YEAR 2021

Department of State

The Department of State received a 65 (D) with transparency and a 70 (C-) without transparency in 2021. The President’s Emergency Plan for AIDS Relief (PEPFAR) Core Program and Policy Priorities, along with the updated DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) Guidance from March 2021 raised this actor’s grade across domains. The February 2021 updates to the Country Operational Plan (COP)/Region Operational Plan (ROP) Guidance for all PEPFAR Countries significantly hindered sexual and reproductive health and rights (SRHR) across all domains because it did not provide specific guidance to help stakeholders understand how the revocation of the Protecting Life in Global Health Assistance (PLGHA) policy would impact their programs. However, the actions graded in the HIV and AIDS domain were largely based in evidence, consistent with human rights, and responsive to need. In contrast, actions graded in the maternal and child health (MCH) and family planning (FP) domains for the Department of State did not include relevant evidence and were not grounded in human rights. Transparency was lower in the MCH and FP domains than in the HIV and AIDS domain. The Department of State grade was raised by high budget scores across domains, because MCH and FP health funds were moderately responsive to need, and HIV funds were highly responsive to need in 2021.

A+

HIV & AIDS

The Department of State received a 94 (A) with transparency and a 98 (A+) without transparency in the HIV and AIDS domain in 2021. This domain grade was raised by the PEPFAR Core Program and Policy Priorities, as well as the updated DREAMS Guidance from March 2021, which were both responsive to need, based in evidence, aligned with human rights norms, and were gender transformative. The February 2021 COP/ROP Guidance and other COP/ROP-related materials did not promote SRHR because they did not include adequate information for partners to understand the revocation of PLGHA and adapt their programs accordingly. Overall, actions graded in this domain were largely gender accommodating, and could have included more gender transformative elements. In the budget evaluation, the Department of State allocated HIV and AIDS funds in accordance with country-level HIV incidence, which significantly promoted SRHR. Transparency was relatively high across actions and budget data in the HIV and AIDS domain.

The Fòs Feminista data index grades government agencies on policies and funding impacting family planning, maternal and child health, and HIV & AIDS foreign assistance.

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2021_2021 Annual PEPFAR Treatment Report to Congress

The Annual Treatment Report from PEPFAR provides information to Congress on PEPFAR-supported treatment programs as required by Section 7611 (g) of Title 22 of the U.S. Code. The 2021 Report focused on the programmatic adaptations PEPFAR implemented in response to the COVID-19 pandemic to ensure that treatment programs were not disrupted. Adaptations included multi-month dispensing (MMD) of antiretroviral drugs (ARVs), the decentralization of drug delivery, the use of virtual platforms like telemedicine, and the implementation of efforts to empower communities, which were responsive to need, based in evidence, and aligned with human rights. The Report cited PEPFAR's ability to strategically invest its resources across operating units (OUs) through data-driven programming to support countries in reaching the 95-95-95 UNAIDS targets, which was responsive to need. Additionally, the Report did not include treatment data related to key populations (KPs), which was an oversight. The Report included a description of DREAMS, a public-private partnership that includes gender transformative elements as a means to decrease HIV acquisition among adolescent girls and young women (AGYW). The DREAMS program was not explained in detail in the Report as DREAMS is primarily an HIV prevention program, not a treatment program, so information about gender transformative programs outside of DREAMS was lacking. The Report moderately promoted SRHR in the HIV and AIDS domain.

2021_Country_Regional Operational Plan 2021 (COP/ROP 2021) Virtual Meeting Handbook

This Virtual Meeting Handbook outlined the ways in which the Office of the Global AIDS Coordinator (OGAC) streamlined the COP/ROP 2021 process in response to the COVID-19 pandemic. The COP/ROP 2021 process was shortened and conducted virtually for the first time, which was highly responsive to need due to the pandemic and this action ensured that PEPFAR stakeholders at all levels had timely information about this process. This action detailed the revised framework for ensuring meaningful stakeholder engagement by mandating transparent discussions with PEPFAR leadership during town halls with stakeholders at all levels and involving partner country governments, communities, civil society organizations (CSOs), multilateral partners, and the private sector, which was responsive to need. This action included guiding principles for PEPFAR during the COVID-19 pandemic that were responsive to need and consistent with evidence and human rights norms, such as protecting program gains, ensuring site safety, and mitigating COVID-19’s impact on programs like DREAMS. This action moderately promoted SRHR in the HIV and AIDS domain.

2021_Department of State and USAID_Fiscal Year (FY) 2022 Annual Performance Plan

The Fiscal Year (FY) 2022 Annual Performance Plan outlined progress made by the Department of State and the United States Agency for International Development (USAID) toward strategic objectives and performance goals in previous years. The Plan outlined each agency’s plans for achieving the goals articulated in their joint strategic plan moving forward. This action was highly responsive to need as it provided key status updates on the Department of State’s activities related to global HIV and AIDS programs, including new HIV diagnoses, the numbers of adults and children receiving antiretroviral (ARV) medication, and the number of voluntary medical male circumcision (VMMC) procedures conducted per FY. The availability of these data supported evidence-based decision making, which was aligned with evidence and responsive to need. The Report was not fully responsive to need as specific programs for KPs and AGYW were not detailed. However, progress related to cross-cutting SRHR issues like gender-based violence (GBV) and gender equality were included in this action, which was responsive to need. The Report was gender accommodating, as it used language that reinforced a gender binary. Importantly, no targets were included for FY 2022 indicators, which was not responsive to need and negatively affected transparency. This action moderately promoted SRHR in the HIV and AIDS domain.

2021_Guiding Principles for the Next Phase of PEPFAR

The Guiding Principles outlined PEPFAR’s goals as of January 20, 2021, and presented progress to date, including national progress toward achieving the 90-90-90 and 95-95-95 targets in specific countries. This action detailed the impact of COVID-19 on PEPFAR programs, as well as outlined programmatic adaptations that OUs implemented to overcome the impacts of the pandemic, which was responsive to need and based in evidence. The Guiding Principles focused on providing people-centered HIV prevention, care, and treatment services and mentioned the need to increase investments in direct prevention and treatment services for women, girls, and KPs, which was responsive to need and aligned with evidence. However, this action did not mention the human rights framework that underpins PEPFAR programming, nor did it discuss the importance of integrated services and universal health coverage (UHC) in advancing PEPFAR’s goals. Additionally, this action was gender accommodating as it included language that reinforced a gender binary. This action moderately promoted SRHR in the HIV and AIDS domain.

2021_PEPFAR 2021 Annual Report to Congress

The PEPFAR 2021 Annual Report to Congress detailed the achievements of PEPFAR and challenges to delivering people-centered HIV services because of the COVID-19 pandemic. This action outlined country-specific progress toward the 90-90-90 targets, documented PEPFAR’s efforts to strengthen health systems, and advocated for integrated GBV programs, which were responsive to need and based in evidence. This action highlighted the importance of addressing barriers to accessing care and working with community- and KP-led indigenous organizations to promote human rights, which was responsive to need and promoted SRHR. Though this action mentioned that PEPFAR provides “condoms for all populations at significant risk of acquiring HIV,” all mentions of condoms in the Report were in relation to PEPFAR’s KP activities, so it neglected to mention the importance of condoms as a dual-prevention method for all people. This action mentioned the gender transformative elements of the DREAMS program, but was gender accommodating as it generally used language throughout that reinforced a gender binary. This action moderately promoted SRHR in this domain.

2021_PEPFAR 2021 Country and Regional Operational Plan (COP/ROP) Guidance for all PEPFAR Countries

On February 11, 2021, OGAC released an updated version of the COP/ROP 2021 Guidance that revised four sections of this critical PEPFAR guiding document. Section 5.9.4 was updated to cross out the text related to the Protecting Life in Global Health Assistance (PLGHA) policy. The action included the following information: “Implementation of Protecting Life in Global Health Assistance in PEPFAR Programs has been deleted as the policy was rescinded by President Biden in January 2021” but did not provide stakeholders with any additional information about what the revocation meant for OUs or ongoing awards. Though this update was timely, it lacked specificity and guidance for stakeholders to understand how the revocation of PLGHA (also known as the Global Gag Rule [GGR]) impacted their work, so it was only somewhat responsive to need and was not based in evidence or human rights. As a result, this action significantly hindered SRHR in the HIV and AIDS domain.

2021_PEPFAR COP/ROP 2021 Frequently Asked Questions

This Frequently Asked Questions (FAQs) document provided regular updates on the COP/ROP 2021 process after it was temporarily paused earlier in 2021. This action included information about civil society and community engagement and provided answers to questions that were specific to technical areas, all of which were responsive to need and based in evidence. For example, this action included FAQs that confirmed that all index testing programs for KPs should never be coercive and must follow PEPFAR guidance for safe and ethical index testing, which was responsive to need and based in evidence and human rights. The action included one question related to the impact of “new policies of the Biden-Harris Administration, such as the rescission of the Mexico City Policy” on the COP/ROP 2021 process. The answer said that “PEPFAR funding and partners are no longer subject to these policy requirements and instead should follow those outlined in the January 28, 2021 Executive Order” and included a hyperlink to the executive action. This answer did not include additional information or guidance for stakeholders to understand how the revocation of this policy impacted their work with PEPFAR, which was not responsive to need. As a result, this action moderately hindered SRHR in the HIV and AIDS domain.

2021_PEPFAR COP/ROP 2021 Temporary Pause FAQs

PEPFAR released this FAQs document on February 17, 2021, which confirmed the Biden administration’s commitment to PEPFAR as well as provided an explanation for the temporary pause of the COP/ROP 2021 process. This action reaffirmed OGAC’s commitment to completing a data-driven COP/ROP 2021 process and ensuring that there were no disruptions in HIV services at the start of FY 2022. Many of the process-specific questions included in this action were included in the previous action, including a question that highlighted the sections that were updated in the February 2021 version of the COP/ROP 2021 Guidance. Most of the questions were procedural and not technical, so this action neither promoted nor hindered SRHR in the HIV and AIDS domain.

2021_PEPFAR Core Program and Policy Priorities

The PEPFAR Core Program and Policy Priorities outlined the focus areas of PEPFAR under the Biden administration. The action included key priorities on HIV prevention and treatment: data-driven HIV testing strategies such as support for KPs, gender equity and equality, cooperation and partnership with community stakeholders and public health leadership, and the strengthening of global health security. These priorities were responsive to need, based in evidence, and aligned with human rights norms. Notably, the action included a priority to promote and protect SRHR, including through the revocation of PLGHA. This action provided a high-level framework for PEPFAR’s focus areas, so information about how PEPFAR would implement the revocation would not be included in this action. The action stated the importance of improving appropriate linkages to and integration of HIV services with other related global health programs, which was responsive to need. Gender transformative elements were highlighted in the section on “HIV prevention, clinical, and health systems programs” and through the Department of State’s commitments to diversity, equity, inclusion, and accessibility (DEIA). This action significantly promoted SRHR in the HIV and AIDS domain.

2021_PEPFAR DREAMS Guidance_Updated March 2021

The PEPFAR DREAMS Guidance provided updated guidance for implementing DREAMS programming for AGYW in 2021. The Guidance highlighted the importance of multi-sector engagement across government leadership and community partners, evidence-based decision making across DREAMS programming, and overall prioritization of DREAMS implementation. The Guidance was based in evidence and human rights as it referenced a variety of peer-reviewed external resources as well as international agreements and frameworks. It highlighted the need to adapt and scale up pre-exposure prophylaxis (PrEP) for AGYW, especially considering the COVID-19 pandemic, which was responsive to need. The Guidance stated the importance of linking AGYW who sell sex or participate in transactional sex to KP programming and clearly stated that it was unethical to withhold condoms for high-risk groups, which was based in evidence and responsive to need. It was gender transformative as it affirmed the importance of HIV and AIDS service provision and comprehensive sexuality education (CSE) and called for changing unequal gender and power dynamics. However, this Guidance used gendered language when mentioning condoms and pregnancy, did not affirm the right to sexual pleasure, and did not include guidance to meet the specific needs of LGBTQI+ women and girls, which was an oversight. This Guidance significantly promoted SRHR in the HIV and AIDS domain.

2021_PEPFAR FY21 Site Improvement through Monitoring System (SIMS) Materials_Version 4.1

The PEPFAR Site Improvement through Monitoring System (SIMS) tool provides a standardized approach for monitoring program quality at PEPFAR-supported sites that perform service and non-service delivery functions. The FY21 Implementation Guide, Above-Side Assessment Tool, and Site Assessment Tool were updated in 2021, though the changes from the previous version were not clearly stated, which negatively affected transparency. The Above-Site and Site Assessment Tools included Core Essential Elements (CEEs) that assessed the site against a set of standard technical requirements, which were based in evidence. The major apparent change in the CEEs was the removal of assessment modules related to the implementation of PLGHA in the Above-Site Assessment Tool. This module was removed without explanation. A new module was not added to ensure that PEPFAR-supported sites stopped implementing the policy after its revocation, which was not responsive to need or consistent with evidence and human rights norms. The updated SIMS materials included the PEPFAR Ethical Framework for Engagement of KPs, which was aligned with human rights and evidence and responsive to need. It included guidance for SIMS assessors to not participate in or condone discriminatory practices based on gender, race, ethnicity, caste, religion, sexual orientation, disability, or socio-economic status, which was based in evidence and responsive to need. The CEEs were somewhat gender transformative because they included guidelines and standards for evaluating interventions related to changing unequal gender norms, but used language that reinforced a gender binary. The SIMS materials updated in 2021 moderately promoted SRHR in the HIV and AIDS domain.

2021_PEPFAR Monitoring, Evaluation, and Reporting Indicator Reference Guide_MER 2.0 (Version 2.6)

The Monitoring, Evaluation, and Reporting (MER) Indicator Reference Guide is reviewed and updated annually to streamline and prioritize the standard indicators used across PEPFAR programs. The 2021 Guide introduced trainings for U.S. government (USG) and implementing partner staff on indicators across technical areas, which was responsive to need. The Guide introduced PREP_CT, a new indicator to measure the continued use of PrEP among patients who returned for a follow-up or re-initiation visit. This update was responsive to need because it provided greater oversight to monitor PrEP adherence and make evidence-based decisions about the implementation of PrEP programs. The indicator was aligned with World Health Organization (WHO) guidelines, included new biomedical prevention products, and encouraged PrEP adherence for sex workers of all genders, which was based in evidence and human rights. Other updates to the MER indicators included new data disaggregations, provided updated reporting frequencies, and clarified definitions, all of which were responsive to need. The Guide maintained the reduced number of disaggregations for KPs, which directed implementing partners to report an individual in the KP category “with which s/he is most identified,” which was not based in evidence or human rights, and was not gender transformative as in reinforced a gender binary and did not include the needs of nonbinary people. This action moderately promoted SRHR in the HIV and AIDS domain.

2021_Prioritizing Sexual and Reproductive Health and Reproductive Rights in U.S. Foreign Policy

Secretary of State Blinken delivered this Press Statement on prioritizing SRHR in U.S. foreign policy, which described how the Department of State would implement the presidential memorandum that rescinded PLGHA. Though this action mentioned the revocation of the GGR, it did not provide guidance for programs about adapting their work to align with the presidential memorandum, which was not responsive to need and was a missed opportunity to highlight the Department of State's specific responsibility to promote SRHR as the funding agency of global health assistance. The action highlighted the reinstatement of funding to the United Nations Population Fund (UNFPA), the withdrawal of the United States from the Geneva Consensus Declaration, and the increased access to vital health services, including HIV and AIDS services for KPs, tuberculosis diagnosis and treatment, and “maternal health and voluntary family planning” services. While these statements were responsive to need and based in evidence and human rights, the lack of detail regarding HIV and AIDS services was an oversight. This action was gender accommodating as it acknowledged gender inequities but used language that promoted a gender binary by only recognizing SRHR for women and girls, even though SRHR is vital for all people. This action moderately promoted SRHR in the HIV and AIDS domain.

2021_Strengthening Health Security Across the Globe_Progress and Impact of United States Government Investments in the Global Health Security Agenda

This Report detailed the progress and impact of the USG’s investments in global health security during FY 2020, including those led by the Department of State. The Report detailed the distribution of Congressional appropriations to advance global health security efforts in 19 partner countries to respond to disease outbreaks and prevent future outbreaks whenever possible. The Report did not mention other global health security efforts by the Department of State as it pertained to HIV and AIDS services. Though the Report focused on global health security, SRHR and other cross-cutting issues such as GBV were not mentioned. The exclusion of these cross-cutting issues was not based in evidence as the inclusion of SRHR and gender equity promotes global health security. This exclusion was not responsive to need as SRHR services are often the first set of "essential services" to be neglected in a health emergency, as evidenced by the initial global response to COVID-19. The Report was gender blind as it made only one mention of gender in the context of OneHealth. This action moderately hindered SRHR in the HIV and AIDS domain.

2021_Trafficking In Persons Report_ Human Trafficking in the Context of a Global Pandemic

The 2021 Trafficking in Persons Report detailed the approach outlined by the Department of State to combat human trafficking, with additional detail about these activities in the context of the COVID-19 pandemic. The Report outlined lessons learned from the pandemic and called for "comprehensive, trauma- and survivor-informed, and victim-centered anti-trafficking responses during the pandemic." The Report stated that global crises such as COVID-19, climate change, and enduring discriminatory policies and practices disproportionately impact people who are already oppressed by other injustices and increase people’s vulnerability to exploitation, which was based in evidence and responsive to need. While the Report recognized that survivors of trafficking are hesitant to interact with carceral systems, it promoted prosecution and a carceral approach to trafficking, which was not responsive to need. The Report mentioned HIV-related outcomes in reference to LGBTQI+ populations who are trafficked but did not meaningfully include HIV outcomes and PEPFAR programming, which was a missed opportunity to highlight the Department of State’s global HIV and AIDS efforts. The Report moderately hindered SRHR in the HIV and AIDS domain.

2021_United States Government Women, Peace, and Security (WPS) Congressional Report

The Women, Peace, and Security (WPS) Congressional Report provided Congress with an overview of progress specific USG agencies have made in implementing the WPS Agenda globally since 2019. The Report evaluated progress in advancing the WPS Strategy's four lines of effort across the Department of State, DoD, Department of Homeland Security (DHS), and the United States Agency for International Development (USAID): participation, protection, internal capabilities, and partnerships. While improved global health outcomes were included as a positive impact of implementing the WPS Agenda, the contributions of global HIV and AIDS programs to the WPS efforts were not meaningfully included in this action. However, the Report included GBV prevention and programming as a measure of progress towards achieving the WPS Agenda, which was responsive to need. The Report highlighted an initiative by the Department of State to lead a data-driven monitoring, evaluation, and learning (MEL) exercise on its WPS efforts for the first time, which was based in evidence and responsive to need. The Report included specific and actionable milestones to measure the actor’s progress on these goals, which was responsive to need and could support evidence-based decision making in the future. The Report included several gender transformative elements, such as enhancing gender-sensitive data analytics, recognizing "the intersectionalities inhabited by women," and supporting initiatives to address and overhaul harmful gender norms. However, it was predominantly focused on women which reinforced a gender binary. The Report moderately promoted SRHR in this domain.

2020_Contraception for Women at High Risk of HIV Technical Update

The purpose of this Technical Update was to explain the implications of the Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial results on “reproductive health programming” funded through U.S. global health assistance. The Technical Update summarized updated guidance from the World Health Organization (WHO) regarding the use of contraception by women at high risk of acquiring HIV, which had been revised based on the ECHO Trial findings. Though the WHO released its revised guidance in August 2019 shortly after the ECHO Trial results were published, the Department of State (as the funding agency for PEPFAR) did not publish this Technical Update until December 2020. Because of this delay, the action was not fully responsive to need. The Technical Update was aligned with international human rights norms and evidence (e.g., quality of care, voluntarism, informed choice, differentiated service delivery models, patient-centered approaches free of stigma and discrimination) and included specific programmatic and policy guidance for working closely with diverse stakeholders to adapt global HIV and FP programs accordingly. The Technical Update mentioned "male and female condoms" as the only contraceptive methods that can reduce the risk of sexually transmitted infection (STI) and HIV transmission, which was based in evidence but it was not gender transformative because it used the outdated “male and female” terminology instead of the gender inclusive “internal and external” terminology. The Technical Update substantially promoted SRHR in the HIV and AIDS domain.

2020_Department of State and USAID Agency Priority Goal Action Plan_HIV/AIDS

To report on their joint progress toward PEPFAR program goals, strategies, milestones, and indicators in fiscal year (FY) 2020, the Agency Priority Goals (APGs) for HIV and AIDS were released quarterly by both the Department of State and the United States Agency for International Development (USAID). This action included providing client-centered treatment services; scaling up index testing and targeted HIV testing approaches; increasing access to voluntary medical male circumcision (VMMC) services; and providing comprehensive packages of health and social services for priority and key populations (KPs), including oral pre-exposure prophylaxis (PrEP) and education on risk reduction. These programmatic efforts and the indicators presented in the APGs were based in evidence and were responsive to need. The APGs reflected commitment from PEPFAR to ensuring that data were collected thoroughly and accurately, while also maintaining accountability to targets which were responsive to need. The APGs were not gender transformative as they did not explicitly mention ongoing activities to address inequitable gender norms, such as the DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) program. It also did not reference any human rights principles or frameworks that guided them. The APGs moderately promoted SRHR within the HIV and AIDS domain.

2020_Department of State and USAID Joint Report to Congress on U.S. Foreign Assistance Gender-Related Programming_Fiscal Years 2017 and 2018

The Department of State and USAID submitted this joint report to Congress on gender-related programming funded through all types of U.S. foreign assistance in FY 2017 and 2018 as required by the Department of State, Foreign Operations, and Related Programs Appropriations Act, 2019. It reported on $110 million of PEPFAR funds that were used during those two fiscal years to provide gender-based violence (GBV) prevention services as well as the full package of post-GBV care, including HIV and violence prevention services in communities and schools where the DREAMS program was being implemented. The Report mentioned specific activities, including community-based mobilization, norms-change efforts, and safe spaces interventions, which were based in evidence, consistent with human rights norms, responsive to need, and gender transformative. This Report included information about numerous other programs and funding types across both the Department of State and USAID, but there was insufficient information to determine if those other programs were considered U.S. global health assistance, which contributed to low transparency. Additionally, U.S. global health funds were not explicitly included in the funding table at the end of the Report, which also contributed to low transparency. This report moderately promoted SRHR in the HIV and AIDS domain.

2020_Department of State and USAID_Fiscal Year (FY) 2020 Annual Performance Report

The 2020 Annual Performance Report outlined Department of State and USAID progress toward strategic objectives, APGs, and performance goals in FY 2020 in accordance with their joint strategic plan. These goals included global health and gender-related programs across all three domains for both actors. The Report detailed the joint efforts by the Department of State and USAID to achieve HIV and AIDS epidemic control within Performance Goal 3. It provided updates on PEPFAR progress towards indicators that were included in the APGs, including increasing antiretroviral therapy (ART) enrollment and coverage, scaling up VMMC, as well as other targets in FY 2020. This Report provided additional explanation for the actor’s progress toward each indicator, which included needing to pause, scale down, or refocus global HIV and AIDS programs due to COVID-19 restrictions. This element of the Report was highly responsive to need based on the presentation of programmatic data and the impact of COVID-19 on global HIV and AIDS programs. However, the Report lacked a description of the evidence and human rights frameworks that guide PEPFAR programming. The Report included data on a few indicators that measured gender norm change, but they were gender accommodating and not gender transformative because they focused on “males and females” which reinforced a gender binary. As such, this report moderately promoted SRHR in the HIV and AIDS domain.

2020_Geneva Consensus Declaration on Promoting Women’s Health and Strengthening the Family

Along with 33 largely authoritarian governments, the United States signed the Geneva Consensus Declaration, a nonbinding declaration to advance the Trump administration’s anti-abortion agenda. Secretary of State Pompeo and Secretary of Health and Human Services Azar jointly participated in the signing ceremony on behalf of the Trump administration. The Declaration cited several international human rights documents to bolster its position that abortion was not to be included in any sexual and reproductive health (SRH) or universal health coverage programs. However, the Declaration did not recognize pregnant people’s right to bodily autonomy. It was also not aligned with evidence as evidence suggests that restricting access to safe abortion services results in increased rates of unsafe abortion. This action was not responsive to need and was not gender transformative because it reinforced a gender binary throughout the Declaration and ignored gender inequalities and other systemic issues that might impact people's ability to access SRHR services, including HIV and AIDS services. In fact, both the language used and the exclusion of SRHR were so deeply rooted in patriarchal structures that the Declaration was gender exploitative. The Declaration failed to acknowledge the human rights of those in the LGBTQI+ community, which threatened to roll back progress made on recognizing the health needs of pregnant people who may not identify as women and/or those who identify as LGBTQI+. The stance of the Administration as demonstrated by the Department of State signing onto this Declaration substantially hindered the ability of U.S. global health assistance to promote SRHR in the HIV and AIDS domain.

2020_Guiding Principles for the Next Phase of PEPFAR

This Guiding Principles document outlined the progress made by PEPFAR toward the 90-90-90 targets as of December 1, 2020, including programmatic adaptations to respond to COVID-19. This action included the approaches PEPFAR plans to implement to contribute to Sustainable Development Goal (SDG) 3 and achieve epidemic control by 2030. The principles focused on delivering inclusive, people-centered HIV prevention and treatment services and incorporating new scientific breakthroughs and technologies, which would decrease individual barriers to accessing HIV services. The Guiding Principles were based in evidence and included data-driven decision-making as a core component of the PEPFAR program, though it did not explicitly mention human rights norms or principles that were incorporated into the design and implementation of PEPFAR programs. It discussed the comorbidities that can impact the health of people living with HIV, including cervical cancer, and documented the progress made to address these health issues, thereby making it responsive to need. By describing the impact of COVID-19 on specific populations and documenting how PEPFAR programs adapted their implementation to continue to serve clients, this action was highly responsive to need. The Guiding Principles were not gender transformative, as they did not meaningfully discuss gender or the gender transformative components of DREAMS and other key programs. The Guiding Principles moderately promoted SRHR in the HIV and AIDS domain.

2020_PEPFAR 2020 Annual Report to Congress

The PEPFAR Annual Report to Congress provided a comprehensive overview of PEPFAR and its accomplishments as of 2020. It outlined the evidence base for PEPFAR programs and the methods used to make data-informed decisions including disaggregating all data by sex, age, and geography through the Monitoring, Evaluation, and Reporting (MER) system. The Report also noted the importance of adhering to guidance from the WHO (e.g., providing Dolutegravir-containing regimens for all women of childbearing age) and creating innovative partnerships with diverse partners, including the private sector, multilateral organizations, civil society and communities, and local organizations. This report also mentioned the importance of connecting PEPFAR's efforts with global health diplomacy, which was responsive to need, based in evidence, and aligned with human rights norms. Ensuring people of “all ages, genders, and at-risk populations know their HIV status” was a focus of this report, which addressed the disproportionate risk of HIV for KPs, women, and girls and was based in evidence and responsive to need. The Report was gender accommodating, as it contained few gender transformative elements. The Report also discussed the importance of economic empowerment activities as part of DREAMS programs and reported on increasing access to PrEP across PEPFAR countries. However, details about the importance of other biomedical HIV prevention products were lacking from the Report. The Report moderately promoted SRHR through this domain.

2020_PEPFAR 2020 Country Operational Plan Guidance for all PEPFAR Countries

Each year, the Office of Global AIDS Coordinator (OGAC) releases the PEPFAR Country Operational Plan (COP) Guidance, which includes the programmatic and policy guidance for global HIV and AIDS activities and provides the basis for the approval of annual bilateral funding for PEPFAR country and regional programs. The 7 Minimum Program Requirements included in the 2020 COP Guidance were aligned with international human rights norms and evidence and were designed to ensure that PEPFAR programs are responsive to need. One major technical update in the 2020 COP Guidance was the pause in index testing across all operating units (OUs) due to human rights and safety concerns that arose through implementation, and the commitment from PEPFAR to develop minimum standards for safe index testing. The decision to pause index testing was evidence-based, consistent with human rights norms, and was responsive to needs raised via civil society organization (CSO) engagement and advocacy. The 2020 COP Guidance also directed PEPFAR programs to cease provision of VMMC for males under the age of 15 and those not reaching Tanner stage 3 sexual development, which was in response to reported adverse events among those under 15. This update was responsive to need and based in evidence. The 2020 COP Guidance also indicated that PEPFAR would double its investment in primary HIV prevention through DREAMS programs, which was based in evidence and responsive to need based on the progress already documented in DREAMS districts. Overall, the Guidance was largely evidence-based, responsive to need, and consistent with human rights norms. However, programmatic adaptations for persons with disability were not meaningfully included in the 2020 COP Guidance, which may impact access to HIV and AIDS services. The Guidance was not gender transformative, as it used language within a gender binary and did not include specific direction for addressing gender inequality and other systems that limit someone's ability to access health services. While it did outline ways to create a more inclusive environment through policy, service provider sensitization, and other such interventions, specific guidance about these topics was lacking. The 2020 COP Guidance moderately promoted SRHR in the HIV and AIDS domain.

2020_PEPFAR 2021 Country and Regional Operational Plan (COP/ROP) Guidance for all PEPFAR Countries

In advance of the COP review process that took place in early 2021, the PEPFAR 2021 Guidance was released in December 2020. The 2021 COP Guidance specified new quality assurance and improvement mechanisms for service delivery and partner management that were consistent with the WHO definitions and guidance. The Guidance also included new details about the therapeutic alliance, which respects client autonomy and agency to be treated as whole people by their healthcare provider. This framing was consistent with human rights norms and recognized the value of integrating HIV and AIDS programs with other areas of SRHR like FP and maternal and child health (MCH). The 2021 COP Guidance instructed partners to abide by the Guidance for Implementing Safe and Ethical Index Testing, which was published by PEPFAR and developed based on the COP20 process that paused index testing until a monitoring process could be developed. The 2021 COP Guidance required partners to implement index testing according to that guidance, which was evidence-based, consistent with human rights, and responsive to need. The Guidance also supported the scale up of oral PrEP programs through differentiated service delivery (DSD) mechanisms, multi-month dispensing (MMD), and task shifting for service providers, which was evidence-based and responsive to the impacts of COVID-19 on PrEP service delivery. Programs were also instructed to incorporate new biomedical HIV prevention products (e.g., Dapivirine vaginal ring and cabotegravir long acting injectable) into existing programs, which was evidence-based and responsive to need. The 2021 COP Guidance was somewhat gender transformative, particularly through the expansion of DREAMS programs, a key programmatic pillar of which is changing unequal gender norms. However, programmatic adaptations for persons with disability were not meaningfully included in the 2021 COP Guidance, which may impact people’s access to HIV and AIDS services. This action moderately promoted SRHR in the HIV and AIDS domain.

2020_PEPFAR FY21 Site Improvement through Monitoring System (SIMS) Version 4.1

The PEPFAR Site Improvement through Monitoring System (SIMS) tool provides a standardized approach to monitoring program quality at PEPFAR-supported sites that perform service and non-service delivery functions. The FY21 SIMS Implementation Guide and Assessment Tools set a high standard for how PEPFAR-supported sites are evaluated for program quality. The FY21 SIMS Implementation Guide and Assessment Tools included new guidance on monitoring index testing programs, engaging KPs, and administering other services offered at PEPFAR-supported sites. The FY21 SIMS tool included new standards for monitoring the quality of index testing services and referenced the PEPFAR Guidance for Implementing Safe and Ethical Index Testing Services, which was responsive to need given the concerns about human rights and confidentiality related to the implementation of index testing. The updates also allowed for virtual assessments during COVID-19, which was responsive to need and ensured that the pandemic did not prevent monitoring visits from happening. The Above-Site and Site Assessment Tools included Core Essential Elements (CEEs) that assessed the site using a technical set of standard requirements, though the evidence base for these standard requirements was not well defined. The CEEs covered areas such as addressing stigma, condom availability, orphans and vulnerable children (OVCs), ensuring commodity availability and promoting MMD, FP/HIV service integration, PMTCT, and GBV. They also included guidance on implementing the Protecting Life in Global Health Assistance (PLGHA) policy, which helped evaluators know if the policy was relevant to the site assessment and ensured that the PLGHA policy was being appropriately implemented. However, specific programmatic adaptations for persons with disability were not meaningfully included in these tools. They were somewhat gender transformative because they included guidelines and standards for evaluating gender norms interventions, but much of the gendered language adhered to a gender binary and was not inclusive. Further, the Tools indicated that condoms and lubricants were considered “easily accessible” if they were available on-site, regardless of whether they were for sale or were freely distributed. This neglected to consider the sociocultural norms that could prevent marginalized populations from accessing condoms and lubricants, especially if they were for sale. This action moderately promoted SRHR in the HIV and AIDS domain.

2020_PEPFAR Guidance for Implementing Safe and Ethical Index Testing Services

This guidance provided an overview of PEPFAR's Index Testing Services and set the minimum requirements for index testing to ensure that index testing protocols going forward would be aligned with human rights norms, evidence, and best practices. This guidance was highly responsive to need because it was developed in response to the directive in the 2020 COP Guidance to pause index testing due to human rights and confidentiality concerns that were raised by global and local advocates. It included the WHO's 5C standards (i.e., consent; counseling; confidentiality; correct test results; and connection to HIV prevention, care, and treatment services) as guiding principles for PEPFAR’s index testing programs. The Guidance also recommended the creation of Community Advisory Boards to assist clients with providing feedback and reporting complaints about index testing services, and support quality improvement and adverse event monitoring, which was responsive to need. It mandated that providers be trained on all index testing procedures, including intimate partner violence (IPV) screening, adverse event monitoring and reporting, and best practices to ensure accountability across index testing programs, which could protect the human rights of clients. The IPV screening standards and guidance were based in evidence and consistent with human rights norms as the Guidance used questions validated by the WHO and followed standard operating procedure to improve adherence and retention for clients that experienced violence. The Guidance was not gender transformative, as the language was mostly gender blind. The exclusion of gender did not adequately capture the unique impact of index testing on violence experienced by women and girls, gender diverse people, and KPs. The Guidance for Implementing Safe and Ethical Index Testing Services substantially promoted SRHR in the HIV and AIDS domain.

2020_PEPFAR Monitoring, Evaluation, and Reporting Indicator Reference Guide_MER 2.0 (Version 2.5)

The Monitoring, Evaluation, and Reporting (MER) Indicator Reference Guide aims to streamline and prioritize indicators for PEPFAR programs and is reviewed annually to ensure that indicators are aligned with PEPFAR initiatives. In 2020, some of the MER indicators were updated, but it remains unclear which evidence or programmatic data prompted these changes. The reporting frequency for the oral PrEP (PrEP_CURR and PrEP_NEW) and GBV (GEND_GBV) indicators were changed from semi-annually to quarterly, which enabled programs to be more responsive to need. The index testing indicator (HTS_INDEX) was updated to reference PEPFAR’s Guidance on Implementing Safe and Ethical Index Testing Services to ensure that index testing programs were aligned with evidence, best practices, and human rights. To standardize the data disaggregation across the clinical cascade indicators, the number of disaggregations for KPs was reduced in 2020. The Guide instructed implementing partners to report an individual in only one KP category “with which s/he is most identified.” This oversimplification of identity was not aligned with evidence or human rights and did not allow for a nuanced understanding of clients’ identity, which could reduce the ability of programs to be responsive to need. Furthermore, this language, along with most of the updates made to the Guide in 2020, were not gender transformative. This version of the MER Indicator Reference Guide moderately promoted SRHR in the HIV and AIDS domain.

2020_PEPFAR Technical Guidance in Context of COVID-19 Pandemic_18 November 2020

Between March and November 2020, PEPFAR regularly released revised versions of this Technical Guidance to support PEPFAR programming throughout the COVID-19 pandemic and ensure that programs remained consistent with recommendations from the WHO and U.S. Centers for Disease Control and Prevention (CDC). The Guidance was responsive to need, consistent with human rights, and was often aligned with evidence, even as the evidence base shifted throughout the first year of the COVID-19 pandemic. The Technical Guidance prioritized HIV treatment services over prevention services to ensure uninterrupted care for children, adolescents, pregnant and breastfeeding women (PBFW), and adults. To assist programs with adapting to COVID-19 lockdowns and service disruptions, the Technical Guidance recommended programs scale up MMD and decentralized drug distribution (DDD) for all people living with HIV (PLHIV), including PBFW and children. The Guidance stated that anyone—even someone who was not a current PEPFAR client—could receive their ART at any PEPFAR clinic. This was highly responsive to need, evidence-based, and consistent with human rights. The Technical Update encouraged gender transformative work through DREAMS and GBV programming to continue within the constraints of COVID-19 protocols and restrictions. However, the Technical Guidance did not mention the disproportionate impact of COVID-19 and GBV on women and girls. The Technical Guidance moderately promoted SRHR in the HIV and AIDS domain as PEPFAR adapted their operations during the COVID-19 pandemic.

2020_President’s Interagency Task Force: Report on U.S. Government Efforts to Combat Trafficking in Persons

This report discussed U.S. government efforts to end trafficking in the United States and globally. This strategy prioritized the needs and perspectives of those who have been trafficked, called for innovations in data gathering, and promoted education and public awareness activities related to human trafficking. While the health impacts of trafficking were mentioned, the Report centered on domestic efforts to combat trafficking even though the actions described in this whole-of-government report would impact global health assistance programs and activities. The Report described its carceral approach to combating trafficking including prosecution, which relies heavily on law enforcement to prevent trafficking even though these systems do not consistently protect the rights of marginalized groups. This report did not define or provide the evidence base for the “victim-centered and trauma-informed approach” it purported to take in its approaches to combating human trafficking, which was significantly lacking. The Report did not integrate international human rights standards as it conflated commercial sex work and trafficking for the purposes of sex, which ultimately denies sex workers their rights and can impede efforts to prevent trafficking. The carceral approach outlined in this report posed additional risks and barriers for sex workers that needed to access health services due to the fear of prosecution or being targeted by law enforcement. While this report briefly mentioned gender, it was largely gender blind and made no mention of how trafficking impacts people in the LGBTQI+ community. The Department of State reported that it opened applications for projects to address the impacts of COVID-19 on efforts to combat trafficking, which was responsive to need. In 2020, the Department of State also updated the introductory course for personnel on human trafficking, but the Report did not make clear if or how the health needs of survivors of trafficking were incorporated into this training. The Report did not sufficiently distinguish which actions were undertaken with U.S. global health funds, which was a transparency issue. The Report moderately hindered SRHR in the HIV and AIDS domain.

2020_Report of the Commission on Unalienable Rights

This Report was released by Secretary Pompeo's Commission on Unalienable Rights. The Report defined “fundamental” or “unalienable” rights as those detailed in the Declaration of Independence. It also cited the Universal Declaration of Human Rights (UDHR) of 1948 as the standard for the human rights that should be protected worldwide. The Report claimed that the expansion of human rights beyond what was detailed in UDHR has weakened the “claims of human rights” and left disadvantaged groups more vulnerable to rights violations. This assertion was not based in evidence, as there is no evidence to support this claim. It was also not aligned with human rights norms as it ignored the rights not explicitly stated in the Declaration of Independence or UDHR, such as sexual and reproductive rights and the rights of LGBTQI+ people, persons with disability, and displaced people. To this end, the Report touted “natural law,” which has been historically used to oppose sexual and reproductive rights and the rights of LGBTQI+ people. This report was not responsive to need, because even though marginalized groups around the world are currently experiencing violations of their human rights, the Commission's approach did not adequately describe how the Department of State would work to protect human rights beyond what is explicitly stated in UDHR. The Report was not gender transformative, as the rights of women, girls, and gender diverse people were almost entirely excluded. The language used throughout the Report was largely gender blind, and arguably gender exploitative as it upheld patriarchal structures by not recognizing the compendium of human rights declarations and modern advances in gender equality. The narrow definition of human rights could have had negative implications on the implementation of global HIV and AIDS programs. The Report on the Commission on Unalienable Rights substantially hindered SRHR in the HIV and AIDS domain.

2020_Report to Congress_Annual Treatment Report from PEPFAR

The Annual Treatment Report from PEPFAR provides information to Congress on PEPFAR-supported treatment programs as required by Section 7611 (g) of Title 22 of the U.S. Code. The 2020 Report focused on the impact of COVID-19 on PEPFAR and the programmatic adaptations that were necessary to ensure that treatment programs were not disrupted. These adaptations included MMD of ART, which was responsive to need. The Report also cited the ability of PEPFAR to strategically invest resources through data-driven programming, which enabled it to provide ART to groups that often experience stigma and discrimination related to accessing HIV treatment such as OVCs and KPs. The Report highlighted the manner in which PEPFAR prioritized investments in primary prevention activities, which was responsive to need, based in evidence, and aligned with human rights norms. The Report was not gender transformative, as it only briefly covered gender issues and used language that promoted a gender binary. While the importance of DREAMS programming to meet the needs of adolescent girls and young women (AGYW) was included in PEPFAR's next steps, it was not adequately explained elsewhere in the Report. The Report neither promoted nor hindered SRHR through PEPFAR's programs and policies.

2020_Review of the Implementation of the Protecting Life in Global Health Assistance Policy (August 2020)

The second review of the Protecting Life in Global Health Assistance (PLGHA) policy summarized the history of the policy and documented its implementation throughout U.S. global health assistance programs. The Review found that in certain cases where partners declined awards, the loss of trusted partners in-country resulted in difficulties replacing these partners and subsequent disruptions in health care services across technical areas. Specifically, the review found that the loss of partners resulted in delays in implementation and distribution of services related to HIV and AIDS, MCH, voluntary FP, tuberculosis, and nutrition, as well as programs providing HIV services for KPs. These findings reinforced the harm of this policy and confirmed that the implementation of the policy led to some disruption in service delivery. The Review stated that most of the Department of State’s partners that conducted work related to HIV and AIDS accepted the terms of the policy. This review was somewhat based in evidence as it directly reflected agency-level data. The data collection for this review ended in May 2019, so this was only somewhat responsive to need given that there was no data to document the impact of the policy from May 2019 to August 2020 when the Review was released. However, the Review provided valuable information on how the policy was being implemented that had not been included in the first review. The Review was not gender transformative, as it did not document whether the policy was being implemented in a way that addressed or affected gender norms and dynamics. The Review moderately hindered SRHR in the HIV and AIDS domain.

2020_Strengthening Health Security Across the Globe: Progress and Impact of U.S. Government Investments in the Global Health Security Agenda, 2019 Annual Report

In 2020, the Department of State released the Strengthening Health Security Across the Globe annual report that identified U.S. government contributions to global health security by country and U.S. government actor. Though several areas of global health were mentioned throughout the report, HIV and AIDS was noticeably absent. Specifically, PEPFAR was only mentioned in relation to the adaptation of existing surveillance mechanisms, laboratory infrastructure, and infection prevention and control (IPC) programs to aid in the global response to COVID-19. HIV and AIDS was the subject of a case study covered in the report in which U.S. government officials identified and contained an HIV outbreak among children in Pakistan. While this inclusion was responsive to need and acknowledged the impact of HIV and AIDS on security, it minimized the value of HIV prevention and treatment efforts in promoting health security beyond this one district in one country. Further, there was no mention of other areas of SRHR that impact health security such as FP, MCH, and GBV. SRHR is a critical aspect of health security. Neglecting SRH in security discussions can contribute to negative health impacts and human rights violations for women, girls, gender-diverse people, and other marginalized groups. The exclusion of SRHR throughout the report contributed to the increased development of siloes that exclude SRHR from other areas of global health, such as disease outbreaks. The Report was largely gender blind, as it ignored the fact that health security is unattainable without gender equity and the countering of harmful norms that affect women and girls. As a result, this Report moderately hindered SRHR in the HIV and AIDS domain.

2020_The Department of State’s Plan to Implement the U.S. Strategy on Women, Peace, and Security 2020-2023

The 2019 United States' Strategy on Women, Peace, and Security (WPS) was developed in response to the Women, Peace, and Security Act of 2017. This Plan laid out the approach undertaken by the Department of State to make progress on three strategic objectives related to WPS from 2020 to 2023. The Plan largely excluded health activities in general, including technical areas related to SRHR. However, it did mention the importance of preventing GBV including sexual violence and early and forced marriage. Though the Plan stated that the Office of the U.S. Global AIDS Coordinator (S/GAC) is responsible for the GBV-centered objective, the HIV and AIDS needs of people who have experienced GBV were not explicitly mentioned. Ignoring HIV acquisition as a potential outcome from sexual violence was a clear gap in this plan that was not based in evidence. The Plan was responsive to need as the objectives were informed by the global need for women's empowerment efforts. However, the exclusion of many SRHR issues was not evidence-based nor consistent with human rights frameworks. The Plan was somewhat gender transformative as it recognized and sought to combat gender norms through a systemic approach, but the Plan used language that reinforced a gender binary and was not inclusive of those who are impacted by the issues detailed in this action who do not identify as women. It was unclear which activities and programming mentioned in the Plan were considered U.S. global health assistance, which was a transparency issue. The Plan neither promoted nor hindered SRHR in the HIV and AIDS domain.

2020_United States Strategy to Prevent Conflict and Promote Stability

The United States government released this strategy in accordance with the Global Fragility Act of 2019 to promote “peaceful, self-reliant nations.” The Department of State was identified as the lead agency to oversee and implement this Strategy with the assistance of other U.S. government agencies to create impactful and sustainable programs in fragile settings. While the Strategy was responsive to need, it did not adequately address the SRHR and the broader health needs of people in conflict settings. The Strategy failed to explain its engagement with specific global health areas, even though HIV and AIDS, MCH, FP, and other cross-cutting SRHR issues are vital to promoting stability and security. Notably, it did not include GBV, which is often a greater risk to women, girls, and gender-diverse people in fragile settings and conflict areas. The Strategy stated that it was grounded in evidence and human rights, but it did not include an explanation of the evidence base or human rights framework that informed it. Additionally, it was not gender transformative. Instead, the language promoted a gender binary, ignored the role of gender inequalities on experiences of violence, and only mentioned women in the context of the WPS Strategy. While the latter was an important inclusion, gender was not meaningfully included in other areas of the Strategy. This action moderately hindered SRHR in this domain.

2019_PEPFAR 2019 Annual Report to Congress

2019_PEPFAR 2019 Country Operational Plan Guidance for all PEPFAR Countries

Released annually by the Office of the Global AIDS Coordinator, the Country Operational Plan (COP) Guidance outlines the plan for the global HIV and AIDS activities funded by the President's Emergency Plan For AIDS Relief (PEPFAR) and provides the basis for the approval of annual bilateral HIV and AIDS funding for partner countries. The 2019 COP Guidance was based in evidence and responsive to need. The document provided comprehensive guidance on the implementation of PEPFAR programs for all populations and, within this domain, discussed the importance of integrating cervical cancer screenings into care for women living with HIV as well as into layered DREAMS programming for adolescent girls and young women. However, much of this language could have been stronger and made mandatory. Depending on the program area, the Guidance was based in human rights norms, as it addressed PEPFAR’s role in protecting the human rights of populations that are criminalized or face stigma, such as the LGBTQI+ community. However, in other areas, the COP Guidance was not based in human rights norms, particularly the high targets for index testing within PEPFAR programs, which create an environment where human rights may be violated by grantees in pursuit of high target numbers and to avoid negative performance evaluations. It is critical that the PEPFAR COP Guidance be more specific about the subservience of targets to voluntarism and informed consent, ensure that this human rights mandate reaches the clinic level, and set more realistic targets to avoid harmful outcomes that will ultimately undermine PEPFAR’s goals. Lastly, the guidance was not gender transformative but demonstrated some gender awareness, as it used “clients” and other gender-neutral language and discussed the impact of gender norms on numerous program areas, including DREAMS, stigma reduction activities, and programs to reach undiagnosed men. Overall, the COP Guidance moderately promoted SRHR through HIV and AIDS programs.

2019_PEPFAR Monitoring, Evaluation, and Reporting Indicator Reference Guide_MER 2.0 (Version 2.4)

The President's Emergency Plan For AIDS Relief (PEPFAR) Monitoring, Evaluation, and Reporting (MER) guidance included the indicators used to monitor and evaluate PEPFAR. All PEPFAR programs were evaluated according to their performance within these indicators and metrics, and this guide helped country teams and PEPFAR implementing partners understand the monitoring and evaluation process. In 2019, some of the MER indicators were updated, but it remains unclear what prompted these changes. The document included many HIV indicators, including indicators that focused on key population (KP) programming and programming for adolescent girls and young women. The updates to the indicators and addition of new indicators provided more detail and definitions about data to be collected, which demonstrated the guide’s responsiveness to need and basis in evidence. The indicators were mostly based in human rights principles, but it is important to note that there is no way to assure that the indicators were implemented in accordance with these norms. For example, all KP-relevant indicators included the "do no harm" mandate, but there was no explicit guidance beyond that. This limitation of the MER Indicators was particularly relevant with the Index testing indicator which reinforced the primacy of testing yield with no measurement for fidelity to human rights. Lastly, the guide was not gender transformative but was gender aware, as it included a vague consideration of structural factors, such as “living and family situation,” that impact HIV and AIDS treatment and prevention. Measures of gender equity were not included as a required reporting element across relevant indicators.

2019_Protecting Life in Global Health Assistance Frequently Asked Questions and Answers_September 2019

The Protecting Life in Global Health Assistance (PLGHA) FAQ document was updated in September 2019 to provide clarity on the implementation of the May 2019 expansion of PLGHA as well as address questions and confusion from the 2018 Department of State’s PLGHA Six Month Review. The text of this document was similar to the 2018 FAQ document but included additional questions and answers (see questions 33-37). The document did not meaningfully discuss the impacts of the May 2019 expansion on HIV and AIDS. Similar to the 2018 FAQs, this document aimed to provide clarity on the implementation of the policy but left many questions unanswered. This document was somewhat responsive to need as it did include additional questions and answers based on confusion expressed by recipients of U.S. global health assistance, specifically regarding the definition of “financial assistance” and the applicability of the policy to technical assistance. The document was not evidence-based, was not grounded in international human rights, and was not gender transformative, as it was based on the PLGHA policy which has been shown to be harmful globally, particularly to women and girls. PLGHA has also been shown to decrease access to HIV and AIDS services. Overall, this document provided a substantial hindrance to SRHR.

2019_State and USAID Agency Priority Goal Action Plan_HIV/AIDS

The Agency Priority Goals (APGs) for HIV and AIDS were released by both the Department of State and USAID to hold the President's Emergency Plan For AIDS Relief (PEPFAR) accountable through quarterly reporting that included details around the goals, strategies, milestones, indicators, and progress made towards controlling the HIV epidemic in FY 2019. The 2019 APGs set goals to scale up antiretroviral therapy (ART) services, voluntary medical male circumcision (VMMC) services, and access to HIV and AIDS services for priority and key populations, including men who have sex with men (MSM), sex workers, transgender people, and adolescent girls and young women (AGYW). This plan was responsive to need and based in evidence but did not explicitly mention human rights principles. The APGs were not gender transformative as gender norms were not discussed. Overall, the document moderately promoted SRHR within this domain.

2019_State and USAID FY 2018 Annual Performance Report_FY 2020 Annual Performance Plan

This document shared the goals and timelines for FY 2020 as well as evaluated and summarized the progress of State and USAID in achieving various strategic goals in FY 2018. These goals included global health and gender-related programs across all three domains. The FY 2020 Performance Plan elements were included throughout the report along with reporting on standard indicators for each Performance Goal under the 4 Strategic Objectives. The Report discussed the joint efforts by the Department of State and USAID to achieve HIV and AIDS epidemic control within the third goal. However, there was very little discussion of the evidence used to inform the President's Emergency Plan For AIDS Relief (PEPFAR) programming or the human rights foundation for such programmatic decisions. The document did not provide a recommendation or detailed plan for the continuation of the success of HIV and AIDS prevention and treatment programming to date. This document was responsive to need but lacked a description of the evidence and human rights frameworks that guided PEPFAR programming. The Plan mentioned the disadvantages of a “gender-blind system” within Strategic Goal 2 but perpetuated such a system by not including a gendered lens throughout the document. As such, this report had little effect on the ability of the Department of State to implement HIV and AIDS programs that promoted SRHR.

2018_DREAMS Report: Dreaming of an AIDS-Free Future

The annual DREAMS report highlights the strengths, challenges, and future directions of the DREAMS program. The report was evidence-based and responsive to need, but lacked a clear gender transformative stance. The DREAMS program does have concrete gender transformative components, but they were not reflected in this report in a clear and substantial way. The report described harmful gender norms that affected HIV and AIDS prevention and treatment programs for adolescent girls and young women (AGYW), but did not mention how to address these barriers in a manner informed by human rights principles.

2018_PEPFAR 2018 Annual Report to Congress

The PEPFAR Annual Report to Congress provides an overview of the PEPFAR program to date and discusses future directions. The report was evidence-based, responsive to need, and included a description of how the Department of State will deliver on the mission of PEPFAR moving forward. The report also discussed factors that made HIV prevention and treatment complex for AGYW and for key populations; however, these programmatic concerns were framed within current constructed gender norms. The programming discussed in this report did not include gender transformative components as a means to provide comprehensive HIV and AIDS services.

2018_PEPFAR 2018 Country Operational Plan Guidance for Standard Process Countries

Released annually by the Office of the Global AIDS Coordinator, the Country Operational Plan (COP) Guidance outlines the plan for PEPFAR-funded global HIV and AIDS activities and provides the basis for the approval of annual bilateral HIV and AIDS funding for partner countries. The 2018 COP guidance was comprehensive and provided updates that were evidence-informed, responsive to need, and based in human rights principles. The 2018 COP Guidance took a holistic approach to PEPFAR programs and discussed intersecting issues, such as: gender-based violence, post-abortion care, contraceptive access, and comprehensive HIV prevention programs. The COP Guidance illustrated gender as a cross-cutting issue within PEPFAR but should have included specific guidance to increase gender transformative programming across PEPFAR countries.

2018_PEPFAR 2018 Progress Report

The PEPFAR Progress Report is issued annually to provide an overview of programs and illustrate PEPFAR priorities in the future. The report shared a program plan that was responsive to need and based in evidence and human rights principles. However, the document did not discuss gender norms or include a commitment to increase gender transformative programming.

2018_PEPFAR Statement on Potential Safety Issue Affecting Women Living with HIV Using Dolutegravir at the Time of Conception

This press release contains PEPFAR's policy and technical guidance in response to data from a study in Botswana indicating a potential association between women of childbearing potential taking dolutegravir (DTG), an antiretroviral, at the time of conception and the risk of neural tube defects. The statement provided a nuanced overview of the data and concluded by issuing the guidance that all PEPFAR programs continue transitioning to a DTG-based regimen. The release recommended that "HIV-infected women who desire to become pregnant" should remain on efavirenz-based regimens until further data are available. The issuance of this statement was timely and provided an accurate explanation of the Botswana study preliminary findings; however, the Department of State's recommendation took away the choice of treatment from a population based solely on their ability or desire to become pregnant. This was in conflict with a human rights, individual-centered framework. It is also unclear from the press release if PEPFAR consulted with civil society or other relevant stakeholders before issuing this statement.

2018_Protecting Life in Global Health Assistance FAQs_September 2018

The PLGHA FAQs provided detailed guidance on the implementation of the expanded Global Gag Rule for implementing partners as of September 2018. The document was responsive to need in that it clarified areas of the policy that partners had expressed are vague or unclear, but the FAQs were not evidence-based or based in human rights principles. The FAQs included a PEPFAR-specific section that provided detailed guidance on the implementation and monitoring of the impact of PLGHA on PEPFAR programs, specifically within DREAMS. However, this discussion of PEPFAR, aside from the mention of DREAMS, did not discuss gender norms or include gender transformative language. This section emphasized the importance of minimizing disruption of HIV and AIDS care and treatment and therefore received a higher score within this domain compared to the other two domains, Family Planning and Maternal and Child Health.

2018_Protecting Life in Global Health Assistance Six Month Review

The PLGHA Six Month Review summarized the PLGHA policy and identified solutions to challenges that had arisen in the process of PLGHA implementation. The review was responsive to need in that it addressed concerns expressed by partners who are required to implement the policy, but it was not evidence-based, based in human rights principles, or gender transformative. The Six Month Review received a higher grade within the HIV and AIDS domain because it discussed the importance of addressing the impact of PLGHA on HIV and AIDS programs and assured that efforts are being made to track the impact of this policy through PEPFAR programming. Still, the Six Month Review substantially hindered the Department of State's ability to support comprehensive HIV and AIDS programs.

2018_State and USAID Agency Priority Goal Action Plan_HIV/AIDS

The Agency Priority Goals (APGs) for HIV and AIDS hold PEPFAR accountable through quarterly reporting that includes details around the goals, strategies, milestones, indicators, and progress made towards controlling the HIV epidemic. Released by both the Department of State and USAID, these reports are useful for government transparency and are responsive to need, and based in evidence and human rights. The 2018 APGs reported on challenges faced by HIV and AIDS programs, but did not provide clear strategies to address them. One such challenge was high HIV and AIDS rates among AGYW and key populations. The APGs mentioned the importance of promoting layered core packages of services for AGYW through the DREAMS program and increasing access to HIV and AIDS services for key populations. However, the APGs did not include indicators specific to either population or data disaggregated by gender as a means to highlight progress made in these areas. As a result, the APGs moderately promoted the ability of the Department of State to support comprehensive HIV and AIDS programs.

2017_PEPFAR Country/Regional Operational Plan (COP/ROP) Guidance 2017

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.

2017_PEPFAR Evaluation Standards of Practice (Version 3.0)

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.

2017_PEPFAR Monitoring, Evaluation, and Reporting Indicator Reference Guide_MER 2.0 (Version 2.1)

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.

2016_Department of State Implementation Plan for the U.S. Adolescent Girls Strategy

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.

2016_PEPFAR Country/Regional Operational Plan (COP/ROP) 2016 Guidance

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.

2014_DREAMS Core Package of Interventions Summary

2013_PEPFAR FY 2014 Updated Gender Strategy

2012_U.S. Department of State Policy Guidance: Promoting Gender Equality to Achieve our National Security and Foreign Policy Objectives

2012_United States Department of State Implementation Plan of the National Action Plan on Women, Peace, and Security

2011_PEPFAR Guidance for the Prevention of Sexually Transmitted HIV infections

Maternal and Child Health (MCH)

The Department of State received a 44 (F) with transparency and a 50 (F) without transparency in the Maternal and Child Health (MCH) domain in 2021. This domain grade was raised by the meaningful inclusion of MCH activities in the PEPFAR Core Program and Policy Priorities and the updated March 2021 DREAMS Guidance, which were both responsive to need, based in evidence, aligned with human rights norms, and gender transformative. The February 2021 COP/ROP Guidance and other COP/ROP-related materials did not promote SRHR in the MCH domain because they did not include adequate information for partners to understand the revocation of PLGHA and adapt their programs accordingly. This domain grade was low overall because the actions did not include data about MCH programs or activities across the board, which reinforced the siloed nature of global health programs, negatively affected transparency, and hindered SRHR. In the budget evaluation, the Department of State allocated MCH funds in a manner that was somewhat in accordance with country-level maternal mortality, which moderately promoted SRHR in the MCH domain in 2021.

The Fòs Feminista data index grades government agencies on policies and funding impacting family planning, maternal and child health, and HIV & AIDS foreign assistance.

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2021_2021 Annual PEPFAR Treatment Report to Congress

The Annual Treatment Report from PEPFAR provides information to Congress on PEPFAR-supported treatment programs as required by Section 7611 (g) of Title 22 of the U.S. Code. The 2021 Report focused on the programmatic adaptations PEPFAR implemented in response to the COVID-19 pandemic to ensure that treatment programs were not disrupted. Adaptations included MMD of ARVs, the decentralization of drug delivery, the use of virtual platforms like telemedicine, and the implementation of efforts to empower communities, which were responsive to need, based in evidence, and aligned with human rights. The Report mentioned the decision to increase the number of people living with HIV (PLHIV) on dolutegravir-containing ARV regimens which was based in evidence, however there was no mention of the importance of ensuring these regimens are available for pregnant PLHIV. As a result, this action was not fully based in evidence, human rights, or responsive to need. The Report did not include treatment data related to specific populations, such as orphans and vulnerable children (OVCs) or the outcomes of prevention of mother to child transmission (PMTCT) of HIV activities, which was an oversight because these programs and activities are critical to the success of PEPFAR. The Report was gender blind, as there was little mention of gender. The Report moderately hindered SRHR in the MCH domain.

2021_Country_Regional Operational Plan 2021 (COP/ROP 2021) Virtual Meeting Handbook

This Virtual Meeting Handbook outlined the ways in which the OGAC streamlined the COP/ROP 2021 process in response to the COVID-19 pandemic. The COP/ROP 2021 process was shortened and conducted virtually for the first time, which was highly responsive to need due to the pandemic and this action ensured that PEPFAR stakeholders at all levels had timely information about this process. This action detailed the revised framework for ensuring meaningful stakeholder engagement by mandating transparent discussions with PEPFAR leadership during town halls with stakeholders at all levels and involving partner country governments, communities, CSOs, multilateral partners, and the private sector, which was responsive to need. This action included guiding principles for PEPFAR during the COVID-19 pandemic that were responsive to need and consistent with evidence and human rights norms, such as protecting program gains, ensuring site safety, and mitigating COVID-19’s impact on OVC and PMTCT activities. This action moderately promoted SRHR in the MCH domain.

2021_Department of State and USAID_Fiscal Year (FY) 2022 Annual Performance Plan

The FY 2022 Annual Performance Plan outlined progress made by the Department of State and USAID toward strategic objectives and performance goals in previous years. The Plan outlined each agency’s plans for achieving the goals articulated in their joint strategic plan moving forward. Though the MCH-specific indicators only included data from USAID, this action was graded across domains for the Department of State because of this actor’s leadership of PEPFAR which includes activities related to MCH, as well as cross-cutting issues including GBV. While the availability of these data was important for evidence-based decision making in the HIV and AIDS domain, indicators that measured the outcomes of PMTCT or other HIV activities related to MCH were not included in this action. As a result, this action was not fully responsive to need or based in evidence or human rights in this domain. The Department of State’s contributions to cross-cutting SRHR issues like gender equality and GBV prevention and response were included in this action, which was responsive to need. However, no targets were included for FY 2022, which was not responsive to need and negatively affected transparency. Additionally, the Plan was gender accommodating as it used language that reinforced a gender binary. This action neither promoted nor hindered SRHR in this domain.

2021_Guiding Principles for the Next Phase of PEPFAR

The Guiding Principles outlined the program’s goals as of January 20, 2021, and presented PEPFAR’s progress to date, including national progress toward achieving the 90-90-90 and 95-95-95 targets in specific countries. This action detailed the impact of COVID-19 on PEPFAR programs, as well as outlined programmatic adaptations that OUs implemented to overcome the impacts of the pandemic, which was responsive to need and based in evidence. The Guiding Principles focused on providing people-centered HIV prevention, care, and treatment services but did not mention OVC, PMTCT, or other PEPFAR activities related to MCH, which was not responsive to need or aligned with evidence. This action did not mention the human rights framework that underpins PEPFAR programming, nor did it discuss the importance of integrated services and UHC in advancing PEPFAR’s goals, specifically for pregnant and breastfeeding persons or persons of reproductive age. This action was gender accommodating as it included language that reinforced a gender binary. This action moderately hindered SRHR in the MCH domain.

2021_PEPFAR 2021 Annual Report to Congress

The PEPFAR 2021 Annual Report to Congress detailed the achievements of PEPFAR and challenges to delivering people-centered HIV services, particularly in light of the COVID-19 pandemic. This action outlined country-specific progress toward the 90-90-90 targets, documented PEPFAR’s efforts to strengthen health systems, and advocated for integrated GBV programs, which was responsive to need and based in evidence. This action highlighted the importance of addressing barriers to accessing care and working with community- and KP-led indigenous organizations to promote human rights, which was responsive to need and promoted SRHR. The Report included outcomes of PMTCT and OVC programs and mentioned pregnant and breastfeeding women (PBFW) as a priority population, which was responsive to need and based in evidence. The action supported dolutegravir-containing regimens as the preferred treatment regimen for women of childbearing age. The “Preventing Infections in Women” section mentioned the strengthening of platforms through which women seek care, including antenatal care (ANC) platforms to support women’s access to PrEP or PMTCT services, which was responsive to need. This action was gender accommodating as it used language that reinforced a gender binary (e.g., PBFW and women of childbearing age). This action moderately promoted SRHR in the MCH domain.

2021_PEPFAR 2021 Country and Regional Operational Plan (COP/ROP) Guidance for all PEPFAR Countries

On February 11, 2021, OGAC released an updated version of the COP/ROP 2021 Guidance that revised four sections of this critical PEPFAR guiding document. Section 5.9.4 was updated to cross out the text related to the PLGHA policy. The action included the following information: “Implementation of Protecting Life in Global Health Assistance in PEPFAR Programs has been deleted as the policy was rescinded by President Biden in January 2021” but did not provide stakeholders with any additional information about what the revocation meant for OUs or ongoing awards. Though this update was timely, it lacked specificity and guidance for stakeholders to understand how the revocation of PLGHA (also known as the GGR) impacts their work, so it was only somewhat responsive to need and was not based in evidence or human rights. This action significantly hindered SRHR in the MCH domain.

2021_PEPFAR COP/ROP 2021 Frequently Asked Questions

This FAQs document provided regular updates on the COP/ROP 2021 process after it was temporarily paused earlier in 2021. This action included information about civil society and community engagement and provided answers to questions that were specific to technical areas, all of which were responsive to need and based in evidence. For example, this action included FAQs that supported pediatric use of dolutegravir-containing regimens, as well as distinctions between OVC and DREAMS funding, which were responsive to need and based in evidence. The action included one question related to the impact of “new policies of the Biden-Harris Administration, such as the rescission of the Mexico City Policy” on the COP/ROP 2021 process. The answer said that “PEPFAR funding and partners are no longer subject to these policy requirements and instead should follow those outlined in the January 28, 2021 Executive Order” and included a hyperlink to the executive action. This answer did not include additional information or guidance for stakeholders to understand how the revocation of this policy impacts their work with PEPFAR, which was not responsive to need. This action moderately hindered SRHR in the MCH domain.

2021_PEPFAR COP/ROP 2021 Temporary Pause FAQs

This FAQs document was released on February 17, 2021 and confirmed the Biden administration’s commitment to PEPFAR as well as provided an explanation for the temporary pause of the COP/ROP 2021 process. This action also reaffirmed OGAC’s commitment to completing a data-driven COP/ROP 2021 process and ensuring that there were no disruptions in HIV services at the start of FY 2022. Many of the process-specific questions included in this action were also included in the previous action, including a question that highlighted the sections that were updated in the February 2021 version of the COP/ROP 2021 Guidance. Most of the questions were procedural and not technical, so this action neither promoted nor hindered SRHR in the MCH domain.

2021_PEPFAR Core Program and Policy Priorities

The PEPFAR Core Program and Policy Priorities outlined the focus areas of PEPFAR under the Biden administration. The action included key priorities on HIV prevention and treatment: data-driven HIV testing strategies such as support for KPs, gender equity and equality, cooperation and partnership with community stakeholders and public health leadership, and the strengthening of global health security. These priorities were responsive to need, based in evidence, and aligned with human rights norms. Notably, the action included a priority to promote and protect SRHR, including through the revocation of PLGHA. This action provided a high-level framework for PEPFAR’s focus areas, so information about how PEPFAR would implement the revocation would not be included in this action. However, this action was not fully responsive to need as the priorities did not specifically include MCH outcomes outside of eliminating the "vertical transmission of HIV and pediatric AIDS.” The action stated the importance of improving appropriate linkages to and integration of HIV services with other related global health programs but did not specifically mention MCH as a related program. Gender transformative elements were highlighted in the section on “HIV prevention, clinical, and health systems programs,” and in the Department of State’s commitments to DEIA. This action moderately promoted SRHR in the MCH domain.

2021_PEPFAR DREAMS Guidance_Updated March 2021

The PEPFAR DREAMS Guidance provided updated guidance for implementing DREAMS programming for AGYW in 2021. The Guidance highlighted the importance of multi-sector engagement across government leadership and community partners, evidence-based decision making across DREAMS programming, and overall prioritization of DREAMS implementation. The Guidance was based in evidence and human rights as it referenced a variety of peer-reviewed external resources as well as international agreements and frameworks. The Guidance included information about parenting and caregiving programs, discussions on pregnancy prevention, linkages to DREAMS through PMTCT and ANC clinics, and affirmed the need for PrEP to be prioritized for young women, "including those who are pregnant or breastfeeding or who may be having transactional sex," which promoted MCH services within DREAMS programming and was responsive to need. However, the Guidance did not mention safe abortion services when addressing unintended pregnancy, which was an oversight and did not reflect the full package of services that should be provided to DREAMS recipients following the revocation of the GGR. It was gender transformative as it called for changing unequal gender and power dynamics. However, this Guidance used gendered language when mentioning condoms and pregnancy, did not affirm the right to sexual pleasure, and did not include LGBTQI+ women and girls, which was an oversight. This Guidance significantly promoted SRHR in the MCH domain.

2021_PEPFAR FY21 Site Improvement through Monitoring System (SIMS) Materials_Version 4.1

The PEPFAR SIMS tool provides a standardized approach for monitoring program quality at PEPFAR-supported sites that perform service and non-service delivery functions. The FY21 Implementation Guide, Above-Side Assessment Tool, and Site Assessment Tool were updated in 2021, though the changes from the previous version were not clearly stated, which negatively affected transparency. The Above-Site and Site Assessment Tools included CEEs that assessed the site against a set of standard technical requirements, which were based in evidence. The major apparent change in the CEEs was the removal of assessment modules related to the implementation of PLGHA in the Above-Site Assessment Tool. This module was removed without explanation. A new module was not added to ensure that PEPFAR-supported sites stopped implementing the policy after its revocation, which was not responsive to need or consistent with evidence and human rights norms. The Guide and CEEs incorporated PMTCT, ANC, and labor and delivery services, which was based in evidence and responsive to need. It included guidance for SIMS assessors to not participate in or condone discriminatory practices based on gender, race, ethnicity, caste, religion, sexual orientation, disability, or socio-economic status, which was based in evidence and responsive to need. The CEEs were somewhat gender transformative because they included guidelines and standards for evaluating interventions related to changing unequal gender norms, but used language that reinforced a gender binary. The SIMS materials updated in 2021 moderately promoted SRHR in the MCH domain.

2021_PEPFAR Monitoring, Evaluation, and Reporting Indicator Reference Guide_MER 2.0 (Version 2.6)

The MER Indicator Reference Guide is reviewed and updated annually to streamline and prioritize the standard indicators used across PEPFAR programs. The 2021 Guide introduced trainings for USG and implementing partner staff on indicators across technical areas, which was responsive to need. The Guide referenced updates to the MER indicators such as new disaggregations, provided updated reporting frequencies, and clarified definitions, which were responsive to need. Several indicators were updated to add additional pediatric age and sex disaggregations as well as reflect the current approved pediatric HIV treatment regimen, which was responsive to need. This action moderately promoted SRHR in the MCH domain.

2021_Prioritizing Sexual and Reproductive Health and Reproductive Rights in U.S. Foreign Policy

Secretary of State Blinken delivered this Press Statement on prioritizing SRHR in U.S. foreign policy, which mentioned how the Department of State would implement the presidential memorandum that rescinded PLGHA. Though this action mentioned the revocation of the GGR, it did not provide guidance for programs about adapting their work to align with the presidential memorandum, which was not responsive to need and was a missed opportunity to highlight the Department of State's specific responsibility to promote SRHR as the funding agency of global health assistance. The action highlighted the reinstatement of funding to the UNFPA, the withdrawal of the United States from the Geneva Consensus Declaration, and the increased access to vital health services, including “maternal health and voluntary family planning” services. These actions were responsive to need, based in evidence, and based in human rights. This action affirmed the United States' commitment to making pregnancy and childbirth safer through strengthening health systems and partnering with governments, the private sector, and international and non-governmental organizations, which was responsive to need and based in evidence. This action was gender accommodating, as it acknowledged gender inequities but used language that promoted a gender binary and only recognized SRHR for women and girls, even though SRHR is vital for all people. The action moderately promoted SRHR in this domain.

2021_Strengthening Health Security Across the Globe_Progress and Impact of United States Government Investments in the Global Health Security Agenda

This Report detailed the progress and impact of the USG’s investments in global health security during FY 2020, including those led by the Department of State. The Report detailed the distribution of Congressional appropriations to advance global health security efforts in 19 partner countries to respond to disease outbreaks and prevent future outbreaks whenever possible. The Report did not mention other global health security efforts by the Department of State as it pertained to MCH services. Though the Report focused on global health security, SRHR and other cross-cutting issues such as GBV were not mentioned. The exclusion of these cross-cutting issues was not based in evidence as the inclusion of SRHR and gender equity promotes global health security. This exclusion was not responsive to need as SRHR services are often the first set of "essential services" to be neglected in a health emergency, as notably evidenced by the initial global response to COVID-19. The Report was gender blind as it made only one mention of gender in the context of OneHealth. This action moderately hindered SRHR in the MCH domain.

2021_Trafficking In Persons Report_ Human Trafficking in the Context of a Global Pandemic

The 2021 Trafficking in Persons Report detailed the approach outlined by the Department of State to combat human trafficking, with additional detail about these activities in the context of the COVID-19 pandemic. The Report outlined lessons learned from the pandemic and called for "comprehensive, trauma- and survivor-informed, and victim-centered anti-trafficking responses during the pandemic." The Report stated that global crises such as COVID-19, climate change, and enduring discriminatory policies and practices disproportionately impact people who are already oppressed by other injustices and increase people’s vulnerability to exploitation, which was based in evidence and responsive to need. While the Report recognized that survivors of trafficking are hesitant to interact with carceral systems, it promoted prosecution and a carceral approach to trafficking, which was not responsive to need. The Report briefly mentioned pregnancy-related interventions but did not meaningfully include global MCH outcomes and programming, which was a missed opportunity to highlight the Department of State’s global MCH efforts. The Report moderately hindered SRHR in this domain.

2021_United States Government Women, Peace, and Security (WPS) Congressional Report

The WPS Congressional Report provided Congress with an overview of progress made in implementing the WPS Agenda globally since 2019. The Report evaluated progress in advancing the WPS Strategy's four lines of effort across the Department of State, DoD, DHS, and USAID: participation, protection, internal capabilities, and partnerships. While improved global health outcomes were included as a positive impact of implementing the WPS Agenda, MCH outcomes were only briefly mentioned. The Report included GBV prevention and programming as a measure of progress towards achieving the WPS Agenda, which was responsive to need. The Report highlighted an initiative by the Department of State to lead a data-driven MEL exercise on its WPS efforts, which was based in evidence and responsive to need. The Report included specific and actionable milestones to measure progress, which was responsive to need. The Report included several gender transformative elements such as enhancing gender-sensitive data analytics, recognizing "the intersectionalities inhabited by women," and supporting initiatives to address and overhaul harmful gender norms. However, it was predominantly focused on women which reinforced a gender binary. The Report moderately promoted SRHR in the MCH domain.

2020_Contraception for Women at High Risk of HIV Technical Update

The purpose of this Technical Update was to explain the implications of the Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial results on “reproductive health programming” funded through U.S. global health assistance. The Technical Update summarized updated guidance from the World Health Organization (WHO) regarding the use of contraception by women at high risk of acquiring HIV, which had been revised based on the ECHO Trial findings. Though the WHO released its revised guidance in August 2019 shortly after the ECHO Trial results were published, the Department of State (as the funding agency for PEPFAR) did not publish this Technical Update until December 2020. Because of this delay, the action was not fully responsive to need. The Technical Update was aligned with international human rights norms and evidence (e.g., quality of care, voluntarism, informed choice, differentiated service delivery models, patient-centered approaches free of stigma and discrimination) and included specific programmatic and policy guidance for working closely with diverse stakeholders to adapt global HIV and family planning (FP) programs accordingly. While the Technical Update stated that women who receive FP counseling should receive information about HIV prevention, it did not include guidance about counseling people who have just given birth about their contraceptive options, and thus was not consistent with evidence or responsive to need in this domain. Additionally, the Technical Update was gender blind, as it did not use gender inclusive language. As the funding agency for global MCH funds, the Department of State had the opportunity to integrate these efforts across implementing agencies through this Technical Update. This Technical Update only moderately promoted SRHR in the MCH domain.

2020_Department of State and USAID Joint Report to Congress on U.S. Foreign Assistance Gender-Related Programming_Fiscal Years 2017 and 2018

The Department of State and USAID submitted this joint report to Congress on gender-related programming funded through all types of U.S. foreign assistance in fiscal year (FY) 2017 and 2018 as required by the Department of State, Foreign Operations, and Related Programs Appropriations Act, 2019. It reported on $110 million of PEPFAR funds that were used during those two fiscal years to provide gender-based violence (GBV) prevention services as well as the full package of post-GBV care, including HIV and violence prevention services in communities and schools where the DREAMS program was being implemented. However, the Report did not include information about the gender-related activities that the Department of State funds through PEPFAR or other mechanisms that are related to MCH, including antenatal care (ANC) and HIV prevention and treatment services for pregnant and breastfeeding people. This report also included information about numerous other programs and funding types across both the Department of State and USAID, but there was insufficient information to determine if those other programs were considered U.S. global health assistance, which contributed to low transparency. U.S. global health funds were not explicitly included in the funding table at the end of the report, which also contributed to low transparency. This report neither promoted nor hindered SRHR in this domain.

2020_Department of State and USAID_Fiscal Year (FY) 2020 Annual Performance Report

The 2020 Annual Performance Report outlined Department of State and USAID’s progress toward strategic objectives, Agency Priority Goals (APGs), and performance goals in FY 2020 in accordance with their joint strategic plan. These goals included global health and gender-related programs across all three domains for both actors. The Report provided data on USAID’s MCH activities within Performance Goal 3 but did not adequately include the Department of State’s MCH activities that were conducted through PEPFAR or other gender-related programs funded through U.S. global health assistance. MCH activities and indicators should be included as a mechanism to monitor this important aspect of PEPFAR programs. The Report included data on a few indicators that measured gender norm change, but they were gender accommodating and not gender transformative because they focused on “males and females” which reinforced a gender binary. Additionally, indicators regarding GBV did not include considerations or disaggregates for people that experience violence during pregnancy. Due to the lack of meaningful reporting of MCH activities through PEPFAR, this report neither hindered nor promoted SRHR in the MCH domain.

2020_Geneva Consensus Declaration on Promoting Women’s Health and Strengthening the Family

Along with 33 largely authoritarian governments, the United States signed the Geneva Consensus Declaration, a nonbinding declaration to advance the Trump administration’s anti-abortion agenda. Secretary of State Pompeo and Secretary of Health and Human Services Azar jointly participated in the signing ceremony on behalf of the Trump administration. The Declaration cited several international human rights documents to bolster its position that abortion was not to be included in any sexual and reproductive health (SRH) or universal health coverage programs. However, the Declaration did not recognize pregnant people’s right to bodily autonomy. It was also not aligned with evidence as evidence suggests that restricting access to safe abortion services results in increased rates of unsafe abortion, which can contribute to maternal morbidity and mortality. This action was not responsive to need and was not gender transformative because it reinforced a gender binary throughout and ignored gender inequalities and other systemic issues that might impact people's ability to access SRHR services, including MCH services. In fact, both the language used and the exclusion of SRHR were so deeply rooted in patriarchal structures that the Declaration was gender exploitative. The Declaration also failed to acknowledge the human rights of those in the LGBTQI+ community, which threatened to roll back progress made on recognizing the health needs of pregnant people who may not identify as women and/or those who identify as LGBTQI+. The stance of the Administration as demonstrated by the Department of State signing onto this Declaration substantially hindered the ability of U.S. global health assistance to promote SRHR in the MCH domain.

2020_Guiding Principles for the Next Phase of PEPFAR

This Guiding Principles document outlined the progress made by PEPFAR toward the 90-90-90 targets as of December 1, 2020, including programmatic adaptations to respond to COVID-19. This action included the approaches PEPFAR plans to implement to contribute to Sustainable Development Goal (SDG) 3 and achieve epidemic control by 2030. The Guiding Principles briefly mentioned linking HIV services to other “relevant health issues” without explicitly naming these health issues. This action did not explicitly mention evidence or human rights norms related to MCH that may have been incorporated into the development of these principles. Given the evidence base that HIV continues to be one of the leading causes of maternal death globally, it was vital that this action explicitly mention the ways that MCH services are included in PEPFAR programming already like prevention of mother-to-child transmission (PMTCT), ANC, and HIV prevention, care, and treatment efforts for pregnant and breastfeeding people. The Guiding Principles were not gender transformative, as they did not meaningfully discuss gender or the gender transformative components of DREAMS and other key programs. Conversely, the Guiding Principles described the impact of COVID-19 on specific populations and documented how PEPFAR programs adapted their implementation to continue to serve clients, which was highly responsive to need. The Guiding Principles neither hindered nor promoted SRHR in this domain.

2020_PEPFAR 2020 Annual Report to Congress

The PEPFAR Annual Report to Congress provided a comprehensive overview of PEPFAR and its accomplishments as of 2020. It outlined the evidence base for PEPFAR's programs and the methods used to make data-informed decisions including disaggregating all data by sex, age, and geography through the Monitoring, Evaluation, and Reporting (MER) system. The report noted the importance of adhering to guidance from the WHO (e.g., providing Dolutegravir-containing regimens for all women of childbearing age), which was responsive to need and based in evidence. According to this report, PEPFAR implemented a comprehensive PMTCT cascade of interventions, which included antenatal services, HIV testing, and use of antiretroviral therapy (ART) for life; safe childbirth practices and appropriate breastfeeding; and infant HIV testing and other postnatal care services. This cascade was aligned with evidence and human rights. PEPFAR also prioritized oral PrEP for prevention and viral load monitoring for pregnant and breastfeeding women (PBFW) as key interventions to ensure that risk of HIV transmission to a fetus during pregnancy remained low, which was based in evidence and responsive to need. With regard to MCH, the Report was comprehensive, based in evidence, and aligned with human rights norms that recognize that one’s pregnancy or ability to get pregnant should not prevent them from accessing care. However, much of the language was gender blind and reinforced a gender binary instead of using more inclusive language like "pregnant and breastfeeding persons" instead of “pregnant and breastfeeding women.” The Report moderately promoted SRHR in the MCH domain.

2020_PEPFAR 2020 Country Operational Plan Guidance for all PEPFAR Countries

Each year, the Office of Global AIDS Coordinator (OGAC) releases the PEPFAR Country Operational Plan (COP) Guidance, which includes the programmatic and policy guidance for global HIV and AIDS activities and provides the basis for the approval of annual bilateral funding for PEPFAR country and regional programs. The 7 Minimum Program Requirements included in the 2020 COP Guidance were aligned with international human rights norms and evidence and were designed to ensure that PEPFAR programs are responsive to need. The 2020 COP Guidance included the importance of integrating PrEP for adolescent girls and young women (AGYW) and targeted HIV testing at ANC clinics. The Guidance worked to improve retention among PBFW using integrated services during pregnancy and postpartum to promote adherence and retention in care. It also called for additional measures like maternal retesting to achieve the elimination of mother to child transmission (MTCT), which was evidence-based. However, programmatic adaptations for persons with disability were not meaningfully included in the 2020 COP Guidance, which may impact people’s access to MCH services. While the Guidance provided a thorough focus on couple-based services, it used language that promoted a gender binary and largely excluded discussion of pregnant people seeking care who are not married, part of a couple, or identify as women. The 2020 COP Guidance also focused on the key challenges for children, specifically, the pediatric treatment gap, high rates of sexual violence against adolescent girls, and the risk to children posed by inadequate adult HIV treatment retention as well as low viral suppression rates. The Guidance included instructions for families with someone living with HIV to seek services specifically for orphans and vulnerable children (OVC) to streamline service provision and inform other programs, like DREAMS. The 2020 COP Guidance moderately promoted SRHR through PEPFAR country and regional programs with respect to MCH.

2020_PEPFAR 2021 Country and Regional Operational Plan (COP/ROP) Guidance for all PEPFAR Countries

In advance of the COP review process that took place in early 2021, the PEPFAR 2021 Country and Regional Operational Plan Guidance was released in December 2020. The 2021 COP Guidance emphasized the importance of integrating services to create "one stop shops" for integrated MCH and HIV services, which would promote SRHR. The 2021 COP Guidance contained extensive sections about PMTCT, integration of ANC into HIV and AIDS programs, and other MCH activities including guidance for OVC programs, early infant diagnosis (EID), and services for HIV-exposed infants (HEI). Many of these suggestions were consistent with the 2020 COP Guidance, and remained aligned with evidence, PEPFAR program data, and international human rights norms. The 2021 COP Guidance also advocated for the incorporation of oral PrEP at every point of service accessed by PBFW and their eligible partners. However, throughout the 2021 COP Guidance, the language related to MCH was very gendered (e.g., the Guidance does not use “pregnant and breastfeeding persons”) and was not gender transformative in relation to MCH activities. One significant issue was that MCH was not included in the section outlining the impact of COVID-19 on PEPFAR programs, even though the impact of the pandemic on pregnancy and postpartum care, services for OVC, and child and newborn care was documented prior to the release of the 2021 COP Guidance. Additionally, programmatic adaptations for persons with disability were not meaningfully included in the 2021 COP Guidance, which may have impacted people’s access to MCH services. This action moderately promoted SRHR in the MCH domain.

2020_PEPFAR FY21 Site Improvement through Monitoring System (SIMS) Version 4.1

The PEPFAR Site Improvement through Monitoring System (SIMS) tool provides a standardized approach to monitoring program quality at PEPFAR-supported sites that perform service and non-service delivery functions. The FY21 SIMS Implementation Guide and Assessment Tools set a high standard for how PEPFAR-supported sites are evaluated for program quality. With respect to MCH, the FY21 SIMS Implementation Guide and Assessment Tools included new guidance on PMTCT services, the prioritization of OVC programs during COVID-19, and the integration of HIV testing, prevention, and treatment at every point of service accessed by PBFW. The updates also allowed for virtual assessments during COVID-19, which was responsive to need and ensured that the pandemic did not prevent monitoring visits from happening. They also included guidance on implementing the Protecting Life in Global Health Assistance (PLGHA) policy, which helped evaluators know if the policy was relevant to the site assessment and ensured that the PLGHA policy was being appropriately implemented. The Above-Site and Site Assessment Tools included Core Essential Elements (CEEs) that assess the site against the standard requirements. The CEEs covered a range of topics related to MCH, and the standards used in the CEEs were based in evidence, consistent with human rights, and responsive to need. The CEEs also explicitly included services specifically for PBFW, people at antenatal clinics, infants, and children. It also included evidence-based and gender aware standards on adolescent-friendly services, specifically for AGYW living with HIV who are pregnant. The guidelines and standards for evaluating gender norms interventions were somewhat gender transformative, but much of the gendered language adhered to a gender binary and was not inclusive. This action moderately promoted SRHR in the MCH domain.

2020_PEPFAR Guidance for Implementing Safe and Ethical Index Testing Services

The Guidance provided an overview of PEPFAR's Index Testing Services and set the minimum requirements for index testing to ensure that index testing protocols going forward would be aligned with human rights norms, evidence, and best practices. This guidance was responsive to need because it was developed in response to the directive in the 2020 COP Guidance to pause index testing due to human rights and confidentiality concerns. It included the WHO's 5C standards (i.e., consent; counseling; confidentiality; correct test results; and connection to HIV prevention, care, and treatment services) as guiding principles for PEPFAR’s index testing programs. The guidelines for intimate partner violence (IPV) screening included a question to be directed to “female clients” asking if they had ever been “beaten” while pregnant. While this question was extremely important given that the risk of IPV during pregnancy is high according to evidence, it was not gender transformative as it only focused on female clients. This reinforced a gender binary as well as the harmful assumption that only “females” or women can get pregnant. This question was the only mention of maternal health throughout this guidance, which was a significant gap considering the intersections between pregnancy, HIV, and the risk of IPV. The Guidance also included a recommendation that “biologic children of HIV-positive individuals” are included in screenings for emotional IPV and index testing. This approach was based in evidence and promoted SRHR for children that are engaged in the index testing process. This guidance moderately promoted SRHR in the MCH domain.

2020_PEPFAR Monitoring, Evaluation, and Reporting Indicator Reference Guide_MER 2.0 (Version 2.5)

The Monitoring, Evaluation, and Reporting (MER) Indicator Reference Guide aims to streamline and prioritize indicators for PEPFAR programs and is reviewed on an annual basis to ensure that indicators are aligned with PEPFAR initiatives, responsive to need, and consistent with evidence and human rights. In 2020, some of the MER indicators were updated, but it was unclear what evidence or programmatic data prompted these changes. One of the oral PrEP indicators (PrEP_NEW) included new language: "Any process to determine PrEP eligibility should include questions about a client’s exposure to or risk of gender-based violence and intimate partner violence, with appropriate interventions or referrals provided as needed." While this update protected the human rights of those that experience violence, pregnancy could have been mentioned as an additional risk factor for GBV. The Guide also included new guidelines for estimating the viral load testing coverage for pregnant women, which was not gender transformative as it used binary language. Furthermore, this language, along with most of the updates made to the Guide in 2020, were not gender transformative. This version of the MER Indicator Reference Guide moderately promoted SRHR in the MCH domain.

2020_PEPFAR Technical Guidance in Context of COVID-19 Pandemic_18 November 2020

Between March and November 2020, PEPFAR regularly released revised versions of this Technical Guidance to support PEPFAR programming throughout the COVID-19 pandemic and ensure that programs remained consistent with recommendations from the WHO and U.S. Centers for Disease Control and Prevention (CDC). The Guidance was responsive to need, consistent with human rights, and was often aligned with evidence, even as the evidence base shifted throughout the first year of the COVID-19 pandemic. The Technical Guidance prioritized HIV treatment services over prevention services to ensure uninterrupted care for children, adolescents, PBFW, and adults. It also provided key guidance on continuing PrEP for all target populations through multi-month dispensing (MMD) and other mechanisms which was responsive to need and based in evidence. To assist programs with adapting to COVID-19 lockdowns and service disruptions, the Technical Guidance recommended that clinic-based HIV testing continue through ANC clinics as well as encouraged the scale up of HIV self-testing for pregnant people through community health workers and mentor-mother groups, which was responsive to need and consistent with evidence and human rights. The Technical Update encouraged gender transformative work through DREAMS and GBV programming to continue within the constraints of COVID-19 protocols and restrictions. However, the Technical Guidance did not mention the disproportionate impact of COVID-19 and GBV on women and girls. The Technical Guidance moderately promoted SRHR through PEPFAR’s MCH activities as programs adapted their operations during the COVID-19 pandemic.

2020_President’s Interagency Task Force: Report on U.S. Government Efforts to Combat Trafficking in Persons

This report discussed U.S. government efforts to end trafficking in the United States and globally. This strategy prioritized the needs and perspectives of those who have been trafficked, called for innovations in data gathering, and promoted education and public awareness activities related to human trafficking. While the health impacts of trafficking were mentioned, the Report centered on domestic efforts to combat trafficking even though the actions described in this whole-of-government report would impact global health assistance programs and activities. The Report described its carceral approach to combating trafficking including prosecution, which relies heavily on law enforcement to prevent trafficking even though these systems do not consistently protect the rights of marginalized groups. This report did not define or provide the evidence base for the “victim-centered and trauma-informed approach” it purported to take in its approaches to combating human trafficking, which was significantly lacking. The Report did not integrate international human rights standards as it conflated commercial sex work and trafficking for the purposes of sex, which ultimately denies sex workers their rights and can impede efforts to prevent trafficking. The carceral approach outlined in this report posed additional risks and barriers for sex workers that needed to access health services due to the fear of prosecution or being targeted by law enforcement. While this report briefly mentioned gender, it was largely gender blind and made no mention of how trafficking impacts people in the LGBTQI+ community. The Department of State reported that it opened applications for projects to address the impacts of COVID-19 on efforts to combat trafficking, which was responsive to need. In 2020, the Department of State also updated the introductory course for personnel on human trafficking, but the Report did not make clear if or how health needs of trafficking survivors were incorporated into this training. The Report did not sufficiently explain which actions were undertaken with U.S. global health funds, which was also a transparency issue. The Report moderately hindered SRHR in the MCH domain.

2020_Report of the Commission on Unalienable Rights

This Report was released by Secretary Pompeo's Commission on Unalienable Rights. The Report defined “fundamental” or “unalienable” rights as those detailed in the Declaration of Independence. It cited the Universal Declaration of Human Rights (UDHR) of 1948 as the standard for the human rights that should be protected worldwide. The Report claimed that the expansion of human rights beyond what was detailed in UDHR has weakened the “claims of human rights” and left disadvantaged groups more vulnerable to rights violations. This assertion was not based in evidence, as there is no evidence to support this claim. It was also not aligned with human rights norms as it ignored the rights not explicitly stated in the Declaration of Independence or UDHR, such as sexual and reproductive rights and the rights of LGBTQI+ people, persons with disability, and displaced persons. To this end, the Report touted “natural law,” which has been historically used to oppose sexual and reproductive rights and the rights of LGBTQI+ people. This report was not responsive to need, because even though marginalized groups around the world are currently experiencing violations of their human rights, the Commission's approach did not adequately describe how the Department of State would work to protect human rights beyond what is explicitly stated in UDHR. The Report was not gender transformative, as the rights of women, girls, and gender diverse people were almost entirely excluded. The language used throughout the report was largely gender blind, and arguably gender exploitative as it upheld patriarchal structures by not recognizing the compendium of human rights declarations and modern advances in gender equality. The narrow definition of human rights could have negative implications on the implementation of global MCH programs. The Report on the Commission on Unalienable Rights substantially hindered SRHR in the MCH domain.

2020_Review of the Implementation of the Protecting Life in Global Health Assistance Policy (August 2020)

The second review of the Protecting Life in Global Health Assistance (PLGHA) policy summarized the history of the policy and documented its implementation throughout U.S. global health assistance programs. The Review found that in certain cases where partners declined awards, the loss of trusted partners in-country resulted in difficulties replacing these partners and subsequent disruptions in health care services across technical areas. Specifically, the review found that the loss of partners resulted in delays in implementation and distribution of services related to HIV and AIDS, MCH, voluntary FP, tuberculosis, and nutrition, as well as programs providing HIV services for KPs. These findings reinforced the harm of this policy and confirmed that the implementation of the policy led to some disruption in service delivery. This review was somewhat based in evidence as it directly reflected agency-level data. The data collection for this review ended in May 2019, so this was only somewhat responsive to need given that there was no data to document the impact of the policy from May 2019 to August 2020 when the Review was released. However, the Review provided valuable information on how the policy was being implemented that had not been included in the first review. The Review was not gender transformative, as it did not document whether the policy was being implemented in a way that addressed or affected gender norms and dynamics. The Review moderately hindered SRHR in the MCH domain.

2020_Strengthening Health Security Across the Globe: Progress and Impact of U.S. Government Investments in the Global Health Security Agenda, 2019 Annual Report

In 2020, the Department of State released the Strengthening Health Security Across the Globe annual report that identified the U.S. government contributions to global health security by country and U.S. government actor. Though several areas of global health were mentioned throughout the Report, global MCH efforts were noticeably absent. For example, the Report mentioned several infectious diseases that posed a threat to health security, including the Zika virus. However, this was a missed opportunity for this report to highlight the impact of infectious diseases like Zika on pregnancy, childhood immunizations, and other aspects of SRH. The exclusion of SRHR throughout the report contributed to the increased development of siloes that exclude SRHR from other areas of global health, such as disease outbreaks. SRHR is a critical aspect of health security. Neglecting sexual and reproductive health in security discussions can contribute to negative health impacts and human rights violations for women, girls, gender-diverse people, and other marginalized groups. The Report was largely gender blind, as it ignored the fact that health security is unattainable without gender equity and the countering of harmful norms that affect women and girls. As a result, this Report moderately hindered SRHR in this domain.

2020_The Department of State’s Plan to Implement the U.S. Strategy on Women, Peace, and Security 2020-2023

The 2019 United States' Strategy on Women, Peace, and Security (WPS) was developed in response to the Women, Peace, and Security Act of 2017. This Plan laid out the approach undertaken by the Department of State to make progress on three strategic objectives related to WPS from 2020 to 2023. The Plan largely excluded health activities in general, including technical areas related to SRHR. However, it did mention the importance of preventing GBV, including sexual violence and early and forced marriage. The Plan did not address pregnancy as a potential outcome of sexual violence, or the resulting MCH services those who experience violence may need. It also did not mention the impact of pregnancy on people's ability to engage in peace and security efforts. The Plan was responsive to need as the objectives were informed by the global need for women's empowerment efforts. However, the exclusion of maternal and child health was not evidence-based nor consistent with human rights frameworks. The Plan was somewhat gender transformative as it recognized and sought to combat gender norms through a systemic approach, but the Plan used language that reinforced a gender binary and was not inclusive of those who are impacted by the issues detailed in the report who do not identify as women. It was unclear which activities and programming mentioned in the Plan were considered U.S. global health assistance, which was a transparency issue. The Plan neither promoted nor hindered SRHR in the MCH domain.

2020_United States Strategy to Prevent Conflict and Promote Stability

The United States released this Strategy in accordance with the Global Fragility Act of 2019 to promote “peaceful, self-reliant nations.” The Department of State was identified as the lead agency to oversee and implement this Strategy with the assistance of other supporting U.S. government agencies to create impactful and sustainable programs in fragile settings. While the Strategy was responsive to need, it did not adequately address the SRHR and the broader health needs of people in conflict settings. The Strategy failed to explain its engagement with specific global health areas, even though HIV and AIDS, MCH, FP, and other cross-cutting SRHR issues are vital to promoting stability and security. Notably, it did not include GBV, which is often a greater risk to women, girls, and gender-diverse people in fragile settings and conflict areas. The Strategy also stated that it was grounded in evidence and human rights, but it did not include an explanation of the evidence base or human rights framework that informed it. Additionally, it was not gender transformative. Instead, the language in this action promoted a gender binary, ignored the role of gender inequalities on experiences of violence, and only mentioned women in the context of the WPS Strategy. While the latter was an important inclusion, gender was not meaningfully included in other areas of the Strategy. This action moderately hindered SRHR in the MCH domain.

2019_PEPFAR 2019 Annual Report to Congress

The President's Emergency Plan For AIDS Relief (PEPFAR) Annual Report to Congress provided an overview of the PEPFAR program’s accomplishments to date and discussed the program’s future directions. This report largely summarized high-level known information about PEPFAR programs. The report provided critical information about maternal and child health programming through PEPFAR, including viral load monitoring for PBFW, maternal retention in treatment, orphan and vulnerable children (OVC) programs, and prevention of mother-to-child transmission (PMTCT) programs. Within this domain, the report was responsive to need and based in evidence and human rights norms. Some HIV and AIDS services were included in antenatal care (ANC) programming such as opt-out HIV testing, and reported activities were based in evidence and international human rights norms. The document was not gender transformative as it did not discuss the impact of gender norms with PEPFAR’s maternal health programming. Overall, the Annual Report moderately promoted SRHR.

2019_PEPFAR 2019 Country Operational Plan Guidance for all PEPFAR Countries

2019_PEPFAR Monitoring, Evaluation, and Reporting Indicator Reference Guide_MER 2.0 (Version 2.4)

2019_Protecting Life in Global Health Assistance Frequently Asked Questions and Answers_September 2019

The Protecting Life in Global Health Assistance (PLGHA) FAQs document was updated in 2019 to provide clarity on the implementation of the May 2019 expansion of PLGHA as well as address questions and confusion from the 2018 Department of State’s PLGHA Six Month Review. The text of this document was similar to the 2018 FAQ document though included additional questions and answers (see questions 33-37). The document did not meaningfully discuss the impacts of the May 2019 expansion on maternal and child health. Similar to the 2018 FAQs, this document aimed to provide clarity on the policy but left many questions unanswered. This document was somewhat responsive to need as it included additional questions and answers based on confusion expressed by recipients of U.S. global health assistance specifically regarding the definition of “financial assistance” and the applicability of the policy to technical assistance. The document was not evidence-based, was not grounded in international human rights, and was not gender transformative as it was based on the PLGHA policy which has been shown to be harmful globally, particularly to women and girls. The PLGHA policy has also been shown to decrease the availability of maternal health services. Overall, this document provided a substantial hindrance to SRHR.

2019_State and USAID FY 2018 Annual Performance Report_FY 2020 Annual Performance Plan

This document shared the goals and timelines for FY 2020 as well as evaluated and summarized the progress of State and USAID in achieving various strategic goals in FY 2018. These goals included global health and gender programs across all three domains. The FY 2020 Performance Plan elements were included throughout the Report along with reporting on standard indicators for each Performance Goal under the 4 Strategic Objectives. The Report mentioned maternal and child health within the USAID Agency Priority Goals but did not discuss the role of the Department of State in the funding of maternal and child health policies or programs. The Report provided an opportunity for the Department of State to clarify its role in both humanitarian and non-humanitarian maternal and child health activities, but it failed to seize that opportunity. Within this domain, the Report was not based in evidence or human rights and was not responsive to need beyond standard Congressional reporting requirements. The Plan was not gender transformative, as it mentioned the disadvantages of a “gender-blind system” within Strategic Goal Two but perpetuated such a system by not including a gendered lens throughout the document. This Report neither promoted nor hindered SRHR with regard to the Department of State’s maternal and child health programs.

2018_Protecting Life in Global Health Assistance FAQs_September 2018

The PLGHA FAQs provided detailed guidance on the implementation of Trump's expanded Global Gag Rule for implementing partners as of September 2018. The FAQs were not responsive to need, evidence-based, human rights-based, or gender transformative within this domain. The FAQs received a lower grade within this domain compared to Family Planning and HIV and AIDS because they did not mention maternal and child health programming specifically, despite the unique impacts this policy could have on maternal and child health services. The FAQs significantly hindered the Department of State's ability to support comprehensive maternal and child health programming in 2018.

2018_Protecting Life in Global Health Assistance Six Month Review

The PLGHA Six Month Review summarized the PLGHA policy and identified solutions to challenges that had arisen in the process of PLGHA implementation. The review was responsive to need in that it addressed concerns expressed by partners affected by the policy, but was not evidence-based, based in human rights principles, or gender transformative. The review received a lower grade within this domain compared to Family Planning and HIV and AIDS because the review did not mention maternal and child health programming specifically, despite the unique impacts this policy could have on maternal and child health services. The Six Month Review significantly hindered the Department of State's ability to support comprehensive maternal and child health programming in 2018.

2016_Department of State Implementation Plan for the U.S. Adolescent Girls Strategy

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 acknowledged the impact of forced marriage, especially early or childhood marriage, and the impact of FGC on the health of AGYW. Specifically, it stated that these practices lead to poor maternal health outcomes, including high morbidity and mortality rates from pregnancy and birth complications, trauma, and other diseases and infections. The Plan provided details on "preserv[ing] the rights of married and pregnant girls and adolescent mothers to attend school" and "remov[ing] barriers to sexual and reproductive health and comprehensive, accessible, youth-friendly health services" to prevent early pregnancy. Though the Plan was responsive to need and grounded in human rights principles, it did not incorporate significant evidence-based programming because it did not address how to meet the clinical needs or provide maternity care of pregnant AGYW. This Plan is gender transformative in that it promoted gender equality by decreasing early marriage and pregnancy through educational empowerment. This Strategy moderately promoted SRHR through the Department of State’s maternal and child health programs.

2012_U.S. Department of State Policy Guidance: Promoting Gender Equality to Achieve our National Security and Foreign Policy Objectives

2012_United States Department of State Implementation Plan of the National Action Plan on Women, Peace, and Security

D-

Family Planning (FP)

The Department of State received a 56 (F) with transparency and a 61 (D-) without transparency in the Family Planning (FP) domain in 2021. This domain grade was raised by the meaningful inclusion of FP activities in the PEPFAR Core Program and Policy Priorities and the March 2021 updated DREAMS Guidance, which were both responsive to need, based in evidence, aligned with human rights norms, and gender transformative. The February 2021 COP/ROP Guidance and other COP/ROP-related materials did not promote SRHR in the FP domain because they did not include adequate information for partners to understand the revocation of PLGHA and adapt their programs accordingly. Though some actions mentioned integrated FP/HIV services, this domain grade was low overall because the actions did not adequately include data about the Department of State’s FP funding, programs, or activities, which reinforced the siloed nature of global health programs, negatively affected transparency, and hindered SRHR. In the budget evaluation, the Department of State allocated FP funds in such a way that was somewhat in accordance with unmet contraceptive need at the country level, which moderately promoted SRHR in the FP domain in 2021.

The Fòs Feminista data index grades government agencies on policies and funding impacting family planning, maternal and child health, and HIV & AIDS foreign assistance.

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2021_2021 Annual PEPFAR Treatment Report to Congress

The Annual Treatment Report from PEPFAR provides information to Congress on PEPFAR-supported treatment programs as required by Section 7611 (g) of Title 22 of the U.S. Code. The 2021 Report focused on the programmatic adaptations PEPFAR implemented in response to the COVID-19 pandemic to ensure that treatment programs were not disrupted. Adaptations included MMD of ARVs, the decentralization of drug delivery, the use of virtual platforms like telemedicine, and the implementation efforts to empower communities, which were responsive to need, based in evidence, and aligned with human rights. The Report was not fully responsive to need or completely based in evidence as there was no mention of integrated FP/HIV programs as key entry points for HIV testing, care, and treatment. There was no mention of the importance of ensuring that PLHIV have access to contraceptives with method mix, which was not consistent with evidence or human rights in this domain. The Report was gender blind, as there was very little mention of gender. The Report moderately hindered SRHR in the FP domain.

2021_Country_Regional Operational Plan 2021 (COP/ROP 2021) Virtual Meeting Handbook

This Virtual Meeting Handbook outlined the ways in which the OGAC streamlined the COP/ROP 2021 process in response to the COVID-19 pandemic. The COP/ROP 2021 process was shortened and conducted virtually for the first time, which was highly responsive to need due to the pandemic and this action ensured that PEPFAR stakeholders at all levels had timely information about this process. This action detailed the revised framework for ensuring meaningful stakeholder engagement by mandating transparent discussions with PEPFAR leadership during town halls with stakeholders at all levels and involving partner country governments, communities, CSOs, multilateral partners, and the private sector, which was responsive to need. This action included guiding principles for PEPFAR during the COVID-19 pandemic that were responsive to need and consistent with evidence and human rights norms, such as protecting program gains and ensuring site safety. However, maintaining integrated FP/HIV programs was not mentioned within the guiding principles, so this action was not fully based in evidence or human rights or responsive to need. This action moderately hindered SRHR in the FP domain.

2021_Department of State and USAID_Fiscal Year (FY) 2022 Annual Performance Plan

The FY 2022 Annual Performance Plan outlined progress made by the Department of State and USAID toward strategic objectives and performance goals in previous years. The Plan outlined each agency’s plans for achieving the goals articulated in their joint strategic plan moving forward. Though the FP-specific indicators only included data from USAID, this action was graded across domains for the Department of State because of this actor’s leadership of PEPFAR which includes activities related to FP, as well as cross-cutting issues including GBV. While the availability of these data were important for evidence-based decision making in the HIV and AIDS domain, indicators that measured the outcomes of FP/HIV integration efforts or other HIV activities related to FP, such as FP/HIV integration, were not included in this action. As a result, this action was not fully responsive to need or based in evidence or human rights. The contributions by the Department of State to cross-cutting SRHR issues like gender equality and GBV prevention and response were included in this action, which was responsive to need. However, no targets were included for FY 2022, which was not responsive to need and negatively affected transparency. Additionally, the Plan was gender accommodating as it used language that reinforced a gender binary. This action neither hindered nor promoted SRHR in the FP domain.

2021_Guiding Principles for the Next Phase of PEPFAR

The Guiding Principles outlined the program’s goals as of January 20, 2021 and presented PEPFAR’s progress to date, including national progress toward achieving the 90-90-90 and 95-95-95 targets in specific countries. This action detailed the impact of COVID-19 on PEPFAR programs, as well as outlined programmatic adaptations that OUs implemented to overcome the impacts of the pandemic, which was responsive to need and based in evidence. The Guiding Principles focused on providing people-centered HIV prevention, care, and treatment services but did not mention support for the provision of internal and external condoms as the only available dual-prevention modality or contraceptives for people living with HIV, or other PEPFAR activities related to FP. As a result, this action was not fully responsive to need or aligned with evidence. This action did not mention the human rights framework that underpins PEPFAR programming, nor did it discuss the importance of integrated FP/HIV services and UHC in advancing PEPFAR’s goals, specifically for pregnant and breastfeeding persons or persons of reproductive age. This action was gender accommodating as it included language that reinforced a gender binary. This action moderately hindered SRHR in the FP domain.

2021_PEPFAR 2021 Annual Report to Congress

The PEPFAR 2021 Annual Report to Congress detailed PEPFAR’s achievements and challenges to delivering people-centered HIV services because of the COVID-19 pandemic. This action outlined country-specific progress toward the 90-90-90 targets, documented the efforts of PEPFAR to strengthen health systems, and advocated for integrated GBV programs, which was responsive to need and based in evidence. This action highlighted the importance of addressing barriers to accessing care and working with community- and KP-led indigenous organizations to promote human rights, which was responsive to need and promoted SRHR. The Report mentioned that PEPFAR provided “condoms for all populations at significant risk of acquiring HIV,” but all mentions of condoms in the Report were in relation to KP activities. It neglected to mention the importance of condoms as a dual-prevention method for all people. The Report did not mention FP activities beyond condom provision and a non-specific reference to “reproductive health care.” There was no discussion of FP/HIV integration, which further siloed FP from HIV and AIDS programs, and was not responsive to need or based in evidence. This action was gender accommodating as it used language throughout that reinforced a gender binary. This action moderately hindered SRHR in the FP domain.

2021_PEPFAR 2021 Country and Regional Operational Plan (COP/ROP) Guidance for all PEPFAR Countries

On February 11, 2021, OGAC released an updated version of the COP/ROP 2021 Guidance that revised four sections of this critical PEPFAR guiding document. Section 5.9.4 was updated to cross out the text related to the PLGHA policy. The action included the following information: “Implementation of Protecting Life in Global Health Assistance in PEPFAR Programs has been deleted as the policy was rescinded by President Biden in January 2021” but did not provide stakeholders with any additional information about what the revocation meant for OUs or ongoing awards. Though this update was timely, it lacked specificity and guidance for stakeholders to understand how the revocation of PLGHA (also known as the GGR) impacted their work, so it was only somewhat responsive to need and was not based in evidence or human rights. This action significantly hindered SRHR in the FP domain.

2021_PEPFAR COP/ROP 2021 Frequently Asked Questions

This FAQs document provided regular updates on the COP/ROP 2021 process after it was temporarily paused earlier in 2021. This action included information about civil society and community engagement and provided answers to questions that were specific to technical areas, all of which were responsive to need and based in evidence. For example, this action included FAQs that encouraged coordination between PEPFAR and Global Fund when procuring commodities, which was responsive to need and based in evidence. The action included one question related to the impact of “new policies of the Biden-Harris Administration, such as the rescission of the Mexico City Policy” on the COP/ROP 2021 process. The answer said that “PEPFAR funding and partners are no longer subject to these policy requirements and instead should follow those outlined in the January 28, 2021 Executive Order” and included a hyperlink to the executive action. This answer did not include additional information or guidance for stakeholders to understand how the revocation of this policy impacted their work with PEPFAR, which was not responsive to need. This action moderately hindered SRHR in the FP domain.

2021_PEPFAR COP/ROP 2021 Temporary Pause FAQs

This FAQs document was released on February 17, 2021 and confirmed the Biden administration’s commitment to PEPFAR as well as provided an explanation for the temporary pause of the COP/ROP 2021 process. This action reaffirmed OGAC’s commitment to completing a data-driven COP/ROP 2021 process and ensuring that there were no disruptions in HIV services at the start of FY 2022. Many of the process-specific questions included in this action were also included in the previous action, including a question that highlighted the sections that were updated in the February 2021 version of the COP/ROP 2021 Guidance. Most of the questions were procedural and not technical, so this action neither promoted nor hindered SRHR in this domain.

2021_PEPFAR Core Program and Policy Priorities

The PEPFAR Core Program and Policy Priorities outlined the focus areas of PEPFAR under the Biden administration. The action included key priorities on HIV prevention and treatment: data-driven HIV testing strategies such as support for KPs, gender equity and equality, cooperation and partnership with community stakeholders and public health leadership, and the strengthening of global health security. These priorities were responsive to need, based in evidence, and aligned with human rights norms. Notably, the action included a priority to promote and protect SRHR, including through the revocation of PLGHA. This action provided a high-level framework for PEPFAR’s focus areas, so information about how PEPFAR would implement the revocation would not be included in this action. However, this action was not fully responsive to need as the priorities did not include any mention of FP/HIV integration efforts. This action stated the importance of improving appropriate linkages to and integration of HIV services with other related programs but did not specifically mention FP services as a related program. Gender transformative elements were highlighted in the section on “HIV prevention, clinical, and health systems programs” and through the Department of State’s commitments to DEIA. This action moderately promoted SRHR in the FP domain.

2021_PEPFAR DREAMS Guidance_Updated March 2021

The PEPFAR DREAMS Guidance provided updated guidance for implementing DREAMS programming for AGYW in 2021. The Guidance highlighted the importance of multi-sector engagement across government leadership and community partners, evidence-based decision making across DREAMS programming, and overall prioritization of DREAMS implementation and impact. The Guidance was based in evidence and human rights as it referenced a variety of peer-reviewed external resources as well as international agreements and frameworks. The Guidance referenced FP/HIV integration toolkits and resources and provided guidance on improving access to voluntary, comprehensive FP services and referrals for FP services if they are not offered on-site (since PEPFAR does not procure FP commodities). This promoted FP services within DREAMS programming, was responsive to need, and was consistent with human rights. It was gender transformative as it included guidance for programs to challenge and change unequal gender and power dynamics. However, this Guidance used gendered language when mentioning condoms and pregnancy, did not affirm the right to sexual pleasure, and did not include LGBTQI+ women and girls, which was an oversight. This Guidance significantly promoted SRHR in the FP domain.

2021_PEPFAR FY21 Site Improvement through Monitoring System (SIMS) Materials_Version 4.1

The PEPFAR SIMS tool provides a standardized approach for monitoring program quality at PEPFAR-supported sites that perform service and non-service delivery functions. The FY21 Implementation Guide, Above-Side Assessment Tool, and Site Assessment Tool were updated in 2021, though the changes from the previous version were not clearly stated, which negatively affected transparency. The Above-Site and Site Assessment Tools included CEEs that assessed the site against a set of standard technical requirements, which were based in evidence. The major apparent change in the CEEs was the removal of assessment modules related to the implementation of PLGHA in the Above-Site Assessment Tool. This module was removed without explanation. A new module was not added to ensure that PEPFAR-supported sites stopped implementing the policy after its revocation, which was not responsive to need or consistent with evidence and human rights norms. The Guide and CEEs included FP/HIV integration service delivery models, though it was unclear what changes and additions were made in the 2021 Guide that were relevant to FP. It included guidance for SIMS assessors to not participate in or condone discriminatory practices based on gender, race, ethnicity, caste, religion, sexual orientation, disability, or socio-economic status, which was based in evidence and responsive to need. The CEEs were somewhat gender transformative because they included guidelines and standards for evaluating interventions related to changing unequal gender norms, but used language that reinforced a gender binary. The SIMS materials updated in 2021 moderately promoted SRHR in the FP domain.

2021_PEPFAR Monitoring, Evaluation, and Reporting Indicator Reference Guide_MER 2.0 (Version 2.6)

The MER Indicator Reference Guide is reviewed and updated annually to streamline and prioritize the standard indicators used across PEPFAR programs. The 2021 Guide introduced trainings for USG and implementing partner staff on indicators across technical areas, which was responsive to need. The Guide included updates to specific MER indicators, such as new age/sex disaggregations, provided updated reporting frequencies, and clarified definitions, which were responsive to need. The updated indicators did not provide any direct references to FP activities funded or supported by PEPFAR. This action moderately promoted SRHR in the FP domain.

2021_Prioritizing Sexual and Reproductive Health and Reproductive Rights in U.S. Foreign Policy

Secretary of State Blinken delivered this Press Statement on prioritizing SRHR in U.S. foreign policy, which described how the Department of State would implement the presidential memorandum that rescinded PLGHA. Though this action mentioned the revocation of the GGR, it did not provide guidance for programs about adapting their efforts to align with the presidential memorandum, which was not responsive to need and was a missed opportunity to highlight the Department of State's specific responsibility to promote SRHR as the funding agency of global health assistance. The action highlighted the reinstatement of funding to the UNFPA, the withdrawal of the United States from the Geneva Consensus Declaration and the increased access to vital health services, including “maternal health and voluntary family planning” services. These actions were generally responsive to need, based in evidence, and based in human rights. This action affirmed the United States' commitment to providing voluntary family planning services through strengthening health systems and partnering with governments, the private sector, and international and non-governmental organizations, which was responsive to need and based in evidence. This action was gender accommodating, as it acknowledged gender inequities but used language that promoted a gender binary and only recognized SRHR for women and girls, even though SRHR is vital for all people. The action moderately promoted SRHR in the FP domain.

2021_Strengthening Health Security Across the Globe_Progress and Impact of United States Government Investments in the Global Health Security Agenda

This Report detailed the progress and impact of the USG’s investments in global health security during FY 2020, including those led by the Department of State. The Report detailed the distribution of Congressional appropriations to advance global health security efforts in 19 partner countries to respond to disease outbreaks and prevent future outbreaks whenever possible. The Report did not mention other global health security efforts by the Department of State as it pertained to FP services. Though the Report focused on global health security, FP, SRHR, and other cross-cutting issues such as GBV were not mentioned. The exclusion of these cross-cutting issues was not based in evidence as the inclusion of SRHR and gender equity promotes global health security. This exclusion was not responsive to need as SRHR services are often the first set of "essential services" to be neglected in a health emergency, as notably evidenced by the initial global response to COVID-19. The Report was gender blind as it made only one mention of gender in the context of OneHealth. This action moderately hindered SRHR in the FP domain.

2021_Trafficking In Persons Report_ Human Trafficking in the Context of a Global Pandemic

The 2021 Trafficking in Persons Report detailed the Department of State's approach to combat human trafficking, with additional detail about these activities in the context of the COVID-19 pandemic. The Report outlined lessons learned from the pandemic and called for "comprehensive, trauma- and survivor-informed, and victim-centered anti-trafficking responses during the pandemic." The Report stated that global crises such as COVID-19, climate change, and enduring discriminatory policies and practices disproportionately impact people who are already oppressed by other injustices and increase people’s vulnerability to exploitation, which was based in evidence and responsive to need. While the Report recognized that survivors of trafficking are hesitant to interact with carceral systems, it promoted prosecution and a carceral approach to trafficking, which was not responsive to need. The Report did not meaningfully include global FP outcomes and programming, which was a missed opportunity to highlight the Department of State’s global FP efforts. The Report moderately hindered SRHR in the FP domain.

2021_United States Government Women, Peace, and Security (WPS) Congressional Report

The WPS Congressional Report provided Congress with an overview of progress made in implementing the WPS Agenda globally since 2019. The Report evaluated progress in advancing the WPS Strategy's four lines of effort across the Department of State, DoD, DHS, and USAID: participation, protection, internal capabilities, and partnerships. While improved health outcomes were included as a positive impact of implementing the WPS Agenda, global FP, contraception, and sexual health programs were not mentioned, though these areas are essential to the successful implementation of the WPS Agenda. The Report included GBV prevention and programming as a measure of progress towards achieving the WPS Agenda, which was responsive to need. The Report highlighted an initiative by the Department of State to lead a data-driven MEL exercise on its WPS efforts, which was based in evidence and responsive to need. The Report included specific and actionable milestones to measure progress, which was responsive to need. The Report included several gender transformative elements such as enhancing gender-sensitive data analytics, recognizing "the intersectionalities inhabited by women," and supporting initiatives to address and overhaul harmful gender norms. However, it was predominantly focused on women which reinforced a gender binary. The Report moderately promoted SRHR in the FP domain.

2020_Contraception for Women at High Risk of HIV Technical Update

The purpose of this Technical Update was to explain the implications of the Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial results on “reproductive health programming” funded through U.S. global health assistance. The Technical Update summarized updated guidance from the World Health Organization (WHO) regarding the use of contraception by women at high risk of acquiring HIV, which had been revised based on the ECHO Trial findings. Though the WHO released its revised guidance in August 2019 shortly after the ECHO Trial results were published, the Department of State (as the funding agency for PEPFAR) did not publish this Technical Update until December 2020. Because of this delay, the action was not fully responsive to need. The Technical Update was aligned with international human rights norms and evidence (e.g., quality of care, voluntarism, informed choice, differentiated service delivery models, patient-centered approaches free of stigma and discrimination) and included specific programmatic and policy guidance for working closely with diverse stakeholders to adapt global HIV and FP programs accordingly. The Technical Update emphasized the importance of improving contraceptive method choice, including emergency contraception, which promoted SRHR because it supported all methods equally. The Technical Update mentioned “male and female condoms” as the only contraceptive methods that can reduce the risk of sexually transmitted infection (STI) and HIV transmission, which was based in evidence but it was not gender transformative because it used the outdated “male and female” terminology instead of the gender inclusive “internal and external” terminology. The Technical Update also adequately accounted for the importance of FP/HIV integration but took a gender-binary approach to FP programs. There was no mention of the LGBTQI+ community and how their FP needs would intersect with their HIV risk. The Technical Update substantially promoted SRHR in the FP domain.

2020_Department of State and USAID Joint Report to Congress on U.S. Foreign Assistance Gender-Related Programming_Fiscal Years 2017 and 2018

The Department of State and USAID submitted this joint report to Congress on gender-related programming funded through all types of U.S. foreign assistance in FY 2017 and 2018 as required by the Department of State, Foreign Operations, and Related Programs Appropriations Act, 2019. It reported on $110 million of PEPFAR funds that were used during those two fiscal years to provide gender-based violence (GBV) prevention services as well as the full package of post-GBV care, including HIV and violence prevention services in communities and schools where the DREAMS program was being implemented. However, the Report did not include the provision of FP as a core component of post-GBV care, which was lacking. Further, the report did not include information about the importance of incorporating GBV screening into contraceptive counseling. It included information about numerous other programs and funding types across both the Department of State and USAID, but there was insufficient information to determine if those other programs were considered U.S. global health assistance, which contributed to low transparency. Additionally, U.S. global health funds were not explicitly included in the funding table at the end of the report, which also contributed to low transparency. This report neither promoted nor hindered SRHR in the FP domain.

2020_Department of State and USAID_Fiscal Year (FY) 2020 Annual Performance Report

The 2020 Annual Performance Report outlined Department of State and USAID’s progress toward strategic objectives, Agency Priority Goals (APGs), and performance goals in FY 2020 in accordance with their joint strategic plan. These goals included global health and gender-related programs across all three domains for both actors. The Report did not adequately report on the Department of State’s FP activities that were conducted through PEPFAR and other gender-related programs funded through U.S. global health assistance. FP/HIV integration activities and indicators should be included as a mechanism to monitor this important aspect of PEPFAR programming. The Report included data on a few indicators that measured gender norm change, which were gender accommodating and not gender transformative because they focused on “males and females” which reinforced a gender binary. As a result, this report neither hindered nor promoted SRHR in the FP domain.

2020_Geneva Consensus Declaration on Promoting Women’s Health and Strengthening the Family

Along with 33 largely authoritarian governments, the United States signed the Geneva Consensus Declaration, a nonbinding declaration to advance the Trump administration’s anti-abortion agenda. Secretary of State Pompeo and Secretary of Health and Human Services Azar jointly participated in the signing ceremony on behalf of the Trump administration. The Declaration cited several international human rights documents to bolster its position that abortion was not to be included in any sexual and reproductive health (SRH) or universal health coverage programs. However, the Declaration did not recognize pregnant people’s right to bodily autonomy. It was also not aligned with evidence as evidence suggests that restricting access to safe abortion services results in increased rates of unsafe abortion. This action was not responsive to need and was not gender transformative because it reinforced a gender binary throughout and ignored gender inequalities and other systemic issues that might impact people's ability to access SRHR services, including FP. In fact, both the language used and the exclusion of SRHR were so deeply rooted in patriarchal structures that the Declaration was gender exploitative. The Declaration also failed to acknowledge the human rights of those in the LGBTQI+ community, which threatened to roll back progress made on recognizing the health needs of pregnant people who may not identify as women and/or those who identify as LGBTQI+. The stance of the Administration as demonstrated by the Department of State signing onto this Declaration substantially hindered the ability of U.S. global health assistance to promote SRHR in the FP domain.

2020_Guiding Principles for the Next Phase of PEPFAR

This Guiding Principles document outlined the progress made by PEPFAR toward the 90-90-90 targets as of December 1, 2020, including programmatic adaptations to respond to COVID-19. This action included the approaches PEPFAR plans to implement to contribute to Sustainable Development Goal (SDG) 3 and achieve epidemic control by 2030. The Guiding Principles briefly mentioned linking HIV services to other “relevant health issues” without explicitly naming these health issues. This action did not explicitly mention evidence or human rights norms related to FP that may have been incorporated into the development of these principles. Given the evidence base that outlines the importance of integrating FP and HIV services to meet the needs of clients, it was vital that this action explicitly mention the ways that FP services are included in PEPFAR programming already. The Guiding Principles were not gender transformative, as they did not meaningfully discuss gender or the gender transformative components of DREAMS and other key programs. Conversely, the Guiding Principles described the impact of COVID-19 on specific populations and documented how PEPFAR programs adapted their implementation to continue to serve clients, which was highly responsive to need. With regards to FP, the Guiding Principles moderately hindered SRHR in the FP domain.

2020_PEPFAR 2020 Annual Report to Congress

The PEPFAR Annual Report to Congress provided a comprehensive overview of PEPFAR and its accomplishments as of 2020. It outlined the evidence base for PEPFAR's programs and the methods used to make data-informed decisions including disaggregating all data by sex, age, and geography through the Monitoring, Evaluation, and Reporting (MER) system. The report noted the importance of adhering to guidance from the WHO (e.g., providing Dolutegravir-containing regimens for all women of childbearing age), which was responsive to need and based in evidence. The ECHO Trial was mentioned in relation to high HIV incidence among adolescent girls and young women (AGYW), but PEPFAR’s integrated FP/HIV work was not mentioned in this report. This gap was not responsive to need and did not align with revised guidance from the WHO related to contraception and HIV programs based on the ECHO Trial results that were released in 2019. The Report only briefly mentioned condoms and lubricant without any differentiation between internal and external condoms, which was also not responsive to need or evidence. Regarding FP, the lack of detail about PEPFAR’s FP/HIV integration efforts reinforced the siloed nature of U.S. global health assistance and was not aligned with evidence or international human rights norms. The Report contained few gender transformative elements, such as acknowledgement of external factors that could impact one's ability to access health services, including gender inequality. The Report moderately hindered SRHR through PEPFAR's FP activities.

2020_PEPFAR 2020 Country Operational Plan Guidance for all PEPFAR Countries

Each year, the Office of Global AIDS Coordinator (OGAC) releases the PEPFAR Country Operational Plan (COP) Guidance, which includes the programmatic and policy guidance for global HIV and AIDS activities and provides the basis for the approval of annual bilateral funding for PEPFAR country and regional programs. The 7 Minimum Program Requirements included in the 2020 COP Guidance were aligned with international human rights norms and evidence and were designed to ensure that PEPFAR programs are responsive to need. The 2020 COP Guidance was updated to align with the WHO recommendations released after the ECHO Trial and called for PEPFAR’s HIV and AIDS programs to seek innovative approaches to expand the HIV prevention options available for women at high risk of HIV, including integration of FP and HIV services. This decision was evidence-based, aligned with human rights norms, and responsive to need as it aimed to bridge the silos across health areas addressed by PEPFAR programs. The Guidance also made it clear that conditioning antiretroviral treatment (ART) provision on contraceptive use violates quality of care standards for family planning programs. This was aligned with guidance from the WHO regarding Dolutegravir (DTG) as the preferred first-line regimen for people living with HIV, including women of childbearing potential regardless of their contraceptive use. However, programmatic adaptations for persons with disability were not meaningfully included in the 2020 COP Guidance, which may impact access to FP services. Regarding FP programs, this guidance was evidence-based, aligned with human rights norms, and responsive to need. However, while the programming presented was mostly gender transformative and took into account the differential factors impacting marginalized groups from accessing services, the language used around these programs was mostly gender blind or reinforced a gender binary. The 2020 COP Guidance moderately promoted SRHR in the FP domain.

2020_PEPFAR 2021 Country and Regional Operational Plan (COP/ROP) Guidance for all PEPFAR Countries

In advance of the COP review process that took place in early 2021, the PEPFAR 2021 Country and Regional Operational Plan (COP/ROP) Guidance was released in December 2020. Most of the sections relevant to FP were consistent with prior versions of the COP Guidance, and the Guidance remained aligned with evidence, PEPFAR program data, and international human rights norms. New in the 2021 COP Guidance was the inclusion of FP commodities in decentralized drug distribution (DDD) efforts which would help to achieve greater efficiency, increase convenience for clients, and reduce stigma so DDD would not be associated with HIV treatment alone. The 2021 COP Guidance also mentioned the importance of integrating GBV prevention and post-violence care into the HIV cascade along with FP services, including emergency contraception. The explicit mention of emergency contraception was new in the 2021 COP Guidance and was aligned with evidence. The 2021 COP Guidance also advocated for free internal and external condoms and lubricants to be distributed through sites where key populations (KPs) receive services. As written, this guidance did not advocate for the inclusion of condom programs and commodities for those who are not KPs. This was a shortcoming given the importance of internal condoms as a protective barrier method for all people who are the receptive partner of penetrative sex. One significant issue was that FP was not mentioned in relation to the impact of COVID-19 on PEPFAR programs, even though the impact of the pandemic on pregnancy and postpartum care, orphan and vulnerable children (OVC) services, and child and newborn care had been documented before the 2021 COP Guidance was released. Additionally, programmatic adaptations for persons with disability were not meaningfully included in the 2021 COP Guidance, which may impact access to FP services. The 2021 COP Guidance moderately promoted SRHR in the FP domain.

2020_PEPFAR FY21 Site Improvement through Monitoring System (SIMS) Version 4.1

The PEPFAR Site Improvement through Monitoring System (SIMS) tool provides a standardized approach to monitoring program quality at PEPFAR-supported sites that perform service and non-service delivery functions. The FY21 SIMS Implementation Guide and Assessment Tools set a high standard for how PEPFAR-supported sites are evaluated for program quality. With respect to FP, the FY21 SIMS Implementation Guide and Assessment Tools detailed how FP should be included and integrated with HIV services at PEPFAR-supported sites which was based in evidence. The updates also allowed for virtual assessments during COVID-19, which was responsive to need and ensured that the pandemic did not prevent monitoring visits from happening. The Above-Site and Site Assessment Tools included Core Essential Elements (CEEs) that assess the site against the standard requirements. These CEEs included FP as a consideration for a wide range of areas covered by PEPFAR programs such as referral networks, services for KPs, and community-based services. They also included guidance on implementing the Protecting Life in Global Health Assistance (PLGHA) policy, which helped evaluators know if the policy was relevant to the site assessment and ensured that the PLGHA policy was being appropriately implemented. Additionally, the Tools provided detailed standards for integrating FP and HIV services for both the general population, as well as KPs. Overall, the SIMS tools were based in evidence, responsive to need, and aligned with human rights norms. However, the Tools indicated that condoms and lubricants were considered “easily accessible” if they were available on-site, regardless of whether they were for sale or were freely distributed. This neglected to consider the social norms that would prevent marginalized populations from accessing condoms and lubricants, especially if they were for sale. They were somewhat gender transformative because they included guidelines and standards for evaluating gender norms interventions, but much of the gendered language adhered to a gender binary and was not inclusive. This policy moderately promoted SRHR in the FP domain.

2020_PEPFAR Monitoring, Evaluation, and Reporting Indicator Reference Guide_MER 2.0 (Version 2.5)

2020_PEPFAR Technical Guidance in Context of COVID-19 Pandemic_18 November 2020

Between March and November 2020, PEPFAR regularly released revised versions of this Technical Guidance to support PEPFAR programming throughout the COVID-19 pandemic and ensure that programs remained consistent with recommendations from the WHO and U.S. Centers for Disease Control and Prevention (CDC). The Guidance was responsive to need, consistent with human rights, and was often aligned with evidence, even as the evidence base shifted throughout the first year of the COVID-19 pandemic. The Technical Guidance provided support for instituting the multi-month dispensing (MMD) of oral contraceptives, condoms, and emergency contraception, which was responsive to need and based in evidence (even though PEPFAR funds cannot be used to procure contraceptives except condoms). To assist programs with adapting to COVID-19 lockdowns and service disruptions, the Technical Guidance recommended integrating FP and HIV supply chain management and distribution efforts to ensure that contraceptives were available, which was highly responsive to need, based in evidence, and consistent with human rights. The Technical Update encouraged gender transformative work through DREAMS and GBV programming to continue within the constraints of COVID-19 protocols and restrictions. However, the Technical Guidance did not mention the disproportionate impact of COVID-19 and GBV on women and girls, which was lacking. The Technical Guidance moderately promoted SRHR in the FP domain as PEPFAR programs adapted their operations during the COVID-19 pandemic.

2020_President’s Interagency Task Force: Report on U.S. Government Efforts to Combat Trafficking in Persons

This report discussed U.S. government efforts to end trafficking in the United States and globally. This strategy prioritized the needs and perspectives of those who have been trafficked, called for innovations in data gathering, and promoted education and public awareness activities related to human trafficking. While the health impacts of trafficking were mentioned, the Report centered on domestic efforts to combat trafficking even though the actions described in this whole-of-government report would impact global health assistance programs and activities. The Report described its carceral approach to combating trafficking including prosecution, which relies heavily on law enforcement to prevent trafficking even though these systems do not consistently protect the rights of marginalized groups. This report did not define or provide the evidence base for the “victim-centered and trauma-informed approach” it purported to take in its approaches to combating human trafficking, which was significantly lacking. The Report did not integrate human rights standards as it conflated commercial sex work and trafficking for the purposes of sex, which ultimately denies sex workers their rights and can impede efforts to prevent trafficking. The carceral approach outlined in this report posed additional risks and barriers for sex workers that needed to access health services due to the fear of prosecution or being targeted by law enforcement. While this report briefly mentioned gender, it was largely gender blind and made no mention of how trafficking impacts people in the LGBTQI+ community. The Department of State reported that it opened applications for projects to address the impacts of COVID-19 on efforts to combat trafficking, which was responsive to need. In 2020, the Department of State also updated the introductory course for personnel on human trafficking, but the Report did not make clear if or how health needs of trafficking survivors were incorporated into this training. The Report did not sufficiently explain which actions were undertaken with U.S. global health funds, which was a transparency issue. The Report moderately hindered SRHR in the FP domain.

2020_Report of the Commission on Unalienable Rights

This Report was released by Secretary Pompeo's Commission on Unalienable Rights. The Report defined “fundamental” or “unalienable” rights as those detailed in the Declaration of Independence. It also cited the Universal Declaration of Human Rights (UDHR) of 1948 as the standard for the human rights that should be protected worldwide. The Report claimed that the expansion of human rights beyond what was detailed in UDHR has weakened the “claims of human rights” and left disadvantaged groups more vulnerable to rights violations. This assertion was not based in evidence, as there is no evidence to support this claim. It was also not aligned with human rights norms as it ignored the rights not explicitly stated in the Declaration of Independence or UDHR, such as sexual and reproductive rights and the rights of LGBTQI+ people, persons with disability, and displaced people. To this end, the Report touted “natural law,” which has been historically used to oppose sexual and reproductive rights and the rights of LGBTQI+ people. This report was not responsive to need, because even though marginalized groups around the world are currently experiencing violations of their human rights, the Commission's approach did not adequately describe how the Department of State would work to protect human rights beyond what is explicitly stated in UDHR. The Report was not gender transformative, as the rights of women, girls, and gender diverse people were almost entirely excluded. The language used throughout the report was largely gender blind, and arguably gender exploitative as it upheld patriarchal structures by not recognizing the compendium of human rights declarations and modern advances in gender equality. The narrow definition of human rights could have had negative implications on the implementation of global FP programs. The Report on the Commission on Unalienable Rights substantially hindered SRHR in the FP domain.

2020_Review of the Implementation of the Protecting Life in Global Health Assistance Policy (August 2020)

The second review of the Protecting Life in Global Health Assistance (PLGHA) policy summarized the history of the policy and documented its implementation throughout U.S. global health assistance programs. The Review found that in certain cases where partners declined awards, the loss of trusted partners in-country resulted in difficulties replacing these partners and subsequent disruptions in health care services across technical areas. Specifically, the review found that the loss of partners resulted in delays in implementation and distribution of services related to HIV and AIDS, MCH, voluntary FP, tuberculosis, and nutrition, as well as programs providing HIV services for KPs. These findings reinforced the harm of this policy and confirmed that the implementation of the policy led to some disruption in service delivery. This review was somewhat based in evidence as it directly reflected agency-level data. The data collection for this review ended in May 2019, so this was only somewhat responsive to need given that there was no data to document the impact of the policy from May 2019 to August 2020 when the Review was released. However, the Review provided valuable information on how the policy was being implemented that had not been included in the first review. The Review was not gender transformative, as it did not mention whether the policy was being implemented in a way that addressed or affected gender norms and dynamics. The Review moderately hindered SRHR in the FP domain.

2020_Strengthening Health Security Across the Globe: Progress and Impact of U.S. Government Investments in the Global Health Security Agenda, 2019 Annual Report

In 2020, the Department of State released the Strengthening Health Security Across the Globe annual report that identified U.S. government’s contributions to global health security by country and U.S. government actor. Though several areas of global health were mentioned throughout the report, FP was noticeably absent. SRHR is a critical aspect of health security. Neglecting to include sexual and reproductive health in security discussions can contribute to negative health impacts and human rights violations for women, girls, gender-diverse people, and other marginalized groups. The Report was largely gender blind, as it ignored the fact that health security is unattainable without gender equity and the countering of harmful norms that affect women, girls, and gender-diverse people. The exclusion of SRHR throughout the report contributed to the increased development of siloes that exclude SRHR from other areas of global health, such as disease outbreaks. As a result, this Report moderately hindered SRHR in this domain.

2020_The Department of State’s Plan to Implement the U.S. Strategy on Women, Peace, and Security 2020-2023

The 2019 United States' Strategy on Women, Peace, and Security (WPS) was developed in response to the Women, Peace, and Security Act of 2017. This Plan laid out the approach undertaken by the Department of State to make progress on three strategic objectives related to WPS from 2020 to 2023. The Plan largely excluded health activities in general, including technical areas related to SRHR. However, it did mention the importance of preventing GBV including sexual violence and early and forced marriage. It failed to acknowledge the FP needs of those who experience violence and neglected to mention the role of FP and reproductive health generally in advancing the WPS agenda. This was not based in evidence because promoting reproductive health is inherently beneficial to empowering women and thus supporting the WPS agenda. The Plan was responsive to need as the objectives were informed by the global need for women's empowerment efforts. However, the exclusion of many SRHR issues was not evidence-based nor consistent with human rights frameworks. The Plan was somewhat gender transformative as it recognized and sought to combat gender norms through a systemic approach, but the Plan used language that reinforced a gender binary and was not inclusive of those who are impacted by the issues detailed in the report who do not identify as women. It was unclear which activities and programming mentioned in the Plan were considered U.S. global health assistance, which was a transparency issue. The WPS Strategy neither promoted nor hindered SRHR in the FP domain.

2020_United States Strategy to Prevent Conflict and Promote Stability

The United States released this Strategy in accordance with the Global Fragility Act of 2019 to promote “peaceful, self-reliant nations.” The Department of State was identified as the lead agency to oversee and implement this Strategy with the assistance of other supporting U.S. government agencies to create impactful and sustainable programs in fragile settings. While the Strategy was responsive to need, it did not adequately address the SRHR and the broader health needs of people in conflict settings. The Strategy failed to explain its engagement with specific global health areas, even though HIV and AIDS, MCH, FP, and other cross-cutting SRHR issues are vital to promoting stability and security. Notably, it did not include GBV, which is often a greater risk to women, girls, and gender-diverse people in fragile settings and conflict areas. The Strategy stated that it was grounded in evidence and human rights, but it did not include an explanation of the evidence base or human rights framework that informed it. Additionally, it was not gender transformative. Instead, the language in this action promoted a gender binary, ignored the role of gender inequalities on experiences of violence, and only mentioned women in the context of the WPS Strategy. While this was an important inclusion, gender was not meaningfully included in other areas of the Strategy. This action moderately hindered SRHR in the FP domain.

2019_PEPFAR 2019 Annual Report to Congress

The President's Emergency Plan For AIDS Relief (PEPFAR) Annual Report to Congress provided an overview of PEPFAR’s accomplishments to date and discussed the program’s future directions. This report largely summarized high-level known information about PEPFAR programs. Within this domain, the report was focused on family health and did not frame family planning as relevant to HIV and AIDS programs, or beneficial to non-traditional families or people who are not in a union/relationship. The report was responsive to need but not based in evidence, as it only referenced condoms in the context of HIV prevention programming and neglected to emphasize the importance of family planning for all people, including non-traditional families, the LGBTQIA+ community, sex workers, and people who are not in a union/relationship. The family-centered approach to this report further stigmatized the aforementioned populations from seeking family planning services and, in the process, decreased the entry points for them to receive HIV and AIDS prevention and treatment services. The report did not include a voluntary family planning component and was therefore not based in international human rights norms. The report was not gender transformative but demonstrated awareness of gender norms in the discussion of layered packages in DREAMS programming. This report hindered SRHR because it promoted a family health narrative and ignored the nuances of voluntary family planning programming.

2019_PEPFAR 2019 Country Operational Plan Guidance for all PEPFAR Countries

Released annually by the Office of the Global AIDS Coordinator, the Country Operational Plan (COP) Guidance outlines the plan for global HIV and AIDS activities funded by the President's Emergency Plan For AIDS Relief (PEPFAR) and provides the basis for the approval of annual bilateral HIV and AIDS funding for partner countries. The 2019 COP Guidance was based in evidence, human rights norms, and was responsive to need. The document continued its comprehensive guidance on the implementation of PEPFAR programs for all populations and, within this domain, emphasized the importance of integration of family planning and HIV and AIDS services. However, language about the integration of family planning and HIV services should be mandatory and should be inclusive of people living with HIV (PLHIV) and prevention purposes. Within the guidance, these integration efforts were undercut by PEPFAR’s refusal to procure any contraceptive commodities except for internal and external condoms. The procurement and provision of contraceptive commodities is key to emphasize the importance of integration and has been specifically requested by populations served by PEPFAR, particularly adolescent girls and young women. This integration also provided a point of entry for HIV and AIDS prevention and treatment which could assist PEPFAR in achieving the last mile. The guidance was not gender transformative but demonstrated gender awareness through the use of gender neutral language such as “clients” or “patients,” as well as through the discussion of the impact of gender norms on numerous program areas, including DREAMS, stigma reduction activities, and programs to reach undiagnosed men.

2019_PEPFAR Monitoring, Evaluation, and Reporting Indicator Reference Guide_MER 2.0 (Version 2.4)

The President's Emergency Plan For AIDS Relief (PEPFAR) Monitoring, Evaluation, and Reporting (MER) guidance listed the indicators used to monitor and evaluate PEPFAR. All PEPFAR programs were evaluated according to their performance within these indicators and metrics, and this guide helped country teams and PEPFAR sub-grantees understand the M&E process. In 2019, some of the MER indicators were updated, but it remains unclear what prompted these changes. The document focused largely on HIV-specific indicators, however, it referenced family planning within the KP_PREV, PP_PREV and FPINT_SITE indicators. These indicators were responsive to need and were evidence-based in that they provided a way to measure the integration of voluntary family planning services into PEPFAR programming (particularly the FPINT_SITE indicator which was consistent with international human rights norms by mandating the availability of a broad range of modern contraceptives at PEPFAR sites). The guide was not gender transformative but gender aware, as it included some consideration of environmental factors, such as family situation in HIV treatment and prevention, but did not address these barriers.

2019_Protecting Life in Global Health Assistance Frequently Asked Questions and Answers_September 2019

The Protecting Life in Global Health Assistance (PLGHA) FAQ document was updated in September 2019 to provide clarity on the implementation of the May 2019 expansion of PLGHA as well as address questions and confusion from the 2018 Department of State’s PLGHA Six Month Review. The text of this document was similar to the 2018 FAQ document, though included additional questions and answers (see questions 33-37). The document did not meaningfully discuss the impacts of the May 2019 expansion on family planning. Similar to the 2018 FAQs, this document aimed to provide clarity on the implementation of the policy but left many questions unanswered, such as when the Department of State will release the follow-up to the 2018 Six-Month Review. This document was somewhat responsive to need as it included additional questions and answers based on confusion expressed by recipients of U.S. global health assistance, specifically regarding the definition of “financial assistance” and the applicability of the policy to technical assistance. The document was not evidence-based, was not grounded in international human rights, and was not gender transformative as it was based on the PLGHA policy which has been shown to be harmful globally, particularly to women and girls. The PLGHA policy has been shown to increase the rate of abortions, many of which are unsafe. Overall, this document was a substantial hindrance to SRHR.

2019_State and USAID FY 2018 Annual Performance Report_FY 2020 Annual Performance Plan

This document shared the goals and timelines for FY 2020 as well as evaluated and summarized the progress of the Department of State and USAID in achieving various strategic goals in FY 2018. These goals included global health and gender programs across all three domains. The FY 2020 Annual Performance Plan elements were included throughout the Report along with reporting on standard indicators for each Performance Goal under the 4 Strategic Objectives. The Report mentioned family planning within the USAID Agency Priority Goals but did not discuss the role of the Department of State in the funding of family planning policies or programs. It is possible that family planning and contraceptive access in humanitarian settings may be a component of the Department of State’s Safe from the Start initiative, but it was not made clear in this report. The Report provided an opportunity for the Department of State to clarify its role in both humanitarian and non-humanitarian family planning, but it failed to seize that opportunity. Within this domain, the Report was not based in evidence or human rights, but was responsive to need with regard to Congressional reporting requirements. The Plan was not gender transformative, as it mentioned the disadvantages of a “gender-blind system” within Strategic Goal Two but did not apply a gendered lens throughout the document. This Report neither promoted nor hindered SRHR with regard to the Department of State’s family planning programs.

2018_Protecting Life in Global Health Assistance FAQs_September 2018

The PLGHA FAQs provided detailed guidance on the implementation of Trump's expanded Global Gag Rule for implementing partners as of September 2018. The FAQs were responsive to need in that they clarified areas of the policy that partners had expressed were vague or unclear. The FAQs were neither based in human rights principles nor evidence. The FAQs were also not gender transformative and substantially hindered the Department of State's ability to implement comprehensive family planning programs in 2018.

2018_Protecting Life in Global Health Assistance Six Month Review

The PLGHA Six Month Review summarized the PLGHA policy and identified solutions to challenges that had arisen in the process of PLGHA implementation. The review was responsive to need in that it addressed concerns expressed by partners affected by the policy, but was not evidence-informed, based in human rights principles, or gender transformative. The document stated that it was too early to assess the impacts of Trump's expanded Global Gag Rule on family planning despite research and literature documenting the harm caused by the policy. The Six Month Review substantially hindered the Department of State's ability to implement comprehensive family planning programs in 2018.

2016_Department of State Implementation Plan for the U.S. Adolescent Girls Strategy

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. The Plan was evidence-based and grounded in human rights with a strategic objective to expand girls’ access to education, health, and services, which included "preserv[ing] the rights of married and pregnant girls and adolescent mothers to attend school, institut[ing] comprehensive sexuality education in national curricula, and remov[ing] barriers to sexual and reproductive health and rights and comprehensive, accessible, youth-friendly health services." Additionally, this Plan outlined the joint responsibility that all governments have in prioritizing adolescent health and rights, promoting accountability of SRH programs, and addressing the lack of access to or availability of education and health services, which would include family planning. This Plan also repeatedly addressed the distinct health needs of adolescent girls that are displaced by insecurity, conflict, or natural disaster. However, it did not address the cultural or structural barriers (i.e., government policies that hinder access to SRHR, stigmatizing attitudes of healthcare providers, and prohibitively high cost of services) that prevent key underserved populations, such as sex workers and women living with disabilities, from accessing family planning services. Additionally, this Plan is gender accommodating because it acknowledged—but does not work to change—existing gender norms and inequities that prevent AGYW from accessing family planning services.

2012_U.S. Department of State Policy Guidance: Promoting Gender Equality to Achieve our National Security and Foreign Policy Objectives

2012_United States Department of State Implementation Plan of the National Action Plan on Women, Peace, and Security

TRANSPARENCY SCORE

TRANSPARENCY SCORE

Department of State

HIV & AIDS

Maternal and Child Health (MCH)

Family Planning (FP)