Attachment_4_CAR_PEPFAR_Gender_Strategy_Final_06_26_2013.pdf

PEPFAR CENTRAL ASIA REGION

GENDER STRATEGY:

Strategic Opportunities

2013–2020

June 26, 2013

This document is made possible by the generous support of the US President’s Emergency Plan for AIDS Relief (PEPFAR) and the US Agency for International Development (USAID) under contract No.

GHH-I-00-0700068-00. The contents are the responsibility of the AIDSTAR-Two Project and do not necessarily reflect the views of USAID or the US Government.

AIDS Support and Technical

Assistance Resources

PEPFAR CAR Gender Strategy Page ii

PEPFAR CAR Gender Strategy Page iii

Table of Contents

Acknowledgements ............................................................................................................. iv

List of Acronyms ................................................................................................................... v

I. Background

II. Goal

III. Strategic Opportunities and Potential Interventions: What needs to be accomplished and how may these opportunities be put into practice?

Strategic Opportunity #1: Promote understanding of and attention to gender norms, relational dynamics, and gender inequalities within the policy and program agendas of principal stakeholders

Strategic Opportunity #2: Reduce major gender-related barriers to HIV services for key populations by implementing gender-responsive HIV outreach and service models

Strategic Opportunity #3: Reduce gender-based violence and its role in exacerbating HIV vulnerability and limiting access to HIV prevention, treatment, care, and support services among key populations

Strategic Opportunity #4: Enhance the capacity of key populations to advocate for and lead policy change that advances gender equality in the HIV response

Annex 1. Gender Opportunities Framework

PEPFAR CAR Gender Strategy Page iv

Acknowledgements

This regional gender strategy is the result of a joint effort undertaken by the USAID-funded AIDSTAR-Two Project, the USAID Central Asia Region (CAR), and the Office of HIV/AIDS in the Global Health Bureau.

The AIDSTAR-Two Project, led by Management Sciences for Health (MSH) in partnership with the International HIV/AIDS Alliance, would like to express its gratitude to the many people who provided input and guidance for this strategy. Anne Eckman, in conjunction with Kateryna Maksymenko and Elizabeth King, are the authors of this document. We would like to thank the USAID Regional Mission in Central Asia, particularly Khorlan Izmailova, HIV/AIDS Technical Advisor and Leslie Perry, Health Director, for their technical guidance and leadership. In addition, a special thanks is given to the PEPFAR CAR team members Indira Aitmagambetova (CDC Kazakhstan), Jesse Joseph (USAID Kazakhstan), Damira Bibosunova (CDC Kyrgyzstan), Chynara Kamarli (USAID Kyrgyzstan), Dilorom Kosimova (USAID Tajikistan), Benjamin Mills (CDC CAR), and Janet Hyman (PEPFAR CAR) for their time, expertise and contribution to the technical consultation process.

We are indebted to USAID staff Britt Herstad, Regional HIV/AIDS Advisor, Global Health Bureau, Office of HIV/AIDS; Diana Prieto, Senior Gender Advisor, Global Health Bureau, Office of HIV/AIDS; Kristina Yarrow, Health Advisor, Asia and Middle East Bureaus; Kai Spratt, Senior Gender Technical Specialist, Asia and Middle East Bureaus; and Cameron Wolf, Senior HIV/AIDS Advisor for Key Populations. Their input based on their experiences on the ground and from the central office was invaluable and helped sharpen the content of this strategy.

We would like to thank the following AIDSTAR-Two staff who provided essential technical and managerial support: Yadira Almodóvar-Díaz, Portfolio Manager; Sarah Johnson, Director; and Julie Dorsey, Program Associate. We would also like to thank Mary Mulhern Kincaid, President of the Iris Group for her technical input into the design of this gender strategy.

PEPFAR CAR Gender Strategy Page v

List of Acronyms

AIDSTAR AIDS Support and Technical Assistance Resources CAR Central Asia Region CSO Civil society organization FWID Female who injects drugs FSW Female sex worker GBV Gender-based violence INGO International nongovernmental organization MAT Medication-assisted treatment M&E Monitoring and evaluation MSM Men who have sex with men MLHIV Men living with HIV PEPFAR U.S. President’s Emergency Plan for AIDS Relief PHDP Positive Health, Dignity, and Prevention PLHIV Person living with HIV PWID People who injects drugs SRH Sexual and reproductive health SW Sex worker TG Transgender persons TRaC Tracking Results Continuously survey (developed by Population Services

International) USG United States Government WLHIV Woman living with HIV

PEPFAR CAR Gender Strategy Page 1

I. Background

The Central Asia Region (CAR) Team of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) identified the need for a regional gender strategy focusing on key populations at risk for HIV. The gender strategy would include strategic opportunities and concrete actions to enhance the response to the HIV epidemic in the CAR. To ground the strategy in the gender-based constraints and opportunities that shape the lives of key populations — people who inject drugs, sex workers, men who have sex with men, incarcerated persons, and people living with HIV — the CAR Team requested that gender assessments be conducted in Kyrgyzstan (conducted in 2012 by AIDSTAR-One), and Tajikistan and Kazakhstan (conducted in March-April 2013 by AIDSTAR-Two). The assessments were carried out within the framework of the PEPFAR gender strategy and the broader U.S. Government (USG) policy context, which promotes gender equality and women’s empowerment as key pillars of diplomacy and development.

Based on the findings of these assessments, the PEPFAR CAR Team participated in two in-person working sessions and a virtual dialogue with the AIDSTAR-Two gender assessment team in April and May 2013 to identify strategic opportunities to advance HIV outcomes through enhanced awareness of and attention to gender norms and inequalities. The following criteria were used by the CAR Team to identify strategic opportunities:

Interventions that promise to have the greatest impact on determinants of the HIV epidemic in the CAR, especially those factors and outcomes prioritized by the PEPFAR HIV strategy and results areas.

Interventions that address male and female key populations’ identified needs.

Interventions that increase gender equity in access to services.

Interventions that promote gender equality and rights, including shifting underlying gender norms and inequalities that increase HIV risk and limit access to services, and doing so in ways that respect local cultural dynamics and avoid polarization.

Interventions that, in the near-term, build on USG implementing partners’ activities under the current PEPFAR CAR strategy, which focuses on access, capacity, and data.

The following sections present potential strategic opportunities to address underlying gender-based constraints and inequities in order to promote more effective prevention, care and support, and treatment programs and services for key populations. The strategic opportunities seek to inform current PEPFAR CAR programming and strategic objectives,1 as well as future strategy documents, such as the Regional and Country Cooperation Development Strategies and the next PEPFAR CAR Strategy (2016–2020). The country-specific assessment findings that inform these strategies are contained in the respective Kyrgyzstan, Tajikistan, and Kazakhstan gender assessment reports.

PEPFAR CAR Strategy – Final Draft (March 2012), which “describes the 2011-2015 Central Asia regional approach to

HIV prevention and control, and support of those infected with HIV.”

PEPFAR CAR Gender Strategy Page 2

II. Goal

The goal of the PEPFAR CAR Regional Gender Strategy (2013-2019) is to reduce gender-related barriers to HIV services and shift underlying gender-inequitable power relations in order to decrease HIV vulnerability, increase healthy behaviors, and enhance the well-being and rights of key populations.

In order to realize this goal, the PEPFAR CAR Team prioritized recommendations from the gender assessments carried out in Kyrgyzstan, Tajikistan, and Kazakhstan as potential strategic opportunities for the regional gender strategy. These strategic opportunities are described below.

III. Strategic Opportunities and Potential Interventions:

What needs to be accomplished and how may these opportunities be put into practice?

The following four strategic opportunities represent a set of linked opportunities to achieve the overall goal of the gender strategy.

1. Promote understanding of and attention to gender norms, relational dynamics, and gender inequalities within the policy and program agendas of principal stakeholders.

2. Reduce major gender-related barriers to HIV services for key populations by implementing gender-responsive HIV outreach and service models.

3. Reduce gender-based violence and its role in exacerbating HIV vulnerability and limiting access.

4. Enhance the capacity of key populations to advocate for and lead policy change that advances gender equality in the HIV response.

No one area of opportunity is more important than the other because they work together synergistically. Each area includes a description of the opportunities, recommended interventions to put them into practice, and potential outcomes if the interventions are implemented. Annex 1, the Gender Opportunities Framework, presents this information categorized by opportunity, capacity building, data, and outcomes.

Strategic Opportunity #1: Promote understanding of and attention to gender norms, relational dynamics, and gender inequalities within the policy and program agendas of principal stakeholders. The principal stakeholders include: donors, host governments, civil society, and PEPFAR implementing partners. It is essential to ensure that policies, programs, and implementing organizations recognize the importance of transforming gender norms and power inequalities, including gender-based violence, which limit change in HIV risk behaviors, especially behaviors related to sexual transmission, condom use, and injecting drug use. Current programming for key populations has taken initial steps to recognize differences between female and male key populations, and started to collect sex-disaggregated data. Yet, it is necessary to address how underlying gender norms, relational dynamics, and

PEPFAR CAR Gender Strategy Page 3 inequalities2 shape the differing needs, barriers, and opportunities that face female and male key populations in CAR. People in same-sex and heterosexual relations, as well as transgender persons are affected by these gender norms and inequalities. Examples of gender norms, relational dynamics, and inequalities in CAR include:

Norms of masculinity that may encourage men who inject drugs and men living with HIV (MLHIV) risk behaviors and limit their health seeking-behaviors. These norms may also result in men asserting control over their partners’ ability to negotiate safer sex and injecting behaviors and to seek health services. They may also contribute to their use of gender-based violence.

Norms of femininity and power imbalances that limit women’s ability to practice safer sexual and injecting behaviors and to access needed information and services. Gender power imbalances are often more severe among female key populations who violate gender norms, meaning appropriate behaviors expected by society (e.g., female injecting drug users).

Gender-related stigma and discrimination that “layers on” stigma and discrimination against already marginalized groups because of behaviors perceived as immoral (e.g., engaging in sex work, injecting drugs, or having same-sex partners) with additional stigmatization for violating expectations of “proper” gendered conduct.3 For instance, women who are HIV-positive face additional stigma, as compared to men, for being perceived as having acquired HIV by being promiscuous. Female sex workers who are HIV-positive face additional stigma because of their violation of gender norms of sexual conduct. And men who have sex with men are stigmatized for violating gender norms that expect men to have sex with women.

Understanding these gender dynamics and the best practices to address them, will enable key stakeholders—including PEPFAR staff, researchers, and implementing partners—to carry out more effective responses to the HIV epidemic. In particular, implementing partners could develop interventions that address gender norms (masculinities and femininities), relational dynamics, and inequalities head on — interventions that will be crucial to decreasing sexual transmission and increasing health-seeking behaviors and well-being.

Potential areas of intervention and approaches are:

1. Support dialogue, advocacy, and coordination:

Increase awareness among international nongovernmental organizations (INGO), civil society organizations (CSO), and government partners on the role of gender norms, relational dynamics, and gender inequalities in HIV. Maximize coordination and synergy in their efforts, and promote ongoing exchange to enable a more integrated and coordinated response to gender and HIV. As part of this, build understanding of how

For further background information, please see section 3.5, Gender (pages 229–235), in PEPFAR, Technical

Considerations Provided by PEPFAR Technical Working Groups for FY 2013 COPS and ROPS, dated October 2012, available at: http://www.pepfar.gov/documents/organization/199147.pdf. Accessed April 2013. Please also see the Kyrgyzstan, Tajikistan, and Kazakhstan gender assessment reports for further details on gender dynamics specific to the Central Asia Region.

Jain, A., and L. Nyblade. 2012. “Scaling Up Policies, Interventions, and Measurement for Stigma-Free HIV Prevention, Care, and Treatment Services.” Working Paper #3. Washington, DC: Futures Group, Health Policy Project.

PEPFAR CAR Gender Strategy Page 4 gender norms and inequalities form a core dimension of HIV- and key population-related stigma and discrimination.

Promote greater linkages between the HIV sector and the women and justice sectors (currently considered the home of “women’s issues”): Encourage dialogue to integrate HIV-related gender concerns, including the specific needs and priorities of females who inject drugs (FWID), women living with HIV (WLHIV), and men who have sex with men (MSM), into the gender and justice sectors; and integrate gender-related issues as central components in HIV policy and programming.

2. Carry out capacity building:

Build a shared understanding of gender norms, relational dynamics, and gender inequalities — and how they increase HIV vulnerability, contribute to stigma and discrimination, and limit prevention, treatment, and care — among INGOs, government partners, civil society, PEPFAR implementing partners, researchers, and PEPFAR staff.

Build the skills of implementing partners in gender-responsive data collection, analysis, and use for decision-making:

o Build capacity of implementing partners to collect, analyze, and present sex-disaggregated data for monitoring and evaluation (M&E). This includes: the ability to ask key questions about differences in behaviors, knowledge, and access by sex;

the underlying gender barriers that shape these differences; and to analyze the results.

o Build capacity of implementing partners to link sex-disaggregated data to gender-integrated program planning, decision making, and advocacy.

o Provide intensive capacity building and tailored technical assistance to M&E and research staff. This includes offering researchers conceptual frameworks for gender analysis, and how to adapt and apply gender analysis methods and measurement scales.

3. Generate strategic information:

Ensure that sex-disaggregated data continues to be collected and reported by PEPFAR implementing partners.

Identify a core set of simple questions about key gender dynamics affecting access and request PEPFAR implementing partners to report routinely on the trends and patterns they see related to these questions using their sex-disaggregated data. This will facilitate basic gender analysis of existing data and link it to program planning. Questions could include the following: What differences do you see in men's and women's access (or levels of participation, knowledge, or [whatever other information is being collected])?

What gender dynamics (expectations related to being a man, expectations related to being a woman, relational dynamics) may account for these differences? What further information or consultation might you undertake to understand these differences?

What changes might need to be considered to respond to these differences?

Support and disseminate formative research in priority areas to enhance stakeholder understanding of key gender dynamics shaping HIV responses and to develop gender-informed interventions, including:

o Review the current planned Gender Challenge Fund survey of partners of people who inject drugs (PWID), and identify: (1) key questions on the gender dynamics that shape sexual HIV-risk and health-seeking opportunities among PWID and their

PEPFAR CAR Gender Strategy Page 5 partners that the study will answer; and (2) if any additional questions, methods (e.g., a subset of qualitative interviews), or analysis will need to be added in order to answer these questions.

o As part of the current Gender Challenge Fund activity to address gender-based violence (GBV) against key populations in Tajikistan, include an assessment of the quality, friendliness, and accessibility of current GBV services to key populations, who likely experience additional barriers due to stigma and discrimination, in order to ensure that systems and providers are in place to respond accordingly. (Please also see Strategic Opportunity #4 on gender-based violence below.)

o Carry out focused, formative, qualitative research to understand the constructions of masculinities, femininities and gender relations in the context of HIV risk and vulnerability (including the use of condoms and safer injecting practices), health-seeking behaviors, and access to services. Use the findings to develop or adapt modules seeking to shift harmful gender norms, and to develop targeted social marketing and behavior change communication strategies. In the case of PWID, such research would supplement the planned survey noted in the first bullet point above, and support the development of interventions that target gender dynamics in this group and their sexual and injecting partners.

o Carry out research to better understand the needs of key populations. There is a range of information gaps about key populations. It will be important to have a size estimation of FWID who need medication-assisted treatment (MAT). It is likewise important to conduct formative qualitative work to better understand the experiences of transgender persons (TG), especially in relation to HIV vulnerability and access to service.

Potential Outcomes:

1. Implementation of evidence-based strategies and activities addressing gender norms and inequalities related to HIV by and among stakeholders in annual work plans and in national HIV and gender strategies, operational plans, and protocols.

2. Strategic information generated and analyzed to understand gender norms and power dynamics that increase HIV risk and limit access to services, which is used to provide a basis for gender-responsive policies, program design, and models of services.

Strategic Opportunity #2: Reduce major gender-related barriers to HIV services for key populations by implementing gender-responsive HIV outreach and service models. Many members of key populations are hidden or face difficulty accessing services due to marginalization based on gendered stigma and discrimination. This is especially true for FWID, WLHIV, MSM, TG, and sex workers (SW), including male and TG SWs. The existence of multiple stigmas (HIV status + risk behavior + gender) worsens access to services and makes those at risk even more hidden and vulnerable. Yet, many packages of services, training, and capacity

PEPFAR CAR Gender Strategy Page 6 development have been developed without considering the gender-specific needs4 of men and women in key populations, including not only specific sexual and reproductive health information and services, but also access to packages of services that meet their particular social and physiological realities. Examples are FWID’s barriers to accessing MAT and lack of access to support in male-dominated rehabilitation centers. Furthermore, gender norms and relational dynamics limit the ability of men and women to enact safer behaviors and access services. To date, programs do not acknowledge or address gender relations. For example, sexual partners do not use condoms because of gender stereotypes and power relations, even though they have the correct knowledge about HIV and risks behaviors. To expand coverage by addressing these gender-related barriers, PEPFAR CAR may consider the following interventions and approaches.

Potential areas of intervention and approaches:

1. Continue and further strengthen existing strategies that respond to gender-related barriers to reaching key populations in the CAR with HIV-related services.

1.a. Continue and expand outreach strategies designed to address gender barriers to reaching men and women in key populations:

Ensure the availability of a sufficient proportion of female and male outreach workers to provide services to key populations of the same sex.

Increase the number of female outreach workers for PWID, and identify if there are changes needed in the proportion of male and female outreach workers for other key populations.

Review and/or estimate the numbers of key populations that need specific services (MWID, FWID, FSW, MSW, MSM, and TG).

Conduct a more-explicit analysis of gender-related patterns of socializing as well as barriers to reaching key populations related to stigma and discrimination. Use the analysis to develop new approaches to reach those who remain hidden. For instance, consider whether to try to reach MSM, including MSM sex workers, through virtual outreach and networking, such as websites and other virtual pathways. Consider new approaches, such as a peer-to-peer cascade approach to reaching female PWIDs.5 As part of expanded efforts to reach those who remain hidden, consider how to better train and equip peers to use “micro-planning” so that they can identify and plan strategies to overcome gender-related barriers to reaching their more hidden peers.6

Gender-specific needs include both the biological and social needs of women and men. For instance, men and women need specific sexual health services that respond to their biology; FWID also need prevention of mother-to-child transmission (PMTCT) services that respond to their specific needs for MAT. Men and women also need outreach and services tailored to their priority concerns and responsibilities (such as childcare for many women or sexual performance and pleasure for many men), or hours and places of work and gathering for women and men).

Finally, while all key populations experience severe stigma and discrimination in health care services, especially women, MSM and transgender people need health care services that do not enact gender discrimination and that are sensitive to how these realities shape their ability to access and adhere to recommended treatment. (PEPFAR 2012 “Gender” in Technical Considerations Provided by PEPFAR Technical Working Groups for FY 2013 COPS and ROPS, pp.229-235, available at: [accessed April 2013]).

Shulga, L, A. Tokar, A. Smirnov, and N. Dvinskykh. 2011. Developing Gender-Sensitive Approaches to HIV Prevention among Female Injecting Drug Users. Kyiv, Ukraine: International HIV/AIDS Alliance in Ukraine. Available at:

http://www.aidsalliance.org.ua/ru/library/pdf/razvitie%20engl.pdf. Accessed April 2013.

Avahan—The India AIDS Initiative: The business of HIV prevention at scale. Bill & Melinda Gates Foundation. New http://www.aidsalliance.org.ua/ru/library/pdf/razvitie%20engl.pdf

PEPFAR CAR Gender Strategy Page 7

1.b. Ensure access to quality condoms and lubricants. Gender norms — such as a belief that condoms inhibit pleasure or signify the lack of trust and love — and power imbalances in sexual relationships present challenges to using condoms. Poor-quality condoms, and the poor-quality of or lack of water-based lubricants, may do harm not only in terms of direct exposure to increased risk of sexual transmission (due to breakage and/or use of ineffective lubrication), but also the exacerbation of the negative reputation of condoms and related gender norms that may already limit condom acceptability.

Carryout advocacy to ensure that:

o Supply packages include both condoms and water-based lubricant, and that they are both of high quality.

o Condoms and lubricants meet the needs of specific key populations, such as MSM.

Involve key populations in defining and monitoring quality to ensure that condoms and water-based lubricant meet their needs.

Collect information on the quality of condoms and lubricants:

o Include an indicator on the quality of condoms (in Population Services

International’s Tracking Results Continuously [TRaC] survey).

o Conduct research and monitoring in collaboration with key populations to ensure that condoms and lubricants meet the needs of those who will be using them. For instance, consult with SWs and MSM to ensure that the products are acceptable to them and to their clients and partners.

o Advocate for a new indicator on condom quality in the Behavioral Surveillance Surveys (BSS).

2. Integrate new approaches that focus on gender norms, relational dynamics, and inequalities in the delivery of HIV services in order to address these key determinants of HIV prevention and access to treatment, care, and support.

2.a. Integrate a focus on gender norms, inequalities, and relational dynamics into outreach materials and messages:

Develop a core set of group education modules for outreach workers to use with key populations that include fundamental information on gender norms, power inequalities, and relational dynamics. Integrate them into current programming that reaches key male and female populations. The modules should be designed for men and women in key populations, and tailored to the specific contexts in which they are involved. The modules would be facilitated by outreach workers. Capacity building for outreach workers is therefore also needed so that they can understand and support the delivery of the educational sessions. (See point 4 on capacity building below.) The main topics would include:

o Gender norms of masculinity and femininity and their links to stigma and discrimination; negotiating safer sex and drug use; and access to prevention, testing and safe disclosure, treatment, care, and support services.

Delhi, India. 2008. Available at: http://docs.gatesfoundation.org/avahan/documents/avahan_hivprevention.pdf.

Accessed April 2013.

http://docs.gatesfoundation.org/avahan/documents/avahan_hivprevention.pdf

PEPFAR CAR Gender Strategy Page 8 o Gender-based violence — raising awareness about what it is, how it links to HIV vulnerability, how HIV can present additional barriers to accessing GBV services, and how to access available resources.

o Sexual and reproductive health and rights – including explicit information on sexuality and pregnancy for men and women living with HIV.

Develop social and behavior change education messages and materials that explicitly address and seek to transform specific gender norms that limit safer sex and injection behaviors among each key population, including norms related to pleasure, safety, strength (and other key norms identified through formative research), and their links to masculinities and gender roles of women. Tailor these materials to account for the specific contexts of each key population.

2.b. Develop approaches that more directly address gender dynamics between partners as a key determinant of HIV prevention and access to treatment, care, and support.

Following on the anticipated results from the current Gender Challenge Fund’s survey of sexual partners of PWID, integrate couples counseling and education as a key intervention for key populations to enable shared decision-making and communication related to reducing sexual and injecting risk. Ensure that such counseling accounts for gender power relations including gender-based violence and appropriate protocols to ensure that couple counseling does not increase risk of harm.

o Consider adaptation of the Renaissance couples counseling intervention with PWID developed and piloted by Columbia University’s Global HIV Research Center for Central Asia to reduce sexual and injecting drug risk.7 o Establish linkages between existing models of coverage (e.g., PWID: Breaking the Circle; PLHIV: UNISON; ex-incarcerated persons: START-Plus; sex workers: ADARA;

MSM: La Sky; and other support groups such as for PLHIV) and couples counseling interventions.

Integrate gender-sensitive approaches into the context of HIV testing and counseling:

include GBV screening and referral as part of the approaches; build linkages between HIV testing and counseling and couple counseling interventions; and improve safe disclosure counseling.

Identify options for including sexual partners for every key population as potential targets in the next PEPFAR CAR Strategy. While the current PEPFAR strategy does not include resources for interventions directed at sexual partners (apart from the Gender Challenge Fund survey), expanding future prevention programming efforts to include sexual partners of other key populations, beyond PWID, could provide an important opportunity to address determinants of HIV transmission.

Consider expanding program targets to include partners of sex workers. For sex workers, much of the power to determine use of condoms also rests with sexual partners, namely clients and partners. Expanding the coverage targets to include clients of sex workers is important to addressing key gender dynamics that limit sex workers’ ability to practice safer sex.

Consider options for reaching migrants and their sexual partners. It may also be important to target migrants (as a group in and of itself) and their sexual

Gilbert L, N. El-Bassel, A. Terlikbayeva, Y Rozental, M Chang et al. 2010. Couple-based HIV prevention for injecting drug users in Kazakhstan: A pilot intervention study. Journal of Prevention & Intervention in the Community 38(2):162- 176.

PEPFAR CAR Gender Strategy Page 9 partners as a key population for HIV prevention in the context of programming to reduce the risk of sexual transmission, especially in light of the gender dynamics of migration, HIV vulnerability, and risk of migrants’ sexual transmission of HIV to their partners.

3. Define a comprehensive package of services that responds to the specific gender-related needs of each key population and promote its adoption through technical support, capacity building, and targeted research. Key elements include the following:

Continue and expand current work focused on FWID, including advancing current capacity building, technical assistance, and advocacy efforts to implement a strategy and package of services for FWID, as articulated in research and policy dialogue documents to date. In addition to addressing sex-specific needs of FWID, this work also incorporates important analysis of the particular gender-related barriers that FWID face as women, and recommendations on how to address them.

Promote the same process of development and advocacy underway with FWID to develop distinct packages of services, tailored to the gender-specific needs of other key populations: MSM, men and women living with HIV, prisoners and recently released incarcerated persons, men who inject drugs, and SWs.

Include sexual and reproductive health (SRH) for men and women key populations as a core component of minimal outreach and comprehensive packages of services, including access to gynecologists, pregnancy tests, and sexually transmitted infection testing on an outreach basis (i.e., non-facility based access). Prepare, publish, and disseminate information, education, and communication materials on SRH separately for men and women, with attention to the main concerns of each key population.

Ensure provision of voluntary contraception. Also include a focus on better information about sexual and reproductive health and rights, especially related to the desires and plans for childbearing among women and men living with HIV.

Support the development of women’s rehabilitation and support centers for WLHIV, FWID, and SWs to enable safe spaces, in the context of severe, gender-related stigma and discrimination, for the provision of needed services (including childcare), and the opportunity to develop peer support and empowerment. Safe spaces for women are especially important given the challenges of disclosing HIV status, their responsibilities as mothers and caregivers, and their limited opportunities to gain peer support and social solidarity.

Strengthen Positive Health, Dignity, and Prevention (PHDP) 8 approaches among men and women living with HIV, including HIV-positive SWs and MSM. Currently, the “layered on” stigma and discrimination faced by SWs and MSM limits their access to treatment and support. Explore options to provide safe access to information, care, and support for SW and MSM who are living with HIV. Also consider women and men focused sessions as part of the current PLHIV support structure, to enable discussion of topics and needs that may not emerge in combined group spaces.

Positive Health, Dignity, and Prevention seeks to expand the “positive prevention” approach by including more holistic attention to leadership by and for PLHIV, and the “importance of addressing prevention and treatment simultaneously and holistically” (p. 2). Please see GNP+ and UNAIDS. 2011. Positive Health, Dignity and Prevention: A Policy Framework. Amsterdam: GNP+, available at:

http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2011/20110701_phdp.pdf Accessed April 2013.

http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2011/20110701_phdp.pdf

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4. Build the capacity of program implementers at all levels to deliver gender-responsive approaches in HIV services:

Provide capacity building on gender-specific needs and underlying gender dynamics to those responsible for implementing gender-responsive services.

o This includes: health care administrators and providers, program managers, and outreach workers.

o Pay special attention to building the capacity of outreach workers and other program staff to understand the role of gender norms and inequalities in HIV vulnerability, stigma and discrimination, and access, as well as the skills to be able to facilitate modules and counseling focused on these issues.

o Train social workers and/or other key staff to provide couples counseling

Build awareness of and capacity to implement best practices and materials related to providing supportive spaces and groups that address the gender-specific needs and priorities of key populations. This may include access to key resources, study tours, and exchanges.

Promote sustainability of capacity and skills to understand and apply gender-transformative approaches that address gender norms and relational dynamics by:

Developing a training of trainers and a cadre of capacitated trainers.

Developing and integrating gender training into ongoing, priority educational programs (e.g., social work, nursing, medicine, or other vocational training, such as those for outreach workers).

Note: These capacity building recommendations build on those offered under Strategic Opportunity #1 above.

5. Include operations research to evaluate the effectiveness of gender-integrated approaches.

Identify appropriate methods (qualitative and quantitative) and measures to evaluate changes in gender relations.

Monitor and document promising practices (and barriers) as female-specific programming for FWID is implemented, given the current programming underway to address their gender-specific needs. Consider similar operations research for other key populations, depending on initiatives undertaken to address their gendered needs.

Effectiveness of gender relations change measurement may include adapting gender scales, such as the Gender Equitable Men scale, sexual power in relationships, and women’s empowerment scales.9 The survey should be conducted with the same clients at baseline and end-line in order to measure changes.

Qualitative methods may provide critical insights about changes — and the process of change — in gender norms, relations, and how they shape prevention and access to care for key population groups.

1. Coverage of current outreach approaches improved and scaled up by overcoming gender-related barriers to reaching key populations.

For further information on these scales please see the Compendium of Gender Scales: Assessing gender-related attitudes and beliefs, and evaluating health interventions that incorporate gender approaches. Accessed on May 15, 2013 at http://www.c-changeprogram.org/content/gender-scales-compendium/index.html.

http://www.c-changeprogram.org/content/gender-scales-compendium/index.html

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2. New approaches to address key gender-related barriers to HIV prevention and access to quality services piloted, evaluated, and scaled up, including:

Gender norms, relational dynamics and inequalities are more fully researched and integrated into programming and services including, for example, educational modules that critically address masculinities and gender norms, and intervention approaches that address relational dynamics, such as couples counseling and gender-sensitive HIV testing and counseling.

Gender-specific comprehensive packages of services for FWID and all key populations tailored to meet different populations’ needs.

Key populations have access to SRH services tailored to their needs, including information and support for the reproductive desires of PLHIV, and these are included in the minimal and comprehensive packages of services.

Support services and centers designed to specifically meet women’s particular psychosocial needs and respond to the “layered on” stigma and discrimination they face. And, assistance expanded to reach all key populations living with HIV with support for PHDP.

3. Increased coverage of sexual partners for key populations in the PEPFAR program and, in turn, improved outcomes for key populations.

Strategic Opportunity #3: Reduce gender-based violence and its role in exacerbating HIV vulnerability and limiting access to HIV prevention, treatment, care, and support services among key populations. As is the case for women in general in the region, key populations marginalized on the basis of gender norms and inequalities, especially WLHIV, FWID, SWs, MSM, and transgender people, face high rates of gender-based violence in intimate partner relationships. Key populations, especially FWID, SWs, MSM, and transgender people, also experience high rates of gender-based violence from the police. Gender-based violence experienced by key populations may serve as a barrier to preventive behaviors and may limit use of HIV and /AIDS services.

1. Build on the Gender Challenge Fund GBV Initiative in Tajikistan to advance community-and service-level systems that address gender-based violence against key populations.

Develop and implement the current Gender Challenge Fund GBV initiative in Tajikistan.

Identify and address possible gaps in the currently planned interventions, such as the need to assess referral services for their friendliness and accessibility for key populations who often face additional barriers related to stigma and discrimination, in order to ensure that appropriate systems are in place to respond to survivors. If needed, carry out such an assessment and related capacity-building that may be needed with the referral network.

Allocate sufficient resources and follow up to:

o Document and disseminate lessons learned and materials.

o Advocate for integration into the approved package of services for key populations.

o Adapt and integrate GBV activities into packages of services in other countries in the region.

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2. Develop a comprehensive approach to addressing police violence against key populations, especially those marginalized on the basis of gender norms and inequalities (e.g., SWs, FWID, and MSM). Such an approach should build on best practices that engage in a systems approach to change within the police (from high-level political commitment, to policy directives, to institutionalization of ongoing training and accountability. In addition, best practices that mobilize and equip key populations (i.e., with awareness of rights, access to immediate legal support, and local police leadership to redress harassment) should be applied to hold police accountable if and when harassment and violence occurs.

3. Promote awareness campaigns and policy dialogue about the links between gender-based violence and HIV, as well as basic principles in GBV programming and policy in current HIV programming among government, implementing partners, and outreach workers, and in policy dialogue, formulation, and implementation. Note: This recommendation links to the recommended interventions in Strategic Opportunity #1 above.

1. Piloting, evaluation, and scale up of strategies to reduce GBV-related barriers to HIV prevention and improved access to quality services.

2. Strategic information generated and analyzed to understand gender norms and power dynamics that increase HIV risk and limit access to services, and to provide a base for gender-responsive program design and new models for services.

Strategic Opportunity #4: Enhance the capacity of key populations to advocate for and lead policy change that advances gender equality in the HIV response. Organizations representing key populations marginalized on the basis of gender (WLHIV, FWID, female SWs [FSW], MSM, and transgender persons) in CAR currently have limited involvement in shaping policy and programming decisions. Strengthening these networks and their leadership would enable greater identification of priority gender-related needs and rights, and the development of a more sustainable response. In particular, networks of women living with HIV are just emerging and present a particular opportunity to strengthen leadership and advocacy for gender needs and rights. Organizations of MSM are also nascent and could benefit from focused support.

1. Build capacity for leadership and advocacy for policy change by key populations:

Support capacity strengthening for networks and organizations of key populations who are marginalized due to gender norms and discrimination. These include networks and organizations by and for WLHIV, FWID, MSM, SWs.

Include focused leadership development and support to women, SW, and MSM leaders of organizations to enable them to engage effectively in policy dialogue and decision-making forums, and strengthen links to current government decision-making processes, including: knowing which key fora to target; advancing a defined advocacy platform; and effectively representing and advocating for gender-related needs and priorities of their constituents. As part of this, engage male leaders and build their capacity to respond to gender-related needs and priorities, as well as their own gender-related concerns.

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Provide focused support to the networks of women living with HIV, given their nascent, yet growing presence.

Consider focused support to MSM organizations given their vital role in articulating their needs, and the limited recognition of their needs within the current CAR HIV response.

2. Map, prioritize, and monitor key decision-making arenas for greater involvement and influence in decision making. Potential sites for mapping and greater involvement include:

key government decision making arenas (at national and local levels, including budgeting), other decision-making fora (such as CCM), and community-advisory boards (CAB) at narcology and AIDS centers.

3. Leverage resources available to PLHIV networks by linking to other USAID initiatives, where appropriate.

Take advantage of the current AIDSTAR-Two NGO capacity assessment and follow-on plans to assess current capacity, and plan tailored support moving forward.

Consider opportunities through linkages to USAID CAR programming in economic growth to provide access to income generating activities and economic enterprise for networks of persons living with HIV, with special attention to women living with HIV because of their limited opportunities to earn income and their increased risk of being kicked out of their home, abandoned, and otherwise marginalized upon sharing their HIV status.

Potential outcomes:

1. Increased leadership by key populations in advocacy for policy and program changes to reduce priority gender-related barriers to quality, comprehensive HIV services and to support gender equality and sexual diversity.

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Annex 1. Gender Opportunities Framework

Potential interventions to support each of these strategic opportunities are presented in table form on the following pages. Potential interventions are organized by strategic opportunity, and further grouped to correspond to the strategic objectives of the current PEPFAR CAR Strategy (access, capacity and data).

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Strategic Opportunities

Access Capacity Building Data Potential Outcomes

1. Promote understanding of and attention to gender norms and gender inequalities within the policy and program agendas of principal stakeholders.

Enhance dialogue and coordination with other INGOs and with/among host-country governments and civil society to advance a more integrated and coordinated response to gender and HIV, and build understanding of how gender norms and inequalities form a core part of HIV- and key population-related stigma and discrimination.

Develop a shared understanding among INGOs, government partners, civil society, PEPFAR implementing partners, researchers, and PEPFAR staff of how gender norms (masculinity and femininity), relational dynamics, and inequalities increase HIV vulnerability and limit prevention, treatment, and care.

Include explicit attention to the links between gender norms and inequalities, and stigma and discrimination in capacity building efforts with these groups.

Take full advantage of PEPFAR-supported research opportunities to include explicit research questions, methods, analysis, and reporting of data that address key gender norms (masculinity, femininity), relational dynamics, inequalities, and gender stigma and discrimination.

Most immediately, this includes the planned Gender Challenge Fund survey of partners of PWID, and the GBV pilot assessment process as well as its evaluation and dissemination

1. Implementation of evidence-based strategies and activities addressing gender norms and inequalities related to HIV by and among stakeholders in annual work plans and in national HIV and gender strategies, operational plans, and protocols.

2. Strategic information generated and analyzed to understand gender norms and power dynamics that increase HIV risk and limit access to services, and that is used to provide a basis for gender-responsive policies, program design, and models of services.

Promote greater linkages between the HIV sector and the women’s and justice sectors, which are currently seen as the home of “women’s issues.”

Build capacity of implementing partners in:

gender-responsive data collection, analysis, and use for decision making integration into program design.

Ensure that implementing partners continue to collect and report sex-disaggregated M&E data and routinely carry out basic gender analysis of M&E data to inform program planning and decision making.

Provide researchers with conceptual frameworks for gender analysis, and how to adapt and apply related gender analysis methods and measurement scales.

Carry out focused, formative, qualitative research to understand the constructions of masculinities, femininities and gender relations in the context of HIV risk and vulnerability (including the use of condoms and safer injecting practices), health-seeking behaviors, and access to services.

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Access Capacity Building Data Potential Outcomes

Ensure that stakeholders and PEPFAR-funded implementing partners understand, contribute to, and use the results of gender analysis to inform policy dialogue and program responses to the HIV epidemic.

Carry out research to better understand the needs of key populations, based on identification of priority information gaps such as a size estimation of FWID who need medication-assisted treatment (MAT) or formative research to understand the experiences of transgendered persons (TG), especially in relation to HIV vulnerability and access to services.

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Access Capacity Building Data Potential Outcomes

2. Reduce major gender-related barriers to HIV services for key populations by implementing gender-responsive HIV outreach and service models.

Continue and expand outreach strategies designed to address gender barriers to reaching men and women in key populations:

Ensure the availability of a sufficient proportion of female and male outreach workers to provide services to key populations of the same sex.

Increase the number of female outreach workers for PWID, and identify if there are changes needed in the proportion of male and female outreach workers for other key populations.

Conduct a more explicit analysis of gender-related patterns of socializing as…