On Thursday March 12, I had the pleasure
of speaking on a panel sponsored by the United
Nations Association – USA
at the Commission on the Status of Women (CSW).  The topic, addressing
the care-giving burdens and gender gaps in PEPFAR, seems as timely as ever as the Obama Administration
has found itself dealing with the results of the Emergency Plan’s
reauthorization process and seeking new leadership at the Office of
the Global AIDS Coordinator (OGAC).  While PEPFAR has made great
progress in addressing the treatment needs of millions living with HIV
and AIDS in the developing world, we know very little about the impact
of PEPFAR’s prevention programs on populations at greatest risk for
infection.  And with new global AIDS law maintaining an emphasis
on abstinence and fidelity in prevention programs, addressing the care-giving
burdens and closing the gender gaps in the Emergency Plan will continue
to pose a challenge to implementers on the ground. 

Women account for half of all adults
living with HIV and AIDS worldwide, and rates among young women are
growing steadily.  OGAC has responded to the need to address HIV
among women and girls by integrating gender
strategies into its care,
treatment, and prevention programs.  The implementation of the
strategies is monitored by a gender technical working group, comprised
of key staff of the various U.S. government agencies tasked with implementing
PEPFAR programs.  OGAC has been consistent in reporting on "gender-sensitive"
activities since 2005, and reported spending $1 billion on these efforts
in 2008.  However, because prevention policies fail to meet the
needs of women, these strategies are missing the mark at adequately
addressing the AIDS pandemic among the female population. 

The fight for better prevention policy
for U.S. global AIDS programs was lost in the reauthorization process
last year.  Three key aspects of the law will have a direct and
almost immediate negative impact on women in need of prevention and
care services.  The first is the "balanced funding requirement,"
which stipulates that if less than 50% of funds for the sexual transmission
of HIV is spent on abstinence and fidelity programs, the Global AIDS
Coordinator must issue a report to Congress.  The second is the
retention of the Anti-Prostitution Loyalty Oath, also known as the prostitution
pledge, which requires NGOs and service-providers receiving aid through
the Emergency Plan to sign an oath opposing prostitution and sex-trafficking. 
The third is that the bill fell short by neglecting to commit U.S. global
AIDS policy to integrate family planning services and HIV/AIDS services,
although nothing in the legislation precludes the integration of these
services. 

The lack in adequately addressing the
prevention of the sexual transmission of HIV among women and girls undermines
all gender strategies implemented in PEPFAR programs.  The fact
that most women and young women are contracting HIV within marriage
or primary partnerships is a clear sign that focusing on abstinence
and fidelity does nothing to empower them in protecting themselves. 
In environments where male dominance and female inferiority prevail,
innovative strategies for prevention that provide women and young women
with the tools required to protect themselves need to be emphasized
and implemented broadly.  The prostitution pledge, which has become
a political football used by conservatives to demonize women and young
women engaged in the sex sector, has done nothing but stigmatize an
already marginalized population and has also caused a number of organizations
whose aim is to meet the prevention and care needs of this population
to curtail their services.  The lack of family planning/HIV integration
that is broad and widespread enough to truly impact women and girls
will only continue to overburden the health systems and health infrastructures
that are already experiencing shortages and pitfalls.  Further,
the inconvenience for women and young women living within resource-constrained
settings forced to visit multiple providers for health care services
related to the reproductive system makes no sense for the largest international
health program in history. 

If the U.S. government is serious about
addressing the gender implications of HIV and AIDS among women and young
women, it must make prevention a priority in PEPFAR.  Adequately
addressing the care-giving burdens and gender gaps of the AIDS pandemic
depends on it.  UNAIDS executive director Michel Sidebé echoed these sentiments in
his speech at the CSW and called for new paradigms in gender inequality
for women: "…give women and girls the power to protect themselves
from HIV…This requires investment in universal access to comprehensive
sexual and reproductive health services."