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GENDER GUIDANCE FOR NATIONAL AIDS RESPONSES

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GENDER GUIDANCE FOR NATIONAL AIDS RESPONSES ...

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    GENDER GUIDANCE FOR

    NATIONAL AIDS

    RESPONSES

    UNAIDS/PCB(22)/08.3

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    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

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    EXECUTIVE SUMMARY

    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.

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    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

    mitigation.

    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

    gender-related initiatives.

    g. Ensure the implementation of essential gender-related actions that promote the

    achievement of both AIDS-related goals and broader gender-equality goals.

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I. INTRODUCTION

    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 HIVfor 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

    responses.

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

    2).

     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).

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    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

    document.

    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

    minorities.

    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

    with men.

    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. 2527 June 2007. 5th UNAIDS. 20 Meeting of the UNAIDS Programme Coordinating Board Conference Room Paper. Review of ProgressSecretary-General‘s Task Force on Women, Girls and HIV/AIDS in Southern Africa, 20032007.

    Working Draft. Summary Report. Geneva, Switzerland, 2527 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).

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; Section II provides an overview of some key gender dimensions of the HIV

    epidemic;

    ; Section III outlines the objectives of the guidance with corresponding

    recommendations;

    ; 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

    implementation.

    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.

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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 6070% 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 3040% 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 HIVa 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 womena 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,

    number 3956]

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Gender Inequality

    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 AfricaRecognising

    the Constraints. SAHARA J 2004; 1:8798. 12 Weis et al. 2007.

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    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 mobilefactors 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 510% 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.

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