YEAR 2021

HIV & AIDS

The U.S. Government received an 88 (B+) with transparency and a 92 (A-) without transparency in the HIV and AIDS domain across all actors in 2021. This grade reflected the continued commitment of the U.S. government (USG) to support the President’s Emergency Plan for AIDS Relief (PEPFAR) to implement programs that were based in evidence, consistent with international human rights norms, and responsive to need. However, the majority of PEPFAR actions graded across actors in 2020 were gender accommodating and not gender transformative. Global HIV and AIDS efforts were largely excluded from the Strengthening Health Security Across the Globe Report, which was graded across all actors except the U.S. Congress. All actors except the U.S. Congress had low transparency for most actions graded in the HIV and AIDS domain. Budget scores were relatively high across actors where budget data were available, and transparency of funding information was high for all actors except the Department of Health and Human Services (HHS) and the Department of Defense (DoD). Consistent with previous years, the domain grade for HIV and AIDS was higher than the Maternal and Child Health and Family Planning domains across actors in 2021.

A-

White House

The White House received a 90 (A-) with transparency and a 94 (A) without transparency in the HIV and AIDS domain in 2021. The White House requested full funding for global HIV and AIDS programs through the Global Fund to Fight AIDS, Tuberculosis and Malaria as well as the President’s Emergency Plan for AIDS Relief (PEPFAR). Generally, actions graded in this domain meaningfully prioritized global HIV and AIDS programs, which supported the ability of U.S. global health assistance to promote SRHR in the HIV and AIDS domain. The White House demonstrated moderate levels of transparency across actions and funding information in this domain. As in previous years, HIV and AIDS was the White House’s highest scoring domain in 2021.

The CHANGE 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_American Rescue Plan Act (H.R.1319)

Signed into law by President Biden, the American Rescue Plan Act appropriated additional U.S. global health funding for specific implementing agencies to prevent, prepare for, and respond to the COVID-19 pandemic, as well as support public health surveillance to respond to other emerging infectious disease threats globally. It included contributions to support multilateral vaccine development partnerships and the Global Fund to Fight AIDS, Tuberculosis and Malaria. In this domain, the law appropriated additional funding for the Department of State to support global HIV and AIDS prevention, care, and treatment programs, as well as mentioned the need to mitigate the impact of COVID-19 on these programs. This action was responsive to need and based in evidence and human rights, though it was not gender transformative. This law should have included a call for data to be disaggregated by sex and/or gender to inform responses to COVID-19 given the disproportionate impacts of the pandemic on women, girls, and gender-diverse people. This action moderately promoted SRHR in the HIV and AIDS domain.

2021_Executive Order on Establishment of the White House Gender Policy Council

This Executive Order (EO) detailed the Biden administration's commitment to gender equity and equality in the United States and globally. It established the White House Gender Policy Council to coordinate activities across the U.S. government (USG) that are related to advancing gender equity and economic security, combating discrimination, increasing access to health care, preventing gender-based violence (GBV), addressing the effects of COVID-19 on women and girls, and promoting SRHR. This action was based in evidence and human rights because it included a directive for the Gender Policy Council to develop and publish a gender strategy and create clear guidelines for reviewing current policies and programs and revoking those that did not align with the administration’s position on SRHR. It was responsive to need because it directed the Gender Policy Council to update outdated or harmful policies such as the 2020 Gender Equality and Women’s Empowerment Policy and the Strategy to Prevent and Respond to GBV, both of which were published by the United States Agency for International Development (USAID). This directive to the Council acknowledged the specific needs of “underserved communities” and extended the focus of these efforts beyond women and girls, which demonstrated a commitment to enacting gender transformative policies by addressing systemic biases and creating policies that advance equity. This action specifically mentioned the importance of promoting SRHR and laid the groundwork for the forthcoming whole-of-government strategy to advance gender equity and equality through specific global health programs, including HIV and AIDS programs. This action significantly promoted SRHR in the HIV and AIDS domain.

2021_Executive Order on Preventing and Combating Discrimination on the Basis of Gender Identity or Sexual Orientation

This EO stated the goal of the Biden administration “to prevent and combat discrimination on the basis of gender identity or sexual orientation” and directed USG agencies to revise, suspend, or rescind any actions that were not consistent with the administration’s nondiscrimination policy. It instructed all heads of agencies to create additional actions as needed to implement the policy to combat overlapping forms of discrimination, including race and disability. This EO was responsive to need and consistent with human rights because it sought to address actions implemented during past administrations that discriminated against people because of their gender identity and/or sexual orientation, which is a violation of people’s human rights. It also directed heads of USG agencies to develop plans to carry out the requirements of this EO within 100 days of the Order, which was actionable and responsive to need. This action was gender transformative as it affirmed people’s gender and sexuality, and aimed to prevent discrimination across all USG agencies, which was responsive to need and based in evidence. Though this action did not explicitly mention global health programs such as those related to HIV and AIDS, the whole-of-government approach to combating discrimination moderately promoted SRHR in this domain.

2021_Executive Order on Tackling the Climate Crisis at Home and Abroad

This EO outlined President Biden's plan to prioritize the climate crisis in U.S. policy. It confirmed the re-engagement by the United States with the Paris Agreement and called for USG agencies engaged in international work to develop implementation plans that integrate climate considerations into their work, which was responsive to need. It established the National Climate Task Force to "facilitate the organization and deployment of a Government-wide approach to combat the climate crisis." Though this action was generally responsive to need because of the urgent imperative to respond to climate change, it did not discuss the direct impacts of climate change on specific sectors within health, including SRHR. As it relates to SRHR, this action was not based in evidence because it did not mention the impact of climate change on SRHR outcomes, including for people living with HIV (PLHIV). It also did not explicitly mention the human rights frameworks that would guide the USG’s response to climate change though there was a strong emphasis on environmental justice and the disproportionate impact of climate change on specific marginalized populations, which was based in evidence and responsive to need. The EO was gender blind as it did not mention the disproportionate impact of climate change on women, girls, and gender-diverse people. Though this was a critical step in addressing the climate crisis, SRHR was not meaningfully included as a cross-cutting issue so this action neither promoted nor hindered SRHR in the HIV and AIDS domain.

2021_Fact Sheet_Advancing Disability Inclusive Democracy in the United States and Globally

This Fact Sheet detailed the commitments made by the Biden administration to prioritizing "disability inclusive democracy" globally across the Federal government. The White House appointed a U.S. Special Advisor on International Disability Rights and expressed support for novel projects and partnerships, which includes global health programs managed by USAID. The goals of these projects were to develop inclusive international health systems that provided assistive products for people living with disability and support people who have been impacted by COVID-19 through quality, equitable, and inclusive teaching and learning tools. Notably missing from this action was a directive to incorporate disability rights in SRHR and global HIV and AIDS programming, making this action only somewhat based in evidence and responsive to need in the HIV and AIDS domain. While the inclusion of people with disabilities strengthens democracy and promotes human rights, there was no mention of gender in this action, which was gender blind. As a result, this action only moderately promoted SRHR in this domain.

2021_Fact Sheet_President Biden’s Global COVID-19 Summit_Ending the Pandemic and Building Back Better

This Fact Sheet detailed the commitments made by the Biden administration at the Global COVID-19 Summit, which included enhancing equitable global access to vaccines, increasing treatment options for people with COVID-19, establishing sustainable health security to prevent and respond to future pandemics, and aligning global targets to end the COVID-19 pandemic. This action mentioned leveraging investments made by PEPFAR to strengthen health systems, infrastructure, and the healthcare workforce to support COVID-19 screening, testing, and vaccine readiness efforts while continuing to address the HIV epidemic. The leveraging of resources was responsive to need, aligned with human rights, and based in evidence. However, this action was gender blind because it did not mention the disproportionate impact of COVID-19 on women, girls, and gender-diverse people. Additionally, the action did not mention cross-cutting issues such as GBV which have worsened during the pandemic. This action moderately promoted SRHR in the HIV and AIDS domain.

2021_Fact Sheet_United States to Announce Commitments to the Generation Equality Forum

This Fact Sheet outlined the domestic and global commitments made by the Biden administration at the Generation Equality Forum, including policy and resource commitments to prevent and respond to all forms of GBV, strengthen women’s economic security, and protect and advance SRHR. This action was responsive to need and based in human rights as it was rooted in the Beijing Platform for Action and aligned with global priorities, including those related to climate, science and technology, leadership and democracy, and education. It summarized the administration’s actions related to global health, such as revoking the Global Gag Rule (GGR) and restoring funding to the United Nations Population Fund (UNFPA), which were consistent with human rights, based in evidence, and responsive to need. It acknowledged the rise in GBV as a shadow pandemic during the COVID-19 crisis as well as the rise in anti-gender initiatives, which was highly responsive to need. The action emphasized the importance of combating harmful gender norms but used language that reinforced a gender binary, which excluded lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI+) people. This action called for doubling the annual investment in the PEPFAR DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) public-private partnership, which is a gender transformative program to prevent new HIV infections among adolescent girls and young women (AGYW). As a result, this action significantly promoted SRHR in this domain.

2021_Memorandum on Advancing the Human Rights of Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex Persons Around the World

This Presidential Memorandum outlined the Biden administration’s policy to end violence and discrimination based on sexual orientation, gender identity or expression, or sex characteristics (SOGIESC) across the USG and around the world. It directed USG agencies that engage in international work to review and rescind policies that are inconsistent with the administration’s stance on this issue, which was responsive to need and supported the implementation of policies based in evidence and human rights. It was highly responsive to need as it directed "all agencies engaged abroad to ensure that United States diplomacy and foreign assistance promote and protect the human rights of LGBTQI+ persons," including in the making of funding decisions, which would include global HIV and AIDS programs. This memorandum was gender transformative because it intended to combat harmful gender norms and end discrimination towards persons of diverse SOGIESC, but it was generally confined to implementation "as appropriate and consistent with applicable law," which could be restrictive depending on the country context. This action did not address the ways in which violence and discrimination are barriers to accessing comprehensive sexual and reproductive health (SRH) services, including safe and ethical HIV testing. This action moderately promoted SRHR in the HIV and AIDS domain.

2021_Memorandum on Protecting Women’s Health at Home and Abroad

This Presidential Memorandum stated that it is the policy of the Biden administration to “support women’s and girls’ sexual and reproductive health and rights in the United States, as well as globally." This action marked the first time that a U.S. administration has actively supported SRHR at the presidential level. This action was responsive to need, consistent with human rights norms, and based in evidence because it directed USG agencies to immediately waive the GGR (also known as Protecting Life in Global Health Assistance (PLGHA) or the Mexico City Policy), which the previous administration had expanded to apply to all U.S. global health assistance funding, including PEPFAR funding. Though immediately revoking the GGR significantly promoted SRHR, this action did not provide a timeline for suspending, revising, or rescinding any policies or actions that conflicted with the directives in this memorandum, including updating ongoing awards to remove the GGR provision, which was not responsive to need. This action withdrew the United States from the Geneva Consensus Declaration and directed USG agencies that were involved in foreign assistance programs to "ensure adequate funds are being directed to support women’s health needs globally," including SRHR services, which was highly responsive to need and based in evidence and human rights. While clearly advocating for global programs that provide women’s SRHR services promoted SRHR, limiting this action to "women’s health needs" was reductive and gender aware as doing so did not affirm the rights of all people to access SRHR services regardless of their gender or sex. The Memorandum did not mention access to safe abortion services as a priority for the administration, which stigmatized abortion services. Nevertheless, this action significantly promoted SRHR in the HIV and AIDS domain.

2021_Memorandum on Restoring Trust in Government Through Scientific Integrity and Evidence-Based Policymaking

This Presidential Memorandum stated the Biden administration’s policy to "make evidence-based decisions guided by the best available science and data" across the federal government, which was based in evidence and responsive to need. This action specifically directed USG agencies to "review and expeditiously update any agency policies, processes, and practices issued or published since January 20, 2017 that prevent the best available science and data from informing the agency’s evidence-based and iterative development and equitable delivery of policies and programs." However, solely focusing on updating anti-science policies from the previous administration was not sufficient, as the review should extend much further to ensure that policies being implemented today are based in evidence, regardless of when they were passed. This action directed USG agencies to develop scientific integrity policies that support policy making based in evidence and listed several approaches and methodologies that could inform this process, including qualitative research, community engagement, and social and behavioral approaches. While SRHR and global health programs were not explicitly mentioned, enforcing evidence-based decision making at all levels of government ultimately benefited global HIV and AIDS programs. This action moderately promoted SRHR in this domain.

2021_Memorandum on Revitalizing America’s Foreign Policy and National Security Workforce, Institutions, and Partnerships

This Presidential Memorandum directed USG agencies to implement policies that revitalize the national security and foreign policy workforce and institutions under the core principles of integrity; transparency; diversity, equity, inclusion, and accountability (DEIA); modernization; service; and accountability. The Memorandum called for the creation of an Interagency Working Group on the National Security Workforce to ensure that workers are recruited and retained to promote the success of the programs implemented by USG agencies. The action required USG agency leadership to meet with partners on a quarterly basis, which promoted transparency, though it did not include directives for transitioning power or funding to local partners, which was a missed opportunity to diversify the partner base. This action advocated for including a wide diversity of voices and perspectives in foreign policy, which was based in evidence and responsive to need. It also provided greater workplace resources to minimize staff burnout and turnover, which often impact the continuity of global HIV and AIDS programs. However, the Memorandum did not explicitly include directives or support for health care workers even though they are critical to ensuring national security and the success of U.S. foreign policy, especially global health assistance. The policy was gender accommodating as it included protections for all USG staff regardless of gender identity, including LGBTQI+ individuals, though it did not include measures to combat gender norms within the workplace. This action moderately promoted SRHR in the HIV and AIDS domain.

2021_Memorandum on the Presidential Determination with Respect to the Efforts of Foreign Governments Regarding Trafficking in Persons

This Presidential Memorandum restricted which forms of U.S. foreign assistance could be received by other countries depending on their compliance with the minimum standards for the elimination of trafficking in persons as defined in the Trafficking Victims Protection Act of 2000 (TVPA). The Memorandum stated that the USG will not provide "nonhumanitarian, nontrade-related assistance"—which includes global health assistance—to specific countries that do not meet these minimum standards, with some exceptions to allow for global health funding, as well as "development assistance that directly addresses basic human needs" on a country-by-country basis. This policy was not based in evidence or responsive to need as cutting off global health assistance for these countries could pose a barrier for survivors of trafficking to receiving essential care, including HIV and AIDS services. It was also not based in human rights norms, as it promoted a carceral approach to preventing and addressing trafficking, which relies on law enforcement to prevent and prosecute trafficking even though justice systems do not consistently protect the human rights and needs of survivors. The policy was gender blind as it did not explicitly recognize the disproportionate impact of trafficking on women and girls. Overall, by leveraging global health assistance as a tool to coerce compliance with TVPA, this action moderately hindered SRHR in the HIV and AIDS domain.

2021_National Action Plan to Combat Human Trafficking

The National Action Plan to Combat Human Trafficking outlined a roadmap for how the United States should address trafficking domestically and in foreign policy. The Plan focused on the four pillars of anti-trafficking efforts: prevention, protection, prosecution, and partnership, and emphasized a commitment to gender and racial equity, workers' rights, fair trade, and providing support to underserved communities. Regarding SRHR and other health outcomes, the Plan was largely domestically focused. It included provisions that applied to global health assistance, but global HIV and AIDS programs were not mentioned. The Plan was responsive to need as it recognized the disproportionate impact of trafficking on "racial and ethnic minorities, women and girls, LGBTQI individuals, vulnerable migrants, and others from historically marginalized and underserved communities." However, the Plan promoted policies that reduced demand for products or services from forced labor, which was not based in evidence as these policies often lead to the prosecution of sex workers and the violation of their rights. Other aspects of the Plan included centering the expertise of survivors and adopting inclusive policies for programs to decrease systemic disparities that negatively impact marginalized communities or increase their vulnerability to trafficking, which was responsive to need as well as based in evidence and human rights norms. While this action used language that enforced the gender binary, it also mentioned LGBTQI+ populations, making the Plan gender accommodating. Since the Plan's focus was mostly within the United States, it neither promoted nor hindered SRHR in the HIV and AIDS domain.

2021_National Strategy for the COVID-19 Response and Pandemic Preparedness

The National Strategy for the COVID-19 Response and Pandemic Preparedness detailed the Biden administration's interagency plan to promote pandemic recovery efforts across domestic and foreign policy. Goal 7, "Restore U.S. leadership globally and build better preparedness for future threats," contained the Strategy's specific initiatives related to foreign policy and global health assistance. The Strategy directed the creation of publicly accessible performance dashboards to establish an evidence-based approach to evaluating progress towards COVID-19 prevention and recovery, which was responsive to need and based in evidence. Even though it recognized the disproportionate impact of the pandemic on women and girls, this action was gender accommodating as it reinforced a gender binary, did not include LGBTQI+ persons, and did not challenge gender inequities that intensified as a result of the pandemic. The Strategy committed to promoting SRHR and included cross-cutting issues that have been impacted by COVID-19, including GBV, tuberculosis, and immunizations. It mentioned HIV as a secondary impact of COVID-19, though did not provide specifics of how HIV services were affected by the pandemic, or how USG programming would address this impact. The Strategy moderately promoted SRHR in the HIV and AIDS domain.

2021_National Strategy on Gender Equity and Equality

The National Strategy on Gender Equity and Equality detailed the whole-of-government approach to promote gender equity both domestically and globally. The Strategy laid out several plans to increase access to health care (including SRH services), advocate for gender equity and equal representation in leadership, and respond to GBV and climate change. The Strategy named the domestic and global promotion of SRHR as a priority. The Strategy called for the end of the GGR and promoted the provision of integrated SRH programs, which was responsive to need. However, it did not explicitly call on Congress to permanently repeal the GGR, which was a necessary action that would significantly promote SRHR globally. The action affirmed the right to access safe abortion care, which was responsive to need but only applied to the domestic implementation of the Strategy. The Strategy committed to working in partnership with "foreign governments and multi-lateral organizations, and non-governmental actors—including faith-based groups, civil society, and private sector organizations" using an intersectional approach to addressing discrimination and advancing gender equity, which was based in evidence and responsive to need. The action included a section on advancing human rights by working to eliminate practices that undermine gender equity, such as female genital mutilation/cutting (FGM/C), child and early forced marriage (CEFM), and GBV. Many aspects of the Strategy were gender transformative, such as the inclusion of people of all genders (i.e., transgender women and girls, gender nonbinary and nonconforming people, and men and boys) and the call for programs to implement cultural and gender norms change. While the Strategy recognized that sociocultural factors make women and girls more susceptible to HIV and AIDS, the action did not meaningfully include PEPFAR or specific global HIV programs that are gender transformative and promote gender equity (e.g., DREAMS). The Strategy moderately promoted SRHR in the HIV and AIDS domain.

2021_Report on the Impact of Climate Change on Migration

This Report provided an overview of the impact of climate change on migration to inform a proposal for how United States foreign assistance could and should address the impacts of climate change on displaced persons. The Report included quality health services as part of the social services package that the USG could provide to partner governments that receive migrant populations, but it did not discuss access to health services for displaced persons in detail. The Report acknowledged the barriers faced by people related to intersectional forms of discrimination and named the expertise of agencies like the Department of State and USAID to provide technical guidance to integrate the unique needs of people with marginalized identities into foreign assistance. The Report stated that planning and policy decisions should include engagement with marginalized populations to ensure that funding and programmatic decisions were responsive to need. It emphasized the importance of multilateral engagement through the Sustainable Development Goals (SDGs), the Paris Agreement, U.N. resolutions, and the role of civil society, which was based in evidence and human rights norms and was responsive to need. However, the role of U.S. global health funding or programs, such as global HIV and AIDS programs, was not specified in the Report. The Report was gender accommodating as it recognized gender as a factor in the context of GBV, and included "women, girls, and gender diverse persons." This report neither promoted nor hindered 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 fiscal year (FY) 2020. 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 mentioned HIV in the context of the Division of Global Health Protection Field Epidemiology Training Program (FETP) within the Centers for Disease Control and Prevention (CDC) as one of the issues addressed by the FETP. However, the Report did not include details to indicate why HIV and AIDS efforts were included in this intervention or explain the outcomes of this programming. 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 the COVID-19 pandemic. The Report was gender blind as it made only one mention of gender in the context of the OneHealth approach. This action moderately hindered SRHR in the HIV and AIDS domain.

2021_U.S. COVID-19 Global Response and Recovery Framework

This Framework built upon the National Strategy for the COVID-19 Response and Pandemic Preparedness' Goal 7: "Restore U.S. leadership globally and build better preparedness for future threats." The Framework prioritized the dissemination of safe and effective COVID-19 vaccinations, addressing food insecurity, reducing GBV, and recognizing the impact of the pandemic on women and girls, youth, displaced persons, and underserved populations. It highlighted cross-cutting principles such as humility, multilateralism, partnerships, diversity, equity, and inclusion (DEI), evidence-based and risk-based decision making, transparency, and accountability. Through its focus on underserved communities and implementing systemic, fair, just, and impartial treatment of all, the Framework was based in human rights norms. While the objectives listed were based in evidence and responsive to need, the Framework did not name specific actors, deliverables, or timelines in accordance with the objectives, which was not responsive to need. The Framework acknowledged gender inequality and the importance of repairing the harm of the pandemic that worsened these inequities, which was gender accommodating. This Framework moderately promoted SRHR in this domain.

2021_U.S. International Climate Finance Plan

The U.S. International Climate Finance Plan outlined a whole-of-government approach to providing and mobilizing financial resources to aid other countries in recusing and avoiding greenhouse gas emissions and building resilience against the impacts of climate change. The Plan included improving human health as a positive impact of climate finance and directed USG departments and agencies that engage in global health to analyze the impacts of climate change on human health, which was responsive to need. The Plan called for USG agencies to align their partnerships and financial investments with what is needed to achieve the goals included in the Paris Agreement, which was based in evidence. The Plan also included time-bound and specific goals and deliverables that apply to USG agencies that would benefit global health assistance and programming, which was responsive to need. However, the Plan did not specifically mention the impacts of climate change on SRHR, including PLHIV, or the potential positive impacts of climate finance on promoting SRHR. The Plan mentioned women and girls but was otherwise gender blind as evidence indicates that climate change disproportionately impacts women, girls, and gender-diverse people around the world. This Plan neither hindered nor promoted SRHR in the HIV and AIDS domain.

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

The Women, Peace, and Security (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, Department of Defense (DoD), Department of Homeland Security (DHS), and USAID: participation, protection, internal capabilities, and partnerships. While improved health outcomes were included as a positive impact of implementing the WPS Agenda, HIV and AIDS and the needs of women living with HIV were not meaningfully included. The Report included GBV prevention and programming as a cross-cutting measure of progress towards achieving the WPS Agenda, which was responsive to need. The Report emphasized the importance of evidence-based implementation and decision-making, and 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 HIV and AIDS domain.

2020_Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 (H.R. 6074)

The Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 became law on March 6, 2020, and appropriated an additional $435 million in Global Health Programs (GHP) funds for the Department of State and United States Agency for International Development (USAID) to “prevent, prepare for, and respond to” the COVID-19 pandemic through September 30, 2022. This action was highly responsive to need because it was passed early in the pandemic and provided much-needed funds to support the initial global health response to the pandemic. The decision to appropriate additional funds to support pandemic response efforts was also based in evidence and human rights. This action moderately promoted the ability of U.S. global health assistance to support HIV and AIDS programs that could address the impacts of COVID-19 related to SRHR.

2020_Executive Order on Advancing International Religious Freedom

This Executive Order (EO) referenced foreign assistance funding for international religious freedom and directed the Department of State and USAID to prioritize religious freedom in the planning and implementation of U.S. foreign policy and within foreign assistance programs. The EO directed the Secretary of the Treasury to identify the economic tools that could be used to pressure other country governments to comply with this EO, including "realigning foreign assistance" though it was unclear how this could affect global health assistance programs. This EO was not evidence-based, responsive to need, or aligned with human rights standards as it prioritized religious freedom over evidence, global health needs, and human rights. Further, it was gender blind as it made no mention of gender and ignored the reality that religious freedom has been used in some settings to hinder gender equity efforts. The EO did not mention HIV and AIDS programs, nor did it consider how the directive might engage with other areas of global health, which contributed to the siloed approach to global health and resulted in a transparency issue. This EO moderately hindered the ability of U.S. global health assistance to support HIV and AIDS programs that are evidence-informed, responsive to need, consistent with internationally-recognized human rights principles, gender transformative, and promote SRHR.

2020_Executive Order on Combating Race and Sex Stereotyping

This EO directed recipients of federal grants to agree not to use federal funds for workplace trainings that promote "divisive concepts," such as "race or sex stereotyping." The EO specifically directed the Office of Personnel Management (OPM) to review training programs that were developed for agency employees to ensure compliance with this action. This EO was not based in evidence or human rights norms as it ignored the impact of white supremacy, systemic racism, and colonization on the health and human rights of Black, Indigenous, People of Color (BIPOC) communities around the world. Furthermore, the EO adhered to a gender binary and did not encourage a gender transformative approach to discussing power and privilege based on race and sex. While this action did not provide technical guidance related to HIV and AIDS, it directed agencies to pose restrictions on the types of trainings that could be supported by federal funds for global health grants and cooperative agreements. Therefore, this EO moderately hindered the ability of U.S. global health assistance to promote SRHR in the HIV and AIDS domain.

2020_Executive Order on Ensuring Access to United States Government COVID-19 Vaccines

This EO dictated how COVID-19 vaccines should be distributed in the United States and abroad. It specified that vaccines should only be distributed outside of the United States upon determination that there was “sufficient” supply for Americans who “choose to be vaccinated.” It directed the Secretary of the Department of Health and Human Services (HHS), the Secretary of State, and Administrator of USAID to facilitate international access to COVID-19 vaccines developed in the United States, though it was unclear if U.S. global health assistance funds would be used to implement this effort. It specified that vaccines should be distributed to “allies, partners, and others, as appropriate and consistent with applicable law.” This demonstrated a vague and potentially inequitable approach to vaccine distribution during a global pandemic when solidarity is required to ensure equitable access to vaccines globally. This approach was not aligned with evidence or international human rights norms and was not responsive to need as this type of American exceptionalism is dangerous and deadly for those who live in countries that are not allies with the United States. It was also gender blind because it did not mention the disproportionate impact of COVID-19 on women, girls, and gender-diverse people, nor did it mention the impact that the global distribution of vaccines would have on women, girls, and people with diverse sexual orientation, gender identity, gender expression, and sex characteristics (SOGIESC). As a result, it moderately hindered the ability of U.S. global health assistance to promote SRHR in this domain.

2020_Executive Order on Rebranding United States Foreign Assistance to Advance American Influence

This EO directed federal agencies to ensure that all U.S. foreign assistance was marketed as “American aid,” and displayed logos and other imagery that “embod[y] the values and generosity of the American people. While this EO did not explicitly mention global health, it applied to all foreign assistance which included global health awards. At its core, this EO created a burden for recipients of foreign assistance to meet these marketing standards. It potentially hindered the ability of global health award recipients to provide health services to people in communities that have anti-American views, where “American aid” branding may be a deterrent or barrier to people seeking services. This EO prioritized the United States’ influence over ensuring that U.S. foreign assistance was evidence-based, responsive to need, and grounded in human rights norms. It was also gender blind because it made no mention of gender in the context of U.S. global health assistance programs. The lack of explicit mention of specific programs, including those related to HIV and AIDS, presented a transparency issue given that the EO would apply to all global health awards. This EO moderately hindered the ability of U.S. global health assistance to support HIV and AIDS programs that were evidence-informed, responsive to need, consistent with internationally-recognized human rights principles, gender transformative, and promote SRHR.

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 relied 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 could 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 Report moderately hindered SRHR in the HIV and AIDS domain.

2020_Presidential Determination with Respect to the Efforts of Foreign Governments Regarding Trafficking in Persons

This Presidential Memorandum applied restrictions on the types of U.S. assistance permissible to different countries based on whether they were compliant with the Trafficking Victims Protection Act of 2000 (TVPA). Based on this memorandum, governments who did not meet the minimum standards for the elimination of trafficking in persons (as defined in the TVPA) would be barred from receiving U.S. non-humanitarian, non-trade assistance, which includes global health assistance. In the context of this policy, global health assistance was explicitly used as a diplomatic tool to pressure foreign governments to comply with the conditions of the TVPA. This policy was not responsive to need because cutting off global health assistance would act as a barrier for people engaged in sex work or people who are trafficked from receiving HIV and AIDS services in specific countries. It was not aligned with human rights norms because the minimum standards with which governments were being asked to adhere enforced a carceral approach to trafficking, which relies heavily on law enforcement to prevent trafficking even though these systems do not consistently protect the rights of marginalized groups that may be trafficked. This poses great risks to those engaged in commercial sex work as it creates barriers to accessing health services due to fear of prosecution or targeting from law enforcement. The Policy was also gender blind, as it made no mention of the impact of gender on its approach or determinations. This Presidential Memorandum hindered the ability of U.S. global health assistance to promote SRHR in the HIV and AIDS domain.

2020_Preventing Hoarding of Health and Medical Resources To Respond to the Spread of COVID–19

This EO directed the Secretary of the Department of Health and Human Services (HHS) to take action to prevent the hoarding of personal protective equipment (PPE) and other supplies to respond to the spread of COVID-19. This EO was intended to be a positive preventative measure by the White House to ensure that there was enough PPE available to those who needed it at the beginning of the pandemic, however the specification for what constituted ‘hoarding’ of PPE was vague and could be difficult to implement accurately. It did not mention gender issues or make accommodations for groups who are disproportionately impacted by COVID-19 like women, girls, and gender-diverse people. This EO contributed to confusion regarding what could be procured with U.S. global health assistance funds across implementing agencies and partner organizations. More information is needed on how funds should be used to purchase PPE and what constituted “hoarding.” The EO neither promoted nor hindered SRHR in the HIV and AIDS domain.

2020_The National Action Plan to Combat Human Trafficking

The National Action Plan to Combat Human Trafficking set the U.S. government’s priorities related to human trafficking. The Plan prioritized a “victim-centered, trauma-informed, and culturally competent” approach to supporting trafficking survivors in alignment with the standards set by the Office for Victims of Crime within the Department of Justice which were based in evidence. The Plan recognized that survivors of trafficking should be able to access comprehensive medical and mental health services, including those related to HIV and AIDS, but it conflated trafficking with sex work which was not consistent with evidence. This National Action Plan was not consistent with international human rights norms beyond the Palermo Protocol because it was based on the Trump administration’s framing of unalienable rights. The Plan also promoted a carceral approach to trafficking, which is based on neither evidence nor human rights and jeopardizes the health and wellbeing of sex workers. The Plan mentioned that “people of all ages, genders, races, religions, and nationalities” including “LGBT+” individuals are disproportionately impacted by trafficking, which was based in evidence and was gender accommodating. This whole-of-government approach was primarily focused on domestic issues and programs, and it was unclear if the role of U.S. global health funding or programs were considered here, which was a transparency issue. This Plan neither hindered nor promoted the ability of the U.S. global health assistance to support SRHR in the HIV and AIDS domain.

2020_Women’s Global Development and Prosperity Initiative_Annual Report 2019-2020

This report described the accomplishments of the Women's Global Development and Prosperity (W-GDP) Initiative in its first year of implementation. The Initiative was based on President Trump’s America First policy and was designed to support USAID’s work toward countries’ self-reliance. Though this was the first whole-of-government report about women’s economic empowerment, it reinforced the silos between economic empowerment and health because it did not include a discussion about HIV and AIDS or health more broadly. While gender-based violence (GBV) was mentioned, the Report made no mention of its connection to health, even though GBV is a cross-cutting SRHR issue. The Report called for removing “cultural barriers” to women's economic empowerment but did not identify the barriers or describe them, which contributed to low transparency. The Report was gender aware because it mentioned women's barriers to economic empowerment but reinforced a gender binary and did not acknowledge the needs of LGBTQI+ communities or others who might also benefit from economic empowerment efforts. Elements of this report were based in evidence and human rights, though details about health and SRHR were significantly lacking. Further, it was unclear if the W-GDP Initiative impacted or engaged with global HIV and AIDS programs during its first year of implementation because the types of funds used by this initiative were not explicitly mentioned, which is a transparency issue. This report neither hindered nor promoted the ability of U.S. global health assistance to support SRHR in the HIV and AIDS domain.

2019_Global Health Innovation Act of 2017 (H.R.1660)

This law signed by the President instituted a new requirement for the Administrator of USAID to report to Congress about USAID’s investment in and development of novel global health technologies. The passage of this bill indicated White House and Congressional interest in global health technologies and implemented a mechanism to hold USAID accountable to continuous innovation of such technologies. HIV and AIDS technologies, unlike family planning technologies, were explicitly mentioned in the Act which provided an accountability mechanism for these specific technologies. The Act did not reference human rights principles or the need for more women and girl-centered technologies, such as multi-purpose prevention technologies that prevent both pregnancy and HIV acquisition. This law was responsive to need and evidence-based, as it emphasized the importance of global health technologies and innovation in achieving global health goals. Overall, this law promoted SRHR within the HIV and AIDS domain because it encouraged the development of technologies to support HIV and AIDS programming.

2019_United States Government Global Health Security Strategy

This document was a cross-agency Strategy to improve global health security both in the U.S. and globally. The Strategy discussed the importance of disease prevention and treatment and outlined the role of the U.S. and other funders invested in strengthening health systems in countries that may not currently have the capacity to respond to outbreaks. This Strategy was high-level and did not specifically discuss relevant global health issues, including HIV and AIDS. The annex of the Strategy mentioned the role of the President's Emergency Plan For AIDS Relief (PEPFAR) in ending the HIV and AIDS epidemic, however the discussion about HIV and AIDS should have been more consistent throughout the Strategy given the importance of this health issue to global health security. This Strategy was responsive to need and evidence-based, as it referenced global standards regarding global health security and data proving the need for strengthening of health systems throughout the Strategy. The Strategy was neither gender transformative nor based in international human rights norms, as it did not discuss the role of gender norms in global health security or specifically reference human rights principles that frame global health security efforts. Overall, this Strategy’s silence on HIV and AIDS did not harm SRHR but it also did not promote SRHR. Future strategies should provide specific details about relevant programs that contribute to global health security, including HIV and AIDS.

2019_United States Strategy on Women, Peace, and Security

The U.S. Strategy on Women, Peace, and Security is the operationalization of the Women, Peace, and Security Act of 2017 and is intended to "increase women’s meaningful leadership in political and civic life by helping to ensure they are empowered to lead and contribute, equipped with the necessary skills and support to succeed, and supported to participate through access to opportunities and resources." However, the Strategy dismissed the important role of health in the wellbeing and participation of women and girls in decision-making processes and institutions both during times of conflict and peace. Given that the Department of State and USAID were named as relevant actors in this Strategy, the lack of discussion of health—specifically of HIV and AIDS treatment and prevention—was an obvious gap in the Strategy. The absence of health was further glaring given the documented impact of the breakdown of health systems on people living with HIV (PLHIV) in conflict and humanitarian settings. The Strategy also did not address the risk of sexual transmission of HIV due to gender-based violence (GBV) in conflict and crisis settings. This Strategy was responsive to need as it addressed the lack of representation of women in conflict resolution and peacebuilding processes. However, the Strategy is not grounded in evidence as evidence shows the key role of health—particularly HIV and AIDS prevention, care, and treatment—in achieving country stability. The Strategy was not grounded in human rights, as the document cited "the United States Government’s interpretation of the laws of armed conflict and International Human Rights Law'' which may have implied that human rights principles were not being followed as written. Lastly, this Strategy was not gender transformative because it recognized but did not take steps to address the root causes of gender inequity within conflict and post-conflict settings, nor did it advocate strongly for the inclusion of all populations in these efforts. It is possible that this Strategy, once implemented, could create avenues for significant gender transformation but this Strategy is narrow in a way that ultimately harms women and girls.

2018_Asia Reassurance Initiative Act of 2018 (S. 2736)

The Asia Reassurance Initiative Act discussed U.S. efforts to improve relations with countries in Asia and promote democracy and human rights within the region. These efforts were responsive to need and based in human rights principles, particularly related to reducing poverty and violations of human rights that have occurred within the region. However, the law was not gender transformative or strongly evidence-based in HIV and AIDS prevention and treatment efforts. It mentions "reducing the HIV and AIDS infection rate” through the Lower Mekong Initiative (LMI), but provided no programmatic guidance on how to accomplish this. The LMI was launched in 2009 and is a multinational partnership among Cambodia, Laos, Myanmar, Thailand, Vietnam, and the U.S. to create integrated sub-regional cooperation among the five Lower Mekong countries. The LMI could serve as a promising platform for HIV and AIDS prevention and treatment efforts, but this could only be implemented if additional policy and technical guidance are released. The law also briefly mentioned supporting women’s equality, but did not discuss the importance of addressing gender-based violence (GBV) and sexual and reproductive health and rights (SRHR) in promoting democracy and human rights. Given the prevalence of GBV against ethnic and religious minorities in the region, this was a missed opportunity by the White House to address this issue. For these reasons, this law will likely only have minimal direct effect on the ability of U.S. global health assistance to support HIV and AIDS programs in the region.

2018_PEPFAR Extension Act of 2018 (H.R. 6651)

The PEPFAR Extension Act amended the PEPFAR Stewardship and Oversight Act of 2013 by extending the authorization of PEPFAR through FY 2023. The law allowed PEPFAR to continue its programming, which is largely evidence-based, responsive to need, and based in human rights norms. However, this law also maintained previous authorization language that is not gender transformative and continued clauses that cause harm to key populations, such as the Anti-Prostitution Loyalty Oath and the refusal clause. With the reauthorization, the White House had the opportunity to revise these harmful aspects of the authorization of PEPFAR and chose not to do so. As a result, this law moderately promoted the ability of U.S. global health assistance to support HIV and AIDS programs that are evidence-informed, responsive to need, consistent with human rights principles, and gender transformative.

2017_Presidential Memorandum of January 23, 2017_The Mexico City Policy (Expanded Global Gag Rule)

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

2016_The United States National Action Plan on Women, Peace, and Security

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

2015_U.S. Statement to UN Women Executive Board Recognizing Sexual Rights

2015_United States Global Strategy to Empower Adolescent Girls

2012_Executive Order-Preventing and Responding to Violence Against Women and Girls Globally

2012_United States Strategy to Prevent and Respond to Gender-based Violence Globally

2011_United States National Action Plan on Women, Peace, and Security

2009_Statement by the President on Global Health Initiative

A+

Congress

Congress received a 97 (A+) with transparency and a 99 (A+) without transparency in the HIV and AIDS domain in 2021. Congress appropriated full funding for the President’s Emergency Plan for AIDS Relief (PEPFAR) and The Global Fund to Fight AIDS, Tuberculosis and Malaria. Passing the American Rescue Plan Act (H.R.1319) moderately increased Congress’ grade in this domain because it appropriated additional funds for the Department of State to support HIV and AIDS prevention, care, and treatment programs as well as mentioned the need to mitigate the impact of COVID-19 on such programs. Congress demonstrated high levels of policy and funding transparency related to HIV and AIDS globally in 2021.

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

Selecting a document will download the file

2021_American Rescue Plan Act (H.R.1319)

The American Rescue Plan Act appropriated additional U.S. global health funding for specific implementing agencies to prevent, prepare for, and respond to the COVID-19 pandemic, as well as support public health surveillance to respond to other emerging infectious disease threats globally. It included contributions to support multilateral vaccine development partnerships and a contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria. The law appropriated additional funding for the Department of State to support HIV and AIDS prevention, care, and treatment programs as well as mentioned the need to mitigate the impact of COVID-19 on such programs. This action was responsive to need and based in evidence and human rights. This law was not gender transformative, as it should have included a call for data to be disaggregated by sex and/or gender to inform responses to COVID-19 given the disproportionate impacts of the pandemic on women, girls, and gender-diverse people. This action moderately promoted SRHR in the HIV and AIDS domain.

2020_Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 (H.R. 6074)

The Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 became law on March 6, 2020, and appropriated an additional $435 million in Global Health Programs (GHP) funds for the Department of State and United States Agency for International Development (USAID) to “prevent, prepare for, and respond to” the COVID-19 pandemic through September 30, 2022. This action was highly responsive to need because it was passed early in the pandemic and provided much-needed funds to support the initial global health response to the pandemic. The appropriation of additional funds to support pandemic response efforts was also based in evidence and human rights. This action moderately promoted the ability of U.S. global health assistance to support HIV and AIDS programs that could address the impacts of COVID-19 related to SRHR.

2019_Global Health Innovation Act of 2017 (H.R.1660)

This law instituted a new requirement for the Administrator of USAID to issue a report to Congress about USAID’s investment in and development of global health technologies. The passage of this bill indicated Congressional interest in global health technologies and implemented a mechanism to hold USAID accountable to continuous innovation of such technologies. HIV and AIDS technologies, unlike family planning technologies, were explicitly mentioned in the Act which provided an accountability mechanism for these specific technologies. This law was responsive to need and evidence-based, as it emphasized the importance of global health technologies and innovation in achieving global health goals. The Act did not reference human rights principles or the need for more women and girl-centered technologies, such as multi-purpose prevention. Overall, this law promoted SRHR within the HIV and AIDS domain because it encouraged the development of technologies to support HIV and AIDS programming.

2018_Asia Reassurance Initiative Act of 2018 (S. 2736)

The Asia Reassurance Initiative Act discussed U.S. efforts to improve relations with countries in Asia and promote democracy and human rights within the region. These efforts were responsive to need and based in human rights principles, particularly related to reducing poverty and violations of human rights that have occurred within the region. However, the legislation was not gender transformative or strongly evidence-based in HIV and AIDS prevention and treatment efforts. It mentioned "reducing the HIV and AIDS infection rate” through the Lower Mekong Initiative (LMI), but provided no programmatic guidance on how to accomplish this. The LMI was launched in 2009 and is a multinational partnership among Cambodia, Laos, Myanmar, Thailand, Vietnam, and the U.S. to create integrated sub-regional cooperation among the five Lower Mekong countries. The LMI could serve as a promising platform for HIV and AIDS prevention and treatment efforts, but this could only be implemented if additional policy and technical guidance are released. The legislation also briefly mentioned supporting women’s equality, but did not discuss the importance of addressing gender-based violence (GBV) and sexual and reproductive health and rights (SRHR) in promoting democracy and human rights. Given the prevalence of GBV against ethnic and religious minorities in the region, this was a missed opportunity by Congress to address this issue. For these reasons, this legislation will likely only have minimal direct effect on the ability of U.S. global health assistance to support comprehensive HIV and AIDS programs in the region.

2018_PEPFAR Extension Act of 2018 (H.R. 6651)

The PEPFAR Extension Act amended the PEPFAR Stewardship and Oversight Act of 2013 by extending the authorization of PEPFAR through FY 2023. The legislation allows PEPFAR to continue its programming, which is largely evidence-based, responsive to need, and based in human rights norms. However, it also maintained previous authorization language that is not gender transformative and continued clauses that cause harm to key populations, such as the Anti-Prostitution Loyalty Oath and the refusal clause. With the reauthorization, Congress had the opportunity to revise these harmful aspects of the authorization of PEPFAR and chose not to do so. As a result, this legislation moderately promoted the ability of U.S. global health assistance to support HIV and AIDS programs that are evidence-informed, responsive to need, consistent with human rights principles, and gender transformative.

2015_Justice for Victims of Trafficking Act of 2015 (S. 178)

2013_PEPFAR Stewardship and Oversight Act of 2013 (S. 1545)

2008_Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (H.R. 5501)

2004_Medically Accurate Information on Condoms_Consolidated Appropriations Act, 2004 (H.R. 2673)

2003_United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (H.R. 1298) (Anti-Prostitution Loyalty Oath and Abstinence-Only Education)

1961_The Foreign Assistance Act of 1961

A+

Department of State

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

Selecting a document will download the file

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

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 information that was known about PEPFAR programs. The report was responsive to need and based in evidence, as it referenced data that demonstrated the need for and efficacy of PEPFAR programs. The report did not mention human rights principles and was not gender transformative but demonstrated awareness of gender norms in the discussion of layered packages in DREAMS 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 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

A-

US Agency for International Development

USAID received an 86 (B) with transparency and a 90 (A-) without transparency in the HIV and AIDS domain in 2021. This domain grade was raised by actions outlining the Agency’s response to the COVID-19 pandemic in a manner that promoted SRHR, such as the USAID Implementation Plan for the U.S. COVID-19 Global Response and Recovery Framework and Issues and Recommendations on Gender-Based Violence Prevention and Response in COVID-19 Programming. The decision to remove the PLGHA section in ADS Chapter 303 without offering additional information or guidance for partners about how to adapt their programs significantly hindered SRHR. Overall, transparency was low for many actions graded in this domain because USAID did not indicate which content had been updated in 2021 from previous versions. USAID had a high level of transparency for funding data and disbursed HIV and AIDS funding in a manner that was highly responsive to need, which increased this actor’s grade in this domain in 2021.

The CHANGE 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_Acting on the Call

The 2021 Acting on the Call Report documented the impacts of U.S. global health financial investments in and commitments to providing critical health services to women, children, and families around the world. This action described the adaptations USAID implemented through global MCH programs in response to the COVID-19 pandemic and climate change, which were responsive to need. Though this action mentioned USAID’s integrated approach to providing primary health care, information about integrated MCH and HIV and AIDS programs, such as prevention of mother-to-child transmission (PMTCT) activities funded by the President’s Emergency Plan for AIDS Relief (PEPFAR), were largely lacking from this Report. As complications from HIV remain a leading cause of death among women of reproductive age around the world, this action was not based in evidence or responsive to need in this domain. Neglecting to mention HIV beyond U.S. global health investments ignored the maternal and reproductive health needs of people living with HIV (PLHIV), including those that are breastfeeding. This action was gender accommodating as it reinforced a gender binary, used gendered language throughout, and did not address harmful social and gender norms that impact PLHIV who may be pregnant or breastfeeding. This action moderately hindered SRHR in the HIV and AIDS domain.

2021_ADS Chapter 200_2021.01.15

ADS Chapter 200 described USAID’s process of creating development policy, as well as the development policy universe that affects all USAID programs and actions. This chapter was edited in January 2021 to update the link for the Agency-wide Policy Framework, which is the Agency’s highest level policy document that guides decision-making across USAID. However, the URL for the current Agency Policy Framework was broken and the Agency Policy Framework was not available elsewhere on the website, which negatively affected transparency. This action neither hindered nor promoted SRHR in the HIV and AIDS domain.

2021_ADS Chapter 201_2021.09.21

ADS Chapter 201 defined USAID’s Program Cycle, which is the Agency’s operational model for planning, delivering, assessing, and adapting development programs that advance U.S. foreign policy. Several sections of ADS Chapter 201 were updated in September 2021, including an update to the definition of “activity design” to include policy dialogue, stakeholder coordination, and capacity building. ADS 201 included an updated Project Design and Implementation section that encouraged integration and coordination across projects for greater sustainability. Many of these edits were responsive to need and aligned with evidence and best practice. Additionally, the responsibilities of the Gender Advisor at the USAID Mission level were updated to include ensuring that “gender equality” was integrated into the design and implementation of activities, which was somewhat gender transformative. This ADS chapter still used gendered language like “female empowerment” and did not address efforts to empower people of diverse sexual orientation, gender identity or expression, or sex characteristics (SOGIESC). The updates to ADS Chapter 201 moderately promoted SRHR in the HIV and AIDS domain.

2021_ADS Chapter 303 Materials_2021.02.04

ADS Chapter 303 described USAID’s internal guidance, policy directives, procedures, and standards for grants and cooperative agreements with non-governmental organizations (NGOs), including those that were established with U.S. global health assistance funds. The main ADS chapter was updated, along with two mandatory references in February 2021: the Standard Provisions for U.S. Nongovernmental Organizations (303maa) and the Standard Provisions for Non-U.S. Nongovernmental Organizations (303mab). All three of these ADS Chapter 303 materials were updated to replace the section related to the implementation of Protecting Life in Global Health Assistance (PLGHA) with the word “Reserved.” No other sections in the ADS Chapter 303 materials were updated to indicate that PLGHA had been revoked by President Biden on January 28, 2021. It was extremely difficult to identify what content had been removed from that section as previous versions of ADS materials were not available on the website. The SRHR Index team referenced the previous version of all three ADS Chapter 303 documents to determine that the PLGHA section had been removed in its entirety. This was USAID’s opportunity to provide information about the policy’s revocation along with guidance for NGOs to implement the policy change and align their programs accordingly. USAID did not provide any information about the revocation of PLGHA in these documents, which negatively affected transparency . This action significantly hindered SRHR in the HIV and AIDS domain.

2021_ADS Chapter 303mab_2021.03.31

ADS Chapter 303mab, Standard Provisions for Non-U.S. Nongovernmental Organizations, was updated in March 2021 to update section M2. Accounting, Audit, and Records. A new subsection outlined the requirement that recipients of grant or cooperative agreement funding had to provide USAID and other U.S. government (USG) officials with “timely and reasonable access” to materials, records, and personnel necessary to complete audits and other oversight processes. This update would apply to U.S. global health programs, but it was unclear whether it would affect the implementation of activities related to SRHR. This action neither hindered nor promoted SRHR in this domain.

2021_ADS Chapter 303_2021.06.07

ADS Chapter 303 was updated again in June 2021 to revise section 303.4.2: Internal Mandatory References. However, none of the individual internal mandatory reference documents were highlighted to indicate that they had been updated, which negatively affected transparency. Highlighting updated content in ADS documents would have helped the reader understand which material had been edited in the revised version. This action neither promoted nor hindered SRHR in the HIV and AIDS domain.

2021_ADS Chapter 303 Materials_2021.07.29.

ADS Chapter 303 was revised in July 2021 to update Section 303.3.5.5: Unsolicited Concept Papers and Applications. The update provided a link to a new Internal Mandatory Reference document: Guide to Unsolicited Applications (303mbd). The Guide to Unsolicited Applications provided guidance and procedures for USAID’s review of unsolicited applications. According to this action, “unsolicited applications provide a method for organizations to submit unique, innovative, or proprietary approaches for solutions to development challenges.” USAID is responsible for determining whether funding such applications would be aligned with the Agency’s development objectives. The addition of this internal mandatory reference document could help ensure that USAID funds programs were responsive to need and not based solely on USAID’s procurement processes. This action was based in evidence and responsive to need as the materials clearly stated that all applications would be reviewed by the programmatic and technical officers to determine strategic alignment with Agency priorities. This action moderately promoted SRHR in the HIV and AIDS domain.

2021_ADS Chapter 308_2021.02.26

ADS Chapter 308, entitled: Agreements with Public International Organizations (PIOs), was updated in February 2021 to state that “PIOs are important partners for the Agency, and many PIOs possess unique comparative advantages.” This action stated that USAID’s Operating Units (OUs) would work with PIOs whenever it was in the best interest of the Agency, which could have fostered partnerships that promoted SRHR through U.S. global health assistance. This action was updated to describe the Organizational Capacity Review process to ensure that the PIO’s organizational framework and operational capacity would add value to USAID’s work. This legal due diligence process was vital to successful partnerships. This action moderately promoted SRHR in the HIV and AIDS domain.

2021_ADS Chapter 308mab_2021.06.15

ADS Chapter 308mab was a mandatory reference for ADS Chapter 308 entitled: Standard Provisions for Cost-Type Agreements with Public International Organizations (PIOs) and was revised in June 2021. Section M19. Sexual Exploitation and Sexual Abuse and Sexual Harassment was updated to outline USAID’s zero-tolerance policy for inaction to addressing sexual exploitation and abuse (SEA) and sexual harassment in all agreements with PIOs. This action required PIOs working in partnership with USAID to apply the Inter-Agency Standing Committee (IASC) Six Core Principles Relating to Sexual Exploitation and Abuse, referenced the United Nations Protocol on Allegations of Sexual Exploitation and Abuse Involving Implementing Partners, and defined a “victim/survivor-centered approach” to SEA and sexual harassment, which aligned this action with evidence and grounded it in human rights. The updated ADS Chapter 308mab stated the requirement for PIO partners to make “reasonable and adequate efforts to address gender inequality and other power imbalances” in their programing, which called for the integration of gender transformative approaches. This action moderately promoted SRHR in the HIV and AIDS domain.

2021_ADS Chapter 312_2021.09.08

ADS Chapter 312 contained information on USAID-financed condoms, pharmaceuticals, and medical supplies designed for USAID technical and procurement staff as well as implementing partners. This chapter was updated to add medical gloves and syringes to the list of laboratory supplies that did not require ADS 312 approval and confirmed that certain USAID technical and programmatic staff had the delegated authority to make determinations about specific pharmaceuticals. It was unclear how these updates would impact the implementation of USAID’s global HIV and AIDS programs, so this action neither hindered nor promoted SRHR in this domain.

2021_Assessing Feasibility and Readiness for Cargo Drones in Health Supply Chains

This report shared the findings of scoping visits in Malawi that explored the feasibility of cargo drones to support global health supply chains with the long-term goal of avoiding stockouts, responding to emergency medical requests, and speeding up diagnostic sample delivery time to benefit global beneficiaries. This action was responsive to need due to supply chain distribution issues that resulted from the COVID-19 pandemic. This action explicitly stated that these findings would not be applicable across all contexts, but that the approach outlined in this report could be adapted for different limited-resource settings. This action suggested that a root cause analysis should be completed to improve project design and inform implementation, which was based in evidence. The guide discussed other best practices that were responsive to need, such as market research, scoping trips, and informational interviews with stakeholders at all levels, from the national government to community health workers. The action included guidance for engaging with community members and designing culturally appropriate community sensitization activities through a participatory approach, which was responsive to need. However, the guide did not include the human rights framework that should be considered when designing drone initiatives. It laid the foundation for future work that could be applied across U.S. global health programs. This action moderately promoted SRHR in the HIV and AIDS domain.

2021_Building Commitment and Capacity to End TB_Tuberculosis Report to Congress_FY2019

This report to Congress documented USAID’s progress toward preventing and treating tuberculosis (TB) and its related comorbidities (e.g., HIV infection and diabetes) around the world. This report was responsive to need as it described the current state of TB infection worldwide, outlined the results of USAID’s Global Accelerator to End TB to date, and described the next steps in USAID’s TB activities in response to the COVID-19 pandemic. PLHIV were mentioned as a key focus of preventative treatment for TB, and TB/HIV cases were reported in each of the country snapshots in the Appendix. However, it was not fully based in evidence as integrated TB/HIV services were not adequately incorporated throughout this action. The action was gender accommodating as it mentioned USAID’s efforts to address stigma, discrimination, gender disparities, and inclusiveness through TB programs, but did not provide additional details about these activities. This Report neither hindered nor promoted SRHR in the HIV and AIDS domain.

2021_Considerations for COVID-19 Response_Digital Accessibility

This action outlined the importance of digital accessibility, particularly during the COVID-19 pandemic, and offered key considerations for designing accessible digital interventions through a universal design approach which was based in evidence. These suggestions, such as involving disability advocacy organizations in digital design processes and adding alt-text to photos, were responsive to need, based in evidence, and aligned with human rights norms. This action built upon USAID’s first-ever Digital Strategy, which was released in 2020. This action acknowledged that lack of access due to disability was intersectional to other inequities, which was based in evidence, but was gender blind as it did not specify the ways in which a person’s gender could be a barrier to access. This action supported the ability of USAID’s global HIV and AIDS programs to be more inclusive of persons with disability. 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 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 accomplishments of global HIV and AIDS programs, including new HIV diagnoses, the numbers of adults and children receiving ARVs, 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 key populations (KPs) or adolescent girls and young women (AGYW) were not included in this action. Additionally, the HIV and AIDS indicators did not have FY 2022 targets. Setting targets at the beginning of the FY is an important way to measure progress and ensure that programs are performing well and are responsive to need. It was unclear why targets were not included for USAID’s global HIV and AIDS activities in FY 2022, so this action was not fully based in evidence and negatively affected transparency . The Report was gender accommodating as it used language that reinforced a gender binary. 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. However, targets were not included for FY 2022, which was not responsive to need and negatively affected transparency. This action moderately promoted SRHR in the HIV and AIDS domain.

2021_Diversity, Equity, and Inclusion Strategy_Executive Summary

In 2021, USAID released the Executive Summary for the forthcoming Diversity, Equity, and Inclusion Strategy. The full Strategy was not publicly available at the time of grading, but the Executive Summary described USAID’s plan to enhance diversity across the Agency, promote inclusion and equity among Agency staff, and strengthen accountability for diversity, equity, and inclusion (DEI) efforts. This action described the methodology that USAID implemented to design the complete DEI Strategy, including stakeholder interviews, focus groups, listening sessions, and consultations at all levels of the Agency. While this approach and the overall goals of the DEI Strategy outlined in this action appeared to be responsive to need, based in evidence, and aligned with human rights, it did not explain how the complete Strategy would impact U.S. global health programs and operations. Though releasing this Executive Summary was responsive to need, this action likely would not have an impact before the complete Strategy was made available. This action neither hindered nor promoted SRHR in the HIV and AIDS domain.

2021_Family Planning and Reproductive Health Program Overview

This Overview detailed the scope of the Family Planning/Reproductive Health (FP/RH) Program at USAID and described the benefits of FP to women and children's health, reducing poverty, and lowering the incidence of HIV and AIDS. The Overview was guided by the principles of voluntarism and informed choice, which was responsive to need, based in evidence, and aligned with human rights. The Overview stated that the RH portfolio included integration with HIV programming and highlighted the impacts of FP on reducing HIV and AIDS by preventing new infections and mother-to-child transmission of HIV, which was responsive to need and based in evidence in this domain. While the Overview mentioned that addressing gender norms was within the RH portfolio, it was gender accommodating as it primarily used language that enforced a sex and gender binary. This Overview moderately promoted SRHR in the HIV and AIDS domain.

2021_Global Health eLearning Course_Antimicrobial Resistance_Part 1

This eLearning course explored antimicrobial resistance as it pertained to diseases such as TB, gonorrhea, malaria, and HIV. The Course described the potential reversal of progress made against these public health challenges, as well as the reality that resistance to common medications has increased in recent years, which has resulted in an increased burden on health systems. This action reported on the higher burden of resistance to specific HIV treatment regimens among women than men and emphasized the importance of fast-tracking the shift to prescribing dolutegravir-containing regimens for all PLHIV, including those who may have developed resistance to other HIV treatment regimens. This recommendation was responsive to need and based in evidence. However, this action did not advance SRHR beyond monitoring resistance to antibiotic treatments, including those that impact sexual and reproductive health (SRH) outcomes. It was gender accommodating as it used gendered language when discussing risk of antibiotic resistance. This action did not clarify which content was updated in the latest version of this eLearning course, which negatively affected transparency . This action neither promoted nor hindered SRHR in the HIV and AIDS domain.

2021_Global Health eLearning Course_Applying Segmentation to SBC in Family Planning

This eLearning course provided information about the benefits of incorporating segmentation—or dividing a population into subgroups with "meaningfully similar characteristics, and significant differences from other subgroups"—for the purposes of social and behavior change (SBC) research and programming. The Course primarily focused on incorporating SBC into FP programming, however the guidance in the Course could be applied to other areas of global health beyond FP. The Course covered several case studies where different SBC approaches could be used to address a wide range of contexts, which was responsive to need. However, it was not fully responsive to need as the Course mentioned HIV and AIDS in examples and case studies but did not provide specific guidance on applying segmentation strategies on applying segmentation strategies to FP activities related to HIV and AIDS outcomes. The Course received a low transparency score as it was not clear what was updated from previous versions of the training. The Course was gender accommodating as it used gendered language that reinforced a gender binary. The Course moderately promoted SRHR in the HIV and AIDS domain.

2021_Global Health eLearning Course_HIV/AIDS Legal and Policy Requirements

This eLearning course provided guidance about the legal and policy requirements that applied to global HIV programs supported by U.S. global health assistance funds. The Course provided information on a wide variety of topics including condoms, sex work, working with local partners such as faith-based organizations or law enforcement, VMMC, FP/HIV integrated services, restrictions related to abortion and involuntary sterilization, and ensuring compliance with these USG requirements. The Course provided useful information to support organizations with implementing these policies, which was responsive to need. However, it mostly focused on restrictions instead of what was allowed under U.S. policy. Though the Course was updated to remove all mentions of PLGHA, removing all references to this policy without providing information about its revocation or guidance for partners on how to implement programming in its absence was not consistent with evidence, responsive to need, or aligned with human rights. The Course highlighted opportunities to support programming such as FP/HIV integration across PEPFAR platforms, including PMTCT activities, KP programming, and DREAMS programming, which was also responsive to need, based in evidence, and aligned with human rights norms. While the Course supported the implementation of some gender transformative elements through DREAMS programming, it was gender accommodating as it used gendered language and did not include guidance on addressing gender norms in global HIV and AIDS programming. The Course did not highlight what was updated or changed for 2021, which negatively affected transparency . This action neither hindered nor promoted SRHR in this domain.

2021_Global Health eLearning Course_U.S. Family Planning and Abortion Requirements

The 2021 eLearning Course on U.S. Family Planning and Abortion Requirements provided an overview of the FP and abortion legislative and policy requirements that apply to U.S. foreign assistance funding and programs. The Course primarily focused on the principles of voluntarism and informed consent through the Tiahrt amendment, which was based in evidence and human rights norms as these principles are regarded as the standard for protecting the human rights of people that access FP services worldwide. The Course emphasized that it was the responsibility of USAID staff to discuss legislative abortion restrictions with implementing partners throughout the life of the award to ensure awareness of the restrictions, which was responsive to need. The Course specifically noted that programs cannot deny access to HIV and AIDS treatment based on FP use and emphasized that the requirements outlined in the course applied to HIV and AIDS programming, which was responsive to need. However, the Course did not clearly state which information was changed for 2021, which negatively affected transparency . Furthermore, it did not mention the Biden administration's policy to support SRHR globally. While the Course mentioned the revocation of the PLGHA policy, it stated that the policy was no longer in effect and that implementing partners still had to comply with other abortion-related restrictions, which was not enough detail or guidance for partners to understand how to implement this policy change. As a result, this action was not fully responsive to need, based in evidence, or consistent with human rights norms. The Course encouraged staff to "be aware of perceptions among program managers, clients, and providers that may suggest potential vulnerabilities," which was not responsive to need as it could lead to unnecessary oversight of people's personal or professional beliefs that would not be relevant to their implementation of abortion restrictions. The Course was gender blind as it did not include a meaningful or inclusive discussion of gender. This Course moderately hindered SRHR in the HIV and AIDS domain.

2021_Issues and Recommendations on Gender-Based Violence Prevention and Response in COVID-19 Programming

This action provided guidance and recommendations for how to include GBV prevention and response efforts in COVID-19-related programming. The action highlighted the increase in GBV during the pandemic, particularly in the form of online and offline harassment, SEA, child and early forced marriage (CEFM), female genital mutilation/cutting (FGM/C), LGBTQI+ abuse, and abuse towards female health workers. This action recognized the lack of health services available to GBV survivors due to health care supplies being diverted away from GBV and SRHR services in favor of COVID-19 mitigation and called for the integration of GBV prevention and response efforts into the health service response to COVID-19. This recommendation was responsive to need and based in evidence. The action provided recommendations for implementing GBV risk mitigation measures, which were responsive to need, based in evidence, and aligned with human rights norms. While SRH services were mentioned one time, the guidance should have explicitly included the promotion of SRHR as a vital component of the pandemic response. This action did not include considerations for HIV and AIDS programs, which was not responsive to need as it did not recognize the HIV-related services needed by GBV survivors. This action was somewhat gender transformative as it advocated for the implementation of SBC activities to promote healthy masculinities and gender equitable relationships, though it used language that reinforced a sex and gender binary. The Report 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 efforts led by USAID. 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 USAID, including global HIV and AIDS programs and 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_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 USAID: participation, protection, internal capabilities, and partnership. While improved global health outcomes were included as a positive impact of implementing the WPS Agenda, the contributions of USAID’s 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 cross-cutting measure of progress towards achieving the WPS Agenda, which was responsive to need. The Report also highlighted USAID’s efforts to integrate WPS activities with other actions related to countering violent extremism and implementation of gender-sensitive interventions during the COVID-19 pandemic. It highlighted USAID's efforts to prevent CEFM and provide gender training for USAID personnel, which was 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.

2021_USAID 2021 Climate Readiness Plan In Reponse to Executive Order 14008

The 2021 USAID Climate Readiness Plan provided an overview of how USAID plans to implement the directives listed in Executive Order 14008, which called for a prioritization of the climate crisis in the United States and globally. The Plan detailed USAID's role in implementing climate solutions in countries most affected by climate change, as well as called for USAID programs to incorporate lessons learned from the COVID-19 response to build climate resilience. The Plan called for increased collaboration with Indigenous peoples, women and girls, youth, and other groups that are disproportionately impacted by the climate crisis, which was responsive to need and based in evidence. It outlined USAID’s commitment to implementing evidence-based decisions across the full scope of programs and revitalized USAID's approach to climate change adaptation, resilience, and mitigation targets. The Plan elaborated on how global health programs were being monitored for climate change vulnerabilities, particularly in relation to the availability of medical supplies for PEPFAR, infectious diseases, MCH and nutrition, and FP/RH programs, which was responsive to need and based in evidence. The Plan was gender accommodating because it acknowledged the gendered impacts of climate change but utilized gendered language that reinforced a gender binary. This Plan moderately promoted SRHR in the HIV and AIDS domain.

2021_USAID Health Systems Strengthening Learning Agenda

The USAID Health Systems Strengthening Learning Agenda provided a guide for how USAID’s global health programs should improve health system strengthening (HSS) programming. The Learning Agenda prioritized supporting high-performing health care; improving health system equity, quality, and resource optimization; advancing USAID's Vision for Health System Strengthening 2030; and supporting locally led efforts to develop sustainable, resilient health systems. These priorities were responsive to need and based in evidence. The Learning Agenda included questions for a variety of stakeholders that advance health system performance and resilience as well as prioritized health outcomes including controlling the HIV and AIDS epidemic. The Learning Agenda directed stakeholders to implement robust HSS research and programming efforts that were based in evidence, responsive to need, and aligned with human rights. The Learning Agenda could have included more detailed information and guidance about how to adequately incorporate SRHR in these efforts. The Learning Agenda was gender accommodating as it mentioned gender as a cross-cutting area of focus but did not specifically discuss the gender norms that impact health systems and people’s access to health services. The Learning Agenda moderately promoted SRHR in the HIV and AIDS domain.

2021_USAID Implementation Plan for the U.S. COVID-19 Global Response and Recovery Framework

The USAID Implementation Plan detailed the Agency's efforts to carry out the U.S. COVID-19 Global Response and Recovery Framework issued by the Biden administration in 2021. The Plan emphasized the importance of implementing essential public health programs, including those related to FP and sexual, reproductive, maternal, and child health as well as tuberculosis, malaria, and HIV, which were negatively impacted by COVID-19. The Plan included a section on how USAID will leverage existing global health programs and investments to respond to the pandemic and recover from its impacts to strengthen health systems, which was responsive to need, based in evidence, and aligned with human rights. The Plan did not include an adequate description of the metrics that would be used to measure health system recovery and the provision of vital health services, which was not responsive to need. The Plan noted the risk of backsliding on targets related to increasing gender equality and recognized the impact of the pandemic on cases of GBV as well as other increased inequities across marginalized groups. The Plan called for USAID programs to promote equity in COVID-19 responses and prioritize the voices of underserved communities, which included a wide range of demographic groups and emphasized a gender-responsive approach to decision making, which was responsive to need. The Plan included goals on combating social norms regarding GBV prevention but was largely gender accommodating as it used gendered language throughout and did not meaningfully provide guidance for programs to overcome the gender norms that impact COVID-19 recovery. The Plan moderately promoted SRHR in the HIV and AIDS domain.

2021_USAID Key Programming Questions to Address Gender and COVID-19 Infographic

This Infographic provided key questions to support USAID programs that implement gender inclusive programming related to COVID-19. The Infographic covered topics such as GBV; agriculture, food security, and nutrition; democracy, rights, and governance; environment; economic growth; health; child protection; education; and water, sanitation, and hygiene (WASH). The Infographic emphasized the importance of providing "essential and routine health services" because of the pandemic but did not explicitly mention SRH services. The lack of specificity in this definition could have siloed SRH services from other services included in this action. It addressed the increased inequities and vulnerabilities faced by women and marginalized groups across these issue areas due to the pandemic which was evidence-based, aligned with human rights, and responsive to need. The Infographic specifically mentioned "women and girls, men and boys, in all their diversity," which acknowledged the complexity of these identities in relation to people’s SOGIESC which was a gender inclusive approach to this issue. This action was gender accommodating as it recognized gender diversity but did not include questions to guide programs to overcome harmful gender norms. This action moderately promoted SRHR in this domain.

2021_USAID Memorandum Authorizing Disaster Relief Flexibilities to Reduce the Burden for Financial Assistance Pursuant to OMB Memorandum M-21-20

This Memorandum outlined the exceptions for USAID agreements and grant recipients that were impacted by the COVID-19 pandemic, including agreements that pertained to global health assistance. The Memorandum outlined the Agency’s authority to provide administrative relief not only to recipients with COVID-19-related financial assistance, but also to recipients that were implementing assistance awards unrelated to COVID-19. This was responsive to need as it recognized that partners may have had difficulty completing program activities due to the pandemic. The Memorandum provided guidelines for increased flexibility with System for Award Management (SAM) registration procedures; Notice of Funding Opportunity (NOFO) publication requirements; and pre-award costs, no-cost extensions, and submission of financial, performance, or other reports, which was responsive to partners' needs. This action supported the implementation of global HIV and AIDS programs that could be flexible and adaptable during the COVID-19 pandemic. This Memorandum moderately promoted SRHR in this domain.

2021_USAID Nutrition Report to Congress_FY 2021

The 2021 USAID Nutrition Report to Congress included an overview of the Agency's approach to providing nutrition care and progress made toward the World Health Assembly targets on nutrition. The Report referenced the 2021 Lancet series on maternal and child undernutrition, which emphasized the importance of good nutrition for survival and the need to focus on "mothers and children in the 1,000 days window from pregnancy to age two." This action emphasized USAID's evidence-based and multisectoral approach to nutrition programming and highlighted the "unfinished agenda" of deficiencies in vitamins and minerals, gaps in the delivery of nutrition interventions, and the importance of incorporating maternal nutrition in health and food systems, which was based in evidence and responsive to need. The Report did not include data or metrics about how nutrition programming was implemented within HIV and AIDS programming, which was lacking as nutrition is a cross-cutting issue that applies to PLHIV and people taking a biomedical HIV prevention method. Additionally, the Report was gender blind as it only referred to “pregnant and breastfeeding women,” which was not gender inclusive of the nutrition needs of pregnant people who do not identify as women. This Report neither hindered nor promoted SRHR in the HIV and AIDS domain.

2021_USAID Policy on Countering Trafficking in Persons

The USAID Policy on Countering Trafficking in Persons (C-TIP) outlined the principles that guided USAID's approach to implementing policies to combat trafficking in persons. The Policy defined USAID’s "survivor-centered and trauma informed" approach to supporting survivors of trafficking, which was responsive to need and based in evidence. It emphasized that survivors should receive shelter, food, counseling, health care, and legal assistance, which was responsive to need. It highlighted the adverse health outcomes that are common for survivors of trafficking, including work-related injuries or accidents, sexual and physical assault, sexually transmitted infections (STIs), infertility, forced abortion, substance abuse, chronic untreated medical conditions, malnutrition, and future victimization or perpetration of violence, which was based in evidence. These outcomes included issues relevant to SRH, which was responsive to need, but only mentioned "forced abortion," which was not inclusive of the need for safe abortion care in the case of an unwanted pregnancy resulting from trafficking or violence. The Policy was gender accommodating as it included efforts to promote gender equity to prevent and address trafficking in persons but used gendered language throughout the Policy and did not actively demonstrate efforts to combat gender norms that enable trafficking. This Policy moderately promoted SRHR in this domain.

2021_USAID Vision for Health System Strengthening 2030

The Vision for Health System Strengthening for 2030 highlighted USAID’s goals for implementing HSS activities across global health programs. The Vision incorporated equity into access to care and quality of care as well as emphasized the importance of collaborating with local partners to ensure the sustainability of health systems. The focus on addressing systemic barriers to providing equitable and essential care, especially for individuals that experience discrimination based on gender, age, and racial and ethnic disparities or other factors, was responsive to need and aligned with human rights. It promoted a definition of wellbeing that went beyond simply treating illnesses, which was based in evidence. The Vision cited the successes of programming related to the management of diseases such as TB and HIV and AIDS as a basis to translate technical guidance to address other burdens on health systems, which was based in evidence and responsive to need. The Vision documented progress made by different countries towards epidemic control of HIV and AIDS, as well as affirmed the need to invest in efforts to manage HIV as a chronic disease and provide client-centered care through a country's health system, which was responsive to need, based in evidence, and aligned with human rights. The Vision was somewhat gender transformative as it mentioned creating equitable gender norms as a facet of HSS, but used language that reinforced a sex and gender binary. This action moderately promoted SRHR in the HIV and AIDS domain.

2021_USAID’s COVID-19 Response Ending The Global Pandemic and Building Back Better

This Report highlighted USAID's response to COVID-19 and included details about the five objectives that guided the Agency’s pandemic response, including investments. The Report explored the Agency’s experience providing access to vaccines, reducing morbidity and mortality from COVID-19, strengthening health systems, and addressing the increased needs of communities across sectors driven by the pandemic. The Report cited the Agency's efforts to support humanitarian responses by addressing GBV and providing primary and reproductive health services, which was responsive to need. The Report did not provide specific interventions or actions related to the implementation of activities that promote SRHR during the pandemic, so this action was not fully responsive to need, based in evidence, or consistent with human rights. The Report was gender aware as it recognized the impact of COVID-19 on women and girls but used gendered language and did not specifically address relevant gender norms. Throughout the Report, it was unclear how USAID’s global health programs were incorporated into the Agency’s COVID-19 response, which negatively affected transparency . If it was clear that the Report included objectives and results for USAID’s global health efforts, the Report would have promoted SRHR. However, given the lack of transparency, this Report neither promoted nor hindered SRHR in the HIV and AIDS domain.

2020_Acting Administrator John Barsa Letter to UN Secretary General Guterres_18 May 2020

John Barsa, Acting Administrator of USAID, sent this letter to António Guterres, the UN Secretary-General, in May 2020 to oppose the inclusion of SRH services with other essential services in the UN’s Global Humanitarian Response Plan (Global HRP) for the COVID-19 pandemic. The letter criticized the Global HRP because it recommended the distribution of “abortion-inducing drugs and abortion supplies” in local country settings. The letter called for the removal of all references to “‘sexual and reproductive health’ and its derivatives” from the Global HRP. This demand demonstrated USAID’s lack of commitment to providing comprehensive health services during a global pandemic. This action was not based in evidence or human rights as people still needed to access SRH services—including prevention, care, and treatment services for HIV and AIDS—during the COVID-19 pandemic. Furthermore, this letter was gender-blind because it did not acknowledge that women, girls, and gender-diverse people are disproportionately impacted by COVID-19 and could experience poor health outcomes such as HIV acquisition if they could not access adequate HIV and AIDS services. This action was rooted in anti-abortion rhetoric rather than evidence, need, or human rights norms, and siloed SRH services from other essential services in response to the pandemic. It significantly hindered SRHR in the HIV and AIDS domain.

2020_Acting on the Call

In honor of the International Year of the Nurse and the Midwife, the 2020 Acting on the Call Report published by USAID focused on the role that nurses and midwives play in improving quality of care and increasing equitable access to essential health care to reduce maternal, newborn, and child mortality. The Report mentioned HIV as an indirect cause of maternal death along with other pre-existing disorders that may be exacerbated by pregnancy. The Report also acknowledged that nurses and midwives can be trained to support prevention of mother-to-child transmission (PMTCT) efforts as well as provide prevention and treatment care for HIV and AIDS. However, it did not include specific information or guidance for integrating these services with other maternal and child health (MCH) programs. Due to the lack of meaningful inclusion of HIV and AIDS programmatic data and reporting throughout the Report, this action was not fully based in evidence, consistent with international human rights norms, or responsive to need in the HIV domain. It siloed HIV and AIDS from MCH programs and services which hindered SRHR in the HIV and AIDS domain.

2020_ADS Chapter 303 Materials_2020.05.18

Chapter 303 of USAID’s Automated Directive System (ADS) governs the grants and cooperative agreements between USAID and non-governmental organizations (NGOs), which includes all of U.S. global health assistance. Two mandatory references for ADS Chapter 303 were updated on May 18, 2020: the Standard Provisions for U.S. NGOs (303maa) and the Standard Provisions for Non-U.S. NGOs (303mab). These updated mandatory references included a new section entitled: M12. Preventing Transactions with, or the Provision of Resources or Support to, Sanctioned Groups and Individuals. The updates to this section maintained that NGOs that received funding through USAID could not “engage in transactions with, or provide resources or support to, any individual or entity that is subject to sanctions” by the U.S. Department of the Treasury Office of Foreign Assets Control or the UN Security Council. Since the UN Security Council list was included as a third-party entity outside of the U.S. Department of the Treasury, this update was aligned with human rights statutes and was based in evidence. The use of the term “sanctioned groups and individuals” in lieu of the pejorative use of “terrorist” in prior versions of this reference may also have been based in evidence, but it was unclear what prompted this change to the ADS. It was also unclear if these sanctions would impact U.S. global health programming, so this update neither hindered nor promoted SRHR in the HIV and AIDS domain.

2020_ADS Chapter 303 Materials_2020.06.19

The updates to ADS Chapter 303: Grants and Cooperative Agreements to Non-Governmental Organizations that were released on June 19, 2020 were not related to SRHR. However, this version of ADS Chapter 303 included a new section entitled: 303.3.34 Abortion Restrictions (Effective Date: 05/29/2020), which had been added since the 2019 version that was graded by the SRHR Index. This section provided guidance for implementing the statutory and policy abortion restrictions that apply to all U.S. foreign assistance awards (e.g., Voluntary Population Planning Activities – Mandatory Requirements) and those that apply to only U.S. global health assistance (i.e., Protecting Life in Global Health Assistance [PLGHA]). This section included links to USAID resources that define and explain legislative and policy requirements related to global health, which could have supported the correct implementation of the PLGHA policy and other restrictions. However, this edit was not responsive to need, as it was unclear why the ADS was only updated to include this guidance in May 2020 when the PLGHA policy had been in effect since 2017 and other abortion restrictions have been in place since 1973. The May 29, 2020 version of ADS Chapter 303 had been replaced on USAID’s website by the June 19, 2020 version and was no longer available at the time of grading, which contributed to low transparency for this action as prior versions of ADS documents are not publicly available once a newer version is released. The updates made to these materials on June 19, 2020 neither promoted nor hindered SRHR in the HIV and AIDS domain.

2020_ADS Chapter 303 Materials_2020.08.18

Two ADS Chapter 303 materials were updated on August 18, 2020: the main ADS chapter itself and the Standard Provisions for Non-U.S. NGOs (303mab). Details regarding allowable cost share, information technology, and telecommunication services were added to the updated version of the main ADS chapter. While these updates may impact program management and some operations for global health programs, the updates neither promoted nor hindered SRHR in the HIV and AIDS domain. The 303mab was also updated to provide more information as well as specific guidance on implementing the prohibition of certain telecommunication and video surveillance services or equipment as was updated in the main ADS chapter. This new section included definitions and references for “covered telecommunication equipment or services,” “covered foreign country,” and “telecommunication costs,” as defined in the Code of Federal Regulations (CFR). This telecommunications prohibition was also included in the Department of Health and Human Services’ (HHS) General Terms and Conditions for Research and Non-Research Grants and Cooperative Agreements, though the HHS guidance included an exemption for PEPFAR funding until 2022 that was not mentioned in these ADS materials. It was unclear how this guidance would affect global health programs, so this action neither promoted nor hindered SRHR in the HIV and AIDS domain.

2020_ADS Chapter 303 Materials_2020.11.19

Two mandatory references for ADS Chapter 303 were updated on November 19, 2020: the Standard Provisions for Non-U.S. NGOs (303mab) and the Standard Provisions for Fixed Amount Awards to NGOs (303mat). Both mandatory reference documents contained one update that was relevant to SRHR: Section RAA6. Universal Identifier and System for Award Management. This section was rewritten to provide notice that the prior Data Universal Numbering System (DUNS) had been replaced by the new Unique Entity Identifier process, which allowed organizations to maintain a current registration in the System for Award Management (SAM) and receive federal funding. This section also included definitions, requirements, and exemptions for the application of this provision, which would enable the effective implementation of this provision. This updated provision was responsive to need because the DUNS process had been identified as burdensome for local organizations with limited administrative capacity as compared to large international NGOs. The streamlining of the SAM process could enable local and smaller organizations to participate in USAID’s global health programs. As such, this update moderately promoted SRHR in the HIV and AIDS domain.

2020_ADS Chapter 303 Materials_2020.12.17

Two ADS Chapter 303 materials were updated on December 17, 2020: the main ADS chapter itself and the Process for Transition Awards Mandatory Reference (303mbb). ADS Chapter 303 was updated to add the brand-new Mandatory Reference 303mbb, which provided guidance on how to make transition awards to local partners. The purpose of transition awards is to develop the capacity for local organizations to receive direct awards from USAID. The Definitions section of the main chapter was updated and defined “transition award” as an assistance award to a “local entity or locally established partner...that is or has been a subrecipient under a USAID assistance award.” The 303mbb Mandatory Reference provided guidance on how to make transition awards to promote self-reliance and strengthen the Agency's engagement with local partners. This process includes making an initial award followed by the transition award with clear roles for USAID staff, prime partners, and the local partner. The creation of the transition award process as explained in these ADS materials was responsive to need because local organizations have asked for support to receive U.S. funding directly as opposed to receiving funds through traditional agreements with prime partners who are often large international NGOs. The development of the transition award process was based in evidence and best practice and aligned with human rights. It supported the ability of USAID to substantially promote SRHR in the HIV and AIDS domain.

2020_ADS Chapter 308_2020.12.04

Updates to ADS Chapter 308, entitled: Agreements with Public International Organizations (PIOs), were released on December 4, 2020. Specifically, Section 308.3.2.1 Organizational Capacity Reviews (OCRs) provided an updated definition of an OCR: “a high-level assessment of whether or not a PIO is organizationally capable of adequately safeguarding USAID resources” and has the means to “highlight any significant concerns, considerations, or risks that should be taken into account in working with the PIO.” This section was also updated to add a requirement that OCRs should be updated at least every five years, but more frequently if specific circumstances warrant earlier reviews. The OCR process was also updated to include PIO policies related to sexual exploitation and abuse (SEA), internationally accepted accounting standards, and environmental and social safeguard policies and procedures. The inclusion of frequent monitoring and reporting of environmental safeguards was responsive to need and based in evidence, though external environmental standards were not explicitly defined. Climate change and other environmental factors can affect a person’s SRHR, so external references supporting this guidance should be included for transparency. This updated guidance was intended to ensure PIOs are maintaining a certain level of ethics and responsibility to reduce the risk or liability for USAID, however the evidence base and human rights framework was lacking throughout this section. It was unclear to which international standards, policies, and procedures PIOs would be held accountable when conducting an OCR. External references are necessary to ensure that PIO OCRs are objective and not subject to administration-level politics or influence. Without additional detail, this action neither hindered nor promoted SRHR in the HIV and AIDS domain.

2020_Agency Priority Goal Action Plan_Maternal and Child Health

The purpose of the Agency Priority Goal (APG) Action Plan on MCH is to report on USAID’s contributions to global efforts to prevent child and maternal deaths in fiscal year (FY) 2020. This action listed the technical teams at USAID that contributed to this reporting, which included representatives that work in population and reproductive health, malaria, nutrition, and health systems strengthening. However, the role of USAID’s HIV and AIDS technical staff and programs was not mentioned in the Plan, even though USAID is an implementing agency of the President’s Emergency Plan for AIDS Relief (PEPFAR) and provides services related to MCH. It should have incorporated PEPFAR programmatic data into existing USAID MCH data to reflect all of USAID’s MCH efforts. The Plan mentioned that HIV and AIDS is a contributor to under-five mortality and reported that improvements in ending preventable child and maternal deaths are the result of “increasingly effective efforts to link diverse health programs,” including HIV and AIDS. It did not report on any indicators related to HIV that might impact MCH outcomes, such as PMTCT or HIV prevention services for pregnant people, so the Plan did not reflect the full evidence base and was not responsive to need in the HIV and AIDS domain. The lack of reporting on HIV and AIDS throughout this Plan further siloed HIV from MCH programs, which moderately hindered SRHR in the HIV and AIDS domain.

2020_Considerations for USAID Mission Staff for Programmatic COVID-19 Preparedness and Response_Digital Technologies and Data Systems

USAID released this guidance on April 6, 2020 to help USAID Missions best respond to the COVID-19 pandemic through the use of digital interventions and data systems. Given the rapid development and publication of these guidelines and the fact that most of the recommendations in this action did not require modifications to current agreements, this action was responsive to need because Missions could implement the guidance as appropriate for the local context. Additionally, the role of USAID health programs was clearly defined: “support host country information systems, health worker education, identify health data needs, identify interoperability needs, and provide TA [technical assistance].” The Guidelines called for collaboration with host country governments to ensure that health workers continued to be paid and that data collection continued through health programs, which was responsive to need and would facilitate data-driven decision making. The Guidance described how gender dynamics interact with one’s access and use of digital technology, which was gender aware. However, there was no guidance for how digital interventions should be adapted to address the impacts of COVID-19 related to SRHR, including gender-based violence (GBV) and reduced access to HIV and AIDS services. As a result, this action neither promoted nor hindered USAID’s ability to support SRHR in the HIV and AIDS 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, including USAID’s global HIV and AIDS programs funded through PEPFAR. 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, this action was not released by PEPFAR (of which USAID is an implementing agency) 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. 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. This 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 APGs for HIV and AIDS were released quarterly by both the Department of State and USAID. APGs 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 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 was 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 program. It also did not reference any human rights principles or frameworks that guided them, which was lacking. The APGs moderately promoted SRHR in 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 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. The role of USAID in DREAMS implementation was not included in this action, which negatively affected transparency and was not responsive to need. 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 implemented with 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 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’s 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 discussed 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’s progress towards the same indicators that were included in the APGs, including increasing ART enrollment and coverage, scaling up VMMC, and other targets in FY 2020. This Report did not explicitly state USAID’s specific contributions or progress toward each indicator, but rather presented these data at the PEPFAR level, including 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, though the role of USAID in these achievements was unclear. However, the Report lacked a description of the evidence and human rights frameworks that guided PEPFAR programming. The Report included data on a few indicators that measured gender norm change, which were gender accommodating but not gender transformative because they focused on “males and females,” which reinforced a gender binary. This report moderately promoted SRHR in the HIV and AIDS domain.

2020_Expedited Procedures Package for Responding to Outbreaks of Contagious Infectious Disease

An Expedited Procedures Package (EPP) provides a blanket restriction on eligibility for both acquisition (e.g., contracts) and assistance (e.g., grants and cooperative agreements) mechanisms and allows for modifications to be made to existing USAID contracts and agreements without triggering competition requirements. This permitted USAID to maintain flexibility to respond rapidly and effectively to an outbreak of an infectious disease. Released on March 27, 2020, this EPP allowed USAID programs to apply for new funding as well as shift existing funds and programmatic priorities to quickly meet the changing needs created by the pandemic, Thus, the EPP was highly responsive to need. The EPP also made it easier to award emergency assistance to USAID programs and enabled USAID to engage with new as well as underused partners, private-sector partners, and community- and faith-based partners to effectively respond to the pandemic. This effort was aligned with evidence, best practice, and human rights. This action enabled USAID to rapidly provide financial and technical support to programs so they could address issues related to COVID-19. Since this EPP could be used by any implementing partner, programs could have adapted to provide SRHR services through the pandemic. This action moderately promoted SRHR in the HIV and AIDS domain.

2020_Global Health eLearning Course_Bureau for Global Health Environmental Management Process Training

The 2020 Global Health eLearning Course on USAID’s environmental management process equipped USAID technical staff (e.g., Program Managers, Agreement Officer’s Representatives/Contracting Officer’s Representatives, Activity Managers) and other stakeholders with an introduction to the Global Health Initial Environmental Examination process and a roadmap for planning and implementing health programs consistent with the Agency’s legal requirements. The Course outlined the processes for conducting environmental assessments, plans, and reports to monitor and mitigate the intended or unintended impact of global health programs on the environment. Agreements that included certain activities were instructed to consult with relevant host country agencies as well as follow necessary permit requirements and instructions, which was aligned with evidence and best practice. The Course used a case study to guide readers through the environmental examination process, which was responsive to need. While the Course mentioned that most health activities generally did not require a complete environmental examination in accordance with the Code of Federal Regulations (CFR), it stated that projects with a categorical exclusion still require annual screenings to identify changes to the program that could require additional environmental review. This annual review process for health programs promoted accurate reporting and mitigated any impact on the environment, which is responsive to need. Climate change and environmental issues have a significant impact on SRHR, so this Course moderately promoted SRHR in the HIV and AIDS domain.

2020_Global Health eLearning Course_HIV/AIDS Legal and Policy Requirements

The 2020 HIV/AIDS Legal and Policy Requirements Global Health eLearning Course provided an overview of the HIV and AIDS legislative and policy requirements that govern USAID-supported HIV and AIDS activities. The course was designed to help USAID staff, implementing partners, and host country government representatives understand the requirements related to medically accurate information about condoms, VMMC, FP and HIV integrated activities, abortion and involuntary sterilization restrictions, and other topics relevant to HIV and AIDS programs. The Course defined the tenets of voluntarism and informed choice, which are consistent with human rights, and included an informative table explaining the policies, requirements, and amendments that applied to specific types of funds and programs in 2020, which was responsive to need and based in evidence. The Course also explained the Protecting Life in Global Health Assistance (PLGHA) policy, though it did not include guidance on the March 2019 expansion, which was not responsive to need. Though complete detail about the PLGHA policy was lacking, the Course was informative and based in evidence as it provided references to external sources and other trainings to provide additional information. The Course did not provide an explanation of the impact of these policies on KPs but did clearly state that HIV and AIDS services should not be denied to sex workers, which was aligned with human rights norms and based in evidence. The Course was gender accommodating as there were few sections specifically related to gender outside of PMTCT though the Course used outdated gendered terms like “female condom,” which was not aligned with evidence nor was it gender transformative. This Course moderately promoted SRHR in the HIV and AIDS domain.

2020_Global Health eLearning Course_Protecting Life in Global Health Assistance and Statutory Abortion Restrictions-2020

The 2020 Global Health eLearning Center Course on the Protecting Life in Global Health Assistance (PLGHA) policy and other statutory abortion restrictions provided USAID staff and implementing partners with technical knowledge about the legal and policy restrictions on abortion-related activities and how to properly implement them through global health programs. The Course described the programs and activities to which the PLGHA policy and other statutory abortion restrictions apply. It also provided recommendations for how to ensure that programs are compliant with these restrictions and included guidance on how to investigate a violation. The Course included the specific exceptions in which health care providers can provide information on abortion and defined the affirmative duty of providers, which was responsive to need. The Course also clarified that the PLGHA policy did not apply to post-abortion care (PAC), which was responsive to need and consistent with human rights norms. The training included some compliance guidelines and was consistent with the May 2019 Standard Provision and data from the 2018 six-month review of the implementation of the PLGHA policy. However, it primarily provided guidance on what activities are not permitted under the policy and could have more clearly supported PAC, comprehensive FP, and other efforts that are not prohibited under the policy. The Course encouraged staff to "be aware of perceptions among program managers, clients, and providers that may suggest potential vulnerabilities," which was not responsive to need as it could lead to unnecessary oversight of people's personal or professional beliefs that are not relevant to their implementation of the PLGHA policy and other abortion restrictions. The Course was not fully responsive to need as it did not include implementation information specific to USAID’s global HIV and AIDS programs, including post-violence care during which programs may encounter people who became pregnant as a result of rape. Additionally, the Course was not gender transformative as it did not use gender inclusive language (e.g., “pregnant persons”). This Course moderately hindered SRHR in the HIV and AIDS domain.

2020_Global Health eLearning Course_U.S. Family Planning and Abortion Requirements

The 2020 Global Health eLearning Course on U.S. FP and abortion requirements provided technical guidance on abortion-related statutes that apply to all U.S. foreign assistance funds. The Course discussed the Helms Amendment but predominantly focused on requirements that apply specifically to FP assistance funds, particularly the Tiahrt Amendment. The Tiahrt Amendment dictates how USAID-supported FP programs deliver services. This component of the Course was based in evidence and human rights norms because the restrictions outlined in the Tiahrt Amendment have been endorsed by USAID and the WHO as a standard for protecting the human rights of people that access FP programs and services. The Course was responsive to need as it provided vital information on voluntarism and informed choice as the cornerstone of all FP programs implemented by USAID. It included guidance for providing proper counseling on FP, including offering contraceptives with method mix at each service delivery point. However, as the Tiahrt Amendment only applies to FP service delivery projects, the Course did not provide specific guidance for how to ensure clients have informed choice in other areas of global health programs that also offer FP services. In particular, the Tiahrt Amendment applies to FP/HIV integrated PEPFAR activities because they receive contraceptives procured by USAID. However, the Course did not explicitly acknowledge that the Tiahrt Amendment applies to these activities or provide guidance for how program staff should incorporate this Course into these activities. The Course was gender blind, as there were no mentions of gender or of how to implement these policies in a way that addressed unequal gender norms. While the Course was useful to guide FP activities, it was not informative on how this guidance should be adapted for HIV and AIDS programs. This Course moderately hindered SRHR in the HIV and AIDS domain.

2020_Guide for Adopting Remote Monitoring Approaches during COVID-19

USAID released the Guide for Adopting Remote Monitoring Approaches during COVID-19 in May 2020 and it provided information to USAID staff and implementing partners about when and how to employ remote monitoring techniques as programs continue to be implemented amidst COVID-19 restrictions. This Guide was responsive to need as it stated that awards should not be amended more than is necessary and that awards should remain in compliance with the initial award conditions. It also indicated that missions and partners should gather feedback from beneficiaries of activities that have been altered due to COVID-19 to remain informed of their current needs and make decisions regarding program adaptation. Regarding USAID’s HIV and AIDS programs, the Guide included changes to the Site Improvement through Monitoring System (SIMS) deadlines for monitoring and reporting on PEPFAR targets during COVID-19, which was responsive to need and based in evidence and human rights as the SIMS process is aligned with WHO guidelines and evidence. The Guide was gender accommodating as it called for implementing partners to monitor how the demographics of a target population may impact their access to and use of digital technology for remote monitoring based on gender, age, and disability and it directed implementers to “account for any biases” that may impact people’s access to digital technology. While this element of the Guide supported SRHR, it did not provide explicit guidance for implementing partners to overcome the barriers that people may experience due to their gender, age, or disability. This Guide supported the ability of USAID’s HIV and AIDS programs to make data-driven decisions through the use of remote monitoring approaches during the COVID-19 pandemic, which moderately promoted SRHR in the HIV and AIDS domain.

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 accessing 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. Several of USAID's approaches and projects contributed to this whole-of-government strategy, including USAID’s flexible approach to programmatic decisions to account for COVID-19, launching the Safe Migration in Central Asia project, and facilitating interagency coordination to streamline international and domestic grants. However, it was unclear whether these programs were funded through global health assistance, and therefore contributed to low transparency. Relevant global health programs within USAID were not included in this report, which ultimately ignored the HIV and AIDS service needs of those who are trafficked globally. The Report moderately hindered SRHR in the HIV and AIDS domain.

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

The second review of PLGHA summarized the history of the policy and presented findings from a review of the policy’s implementation throughout U.S. global health assistance programs since 2017. The Review found that in certain cases where USAID partners declined awards due to the PLGHA policy, the loss of trusted partners in-country resulted in difficulties replacing these partners and caused subsequent disruptions in healthcare services across technical areas. Specifically, the Review found that the loss of partners resulted in delays in the implementation and distribution of USAID’s services related to HIV and AIDS, MCH, voluntary FP, tuberculosis, and nutrition. Regarding HIV and AIDS, disruptions in healthcare services impacted the provision of HIV prevention, care, and treatment services for KPs in welcoming settings. The declinations of global health assistance due to the policy also had significant impacts on cross-cutting activities, such as cervical pre-cancer screening, mobile outreach for HIV testing, care, and treatment, and HIV and AIDS programs related to orphans and vulnerable children (OVCs) and voluntary male medical circumcision (VMMC). These findings confirmed that the implementation of the policy led to some disruption in service delivery, which USAID was required to navigate. While PLGHA itself did not promote SRHR, USAID’s role in providing mechanism-level data for this report was responsive to need and based in programmatic data and evidence, which provided a clear overview of USAID’s implementation of the policy. The Review moderately promoted 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, in collaboration with other U.S. implementing agencies including USAID, released the Strengthening Health Security Across the Globe annual report that identified the U.S. government’s contributions to global health security by country and U.S. government agency. Though several areas of global health were mentioned throughout the report, data related to HIV and AIDS were noticeably absent. PEPFAR was only mentioned in relation to infection prevention and control (IPC) programs to aid in the global response to COVID-19. USAID’s role in implementing global HIV and AIDS programs was not included in the Annual Report at all, which minimized the value of HIV prevention and treatment efforts in promoting global health security. 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 to mention SRH issues in global health 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 advancing gender equity and countering harmful norms that affect women and girls. 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. This Report moderately hindered SRHR in the HIV and AIDS 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 (like USAID) 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 or integration with specific global health program areas, even though addressing HIV and AIDS, MCH, FP, and other cross-cutting SRHR issues is vital to promoting stability and security. Notably, it did not include guidelines for responding to GBV even though the risk of violence is often greater to women, girls, and gender-diverse people in fragile settings and conflict areas compared to peaceful settings. 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 Women, Peace, and Security (WPS) Strategy. This action moderately hindered SRHR in the HIV and AIDS domain.

2020_USAID Digital Strategy 2020-2024

The Digital Strategy described the Agency's vision for the responsible use of digital technology in international development and humanitarian work. The goal of this strategy was to sustain digital ecosystems that increase self-reliance as well as promote positive development and humanitarian assistance outcomes. The Strategy described the mechanisms through which USAID staff will achieve these goals and highlighted previous successes with incorporating digital technologies into the Agency's activities. The Strategy noted the importance of digital infrastructure amid COVID-19, which was responsive to need and based in evidence as it promoted the use of telemedicine to protect health care workers and patients while also providing vital health services. However, the Strategy did not describe the specific use of digital interventions to provide HIV and AIDS services. It would have been helpful to include examples of digital technologies used successfully by USAID’s HIV and AIDS programs funded through PEPFAR, making the absence of these examples a gap in this Strategy. The human rights basis was explicitly stated in the Strategy, as it detailed the potential for “digital authoritarianism” to infringe on human rights. The Strategy was gender aware because it acknowledged gender disparities and the “gender digital divide” which contributes to inequitable use of technology across genders. However, it used a gender binary to describe these impacts and did not use inclusive language. While the Digital Strategy set a positive tone for the use of emerging technologies and digital infrastructure in USAID's activities, it did not meaningfully include strategic thinking related to HIV and AIDS, and thus neither hindered nor promoted SRHR in the HIV and AIDS domain.

2020_USAID Gender Equality and Women’s Empowerment 2020 Policy

This Policy detailed USAID's investment in and commitment to supporting gender equality and women’s empowerment efforts to date. It outlined the strategic objectives and principles necessary for the Agency to achieve this vision and increase self-reliance in partner countries. The Policy referenced global health programs and cross-cutting issues related to SRHR, including activities to eliminate GBV, increase the capability of women and girls to exercise their “basic and legal rights fully,” and improve women and girls’ access to education and employment. While the section on HIV and AIDS identified the impacts of gender norms on women and girls’ rights, the section did not provide guidance for changing these gender norms and did not include specific guidance for engaging with gender diverse people, KPs, underserved communities, or others who might experience higher risk of HIV. This policy stated that harmful gender norms, inequalities, and GBV are drivers of HIV acquisition among adolescent girls and young women (AGYW) in sub-Saharan Africa, which was consistent with evidence. However, this policy did not acknowledge the role of USAID in implementing programs that promote AGYW’s agency or support their ability to make autonomous decisions about engaging in consensual pleasurable sexual activity. The Policy was not grounded in human rights norms or responsive to need because of its exclusion of LGBTQI+ people and its basis in “unalienable rights,” which do not include all international human rights. Exclusion of LGBTQI+ people was not based in evidence as research shows that members of the LGBTQI+ community are at an increased risk of experiencing GBV and other inequitable gender norms that limit their access to health services, education, employment, and other measures of empowerment. The 2020 version of this policy was not responsive to need because it was less inclusive than the previous version from 2012, which explicitly included all people regardless of gender identity, disability status, HIV and AIDS status, geographic area, and migratory status. It also did not acknowledge the contributions of SRHR programs to gender equality efforts. Additionally, the Policy was not gender transformative due to its use of a gender binary and exclusion of LGBTQI+ people, but was gender accommodating because it acknowledged the impact of existing gender inequities in global health and development areas. This policy moderately hindered SRHR in the HIV and AIDS domain.

2020_USAID MOAA COVID-19 Implementing Partner Guidance_Frequently Asked Questions Published on 11.03.2020

This Guidance from the Bureau for Management Office of Acquisition and Assistance (MOAA) within USAID compiled all questions related to COVID-19 from implementing partners in one place. The Guidance was regularly updated throughout 2020, which was responsive to need. The primary section related to HIV and AIDS was the section about PEPFAR and USAID, which answered questions related to the roles of PEPFAR and USAID staff, outlined how PEPFAR programs could be used to respond to COVID-19, and provided external references for additional technical guidance for PEPFAR programs. The Guidance clarified differences between information from the Department of State's Global AIDS Coordinator (S/GAC) and USAID for program implementation, which was responsive to need. The Guidance was based in evidence and human rights norms as it referred to PEPFAR and USAID's standards for HIV and AIDS programming and USAID agreement processes to ensure that people living with HIV (PLHIV) continued to receive the care they needed during the COVID-19 pandemic. The Guidance was not gender transformative as it did not include guidance for adapting programs in response to the disproportionate impact of COVID-19 on women and girls as well as the rise in GBV, which was lacking. This Guidance moderately promoted SRHR in the HIV and AIDS domain.

2020_USAID Over the Horizon Landscape Analysis and Snapshot

The Snapshot described how USAID aimed to shift its programming to accommodate a world altered by the COVID-19 pandemic. It highlighted the persistence of inequities in access to essential services as well as the adverse impact of the pandemic among “vulnerable and marginalized groups,” but did not define these groups, establish the evidence base, or define the human rights framework as the foundation for this action. The Snapshot mentioned the increased risk of GBV due to COVID-19, which was based in evidence and responsive to need. The Snapshot listed USAID's responses to the pandemic and described the active USAID development policies, field consultations, partner roundtables, and collaborative research that was used to adapt operations to respond to COVID-19. However, USAID’s HIV and AIDS programming was not mentioned throughout this action, even though COVID-19 impacted the performance and achievement of its HIV and AIDS activities funded through PEPFAR. This action was gender accommodating because it aimed to increase women's participation in pandemic relief efforts but did not document the disproportionate impact of COVID-19 on women and girls beyond GBV. The Snapshot moderately hindered SRHR in the HIV and AIDS domain.

2020_USAID Policy on Promoting the Rights of Indigenous Peoples

This policy provided guidance for engagement and partnerships on projects that impact Indigenous Peoples and detailed USAID's efforts to engage them as “meaningful partners” in Agency program development processes. The Policy stated the importance of ensuring that activities like data collection are conducted in a way that is responsive to Indigenous Peoples' input and needs through the free, prior, and informed consent (FPIC) process, which is a vital component of Indigenous organizing that respects their rights and autonomy. The Policy was grounded in human rights as it included adherence to international standards of human rights as a central pillar but did not acknowledge the impact of colonization and occupation on the health and wellbeing of Indigenous communities. With respect to health outcomes, the Policy acknowledged that many Indigenous groups experience worse health outcomes compared to national or regional averages, which was based in evidence. The Policy posed potential solutions such as integrating programs and promoting cross-sectoral development approaches to expand the availability of assistance that Indigenous peoples could access, which was evidence-based and responsive to need. However, the Policy did not elaborate on these approaches or explain how USAID and implementing partners should implement these programs. The Policy did not discuss SRHR issues, including HIV and AIDS programs or GBV prevention and treatment, which was lacking. This Policy applied to all USAID activities, including global HIV and AIDS programs, so the lack of discussion on how these programs and activities should be adapted to better serve Indigenous peoples was a gap in USAID's approach. The Policy was not responsive to need or based in evidence in the HIV and AIDS domain. Additionally, the Policy was gender accommodating as it acknowledged cultural norms and other factors that could impact the decision-making rights of Indigenous women but did not provide adequate guidance for overcoming or changing those norms. This Policy neither promoted nor hindered SRHR through this domain.

2020_USAID Policy on Protection from Sexual Exploitation and Abuse (PSEA)

This policy detailed USAID's operating procedures to protect individuals from sexual exploitation and abuse (SEA). This policy applied to all USAID-funded services and activities, intended to center the needs and perspectives of survivors, and employed USAID's zero-tolerance policy for inaction on allegations of SEA. The Policy acknowledged the power dynamic that drives many instances of SEA and identified the need for increased attention for vulnerable groups including “women and children, and those most at risk of discrimination on the basis of disability, gender identity and sexual orientation, race, ethnicity, age, or religion.” This level of specificity indicated an inclusive understanding of how people's identities shape their experiences of SEA. The Policy was responsive to need and grounded in human rights norms as it prioritized the safety of people that participate in USAID programs. However, it was not evidence-based because evidence indicates that there are numerous health and SRHR needs that arise as a result of SEA that were not mentioned in this policy, such as HIV acquisition. Like GBV, SEA is a cross-cutting SRHR issue and warrants an integrated response for both prevention and treatment, which was lacking in this policy. The Policy was gender accommodating as it was inclusive of all peoples' experiences though did not adequately describe how the Policy would overcome gender norms that both contribute to SEA and prevent people from receiving care for SEA. This Policy moderately hindered SRHR in the HIV and AIDS domain.

2020_USAID Protecting Life in Global Health Assistance Letter to Implementing Partners_30 October 2020

Alma Golden, Assistant Administrator of the Bureau for Global Health within USAID, sent this letter to USAID implementing partners on October 30, 2020 to reiterate the importance of complying with abortion-related statutory and policy restrictions that apply to global health awards. The letter was somewhat responsive to need as it explained the difference between statutory restrictions related to abortion and the PLGHA policy, which are often confused. The letter detailed best practices to ensure compliance with these restrictions and directed recipients to access publicly available trainings and resources to understand the applicable restrictions. The letter also mandated that all implementing partners across domains submit documented evidence of their efforts to assure the compliance of foreign NGO sub-partners with the PLGHA policy within one month of the issuance of the letter, which was an extreme burden for implementing partners. The compliance reporting requirement outlined in the letter was not necessarily responsive to need as it was unclear what prompted this action or how this information would be used to influence the future implementation of the policy. This letter moderately hindered SRHR in the HIV and AIDS domain.

2020_USAID’s Women, Peace, and Security Implementation Plan

The Women, Peace, and Security (WPS) Implementation Plan outlined USAID's efforts to support the U.S. government’s WPS Strategy through development and humanitarian assistance. The Implementation Plan expanded on the role of USAID in fulfilling the WPS Strategy's focus on women and girls' empowerment to overcome crisis, conflict, and fragility. This Plan was somewhat based in evidence and responsive to need as it identified several factors that can promote women's empowerment but did not recognize the importance of addressing individual SRHR needs as part of this Plan. The main mentions of health outcomes related to SRHR throughout this Plan were in the context of GBV, as well as “teenage pregnancies” that result from violence. However, the exclusion of other areas of SRHR, such as HIV and AIDS, disregarded the importance of these health outcomes in empowering women and accomplishing the goals of the WPS Strategy. The Plan was not fully consistent with human rights norms as it excluded LGBTQI+ people in its efforts to achieve gender equality. Additionally, the Plan was gender accommodating as it worked to empower women within existing gender norms but did not use gender inclusive language throughout the Plan, nor did it outline a strategy for changing inequitable gender norms through USAID’s programs. This Plan moderately hindered SRHR in this domain.

2019_Acting on the Call

Acting on the Call is USAID's annual flagship report for reproductive, maternal, newborn, and child health services. As in the 2018 report, the 2019 report mentioned child mortality caused by HIV and AIDS in the country-level analyses, but the inclusion of HIV and AIDS programming was not included in a standardized way across all countries. For example, the country-specific section for Tanzania mentioned the following: “Integrated voluntary family planning within existing HIV care in 5,600 facilities and care delivery points, which increased the availability of voluntary family planning by 300 percent.” This was a unique case where HIV and AIDS programming was mentioned at the country level, so more country-level data is needed to document the intersections between maternal and child health and HIV and AIDS programs across the board. There was no mention of HIV as a leading cause of maternal death, nor any emphasis on the integration of HIV testing and treatment into antenatal care (ANC) services. Prevention of mother-to-child transmission (PMTCT) services and programs for orphans and vulnerable children (OVC) were not discussed, both of which directly contribute to maternal and child health outcomes. Overall, this report was responsive to need, but was not based in evidence or human rights principles, nor was not gender transformative. It substantially hindered SRHR because it did not address HIV and AIDS as a primary cause of maternal mortality globally. The exclusion of HIV and AIDS within this report reinforced the fragmented and siloed nature of U.S. global health programs across program and budget areas.

2019_Additions to the Answers to FAQs Related to the Revised Standard Provision for Grants and Cooperative Agreements to Implement the PLGHA Policy_June 2019

These additional Frequently Asked Questions (FAQs) were released in June 2019 after the assurance by Secretary Pompeo in March 2019 that the language surrounding financial assistance in the guidance on the implementation of the Protecting Life in Global Health (PLGHA) would not change. This additional document asserted that the definition of financial assistance will remain unchanged and that organizations who sub-grant will be required to ensure their subgrantee’s compliance with the policy. Similar to the original FAQ document, there was no discussion of the impacts of this policy or its expansion on HIV and AIDS. 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. The document was not evidence-based, based in international human rights, or 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 access to HIV and AIDS services. Overall, this document provided a substantial hindrance to SRHR.

2019_ADS Chapter 212_Breastfeeding and Infant and Young Child Nutrition Promotion, Protection, and Support

This Automated Directive System (ADS) chapter was updated in its entirety for the first time since 2012 and addressed USAID’s priorities and positions related to breastfeeding and child nutrition. The update expanded the chapter’s guidance regarding infant and young child nutrition as well as incorporated new language on the donation of breastmilk in humanitarian crises. The chapter also included language regarding breastfeeding and HIV, and referenced the WHO guidance on this subject that was released in 2016. The update also included a shift away from the stigmatizing “HIV-infected” language and instead used the accepted language of “people living with HIV” (PLHIV). This document was responsive to need and based in human rights and evidence. However, the document was not gender transformative. Though it discussed the importance of policies on paid family leave or workplace breastfeeding, it did not take steps to ensure these policies were put in place (which could be achieved through the requirement for partners to report on the implementation of this guidance in their programs through mandatory performance reports). The guidance was gender blind because it ignored gender inequalities and stereotypes that could have influenced a person’s ability to adhere to this guidance, such as a pregnant person who is transgender. Overall, this chapter moderately promoted SRHR with regard to guidance for pregnant and breastfeeding women (PBFW) who are living with HIV.

2019_ADS Chapter 303_Grants and Cooperative Agreements to Non-Governmental Organizations and Standard Provisions

This chapter of the Automated Directive System (ADS) governs the grants and cooperative agreements between USAID and NGOs and included three reference documents that were updated in 2019: the ADS 303maa, 303mab, and 303mat. The ADS 303maa was the Standard Provisions that specified the expectations of U.S.-based NGOs that receive funding from USAID through grants and cooperative agreements. The ADS 303mab was the Standard Provisions for foreign NGOs, and the ADS 303mat was the Standard Provisions for fixed amount awards to NGOs. These provisions were updated in 2019 to incorporate the newly expanded Protecting Life in Global Health (PLGHA) policy, including additional guidance regarding the consequences of violation of the PLGHA policy and a new requirement for prime partners to ensure compliance with PLGHA among all sub-partners, regardless of donor. With regard to violations of the policy, the updated ADS allowed for USAID to determine “consistent with 2 CFR 200.338, that other corrective action is warranted” while the previous version only listed termination of the USAID award and repayment of funds as a consequence of a PLGHA violation. Given that USAID was required to implement the PLGHA policy, the agency was only graded for their implementation of the policy and not for the existence of the policy. All of the ADS 303 updates were responsive to need, as it was clear that USAID attempted to address some of the confusion surrounding the policy, particularly amongst grantees and sub-grantees. However, this chapter of the ADS was still not based in evidence nor human rights and was not gender transformative, so therefore may or may not have impacted USAID’s ability to implement HIV and AIDS programs that promoted SRHR.

2019_ADS Chapter 308_Agreements with Public International Organizations and Standard Provisions

This chapter of the Automated Directive System (ADS) governed the agreements between USAID and Public International Organizations (PIOs) (such as UNAIDS, UNICEF, WHO, etc.) and included one reference document that was updated in 2018 and 2019: the ADS 308mab. The ADS 308mab was the Standard Provisions for Cost-Type Agreements with Public International Organizations and specified the mandatory policies and guidelines that must be followed by PIOs who receive funding from USAID. The provisions were updated in August 2018 to require abortion-related restrictions to be included in all health awards. In previous iterations of the ADS 308mab, these restrictions were only required to be included in awards that funded family planning activities. As such, the 2018 update of the ADS 308mab constituted an expansion of the implementation of pre-existing statutory requirements regarding abortion and involuntary sterilization. This updated language expanded the PIO programs to which these pre-existing statutory requirements apply. The 2018 update also added a new requirement that the PIO that received U.S. funds “must insert this provision in all subsequent subawards and contracts” whereas this was not required in prior versions of the ADS 308mab. The 2018 updates to the ADS 308mab substantially hindered SRHR. The updates released in November 2019 were not related to SRHR. The references to voluntarism and the prohibition of involuntary sterilization in this chapter were based in evidence and human rights, however the expansion of the implementation of abortion restrictions and the expansion of these restrictions to all health awards was not based in evidence or human rights, was not responsive to need, nor was gender transformative. Note: The 308mab was updated in August 2018 but CHANGE has been unable to confirm that this version was ever uploaded onto USAID’s website as required by law. Instead, the 2014 version of the document was replaced in 2019 with the 2019 version of the document with the 2018 edits included but not highlighted as new. For this reason, USAID was significantly docked in the transparency grade, as this lack of transparency by USAID hindered the ability of grantees, sub-grantees, partners and civil society to access and respond to the ADS accordingly.

2019_Agency Financial Report_Fiscal Year 2019

This document was in response to congressionally mandated reporting on the spending of USAID. The report highlighted HIV and AIDS programming within the context of reducing child transmission and included a testimony of a woman living with HIV in Tanzania to demonstrate the importance of USAID’s programming. However, the report did not discuss HIV and AIDS in a meaningful way. This report was responsive to need, as expressed by Congress, and based in evidence however there was no mention of human rights principles or gender norms. Overall, this document neither harmed nor promoted SRHR.

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 concerns from the 2018 Department of State’s Six Month Review. The text of this document was similar to the 2018 FAQ document, though also 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 prevention and treatment. 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 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 via 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). As a result, this plan was responsive to need and based in evidence and human rights. The APGs were not gender transformative as gender norms were not discussed. Overall, the APGs moderately promoted 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. 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 discussed the joint efforts by the Department of State and USAID to achieve HIV and AIDS epidemic control within the third goal. However, there is very little discussion of the data that was used to inform 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. This document was responsive to need but was not evidence based, based in human rights nor gender transformative. The Plan 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.

2019_USAID Policy Framework: Ending the Need for Foreign Assistance

This document discussed USAID's new policy framework to achieve self-reliance through a three-step approach. The document was general and did not discuss any particular aspect of assistance, such as HIV and AIDS. There was one mention of HIV and AIDS as a foreign assistance success, but it was without a discussion of President's Emergency Plan For AIDS Relief (PEPFAR) as the main mechanism by which USAID has carried out these programs. This policy was responsive to need in that it reflected conversations about democratizing foreign assistance and creating more sustainable systems, however the framework did not mention the evidence or international human rights norms that should be the foundation of such programs. This policy framework was also not gender transformative, as it contained very little about the role of gender in a country's "Journey to Self-Reliance." USAID’s Policy Framework moderately hindered the ability of USAID to support HIV and AIDS programs that promote SRHR.

2018_Acting on the Call

Acting on the Call is USAID's annual flagship report for reproductive, maternal, newborn, and child health services. Within the 2018 report, HIV and AIDS was discussed strictly in the context of child mortality despite the fact that HIV is a leading contributor of maternal mortality worldwide. Evidence suggests that HIV and AIDS are key factors in maternal mortality and wellness and in child health through the prevention of maternal to child transmission (PMTCT). By leaving out HIV and AIDS data herein, the framework of this report reinforced the silos between maternal and child health, family planning, and HIV and AIDS programming that challenged USAID's ability to support integrated SRHR programs in 2018.

2018_Acquisition and Assistance Strategy

As USAID’s first-ever Acquisition and Assistance (A&A) Strategy, this guidance document increased the accountability and transparency of USAID's procurement, partnering, and project management processes across the Agency. The goal of this Strategy was to streamline "approaches to design and procurement" and develop "new and innovative methods of collaboration" to advance USAID's Journey to Self-Reliance mandate. The Strategy was responsive to need and evidence-based because it cited the current make-up of USAID foreign assistance funding recipients and set specific goals to diversify this partner base. Many of the strategies and shifts put forward in the report incorporated feedback received from smaller and/or local partners. The Strategy also demonstrated a commitment to human rights norms, specifically to the right of self determination, by actively incorporating local partners in the design, procurement, and implementation of USAID's programming. Though the Strategy referenced the importance of "diverse" partners, it did not define who these partners were except for a specific mention of faith-based organizations. Women's rights and human rights groups should also be explicitly mentioned as underutilized partners because of their important role in advancing SRHR for all populations. This Strategy indicated a meaningful effort by USAID to ensure that local partners and recipient countries are included and supported throughout the Journey to Self-Reliance. However, this effort by USAID seemed to be in direct conflict with the Trump Administration's strategy of decreasing appropriated funds as a means to ‘motivate’ self-reliance and haphazardly decrease U.S. involvement in foreign assistance. It is unclear in this Strategy how USAID aims to reconcile this conflict.

2018_ADS Chapter 312sae_Condoms and Pharmaceuticals

The Automated Directives System (ADS) contains the operational policies that guide USAID's programs and operations. The Condoms and Pharmaceuticals ADS Help Document is an addendum to ADS Chapter 312 that was revised in 2018 to guide the procurement of condoms and pharmaceuticals by USAID’s Bureau for Global Health. The updated directive required that the procurement of all condoms (internal and external) be managed by the Office of HIV/AIDS. While this directive was detailed and informative and included the procurement of female (internal) condoms, it is unclear what prompted this update. As a result, it was challenging to gauge whether the guidance was responsive to need, evidence-based, human rights-based, or gender transformative. It was also unclear how the consolidation of procurement of all condoms under the Office of HIV/AIDS will impact USAID's HIV and AIDS programming and, therefore, SRHR overall, given that condoms are an important intervention in both family planning and maternal and child health.

2018_Protecting Life in Global Health Assistance FAQs_August 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 USAID's ability to implement comprehensive HIV and AIDS programs that were evidence-informed, responsive to need, consistent with internationally-recognized human rights principles, and gender transformative.

2018_State and USAID Agency Priority Goal Action Plan_HIV/AIDS

The Agency Priority Goals (APGs) for HIV and AIDS hold the President’s Emergency Plan for Aids Relief (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. However, the APGs did not explain the role of USAID, specifically, in HIV and AIDS programming and only discussed PEPFAR-level successes and challenges. As a result, the APGs did not hinder or promote USAID's ability to support comprehensive HIV and AIDS programs, so the APGs did not increase or decrease USAID's score in this domain in 2018.

2016_USAID Adolescent Girl Strategy Implementation Plan

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

2014_Acquisition and Assistance Policy Directive (AAPD)

2013_Counter-trafficking in Persons Field Guide

2012_Ending Child Marriage and Meeting the Needs of Married Children: The USAID Vision for Action

2012_Gender Equality and Female Empowerment Policy: USAID Policy

2012_United States Strategy to Prevent and Respond to Gender-based Violence Globally

2012_USAID Implementation of the United States National Action Plan on Women, Peace, and Security

D-

C-

Department of Health and Human Services

HHS received a 62 (D-) with transparency and a 71 (C-) without transparency in the HIV and AIDS domain in 2021. This domain grade was raised by the action: “CDC Virtual Training Prepares Mentors and Peer Educators to Respond to Disclosures of Violence” because it was based in evidence, consistent with human rights, and responsive to need. Several of the Additional Requirements (ARs) and the General Terms and Conditions for Research and Non-Research neither promoted nor hindered sexual and reproductive health and rights (SRHR) because it was unclear whether these actions were relevant to the HHS’ global HIV and AIDS programs. AR 35 noted that the PLGHA policy had been revoked, but did not provide additional guidance or directives for implementing partners to adapt their programs to align with the policy change, which moderately hindered SRHR. Funding data for global HIV and AIDS efforts implemented by HHS were not publicly available at the time of grading, which contributed to the low transparency grade in the HIV and AIDS domain in 2021

The CHANGE 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_CDC Additional Requirement – 1: Human Subjects Requirements

AR 1 outlined the regulations that institutions must follow if they engage in projects involving research with human subjects. AR 1 applied to all CDC projects that conducted human subjects research and provided guidance for institutions to obtain the necessary approvals as well as included hyperlinks to the specific Code of Federal Regulations (CFR) sections that protect human research subjects. AR 1 was consistent with human rights, based in evidence, and responsive to need. Requiring the protection of human subjects helped to ensure that the rights of people enrolled in global research projects related to HIV and AIDS were protected. Specific protections for human subjects across genders were not included in AR 1, nor did it include considerations for other protected classes or specific populations that may warrant extra protections as human subjects. This action moderately promoted SRHR in the HIV and AIDS domain.

2021_CDC Additional Requirement – 2: Requirements for Inclusion of Women and Racial and Ethnic Minorities in Research

AR 2 outlined the requirements for CDC-supported research projects that involved human subjects and the inclusion of "individuals of both sexes and the various racial and ethnic groups" whenever feasible and appropriate. AR 2 referred to the Federal Register to provide additional guidance on the application of this requirement. AR 2 was responsive to need and based in evidence because it promoted the ethical inclusion of women and racial and ethnic minorities in research. However, it was gender exploitative as it reinforced a sex and gender binary and did not acknowledge other identities that may be underrepresented in human subjects research. To more fully promote inclusivity, AR 2 should have been more inclusive of people of diverse sexual orientation, gender identity or expression or sex characteristics (SOGIESC) in human subjects research. Nevertheless, the inclusion of underrepresented groups across racial and ethnic minorities is important for research as it applies to global health programs, including HIV and AIDS programs funded by the President’s Emergency Plan for AIDS Relief (PEPFAR). AR 2 moderately promoted SRHR in the HIV and AIDS domain.

2021_CDC Additional Requirement – 4: HIV/AIDS Confidentiality Provisions

AR 4 outlined requirements for the protection of personal data collected through HIV and AIDS surveillance activities across all CDC projects. The requirements promoted the confidentiality and security provisions of HIV and AIDS surveillance data, which was based in evidence, consistent with human rights norms, and responsive to need. However, it was unclear if the requirements applied to domestic programs only or if they also applied to global health programs like PEPFAR, which did not promote transparency . This action neither hindered nor promoted SRHR in the HIV and AIDS domain.

2021_CDC Additional Requirement – 5: HIV Program Review Panel Requirements

AR 5 provided the requirements for creating and selecting members of a program review panel for HIV and AIDS research, projects, and other activities. AR 5 required that projects that included funding for a conference must receive approval for all conference materials from the panel. This action did not promote transparency as it was unclear what the intended purpose and responsibilities of the program review panel were nor was it clear if this requirement applied to global health programs, including global HIV and AIDS programs funded through PEPFAR. This action neither hindered nor promoted SRHR in the HIV and AIDS domain.

2021_CDC Additional Requirement – 6: Patient Care

AR 6 stated that all “STD or HIV infected patients” participating in CDC-funded projects were to be linked to a local care system to provide medical care, counseling, social services, and therapy. This guidance was based in evidence and human rights and was responsive to need. However, the use of outdated language such as “HIV infected patients” was stigmatizing and did not reflect current best practices. While AR 6 provided necessary guidance, it did not provide any external references for additional guidance or protocols to guide the implementation of relevant programs. Overall, AR 6 moderately promoted SRHR in the HIV and AIDS domain.

2021_CDC Additional Requirement – 25: Data Management and Access

AR 25 outlined the requirements for project recipients that conduct data collection with federal funds to develop, submit, and comply with a Data Management Plan (DMP) for the collection and generation of public health data. It provided detail on inclusion and exclusion criteria for the DMP and explained which projects were required to submit a DMP. AR 25 was based in evidence and responsive to need as the availability of public health data could promote innovation and advance global health priorities, including those related to HIV and AIDS. It promoted transparency by minimizing the possibility for data to be misrepresented. AR 25 moderately promoted SRHR in the HIV and AIDS domain.

2021_CDC Additional Requirement – 28: Inclusion of Persons Under the Age of 21 in Research

AR 28 provided clear guidelines and expectations for the inclusion of persons under 21 in all CDC-funded research, including global health research. AR 28 stated that if a project intentionally does not involve persons under 21, they must provide a particular reason or justification for this exclusion. AR 28 was based in evidence and best practices and was aligned with human rights norms because it emphasized the inclusion of young people in research, which would include research related to SRHR. AR 28 moderately promoted SRHR in the HIV and AIDS domain.

2021_CDC Additional Requirement – 35: Protecting Life in Global Health Assistance is waived, effective January 28, 2021

AR 35 announced the revocation of Protecting Life in Global Health Assistance (PLGHA), also known as the Global Gag Rule (GGR). Though announcing the removal of this policy was responsive to need, AR 35 did not provide additional guidance or directives for implementing partners that were impacted by the policy to adapt their programs to align with the policy change. Through AR 35, HHS and CDC could have released information that addressed questions from implementing partners and other stakeholders impacted by the policy as it applied to CDC grants, but this was not done. Additionally, it was unclear when AR 35 was updated to reflect the revocation of PLGHA, which did not promote transparency . AR 35 moderately hindered SRHR in the HIV and AIDS domain.

2021_CDC Additional Requirement – 36: Certificates of Confidentiality

AR 36 provided guidance on issuing Certificates of Confidentiality to participants engaged in biomedical, behavioral, clinical, or other research activities that contain identifiable information, as required by the Public Health Service Act. AR 36 defined which kinds of information collected through research were considered sensitive, the responsibilities of data collection teams to protect these types of data, and how to use the collected data responsibly. AR 36 was based in evidence and human rights norms and was responsive to need because it provided necessary protections for sensitive data collected through CDC research, including global health research. However, AR 36 did not explicitly mention SRHR, so the benefits for SRHR research may have only been indirect. AR 36 neither promoted nor hindered SRHR in the HIV and AIDS domain.

2021_CDC Additional Requirement – 37: Prohibition on certain telecommunications and video surveillance services or equipment for all awards issued on or after August 13, 2020

AR 37 provided information about the prohibition of the use of federal grant or cooperative agreement funds from HHS to procure or obtain telecommunication and video surveillance services or equipment from specific companies. This telecommunications prohibition mirrors that which can be found in the August 2021 version of the HHS General Terms and Conditions for Research and Non-Research Grants and Cooperative Agreements. AR 37 included relevant references to the CFR and provided recommendations for how recipients should implement AR 37 and maintain compliance with these restrictions throughout the course of their agreement. AR 37 included an exemption for PEPFAR funding until 2022, though it stated that “PEPFAR recipients are expected to work toward implementation” of this federal regulation. This exemption may provide greater flexibility for PEPFAR recipients but would likely have little effect on HHS’s ability to promote SRHR through its global HIV and AIDS efforts. This action neither promoted nor hindered SRHR in the HIV and AIDS domain.

2021_CDC Global Health Strategy 2019-2021

The Executive Summary of the CDC Global Health Strategy for 2019 through 2021 was updated in January 2021 to include the CDC’s response to the COVID-19 pandemic and emerging threats to global health. The rest of the Strategy was unchanged, so only the Executive Summary was graded in 2021. The updated Executive Summary mentioned that COVID-19 has had “far-reaching social and economic impacts, including disruption of essential healthcare services” and the upending of global health programs, including those that provided HIV and AIDS services. It also highlighted the importance of supporting diverse partnerships and collaboration across sectors. This updated content was based in evidence and responsive to need, though it was gender blind because there was no mention of the pandemic’s disproportionate impact on women, girls, gender-diverse people, or people living with HIV (PLHIV), specifically. The exclusion of SRHR and gender in the Executive Summary contributed to the silos that isolate SRHR from other global health issues, which was not based in human rights or evidence. Given the high-level nature of this action, however, it would likely have very little effect on the CDC’s ability to promote SRHR through its global health programs. This action neither promoted nor hindered SRHR in the HIV and AIDS domain.

2021_CDC Strategy for Global Response to COVID-19 2020-2023

This Strategy defined the CDC’s programmatic priorities and outlined the criteria for monitoring and evaluating the CDC’s health security efforts both domestically and internationally in the context of COVID-19. This action included high-level goals to guide the CDC’s immediate response to COVID-19 and prepare for future health threats. The principles and objectives outlined in the Strategy were generally based in evidence and responsive to need (e.g., the principle of leveraging existing global health programs and investments as a part of outbreak response). It mentioned the importance of coordinating pandemic response activities with the provision of essential health services, including HIV/tuberculosis (TB) programs, which was responsive to need, based in evidence, and aligned with human rights. However, it did not define the pandemic’s disproportionate impacts on specific populations beyond labeling them as “vulnerable,” so this action was not fully based in evidence and was gender blind. This action moderately promoted SRHR in the HIV and AIDS domain.

2021_CDC Virtual Training Prepares Mentors and Peer Educators to Respond to Disclosures of Violence

This CDC Success Story reported on a virtual training program to prevent and respond to gender-based violence (GBV) through PEPFAR’s DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) programs. The CDC adapted the Listen, Inquire, Validate, Enhance safety, and Support (LIVES) training created by the World Health Organization’s (WHO) into the CDC’s Listen, Ongoing connection, Validate, Encourage safety, and Support (LOVES) Virtual Training Program, which was based in evidence and consistent with human rights. The slight adjustments between the two trainings were made to acknowledge potential safety concerns of the mentors as well as the adolescent girls and young women (AGYW) as well as consider what was reasonably within a mentor’s control, which was responsive to need. The LOVES Virtual Training Program trained mentors to immediately respond with empathy to disclosures of violence among AGYW, which was responsive to need and based in evidence and human rights. The LOVES training package includes pre-recorded training materials and videos, as well as three live interactive virtual sessions, which was responsive to need because mentors could complete the training virtually during the COVID-19 pandemic. The action lacked detail on the level to which this training had been introduced across DREAMS sites and did not include the outcomes of the training. DREAMS includes gender transformative components and this training supported immediate responses to disclosures of GBV and challenged gender norms that enable violence. This action moderately promoted SRHR in the HIV and AIDS domain.

2021_CDC’s Center for Global Health Responds to Outbreaks

This action highlighted the ways in which the CDC’s Center for Global Health has leveraged existing capacities to address COVID-19 and described how programs have adapted to the pandemic to continue addressing ongoing global health threats. This action discussed the general importance of leveraging PEPFAR programs in outbreak response and outlined how the CDC has adapted global HIV and AIDS programs to continue to provide health services during COVID-19. The action listed innovations that the CDC had instituted during the COVID-19 pandemic, such as differentiated service delivery models, multi-month dispensing (MMD) of antiretroviral therapy (ART), and community-based service delivery options. These innovations were based in evidence, consistent with human rights, and responsive to need. However, this action did not mention the impact of the pandemic on key and priority populations such as men who have sex with men (MSM), sex workers, AGYW, or pregnant and breastfeeding persons, nor did it explore how these innovations would meet their needs related to HIV prevention, care, and treatment during the pandemic. Thus, it was gender blind and not fully responsive to need. This action moderately promoted SRHR in the HIV and AIDS domain.

2021_General Terms and Conditions for Non-Research Grant and Cooperative Agreements

The General Terms and Conditions list the federal regulations and policies, funding restrictions and limitations, and reporting requirements that apply to HHS non-research grants and cooperative agreements. The updated version from August 2021 included guidance for regular financial and performance reporting, requirements for a data management plan, audit requirements, key personnel guidelines, guidance for acknowledgement of federal funding, and CDC staff responsibilities for award management. The General Terms and Conditions did not include specific technical guidance related to evidence or human rights. However, this action was responsive to need because it provided guidance for how awards should be managed. Though this action was revised in August 2021, there was no indication of which information had been changed from the previous version, and prior versions were not available on the website for comparison, which did not promote transparency and was not responsive to need. This action neither promoted nor hindered the ability of HHS to support SRHR through non-research awards related to HIV and AIDS.

2021_General Terms and Conditions for Research Grant and Cooperative Agreements_Revised August 2021

The General Terms and Conditions list the federal regulations and policies, funding restrictions and limitations, and reporting requirements that apply to HHS research grants and cooperative agreements. The updated version from August 2021 included guidance for regular financial and performance reporting, requirements for a data management plan, audit requirements, key personnel guidelines, guidance for acknowledgement of federal funding, and CDC staff responsibilities for award management. The General Terms and Conditions provided technical guidance for research awards, including a definition of human subjects and confidentiality requirements, which were consistent with human rights norms and research ethics. This action was responsive to need because it provided guidance for how awards should be managed, but there was no indication of which information had been changed from the previous version, and prior versions were not available on the website for comparison, which did not promote transparency and was not responsive to need. This action neither hindered nor 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 fiscal year (FY) 2020, including efforts completed by HHS and CDC. 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 mentioned HIV in the context of the CDC's Division of Global Health Protection Field Epidemiology Training Program (FETP) as one of the issues addressed by the FETP. However, the Report did not include details to indicate why HIV and AIDS efforts were included in this intervention or explain the outcomes of this programming. Though the Report focused on global health security, SRHR and other cross-cutting issues such as gender and GBV were not mentioned. This was not based in evidence as the inclusion of SRHR and gender equity promotes global health security. This exclusion was also 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 action made one mention of gender in the context of OneHealth, and was therefore gender blind. This action moderately hindered SRHR in the HIV and AIDS 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, including the HHS’s HIV and AIDS programs funded through PEPFAR. 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 because of the ECHO Trial findings. Though the WHO released its revised guidance in August 2019 shortly after the ECHO Trial results were published, PEPFAR implementing agencies, including HHS and the CDC, 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. 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 was not gender transformative because it used the outdated “male and female” terminology instead of the gender inclusive “internal and external” terminology. This Technical Update substantially promoted SRHR in the HIV and AIDS domain.

2020_General Terms and Conditions for Non-Research Grants and Cooperative Agreements

The General Terms and Conditions list the federal regulations and policies, funding restrictions and limitations, and reporting requirements that apply to HHS non-research grants and cooperative agreements. The version that was updated in December 2020 included information about regular financial and performance reporting, requirements for a data management plan, audit requirements, key personnel guidelines, acknowledgement of federal funding, and CDC staff responsibilities for award management. The General Terms and Conditions did not include specific technical guidance related to evidence or human rights. However, it was responsive to need because it provided guidance about how awards should be managed. This action included the same prohibition of the purchase of certain telecommunications and video surveillance services or equipment as was included in the United States Agency for International Development (USAID) Automated Directive System (ADS) Chapter 303. It also mentioned an exemption for PEPFAR funding until 2022, which was not included in ADS Chapter 303. This exemption likely had little effect on the ability of HHS to promote SRHR through its global HIV and AIDS efforts. Though this action was revised in December 2020, there was no indication of which information had been changed from the prior version, and prior versions are not available on the website for comparison, which contributed to very low transparency. This action neither hindered nor promoted SRHR in the HIV and AIDS domain.

2020_General Terms and Conditions for Research Grants and Cooperative Agreements

The General Terms and Conditions list the federal regulations and policies, funding restrictions and limitations, and reporting requirements that apply to HHS research grants and cooperative agreements. The version that was updated in December 2020 included information about regular financial and performance reporting, requirements for a data management plan, audit requirements, key personnel guidelines, acknowledgement of federal funding, and CDC staff responsibilities for award management. The General Terms and Conditions provided technical guidance for research awards, including a definition of human subjects and confidentiality requirements, which were consistent with human rights norms and research ethics. This action included the same prohibition of the purchase of certain telecommunications and video surveillance services or equipment as was included in USAID’s ADS Chapter 303. It also mentioned an exemption for PEPFAR funding until 2022, which was not included in ADS Chapter 303. This exemption likely had little effect on the ability of HHS to promote SRHR through its global HIV and AIDS efforts. Though this action was revised in December 2020, there was no indication of which information had been changed from the prior version, and prior versions are not available on the website for comparison, which contributed to very low transparency. This action neither hindered nor promoted the ability of HHS to support 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 HHS signing onto this Declaration substantially hindered the ability of HHS to promote SRHR in the HIV and AIDS domain.

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

This report discussed the U.S. government's 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 accessing 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 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 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, in collaboration with other U.S. implementing agencies including HHS and CDC released the Strengthening Health Security Across the Globe annual report that identified the 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, HIV and AIDS were noticeably absent. 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. It was unclear if HHS was engaged in this work given that the CDC supports laboratory infrastructure in PEPFAR countries, so this contributed to low transparency. 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 in one district in one country, it minimized the value of the CDC’s HIV prevention and treatment efforts in promoting health security given the vast amount of clinical and laboratory infrastructure worldwide that are supported through U.S. global health assistance funds managed by HHS. Further, there was no mention of other areas of SRHR that impact health security such as FP, maternal and child health (MCH), and gender-based violence (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 countering harmful norms that affect women, girls, and gender diverse people. This report moderately hindered SRHR through the HIV and AIDS domain.

2020_Violence Against Children and Youth Survey Country Process

The Violence Against Children and Youth Survey (VACS) Country Process action laid out the strategy for engaging countries in this process. The guidance included considerations for programmatic response, ethical standards, process sustainability, survey support, partner support, and in-country capacity. There were very few mentions of SRHR-related topics, and no consideration of the HIV and AIDS service needs of participants or detail regarding how survey participants would be referred to relevant health services if they reported experiencing violence while being surveyed. However, this guidance was evidence-based and consistent with human rights because it cited the recommendations from the World Health Organization (WHO) on ethics and safety regarding patients' rights as guiding principles in developing these surveys. This action also noted the importance of connecting findings from the VACS with evidence-based and evidence-informed policies and programs to prevent and respond to violence to form the basis for a National Action Plan, which is a distinct opportunity to decrease violence and promote SRHR at the country level. This action stated that participants in these surveys should be offered services that included free programs, services, and amenities based on their country's response plan, which was responsive to need and grounded in human rights. The guidance was not gender transformative as it instructed interviewers to only engage with participants of the same sex, which overlooked the experiences of participants who experienced violence from people of the same sex. There were also no discussions of gender norms or other policies that might impact people's experiences of violence, which was gender blind. This Country Process action moderately promoted SRHR in the HIV and AIDS domain.

2019_CDC Global Health Strategy_2019-2021

The CDC Global Health Strategy, 2019-2021 presented data to document the CDC’s progress to date with regard to HIV and AIDS activities. It provided evidence to support continued investment in CDC’s programs across the spectrum of HIV and AIDS prevention, care, and treatment through the President’s Emergency Plan for AIDS Relief (PEPFAR). This Strategy was based on programmatic and global evidence but did not include an international human rights component. The Strategy also did not include a gender transformative approach to the CDC’s HIV and AIDS programs. In fact, the word "gender" was not mentioned in the entire document, despite gender being a vital factor in HIV and AIDS programming. However, the Strategy advocated for the continued support of evidence-based HIV and AIDS programs carried out by the CDC and therefore moderately promoted SRHR.

2019_Joint Statement on the Nairobi Summit on the ICPD25

This Statement by the U.S. Secretary of Health and Human Services Alex Azar only affirmed the specific elements of the International Conference on Population and Development (ICPD) Programme of Action that aligned with the Trump Administration’s ideology. It asserted that any outcomes of the Nairobi Summit—including any discussions or decisions related to SRHR—were not to be considered reflective of Member State consensus. Though this Statement might not immediately impact the implementation of global health programs related to SRHR, including HIV and AIDS efforts, it reflects the U.S. government’s stance on SRHR generally and amplifies and emboldens anti-SRHR ideals globally. This Statement operated within traditional gender norms and was based on ideology, not evidence or international human rights norms. Furthermore, the Statement conflicts with comprehensive sexuality education "that fails to adequately engage parents" and mentioned the importance of "giving young people the skills to avoid sexual risk" which suggested support for abstinence-only programs. The language did not promote autonomy and agency of all people to engage in sexual experiences free of shame, coercion, and violence and substantially hindered SRHR.

2019_Joint Statement_Item 12.8: Global Strategy for Womens, Childrens, Adolescents Health (2016-2030)

This Statement denounced "ambiguous" terms such as "the right to sexual and reproductive health (and its derivatives)" at a World Health Assembly meeting to discuss the WHO Global Strategy for Women’s, Children’s, and Adolescents’ Health. This Statement highlighted the role of the family over the rights of the individual and omitted inclusive language regarding gender or the specific health needs of key populations. This Statement did not mention HIV and AIDS as a health issue that is relevant for women, adolescents, and children. This Statement was not based in evidence or international human rights norms and substantially hindered SRHR.

2019_U.S. Commitment Statement to the Nairobi Summit on ICPD25

This Commitment Statement undermined international human rights norms related to SRHR and their supporting processes, including the U.S. government’s own commitments under the International Conference on Population and Development Programme of Action. This Commitment Statement sought to excuse the U.S. government from its commitments to comprehensive SRHR included in the ICPD Programme of Action under the guise of protecting "the inherent value of every human life -- both born and unborn" and the role of "caring fathers" and faith-based organizations (FBOs) in supporting women and girls access to healthcare. This Statement included an account of some relevant U.S. global health or development initiatives that contributed to ICPD, including the HIV and AIDS programming administered by PEPFAR. This statement moderately hindered SRHR because it was not based in evidence or international human rights norms and was not gender transformative.

2019_U.S. Government Statement at the U.N. High Level Meeting on Universal Health Coverage

This Statement emphasized the U.S. government’s commitment to universal health coverage (UHC) but condemned the inclusion of SRHR language and sexual education that "diminishes the protective role of the family in improving health." This Statement also rejected that there is an international right to abortion. Though language included was possibly more immediately related to domestic U.S. health policy, it directly translates to the ideology being used to shape U.S. global health assistance through the Protecting Life in Global Health Assistance (PLGHA) policy and other mechanisms. This Statement substantially hindered SRHR because it did not discuss HIV and AIDS as a vital health issue, was not based in evidence or international human rights norms, and was not gender transformative.

2018_HHS Strategic Plan_Strategic Goal 2: Protect the Health of Americans Where They Live, Learn, Work, and Play

The HHS Strategic Plan provides an overview of the Agency's domestic and global strategy that is based on evidence and human rights norms. Strategic Objective 2.2 within the Strategic Plan states that the Centers for Disease Control and Prevention (CDC) will implement HIV programs "including prevention, testing, treatment, and retention interventions, provide technical assistance, and conduct research in support of PEPFAR." The Strategic Plan did not include any other specific information, so was determined to have little effect on the ability of HHS to implement HIV and AIDS programs that are evidence-based, responsive to need, consistent with internationally-recognized human rights principles, and gender transformative .

2018_Protecting Life in Global Health Assistance FAQs_August 2018

The Protecting Life in Global Health Assistance (PLGHA) FAQs provided detailed guidance on the implementation of the expanded Global Gag Rule for implementing partners as of September 2018. HHS was graded based on the "HHS Specific Information" section on page 17 that outlined how HHS administered grants according to the Code of Federal Regulations (CFR). The information offered in this section did not have an effect on the ability of HHS to implement HIV and AIDS programs that were evidence-based, responsive to need, consistent with internationally-recognized human rights principles, and gender transformative .

Department of Defense

DoD received a 65 (D) with transparency and a 74 (C) without transparency in the HIV and AIDS domain in 2021. Both graded actions lacked specific information about the contributions of the DoD’s global HIV and AIDS programs to global health security efforts and the implementation of the Women, Peace, and Security (WPS) Agenda. The lack of detail in the actions along with the unavailability of budget information contributed to the low transparency score for both actions and budgetary data in the HIV and AIDS domain in 2021.

The CHANGE 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_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 U.S. government’s investments in global health security during fiscal year 2020, including efforts led by DoD. 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 include any information about the DoD’s efforts to promote global health security through programs or activities funded through global health assistance, which was not responsive to need and negatively affected transparency . Though the Report focused on global health security, SRHR and other cross-cutting issues such as gender-based violence (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 also 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. This action 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 U.S. government 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. The Report emphasized the importance of evidence-based implementation and decision-making, which was rooted in evidence and best practices. The Report included specific and actionable milestones to measure each agency’s progress toward the WPS Strategy Lines of Effort, which was responsive to need. While improved health outcomes were included as a positive impact of implementing the WPS Agenda across agencies, HIV and AIDS and the needs of people living with HIV (PLHIV) were not meaningfully included in relation to DoD activities. The Report stated that the DoD hired gender advisors and developed networks of gender focus point staff to coordinate the implementation of WPS activities across the Department, which was responsive to need. However, this action did not outline any other steps that the DoD undertook to support WPS efforts through programs funded by global health assistance. These actions reinforced a gender binary by only referring to “women,” which was gender accommodating. The Report neither hindered nor promoted SRHR in the HIV and AIDS domain.

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

This report discussed the U.S. government's 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 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_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, in collaboration with other U.S. implementing agencies including DoD, released the Strengthening Health Security Across the Globe annual report that identified the 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, HIV and AIDS was noticeably absent. There was no mention of the role played by DoD in implementing global HIV and AIDS programs related to global health security in partnership with foreign militaries. 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 exclusion of SRHR throughout the report contributed to the increased development of siloes that exclude SRHR from other areas of global health. 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. This Report moderately hindered SRHR through the HIV and AIDS 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 (like DoD) to create impactful and sustainable programs in fragile settings. While the Strategy was responsive to need, it did not adequately address 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, voluntary FP, and other cross-cutting SRHR issues are vital to promoting stability and security. Notably, it did not include gender-based violence (GBV), which is often a greater risk to women, girls, and gender-diverse people in fragile settings and conflict areas, particularly settings where foreign militaries might be engaged. 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 Women, Peace, and Security (WPS) Strategy. This action moderately hindered SRHR in the HIV and AIDS domain.

2018_Department of Defense Directive_DoD HIV/AIDS Prevention Program to Support Foreign Militaries

This directive discussed the DoD HIV and AIDS Prevention Program and its efforts to protect foreign armed forces from the threat of HIV and AIDS. The program provided funding for the development of programs and interventions to protect foreign nation armed forces from HIV and AIDS. This directive was originally written in 2013 and was revised in 2018 to extend it indefinitely. By doing so, this directive allows the DoD to continue minimizing the threat of HIV and AIDS among the U.S. and foreign militaries. This directive was responsive to need, evidence-based, and human rights based; however, it did not discuss gender norms which are particularly relevant in the armed forces.

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