Overview

For more than 25 years, AIDS has been taking a ravaging global toll. Women now make up half of those living with HIV infection. In Sub-Saharan Africa—the region most affected—women account for nearly 60% of those living with HIV (UNAIDS, 2008). Women’s and girls’ vulnerability to HIV infection stems from a greater biological risk that is compounded by gender inequalities, violations of women’s human rights, including violence, and, for some women, criminalization and marginalization.

The impact of the HIV/AIDS epidemic among women and girls has not gone unnoticed. Numerous international political declarations have recognized women’s and girls’ specific risks and needs and have committed to act to address them. Multilateral and bilateral donors have established strategies to better address women, girls, gender equality and HIV/AIDS and a number of countries have developed national action plans. However, the funding and implementation of evidence-based programs for women and girls continue to lag.

There is an urgent need to develop and scale up strategies to address the needs of women and girls in the global AIDS response and to support women as agents of change. To do this effectively, we need evidence. The purpose of What Works for Women and Girls: Evidence for HIV/AIDS Interventions is to provide the evidence necessary to inform country-level programming. What Works is a comprehensive review, spanning 2,000 articles and reports with data from more than 90 countries, that has uncovered a number of interventions for which there is substantial evidence of success: from prevention, treatment, care and support to strengthening the enabling environment for policies and programming. What Works also highlights a number of gaps in programming that remain.

International Political Commitments on Women, Girls and HIV/AIDS

Since the 1994 International Conference on Population and Development, governments have recognized that action must be taken to prevent HIV infections among women and girls, provide care and support, and address the “social, economic, gender and racial inequities” that increase vulnerability (ICPD Programme of Action, 1994). At the United Nations General Assembly Special Session in 2001, governments noted that “women and girls are disproportionately affected by HIV/AIDS” and committed to develop national strategies to “promote the advancement of women and women’s full enjoyment of all human rights; promote shared responsibility of men and women to ensure safe sex; empower women to have control over and decide freely and responsibly on matters related to their sexuality to increase their ability to protect themselves from HIV infection” (United Nations Declaration on HIV/AIDS, 2001).

In 2006, member states of the United Nations General Assembly went further in the Political Declaration on HIV/AIDS, committing themselves to, among other things:

Promote responsible sexual behavior among youth and adolescents (including the use of condoms)
Provide evidence- and skills-based, youth-specific HIV education and mass media interventions
Provide youth-friendly health services
Eliminate gender inequalities, gender-based abuse and violence
Provide health care and services, including for sexual and reproductive health, as well as comprehensive information and education to increase the capacity of women and adolescent girls to protect themselves from the risk of HIV infection
Ensure that women can exercise their right to have control over, and decide freely and responsibly on, matters related to their sexuality in order to increase their ability to protect themselves from HIV infection
Take all necessary measures to create an enabling environment for the empowerment of women and strengthen their economic independence
Strengthen legal, policy, administrative and other measures for the promotion and protection of women’s full enjoyment of all human rights
Ensure that pregnant women have access to antenatal care, information, counseling and other HIV services;
Increase the availability of and access to effective treatment to women living with HIV and infants in order to reduce mother-to-child transmission of HIV
Ensure effective interventions for women living with HIV, including voluntary and confidential counselling and testing, with informed consent; access to treatment, especially life-long antiretroviral therapy; and the provision of a continuum of care

Global Initiatives on Women, Girls and HIV/AIDS

A number of multilateral and bilateral donors have developed gender policies or strategies, including the two largest donors for AIDS: the Global Fund to Fight AIDS, Tuberculosis and Malaria and the U.S. President’s Initiative for AIDS Relief.

The Global Fund’s Gender Equality Strategy, approved in late 2008 (Global Fund, 2009), is aligned with the principles underpinning the Global Fund’s approach: country-led initiatives; evidence-based practices; subject to independent review; and able to be monitored. Based on the Gender Equality Strategy, the Global Fund promotes programs and seeks proposals that:

Scale up services and interventions that reduce gender-related risks and vulnerabilities to infection
Decrease the burden of disease for those most at-risk
Mitigate the impact of the three diseases
Address structural inequalities and discrimination

The legislation authorizing PEPFAR in 2003 contained strong language related to gender and the need to address the vulnerability of women and girls with strong programming to reduce gender inequity (Ashburn et al., 2009: USAID/AIDSTAR-One, 2009). The Office of the Global AIDS Coordinator (OGAC) defined five strategies to address gender inequity, including:

Increasing gender equity in HIV/AIDS activities and services
Reducing violence and coercion
Addressing male norms and behaviors
Increasing women’s legal protection
Increasing women’s access to income and productive resources

National Strategies

Some countries have created agendas that address gender issues within the AIDS pandemic. For example, Brazil brought together government agencies, the Ministry of Health and the Special Secretary for Women’s Policies, along with leaders in women’s rights and health promotion to develop an intersectoral policy to address women’s needs in the AIDS pandemic: access to health services; sexual and reproductive health care; social service needs, etc. (Guimaraes de Andrade et al., 2008). Similarly, seven Southern African countries have established national action plans on women, girls and HIV with multi-stakeholder involvement that include “a range of activities aimed at improving HIV prevention for women and girls and mitigating the impact of AIDS on them.” However, in 2007 only six of these plans had been costed out and partial funding had been provided for their implementation in just three countries (UNAIDS 2007c).

Analysis of the National Composite Policy Index from 130 countries of progress in creating an enabling policy environment for women suggests that policies and strategic plans are integrating women-related issues, but that funding for implementation is lagging (Carael et al., 2009).

Evidence to Inform Programming

One reason for the lag in program implementation is the lack of easily accessible information on which strategies are most effective in addressing women’s and girls’ HIV prevention, treatment, care and support needs. What Works for Women and Girls: Evidence for HIV/AIDS Interventions compiles the evidence available to support successful interventions for HIV and AIDS among women and girls with some attention to TB, malaria and hepatitis as they relate to HIV and AIDS.

Clearly, the question of “what works,” is complex. A more meaningful question is: “What policies did the country develop that led to implementation of specific interventions that can be shown to have reduced risk behavior resulting in fewer new infections, which became evident in falling HIV prevalence rates?” (Parkhurst, 2008). In designing HIV and AIDS programs, policymakers and program planners are faced with a wide array of interventions. With scarce resources and growing demand for services, program priorities must be based on effective interventions. Most scientific and biomedical research on HIV and AIDS interventions has been written for scientists; little has been written specifically for policymakers. This material is intended for practitioners who are designing HIV and AIDS interventions meant to address the needs of women and girls, and who are deciding among priority interventions. Organizations that provide assistance to programs worldwide will also benefit from this evidence.

This evidence was obtained primarily through detailed searches of peer-reviewed publications documenting evaluated interventions for women and girls. There are obvious limitations inherent in this approach: many worthwhile interventions do not have sex-disaggregated data, many interventions are not thoroughly evaluated, still others are not published in peer-reviewed journals or are not published at all. While this website covers many aspects of HIV/AIDS programming that are relevant for both women and men, it is not intended to be an exhaustive review of all HIV/AIDS programming. Instead, the review focuses on interventions that have an impact on HIV outcomes for women and girls.

This website is also not meant to be a set of guidelines for gender-sensitive programming, as it does not cover what should be done; it merely documents practices for which there is evidence of successful approaches. This document is best used with the range of guidelines for programming and it highlights some of those guidelines. Ideally, this document will serve to spur more programmers to evaluate their successful approaches and add them to the lexicon of “what works,” as well as to encourage researchers to set research agendas based on areas that are clear and critical gaps for women and girls.

Scaling Up

The interventions highlighted on this website are, for the most part, implemented on a small scale. Scant information is available on the costs of the interventions. It will be important to scale up the interventions to reach a broad range of relevant women and girls. In determining the feasibility of scaling up, it is important to assess the geographic coverage of the intervention, how gender was integrated and how well the intervention linked to a broader program strategy. How many countries were included? What populations/contexts within countries were included? Are any data regional, national or cross-national in scale? How well was gender integrated from conceptualization through implementation to evaluation? Was a gender analysis conducted to guide development of the program? Can the evidence be linked to a program strategy?

It is also important to assess whether:

Political support and buy-in for broad-scale implementation can be secured
Wider standards could be developed from the pilot or smaller-scale intervention
The intervention could be integrated into the public health system
Gender analysis in the broader program context is conducted and the intervention can be implemented given existing gender and epidemiology contexts
The intervention would have wide acceptability
Strategies can be devised to ensure acceptability
Information is available on the costs of the interventions

Effective interventions identified on this website will need to be adapted to local contexts and needs. Implementation of successful interventions for women and girls must also always respect their human rights.

Countries included in What Works (N=90)

Table 2. Countries included in What Works (N=90)
Africa	East/South East Asia	South Asia	Latin America and the Caribbean	Eastern Europe and Central Asia	North Africa/Near East	North America/Western and Central Europe and Oceania
30	13	4	16	12	3	12
Angola	Cambodia	Bangladesh	Argentina	Azerbaijan	Egypt	Australia
Benin	China	India	Bahamas	Bosnia and Herzegovina	Iran	Canada
Burkina Faso	Indonesia	Nepal	Brazil	Estonia	Turkey	France
Cameroon	Laos	Sri Lanka	Chile	Georgia		Italy
Côte d'Ivoire	Malaysia		Colombia	Kazakhstan		Spain
Democratic Republic of Congo/Zaire	Mongolia		Cuba	Moldova		New Zealand
Ethiopia	Myanmar		Dominican Republic	Romania		Papua New Guinea
Gabon	Philippines		Ecuador	Russia		Poland
Ghana	South Korea		Guyana	Tajikistan		Serbia
Kenya	Taiwan		Haiti	Ukraine		Switzerland
Lesotho	Thailand		Honduras	Uzbekistan		United Kingdom
Liberia	Vietnam		Jamaica			United States
Madagascar			Mexico
Malawi			Nicaragua
Mauritius			Peru
Mozambique			Trinidad and Tobago
Namibia
Nigeria
Republic of Congo
Rwanda
Senegal
Sierra Leone
South Africa
Sudan
Swaziland
Tanzania
Uganda
Zambia
Zimbabwe