32813 Africa Region Human Development Working Paper Series Integration of Gender Issues in Selected HIV/AIDS Projects in the Africa Region A baseline Assesment Daniela P. Ligiéro Kees Kostermans PREM Gender and Development Anchor & Africa Region The World Bank Washington, D.C. © Mars 2004 PREM Gender and Development Anchor & Africa Region The World Bank The views expressed herein are those of the authors and do not necessarily reflect the opinions or policies of the World Bank or any of its affiliated organizations Cover design by Word Express Interior design by Word Design, Inc. Cover photo: Kees Kostermans ii Table of Contents Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v Abbreviations and Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 1 Introductiont . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 HIV/AIDS in the Africa Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 Gender and HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 Vulnerable and At-Risk Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 Poverty, Gender, and HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 2 Integration of Gender Issues in HIV/AIDS Projects . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Cape Verde . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 The Gambia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Guinea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Senegal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 Sierra Leone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 3 Findings and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 Main Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 Remaining Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 Recommendations and Next Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 Annex: Potendial Entry Points for Gender Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33 iii Foreword H IV/AIDS continues to spread in Sub- The rationale behind this report is that by Saharan Africa, progressively devas- increasing gender-sensitivity, World Bank proj- tating many parts of the continent and ects will be able to combat the spread of reversing decades of hard-won social HIV/AIDS more effectively and sustainably. progress. AIDS is now the leading cause of This report documents existing how gender death in the region and, since the epidemic issues are addressed in HIV/AIDS projects in began, it is estimated that more than 20 million Cape Verde, The Gambia, Guinea, Senegal and Africans have died of AIDS. In fact, no region Sierra Leone. It recommends actions to further in the world has experienced the damaging integrate gender issues in these and future proj- effects of HIV/AIDS like Sub-Saharan Africa, ects. The report finds that while the HIV/AIDS where there are over 29 million currently projects reviewed have incorporated gender infected. issues in their design, there is, however, room Understanding and addressing the social, for improvement. Additional attention to gen- gender and economic factors that influence the der issues at the implementation and supervi- spread of the virus is central to any effective sion phases, and throughout monitoring and intervention to fight HIV/AIDS. Empirical evi- evaluation, will increase the effectiveness and dence on the connections between gender and sustainability of Bank HIV/AIDS interventions. HIV/AIDS has grown significantly in the last This report is the result of a collaboration few years. The World Bank's Policy Research between the Africa Region Human Develop- Report on Gender, Engendering Development ment 2 Unit (AFTH2) and the PREM Gender Through Gender Equality in Rights, Resources and Development Anchor (PRMGE). It was and Voice (World Bank, 2001) shows that the prepared by Daniela Ligiéro under the supervi- more unequal the gender system of a country, sion of A. Waafas Ofosu-Amaah (PRMGE). the higher its HIV prevalence rate. Additional- Task manager was Kees Kostermans (AFTH2). ly, the fastest growing infected group in Sub- Several World Bank staff members provided Saharan Africa is women. Incorporating a gen- substantive inputs, advice and comments dur- der-sensitive approach is therefore an ing its preparation and review, including important element in efforts to combat Helene Carlsson (PRMGE), Sheila Dutta HIV/AIDS in the region. (AFRHV), Lucia Fort (PRMGE), Astrid Helge- v vi Integration of Gender Issues in Selected HIV/AIDS Projects in the Africa Region land-Lawson (AFTH1), John May (AFTH2), (PRMGE) for their assistance in the prepara- Shimwaayi Muntemba (AFTPM), Gylfi Pals- tion of this report. son (AFTTR), Khama Odera Rogo (AFTHD), Richard Seifman (AFRHV), and Tshiya Subayi Ok Pannenborg Cecilia Valdivieso (AFTH3). Many thanks to Dawn Ballantyne Senior Advisor Sector Manager (PRMGE), Milford Rivas Garcia (AFTH2), AFTHD PRMGE Elsie Lauretta Maka (AFTHD), Catherine Naggar (AFTH2), and Max Jira Ponglumjeak September 2003 Acronyms and Abbreviations AFTH2 Africa Region Human Development 2 Unit AIDS Acquired Immunodeficiency Syndrome BCC Behavior Change Communication CBO Community Based Organization CSW Commercial Sex Workers FGM Female Genital Mutilation HIV Human Immunodeficiency Virus IEC Information Education and Communication IGA Income-Generating Activity ILGA International Lesbians and Gay Association MAP Multi-Country HIV/AIDS Program MDG Millennium Development Goals MSM Men who have Sex with Men MTCT Mother-to-Child Transmission NGO Non-Governmental Organization PAD Project Appraisal Document PLWA People Living with AIDS PREM Poverty Reduction and Economic Management PRMGE PREM Gender and Development Group STD Sexually Transmitted Disease STI Sexually Transmitted Infection TTL Task Team Leader UN United Nations UNAIDS The Joint United Nations Programme on HIV/AIDS UNICEF United Nations Children's Fund UNIFEM United Nations Development Fund for Women VCT Voluntary Counseling and Testing WHO World Health Organization vii Executive Summary T his report reviews gender issues in World Bank Goals HIV/AIDS projects being developed or implemented in five African countries The World Bank has officially endorsed the (Cape Verde, The Gambia, Guinea, Millennium Development Goals (MDG) as a Senegal, and Sierra Leone). It was produced as roadmap for development. One of the main a joint collaboration of the Africa Region threats to achieving the MDG is HIV/AIDS. Human Development 2 Unit (AFTH2) and the HIV/AIDS is the leading cause of death in PREM Gender and Development Anchor Africa, and has claimed the lives of more than (PRMGE) to provide information to Task 20 million women, men and children. Another Teams and Bank staff involved in the design of 29 million are living with HIV/AIDS today, the HIV/AIDS projects. Additionally, it may be vast majority of them in the prime of their lives useful to national HIV/AIDS practitioners and as young adults, workers, parents, and stu- other persons involved in HIV/AIDS activities. dents.1 In response this devastating epidemic, This report was based on a desk review of the World Bank launched the Multi-Country Project Appraisal Documents (PADs), supple- HIV/AIDS Program (MAP) for Africa, which is mented with interviews with available Task now in its second phase. Team Leaders (TTLs). Because few of the proj- The rationale behind this report is that by ects reviewed had undergone full implementa- increasing gender-sensitivity, MAP projects tion over an extensive period, this review did will become more effective at combating the not include visits to project sites, or a deeper spread of HIV/AIDS. This will aid in the analysis of the implementation process. The achievement of the MDGs, particularly Millen- report is meant to be a baseline analysis, rather nium Development Goal 1 (eradicate extreme than a full-scale review, to identify attention to poverty and hunger), Goal 2 (achieve universal gender issues in the design of projects. While it primary education), Goal 3 (promote gender may be too early to assess the results and equality and empower women), Goal 4 (reduce impacts of the projects' provisions on gender, child mortality), Goal 5 (improve maternal this report provides an opportunity to identify health) and Goal 6 (combat HIV/AIDS, malar- potential gaps and areas for further attention ia and other diseases). on gender issues. 1 2 Integration of Gender Issues in Selected HIV/AIDS Projects in the Africa Region Gender and HIV/AIDS Findings and Recommendations Gender norms are central to shaping sexual Because in Sub-Saharan Africa HIV/AIDS is behavior, and affect women and men's respec- transmitted predominantly through sexual tive vulnerabilities and risk to HIV/AIDS.2 A contact, and because gender norms are intrin- vulnerability factor makes it more likely that a sically tied to sexual behavior, any prevention person will engage in risky behavior, or indi- efforts should include attention to gender cates that a person may lack the power to pro- issues. To fight this epidemic effectively and tect him or herself from HIV/AIDS. On the sustainably, attention to gender issues and vul- other hand, persons at-risk are those already nerability/risk factors should be included in all engaging in risky behavior. Therefore, individ- HIV/AIDS programming and policy. Thus, just uals may be both vulnerable and at-risk. as there is an effort to mainstream HIV/AIDS programming and policy into various sectors, Women's vulnerabilities and risk to HIV/AIDS so too should there be an effort to mainstream are fueled by several factors, including poverty gender issues into HIV/AIDS programming (which makes women more economically and and policy. socially dependent than men, and sometimes pushes them into risky behavior, including 1. Findings: Many projects reviewed have coerced sex or commercial sex work); cultural already taken important steps toward integrat- norms (which define women as the primary ing gender considerations. For example, care-givers); sexual norms (which encourage through the: passivity, modesty, innocence and sometimes ignorance in sexual matters); violence against · Elaboration of gender-specific key per- women; lack of legal protection and property formance indicators and HIV/AIDS vul- rights; displacement; greater physiological sus- nerability and risk factors. ceptibility to the virus; and female genital mutilation (FGM). · Acknowledgement that gender disparities and poverty are key drivers of the epi- Men's vulnerabilities and risk to HIV/AIDS are demic. also fueled by several factors, including pover- ty (which pushes boys and men into commer- · Identification of vulnerable groups cial sex work); long distance employment; cul- (including women, young girls, orphans) tural norms (which encourage a denial of risk); and inclusion in the target population. sexual norms (which encourage men to be the dominant partner in economic, social, and inti- · Identification of at risk-groups (such as mate relations, including sometimes having CSWs and long-distance workers) and many sexual partners); homophobia and taboo inclusion in the target population. surrounding homosexuality (which forces men who have sex with men to keep their behavior · Focus on increasing direct aid to commu- secret and deny their risk); and incarceration nities through NGOs and CBOs working (which makes it hard for incarcerated people-- on HIV/AIDS, including women's organi- the majority of whom are males--to protect zations. themselves from unsafe sex). Executive Summary 3 While such explicit references to gender in · Public sector initiatives: project design are good indications of the proj- Main line ministries: incorporate rele- ects' ability to address these issues effectively, it vant gender considerations for the pop- is too early to assess the results and impacts of ulations they serve in their HIV/AIDS these provisions. Furthermore, there is no com- Action Plans; e.g., Senegal. prehensive set of tools, guides and good prac- Educational system: incorporate a gen- tices that are incorporated in MAP operational der-sensitive skill-based approach to manuals to assist task team in all aspects of the learning about HIV/AIDS at an early project cycle. More work needs to be done to age; e.g., Senegal. assess how well gender issues and considera- tions manifest themselves during implementa- · Civil society and private sector initiatives: tion and monitoring. encourage these initiatives to include and address gender-based vulnerability and 2. Recommendations: Based on the foregoing risk factors that receive little attention; findings, the following recommendations are e.g., Cape Verde. proposed to strengthen attention to gender issues by focusing on the following key entry · Monitoring and evaluation: assess the dif- points: ferential impacts of the project on males and females, and on existing vulnerability · Performance indicators: include more and risk factors. indicators that address specific vulnerabil- ity/risk factors for men and women; e.g., · Key policy and institutional reforms: Sierra Leone and Guinea. include reforms that will decrease vulner- ability/risk to HIV/AIDS for both men · Capacity building: include gender-based and women. vulnerabilities and risk factors in the training of staff in the public sector, the private sector, and civil society; e.g., Sier- ra Leone. CHAPTER 1 Introduction T he purpose of this report is to review ing general suggestions for further incorporat- gender issues in HIV/AIDS projects ing gender issues in HIV/AIDS projects in the being developed or implemented in five Africa Region. African countries (Cape Verde, The This report was based on a desk review of Gambia, Guinea, Senegal, and Sierra Leone), Project Appraisal Documents (PADs), supple- and to offer recommendations for these proj- mented with interviews with available Task ects (and potentially for others in the region as Team Leaders (TTLs). Because few of the proj- well) to improve attention to gender issues. It ects reviewed had undergone full implementa- seeks to provide information to TTLs and tion over an extensive period, this review did Bank staff engaged in designing HIV/AIDS not include visits to project sites, or a deeper projects. Additionally, it may be useful to analysis of the implementation process. The national HIV/AIDS practitioners and other report is meant to be a baseline analysis, rather persons involved in HIV/AIDS activities. than a full-scale review, to identify attention to The rationale behind this report is that by gender issues in the design of projects. While it increasing gender-sensitivity, projects will com- may be too early to assess the results and bat the spread of HIV/AIDS in a more effective impacts of the projects' provisions on gender, and sustainable manner. It was produced as a this assessment provides an opportunity to joint collaboration of the Africa Region identify potential gaps and areas for further Human Development 2 Unit (AFTH2) and the attention on gender issues during all stages of PREM Gender and Development Group the project cycle. (PRMGE). This report reviews the five selected HIV/AIDS projects to document the extent to HIV/AIDS in the Africa Region they consider and integrate gender issues and considerations into project activities. The AIDS, the leading cause of death in Africa, has report outlines the gender-based (male and claimed the lives of more than 20 million female) vulnerabilities to and risk factors for women, men and children. Another 29 million HIV/AIDS. Finally, it indicates suggestions to people are living with HIV/AIDS today, the improve these projects' effectiveness by provid- vast majority of them in the prime of their lives 4 Introduction 5 Estimated Number of People Living with HIV/AIDS in Selected African Countries 40000 30000 Women (15-49) 20000 Men (15-49) 10000 Children (0-15) 0 The Gambia Senegal Sierra Leone Source: UNAIDS 2002. as young adults, workers, parents, and stu- and voice at the household, community and dents.3 In response this devastating epidemic, national levels. The World Bank's Policy the World Bank helped launch the Multi- Research Report on gender development docu- Country HIV/AIDS Program (MAP) for Africa, mented that, overall, women have less access which is now in its second phase. than men to and control of productive The overall objective of the MAP is to great- resources such as income, land, credit, and ly increase "access to HIV/AIDS prevention, education, and this is true for all regions, care, support, and treatment programs, with including in Sub-Saharan Africa. emphasis on vulnerable groups, and to miti- Generally, there is an unequal power bal- gate the burdens AIDS will impose on the pub- ance in heterosexual interactions--men have lic sector, the private sector, and households."4 greater control than women over when, where, To accelerate action against the HIV/AIDS and how sex takes place.5 Women are encour- pandemic, MAP offers flexible and rapid fund- aged to be passive and to have limited knowl- ing to countries that meet certain pre-estab- edge of sexual matters while there is, in many lished lending criteria. societies, a "tacit acceptance" of males having In Sub-Saharan Africa, HIV/AIDS is spread multiple sexual partners. Notions of masculin- primarily through heterosexual sex. This pat- ity and femininity also influence these vulnera- tern of transmission and infection prompt a dis- bility and risk factors. For example, the role- tinctive reflection on the determinants of sexu- models for masculinity and the taboo al relations. An analysis of specific male and surrounding homosexuality have a strong female vulnerabilities and risks to HIV/AIDS impact on homosexual behavior patterns, may help understand the spread of the disease sometimes forcing men who have sex with men and may suggest effective interventions. to demonstrate their "masculinity" by marry- ing and/or engaging in heterosexual sex, exposing their female sexual partners to Gender and HIV/AIDS HIV/AIDS risk. Therefore, this power imbalance in gender Gender refers to the socially constructed roles relations increases both men's and women's ascribed to males and females. These roles are vulnerability and risk to HIV. learned, change over time, and vary widely within and across cultures. However, there are some consistencies across cultures. Studies Vulnerable and At-Risk Groups have shown that different gender roles result in disparities in male and female rights, responsi- A vulnerability factor makes it more likely that bilities, access to and control over resources a person will engage in risky behavior, or indi- 6 Integration of Gender Issues in Selected HIV/AIDS Projects in the Africa Region cates that a person may lack the power to pro- · Displacement: makes women more likely tect him or herself from HIV/AIDS. On the to exchange sex for favors (such as money other hand, persons at-risk are those already or food) and increases their risk of expe- engaging in risky behavior. Therefore, individ- riencing sexual violence or coercion. uals may be both vulnerable and at-risk. Fol- lowing are descriptions of female- and male- · Physiological factors: make women more specific vulnerability and risk factors. vulnerable than men to contracting the Additional details are provided in the individ- HIV virus. ual country sections. · Female genital cutting: increases women's Determinants of women's vulnerability risk of contracting HIV/AIDS. and risk to HIV/AIDS in selected countries:6 Determinants of men's vulnerability and risk to HIV/AIDS in selected countries:7 · Poverty: sometimes prompts women to exchange sex for gifts or money, to depend · Poverty: prompts men to migrate away on men who engage in risky behavior, and from their homes in search of work, be unable to negotiate safe sex. increasing the likelihood of several part- ners, boys and men to exchange sex for · Cultural norms: often place a high value gifts or money. on motherhood, attach a negative stigma to HIV-infected women, and view women · Long distance employment: requires men and girls as primary caregivers, placing a to travel away from home and increases significant burden on them. their likelihood of having multiple sexual partners. · Sexual norms: often encourage passivity, modesty, innocence and sometimes igno- · Cultural norms: attach a negative stigma rance in sexual matters, and make it diffi- to HIV-infected men; teach men to be self- cult for married women to refuse unsafe reliant and to not seek assistance, and sex with their husbands. encourage denial of risk. · Violence against women: forces women to · Sexual norms: discourage men from engage in sexual activity against their admitting lack of knowledge about sexu- will, keeps women away from voluntary al matters; allow men to have many sexu- counseling and testing (VCT), and keeps al partners; and emphasize power and women from complying with the neces- domination in sexual relations. sary steps to prevent mother-to-child transmission (MTCT). · Homophobia and taboo surrounding homosexuality: prompts men who have · Legal issues/enforcement of laws: especial- sex with men to keep their behavior secret ly those in the areas of reproductive health, and deny their sexual risk. marriage, coerced sex, rape, sexual abuse, inheritance and succession, access to prop- · Incarceration: increases sexual activity erty rights and land tenure, etc., may not between men, whether voluntarily or by protect infected and affected HIV/AIDS force; and leaves little option for protection women, and victims of sexual violence. from HIV if condoms are not provided. Introduction 7 Although often overlooked, adolescence inequalities to fuel the spread of the epidemic, itself brings with it a series of vulnerabilities which in turn impoverishes families. Gender and risk factors that need to be considered in differences in access to education and paid HIV/AIDS programming, particularly because employment are factors that increases women's young people are at a high risk for infection vulnerability to poverty, thus contributing to (See Box 1). their economic dependence on men. This dependence, in turn, makes it difficult to nego- tiate or refuse sexual practices that put women Poverty, Gender and HIV/AIDS at risk for HIV infection.8 Poverty also pushes many women and girls to engage in unsafe In Sub-Saharan African countries, the sexual practices and commercial sex as a way HIV/AIDS epidemic is embedded in the cycle of earning a living. In most countries, the inci- of poverty. Poverty combines with gender dence of HIV/AIDS among female commercial Box 1. Adolescent HIV/AIDS Vulnerability and Risks Adolescent girls and boys are both vulnerable to HIV infection. In some African countries up to 60 per- cent of all new HIV cases occur among 15-24 year olds. This risk is increased by socio-cultural, politi- cal and economic forces, such as poverty, migration, war and civil disturbance. The high social value placed on virginity among unmarried girls often leads parents and the communi- ty to ensure that young women are kept ignorant about sexual matters. This prevents girls from seek- ing information about sex or services relating to sexual health. On the other hand, dominant notions of masculinity encourage young men to seek sexual experience with a variety of partners and to be more knowledgeable about sexual matters. Also, because sexual ignorance is socially unacceptable, young men are reluctant to admit they are lacking in knowledge and therefore are prevented from openly seek- ing it. In addition, several other obstacles make it difficult for young people to protect their sexual health. First, they often have less access to information, services, and resources than those who are older. Sec- ond, health services are rarely designed to meet their needs. Young people in a variety of contexts report that access to condoms is difficult, and that they are not appropriately treated by health workers. Third, legislation and policies which limit sex education prevent many young people from obtaining appro- priate information to protect their sexual health. Many adults fear that young people are naturally sex- ually promiscuous, and that giving them information about sex will make them more sexually active. However, research indicates that the majority of young persons are at least as responsible as their par- ents, and some may be even more so. Finally, sex is a subject that is not easily or openly discussed in most African societies. Families, educa- tors, and community leaders find it difficult to communicate with both female and male children and adolescents about sex and sexually transmitted diseases. Furthermore, authority figures tend to have mixed views on the effectiveness and appropriateness of sex education, condoms, and the role of sex in the lives of young, unmarried people. Open discussions about condom use and safe sex are often asso- ciated with promiscuity, especially for girls. As a result, children and adolescents can be confused, mis- informed, and frightened about sex, as well as unclear about how to prevent the contraction of HIV/AIDS. Consequently, lack of communication leads to the spread of the virus. Source: UNAIDS. Adolescent Sexuality. 1999. 8 Integration of Gender Issues in Selected HIV/AIDS Projects in the Africa Region sex workers is among the highest of any vulnerability and/or risk to the HIV virus. In group.9 several African countries, poverty has driven In addition, migration, urbanization, and many boys and young men to engage in com- social dislocation have given the virus an easy mercial sex work, exchanging sex for gifts or transmission route, and have increased men's money, primarily with men. CHAPTER 2 Integration of Gender Issues in HIV/AIDS Projects T his review of five HIV/AIDS projects in possible, these should be gender-specific. the region (Cape Verde, The Gambia, Non-disaggregated indicators make it dif- Guinea, Senegal, and Sierra Leone) ficult to analyze the potential gendered documents the extent to which the impact of the project. PADs outline gender-specific issues. The Sierra Leone HIV/AIDS Project (SHARP) and the · Strategic Context, Sector Issues and Guinea HIV/AIDS Project contain good exam- Strategic Choices: Strategic choices for ples of gender issues in project design, and are the project are an excellent entry point to summarized in the box below. address gender issues, and wherever pos- The tables that follow present the situation sible should focus on how such choices analysis of the treatment of gender in each of will impact vulnerable groups and/or the five projects. The initial section for each address gender-related vulnerabilities. country describes specific male and female vul- nerabilities and risk to HIV/AIDS in the partic- · Project Description Summary, Project ular country. The Project Appraisal Document Components: The Project Description is a (PAD) includes a standard format, with five key key entry point for incorporating gender sections (listed below) that are considered issues. If gender issues are to be main- excellent entry points for the integration of gen- streamed throughout the project, all com- der considerations and concerns. The analysis ponents should focus on gender issues of the project documents the extent to which and/or vulnerability/risk factors (as iden- gender issues were considered and integrated tified in the target population). into project activities in these key entry points, and offers suggestions to improve these proj- · Project Description Summary, Benefits ects' effectiveness with regard to gender issues. and Target Population: Focusing on vul- nerable groups is an important aspect of · Project Development Objective, Key Per- mainstreaming gender issues. formance Indicators: The performance indicators provide an opportunity to · Summary Project Analysis, Social: The address gender concerns. To the extent project's social analysis can be a particu- 9 10 Integration of Gender Issues in Selected HIV/AIDS Projects in the Africa Region Box 2. Good Practice Examples Capacity Building in Sierra Leone: Training of Trainers Workshop for Engendering HIV/AIDS for Development (February, 2002) This national workshop was sponsored by the World Bank (through a GENFUND award), and organ- ized in collaboration with the Ministry of Social Welfare, Gender, and Children's Affairs, and the Min- istry of Development and Economic Planning. The workshop included officials from several ministries as well as women's organizations. It will be followed up by four workshops at the regional (provincial) level. The main objective of this workshop was to integrate gender in the fight against the HIV/AIDS pandemic by: Increasing participants' understanding of gender issues in general; Raising participants' awareness of how gender issues are connected to HIV/AIDS and equipping participants with tools for integrating gender into HIV/AIDS programs and training. Ending Female Genital Mutilation in Guinea The Bank is involved in a project to help end FMG in Guinea. The project is providing circumcisers with training to pursue alternative sources of livelihood, along with access to small business start-up funds. In other words, the strategy to end FGM involves enlisting the support of the circumcisers them- selves. In 2000, this project was recognized by the Development Marketplace with a $150,000 award. By working to end FGM this project is addressing one of the root causes of female vulnerability/risk to HIV/AIDS in Guinea. larly effective means of addressing gen- commercial sex work. Juvenile prostitution der-based vulnerabilities and risks. is a sizeable problem. · Sexual norms: Existing norms that dictate Cape Verde ignorance and passivity for women in sex- Credit Amount (US$m): 9.0 ual interactions make it difficult for Effectiveness Date: 06/01/2002 women to be informed about risk reduc- tion or, even when informed, make it dif- In 1997, when the last sentinel surveillance ficult for them to be proactive in negoti- data were available, HIV/AIDS prevalence in ating safer sex. the general population was estimated at between 1.5 and 2.5 percent. The main mode · Violence against women: Several women's of transmission of HIV is heterosexual contact, organizations suggest that, in Cape Verde, although MTCT also contributes to new cases domestic violence and sexual abuse/coer- among children. cion are fairly common, but there are no studies indicating the extent of these Gender-based vulnerabilities to problems. HIV/AIDS in Cape Verde · Long Distance Employment: Many men · Poverty: Female-headed households (40 in Cape Verde engage in long distance percent in 2000) are among the poorest. employment, as migrant workers, mar- Poverty frequently leads women to depend itime crews, and construction workers. on men for additional income, and has They are more likely to have multiple sex- driven many women, girls and boys into ual partners and are therefore at increased risk for HIV infection. Integration of Gender Issues in HIV/AIDS Projects 11 Table 1. Analysis of the Cape Verde HIV/AIDS Project Specific Reference to PAD Provisions Gender in PAD Recommendations A.Project Development Objective · Key Performance Indicators: · Include social indicators that Reduce the spread of HIV "By 2005, reduce by 20% the address vulnerability/risk factors for infection in the country. HIV prevalence among women women and men, e.g. "% of women Mitigate the health and socio- attending ante-natal care clinics leaving commercial sex trade to par- economic impact of HIV/AIDS at (compared with the first year of ticipate in alternative income gener- individual, household, and the project)." ating activities." community levels "By 2005, reduce by 25% the · Output Indicator #1 could be a Establish a strong and incidence of reported sexually "gender-sensitive skills-based" sustainable national capacity to transmitted (urethritis) infections approach, focusing on specific skills respond in men age 15-49 years in the that boys and girls need. previous 12 months, compared with the first year of the project)." B.Strategic Context "Strengthening coping · "Mainstreaming of HIV/AIDS into · Sector Issues and Strategic mechanisms including offering a all sectors of government and civil Choices safety net for orphans and for society" should involve attention to households headed by women, gender issues, especially because the very young, and the elderly women's organizations are involved (usually because of the deaths of in civil society initiatives. husbands, parents, or guardians)." C.Project Description Summary Civil society and private sector · Capacity building: include gender · Project Components initiatives: "Targeted support to issues in the training of staff in the Capacity Building orphans, guardians of poor public sector, the private sector, and Public Sector Initiatives orphans, and AIDS-stricken civil society. Civil Society and Private Sector impoverished households, includ- · Public sector: incorporate rele- Monitoring and Evaluation ing those headed by women, vant gender issues for the popula- · Key Policy and Institutional young people, and the elderly." tions they serve in their HIV/AIDS Reforms Supported by the Project Monitoring and evaluation: Action Plans. · Benefits and Target Population "Gender-specific indicators have · Civil society & private sector: been included among the project encourage organizations to include performance indicators." or strengthen existing attention to · Key policy and institutional gender issues that receive little reforms: "The project supports the attention (e.g., violence against development of relevant legal and women, homosexuality, CSW). social initiatives to protect the most · Monitoring and evaluation: vulnerable, e.g., women, young peo- assess differential impact of project ple (especially adolescent girls) and on women and men. people living with HIV/AIDS." · Policy and institutional reforms: · Target population: Groups particu- changes to protect people living larly at risk and targeted include with HIV/AIDS are clearly stated. "young people (particularly teenage However, policy and institutional girls), pregnant women, maritime changes to protect groups identified crews (predominantly men), com- as particularly vulnerable should be mercial sex workers (men and further clarified. E.g., address vio- women), migrants predominantly lence against women (domestic vio- men), road and other long distance lence, sexual assault, sexual coer- construction workers (predominantly cion); acknowledge the existence of continued on next page 12 Integration of Gender Issues in Selected HIV/AIDS Projects in the Africa Region Table 1 (continued) Specific Reference to PAD Provisions Gender in PAD Recommendations men), fishermen (predominantly prostitution in general (male, female, men), the military (predominantly child), and regulate it to promote men), the prison population (pre- safe sex behaviors. dominantly men), and impoverished households, with a focus on those headed by women, the elderly and youths." D. Project Rationale · "This project will, among others, · The project should also address · Lessons Learned and Reflected in focus on the vulnerable groups, the root causes of vulnerability/risk the Project Design including youth, orphans, women in each of the project components. and widowers in prevention and impact mitigation effects." E. Summary Project Analysis · "Supports the development of rel- · Further clarify what legal and · Social evant legal and social initiatives to social initiatives will be developed to protect the most vulnerable, e.g., protect other vulnerable groups women, young people (especially such as prisoners and homosexuals. adolescent girls) and people living with HIV/AIDS." Source: Cape Verde HIV/AIDS Project Appraisal Document (PAD) March, 2002; Project ID: P0742 · Incarceration: Prisoners in Cape Verde are 5,400 men, and 520 children (UNAIDS 2000), primarily male. Severe overcrowding and and the predominant means of HIV transmis- lack of adequate health care are consider- sion is heterosexual. able problems. Gender-based vulnerabilities to · Homophobia and Taboo Surrounding HIV/AIDS in The Gambia Homosexuality: Homosexuality is illegal in Cape Verde. The stigma and fear asso- · Poverty: Because of traditional gender ciated with homosexuality sometimes roles, which limit women's access to edu- forces men who have sex with men to cation, resources, and household income, keep their sexual behavior secret and Gambian women experience greater deny their sexual risk, thereby increasing poverty than do men. This makes women their own risk, as well as the risk of their and young girls vulnerable to HIV infec- partners--female or male. tion by pushing many of them to exchange sex for gifts or money, and by reducing their power to negotiate safe The Gambia sex. Poverty has also led many young men Credit Amount (US$m): 15.0 in The Gambia to exchange sex for gifts Effectiveness Date: 03/15/2001 or money, thus increasing their risk of HIV/AIDS. The large tourist industry has Currently, in The Gambia, approximately 1.95 fueled such practices, and many of these percent of the adult population is believed to men are known as "bumsters." be infected with the HIV virus--6,600 women, Integration of Gender Issues in HIV/AIDS Projects 13 Table 2. Analysis of The Gambia HIV/AIDS Rapid Response Project Specific Reference to PAD Provisions Gender in PAD Recommendations A.Project Development Objective · Key Performance Indicators: · Further disaggregate youth (15 to Maintain the current low levels "Stabilize and reduce the 24 year olds) by sex. of the epidemic. prevalence of HIV among · Include social indicators that Reduce its spread and mitigate pregnant women." address vulnerability/risk factors for its effects. women and men, e.g. "% of women Increase access to prevention leaving commercial sex trade to par- services as well as care and ticipate in alternative income gener- support for those infected and ating activities;" "percentage of affected. girls attending school;" etc. · Key Performance Indicators B.Strategic Context "Empower women, youth, and · "Support to capacity building and · Sector Issues and Strategic other vulnerable groups at risk to policy development in the various Choices take action to protect themselves sectors" should involve attention to against HIV/AIDS." gender issues. "Encourage delays in the onset · Training of government staff, of sexual activity among teachers, and health professionals adolescents." should include attention to gender "Promote reductions in the issues and vulnerabilities. number of sexual partners." "Empower women and girls to reduce their risk of, and vulnerability to, HIV..." C. Project Description Summary · Project components: · Capacity building: include gender · Project Components Civil society and private sector issues in the training of staff in the Capacity Building initiatives: "Support to high-risk public sector, the private sector, and Public Sector Initiatives groups and priority target groups" civil society. Civil Society and Private Sector (including commercial sex · Public sector (Ministries): incor- Monitoring and Evaluation workers and their clients, long porate relevant gender issues for · Key Policy and Institutional distance transport workers, the populations they serve in their Reforms Supported by the Project prisoners, etc.) HIV/AIDS Action Plans. · Target population: · Civil society & private sector: · Benefits and Target Population High risk group: " commercial encourage organizations to include sex workers (men and women) or strengthen existing attention to and their clients (primarily men), gender issues that receive little truck drivers or long distance attention (e.g., violence against transport personnel (primarily women, homosexuality, CSW). men), migrant workers, and those · Monitoring and evaluation: assess already infected. differential impact of project on Priority target group: "women, women and men; particularly within youths ages 15-24, orphans, and the target group of 15-24 year olds. line Department personnel such · Policy and institutional reforms: as educators, health workers, the Explicit references should be made tourist industry and personnel in to policies to protect women's prop- uniform." erty rights; address domestic vio- lence, sexual assault, sexual coer- cion, FGM and CSW (including males and children). continued on next page 14 Integration of Gender Issues in Selected HIV/AIDS Projects in the Africa Region Table 2 (continued) Specific Reference to PAD Provisions Gender in PAD Recommendations D. Project Rationale · In addition to an intensification of · Lessons Learned and Reflected in services to groups identified as the Project Design high-risk or vulnerable in the target population, the project should also address the root causes of their vul- nerability/risk through each of the project components described above. E. Summary Project Analysis · Further clarify how the gender- · Social related (such as "empower women, youth, and other vulnerable groups at risk to take action to protect themselves against HIV/AIDS;" and "empower women and girls to reduce their risk of, and vulnerability to, HIV infection.") will be achieved. Source: The Gambia HIV/AIDS Rapid Response Project Appraisal Document (PAD); December 2000; Project ID: P0603. · Sexual Norms: Existing norms that dic- cedure, which give easy access to the HIV tate ignorance and passivity for women in virus. sexual interactions make it difficult for women to be informed about risk reduc- · Sexually Transmitted Infections: Research tion or, even when informed, make it dif- indicates that the risk of becoming infect- ficult for them to be proactive in negoti- ed with HIV during vaginal intercourse ating safer sex. without a condom is as much as 2-5 times greater for women than men. The pres- · Cultural Norms: Traditional views of ence of an STI increases this risk. A rapid women's roles as caretakers lead them to STI assessment in The Gambia, conduct- stay home and take care of ill family ed in 1994, showed that one in three members. Since approximately 84 percent pregnant women had signs of an STI. of women in The Gambia's agricultural sector are subsistence farmers, HIV/AIDS · Legal Issues/Enforcement of Laws: Tradi- may increase poverty by threatening the tional divorce and inheritance laws and household's food availability. practices in The Gambia place women at a disadvantage in terms of the distribu- · Female Genital Mutilation: Between 60 tion of assets and property. and 90 percent of girls in The Gambia undergo this procedure, which is per- · Violence Against Women: Several women's formed at varying ages (shortly after birth organizations suggest that, in The Gam- to 18 years old). FGM increases the like- bia, domestic violence and sexual abuse/ lihood of HIV infection, either due to coercion are fairly common, but there are infection during the procedure, or to no studies indicating the extent of these infection and cuts resulting from the pro- problems. Integration of Gender Issues in HIV/AIDS Projects 15 · Long Distance Employment: Many men in · Sexual norms: Existing norms that dictate The Gambia are engaged in long distance ignorance and passivity for women in sex- employment, such as migrant workers and ual interactions make it difficult for truck divers. They are more likely to have women to be informed about risk reduc- multiple sexual partners and are therefore tion or, even when informed, make it dif- at increased risk for HIV infection. ficult for them to be proactive in negoti- ating safer sex. · Homophobia and Taboo Surrounding Homosexuality: In The Gambia, the stig- · Cultural Norms: Traditional views of ma and fear associated with homosexual- women's roles as caretakers lead them to ity forces men who have sex with men to stay home and take care of ill family mem- keep their sexual behavior secret and bers. Since women are responsible for deny their sexual risk, thereby increasing nearly 80 percent of the country's food their own risk, as well as the risk of their crop production, HIV/AIDS may increase partners--female or male. poverty by threatening the household's food availability. Additionally, young girls may be removed from school to care for Guinea sick relatives, thus further promoting exist- Credit Amount (US $ m): 20.30 ing gender disparities in education (gross Effectiveness Date: 04/03/2003 primary enrolment is approximately 68 percent for boys and 40 percent for girls). A 2001 study indicated that prevalence of HIV among pregnant women was 4.4 percent, with · Dislocation: In Guinea, there are large even higher rates in Conakry (5 percent). The numbers of refugees from neighboring predominant means of transmission is hetero- Sierra Leone. There are generally more sexual. women than men among these popula- tions, and poverty is rampant. Such Gender-based vulnerabilities to women are particularly at risk for sexual HIV/AIDS in Guinea violence and coercion, and are more like- ly to exchange sex for valuable resources · Poverty: Approximately 40 percent of such as food or money. households are below the poverty line. But, because of traditional gender roles, · Female Genital Mutilation: Between 65 which limit women's access to education, and 90 percent of girls in Guinea undergo resources, and household income, this procedure, and infibulation, the most Guinean women experience greater pover- dangerous form, is practiced in the forest ty than do men. This makes women and region. FGM increases the likelihood of young girls vulnerable to HIV infection by HIV infection, either due to infection dur- pushing many of them to exchange sex for ing the procedure, or to infection and cuts gifts or money, and by reducing their resulting from the procedure, which give power to negotiate safe sex. This is partic- easy access to the HIV virus. ularly true among the large numbers of street children, and child prostitution is a · Long Distance Employment: Many men serious problem in Guinea. These young in Guinea are engaged in long distance girls are also vulnerable to sexual assault employment, such as miners and truck and coercion. drivers. They are more likely to have mul- 16 Integration of Gender Issues in Selected HIV/AIDS Projects in the Africa Region Table 3. Analysis of Guinea Multi-Sectoral AIDS Project (MAP) Specific Reference to PAD Provisions Gender in PAD Recommendations A.Project Development Objective · Key Performance Indicators: · Further disaggregate youth (15 to Mitigate socioeconomic impact "Keep the HIV prevalence 24 year olds) by sex. of HIV/AIDS within framework of among 15 to 24 year old urban · Include social indicators that poverty reduction strategy. pregnant women below 5% by address vulnerability/risk factors for Limit and reverse the trend of 20006." women, e.g. "% of women leaving the epidemic b preventing new "100% of truck stops offer an commercial sex trade to participate infections. HIV/AIDS prevention program to in alternative income generating · Key Performance Indicators drivers" (mostly male) activities;" "percentage of girls attending school;" etc. (Many male vulnerability/risk factors are already addressed) B. Strategic Context "subordinate status and lack of · Targeting high-risk groups such as · Sector Issues and Strategic empowerment among women" truck drivers and miners, is Choices contribute to the spread of the important. Strategic choices should virus. also discuss how the project will Strategic choices include address women, and the root prevention efforts among truck causes of their vulnerability/risk drivers and miners (mostly men). (which the project identifies as "women's subordinate status" and "lack of empowerment"). C. Project Description Summary · Project components: · Capacity building: include gender · Project Components Public Sector Initiatives: "The issues/vulnerabilities that facilitate Capacity Building project will support the PMTCT the spread of the virus in the train- Public Sector Initiatives program." The Ministry of ing of staff in the public sector, the Civil Society and Private Sector Transport and Public Works will private sector, and civil society. Monitoring and Evaluation focus on male high-risk groups · Public sector (Ministries): · Key Policy and Institutional such as truck drivers. · Civil society & private sector: Reforms Supported by the Project · Target population: Youth, women, encourage organizations to include and high-risk groups (sex-workers, or strengthen existing attention to · Benefits and Target Population truck drivers, military, and miners). gender issues that receive little attention (e.g., violence against women, homosexuality, CSW). · Monitoring and evaluation: assess differential impact of project on women and men. · Policy and institutional reforms: Proposed reforms should address policy, legal and institutional issues to protect women's property rights, domestic violence, sexual assault, sexual coercion, FGM and all forms of prostitution (including male and child) continued on next page Integration of Gender Issues in HIV/AIDS Projects 17 Table 3 (continued) Specific Reference to PAD Provisions Gender in PAD Recommendations D. Project Rationale · N/A · The project should also address · Lessons Learned and Reflected in the root causes of their vulnerabili- the Project Design ty/risk in each of the project compo- nents. E. Summary Project Analysis · Social: The project will "raise · Project implementation should · Social awareness of high-risk groups (e.g., include strategies to address gender CSWs, truckers, miners, youth, the issues, including the difficulty in military) and encourage safe-sex recruiting women as peer trainers. behavior among the population at large." Also, "one key social issue that needs to be flagged is the diffi- culty in recruiting women as peer trainers." Source: Guinea: Guinea Multi-Sectoral AIDS Project (MAP) Project ID P073378 tiple sexual partners and are therefore at lack of access to critical resources such as increased risk for HIV infection. land, credit, education, and technology. This makes women more dependent on · Homophobia: Homosexuality is illegal in men while reducing their power to nego- Guinea, and homosexuals are sometimes tiate safe sex. Moreover, poverty has driv- the victims of severe hate crimes. The stig- en many women and young girls into ma and fear associated with homosexual- commercial sex work, a practice fueled by ity forces men who have sex with men to the large tourist industry. keep their sexual behavior secret and deny their sexual risk, thereby increasing · Sexual norms: Existing norms that dictate their own risk, as well as the risk of their ignorance and passivity for women in sex- partners--female or male. ual interactions make it difficult for women to be informed about risk reduc- tion or, even when informed, make it dif- Senegal ficult for them to be proactive in negoti- Credit Amount (US$m): 30.0 ating safer sex. Effectiveness Date: 02/07/2002 · Cultural Norms: Traditional views of In Senegal, approximately 1.77% of the popu- women's roles as caretakers lead them to lation is believed to be infected with HIV-- stay home and take care of ill family 40,000 women, 36,000 men, and 3,300 chil- members. As the HIV virus spreads, this dren. The predominant means of transmission has a direct impact on the education of is heterosexual. girls and on food availability (given that women in Senegal are primarily employed Gender-based vulnerabilities to in the agricultural sector and in subsis- HIV/AIDS in Senegal tence farming). Additionally, young girls may be removed from school to care for · Poverty: In Senegal, women are more like- sick relatives before boys, thus further ly to be poor than men, due primarily to promoting existing gender disparities in 18 Integration of Gender Issues in Selected HIV/AIDS Projects in the Africa Region Table 4. Analysis of the Senegal HIV/AIDS Prevention and Control Project Specific Reference to PAD Provisions Gender in PAD Recommendations A. Project Development Objective · Key Performance Indicators: most · Include a performance indicator Prevent the spread of HIV/AIDS are gender-specific; examples that focuses on 15-19 year old girls by reducing transmission among include: (as well as boys, who are already the high risk groups. "65% of adult males report listed in the project). Expand access to treatment, using a condom with a casual · Include social indicators that care and support of people living partner during their last sexual address vulnerability/risk factors for with HIV/AIDS. encounter." women and men, e.g. "% of women Support civil society and "Knowledge of at least two leaving commercial sex work to par- community initiatives. methods of protection against ticipate in income generating activi- · Key Performance Indicators HIV/AIDS among women (20-49 ties;" "% of long distance workers year-olds) increases to 80%." who have access to condoms;" etc. B. Strategic Context 70% of IDA resources will · Strategic choices should also dis- · Sector Issues and Strategic finance community activities cuss how the project will address Choices aimed at, "the reduction and the root causes of vulnerability/risk containment of HIV infection and (which the project identifies as transmission among women, "women's subordinate status" and newborns, adolescents and high "low literacy--especially among risk groups." rural women"). C. Project Description Summary · Project components: · Capacity building: include gender · Project Components Public Sector Initiatives: "the issues/vulnerabilities that facilitate Capacity Building design, implementation and the spread of the virus in the train- Public Sector Initiatives evaluation of IEC programs aimed ing of staff in the public sector, the Civil Society and Private Sector at specific audiences such as private sector, and civil society. Monitoring and Evaluation adolescents (both genders) in and · Public sector (Ministries): "The · Key Policy and Institutional out of school, women, youth, men ministry in charge of women will Reforms Supported by the Project in uniform, and high risk groups work with the Ministry of Social such as CSW and MSM." Development to include HIV/AIDS · Benefits and Target Population Civil society and private sector prevention activities in existing initiatives: 70% of IDA resources women's groups' plans of action, will go to financing community focusing on gender-related issues activities aimed at, among others, and socio-cultural barriers that "the reduction and containment of could increase the spread of AIDS." HIV infection and transmission This approach should be extended among women, newborns, ado- to other ministries, and in program- lescents and high risk groups." ming directed at male populations. Monitoring and evaluation: · Civil society & private sector: gender disaggregated indicators encourage organizations to include will allow the project to monitor or strengthen existing attention to its impact on distinct groups of gender issues that receive little men and women. attention (e.g., violence against · Target population: includes youth women, homosexuality, CSW). (in and out of school); women; CSW; · Monitoring and evaluation: populations with signs and symp- assess differential impact of project toms of STIs; workers; armed forces; on women and men. migrants; health workers; MSM; · Policy and institutional reforms: prisoners; other groups. policy and institutional changes continued on next page Integration of Gender Issues in HIV/AIDS Projects 19 should be explicit about issues such as: giving women greater economic power by acknowledging them as heads of the household (currently only men are); and addressing issues of sexual violence and CSW. D. Project Rationale · "The combination of poverty, illit- · The project should also address · Lessons Learned and Reflected in eracy and gender disparities exac- the root causes of their vulnerabili- the Project Design erbate exposure to the virus." The ty/risk through each of the project project will target groups with differ- components described above. ential behavior change information, and pilot income-generating activi- ties. E. Summary Project Analysis Social: "Socially marginalized · Further clarify how marginalized · Social groups such as MSM, CSW, inmates groups will receive support from the and PLWA and their families whose project. Also, what legal and social economic and human rights are sub- initiatives will be developed to pro- ject to violation will also receive tect other vulnerable groups. support through the project." Source: Senegal HIV/AIDS Prevention and Control Project Appraisal Document, November 2001 (P074059). education (the illiteracy rate for 15-24 considered heads of household, and there- year-olds is 41 percent for males and 59 fore women pay higher taxes than men for percent for females). equal wages, and employers pay child allowances to men and not women. · Female Genital Mutilation: It is estimated that about 20 percent of Senegalese girls · Violence Against Women: There are cred- undergo the procedure. Infibulation, the ible reports that, in Senegal, domestic vio- most extreme and dangerous form of lence and sexual abuse/coercion are fairly FGM, is practiced by the Toucouleur and common. In fact, several women's groups Fulani peoples. have formed to address this problem. · Legal issues/enforcement of laws: Despite · Long Distance Employment: Many men constitutional protections, women face in Senegal are engaged in long distance extensive discrimination, and the Govern- employment, such as migrant workers, ment frequently fails to enforce anti-dis- maritime crews, and construction work- crimination laws. This is particularly true ers. A 1998 study indicated that only 63 in rural areas, where women normally percent of all truck drivers had access to receive a lower proportion of the assets dis- condoms. tributed through inheritance and divorce than do male relatives and men respective- · Incarceration: Prisoners in Senegal are ly. Additionally, in Senegal, men are legally primarily male. A 1998 study indicated 20 Integration of Gender Issues in Selected HIV/AIDS Projects in the Africa Region that approximately 93 percent of them ly to exchange sex for valuable resources had knowledge of HIV-related preventive such as food or money. practices, yet only 56 percent of them had access to condoms. · Violence Against Women: Gender vio- lence, such as sexual assault, sexual coer- · Homophobia and Taboo Surrounding cion, and domestic violence within house- Homosexuality: Homosexuality is illegal holds, is a major problem in Sierra Leone. in Senegal. Rape and sexual slavery have been used as war tactics, affecting huge numbers of women. Sierra Leone Credit Amount (US$m): 16.0 · Sexual Norms: Existing norms that dic- Effectiveness Date: 07/01/2002 tate ignorance and passivity for women in sexual interactions make it difficult for The latest HIV surveillance, conducted in1997, them to be informed about risk reduction estimated that the adult prevalence of HIV in or, even when informed, make it difficult Sierra Leone was 3.2 percent, and the main for them to be proactive in negotiating mode of transmission was heterosexual con- safer sex. tact. · Cultural Norms: Traditional views of Gender-based vulnerabilities to women's roles as caretakers lead them to HIV/AIDS in Sierra Leone stay home and take care of ill family members. Given limited access to formal · Poverty: Sierra Leone is one of the poor- sector employment, women in Sierra est countries in the world, with a life Leone resort mainly to food production expectancy of 38.4 years and a GDP per and petty trading. Therefore, HIV/AIDS capita of $448. Women lack adequate may increase poverty by threatening the access to productive assets including land, household's food availability. Additional- credit, training and technology, and are ly, young girls may be removed from therefore generally poorer than men. This school to care for sick relatives, thus fur- makes women and young girls vulnerable ther promoting existing gender disparities to HIV infection by pushing many of in education. them to exchange sex for food, gifts, and/or money, and by reducing their · Female Genital Mutilation: It is estimated power to negotiate safe sex. This is par- that up to 90 percent of girls in Sierra ticularly true among the large numbers of Leone undergo this procedure, and the street children, who are also vulnerable to form practiced is excision. sexual assault and coercion. · Sexually Transmitted Infections: Limited · Dislocation: Because of civil strife, there studies on former girl captives in Sierra are large numbers of refugees and dislo- Leone indicate that up to 99 percent of cated persons. There are generally more them test positive for STIs, often having women than men among these popula- multiple infections. tions, and poverty is rampant. Such women are particularly at risk for sexual · Legal Issues/Enforcement of Laws: Tradi- violence and coercion, and are more like- tional divorce and inheritance laws and Integration of Gender Issues in HIV/AIDS Projects 21 Table 5. Analysis of the Sierra Leone HIV/AIDS Response Project (SHARP) Specific Reference to PAD Provisions Gender in PAD Recommendations A. Project Development Objective · Key Performance Indicators: · Further disaggregate "youth" and Contribute to reducing "By the end of the project 70% "adults" by sex. HIV/AIDS prevalence. of youth, women, commercial sex Mitigate the impact of HVI/AIDS workers (women), uniformed on persons infected or affected by services (primarily men), and ex- HIV/AIDS. combatants (men) can site at least · Key Performance Indicators two major modes of HIV/AIDS transmission and at least two methods of protection." "By the end of 2006, an appreciable number of sex workers will have left the trade and received skills to establish small micro enterprises." B. Strategic Context The project acknowledges that · Strategic choices should also · Sector Issues and Strategic "fully integrating gender into discuss how the project will address Choices HIV/AIDS strategies and plans" is the root causes of vulnerability/risk important. (e.g., address violence against "The Ministry of Social Welfare, women--which is identified in the Gender, and Children's Affairs will project as a major problem for monitor gender inclusion in fighting HIV/AIDS). activities undertaken by other line ministries and implementing NGOs." C. Project Description Summary · Project components: · Capacity building: continue to · Project Components Capacity Building: Training of include gender issues/vulnerabilities Capacity Building Trainers Workshop for that facilitate the spread of the virus Public Sector Initiatives Engendering HIV/AIDS for in the training of staff in the public Civil Society and Private Sector Development in Sierra Leone sector, the private sector, and civil Monitoring and Evaluation [February, 2002] society (such as was done with the · Key Policy and Institutional Public Sector Initiatives: "The Training of Trainers Workshop for Reforms Supported by the Project Ministry of Social Welfare, Engendering HIV/AIDS for Develop- Gender, and Children's Affairs will ment in Sierra Leone [February, · Benefits and Target Population monitor gender inclusion." 2002] funded by the GENFUND). Civil society and private sector initiatives: Activities will include "support to high-risk groups such as CSW and vulnerable groups subject to sexual abuse and discrimination;" "assistance to women." continued on next page 22 Integration of Gender Issues in Selected HIV/AIDS Projects in the Africa Region Table 5 (continued) Specific Reference to PAD Provisions Gender in PAD Recommendations Monitoring and Evaluation: "A · Public sector (Ministries): incor- social and gender assessment porate relevant gender issues for was contracted to national the populations they serve in their consultants. This report provides HIV/AIDS Action Plans. Additionally, a baseline for SHARP. Similar ministries can help target the root efforts will be undertaken during causes of men an women's vulnera- the life of the project, and until bility/risk to HIV/AIDS. For example, completion, along with other the Ministry of Defense "has devel- performance and monitoring oped plans to address HIV/AIDS evaluation exercises." within the armed forces, including · Target population: include youth policies addressing the rights of (in and out of school); women, PLWA." This ministry could also orphans and other vulnerable chil- address violence against women. dren, commercial sex workers and · Civil society & private sector: their clients; uniformed services and encourage organizations to include ex-combatants; refugees and inter- or strengthen existing attention to nally displaced persons; transport gender issues that receive little and education workers; health attention (e.g., violence against workers including traditional healers women, homosexuality, CSW). and birth attendants; and miners and · Policy and institutional reforms: other workers in the private sector. Support policy and institutional changes to protect groups identified as particularly vulnerable (such as in the target population) E.g., ad- dress violence against women; female inheritance and property rights; FGM; male commercial sex work; etc. D. Project Rationale · Social: · The project components should · Lessons Learned and Reflected in The project seeks to "increase each address the root causes of vul- the Project Design community awareness and nerability/risk. accountability surrounding gender E. Summary Project Analysis and vulnerable children's issues" · The project seeks to raise · Social and "destigmatize PLWA and awareness regarding gender issues others affected by the disease, throughout its various components. especially women and children, Similar efforts should be included to who are more likely to be stigma- address the root causes of tized and discriminated against." vulnerability/risk to HIV/AIDS, A social and gender assess- particularly for women and children. ment was undertaken (see M&E above). Source: Sierra Leone HIV/AIDS Response Project (SHARP) - Project Appraisal Document (P073883). Integration of Gender Issues in HIV/AIDS Projects 23 practices in Sierra Leone place women at keep their sexual behavior secret and a disadvantage in terms of the distribu- deny their sexual risk, thereby increasing tion of assets and property. their own risk, as well as the risk of their partners--female or male. UNAIDS data · Homophobia and Taboo Associated with indicate that, in 1996 and 1997, approxi- Homosexuality: In Sierra Leone, the stig- mately 11 percent of the HIV infections in ma and fear associated with homosexual- men were caused by homosexual contact ity forces men who have sex with men to between men. CHAPTER 2 Findings and Recommendations I n Sub-Saharan Africa HIV/AIDS is trans- · Key performance indicators are gender- mitted predominantly through sexual specific and address some vulnerability/ contact. Because gender norms are risk factors. intrinsically tied to sexual behavior, any prevention efforts should include attention to · Acknowledgement that gender disparities gender issues, and vulnerability/risk factors and poverty are key drivers of the epi- should be included in all HIV/AIDS program- demic. ming and policy. Thus, just as there is an effort to mainstream HIV/AIDS programming and · Identification of vulnerable groups policy into various sectors, so too should there (including women, young girls, orphans) be an effort to mainstream gender issues into and inclusion in the target population. HIV/AIDS programming and policy. · Identification of at risk-groups (such as CSWs and long-distance workers) and Main Findings inclusion in the target population. This report has provided a snapshot of how · Focus on increasing direct aid to commu- gender issues are being integrated in five nities through NGOs and CBOs working HIV/AIDS projects in the Africa Region, with on HIV/AIDS, including women's organi- examples of text from each of the projects. It is zations. a first step in ensuring that gender issues are mainstreamed in all Bank HIV/AIDS projects, and indicates areas that require additional Remaining Challenges attention. Many projects in the Africa Region have already taken important steps toward Mainstreaming gender issues in the fight integrating gender considerations in the fol- against HIV/AIDS in Africa will require con- lowing manner: tinuing commitment, creativity, and persever- 24 Findings and Recommendations 25 ance. As noted in the listing of vulnerability Recommendations and Next Steps and risk factors for each project, there are many important gender issues related to The World Bank and client countries' multi- HIV/AIDS. Some of these were mentioned sectoral approach to fighting the HIV/AIDS briefly, but still require significant amount of epidemic involves mainstreaming HIV/AIDS in-depth review, especially in country and proj- programming and policy in public institutions, ect settings, in order to provide concrete empir- and increasing aid to NGOs and CBOs for ical evidence of their relevance, importance HIV/AIDS-related programs. This approach and impacts on the spread of AIDS. Further, presents multiple opportunities to incorporate identification of the gender-based vulnerabili- gender-based vulnerabilities in project design ties and risk is only the beginning of the and implementation. Due to the standard for- process of developing the most appropriate mat of the PAD, this report recommends that interventions. Although MAP manuals exist on the main sections should be considered as key various aspects of the implementation of MAP entry points for the integration of gender con- projects, they contain little information on the cerns. Some of the projects contain excellent topics and issues discussed in this baseline examples of how these entry points have been assessment. Most of them could benefit from used, and they are identified in the following addressing some of the key questions outlined recommendations and elaborated upon in in the checklist shown in Box 3 below. And all Table A1 in the Annex presents additional gen- projects require guides and tools to assist with eral recommendations for client countries' better integration of gender issues during HIV/AIDS strategies and plans. implementation, supervision and monitoring. Box 3. How Gender-Sensitive is Your Work? 1. Are all program implementers able to address gender issues? 2. Are women's organizations involved in policy and program development and decision-making processes? 3. Do your interventions combat violence against women and girls (active policy goals, educa- tional programs, legislation)? 4. Do your programs consider differences in gender roles, access to resources and decision-mak- ing that affect women's and men's abilities to protect themselves? 5. Do your programs call for gender-based sexual health education in school curricula? 6. Do your programs encourage couples, parents and/or children to discuss sexual health? 7. Do your interventions aim to develop and strengthen men's concern and caring for their fami- lies? 8. Do your education and communication programs encourage men to respect women's rights to say "no" to sex or to request condom use? 9. When promoting safer sex, do your programs: · challenge double standards between men and women regarding a) teenage sexuality, b) casual sex, and c) sex outside marriage? · address difficulties in condom use from women's and men's perspectives? · teach both women and men how to use condoms? · promote easy access to condoms for women and men? · enhance women's and men's skills in negotiating safer sex? · enhance women's self-confidence? · address sexual abuse/assault/coercion? Source: UNAIDS, Best Practice Digest; UNFPA. Sixteen ways UNFPA is fighting HIV/AIDS. 26 Integration of Gender Issues in Selected HIV/AIDS Projects in the Africa Region · Performance indicators: Cape Verde, · Toolkit: Develop a toolkit that would Senegal, Sierra Leone and Guinea. include critical issues such as: the roles of men, women, boys and girls in African · Capacity building: Sierra Leone. societies; gender identities and sexual relations; reproductive and sexual · Public sector initiatives, such as among health--with particular attention to ado- main line ministries and the educational lescents' access to this information; ado- system: Senegal. lescent health and youth issues; homosex- uality and MSM issues, etc. These could · Civil society and private sector initiatives: include checklists such as those presented Cape Verde. in Box 3. · Monitoring and evaluation: assess the dif- · Key entry points: Finalize a list of key ferential impacts of the project on males entry points for including gender issues in and females, and on existing vulnerability HIV/AIDS interventions at different lev- and risk factors. els, such as national strategies and local government interventions, etc. Annex 1 · Key policy and institutional reforms: presents some examples of key entry include reforms that will decrease vulner- points in client countries' national strate- ability/risk to HIV/AIDS for both men gies. and women. · Good practices and promising approach- In addition to these recommendations, this es: Identify and disseminate best practices report proposes future actions to address the and the most effective manner of address- challenges outlined above. These next steps will ing HIV/AIDS in a gender-sensitive man- lead to further inclusion of gender issues in ner in various settings. HIV/AIDS interventions in a concrete and com- prehensive manner. They will set the stage for · Capacity building: Incorporate gender- better mainstreaming of gender issues in MAP specific issues and questions related to Operations and Monitoring and Evaluation HIV/AIDS in training and capacity build- Manuals, and assist project staff in operational- ing programs within the Bank and at izing the implications of the gender-based vul- national and local levels. nerability and risk factors outlined in this report: PAD Provisions Recommendations Gender-Sensitive Examples * Findings and Recommendations 27 Table 6. PAD Provisions Recommendations Gender-Sensitive Examples A. Project Development Objective · Key Performance Indicators · Key Performance Indicators: · Project Development Objective should: 1. Cape Verde: "By 2005, reduce by · Key Performance Indicators 1. Be gender-specific (wherever 20% the HIV prevalence among possible). women attending ante-natal care 2. Take into account existing gender clinics." differences in sexual behavior. 2. Senegal: "Knowledge of at least 3. Include social indicators that two methods of protection against address vulnerability/risk factors for HIV/AIDS amount women increases men and women. to 80%." 3. Sierra Leone: "By the end of 2006, an appreciable number of sex work- ers will have left the trade and received skills to establish small micro enterprises." 4. Guinea: "100% of truck stops offer an HIV/AIDS prevention program to drivers" (mostly male) B. Strategic Context · Strategic Choices: · Strategic Choices: · Sector Issues and Strategic 1. Include attention to gender issues 1. The Gambia: Prevention strate- Choices in overall strategy. gies include "Empower women and 2. Include attention to how gender girls to reduce their risk of, and vul- issues influence the spread of the nerability to, HIV infection." virus in efforts to mainstream 2. Sierra Leone: "The Ministry of HIV/AIDS into all sectors of govern- Social Welfare, Gender, and Chil- ment and civil society. dren's Affairs will monitor gender inclusion in activities undertaken by other line ministries and implement- ing NGOs." C. Project Description Summary · Project components: All compo- · Project components: · Project Components nents should focus on gender issues 1. Sierra Leone: "Training of Trainers 1. Capacity Building and/or vulnerability/risk factors (par- Workshop for Engendering HIV/AIDS 2. Public Sector Initiatives ticularly as identified in the target for Development in Sierra Leone 3. Civil Society and Private Sector population). (February, 2002)." 4. Monitoring and Evaluation 1. Capacity Building: include gender 2. Senegal: The project will support · Key Policy and Institutional issues in the training of staff in the a government multi-sector program, Reforms Supported by the Project public sector, the private sector, and which includes "the design, imple- · Benefits and Target Population civil society. mentation and evaluation of IEC pro- 2. Public Sector Initiatives: Incorpo- grams aimed at specific audiences rate relevant gender issues for the such as adolescents (both genders) populations they serve in their in and out of school, women, youth, HIV/AIDS Action Plans. men in uniform, and high risk groups 3. Civil Society & Private Sector: such as CSW and MSM." Encourage organizations to include 3. Cape Verde: Project includes "tar- gender issues and/or vulnerabilities geted support to orphans, guardians in their work of poor orphans, and AIDS-stricken impoverished households, including those headed by women, young people, and the elderly." 4. N/A. 28 Integration of Gender Issues in Selected HIV/AIDS Projects in the Africa Region Table 6 (continued) PAD Provisions Recommendations Gender-Sensitive Examples 4. Monitoring and Evaluation: · Key Policy and Institutional Assess the differential impact of Reforms: project on women and men based 1. N/A on gender-sensitive indicators; · Target Population: assess progress on decreasing vul- 1. The Gambia: High risk groups nerability/risk factors for men and include "commercial sex workers women. and their clients, truck drivers or · Key Policy and Institutional long distance transport personnel, Reforms: migrant workers, and those already 1. Consider reforms that decrease infected." vulnerability/risk factors for both men and women (e.g., changes in laws that afford women greater property rights, increased education for women, protecting women from male violence, acknowledging male prostitution, etc.) · Target Population: Include both at-risk and vulnerable groups of males and females. D. Project Rationale · Lessons Learned: · Lessons Learned: · Lessons Learned and reflected in 1. Include the fact that various gen- 1. Senegal: The project acknowl- the Project Design der-specific vulnerability and risk edges that focusing on vulnerabili- factors are key drivers of the epi- ty/risk factors and high risk groups demic. is essential for future success. "The combination of poverty, illiteracy and gender disparities exacerbate exposure to the virus." For this rea- son the project will target these groups with differential information geared to behavior change, and will also pilot some income-generating activities. E. Summary Project Analysis · Social: · Social: · Social 1. Social development outcomes: 1. Sierra Leone: The project seeks to include the gender-specific impacts "increase community awareness of the project on gender-based vul- and accountability surrounding gen- nerability and risk factors. der and vulnerable children's issues" and "destigmatize PLWA and others affected by the disease, especially women and children who are more likely to be stigmatized and discriminated against." ANNEX Potential Entry Points for Gender Issues Eligibility criteria for MAP funds include: neling grant funds for HIV/AIDS activi- ties directly to communities, civil society, · Satisfactory evidence of a strategic and the private sector; and approach to HIV/AIDS, developed in a participatory manner; · Agreement by the government to use mul- tiple implementation agencies, especially · Existence of a high-level HIV/AIDS coor- NGOs/Community Based Organizations. dinating body, with broad representation of key stakeholders from all sectors, Therefore, including gender issues in bor- including people living with HIV/AIDS; rower's strategies and plans is critical to main- streaming gender throughout the project. The · Government commitment to quick imple- following are suggestions regarding how this mentation arrangements, including chan- might be achieved: 29 30 Integration of Gender Issues in Selected HIV/AIDS Projects in the Africa Region Annex: Potential Entry Points for Gender Issues 30 Key Entry Points for Incorporating Gender Issues Suggestions A. HIV/AIDS National Strategy Plan 1. Creation of the Plan: Include the following groups of people in its 1. Creation of the Plan formulation: 2. Content of the Plan · Women · Members from NGO and CBO already working on gender issues · Men and women living with HIV/AIDS 2. Content of the Plan: a. Analysis of the situation: · Identify vulnerable and at risk groups · Identify social and/or economic conditions that create gender specific vulnerabilities b. Strategies and objectives · Identify concrete strategies to target vulnerable and at risk groups · Identify concrete strategies to reduce specific male and female vulner- abilities by addressing the social and/or economic conditions that cre- ate such vulnerabilities in the first place. B.Public Multi-Sectoral Action All main line ministries have an important role to play in terms of main- Plans streaming gender issues in the fight against the HIV/AIDS epidemic. 1. Main line ministries serving pri- 1. Action plans for ministries serving primarily male populations should marily male populations include a focus on: 2. Main line ministries serving pri- · Reducing the number of partners. marily female populations · Fostering an ethic of responsibility (as a husband and/or father) for their 3. Main line ministries serving both partner's and/or children's health. female and male populations · Respecting women's rights to say "no" to sex, or to request condom use. · Open communication about sex and HIV/AIDS with both sons and daughters. · Information about heterosexual and homosexual transmittal of HIV/AIDS 2. Action plans for ministries serving primarily female populations should include a focus on: · Encouraging women to be knowledgeable about sexual matters, includ- ing HIV/AIDS, and train them to negotiate safe sex. · Reinforcing women's rights to say "no" to sex, or to request condom use. · Providing women with alternatives to risky relationships, such as income generating activities. · Open communication about sex and HIV/AIDS with both sons and daughters. 3. Action plans for ministries serving both female and male populations should focus on both 1 and 2 above. C.Capacity Building and Training Incorporating gender issues that are relevant to HIV/AIDS in all training is 1. Groups to be trained essential to the fight against this pandemic. 2. Content of training 1. Groups to be trained Trainers Personnel in every ministry participating in the project Health workers and counselors NGO and CBO members Integration of Gender Issues in HIV/AIDS Projects 31 Key Entry Points for Incorporating Gender Issues Suggestions 2. Content of training: In addition to health-related information about HIV/AIDS, the following issues should also be included in training: · Defining gender. · Addressing how, in the specific country, gender is related to HIV/AIDS (e.g., cultural norms that dictate passivity and ignorance for women in sexual matters, and encourage multiple sexual partners for men)-- preferably based on a country gender assessment. · Focusing on gender-related vulnerabilities or issues that are most salient for the population being targeted. · Providing ways to counter gender-related vulnerabilities (e.g., training women to negotiate safe sex, higher school enrolment for women, encouraging men to adopt an ethic of responsibility by restricting their unsafe sexual behaviors, etc.). D. School Curricula Including HIV/AIDS information in school curricula is an effective way to reach large numbers of young people. Such information should be provid- ed to youth at an early age, before they become sexually active. A gen- der-sensitive approach should focus on: · Communicating about sex · Incorporating a gender-specific skills based approach to negotiating safe sex: 1. Girls: focus on being assertive, protecting self from infection, etc. 2. Boys: focus on less partners, respecting women's rights to refuse sex or request condom use, protecting self and partners from infection, etc. · Providing a range of safe choices, including abstinence, delayed sexual onset, AND condom use for both boys and girls. · Involving parents and community members · Making condoms available to both boys and girls · Teaching both boys and girls how to use male and female condoms. Notes Executive Summary Chapter 1 1. World Bank. MAP2 for the Africa region. 3. World Bank. MAP2 for the Africa region. 2001. 2001. 2. Visit http://www.worldbank.org/gender/ 4. Ibid. resources/briefing/hivaids.pdf for a briefing note 5. 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