HIV & AIDS

President Trump reinstated and expanded the Mexico City Policy, often known as the Global Gag Rule, and renamed it the Protecting Life in Global Health Assistance (PLGHA) policy. When in place under previous administrations, the policy applied only to international family planning assistance, whereas Trump’s version of the policy "extend(s) the requirements... to global health assistance furnished by all departments or agencies." Research has documented the harms of this policy in previous administrations when the policy was in effect, and the expansion of this policy via this 2017 Presidential Memorandum demonstrated a disregard for evidence and international human rights norms. This policy spurred a chain of events that significantly reduced community and government engagement in HIV prevention, care, and treatment programs and prohibits beneficiaries from accessing key services in many countries that receive U.S. global health assistance. The expansion of the PLGHA policy was against evidence, need, and human rights principles and was not gender transformative; this policy was gender blind, as it did not discuss the role of gender norms on the promotion of SRHR through U.S. global health assistance programs.

The United States National Action Plan on Women, Peace, and Security described what the U.S. continues to do to empower women as equal partners in preventing conflict and building peace in countries threatened and affected by war, violence, and insecurity. The Plan moderately promoted SRHR by calling for better access to "clinical care and reproductive health services such as family planning, HIV testing, counseling, and treatment…" though HIV testing, counseling, and care was not discussed in further detail. The Plan did not explain the impact of access to HIV and AIDS prevention and treatment services on conflict prevention and country stability nor did it acknowledge the relationship between gender-based violence (GBV) in conflict and the prevalence of HIV and AIDS among women and girls. In fact, there was little discussion on any structural, cultural, and safety barriers that prevented women in conflict-ridden areas from accessing the HIV and AIDS care they wanted and needed. However, the Plan did discuss the intersections of HIV and AIDS with other sexual and reproductive health (SRH) issues, such as maternal mortality. Additionally, this plan is moderately gender transformative as it called for more gender equality and inclusivity in all initiatives, especially regarding “members of marginalized groups, including youth, ethnic, racial or religious minorities, persons with disabilities, displaced persons and indigenous peoples, lesbian, gay, bisexual, transgender, and intersex (LGBTI) individuals, and people from all socioeconomic strata.” The Plan also discussed the distinct needs of ex-combatants and former violent extremists who are female, specifically stating that these women have a difficult time adhering to traditional gender norms upon their return from combat. However, it did not explicitly mention the disproportionate impact of HIV and AIDS on former combatant populations or other key populations such as female sex workers or people who inject drugs (PWID). This National Action Plan supported the U.S. government's ability to promote SRHR with regard to HIV and AIDS programs and funding.

The Country Operational Plan (COP) Guidance is an annual document released by the Office of the Global AIDS Coordinator. It outlines the plan for global HIV and AIDS activities funded by PEPFAR and provides the basis for the approval of annual bilateral HIV and AIDS funding for partner countries. The 2017 COP Guidance was evidence-informed and ensured continued community and government engagement in PEPFAR programs. It also discussed the intersection of gender-based violence with HIV and AIDS and the importance of including contraception and counseling into HIV and AIDS programs. This guidance moderately promoted SRHR because it was responsive to need and addressed the disproportionate impact of HIV and AIDS on adolescent girls and young women, men who have sex with men (MSM), female sex workers, and transgender individuals. The plan was gender accommodating, as it did not seek to dismantle existing gender differences and inequalities. Such guidance should instead outline how to change inequitable gender norms and dynamics and promote gender equity.

The PEPFAR Evaluation Standards of Practice was released to increase the quality of evaluations conducted by all PEPFAR implementing agencies. These standards emphasized the importance of evidence-informed evaluation planning and provided a detailed explanation of the ethics and human rights principles that should be incorporated in all PEPFAR-funded evaluations, particularly for "children, prisoners, pregnant women, and other vulnerable groups." Additionally, these standards laid the groundwork for adaptive programming and the continued commitment of all key stakeholders, including community members and government personnel, in PEPFAR programs. Although the Standards of Practice acknowledged that evaluations should be “context-sensitive” and “culturally relevant,” they did not include a gender transformative component. There was no mention of the gendered power dynamics and cultural barriers that may prevent people living with HIV, sex workers, or lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI+) persons from participating in evaluations. Despite this, the Standards of Practice were responsive to need and were based in evidence. The Standards moderately supported the ability of PEPFAR programs to promote SRHR.

The 2017 PEPFAR Monitoring, Evaluation, and Reporting (MER) Indicator Reference Guide provided guidance for monitoring and evaluating PEPFAR’s HIV and AIDS programs. The indicators were evidence-informed, based on human rights principles, and detailed the importance of sustained “district and community” engagement. The document included an extensive list of indicators for HIV and AIDS program evaluation, including the number of key and priority populations reached with specifically tailored HIV prevention programs, and the percentage of pregnant women living with HIV that receive antiretroviral therapy (ART) to reduce mother-to-child transmission. Though the Reference Guide listed sex workers, MSM, and transgender individuals as key populations, it did not address their distinctive needs when discussing how to evaluate interventions that were tailored for these populations. This lack of clarity can be harmful as evaluators may not understand how to meaningfully engage with these key populations during the evaluation, monitoring, and reporting processes. The indicators were somewhat gender transformative, as they included a limited discussion of gender norms and related stigma, though this element should be standardized throughout the Reference Guide. The updates within this version of the MER Reference Guide were responsive to need and based in human rights norms and evidence, including WHO and UNAIDS indicators.

The Department of State Implementation Plan for the U.S. Adolescent Girls Strategy was launched in partnership with three other U.S. implementing agencies as part of the first U.S. Global Strategy to Empower Adolescent Girls in 2015. This Plan moderately promotes sexual and reproductive rights (SRHR) because it discussed the importance of incorporating HIV prevention in all adolescent girls' empowerment programs, especially those that address girls’ political, civic, and economic participation and programs that increase peace and security. This Plan specifically acknowledged the relationship between girls who have undergone female genital cutting (FGC) and their increased risk of acquiring HIV. The Plan also mentioned HIV as a barrier to girls’ education and provided examples of existing Department of State programs that are responsive to need and grounded in human rights, including the President’s Emergency Plan for Aids Relief (PEPFAR). However, this Plan did not disclose how to support the needs of adolescent girls and young women (AGYW) who are living with HIV. It only discussed preventing HIV transmission to AGYW. The Plan is gender accommodating, not gender transformative because it relied on existing gender norms and references unequal gender and age dynamics that put AGYW at a higher risk of HIV incidence.

The Country Operational Plan (COP) Guidance is an annual plan that outlines global HIV and AIDS activities funded by PEPFAR and provides the basis for the approval of annual bilateral HIV and AIDS funding for partner countries. The fiscal year (FY) 2016 COP Guidance was responsive to need and addressed the disproportionate impact of HIV and AIDS on AGYW and other key populations such as men who have sex with men (MSM), female sex workers, pregnant women and infants living with HIV, and transgender individuals. The programming was evidence-informed and promoted community and government engagement. Although the Guidance discussed the intersection of gender-based violence (GBV) and HIV and AIDS, it failed to strongly incorporate the positive impact that comprehensive and integrated sexual and reproductive health (SRH) services can have on reducing HIV transmission amongst key populations.

The USAID Adolescent Girl Strategy Implementation Plan was launched in partnership with three other U.S. implementing agencies as part of the first U.S. Global Strategy to Empower Adolescent Girls in 2015. The Plan moderately promoted SRHR, noting the importance of using USAID’s “whole-of-girl” approach (which “encompasses the interconnected events that resonate across a girl’s life from birth to adulthood”) to reduce gender disparities and gender-based violence (GBV) and increase capacity of women and girls through USAID’s programs. Though it did not explicitly mention USAID’s HIV and AIDS programs through the President’s Emergency Plan for Aids Relief (PEPFAR), this Plan provided a high-level overview of the programs, best practices, and indicators that were used to measure USAID’s progress in implementing the Adolescent Girl Strategy across programs, including HIV and AIDS. The Plan was responsive to need and based in evidence. The Plan referenced USAID’s ongoing work on gender (e.g., implementing USAID’s 2012 Gender Equality and Female Empowerment Policy) and directly acknowledged the importance of incorporating activities that foster gender equity in all USAID programs. This plan supported the ability of USAID to implement HIV and AIDS programs that moderately promoted SRHR.