12 Mar 2015

The Global Fund's efforts to put women and girls at the center of its interventions in HIV, TB and malaria have yet to bear significant fruit at the country level, according to the ATHENA Network.

In an interview with Aidspan, Luisa Orza, director of programs for the network, said that there was still a critical disconnect in many of the concept notes presented to the Global Fund, between the narrative analysis of gender-related issues and an actual programmative prioritization of activities focusing on women and girls. This is also having a financial impact, she said, as the budgeting of concept notes failed to demonstrate prioritizing of gender-specific interventions. The Network is releasing this paper in March to delve deeper into these concerns.

The lack of prioritization may be due in part to the roots of concept notes: within the national strategic plans (NSP) are developing for their own response to HIV, TB and malaria. As NSP tend to be "quite bio-medical in approach" they can be weak in "preventing and addressing violence, and again where linkages are made between HIV and violence, there is often a failure to back these up with costed programs and budgets in the operational plan, or to include them in accountability frameworks,” she said.

Orza's comments reflected some of the concerns flagged by the Technical Review Panel in its recent report (see article here), and the absence of a clear gender integration strategy in most concept notes already submitted. 

The problem, according to Orza, is deep-seated, beginning with the composition of country coordinating mechanisms (CCM) in countries. While there are now representation requirements for women on CCMs, this has not translated into women being more engaged in decision-making. Furthermore, she noted, women are not as well-represented among the seats in CCMs reserved for key populations. This is particularly problematic with respect to CCM representation for people living with the diseases, Orza said, which can mean that a "huge raft of issues pertaining to women living with HIV may be missed."

"There [in some CCMs] may only be one seat for key populations. If the person on that seat comes from the men-who-have-sex-with-men community, how are they going to speak to the issues affecting women who do sex work, or women who use drugs?"

Another problem stems from a lack of capacity, Orza said. "Just because a woman is a woman, it doesn’t mean she has a good understanding of ‘gender’ as a socio-structural determinant of well-being. So there is a need to ensure gender expertise among CCM members, be they men, women or transgender people, as well as representatives of women as women."

These representatives of women as women also need to be able to make a  delineation between programs focused on pregnant women and women who are not pregnant but still requiring access to health services. There has been so much rightful emphasis on prevention of vertical transmission of HIV and reducing the risk of malaria for pregnant women that sometimes women who are not actively childbearing are forgotten.

So in working to prevent babies from acquiring HIV, most vertical transmission programs fail to encompass what Orza called a "broader sexual and reproductive health and rights agenda for the mother".

She called the WHO's four-pronged approach to preventing vertical transmission acceptable and "more holistic" but said it still fell short of a "comprehensive sexual and reproductive health rights agenda". Yet in most concept notes submitted to the Global Fund, she noted that, to their detriment, most programs were narrowly focused on Prong 3: PMTCT.

 "These programs can be astonishingly gender blind, even though it’s hard to imagine how, and with a push to achieve high targets in this area, women can be pushed into mandatory testing and treatment programs, even if they don’t feel ready to do so," she said. "One of the implications of this is that you often see quite high rates of loss-to-follow-up among women who have been ‘forced’ to test, or start treatment for life before they are ready."

In some countries, including Malawi and Uganda, this has translated into much higher rates of women defaulting on treatment -- particularly among those women who begin treatment very soon after their positive diagnosis.

Another consequence of this rush to treatment has been a higher potential for domestic abuse among women who have been encouraged, or, as Orza firmly stated "pushed into disclosing their status to partners".

"This can be a trigger for violence, and the fact of testing positive can result in them encountering all sorts of rights violations within maternal health services," she said.

The problems with gender integration into programming are deep-seated but by no means insurmountable, Orza said. Some critical and immediate changes to how programs are measured and evaluated will go a long way towards addressing the gender imbalance -- beginning with the essential need for a disaggregation of data by sex.

"Without sex disaggregation we have no evidence base from which to begin to explore and address gendered aspects and impacts of the epidemic and the response," she said. "In terms of accountability to women and girls, I’d almost see this as a prima facie step."

Also important is a disaggregation of data by age to reveal trends and risk areas, particularly with respect to HIV data collection due to the disproportionate impact on young women of HIV infection. In sub-Saharan Africa, women aged 15 to 24 are three times more likely to acquire HIV than their male age-mates, she said, and there has been little research to unpack why this disparity is so pronounced.

The Global Fund is one among a panoply of technical agencies collaborating with civil society to find answers to these questions and address the gaps in gender integration in health programs.

"I do feel like we are seeing some changes at the international level … but these are taking time to trickle down to the ground to where they are needed most, and that needs an even greater injection of not only will but resources," she said. While the Global Fund's gender strategy was developed in 2008, it remains mostly unimplemented (see commentary here), lending a sense of urgency to the need to include a more focused, nuanced, actionable and funded gender plan of action in the Fund's next strategic plan.

"The current Global Fund strategy runs out this year, even though the operational plan for the gender strategy runs till 2017, and planning for the next institutional strategic plan is already underway," Orza said. "It’s really important that addressing gender remains a priority in the next strategic plan."

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