Approaches to gender and sexuality: Responding to HIV
Gender and sexuality have long been recognised as key factors affecting the dynamics of the HIV epidemic. Issues vary across communities and countries, but power imbalances, harmful social norms, violence and marginalisation affect women, men, girls, boys and transgender people across the world, limiting their ability to prevent HIV infection. In May 2010, we carried out a survey of our national Linking Organisations to map our current work; assess capacity, challenges and aspirations around gender and sexuality programming; and better understand the gender and sexuality context in which our partners work.
Supporting community action on AIDS in developing countries ApproAches to gender And sexuAlity: responding to hiV Report on the findings of a survey among Alliance Linking Organisations Acknowledgements The Alliance is grateful to the many people and organisations that supported the gender and sexuality survey. This report was written by Sarah Middleton-Lee, an independent consultant. cover images Sex worker in Hyderabad, India. � Shailaja Jathi � International HIV/AIDS Alliance 2010 Information contained in this publication may be freely reproduced, published or otherwise used for non-profit purposes without permission from the International HIV/AIDS Alliance (the Alliance). However, the Alliance requests that they be cited as the source of the information. Published: February 2011 ISBN: 978-1-905055-84-5 Design: www.janeshepherd.com A focus group for sex workers and female survivors of violence at Ennakhil, a Moroccan organisation dedicated to helping women and children. � 2006 Nell Freeman for the Alliance KHANA's Integrated Care and Prevention Programme focuses on the provision of home-based care services to people living with HIV, orphans and vulnerable children and their families in Cambodia. � Michael Nott for KHANA and the Alliance Founders of the Association African Solidarit�, a group offering treatment, home-based care and support to adults and children living with HIV, Ouagadougou, Burkina Faso. � Gideon Mendel for the Alliance 1 ApproAches to gender And sexuAlity: responding to hiV CONtENtS executive summary 1. introduction The global context The Alliance context Survey purpose, methods and participants Survey limitations 3 8 8 10 12 12 14 14 16 18 28 29 31 31 32 34 34 35 36 38 2. Findings What are the most important gender concerns? What is a gender and sexuality approach to HIV? What gender and sexuality work are we doing? What challenges are there in doing gender and sexuality work? Assessing our capacity and future support needs 3. conclusions and recommendations Conclusions Recommendations Annexes Annex 1: Examples of gender-transformative approaches Annex 2: Gender and sexuality survey questions Annex 3: Alliance good practice HIV programming standards Annex 4: Key global guidance on gender and sexuality approaches APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV 2 ACRONyMS Alliance CBO GIPA Global Fund NGO SRH SRHR STI UNGASS International HIV/AIDS Alliance Community-based organisation Greater involvement of people living with HIV Global Fund to Fight AIDS, Tuberculosis and Malaria Non-governmental organisation Sexual and reproductive health Sexual and reproductive health and rights Sexually transmitted infection United Nations General Assembly Special Session on AIDS COuNtRIES/PARtNERS RESPONdING tO GENdER ANd SExuALIty SuRVEy Bangladesh Bolivia Burkina Faso Cambodia China C�te d'Ivoire Haiti India HIV/AIDS and STD Alliance Bangladesh (HASAB) Instituto de Desarrollo Humano (IDH) Initiative Priv�e et Communautaire de lutte Contre le SIDA (IPC) Khmer HIV/AIDS NGO Alliance (KHANA) International HIV/AIDS Alliance in China (Alliance China) Alliance Nationale contre le SIDA en C�te d'Ivoire (ANS-CI) Promoteurs Objectif Zerosida (POZ) Tamil Nadu Social Service Society (TASSOS); South Indian AIDS Action Programme (SIAAP); MAMTA Health Institute for Mother and Child (MAMTA); International HIV/AIDS Alliance India (Alliance India); Network of Maharashtra People with HIV (NMP+); Humsafar; Palmyrah Workers Development Society (PWDS); Social Awareness Service Organisation (SASO) Rumah Cemara Kenya AIDS NGO Consortium (KANCO) Soins Infirmiers et D�veloppement Communautaire (SIDC-Helem-Liban) Malaysian AIDS Council (MAC) National AIDS Foundation (NAF) Association Marocaine de Solidarit� et D�veloppement (AMSED) Red Latinoamericana y del Caribe de personas Trans (RedLacTrans) Network on Ethics, Human Rights, Law, HIV/AIDS Prevention, Support and Care (NELA); Civil Society for HIV/AIDS in Nigeria (CiSHAN) Alliance Nationale Contre le SIDA (ANCS) International HIV/AIDS Alliance in Uganda (Alliance Uganda) International HIV/AIDS Alliance in Ukraine (Alliance Ukraine) Indonesia Kenya Lebanon Malaysia Mongolia Morocco Latin America and Caribbean Nigeria Senegal Uganda Ukraine APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV 3 executiVe summAry Gender and sexuality have long been recognised as key factors affecting the dynamics of the HIV epidemic. Issues vary across communities and countries, but power imbalances, harmful social norms, violence and marginalisation affect women, men, girls, boys and transgender people across the world, limiting their ability to prevent HIV infection. There are a growing number of HIV and broader health initiatives that not only highlight gender issues, but also aim to change harmful norms and practices. These are called `gender-transformative' approaches. However, there are few approaches to achieve gender transformation, and many organisations within and outside the Alliance have struggled to overcome the controversies, sensitivities and structural barriers that impede progress. In May 2010, we carried out a survey of our national Linking Organisations to map our current work; assess capacity, challenges and aspirations around gender and sexuality programming; and better understand the gender and sexuality context in which our partners work. Some 28 organisations from 19 countries responded. APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV 4 A mother and baby at Mukono Health Centre, Mukono district, uganda. the clinic has a prevention of mother-to-child transmission programme which is led by one nurse and several Network Support Agents. � Nell Freeman for the Alliance APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV 5 Key findings 1. Gender inequality and discrimination, fuelled by socio-cultural issues, are the most common gender concerns. Other concerns include barriers to accessing services; lack of gender-responsive programming; lack of attention to gender-related human rights, stigma and discrimination; lack of political leadership; lack of supportive legal frameworks; and the need to integrate gender within organisations. 2. Alliance partners have mixed opinions about how much national programmes respond to these gender-related challenges � ranging from partial support to active exclusion. Global Fund support has driven gender-related action even where national programmes are unsupportive. 3. Many respondents believe a gender and sexuality approach provides a useful way of understanding HIV work that is based on the roles and expectations that affect people's lives, choices and interactions (particularly in terms of sexual feelings, desires and behaviours). Others think it provides an insight into the driving forces behind women and men's differences and inequalities. 4. Alliance partners are involved in a wide range of work that is relevant to gender-transformative approaches. 82% of partners are taking actions at an organisational and programming level, 86% at individual, family and peer level, and 75% at community and service provider level. Over half (57%) are also carrying out actions at the policy and society level, with 12 partners (43%) taking action at all four levels. 5. Key challenges to gender and sexuality work include discriminatory gender norms and inequality; low male involvement in programming and interventions; limited access to education for women and girls; poor understanding or consensus on gender and sexuality; inadequate opportunities to share good practice; low funding levels; stigma and discrimination; and a lack of leadership, human resources, capacity and tools on gender and sexuality. 6. Only 25% of respondents feel they have the capacity to apply a gender and sexuality approach. The remaining 75% have limited capacity. The two most common capacity barriers are lack of donor funds for relevant initiatives, and lack of skilled staff and training. APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV 6 conclusions And recommendAtions The survey confirmed that Alliance partners are focusing significant efforts on gender and sexuality work. However, the comparatively low number of partners involved in policy and society-level advocacy means efforts may not always respond to the wider political and legislative environment. To make gender transformation a reality they will need to. There are also indications that, in some circumstances, partners may be less actively engaged in some of the more sensitive or complex aspects of comprehensive gender-transformative approaches. On the other hand, while capacity is clearly an issue, there is also an indication that some partners may be doing, or are already able to do more gender-transformative work than they think. There can be a false perception that a gender-transformative approach is a separate and highly specialised area that is distinct from the usual work of our partners. The survey did confirm that issues of gender and sexuality are seen to be inextricably linked with human rights. Individual responses indicate that some partners need greater clarity about what a gender-transformative approach encompasses � in practice as well as theory. To improve our work on gender and sexuality in the future, we should: 1. develop a gender strategy for Alliance partners 2. carry out a more specific assessment of the capacity needs of Alliance partners for gender-transformative approaches, and develop a plan to address these needs 3. document examples of good practice of gender-transformative approaches by Alliance partners working in generalised epidemics, concentrated epidemics, and mixed epidemics 4. ensure that gender transformation is fully integrated and addressed in the Alliance's existing and future work on good practice responses to HIV. APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV 7 Married man who has sex with men, India � Jenny Mathews/the Alliance/Photovoice APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV 8 section 1: introduction tHE GLOBAL CONtExt Why gender and sexuality matter Gender and sexuality � and their related norms and practices � have long been recognised as key factors affecting the dynamics of HIV and the global response to it.1 Gender inequalities fuel and exacerbate HIV epidemics. Although gender issues vary across communities and countries, power imbalances, harmful social norms, violence and marginalisation affect both women, men, girls and boys across the world.2 They increase people's vulnerability and limit their ability to prevent HIV infection.3 Half of all people living with HIV are female. However, in Sub-Saharan Africa, there are three young women living with HIV for every one young man.4 And in nearly every country in the region, the majority of HIV-positive people are females, especially those aged 15�24. Meanwhile, in other regions of the world, men are more likely to be infected with HIV than women, often within concentrated epidemics that disproportionately affect key populations, such as men who have sex with men, transgender people, people who use drugs and who have transactional sex. In Latin America and the Caribbean, for example, nearly three times as many men as women are HIV-positive, with transmission predominantly among men who have sex with men.5 However, the real gender picture is often more nuanced and complex than data indicate. For example, in some countries in the Caribbean, the majority of those living with HIV are female. Also, within the generalised epidemics of many Sub-Saharan Africa countries, men who have sex with men have a particularly high burden of HIV infection. But because of homophobia and the widespread criminalisation of homosexuality, national responses largely neglect same sex behaviour.6 Gender inequalities also have an impact on HIV-related care, treatment and mitigation. For example, while women and girls assume the bulk of care-giving for sick family members, there are indications that men who have sex with men and transgender people are less likely to access appropriate treatment and support services than other groups.7 To have the greatest impact on HIV, it is important that those in the HIV response take into account the full range and diversity of gender-related issues that affect individuals, communities and countries. For example, many men who have sex with men also have sex with female partners. Meanwhile, in Asia, a recent study highlighted that women are predominantly infected by their husbands or intimate partners � showing the need to better understand the complex relationships within some marriages and long-term partnerships.8 1. In this report, gender is defined to include men, women, boys, girls, men who have sex with men, women who have sex with women and transgender people. 2. UNAIDS (2010), `Report on the Global AIDS Epidemic 2010'. 3. UNAIDS (accessed 22.11.10), Gender, available at: www.who.int/gender/hiv_aids/en/ 4. UNAIDS (2010), `Report on the Global AIDS Epidemic 2010', available at: www.unaids.org/documents/20101123_GlobalReport_em.pdf 5. WHO, UNAIDS, UNICEF (2009), `Towards Universal Access: Scaling Up Priority HIV/AIDS Interventions in the Health Sector: 2009 Progress Report'. 6. UNAIDS (2010), `Report on the Global AIDS Epidemic 2010', available at: www.unaids.org/documents/20101123_GlobalReport_em.pdf 7. UNAIDS (2009), `UNAIDS Action Framework: Universal Access for Men who have Sex with Men and Transgender People'. 8. UNAIDS (2009), `HIV Transmission in Intimate Partner Relationships in Asia'. APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV 9 policy responses to gender and sexuality Gender lies at the heart of many of the political commitments made by the world's governments. For example, the Declaration of Commitment on HIV/AIDS9 and Political Declaration on HIV/AIDS10 acknowledge the need, within the framework of universal access, to challenge gender stereotypes, inequalities and discrimination relating to women, girls and vulnerable groups. Indicators to assess progress are also included in the national-level monitoring processes of the Universal Access framework established by the United Nations General Assembly Special Session on AIDS (UNGASS). Over the years, `women and AIDS' has been the subject of a number of global initiatives, including the Global Coalition on Women and Girls launched in 2004.11 More attention has also been paid to sexual minorities recently, as more concrete data has become available to provide an evidence base for how and why groups such as men who have sex with men, sex workers and transgender people experience heightened vulnerability and need to be strategic priorities for support.12 However, gender � as an umbrella term for policy and programme approaches � has also been the subject of intense debate. In particular, there have been tensions over its definition: whether it should refer solely to women and girls, or more comprehensively to women, girls, men and boys, and sexual minorities.13 Views on this have been influenced by a variety of factors. These include the different priorities of generalised HIV epidemics (where the mode of transmission is predominantly heterosexual intercourse and females are often disproportionately affected) and concentrated HIV epidemics (where the modes of transmission may be more varied and where key populations are often disproportionately affected). Some institutions have explicitly promoted a comprehensive understanding of, and commitment to gender. For example, gender equality is one of the three strategic directions of UNAIDS' 2011-15 strategy, with goals addressing both women and girls and sexual minorities.14 Also, while all of the priorities advocated in the UNAIDS Outcome Framework 200911 have gender dimensions, two specifically focus on gender commitments: `we can empower men who have sex with men, sex workers and transgender people to protect themselves from HIV and to full access antiretroviral therapy'; and `we can meet the HIV needs of women and girls and can stop sexual and genderbased violence'.15 The `how to' of these commitments is set out in resources including the UNAIDS Action Framework: Universal Access for Men who have Sex with Men and Transgender People16 and the Agenda for Accelerated Country Action for Women, Girls, Gender Equality and HIV (see Annex 4 for a summary of key points from both documents).17 Meanwhile, the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) has developed strategies on gender (focusing on women and girls) and sexual orientation and gender identities (focused on sexual minorities),18 aiming to achieve a positive bias in its allocation of funding. Gender has also been central to the policies of many other international donors. Agencies with policies or strategies prioritising genderrelated issues � such as the Canadian International Development Agency, Swedish International Development Cooperation Agency, UK Department for International Development and United States Agency for International Development � often require that organisations not only articulate their commitment to gender-sensitivity, but demonstrate how they will implement it through their work. 9. United Nations General Assembly (2001), `Declaration of Commitment on HIV/AIDS'. 10. United Nations General Assembly (2006), `Political Declaration on HIV/AIDS'. 11. A worldwide alliance of civil society organisations, networks of women living with HIV, women's organisations, AIDS service organisations and the United Nations system, committed to strengthening HIV programming for women and girls. Global Coalition on Women and AIDS (accessed 22.11.10), available at: www.womenandaids.net/News-and-Media-Centre/Latest-News/UNAIDS-takes-action-to-empower-women-and-girls-to-.aspx. 12. WHO, UNAIDS, UNICEF (2009), `Towards Universal Access: Scaling Up Priority HIV/AIDS Interventions in the Health Sector: 2009 Progress Report'. 13. See documents relating to 22nd Meeting of the Programme Coordinating Board April 2008, UNAIDS. Available at: www.unaids.org/en/AboutUNAIDS/ Governance/PCBArchive/22nd_PCB_Meeting_April_2008.asp 14. UNAIDS (2010), `UNAIDS Strategy 2011-2015'. 15. UNAIDS (2010), `Joint Action for Results: UNAIDS Outcome Framework 2009-11'. 16. UNAIDS (2009), `UNAIDS Action Framework: Universal Access for Men who have Sex with Men and Transgender People'. 17. UNAIDS (2010), `Agenda for Accelerated Country Action for Women, Girls, Gender Equality and HIV: Operational Plan for the UNAIDS Action Framework: Addressing Women, Girls, Gender Equality and HIV'. 18. The Global Fund to Fight AIDS, Tuberculosis and Malaria (2009), `The Global Fund Gender Equality Strategy' and `The Global Fund Strategy in Relation to Sexual Orientation and Gender Identities'. APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV 10 These donor priorities are informed by the Millennium Development Goals and wider trends within global funding and the architecture of health and health systems. Broadly speaking, the latter presents both an opportunity and threat to gender-related initiatives. Increased attention to the linkages between HIV and sexual and reproductive health and rights (SRHR) is a critical opportunity to address the full needs of women, girls and sexual minorities.19 But broader and more mainstream national responses to health could threaten support to and involvement of marginalised groups, such as men who have sex with men and transgender people. Meanwhile, there are also challenges within the legal context of gender and sexuality-related responses to HIV. For example, many countries lack adequately comprehensive laws against gender-based violence, and in others there are concerns about a wave of new legislation against homosexuality and sex between men.20 due to the obstacles that make this kind of approach hard to put into action. In particular, entrenched structural barriers (such as cultural norms and legal restrictions) remain an immense impediment to progress. There are few quick fixes, with action needing significant time, skills and creativity. Furthermore, while the comprehensive definition of gender promoted by the Alliance and some other organisations will likely produce greater and more sustainable results in the longer term, initially it can make the design and implementation of programmes more complex and challenging. tHE ALLIANCE CONtExt Since its establishment in 1993, there has been a significant awareness of and commitment to gender and sexuality issues within the Alliance. However, to date, the Alliance has not articulated a formal gender strategy, nor systematically implemented approaches or standards across its programming. The Alliance's international board, donors, and an external evaluation have all highlighted the need to address this gap. The Alliance's strategy for 2010-12 (HIV and Healthy Communities)21 provides firm foundations for a gender and sexuality strategy. It clearly articulates the need to build on work to date and adopt a gendertransformative approach (see Box 2 for an Alliance definition). Gender issues are referred to throughout the strategy's three aims and four strategic responses. Of note, Aim 1 (protect human rights) commits to action on gender inequality and promotes a comprehensive gender-transformative approach addressing women, men, girls and boys, including those perceived to transgress gender norms, such as men who have sex with men, women who have sex with women, sex workers, unmarried sexually active women and transgender people. Also of note, Strategic Response 1 (scale up integrated programming) outlines different ways to work on gender equality and the human rights of sexual minorities within generalised and concentrated epidemics. programmatic responses to gender and sexuality There are also a growing number of HIV initiatives that have built on, and moved beyond earlier `women and girls', `gender mainstreaming' and `gender sensitive' approaches. These not only highlight gender-related issues, but actually aim to change harmful norms and practices. Examples of such `gender-transformative' approaches include the Stepping Stones toolkit (developed by Strategies for Hope), the Men as Partners programme (developed by Engenderhealth), Programme M (developed by Promundo), the One Man Can campaign (developed by Sonke Gender Justice), and the Frontiers Prevention Programme (developed by the International HIV/AIDS Alliance). (See Annex 1 for brief descriptions of these approaches). While each of these examples responds to their specific context, they also share a number of common characteristics (see Box 1). However, many organisations across the world have struggled with the very real challenges of gender and sexuality work, particularly in terms of achieving transformation. In some contexts, this has been because of a lack of understanding about the importance of gender issues, or fear of the associated controversies and sensitivities. In others, it has been 19. Global AIDS Alliance, International HIV/AIDS Alliance, Interact Worldwide, Population Action International, International Planned Parenthood Federation and Friends of the Global Fund Africa (2010), Make or Break: 2010: A Pivotal Year for Scaling Up RH/HIV Integration and Accelerating Progress Towards MDGs 5 and 6. 20. Please refer to International HIV/AIDS Alliance (2010), `Advancing human rights, responding to HIV: Report on the findings of a human rights survey among Alliance partners' for more information. 21. International HIV/AIDS Alliance (2010), `HIV and Healthy Communities: Strategy 2010-2012'. APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV 11 BOx 1: gender-transformative approaches � characteristics of good practice gender-transformative programmes: 4 recognise that gender issues are influenced by and relevant to men and boys, women and girls, and transgender people 4 actively involve and provide constructive roles for all these groups 4 use a comprehensive definition of gender, recognising the full diversity of identities and practices 4 address a comprehensive range of issues, norms and practices that shape gender relations and dynamics, and affect people's health, well-being and vulnerability. This particularly includes issues that may be sensitive or controversial, such as gender-based violence and sexual diversity 4 use diverse, creative and context-appropriate methods to engage and mobilise participants 4 empower communities � enabling participants to identify their own gender issues, discuss them together, and identify ways to change harmful practices 4 create safe spaces to enable community members to talk openly and freely 4 complement programmatic work with advocacy � or links to advocacy initiatives � to address structural barriers to gender transformation 4 complement community mobilisation with providing or referring to HIV and gender services 4 build cross-sectoral action on gender, for example involving community gatekeepers and decision-makers 4 promote gender transformation within organisations and among people that provide services and programmes, through training of NGO staff and health workers. BOx 2: definition of a gender-transformative approach An approach that engages people in changing harmful gender norms, both of masculinity and femininity, which shape and limit individuals' autonomy and capacity, and are key to understanding and addressing HIV risk, vulnerability and effective HIV prevention. The approach engages men and women separately and together, according to local circumstance, and addresses violence, coercion and abuse of all those who are perceived to challenge or transgress gender norms. It addresses both gender inequality and the specific vulnerabilities of men and boys such as sexual coercion between men and boys, sex in prison settings and the legal status of sex between men." HIV and Healthy Communities: Strategy 2010-12, International HIV/AIDS Alliance APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV 12 SuRVEy PuRPOSE, MEtHOdS ANd PARtICIPANtS In May 2010, the Alliance undertook a survey among its national Linking Organisations and other country partners.22 The survey aimed to: n SuRVEy LIMItAtIONS There are a number of limitations to this survey. In particular, the use of open-ended questions means that the results provide a brief overview of partners' work and issues relating to gender and sexuality, rather than a systematic, quantitative assessment. For example, partners were asked to comment on `What gender and sexuality work does your organisation do?' and not given a list of types of work from which to select. Because of this, although a partner may not have mentioned a type of work, it does not necessarily mean that they are not carrying it out. Another limitation of the survey was that about a third of responses (9 of 28) were from one country (India). map current Alliance work, capacity, challenges and aspirations around gender and sexuality programming better understand the gender and sexuality context in which partners work. n It included two introductory and 11 open-ended questions (see Annex 2). Some 28 organisations from 19 countries responded (see Table 1).23 This report presents a synthesis of the responses24 and uses the Alliance's Good Practice HIV Programming Standards as a reference point for analysis. It also uses case studies to highlight partners' work and provides observations and recommendations for improving future action. table 1: survey participants region Asia and Eastern Europe Africa Latin America and Caribbean total countries 8 8 3 partners 16 9 3 19 28 22. The Alliance works with nationally based Linking Organisations (that develop and support the capacity of community organisations) and other partners, for example those that work with specific populations, such as men who have sex with men. In this report, Linking Organisations and other partners are referred to collectively as `partners'. 23. Responses were received from two Alliance partners in Nigeria and nine in India. This is why the number of partners included in the survey is greater than the number of countries. 24. A total of 30 people from the 28 organisations participated in the survey. However, in this report, percentages are taken from the total number of organisations, not individuals that participated. APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV 13 HIV and health discussion group for teenage girls run by Alliance Nationale Contre le SIdA, Senegal. � 2007 Nell Freeman for the Alliance teacher Helvina Phiri, distributes text books on sexuality and life skills to her class at Chiwoko Basic School, one of the schools agreeing to be a pilot centre for including sexuality and life skills as a regular subject on the academic curriculum, Zambia. � 2006 Nell Freeman for the Alliance APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV 14 section 2: findings patriarchal societies, while other partners noted specific socio-cultural issues. For example, Soins Infirmiers et D�veloppement Communautaire (SIDC-Helem-Liban, Lebanon) cited gender-based violence and Palmyrah Workers Development Society (PWDS, India) cited early marriage and sexual exploitation. Other examples of major issues included: n WHAt ARE tHE MOSt IMPORtANt GENdER CONCERNS? gender and sexuality concerns Survey respondents were asked to identify the most important gender and sexuality concerns in their country; a range of themes emerged. n Gender inequality and discrimination were the most commonly cited concerns, fuelled by sociocultural issues affecting women, girls and sexual minorities, such as men who have sex with men, sex workers and transgender people. The Kenya AIDS NGO Consortium (KANCO) articulated how gender issues are culturally constructed through religious and conservative norms. These leave women unable to fulfil their rights and drive key populations underground � making it harder to reach these priority groups. Rumah Cemara (Indonesia), Civil Society for HIV/AIDS in Nigeria (CiSHAN) and the Network of Maharashtra People with HIV (NMP+, India) also described the challenging impacts of Barriers to accessing services. International HIV/AIDS Alliance in Ukraine (Alliance Ukraine) stated that a wide range of gender-related issues (such as male dominance, gender-based violence and women's low access to information) restrict women's uptake of services and commodities. Lack of gender-responsive programming. The Malaysian AIDS Council (MAC) noted the need for programmes to address the specific gender-related issues of local HIV epidemics. In Malaysia this is within a context where women are predominantly infected through heterosexual intercourse and men through drug use. This need was echoed by Alliance Ukraine, which called for responses to address the n BOx 3: gender concerns, Bolivia The social construction of gender determines different paradigms of masculinity or femininity. There are families and communities in Bolivia that tolerate, encourage and shape the patterns of machista sexual behaviour, while women are valued for their passivity, submission and self-marginalisation. Women do not have access to information about reducing risks and even when informed, they cannot negotiate condom use. As a result, Bolivia continues to pass on these standards and values that encourage the transmission of HIV. The inequalities are closely related to attitudes toward women that translate into subordination, oppression and exploitation. These attitudes are determined by domestic violence, humiliation, physical and sexual abuse. Various cultural aspects, myths and even jokes determine behaviour that conveys a lack of respect for the dignity of women." Instituto de Desarrollo Humano, Bolivia APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV 15 specific vulnerabilities of women and other groups, as well as to mainstream a gender-transformative approach and improve the measurement of genderrelated results. Meanwhile, Association Marocaine de Solidarit� et D�veloppement (AMSED, Morocco) noted challenges in developing appropriate, rightsbased programming approaches that respond to stigma and discrimination and gender-based violence. n proposed anti-homosexuality bill was a major issue for the International HIV/AIDS Alliance in Uganda (Alliance Uganda). n The need to integrate gender within organisations. AMSED identified the need to integrate gender into all levels of its own organisation, including in planning, programming and budgeting. Lack of attention to gender-related human rights, and action on stigma and discrimination. Partners such as HIV/AIDS and STD Alliance Bangladesh (HASAB) emphasised that more efforts are needed on the ground to promote the rights of key populations, such as sex workers, men who have sex with men and transgender people. International HIV/AIDS Alliance in China (Alliance China) felt that action is also needed on stigma and discrimination, which currently drives marginalised groups such as men who have sex with men underground. Lack of political leadership on gender. MAC (Malaysia) called for stronger national leadership on gender and sexuality issues. Lack of supportive legal frameworks for gender work. The need for, or lack of, a supportive legislative environment for gender and sexualityrelated work was noted by partners in countries as varied as Kenya and Lebanon. Rumah Cemara, South Indian AIDS Action Programme (SIAAP) and Initiative Priv�e et Communautaire de Lutte Contre le SIDA (IPC, Burkina Faso) highlighted concerns about legislation against vulnerable groups, such as sex workers. At the time of completing the survey, a gender issues in national hiV responses When asked how much national programmes respond to these gender-related challenges, Alliance partners again had mixed opinions. Many partners indicated gender issues were included to some degree in national HIV responses, in countries including Cambodia, China, India, Kenya, Malaysia, Mongolia, Morocco and Nigeria. For example, in Morocco the National AIDS Strategic Plan articulates commitment to universal access, with guiding principles focused on equality, confidentiality, human rights and combating stigma and discrimination. In Malaysia the National Strategic Plan on HIV/AIDS commits to reducing vulnerability among women living with HIV, female partners of people who use drugs, and women in the general population. Two Alliance partners, National AIDS Foundation (NAF, Mongolia) and Alliance Ukraine, specifically noted how gender-related action in their country has expanded through support from the Global Fund. For example, in Ukraine, while the national strategy on HIV is not oriented towards gender, Global Fund programmes have allowed attention to be focused on relevant n n BOx 4: Viewpoint on gender and political leadership Strategies to reverse the HIV epidemic cannot succeed unless continued political leadership is embraced and women and girls are empowered. The government must utilise resources to address the needs and realities of women and girls. These resources must be made available where they are most needed, in programmes for women and girls affected by HIV and AIDS. There should be more gender-specific HIV programmes and interventions which take into account the dual nature of the epidemic in Malaysia, whereupon currently women are getting infected through heterosexual transmission while men acquire HIV through injecting drug use ... The multifaceted nature of women and HIV requires the deeper involvement of other ministries and the establishing of wider networks of multi-sectoral collaboration. Without recognition of this urgency, leadership, political will and commitment, the situation for women and girls will continue to deteriorate and the female proportion of the Malaysian epidemic will increase." Malaysia AIDS Council, Malaysia APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV 16 gender issues. Other partners noted that action on gender is being incorporated into the roll-out of national strategies. In China, for example, project management partners, such as government agencies, increasingly invite men who have sex with men to participate in programmes. In Bangladesh, there are national programmes that support sex workers, men who have sex with men and transgender people. Overall, however, many partners qualified their positive feedback on the national response. For example, KANCO felt that, although included in Kenya's national strategy, attention to gender is inadequate. Similarly, Alliance Nationale contre le SIDA en C�te d'Ivoire (ANSCI) felt that their country "could do more" � a sentiment reflected by both the Network on Ethics, Human Rights, Law, HIV/AIDS Prevention, Support and Care (NELA) and CiSHAN in Nigeria, with the latter calling for a systematic review of how policies and programmes could better address gender. MAC noted how a lack of available and disaggregated data � and the resulting lack of analysis and evidence on gender and sexuality � poses a major barrier to a clear understanding of the complex context in Malaysia and the development of appropriate programmes to reduce vulnerability. A range of Alliance partners from India felt that attention to gender is inadequate within their national response. Here, programmes tend to be diseasefocused (rather than oriented towards areas such as empowerment and human rights) and there is an urgent need for more widespread `gender mainstreaming', including in programme areas such as women's and adolescents' health. Another group of Alliance partners, in countries such as Bolivia and Uganda, were more negative and reported the exclusion of gender from national HIV responses. Promoteurs Objectif Zerosida (POZ, Haiti) stated that gender is only addressed in initiatives by the Ministry of the Status of Women, while IPC felt that, despite progress in some programmes, the national response remains shaped by what is "morally acceptable", rather than human rights. RedLacTrans (Latin America and Caribbean) commented that national programmes are often centred on the vertical transmission of HIV, while Rumah Cemara noted the lack of a national programme directly related to gender equality. Meanwhile, SIDC-Helem-Liban reported that, although there are no specific national strategies on the subject, recognition and respect of gender-related issues is incorporated into the development of HIV interventions. WHAt IS A GENdER ANd SExuALIty APPROACH tO HIV? A number of themes emerged from answers to the question: `What is meant by a gender and sexuality approach to HIV?' A common view � among partners in countries such as India, Malaysia and Uganda � is that such an approach provides a way of understanding HIV work that is based on roles and expectations that affect people's lives, choices and interactions (particularly in terms of sexual feelings, desires and behaviours). While perhaps related to biological differences, these roles and expectations are generated and affirmed by societal, cultural, economic and political factors. Several partners, such as Alliance Uganda, MAMTA Health Institute for Mother and Child (MAMTA, India) and AMSED (Morocco), emphasised that a gender and sexuality approach provides an insight into the driving forces behind the differences and inequalities of males and females within a specific context. In turn, these forces affect an individual's vulnerability and risk, as well as their access to services and ability to fulfil their human rights. IPC (Burkina Faso) concluded that gender and sexuality is a complete approach that takes on board all of the issues that affect HIV. BOx 5: Viewpoint on gender and sexuality approach A gender and sexuality approach to HIV in our work involves improved coverage of issues linked to gender and sexuality when designing new policies and programmes to combat HIV. In other words, for stakeholders in the fight against AIDS it involves placing emphasis on the needs of women and on minority groups (sexual and social) during planning exercises and when designing policies." Alliance Nationale Contre le SIDA, Senegal APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV 17 In some cases, definitions reflected different areas of emphasis. Some partners in Africa (such as NELA and CISHAN in Nigeria and ANS-CI in C�te d'Ivoire) spoke almost exclusively of the need to address women's rights and access to services (within the context of epidemics where the most frequent mode of transmission is heterosexual sex). However, other partners, such as Alliance China and Rumah Cemara (Indonesia) � both working within an Asian context of concentrated epidemics � emphasised that there is also a need to address issues relating to key populations, such as men who have sex with men and sex workers. The need for a comprehensive approach was cited by Alliance India � where the national context requires attention to both the increasing feminisation of the epidemic and heightened prevalence among men who have sex with men and transgender people. Some partners included specific issues in their definitions. NELA (Nigeria) and NAF (Mongolia) emphasised attention to gender-based violence, while SIDC-Helem-Liban, (Lebanon) and NMP+ and MAMTA (both India) emphasised gender inequalities relating to people living with HIV, especially women. Alliance China articulated the need to look at specific issues around men who have sex with men, female sex workers and women that use drugs, while SIAPP (India) noted the need to design programmes to address the specific gender and sexuality issues of transgender people. While some partners focused on a more theoretical definition of gender and sexuality, others, such as HASAB (Bangladesh) and NAF (Mongolia), articulated that such an approach must be put into practice in programme and policy work. AMSED (Morocco) explained that the approach is about understanding gender-related inequalities and risks and how they relate to HIV, and then using that understanding to design interventions that reduce inequalities and combat HIV. SASO (India) argued that an understanding of gender and sexuality is inseparable from an effective response to HIV. KANCO (Kenya) saw the approach involving a set of components, from mainstreaming gender and sexuality into HIV programming, to making the concerns of both men and women integral to the design, implementation, monitoring and evaluation of all programmes. Some partners indicated the need to move beyond gender sensitivity towards a gender-transformative approach. For example, HASAB (Bangladesh) specified that interventions to address gender inequality must not only empower women, but also men, by challenging traditional ideas of masculinity and building genderequitable relationships. KANCO (Kenya), as well as other partners including NAF and RedLACTrans (see Case study 1), emphasised that a gender and sexuality approach is also about policy and advocacy work to address legislative and policy barriers. CASE Study 1 Red Latinoamericana y del Caribe de Personas Trans (RedLacTrans) is a regional network of transgender people covering 16 countries in Latin America and the Caribbean. It was set up to disseminate information, take action and provide a platform for reporting human rights abuses affecting transgender people. In 2008, the network's policy and advocacy work with heads of government and civil servants working on health, led to greater representation of transgender people in regional decision-making forums. It also influenced policies to raise their visibility and integrate their priorities into health policy and legal reform. In Guatemala, RedLacTrans and local organisation Reinas de la Noche used the media to publicise murders and NEtWORKING FOR GENdER-tRANSFORMAtIVE AdVOCACy IN LAtIN AMERICA ANd tHE CARIBBEAN disappearances of transgender people and participated in a national demonstration to stop violence against women. However, this made the situation worse. As Johana, Director of RedLacTrans, describes: "As a result of those actions, there were more attacks, more threats. I was attacked and someone tried to kill me." This illustrated that, when hate and violence originate in the police force and a public ministry, it is difficult to protest for justice. Now, transgender organisations go to the Office of Human Rights to denounce and publicise hate crimes. RedLacTrans are also working to gain a hearing before the Inter-American Court of Human Rights to apply pressure internationally. APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV 18 WHAt GENdER ANd SExuALIty WORK ARE WE dOING? Alliance good practice hiV programming standards In June 2010, the Alliance released its Good Practice HIV Programming Standards to guide the design, implementation and evaluation of Alliance programmes25 (see Annex 3 for further details). The standards relate to seven programme areas:26 1. human rights and greater involvement of people living with HIV (GIPA) 2. research, evaluation and documentation 3. HIV prevention 4. integration of sexual and reproductive health, HIV and rights 5. HIV and tuberculosis 6. HIV programming for children 7. HIV and drug use. Each programme area includes a number of agreed standards, which are measurable and evidence-based benchmarks' of quality. For each standard, there is a description of what it means and what evidence supports it, alongside suggested implementation actions, markers of progress and a list of relevant resources and research. The standards provide a framework for examining the extent to which the Alliance's gender-related work correlates with good practice and, in turn, identifying what support might be need to enable organisations to fulfil these standards. The following section focuses on standard 3.9, which explicitly addresses a gendertransformative approach, while also briefly reviewing examples of other relevant standards. In this report, to enable a broad exploration of gendertransformative approaches, standard 3.9 is interpreted to address HIV prevention and care, support and treatment. Responses to the survey question: `What gender and sexuality work does your organisation do?', are mapped against the four groups of implementation actions described for 3.9 in the programming standards (see Table 2). organisational and programming level actions (implementation actions group 1) 82% of the 28 partners indicated that they are carrying out one or more of the organisational and programming level implementation actions for standard 3.9 (as listed in table 2). These include actions to integrate gender analysis into organisational planning, programming and assessments; collect and analyse gender disaggregated data; assess and build organisational capacity in gender; and incorporate a gender-transformative approach into existing and future HIV programmes. A number of partners indicated that their organisational strategies have been informed through some type of gender analysis. CiSHAN (Nigeria) uses such an analysis to explore differences in sex-disaggregated information, so that its policies, programmes and projects identify and meet the different needs of men and women. For AMSED (Morocco), integrating a gender approach was one of the key recommendations of a knowledge, attitudes and practices study on illiterate girls and women, sexually transmitted infections (STIs) and HIV prevention. This led to AMSED's programmatic focus on illiterate girls and women and sex workers. Meanwhile, MAC (Malaysia) based its strategy on the government's National Strategic Plan for HIV, informed by the national epidemiology and context, and characterised by strong gender inequity. MAC focuses on supporting women living with HIV, the female partners of people who use drugs, and women in the general population. IPC (Burkina Faso) has used information on the country's epidemiological situation to explore issues of vulnerability and identify the strategic direction for its programming � the integration of gender and SRHR. The IPC's values and principles promote equal rights for all and are central to its planning and implementation Alliance good practice standard on gendertransformative approaches programme area 3. hiV prevention good practice standard 3.9 our organisation uses a gender-transformative approach to hiV prevention 25. The Alliance was a lead organisation in the development of the `Code of Good Practice for NGOs Responding to HIV' (2004) and has endorsed the code. The programming standards reflect the Alliance's commitment to implementing the code. 26. Treatment and care standards are being developed and will be incorporated at a later date. APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV 19 table 2: percentage of Alliance partners reporting at least one implementation action relevant to using a gender-transformative approach groups of implementation actions for Alliance good practice hiV programming standard 3.9: `our organisation uses a gender-transformative approach to hiV prevention' implementation actions group 1: organisational and programming level actions > Integrate gender analysis into the planning and programming cycle of the organisation and incorporate gender-related issues into participatory community assessments. > Collect and analyse programme-related data and indicators disaggregated by sex, age and other equity parameters. Embed them in the organisational monitoring and evaluation system. > Assess and build the organisational capacity needed to understand and address links between gender inequalities and HIV. > Incorporate a gender-transformative approach into existing and future HIV prevention programmes. % of partners 82% implementation actions group 2: individual, family and peer level actions > Engage people of all gender identities, separately and together (including those living with HIV), in HIV prevention programmes; improve the quality of relations between them and integrate gender into behaviour change communication interventions and materials. > Provide people of any gender identity who are especially vulnerable or at risk of HIV/violence with safe, supportive and nonjudgmental spaces (or refer them to such spaces). > Strengthen mechanisms for documenting, reporting and responding to gender-based violence and other rights abuses. > Empower people of all gender identities to have more control over sexual decision-making and risk reduction, by building their skills and providing them with, or referring them to livelihood support services that address socio-economic inequalities. > take a family-centred approach and work with families to create a home environment that helps change gender and social norms (men as caregivers, for example). this can be done through behaviour change communication, skills-building, and livelihood interventions that empower families (particularly women) to access financial and other resources. > Change group norms through educational activities and increase peer support for positive gender norms. 86% implementation actions group 3: community and service provider level actions > Engage community leaders in educational activities, campaigns and the media to challenge harmful gender norms. > Mobilise communities through outreach, information, education and participatory interventions. > Make local environments safer in cooperation with local communities. > train and sensitise health care workers, police, prison and other key service staff to provide services that are nondiscriminatory and sensitive to of the needs of people of all gender identities. > Provide people with, or refer them to health, social, legal and other services that are inclusive of people of any gender identity or sexual orientation. 75% implementation actions group 4: policy and society level actions Advocate for: > Equitable access to HIV and HIV-related/integrated services for people of any gender identity or sexual orientation. > Protection against gender-based violence, coercion and abuse, especially for those perceived to challenge or transgress gender and sexuality norms. > Change policies, laws or customs that limit the power and autonomy of women, that prescribe traditional or limiting definitions of masculinity, femininity and other gender identities, and that affect property and inheritance rights and access to education. > Find allies (such as human rights organisations, women's organisations and community networks, among others) and build their capacity to make links between HIV, human rights and gender. > Prioritise needs in situations of conflict, war and displacement. > Ensure that gender-transformative interventions reflect the diversity of gender identity and sexual orientation and address their specific and changing needs. For example, promote critical thinking about gender identity and adolescents' roles through information, education, special events, and campaigns; engage men in maternal and child health, prevention of mother-to-child HIV transmission, and violence prevention strategies; make women part of male circumcision programmes. > Pay special attention to people most at risk of HIV infection, such as discordant couples, families and individuals affected by HIV, adults and young people in concurrent and inter-generational sexual relations, and transgender women. 57% APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV 20 processes, as well as its approach to monitoring and evaluation. Similarly, Alliance Nationale Contre le SIDA (ANCS, Senegal) responded to its national context � characterised by the feminisation of the epidemic and heightened prevalence among key populations � by developing a dual strategy that addresses women and sexual minorities, particularly men who have sex with men and sex workers. Examples of ANCS' strategies to address gender-related issues within these populations include: mobilisation and sensitisation; reduction of stigma and discrimination; promotion of prevention of mother-to-child transmission services; distribution of male and female condoms; increased access to HIV testing and counselling; and group discussions. Alliance partners have also supported nongovernmental organisations (NGOs) and communitybased organisations (CBOs) to base their work on an analysis of their gender environment. For example, Alliance China supported a group of men who have sex with men in Kaiyuan City, Yunnan, to include issues about gender and sexuality in a participatory community assessment. This was followed up by involving the men in the design and implementation of the project, with intensive mentoring about programming approaches. Similarly, some other partners indicated that they have collected and analysed data and indicators disaggregated by sex, age and other equity factors. KANCO (Kenya) carried out an audit of the level of gender mainstreaming among its member organisations, alongside a baseline study of HIV-related gender and human rights-related violations in communities. The findings of both were critical to defining the organisation's programmes and advocacy. Some partners also specified steps that they have taken to assess and build their own organisational capacity on gender. For Alliance Ukraine, these have included observing gender equity in recruitment processes; providing training for staff; keeping staff up-to-date on gender issues; doing research into gender and sexuality; re-programming, with the support of the United Nations Development Programme and Open Society Institute; and developing gender-sensitive targeted information materials (on women and girls and men and boys). AMSED (Morocco) has also provided its staff with training on gender and sexuality, focused on stigma and discrimination, as has NMP+ (India). A large number of partners � such as Alliance Uganda, IPC (Burkina Faso) and KANCO (Kenya) � noted that they provide capacity building on gender for the NGOs APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV and CBOs that they support. Specific examples include: n RedLacTrans provides workshops for transgender people addressing issues such as gender identity SIAAP (India) integrates detailed information on gender and sexuality into training on areas such as counselling for NGOs and CBOs working with sex workers and gay and bisexual men AMSED (Morocco) provides capacity building on issues relating to HIV prevention and violence for projects with sex workers Alliance Ukraine combines gender-related training with the provision of information and materials to partners. n n n The capacity building work of SIDC-Helem-Liban (Lebanon) has included: training groups of young people on gender, sexuality and HIV; integrating gender into education and prevention work; and building the capacity of women living with HIV to care for themselves. MAMTA (India) � which has gender, sexuality and human rights as cross-cutting issues within its programme � complements its capacity building of NGOs and CBOs by developing materials and manuals (such as on sexuality education and gender training); creating a pool of national and international resources; and facilitating a network of 134 NGOs across seven Indian states focusing on young people and sexual and reproductive health (SRH). Meanwhile, Alliance China has, since 2005, funded a programme to support HIV-positive women. This combines capacity building with involvement in project design, implementation and management. Finally, although the Alliance survey did not specifically ask respondents to define or describe a gendertransformative approach, there were indications of relevant strategies being used. For example, through support from the Global Fund, NAF (Mongolia) supports prevention programmes for key populations, such as sex workers, men who have sex with men, mobile populations, miners and people who use drugs. Through capacity building and training, it covers a range of issues from sexual orientation to safer sex and reproductive health. Similarly, Instituto de Desarrollo Humano (IDH, Bolivia) incorporates gender and sexuality in its prevention programming, for example working with parents to raise their understanding about issues of sexuality. For IDH � as for the Khmer HIV/AIDS NGO Alliance (KHANA) in Cambodia (see Case study 2) � organisational commitment to gender and transformative approaches has led to the development of comprehensive organisational strategies and policies. CASE Study 2 dEVELOPING AN ORGANISAtIONAL StRAtEGy ON GENdER, SExuALIty ANd dIVERSIty IN CAMBOdIA In 2010, KHANA � the largest national HIV NGO in Cambodia, supporting approximately 70 local organisations � developed a gender, sexuality and diversity strategy. This was based on a rapid assessment commissioned by the senior management team to identify gender-related gaps and issues in programming, institutional culture and organisational practice. The assessment took a broad approach to gender, addressing the range of socially constructed roles and relationships, personality traits, attitudes, behaviours, values, powers and influence that society ascribes to women and men. The gender strategy commits KHANA to organisational policy, planning and programmes that will: > be informed by comprehensive gender and sexuality analysis and data disaggregated by sex, age and other relevant diversity factors > mainstream gender and sexuality into every stage of planning, implementation, monitoring and evaluation > ensure sufficient funding and technical resources are available to build gender and sexuality mainstreaming capacity and change attitudes to gender equality and human rights within KHANA and its implementing partners > promote gender equality and human rights for all > promote diversity and the meaningful involvement of people living with and affected by HIV within KHANA, its implementing partners and the national response to HIV > actively address homophobia, sexual discrimination, harassment and inequality within the organisation through a code of conduct, awareness-raising and accountability systems > address systemic practices that create barriers to reducing the vulnerability of women and girls to HIV, including gender-based violence and sexual exploitation and abuse > actively involve men and boys as allies in promoting gender equality and meeting the practical and strategic gender needs of women > engage and coordinate with partners, governments, funders and civil society organisations to promote and support effective, creative ways to promote gender equality > monitor, evaluate and institutionalise organisational learning on mainstreaming gender into communitybased HIV programmes > ensure budgeting, recruitment, training, management, and decision-making systems support women's rights and gender equality. The strategy focuses on both internal and external actions, based on four objectives. 1. Creating an enabling internal environment that promotes diversity and equality of opportunity regardless of gender, sexuality or HIV status and supports staff to contribute fully. Key activities include: having family-friendly workplace policies; increasing KHANA's ability to recruit and promote female staff; awareness-raising, leadership and role modelling from the senior management team on diversity and equality of opportunity; and addressing gender norms that discourage women from applying for promotion. 2. Integrating gender analysis and mainstreaming throughout the programming cycle, i.e. during needs assessment and planning, contracting and technical support to implementing partners, service delivery and monitoring and evaluation. Key activities include: raising awareness of gender inequality and its impact on HIV vulnerability; building capacity for gender and sexuality mainstreaming; addressing gender and sexuality norms and inequality in HIV prevention programming; and generating and disseminating the information needed to support gender mainstreaming. 3. Advocacy to promote, protect and realise the rights of women, men, transgender people and children to prevent and mitigate the genderbased vulnerabilities to and impacts of HIV. Key activities include: advocacy within KHANA and implementing partners; and advocacy around national programming and policy. 4. Empowering people living with or affected by HIV, and most at risk populations, to minimise their vulnerability to HIV infection and mitigate the gender-based impacts of HIV. Key activities include: working with other organisations that have empowerment programmes and expertise; and providing people with the knowledge, skills and opportunities they need to empower themselves. The gender strategy includes an indicative work plan, with key actions accompanied by short, medium and long-term indicators. The strategy also fed into KHANA's annual replanning process. The draft strategy was presented to the KHANA board of directors in April 2010 and informally endorsed. APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV 21 22 individual, family and peer level actions (implementation actions group 2) 86% of partners indicated that they are carrying out one or more of the individual, family and peer level implementation actions for standard 3.9 (as listed in table 2). These include actions such as engaging people of all gender identities in programmes; providing people with safe spaces; documenting or responding to gender-based violence and other human rights abuses; empowering people to have control over their sexual decision-making and risk reduction; taking a familycentred approach to changing gender norms; and changing group norms through educational activities and peer support. The survey confirmed that Alliance partners support gender and sexuality-related work among a range of different types of communities (see Box 6). Examples of relevant actions include those of AMSED (Morocco) which builds the capacity of sex workers to negotiate condom use, alongside HIV prevention awarenessraising among their clients. MAC (Malaysia) is targeting its efforts to empower women in the general population, women living with HIV, and female partners of people who use drugs. It combines providing shelters with outreach, workshops, awareness-raising and peer support (see Case study 3). A small number of partners, including TASSOS (India), described efforts to address issues of gender-based violence. Meanwhile, educational activities were cited by Hamsafar (India) which organises workshops on sexuality in schools and colleges. Rumah Cemara (Indonesia) described its peer support approach among different types of people living with HIV in West Java, including men who have sex with men, transgender people, women, sex workers and people who use drugs. The work involves providing information and condoms, as well as increasing access to services, such as treatment of STIs and voluntary counselling and testing. A meeting of the peer support group for people living with HIV is held every three months. The work has helped to achieve unity among different groups in the region and to support people living with HIV to work with the AIDS Commission and be involved in programmes. Meanwhile, peer support relating to gender was also cited by NMP+ (India). Through its targeted prevention programmes, ANSCI (C�te d'Ivoire) enables women to better discuss and negotiate condom use during transactional sex. The voluntary counselling and testing centres that it supports also collaborate with youth centres, which carry out activities related to gender and sexuality. NELA (Nigeria) provided an illustration of what its gender-related work means for an individual woman. Their work includes attention to economic support, women's empowerment and information on HIV, STIs and family planning. They described how a client had been maltreated by her husband and was referred to a NELA clinic from the nearby primary health care centre. Both the woman and her husband were given counselling, but he continued to neglect her and refused to give support. NELA helped the woman set up an income generating project which enabled her to feed herself and her baby. On seeing his wife healthy and doing well, the husband apologised to her. BOx 6: communities we work with Among the 28 Alliance partners responding to the survey, 82% work with sex workers, 79% with men who have sex with men, 39% with people who use drugs and 36% with transgender people. Other groups include: women living with HIV; children living with HIV; orphans and vulnerable children; illiterate girls and women; women in the general population; school children; female partners of people who use drugs; street children; clients of sex workers; young people; students; exdrug users; prisoners; people with disabilities; teachers; parents; rural youth; and migrant workers. APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV 23 CASE Study 3 SuPPORtING ANd EMPOWERING VuLNERABLE WOMEN IN MALAySIA MAC recognises that gender inequality in Malaysia affects the vulnerability of women who are in the general population, living with HIV and the partners of drug users, in both similar and different ways. Deeply entrenched beliefs and expectations around the social roles and behaviours of women and girls prevent them from accessing adequate education, services and support. Women living with HIV and the female partners of drug users face increased stigma as their status is seen as outside accepted gender norms. MAC's work focuses on empowering women in these groups through a range of activities, such as outreach programmes, community sensitisation events, workshops, drop-in clinics, peer support programmes and the provision of shelters. The outreach programmes that MAC and its partners implement revolve around SRH education. Some of the activities, in partnership with the Ministry of Women, take the form of community sensitisation events and workshops that seek to raise awareness around gender inequality and discrimination, and to provide focused training on SRH. These initiatives are targeted at entire communities and try to involve men as well as women and to increase their awareness of gender-related issues. Since 2006, MAC has also conducted capacity building workshops specifically with women living with HIV. These `training of trainers' workshops give the participants the skills to `cascade' the information to other women living with HIV. As a result, a number of women living with HIV who participated in the workshops are now working on the ground with MAC or with their implementing partners. With their partners, MAC also supports four residential shelters that accommodate specific groups of vulnerable women. Two shelters provide temporary accommodation for women living with HIV and their children, with referrals primarily from hospitals. Shelter staff use a family-centred approach, combining onsite educational activities with outreach to the friends and families of the women to facilitate their eventual reintegration into the community. A third shelter caters to female partners of drug users, while the fourth provides accommodation and services for sex workers and homeless women living with HIV. MAC advises each of these shelters to work with families and communities so that the women can eventually move out of the centre and pursue livelihoods in their own communities. Some of the shelters also operate drop-in clinics for women living with HIV and the female partners of drug users, providing educational information and support. Finally, MAC also operates hospital-based peer support programmes for men and women living with HIV. These rely on hospital referrals and primarily focus on psychosocial support and adherence to antiretroviral treatment. In particular, MAC sees an opportunity here for integrating the peer support programmes with outreach activities. They are currently targeting advocacy efforts to get government support for a home-based care programme that would enable workers to combine treatment and care for individuals living with HIV with sensitisation activities with their families. MAC believes that this approach can play a key role in reducing stigma and spreading awareness. Although MAC has witnessed successful results in each of its different programmes and activities, it has also identified new opportunities for broadening the scope of its gender sensitive work. In particular, MAC sees the potential of applying a family-centred approach to programming with drug users, to draw in the partners of those community members and encourage protection. They argue that this requires an ideological shift from considering only the health aspects of drug use to considering the gender-related aspects of the relationships of drug users and focusing on the empowerment of their partners. Accordingly, MAC has begun to target national advocacy efforts in this area. APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV 24 community and service provider level actions (implementation actions group 3) 75% of partners indicated that they are carrying out one or more community and service provider level implementation action for standard 3.9 (as listed in table 2). These cover gender-related actions such as mobilising communities through outreach; training health care personnel and other stakeholders; engaging community leaders; and providing people with social and legal services. TASSOS (India) has promoted a gender policy at the state level and disseminated a translated version to all its partners. It carries out workshops and training for health workers in Tamil Nadu and Pondicherry. SIAAP (India) has empowered female sex workers and gay and bisexual men by building community organisations to address gender and sexuality-related stigma and discrimination. Alongside a range of training programmes addressing issues of gender and sexuality, it provides support for sex workers when they are arrested, including legal help. A strong example of a comprehensive approach to community and service provider level actions was shown by IDH (Bolivia), which has addressed issues of gender in a challenging socio-cultural environment (see Case study 4). CASE Study 4 AddRESSING NEGAtIVE GENdER NORMS tHROuGH tRAINING ANd OutREACH IN BOLIVIA IDH sees gender as an issue that cuts across all its work, and has developed internal gender programming standards. The organisation recognises that gender inequality is a structural driver of HIV transmission in Bolivia, where the firmly rooted culture of machismo fuels issues like gender-based violence and excessive alcohol consumption. IDH's extensive work in this area involves a gender analysis of machismo and the socio-economic and cultural status of women. It also examines the consequences of excessive alcohol consumption and its impact on families, children, wives, sexual relations, disease and violence. Since 2010, IDH has included the theme of gender and sexuality in its prevention programme, recognising that sexuality is a necessary starting point for a better understanding of HIV. However, IDH understands that inequality also impacts on access to HIV treatment and care and, as a result, has trained over a thousand health care workers in urban and rural settings on gender issues. IDH has also led training sessions with schools, universities, the police and the military. Facilitators usually use one of two main methods: film screenings (to stimulate reflection and discussion among participants); or forum theatre (to enable participants to explore how gender, alcohol and HIV issues influence their own lives). Surveys administered before and after interventions have indicated positive changes in knowledge about HIV, gender and high risk behaviours related to alcohol and violence. The surveys have also shown a greater awareness of, and ability to critique machismo, among the participants. Implementing gender work can be challenging in Bolivia, especially considering the degree to which machismo, alcohol and violence are normalised in its society. IDH has learned that it must challenge these issues in a sensitive manner. This is particularly the case when addressing aspects of machismo present in indigenous culture, as criticising any aspect of indigenous culture is politically sensitive. IDH has also learned that there are already many organisations engaging with women on gender issues; so it has decided to focus its work on issues of masculinity and engaging men for social change. APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV 25 policy and society level actions (implementation actions group 4) 57% of the 28 partners indicated that they are carrying out one or more of the policy and society level implementation actions for standard 3.9 (as listed in table 2). These actions focus on different types of advocacy around a gender-transformative approach, for example in relation to equity; gender-based violence, coercion and abuse; and policies, laws and customs that limit the autonomy of women. Actions also focus on finding allies and building movements on gender; prioritising needs in conflict situations; ensuring interventions reflect the full diversity of gender and sexual orientation; and paying special attention to people most at risk of HIV infection. In some contexts, for example, Alliance partners have mobilised civil society organisations to collaborate and explore issues on gender and sexuality and identify common messages. RedLacTrans organised a meeting on gender and sexuality that brought together 16 organisations representing diverse sexual identities in Nicaragua; and NAF (Mongolia) has provided a civil society voice in the policy and legislative environment on issues that affects people living with HIV, sex workers and men who have sex with men. KANCO (Kenya) has actively participated in a range of national advocacy initiatives, from being a member of the national gender task force to promoting the development and implementation of gender-related policies (see Case study 5). CASE Study 5 SHAPING tHE NAtIONAL HIV StRAtEGy IN KENyA KANCO is one of Kenya's leading HIV organisations, with a membership of 960 community groups, faithbased organisations and NGOs. Gender is an important component KANCO's programmes and policy work. In recent years its gender programmes have included a community gender development project which trained women and girls, and some men and boys, on gender, HIV and human rights issues; and a capacity building programme for its member organisations on gender mainstreaming and gender-based violence. To complement its programmatic work, KANCO has also been a member of various national policy and coordination bodies, advocating for the development and implementation of gender-related policies. For example, it contributed to the National Gender Taskforce through participation in the Joint AIDS Programme review meeting and other forums during the review of the National Strategy on AIDS. Kenya's new strategy includes gender-disaggregated indicators, priorities, targets and budgets. KANCO is also working to ensure that gender is mainstreamed in the country's laws. KANCO contributed to the development of the HIV Laws Act, ensuring that, when the act is violated, a tribunal is held in which two of the seven members must be women. KANCO is currently working to amend aspects of the Law of Succession Act (which determines how property moves from one person to another) to ensure it is more gender sensitive. KANCO was also involved in establishing provisions within the national constitution that state that some committees cannot be held without a certain percentage of women. Despite recent gender-sensitive changes to Kenyan law, implementation remains a major challenge. Cultural practices, such as wife inheritance and the disinheritance of widowed women (which leaves women impoverished and vulnerable to high risk behaviours like unprotected transactional sex work) persist, contributing to the spread of HIV. Another challenge is the deeply engrained nature of gender inequality in Kenyan society, particularly in rural areas. While women often emerge from gender training workshops feeling empowered and more aware of their rights, many find it difficult to actually challenge gender inequality in their daily lives. From this experience, KANCO has learned that more programmes need to incorporate male role models to work with other men to change harmful gender norms. APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV 26 MAMTA (India) supported the National AIDS Control Organisation to form an expert committee to review the curriculum of the national adolescence education programme, and revise its content to ensure a broader perspective of SRHR, including gender and sexuality issues. As well as government bodies, the committee included representatives of research and training institutions, teachers and parent-teacher associations. The revised 16-hour curriculum has now been rolled out by the government across the country. A number of partners responding to the Alliance gender and sexuality survey are implementing the South Asia Action Project (HASAB in Bangladesh and Alliance India, MAMTA and SASO in India). This project is a community mobilisation and advocacy initiative designed to support the SRHR of vulnerable adolescents and young people in the region. The project strengthens youth groups and networks and advocates for young people's participation in SRHR programming and policy processes. It increases the access of young people from vulnerable communities to comprehensive SRHR education and services. Alongside promoting youth-friendly services, the advocacy work aims to address harmful cultural and gender norms and build knowledge and life-skills among young people, particularly young men who have sex with other men and young people using drugs. HASAB (Bangladesh) indicated that their project `Promoting Rights of Extreme Socially Excluded People' responds to standard 1.4. The project supports sex workers to protect and promote their rights, reduce stigma and discrimination and increase their condom negotiation skills. It involves the provision of regular training for sex workers to build their skills to take collective action and make their voices heard. Mina (a sex worker based at Maymenshing Brothel and involved in the project) reported how her clients had always refused to use condoms. After training on human rights and HIV by a self-help group of sex workers, she gained the skills, knowledge and confidence to negotiate condom use. Mina and other members of the group now all try to negotiate condom use with clients. HASAB supports another project with the clients of sex workers, and overall about 80% of the clients of Maymenshing Brothel now use condoms. Survey responses also indicated that many Alliance partners are addressing gender within their support to people living with HIV, and through their efforts to put the principle of the greater involvement of people living with HIV (GIPA) into practice (standard 1.7). Of particular note, SIDC-Helem-Liban (Lebanon) reports that it involves HIV-positive women in HIV prevention and education activities, alongside building their capacity to take care of themselves. The work has involved supporting a workshop for 20 women living with HIV in the Middle East and North Africa region, which focused on the specific needs of women, including sexuality. other gender and sexuality-related Alliance good practice standards In addition to standard 3.9, a number of other Good Practice HIV Programming Standards have direct relevance to the gender and sexuality-related work of Alliance partners. These standards are set out below, along with a brief snapshot of work being done in these areas from responses to the survey. programme area 4. integration of sexual and reproductive health, hiV and rights good practice standards 4.9 our organisation works with others to promote and/or implement programmes that address gender and sexuality as an integral component of the srh and hiV response 4.10 our organisation promotes and/ or provides interventions to address gender-based and sexual violence and abuse in its hiV and srh responses 4.11 our organisation has a policy and programme to address stigma and discrimination, which act as a barrier to protective behaviours, support and access to srh and hiV prevention and treatment programme area 1. human rights and the greater involvement of people living with hiV (gipA) good practice standards 1.4 our programmes are designed to build the capacity of both rights holders and duty bearers to claim their rights and to promote, protect and respect the rights of others 1.7 our organisation is committed to the effective implementation of the gipA principle throughout all areas of our organisation APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV 27 As described earlier, the answers to the question `What gender and sexuality work does your organisation do?' indicated that many Alliance partners do apply some type and degree of gender and sexuality approach to their programming, based upon a broad definition that includes issues not only related to HIV, but wider areas such as SRH (standard 4.9). There were also indications of attention to gender-based and sexual violence and abuse (standard 4.10), for example by AMSED (Morocco) whose work with sex workers involves building their capacity to address key issues, including violence and HIV prevention, that affect their lives. In relation to standard 4.11, survey responses confirmed that action on stigma and discrimination is critical to the Alliance's approach to gender-related programming. In answer to the question `Do you do any stigma and discrimination work?', 25 out of the 28 partners (89%) said yes. Examples of their work include supporting NGOs/CBOs through grants for relevant programmes; supporting stigma and discrimination audits; and providing training and `training of trainers' to participants such as health workers, people living with HIV, sex workers, community leaders and religious leaders. For some partners, tackling stigma and discrimination involves a range of strategies. KHANA (Cambodia) supports community counselling, community awareness, event organising, forums, media work, meetings and workshops. Similarly, the comprehensive approach of KANCO (Kenya) includes sensitising its members, supporting stigma audits, disseminating GIPA guidelines and the civil society code of conduct, advocacy on the eradication of HIV-related stigma and discrimination, and the development of supportive workplace policies. Addressing stigma is also central to the work of ANCS (Senegal). One aspect of this is training trainers among people living with HIV, men who have sex with men, sex workers and other community actors. In many cases, partners' work on stigma and discrimination has involved awareness-raising and advocacy among a wide range of stakeholders and community `gatekeepers'. For example, while TASSOS (India) has targeted medical students and young people, HASAB (Bangladesh) has carried out dialogue with the media, health service providers, law enforcement agencies, religious leaders, elected leaders, young people, teachers, advocates, house owners, shop keepers, rickshaw pullers, truck drivers, members of the elite, employers, government stakeholders, NGOs and human rights groups. IPC (Burkina Faso) and CISHAN (Nigeria) are among a number of partners that have carried out national advocacy on stigma and discrimination, calling on their governments to pass anti-discrimination legislation. CASE Study 6 In India, female sex workers experience violence from criminals, partners, pimps, madams and the police. This restricts their ability to negotiate the use of condoms or access health services, which in turn reduces the likelihood of them adopting safer health behaviours and increases their vulnerability to HIV. To address this, the Bill and Melinda Gates Foundation's Avahan project � of which Alliance India is a partner �builds the capacity of organisations and, especially female sex workers themselves, to increase their protection from violence and sensitise perpetrators. The project believes that an individual is less likely to take action against violence than groups of women working together. As such, it helps female sex workers to form support groups. The project's key approaches are advocacy training for female sex workers, developing crisis response teams (involving sex workers and non-NGO partners) and raising community awareness on the rights of female sex workers. The project has AddRESSING VIOLENCE AGAINSt FEMALE SEx WORKERS IN INdIA also worked with senior officials in the police force to influence officers' behaviour, reinforced by a media campaign to `name and shame'. Although the response to the project has been positive, it is difficult to assess how much this advocacy has reduced the levels of violence � as reporting by sex workers is low (due to loyalty or fear of reprisals). The project has called for more emphasis on protection, based on the idea that women who are less intimidated by the threat of violence are more able to avoid it. In the state of Manipur, women claimed that the biggest contribution to reducing violence was the opening of a night shelter that allowed them to hide from criminals and the police and get advice on protection options. In Andhra Pradesh, women said that confidence was the greatest form of protection. Female sex workers who were trained as outreach workers reported almost eliminated violence from their lives, as they were better able to stand up for themselves. APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV 28 Partners' efforts have often involved targeted interventions. For example, Alliance China is supporting groups of people living with HIV to do an anti-stigma programme and produce a publication sharing their experiences; and Alliance India is supporting a crisis response team for men who have sex with men, female sex workers and transgender people (see Case study 6). Alliance Ukraine has conducted advocacy training for NGOs that are working with drug users and sex workers. programme area 7. hiV and drug use good practice standards 7.6 our programmes targeting people who use drugs are gender-sensitive, and include interventions for the sexual partners of people who use drugs men through drug use; now, although the overall proportion of women living with HIV remains low, the number of new cases among females is increasingly dramatically. CiSHAN (Nigeria) also commented how there is a relationship between poverty, women's lower social status, gender-based violence and HIV. This results in a "downward spiral of more infection and more poverty". Similarly, HASAB (Bangladesh) described how the challenges of gender and sexuality reflect the whole socio-economic and political status of women. Here, discussion about sexuality is not culturally acceptable and a woman's role is to be passive, with men taking decisions about where and how sex will occur (among other things). Gender inequality and discrimination against women were also cited as challenges by partners in Bolivia, Cambodia, India, Kenya, Lebanon, Morocco, Nigeria and Uganda. AMSED noted that cultural issues in Morocco affect women in the general population and women from key populations, and that this translates into lack of access to services. n Partners from Malaysia, India and Ukraine reported that their work to support drug users and their partners addresses gender-related issues. MAC (Malaysia) empowers the female partners of drug users through outreach, workshops, awareness-raising and peer support. SASO (India) has changed from an organisation focused on men who use drugs to one that includes women drug users, as well as partners and children of drug users. Alliance Ukraine has supported research into gender-sensitive approaches to HIV prevention and harm reduction interventions among drug users, with recommendations about how to develop these approaches in future programming. Low male involvement in programming and interventions. NELA (Nigeria) noted that men are often reluctant to get involved in programmes, even at the level of getting tested for HIV or accessing care and support in a timely manner. IDH (Bolivia) noted that a holistic approach is required for interventions � one that actively involves both men and women. Limited access to education (formal and informal) for women and girls. This challenge was cited by NELA (Nigeria) and Humsafar and NMP+ (both India). Poor understanding or consensus on gender and sexuality. SIAAP (India) expressed concern that key national stakeholders and policymakers view gender and sexuality issues from a public health, rather than a rights, perspective. TASSOS (also India) felt that organisations have different understandings about what gender and sexuality mean. Lack of national platforms and opportunities to share good practice. Partners in India (SIAPP), Nigeria (CiSHAN) and Senegal (ANCS) noted the lack of opportunities for different types of stakeholders to share their gender and sexuality experiences and practices. SIAPP was concerned that there is no platform for community members to engage with law enforcement agencies, government officials and policymakers on an ongoing basis. ANCS highlighted the lack of a mechanism to facilitate exchange n WHAt CHALLENGES ARE tHERE IN dOING GENdER ANd SExuALIty WORK? Responses to the Alliance survey confirmed that partners face a significant number of challenges to their work on gender and sexuality. These include: n Gender norms and inequality. MAC noted, for example, that despite progress in empowerment, women in Malaysia remain vulnerable to HIV for a range of biological, economic and cultural reasons that place them in subservient roles in relationships. Girls and young women are expected to be sexually na�ve, so have little access to information and services, and are at greater risk of sexual coercion and violence. All the while the dynamics of the national epidemic are also changing. Previously it was characterised by transmission among n n APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV 29 between those working in the HIV response and in the field of gender and sexuality. n Lack of national policy and leadership on gender and sexuality. Partners in countries such as Senegal (ANCS), Kenya (KANCO) and Burkina Faso (IPC) were concerned about the poor integration of gender and sexuality into national policies, structures and technical guidance. Lack of human resources, capacity and tools on gender and sexuality. This lack of resources among national stakeholders, Linking Organisations and implementing NGOs and CBOs was cited as a challenge by AMSED (Morocco), CiSHAN (Nigeria), KHANA (Cambodia), IPC (Burkina Faso), MAMTA and Alliance India (both India), POZ (Haiti) and RedLacTrans (Nicaragua). A number of specific concerns were also expressed. These included that too few tools are available in Spanish and successful experiences are not well documented (RedLACTrans); that there is little choice of tools (modules, toolkits, and so on) to carry out sessions (ANCS); and that there is a need for more tools and support materials on programming and advocacy work (IPC). Limited `how to' for programming gender and sexuality. AMSED (Morocco) cited challenges around building the negotiation skills of women, and promoting human rights to combat violence against women, stigma and discrimination. IDH (Bolivia) noted that, while knowledge about gender and sexuality has increased, more work is needed to change attitudes. Alliance Ukraine cited the challenge of finding appropriate ways of working with female drug users and addressing violence against drug users and sex workers. Low funding levels for gender and sexuality initiatives. Funding was identified as a challenge in Bolivia (IDH), Burkina Faso (IPC), Mongolia (NAF), Nigeria (CiSHAN) and Senegal (ANCS). NAF (Mongolia) highlighted the challenge of scaling up gender and sexuality work when resources for work with marginalised communities are already limited. Stigma and discrimination. This remains a significant barrier to the work of many Alliance partners. Some of the areas being addressed include stigma and discrimination against men who have sex with men (Alliance China), self-stigma among people living with HIV (NMP+, India), and the double stigma of people affected by HIV and members of key populations (Rumah Cemara, Indonesia). ASSESSING OuR CAPACIty ANd FutuRE SuPPORt NEEdS only 25% of responding partners said they have the capacity that they need to apply a gender and sexuality approach. the remaining 75% said they have limited capacity. Just over half (54%) have a focal person that deals with gender and sexuality. The two most commonly cited capacity barriers were lack of donor funds for relevant initiatives and lack of skilled staff and training (in gender and sexuality, and related areas such as human rights). When asked about the capacity needed to apply a gender and sexuality approach, responses cited an extensive and varied list. The most common need, articulated by partners such as KANCO and ANCS, was for training and capacity building to understand the theory and, more importantly, practice of gender and sexuality approaches (both for their own staff and the NGOs/CBOs that they support). In some cases, such as ANC-CI and ANCS, technical support was requested for general approaches to integrating gender, including human rights. In others, it was requested for specific areas, such sex work (MAC) and other key populations (Alliance Ukraine). Another common need, expressed by partners such as KHANA and MAC, was for a gender analysis to collect, analyse and publish gender-disaggregated data, combined with social research to increase understanding about how such data connects to HIV-related vulnerabilities and risk. MAC, alongside other partners from Morocco, Senegal and Nigeria, identified capacity gaps in gender-related advocacy work to revise national laws and policies, and engage relevant stakeholders such as policymakers, law enforcement officials and the judiciary. Other gaps in capacity included leadership; resource mobilisation; technical guidelines and tools (such as simplified planning guides); focal points or `desks' for gender and sexuality; ways of involving community leaders; culturally-specific approaches to gender and sexuality; and gender-sensitive indicators. Other needs partners identified included: gender programme design and management; up-to-date information (including gender-disaggregated data and analysis, materials, manuals and tools); examples of good practice; opportunities to publish and share experiences; commodities (such as condoms, lubricants and contraceptives); and networking (with partners at regional and international levels, and local organisations). APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV n n n n 30 Jaqueline Anchundia Paladines from the Organisation of Sex Workers of Esmeraldas doing outreach work in a local park, Ecuador. � 2006 Marcela Nievas for the Alliance N'deye Coumba Gaye, President of the Sex Workers Association, dakar, Senegal. � 2007 Nell Freeman for Alliance APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV 31 section 3: reflections And future Actions CONCLuSIONS n Action at all levels on gender and sexuality The survey confirmed that Alliance partners are focusing significant efforts on gender and sexuality. Assessed against the Alliance's own Good Practice Standard for a gender-transformative approach, a high proportion of partners are taking actions at an organisational and programming level (82%), at individual, family and peer level (86%), and at community and service provider level (75%). Over half (57%) are also carrying out actions at the policy and society level. Twelve partners (43%) are taking action at all four levels. The results of the survey show that the work of partners is broadly in line with the Alliance's standards for this area, with the strategies promoted by agencies setting global norms (see Annex 4), and with the good practice of other organisations (see Box 1 and Annex 1). However, as noted in the Introduction to this report, the survey has a number of limitations. While giving an indication of the work being undertaken, the responses provide little systematic detail or analysis of exactly what approaches they have taken, and how work is being done. As such, it is not possible to assess the quality, effectiveness or impact of work. work with women or sexual minorities � 79% with men who have sex with men and 36% with transgender people, for example. However, there was little detail about whether the community-level actions by NGOs and CBOs involve working within such groups and, critically, bringing groups together to actually change gender norms and address issues of inequality. Also, the comparatively low number of partners involved in policy and societylevel advocacy could mean that efforts do not always respond to the wider political and legislative environment; to make gender transformation a reality they will need to. The survey also provided some indications that, in some circumstances, partners may be less actively engaged in some of the more sensitive or complex aspects of comprehensive gender-transformative approaches. For example, relatively few partners noted efforts to address gender-based violence or to involve heterosexual men and boys. n clarity on theoretical and practical approaches Partners were asked what they understood by a gender and sexuality approach. Taken together, their responses reflect a good understanding, with particularly clear and passionate explanations of how gender and sexuality impact on people's vulnerability, and why they are critical to action on HIV. However, individual responses indicate that some partners need greater clarity about what such an approach encompasses � especially in practice, rather than theory. n gender-transformative or gender sensitive approaches? It is challenging to assess the extent to which Alliance partners are carrying out approaches that are gender-transformative (as defined in HIV and Healthy Communities: Strategy for 2010-12, see Box 2) as opposed to gender `sensitive' or `responsive'. Many partners confirmed that they n perceptions of capacity A gender-transformative approach involves consciously and systematically addressing APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV 32 gender-related issues at all levels, including within the design, implementation, management and monitoring and evaluation of programmes and policies. However, 75% of responding partners state they only have limited capacity to carry out such work � with gaps in skills and expertise, technical resources, and funding. While respecting the views of these partners, some may actually underestimate their existing capacity for gender and sexualityrelated approaches. They may be doing, or already able to do, more gender-transformative work than they think. There can be a perception that a gendertransformative approach is a separate and highly specialised area that is distinct from the usual work of Alliance partners. This perception can be exacerbated by some of the academic terminology associated with the subject. n includes attention to sensitive issues (such as gender-based violence) n clearly articulates and promotes what such an approach means in practice, with examples of relevant strategies, activities and indicators addresses how such an approach can be measured is informed both by the national, regional and global experiences of the Alliance itself and international good practice and policy dialogue, including on the wider health Millennium Development Goals. n n 2. carry out a more specific assessment of the capacity needs of Alliance partners for gendertransformative approaches. develop a plan to address these needs by: n gender, sexuality and human rights Finally, the survey also confirms that issues of gender and sexuality are inextricably linked with human rights. This reiterates the findings of a similar 2010 survey of Alliance partners, focused on human rights.27 This identified issues around gender inequality and discrimination, and criminalisation of sexual minorities as top human rights issues. It demonstrated that many partners view gender issues as integral to the definition of a human rightsbased approach. n maximising existing resources by the Alliance and others, such as gender analysis tools and guides on gender mainstreaming ensuring that the Alliance's Technical Support Hubs can provide high quality capacity building, based on a common understanding of, and technical strategies for a gender-transformative approach mobilising and supporting Alliance partners to develop their own gender strategies building capacity of Linking Organisations to include gender-transformative approaches into proposal development and resource mobilisation activities. n n RECOMMENdAtIONS Based on the findings of the survey and the conclusions drawn, a number of recommendations are set out below for the Alliance to improve its work on gender and sexuality. 3. document examples of good practice of gendertransformative approaches by Alliance partners working in generalised epidemics, concentrated epidemics, and mixed epidemics. In particular, use the Alliance's comparative advantage as an organisation with extensive experience of community mobilisation and support with groups most affected by HIV, to articulate the complexity and necessity of transformative approaches at the community level. 1. develop a gender strategy for Alliance partners that: n responds to HIV and Healthy Communities: Strategy for 2010-12 and the Good Practice HIV Programming Standards confirms a common understanding of a gendertransformative approach and of terms such as gender and sexuality promotes a comprehensive approach to a gendertransformative approach that is rights-based and n 4. ensure that gender transformation is fully integrated and addressed in the Alliance's existing and future work on good practice responses to hiV. Examples include: surveys among Alliance partners on other thematic areas; good practice guides; the Alliance's accreditation process; and monitoring and evaluation of HIV and Healthy Communities: Strategy 2010-12. n 27. `Advancing Human Rights, Responding to HIV: Report on the Findings of a Human Rights Survey among Alliance Partners', International HIV/AIDS Alliance, September 2010. APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV 33 drop-in centre for men who have sex with men, Battambang, Cambodia � Eugenie dolgberg for the Alliance APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV 34 Annex 1: exAmples of gendertrAnsformAtiVe ApproAches Stepping Stones was developed by Strategies for Hope and ActionAid in 1995 and has been used throughout the world. It is a training package on gender, HIV, communication, relationship skills and life-skills. It covers many aspects of people's lives, including why people behave in the ways they do, how gender, generation and other issues influence this, and ways in which people can change their behaviour. Stepping Stones uses a series of 14 sessions among individual or combined peer groups. These use a participatory approach through discussions and activities based on the participants' own experiences and using methods such as role play and drawing. Strategies for Hope (1995), Stepping Stones: A Training Package in HIV/AIDS, Communication and Relationship Skills. Men as Partners was started by EngenderHealth in 1996 and has been implemented in over 15 countries in Africa, Asia, Latin America and the USA. The programme works with men to play constructive roles in promoting gender equity and health in families and communities. Its approaches include: interactive, skillsbuilding workshops that confront harmful stereotypes of what it means to be a man; training health care professionals in providing male-friendly services; leading local and national public education campaigns; and building national and international advocacy networks to create a global movement. Engenderhealth (accessed 6.1.11), Men as Partners, available at: www.engenderhealth.org/our-work/gender/ men-as-partners.php Promundo is a Brazilian NGO set up in 1997 to promote gender equality and end violence against women, children and youth. Its combines research and advocacy with programmes to promote positive changes in gender norms and behaviours among individuals, families and communities. For example, Programme M (`M' being for Mulheres and Mujeres � `women' in Portuguese and Spanish) seeks to promote the health and empowerment of young women through critical reflections about gender, rights and health. It consists of educational workshops, community campaigns and innovative evaluation instruments to assess impact on young women's gender-related attitudes and perceived self-efficacy in interpersonal relationships. The curriculum was field-tested in Brazil, Jamaica, Mexico and Nicaragua and has been adapted for India and Tanzania. Promundo (accessed 6.1.11), Programmes, available at: www.promundo.org.br/en/activities/programs The Sonke Gender Justice project started in 2006 and works across Africa to strengthen government, civil society and citizen capacity to support men and boys to take action. The One Man Can campaign supports men and boys to end domestic and sexual violence and promote healthy, equitable relationships that men and women can enjoy. It promotes the idea that each person has a role to play and can create a better, more equitable and just world. It encourages men to work together with other men and women to take action. The campaign includes an action kit (with music and fact sheets) and suggests action ideas for men � for example supporting a survivor or challenging other men to take action. Sonke Gender Justice (accessed 6.1.11), One Man Can, available at: www.genderjustice.org.za/ onemancan/?php MyAdmin=l06quHmc2HyKa50XHUS FkShStJ8 The Frontiers Prevention Project by the International HIV/AIDS Alliance India included a focused prevention programme in Andhra Pradesh, targeting key populations and reaching over 22,000 female sex workers and 12,000 men who have sex with men. The programme's gender-transformative approach combined multiple strategies including participatory site assessments; promoting networks to provide mutual support; training leaders; building capacity to address structural determinants of inequality (including gender-based violence); advocacy on policymaking; outreach to gatekeepers; providing safe spaces; and strengthening the capacity of NGOs. International HIV/AIDS Alliance India (2006), Focused Prevention in Andhra Pradesh. AdVANCING HuMAN RIGHtS: RESPONdING tO HIV 35 Annex 2: gender And sexuAlity surVey Questions introduction 1. 2. 3. 4. 5. 6. Linking Organisation/partner Is there a focal person that deals with gender and sexuality within your organisation? What do you understand by a gender and sexuality approach to HIV? What gender and sexuality work does your organisation do? (Please include programming, policy, capacity building work in your response) Do you have a good case study of successful work you could share? What are the challenges you face doing gender and sexuality work? capacity 7. 8. 9. What capacity do you think is needed to apply a gender and sexuality approach to programming? Do you feel that your organisation has that capacity? What type of support in the area of gender and sexuality do you need? national context 10. What are the most important gender and sexuality issues in your country with regard to HIV at the moment? 11. Do national programmes respond to the most important issues? 12. Are you doing work with the following groups? (please tick all that apply) 13. Do you do any stigma and discrimination work? 14. Which key population(s) in your country has their human rights most frequently violated? AdVANCING HuMAN RIGHtS: RESPONdING tO HIV 36 Annex 3: AlliAnce good prActice hiV progrAmming stAndArds WHAt ARE tHE ALLIANCE'S GOOd PRACtICE HIV PROGRAMMING StANdARdS? n These programming standards define the Alliance approach to HIV programming. They set out what our beneficiaries can expect from our HIV programmes and our research. Programme standards define good practice in various technical areas, and are based on evidence, and on Alliance experience and values. The standards refer to tools that define good practice for specific intervention types, or that assist in implementing the standard. They do not define reach and scope. Targets for reach and scope are set by people closer to the specific programmes, according to local epidemiology and context. These standards are aspirational. Where our programming is not meeting them, it will highlight our quality improvement priorities, and help with identifying technical support needs. These standards are not yet complete. We are currently working on treatment and care standards which will be incorporated into the final standards document. These standards refer to a range of themes and topics. They are only to be applied to work currently undertaken. For example, if a Linking Organisation is not developing work on drug use and HIV, then the HIV and drug use standards do not apply. Some of the standards are cross-cutting and will be relevant for the whole Alliance, such as those on the human rights and GIPA. n n n n n WHy dEVELOP PROGRAMMING StANdARdS? n To define and promote good practice in community-based HIV programming. Definitions of good practice and quality are based on evidence and programme learning, and are shaped by the Alliance's values. To support assessment and evaluation of programme quality. To influence programme design. To build an evidence base for quality programming. To shape the provision of technical support provided through the Alliance's Technical Support Hubs. n n n n APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV 37 WHO IS INVOLVEd? n Alliance Linking Organisations and their implementing partners (community- and faith-based organisations), and the Alliance's Technical Support Hubs, their users and beneficiaries, will use programming standards to design, implement and evaluate HIV programmes. Users or beneficiaries of Alliance services and programmes can use programming standards to understand what our programmes are for, and to help evaluate Alliance programmes. Alliance programme officers and programme managers will use programming standards to assess, design and evaluate programmes (using a self-assessment tool). Alliance resource mobilisation staff will use programming standards to develop high quality proposals. Funders of Alliance programmes have an interest in programming standards. Alliance standards illustrate that our programmes are shaped by a culture of quality and good practice, are informed by evidence, and are monitored and evaluated according to a set of standards. Other civil society organisations are interested in quality standards for their community level programmes. Alliance programming standards can influence and guide good programming in other civil society organisations. n n n n n ARE WE MEEtING tHE StANdARdS? We have developed a self-assessment tool which Alliance organisations can use to: 1. objectively appraise and describe the current status of an organisation and its programmes in relation to Alliance good practice quality programming standards 2. enable organisations to identify and agree on a plan for continuous development of good practice programming (including building capacity and delivering technical support) 3. report on the quality of our programming. APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV 38 Annex 4: Key gloBAl guidAnce on gender And sexuAlity ApproAches 1. Agenda for Accelerated country Action for Women, girls, gender equality and hiV: operational plan for the unAids Action Framework: Addressing Women, girls, gender equality and hiV, unAids (2010) principles: Human rights-based approach; participation; evidence-informed and ethical responses; partnership; engaging men and boys; and strong and courageous leadership. issue 2: Translating political commitment into scaled up action to address the rights and needs of women and girls in the context of HIV recommendation: Reinforce the translation of political commitments into scaled-up action and resources for policies and programmes that address the rights and needs of women and girls in the context of HIV, with the support of all relevant partners, at the global, national and community levels. results: n issue 1: Knowing, understanding and responding to the particular and various effects of the HIV epidemic on women and girls Stronger accountability from governments to move from equality to results, for more effective AIDS responses. All forms of violence against women and girls are recognised as violations of human rights and are addressed in the context of HIV. Women and girls have universal access to integrated multi-sectoral services for HIV, tuberculosis and sexual and reproductive health and harm reduction, including services addressing violence against women. Strengthened HIV prevention efforts for women and girls through the protection and promotion of human rights and increased gender equality. recommendation: Jointly generate better evidence and increased understanding of the specific needs of women and girls in the context of HIV and ensure prioritised and tailored national AIDS responses that protect and promote the rights of women and girls (knowing your epidemic and response). n n results: n Quantitative and qualitative evidence on the specific needs, risks of and impacts on women and girls in the context of HIV exists through a process of comprehensive and participatory data collection, including on male and female differentials in the epidemic, and better inform the implementation of effective policies and programmes that promote and protect the rights and meet the needs of women and girls. Harmonised gender equality indicators are used to better capture the socio-cultural, economic and epidemiological factors contributing to women's and girls' risk of and vulnerability to HIV. Evidence-informed policies, programmes and resource allocations that respond to the needs of women and girls are in place at the country level. n issue 3: An enabling environment for the fulfilment of women's and girls' human rights and their empowerment, in the context of HIV recommendation: Champion leadership for an enabling environment that promotes and protects women's and girls' human rights and their empowerment, in the context of HIV, through increased advocacy and capacity and increased resources. n n results: n Women and girls empowered to drive transformation of social norms and power dynamics, with the AdVANCING HuMAN RIGHtS: RESPONdING tO HIV 39 engagement of men and boys working for gender equality, in the context of HIV. n Strong, bold and diverse leadership for women, girls and gender equality for strengthened HIV responses. Increased financial resources for women, girls and gender equality in the context of HIV. Gender-responsive UNAIDS. including the support of non-governmental and community-based organisations, including organisations of people living with HIV n n public campaigns to address homophobia and transgender discrimination training and sensitisation of health care providers to avoid discriminating against, and ensure the provision of appropriate HIV-related services for men who have sex with men and transgender people access to medical and legal assistance for boys, men and transgender people who experience sexual abuse the promotion of multi-sectoral links and coordinated policy-making, planning and programming, including ministries of health, justice (including the police), home, and social welfare (and similar and related ministries), at the national, regional and local levels. n n 2. unAids Action Framework: universal Access for Men who have sex with Men and transgender people, unAids (2009) The Action Framework focuses on three objectives: 1. improve the human rights situation for men who have sex with men and transgender people--the cornerstone to an effective response to HIV 2. strengthen and promote the evidence base on men who have sex with men, transgender people and HIV 3. strengthen capacity and promote partnerships to ensure broader and better responses for men who have sex with men, transgender people and HIV. Within a comprehensive package of measures to address HIV-related issues among men who have sex with men and transgender people, the need for a conducive legal, policy and social environment requires: n n n All interventions should be evidence-informed, developed with, and protect the rights of men who have sex with men and transgender people and should include safe access to: n information and education about HIV and other sexually transmitted infections, and support for safer sex and safer drug use, through appropriate services (including peer-led, managed and provided services) condoms and water-based lubricants confidential, voluntary HIV counselling and testing detection and management of sexually transmitted infections through the provision of clinical services (by staff members trained to deal with sexually transmitted infections as they affect men who have sex with men and transgender people) referral systems for legal, welfare and health services, and access to appropriate services safer drug-use commodities and services appropriate antiretroviral and related treatments, where necessary, together with HIV care and support prevention and treatment of viral hepatitis referrals between prevention, care and treatment services services that address the HIV-related risks and needs of the female sexual partners of men who have sex with men and transgender people. the promotion and guarantee of the human rights of men who have sex with men and transgender people, including protection from discrimination and the removal of legal barriers to accessing appropriate HIV-related prevention, treatment, care and support services for them, such as laws that criminalise sex between males an assessment and understanding of the numbers, characteristics and needs of men who have sex with men and transgender people regarding HIV and related issues, including risks associated with injecting drug use, sex work, and prison confinement ensuring that men who have sex with men and transgender people are appropriately addressed in national and local AIDS plans, that sufficient funding is budgeted for work, and that this work is planned and undertaken by suitably qualified and appropriate staff the empowerment of men who have sex with men and transgender communities to participate equally in social and political life ensuring the participation of men who have sex with men and transgender people in the planning, implementation and review of HIV-related responses, n n n n n n n n n n n n n Issues that need to be addressed specifically in relation to transgender people: n access to appropriate information, counselling and support on transgender issues APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV 40 n access to drugs, gender reassignment procedures and support, where necessary the ability to change one's name and gender identity on official documents, and the legal right to live as another gender, free from stigma and discrimination an understanding of the effects of HIV antiretroviral medicines and HIV opportunistic infection treatments for transgender people taking gender reassignment drugs work to understand HIV risk in relation to gender reassignment drug treatment and surgical procedures. n n n (Based on the recommendations from the WHO consultation meeting on men who have sex with men, HIV and other STIs, held in Geneva, 15�17 September 2008, WHO's August 2008 publication, `Priority Interventions: HIV/AIDS Prevention, Treatment and Care in the Health Sector, the UNAIDS 2007 publication, Practical Guidelines for Intensifying HIV Prevention: Towards Universal Access', and the UNAIDS Policy Brief on HIV and Sex Between Men.) APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV Isaiah Wabwire an outreach worker with dARAt sits with injecting drug users `Niko' and `Omar', Mombasa, Kenya. � Nell Freeman for the Alliance An MSM couple living with HIV. After taking part in a photographic project, working for an outreach service and with counselling from KHANA the couple were empowered to seek treatment and disclose to their families. Battambang, Cambodia. � Eugenie dolberg for the Alliance APPROACHES tO GENdER ANd SExuALIty: RESPONdING tO HIV About the International HIV/AIDS Alliance Established in 1993, the International HIV/AIDS Alliance (the Alliance) is a global alliance of nationally-based organisations working to support community action on AIDS in developing countries. To date we have provided support to organisations from more than 40 developing countries for over 3,000 projects, reaching some of the poorest and most vulnerable communities with HIV prevention, care and support, and improved access to HIV treatment. The Alliance's national members help local community groups and other NGOs to take action on HIV, and are supported by technical expertise, policy work, knowledge sharing and fundraising carried out across the Alliance. In addition, the Alliance has extensive regional programmes, representative offices in the USA and Brussels, and works on a range of international activities such as support for South-South cooperation, operations research, training and good practice programme development, as well as policy analysis and advocacy. International HIV/AIDS Alliance (International secretariat) Preece House 91-101 Davigdor Road Hove, BN3 1RE UK Telephone: +44(0)1273 718900 Fax: +44(0)1273 718901 firstname.lastname@example.org www.aidsalliance.org Registered charity number: 1038860 G&SR_02/11