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

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

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

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

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