people are more vulnerable to
experiencing and witnessing violence as traditional security and social safety nets break
down. Victims of trafficking are also likely to experience violence and increased risk of
infection, while also being less able to seek treatment, care and support.
8. In many parts of the world, women and girls are bearing a disproportionate burden of
care giving for sick family members and children orphaned by AIDS. This is particularly
acute in sub-Saharan Africa where up to 90% of home-based care for people living with 10HIV is provided by women and girls. The burden of providing care reduces women‘s
and girls‘ access to income, education, food and other resources; this, in turn, 11contributes to increasing vulnerability to HIV. For example, food insufficiency is an
important factor in increasing sexual risk-taking among women in Botswana and 12Swaziland.
8 Dunkle, K et al. Gender-based violence, relationship power, and risk of HIV infection in women attending antenatal clinics in South Africa. The Lancet 363 (9419):1415, 2004. 9 Maman, S et al. HIV and Partner Violence: Implications for HIV Voluntary Counseling and Testing Programs in Dar es Salaam, Tanzania. New York, Horizons, USAID and Population Council, 2001. 10 UNAIDS, UNFPA, UNIFEM. Women and AIDS: Confronting the Crisis. New York, 2004. 11 Seeley J, Grellier R, Barnett T. Gender and HIV/AIDS Impact Mitigation in Sub-Saharan Africa–Recognising
the Constraints. SAHARA J 2004; 1:87–98. 12 Weis et al. 2007.
9. Women in many parts of the world bear a disproportionate burden of the social and
economic consequences of AIDS, including loss of property and inheritance and custody
of children. Poverty gravely affects women‘s ability to deal with the impact of AIDS, as
does the denial of property and inheritance rights to women and children. It also
influences their access to health care and nutritious foods. There are also gender
dimensions to the growing orphan crisis. Gender and orphan challenges overlap in that
orphaned girls are often vulnerable to sexual abuse and other forms of exploitation, while
having less access to education and health-care services, which increase their 13vulnerability to HIV infection.
10. The interaction between gender, education and poverty is complex. In the early stages of
many Eastern and Southern African epidemics, the girls and women most likely to
contract HIV tended to have higher levels of educational participation and achievement
than women who were HIV-negative, probably because educated women were also
more likely to be urbanized and mobile—factors that played a key role in early epidemic
spread. In the past 10 years, however, the association between educational attainment
and HIV risk has evolved, and it is clear that when girls enter and remain in schools with 14good-quality education the effectiveness of prevention programmes is enhanced. This
is partly because HIV and sex education delivered through school curriculum-based
programmes can be effective in improving students‘ knowledge, skills and behavioural
intentions and can delay the initiation of sex, decrease the number of sexual partners 15and promote condom use among the sexually active. But even apart from direct HIV
education, enrolling girls in school and keeping them there longer is associated with a
lower risk of HIV infection in some countries of Eastern and Southern Africa, given the
role of education in empowering girls and women in their relationships and in escaping 16poverty. This applies equally to boys in parts of the Caribbean and Africa, where male
participation in formal schooling remains a critical issue.
11. While the links between gender inequality and HIV are most obvious when focusing on
sexual transmission, these dynamics are also important in HIV transmission associated
with drug use. Because most injecting drug users are male, comprehensive HIV
prevention and care programmes for injecting drug users often do not adequately deal
with female drug users, who may have different patterns of drug use and service access.
Women injecting drug users, who have children, may avoid accessing HIV prevention
and care services because of a fear that government authorities may separate them from
their children. Similarly, many programmes do not yet adequately focus on the needs of
female sexual partners of male drug users.
12. Sex between men is thought to directly account for at least 5–10% of HIV infections
globally. Sex between men is a predominant mode of transmission in high-income
countries and in many middle- and low-income countries – and it contributes to the 17epidemic to some degree in all countries. For example, while HIV epidemics in sub-
Saharan Africa are largely driven by heterosexual sex, data are increasingly revealing
that men who have sex with men are highly vulnerable to infection. This puts their female
partners at particular risk. A study in Kenya has revealed HIV prevalence of 43% for men
who have sex exclusively with other men, and 12.3% for men who have sex with both
13 Commission on HIV/AIDS and Governance in Africa. Impact of HIV/AIDS on Gender, Orphans and Vulnerable
Children. Addis Ababa, CHGA, 2004. 14 Hargreaves, JR et al. Systematic review exploring time trends in the association between educational attainment and risk of HIV infection in sub-Saharan Africa. AIDS. 22(3):403-414, 30 January 2008. 15 Kirby, D, Laris, BA, Rolleri, L. Impact of sex and HIV education programs on sexual behaviors of youth in developing and developed countries. Global Health Council, 2007 16 De Walque D. How does the impact of an HIV/AIDS information campaign vary with educational attainment? Evidence from rural Uganda. Washington, World Bank Development Research Group, 2006. 17 http://www.unaids.org/en/Issues/Affected_communities/men_who_have_sex_with_men.asp.