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World Health Organization
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E-mail: genderandhealth@who.int
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ISBN 92 4 159039 4
Integrating Gender 
into 
HIV/AIDS Programmes
a review paper
World Health Organization
Integrating Gender into HIV/AIDSProgrammesAReview Paper World Health Organization
Integrating Gender 
into
HIV/AIDS Programmes
a review paper
Department of Gender and Women?s Health
Family and Community Health
World Health Organization
Integrating Gender into HIV/AIDS Programmes
? World Health Organization 2003
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Acknowledgements
This publication was prepared for WHO by Dr Geeta Rao Gupta, Mr Daniel
Whelan and Ms Keera Allendorf of the International Center for Research on
Women (ICRW) in Washington, D.C. 
It benefited from the discussion and input from participants at the Expert
Consultation meeting on Integrating Gender into HIV/AIDS programmes, held in
Geneva from 3-5 June 2002: Dr Quarraisha Abdool Karim, Dr Amel Ben Said,
Dr Mabel Blanco, Ms Elaine Chase Pevsner, Dr Raquel Child Goldenburg,
Dr Suneeta Dhar, Dr Yitades Gebro, Dr Janet Gruber von Kerenshazy, Mr Juan
Carlos Hernandez, Dr Josephine Kibaru, Dr Julia Kim, Dr Esteban A. Loy,
Ms Marina Mahathir, Dr Suzanne Maman, Dr Ann McCauley, Ms Inviolata
Mmbwavi, Dr Velepi C. Mtonga, Ms Betty Nabirye, Dr Borworn Ngamsiriudom, 
Dr Marina Nikitina, Dr Alena Peryshkina, Dr Alusio Segurado, Dr Suniti Solomon,
Dr Sally Theobald, Dr Khuat Thu Hong, Dr Ana Lucia Vasconcelos, Dr Kwaku
Yeboah, Dr Teerawattanon Yot and Dr Najma Yousouf Ali.
It also benefited from extensive review by several people in the Departments of
Gender and Women's Health (GWH) and HIV/AIDS of WHO, particularly 
Dr Claudia Garcia-Moreno, GWH and Dr Isabelle de Zoysa (HIV/AIDS).
WHO Library Cataloguing-in-Publication Data
1. HIV infection - prevention and control  2. Acquired immunodeficiency syndrome - prevention and
control  3. Sex factors  4. Women  5. Socioeconomic factors  6. Gender identity  7. Social justice
I. Rao Gupta, Geeta.  II. Whelan, Daniel.  III. Allendorf, Keera.
ISBN 92 4 159039 4 (NLM classification: WC 503.71)
Printed in Switzerland. Ms Carla Salas-Rojas in GWH was responsible for design and layout.
CONTENTS
1.EXECUTIVE SUMMARY 5
2.BACKGROUND AND RATIONALE 7
3.THE IMPACT OF GENDER ON THE HIV/AIDS PANDEMIC 9
3.1 THE ROLE OF GENDER AND SEXUALITY IN DETERMINING
VULNERABILITY 10
3.2 SOCIOCULTURAL FACTORS: NORMS OF MASCULINITY AND FEMININITY 10
3.3 ECONOMIC FACTORS: POVERTY AND DEPENDENCY 17
3.4 THE SPECIAL VULNERABILITIES OF ADOLESCENTS AND YOUTH 22
4.INTEGRATING GENDER INTO HIV/AIDS PROGRAMMING
AND POLICIES 26
4.1 TECHNICAL APPROACHES FOR GENDER INTEGRATION 27
4.1.1 ?DO NO HARM? 27
4.1.2 ?GENDER SENSITIVE? PROGRAMMES 31
4.1.3 ?TRANSFORMATIVE? INTERVENTIONS 33
4.1.4 INTERVENTIONS THAT EMPOWER 38
4.2 STRUCTURAL ELEMENTS FOR GENDER INTEGRATION 41
5.THE CHALLENGES THAT LIE AHEAD 44
6.CONCLUSION 46
7.REFERENCES 47

5
Integrating Gender into HIV/AIDSProgrammes
In the HIV/AIDS epidemic,gender ? defined as the
norms, customs and practices
that define ?masculine? and ?fem-
inine? attributes and behaviours
? plays an integral role in deter-
mining an individual?s vulnera-
bility to infection, his or her
ability to access care, support 
or treatment, and the ability to
cope when infected or affected.
Gender norms, for example,
often dictate that women and
girls should be ignorant and
passive about sex, which greatly
constrains their ability to negoti-
ate safer sex or access appropri-
ate services. Similarly, gender
norms cast women as being pri-
marily responsible for reproduc-
tive and productive activities
within the home, in sharp con-
trast to men who are cast as pri-
mary economic actors and pro-
ducers outside the home. Such
gender stereotypes account for
women having much less access
than men to key productive
resources such as education,
land, income, credit, and
employment, which significantly
reduces the leverage they have
in negotiating protection with
their partners and greatly affects
their ability to cope with the
impact of infection. For men and
boys, gender norms create social
pressure to take risks, be self-
reliant, and prove their man-
hood by having sex with multi-
ple partners. Such norms
expose men and boys to the risk
of infection and create barriers
to their use of HIV/AIDS preven-
tion, care, or support services.
Youth, especially girls, are par-
ticularly vulnerable in the epi-
demic. Furthermore, research
indicates that even gender
norms which supposedly protect
youth, such as those that expect
unmarried girls to remain vir-
gins, can put them at risk by
restricting their access to full
information about sexuality 
and reproductive health services.
While our collective stock of
knowledge about the gender-
related determinants of risk and
vulnerability to HIV and the con-
sequences of AIDS has grown
substantially over the past
decade, putting that knowledge
to good practice has proved 
to be a formidable challenge.
A framework that categorizes 
the different approaches to inte-
grating gender into HIV/AIDS
programming can be useful to
meet this challenge.
Reviewing existing approaches
to address gender in HIV/AIDS
programmes suggests that there
is a continuum of approaches
that have been used ranging
from harmful to empowering.
Interventions can cause harm by
1. Executive
Summary
1. Executive
Summary
reinforcing damaging gender and
sexual stereotypes that perpetu-
ate the epidemic either directly
or indirectly. To be useful, inter-
ventions must, at a minimum,
do no harm. A step up on the
continuum are gender-sensitive
interventions that recognize that
men and women?s needs often
differ and find ways to meet
those needs differentially. The
third, gender-transformative
interventions are a more sophis-
ticated set of approaches that
not only recognize and address
gender differences but go a step
further by creating the condi-
tions whereby women and men
can examine the damaging
aspects of gender norms and
experiment with new behaviours
to create more equitable roles
and relationships. Finally, the
most evolved set of interventions
are structural interventions that
go beyond health interventions
to reduce gender inequalities by
empowering women and girls. 
By increasing their access to
economic and social resources,
such interventions can funda-
mentally change the economic
and social dynamic of gender
roles and relationships, and in
the long term protect women as
well as men and families in the
HIV/AIDS epidemic. 
The challenge of integrating
existing knowledge about the
impact of gender norms and
inequality on HIV/AIDS into
interventions, while formidable,
can be met. There are several
examples of programmes from
around the world that have
adopted different approaches to
integrate gender considerations
in their work. It is important to
draw upon the lessons learned
from these implementation expe-
riences to develop concrete and
practical guidelines for national
HIV/AIDS programme managers
so as to help them integrate gen-
der issues into HIV/AIDS pro-
grammes. The need for such
guidelines is underscored by a
single fact: the effectiveness of
HIV/AIDS programmes and poli-
cies is greatly enhanced when
gender differences are acknowl-
edged, the gender-specific con-
cerns and needs of women and
men are addressed, and gender
inequalities are reduced.
6 Integrating Gender into HIV/AIDSProgrammes
The global pandemic ofHIV/AIDS has now
Research conducted over the
past decade has revealed that
gender roles and relations
directly and indirectly influence
the level of an individual?s risk
and vulnerability to HIV infec-
tion. Gender is also a factor in
determining the level and quali-
ty of care, treatment, and sup-
port that HIV-positive men and
women receive, the burden of
care taken on largely by
women, and the negative eco-
nomic and social consequences
of AIDS. These realities demon-
strate the necessity of compre-
hensively integrating gender
considerations into all levels 
of HIV/AIDS programming in
order to enhance our response
to the pandemic. Integration
will not only benefit women and
girls ? who are often the most
vulnerable ? but men and boys
who also experience gender-
related risks and vulnerabilities
to HIV/AIDS.
a178 While some programme
managers and policy makers
who design and implement
HIV/AIDS prevention, care 
and treatment programmes rec-
ognize the central importance 
of addressing gender, this
recognition is far from universal
or even widespread. The depth
and breadth of our knowledge
about gender-related determi-
nants, barriers and impacts 
of HIV/AIDS has grown signifi-
cantly over the past decade, 
but this knowledge continues 
to outpace our ability to know
precisely how we should
respond programmatically to
these issues in a comprehen-
sive manner. 
a178 In 1999, the Joint United
Nations Programme on
HIV/AIDS (UNAIDS) published
a technical paper entitled
Taking Stock of Research and
Programmes on Gender and
HIV/AIDS. The paper reviewed
research on gender-related
determinants of risk and vul-
nerability to HIV infection
among men and women and
the differential impacts men
and women experience as a
result of actual illness, access-
ing treatments, or seeking and
receiving care and social sup-
port. The review also examined
programmatic activities that
attempted to address gender
dimensions in prevention, care,
treatment and social support.
The findings demonstrated that
although limited in scale,
HIV/AIDS programmes that
address gender equality as a
central goal maximize their
overall effectiveness. 
a178 In order to update and 
build upon the UNAIDS effort,
2. Background
& Rationale
2. Background
& Rationale
7
Integrating Gender into HIV/AIDSProgrammes
8 Integrating Gender into HIV/AIDSProgrammes
the World Health Organization
(WHO) has identified the need to
develop a set of guidelines to
help national level HIV/AIDS
programme planners and man-
agers integrate gender-based
issues and needs comprehen-
sively within HIV/AIDS policies
and programmes. These guide-
lines are intended to go beyond
the ?what? and the ?why? to the
?how? by providing a comprehen-
sive framework for addressing
gender in our response to the
HIV/AIDS epidemic.
a178 To initiate the drafting of
the guidelines, WHO held an
Expert Consultation in Geneva
in June 2002. This Consultation 
brought together experts from
the fields of HIV/AIDS, gender,
health and development, as well
as programme managers who
implement HIV/AIDS pro-
grammes at the national level.
Participants at the Consultation
reviewed existing types of
HIV/AIDS interventions ? volun-
tary counselling and testing pro-
grammes (VCT); efforts to
reduce the incidence of mother-
to-child-transmission of HIV
(MTCT); care, treatment and
support programmes; and pro-
grammes to address the needs
and vulnerabilities of adoles-
cents and youth ? for the pur-
pose of suggesting a set of rec-
ommendations and guidelines to
address gender effectively within
those programmes and interven-
tions. The Guidelines are meant
primarily for HIV/AIDS pro-
gramme managers in WHO
country offices and within
national Ministries of Health.
They might also be useful for
non-governmental organizations
(NGOs) that are involved in
advocacy, research and service
provision. While these specific
types of interventions provide
key opportunities for the incor-
poration of gender issues, they
are by no means exhaustive.
The principles and approaches
discussed here can equally be
applied to other important inter-
vention areas, such as condom
promotion and mass communi-
cation strategies.
a178 This Review Paper aimed 
to provide participants of the
Expert Consultation with back-
ground information and a sug-
gested framework for consider-
ing the issues and challenges of
integrating gender into program-
matic and policy action. It also
offers some programmatic exam-
ples of successful HIV/AIDS
interventions that have
addressed gender issues in a
meaningful and significant
way. This Review Paper is not
intended to be an exhaustive
review of literature on gender
and HIV/AIDS, but rather to
draw from the literature to cre-
ate a picture, in broad strokes,
of the ways in which gender
influences women?s and men?s
vulnerability in the epidemic
and the range of potential pro-
grammatic responses.
9
Integrating Gender into HIV/AIDSProgrammes
Epidemiological and bio-medical research has 
between an individual?s sex and
his or her risk of HIV infection.
It is well known, for example,
that physiological factors
account for the more efficient
transmission of infection from
an infected man to a woman
than from an infected woman to
a man(WHO 1994; Foundation
for Women 1997). More recent-
ly, however, research has also
identified the role that gender
plays in determining individual
risk and vulnerability in the
HIV/AIDS epidemic. Socio-cul-
tural norms about masculinity
and femininity, and the
unequal power relations
between men and women that
arise from those norms, con-
spire with biological and physi-
ological factors to compound
individuals? risk of infection,
resulting in epidemics of signifi-
cant size and proportion in dif-
ferent parts of the world. 
a178 Whereas ?sex? defines the
biological distinction between
women and men, ?gender? is a
social construct that differenti-
ates the power, roles, responsi-
bilities, and obligations of
women from that of men in
society. Gender determines to a
great extent how we think, how
we feel, and what we believe we
can and cannot do as women
and men. Gender roles, norms
and expectations vary over the
life cycle of women and men,
and vary within and between
cultures.
a178 In the HIV/AIDS epidem-
ic, both a person?s sex and gen-
der determine the extent to
which he or she will be vulnera-
ble to infection and his or her
ability to access available treat-
ments. Additionally, gender
inequality influences the extent
to which an individual will be
able to cope with the burden of
infection and illness, caring for
a family member, or surviving
the death of family members,
both economically and socially.
a178 Gender is a culture-spe-
cific construct. As a result there
are significant differences in
what women and men can or
cannot do in one culture as
compared to another. But what
is fairly consistent across cul-
tures is that there is always a
distinct difference between
women?s and men?s roles,
access to productive resources,
and decision-making authority.
Typically, men are expected
to be responsible for the pro-
3. The Impact
of Gender
on the
HIV/AIDS
Pandemic
3. The Impact
of Gender
on the
HIV/AIDS
Pandemic
10 Integrating Gender into HIV/AIDSProgrammes
ductive activities outside the
home while women are expect-
ed to be responsible for the
reproductive and productive
activities within the home. In
addition, in almost every coun-
try worldwide women have less
access to and control of pro-
ductive resources than men,
creating an unequal balance of
power that favors men. Gender
gaps between women and men
in literacy, school enrollment,
labor force participation, land
ownership, and access to credit
testify to this imbalance in
power (UNIFEM 2000).
3.1 The Role of
Gender and
Sexuality in
Determining
Vulnerability
a178 The imbalance in power
created by a differential access
to productive resources trans-
lates into an unequal balance 
of power in sexual interactions
in which the satisfaction of
male pleasure is more likely to
supersede that of female pleas-
ure, and where men have
greater control over their sexu-
ality. Sexuality is the social
construction of a biological
drive. An individual?s sexuality
is defined by whom one has sex
with, in what ways, why, under
what circumstances, and with 
what outcomes. It is a multidi-
mensional and dynamic con-
struct. Explicit and implicit
rules imposed by society, as
defined by gender and age pro-
foundly influence an individ-
ual?s sexuality (Dixon-Mueller
1993; Zeidenstein and Moore
1996; Parker and Aggleton
1999).
a178 The balance of power in
any sexual interaction deter-
mines its outcome. In the worst
cases, this power imbalance
plays itself out in terms of vio-
lence against women. An
understanding of individual
sexual behaviour or sexual risk
thus necessitates an understand-
ing of gender and sexuality as
constructed by a complex inter-
play of sociocultural and eco-
nomic forces that determine the
distribution of power.
3.2 Sociocultural
Factors:
Norms of
Masculinity
and Femininity
a178 Gender norms that create
an unequal balance of power
between women and men are
deeply rooted in the sociocultu-
ral context of each society and
are enforced by that society?s
institutions, such as schools,
workplaces, families, and
health systems (Wingood and
11
Integrating Gender into HIV/AIDSProgrammes
DiClemente 2000). By defining
the societal ideals of feminine
and masculine behaviour and
sexuality, gender norms greatly
affect women?s and men?s
access to information and serv-
ices, their sexual behaviour and
attitudes, and how they cope
with illness once infected or
affected. This section provides
an overview of the different
ways in which cultural pre-
scriptions for masculinity and
male sexuality and femininity
and female sexuality influence
both women?s and men?s vul-
nerability in the HIV/AIDS epi-
demic by affecting what women
and men know, their sexual
communication and behaviour
within relationships, and their
ability to access resources and
services when infected or affect-
ed by HIV/AIDS. 
a178 The dominant ideology of
femininity in most societies
casts women in a subordinate,
dependent, and passive position
with virginity, chastity, mother-
hood, moral superiority, and
obedience as key virtues of the
ideal woman. In terms of
HIV/AIDS, this ideology often
assigns to women particular
roles (as vectors of disease or
merely as bearers of unborn
children) that substantially
influence the design of
HIV/AIDS interventions that
are ultimately harmful and
counterproductive. In sharp
contrast, the dominant ideology
of masculinity characterizes
men as independent, dominant,
invulnerable aggressors and
providers, whose key virtues are
strength, virility and courage.
a178 It is important to remem-
ber, however, that in every soci-
ety there are many kinds of
masculinity and femininity that
vary by social class, ethnicity,
sexuality, and age. It is also
now recognized that the multi-
ple forms of masculinity and
femininity are dynamic, subject
to change, constructed through
social interaction (Gutmann
1996; Rivers and Aggleton
2001). This more nuanced
understanding of masculinity
and femininity is very useful in
terms of HIV prevention
because it implies that modifi-
cations in the construction of
gender identities may be possi-
ble over time and that there are
alternate forms of gender iden-
tities that can serve as models
for promoting more equitable
gender relationships and safer
sex.
a178 Despite the existence of
multiple masculinities and fem-
ininities, however, it is the
dominant ideology that most
greatly influences women?s and
men?s attitudes and behaviour,
making both women and men
more vulnerable in the
HIV/AIDS epidemic. Some of
the ways in which the domi-
nant and damaging ideologies
of masculinity and femininity
manifest and influence women?s
12 Integrating Gender into HIV/AIDSProgrammes
and men?s vulnerabilities are
described below.
a178 Knowledge of Sex and
HIV Risk: In many societies the
dominant ideology of femininity
dictates that ?good women? are
expected to be ignorant about
sex and passive in sexual inter-
actions (Rao Gupta and Weiss
1993; Paiva 1993). A recent
analysis of levels of knowledge
about HIV/AIDS prevention in
23 developing countries found
that levels of knowledge are
almost always higher among
men than among women, with
75% of men, on average, having
accurate knowledge about
HIV/AIDS transmission and
prevention as compared to
roughly 65% of women
(Gwatkin and Deveshwar-Bahl
2001). This knowledge imbal-
ance greatly hinders women?s
ability to be informed about
risk reduction. 
a178 Some studies have shown
that a lack of knowledge or
incomplete knowledge also fos-
ters the development of fears
and myths about condom use.
For example, studies conducted
in diverse settings ? Brazil,
Guatemala, India, Jamaica,
Mauritius and South Africa ?
have found that women did not
like using condoms because
they feared that if the condom
fell off inside the vagina it could
get lost or travel to the throat,
or that a woman?s reproductive
organs would come out when
the condom was removed (Rao
Gupta and Weiss 1993). Even
when a woman is informed or
has accurate information about
sex and HIV prevention, the
societal expectation that a
woman, particularly a young
woman, should be na?ve makes
it difficult for her to be proac-
tive in negotiating safer sex. 
a178 Simultaneously, prevail-
ing norms of masculinity expect
men to be more knowledgeable
and experienced about sex.
This assumption puts men ? par-
ticularly young men ? at risk of
infection because such norms
prevent them from seeking
information or admitting their
lack of knowledge about sex or
protection. Many men, as a
result, have erroneous informa-
tion about sexual and repro-
ductive health (Barker and
Lowenstein 1997; UNAIDS
1999).
a178 Fidelity versus Multiple
Partnerships: In many societies
the dominant ideal of femininity
emphasizes uncompromising
loyalty and fidelity in partner-
ships. It is this ideal that dis-
tinguishes a ?good? woman from
a ?woman of the street? and
defines sexual practices linked
to reproduction as moral and
those that are linked to pleas-
ure as immoral (Rao Gupta and
Weiss 1993).
a178 In sharp contrast, in 
many societies it is believed 
13
Integrating Gender into HIV/AIDSProgrammes
that variety in sexual partners 
is essential to men?s nature 
as men and that men will
inevitably seek multiple part-
ners for sexual release (Mane,
Rao Gupta et al. 1994; Weiss,
Whelan et al. 1996; Rao Gupta
2000). Results from sexual
behaviour studies from around
the world indicate that hetero-
sexual men, both married and
single, as well as homosexual
and bisexual men, have higher
reported rates of partner
change than women (Sittitrai
1991; Orubuloye, Caldwell et
al. 1993; Rao Gupta and Weiss
1993). Recognition and condon-
ing of multiple sexual partner-
ships for men but not for
women sets a double standard
for sexual behaviour that seri-
ously challenges the effective-
ness of HIV prevention efforts
that expect men to be faithful
and reduce the number of sex-
ual partners (Rao Gupta 2000).
Moreover, breakdowns in men?s
ability to meet some masculine
norms, such as providing for
the family, can result in men
seeking self-esteem by fulfilling
other masculine norms, such
as engaging in sex with multi-
ple partners (Silberschmidt
2001). This underscores the
need for HIV/AIDS prevention
efforts to change the gendered
norms of sexuality, if interven-
tions are to be effective.
a178 Motherhood as the
Ideal: Being a mother is con-
sidered to be a feminine ideal in
many cultures. Children pro-
vide a social identity for many
women and guarantee them
some status in kinship groups
(UNAIDS 1999). In addition, in
data from countries in Latin
America and the Caribbean and
some parts of Africa point to
the economic realities that rein-
force the value of motherhood
for women (Le Franc, Wyatt et
al. 1996; Malow, Cassagnol et
al. 2000).
In Jamaica, for example, 
women have children to guar-
antee economic support from
the father. These social and
economic realities pose signifi-
cant hurdles for women in HIV
risk reduction because the use
of barrier methods or non-pene-
trative sex prevents conception
(Heise and Elias 1995; UNAIDS
1999). These realities have con-
sequences in programmatic
terms. In some cases, the prior-
ity is placed on preventing
transmission to the unborn
child without regard for the
rights of the mother to be
informed and choose appropri-
ately what is best for her and
her child. This may include 
loss of choice over whether to
be tested for HIV, whether to
accept an intervention to pre-
vent MTCT if it is available, 
or whether to freely choose
pregnancy termination. In addi-
tion, these programmes often
do not encourage male involve-
ment or male responsibility.
14 Integrating Gender into HIV/AIDSProgrammes
a178 Additionally, programmes
that seek to prevent MTCT by
encouraging women not to
breastfeed may also, in some
settings, present significant
obstacles for women.
Breastfeeding is often an inte-
gral part of the ideal of mother-
hood and in many places
women who do not breastfeed
are seen as bad mothers or
treated as handicapped (Rao
Gupta 2000). The avoidance 
of breastfeeding has also
become associated with being
HIV-positive and thus can be a
significant source of stigma.
a178 Dependence versus Self
Reliance: Women?s economic
and social dependency on men
greatly affects their use of serv-
ices and their ability to adhere
to treatments and other medical
regimens. They are encouraged
and sometimes forced to ask for
permission from their husband
or other family members to
access services. Often, women
will choose not to ask or will be
denied, making it less likely
that they will use services.
Further, even if women do
access services they often must
consult their husbands or oth-
ers in order to act upon the rec-
ommendations of service
providers, thereby creating a
potential barrier to women?s
adherence to treatment and 
care regimens.
a178 Unlike women, who are
expected to be dependent on
others to make decisions and
access resources, men in many
societies are socialized to be 
self-reliant, not to show their
emotions, and not to seek
assistance in times of need or
stress (WHO 1999). This expec-
tation of invulnerability associ-
ated with being a man runs
counter to the expectation that
men should protect themselves
from potential infection and
encourages the denial of risk.
Overall, these manifestations of
traditional notions of masculin-
ity are strongly associated with
a wide range of risk-taking
behaviour. Mane and Aggleton
(2001) point out that ?cultural
and societal expectations and
norms create an environment
where risk is acceptable and
even encouraged for ?real? men?.
It is not surprising therefore
that men are less likely to seek
health care than women and
are much more likely to use
illegal substances and engage
in unsafe sexual practices
(Luck, Bamford et al. 2000).
a178 Sexual Domination,
Homophobia, and Violence
Against Women: Notions of
masculinity that emphasize
sexual domination over women
as a defining characteristic of
manhood contribute to homo-
phobia and the stigmatization
of men who have sex with men.
The stigma and fear that result
compel men who have sex with
men to keep their sexual behav-
iour secret and deny their sexu-
15
Integrating Gender into HIV/AIDSProgrammes
al risk, thereby increasing their
own risk as well as the risk of
their partners, female or male
(UNAIDS 1999).
a178 Another disturbing out-
come of the emphasis on sexual
and physical domination of
women as central to masculini-
ty is violence against women. 
In population-based studies
conducted in a wide range of
countries worldwide, 10 to over
50% of women report physical
assault by an intimate partner.
One-third to one-half of physi-
cally abused women also report
sexual coercion (Heise, Ellsberg
et al. 1999). Research conduct-
ed in a wide range of countries,
including Guatemala, Haiti,
India, Jamaica and Papua 
New Guinea found that violence
against women contributes
both directly and indirectly to
women?s vulnerability to HIV.
Most obviously, violent sexual
acts such as rape are likely to
result in vaginal tearing or lac-
erations, thus dramatically
increasing the risk of contract-
ing an STI or HIV from the
rapist (Maman, Campbell et al.
2000). Additionally, fear of vio-
lence or abandonment often
prevents women from dis-
cussing fidelity with their 
partners or asking their part-
ners to wear a condom.
a178 Fear of violence has also
been found to be a barrier to
the success of efforts that seek
to reduce the perinatal trans-
mission of HIV. In a study of
MTCT prevention programmes
in six African countries, fear of
ostracism and domestic vio-
lence were important reasons
for which pregnant women
refused HIV testing or did not
return for their test results.
HIV-positive women who have
been advised to bottle-feed 
their babies to avoid risk of HIV
transmission have voiced simi-
lar concerns (Brown 1998;
Nyblade and Field-Nguer 2000).
a178 The nexus between vio-
lence, risky behaviour, and
reproductive health has been
documented by a review of liter-
ature on sexual and physical
violence, which showed that
individuals who have been sex-
ually abused as children are
more likely to engage in unpro-
tected sex, have multiple part-
ners, and trade sex for money
or drugs (Heise, Ellsberg et al.
1999). This relationship is also
apparent from the results of a
study conducted in India in
which men who had experi-
enced extramarital sex were 
6.2 times more likely to report
wife abuse than those who had
not. In addition, men who
reported symptoms of sexually
transmitted infections were 
2.4 times more likely to abuse
their wives than those who did
not (Martin, Kilgallen et al.
1999).
a178 The experience of violence
has also been found to be a
16 Integrating Gender into HIV/AIDSProgrammes
strong predictor of HIV. In 
a study conducted in Tanzania
among women who sought
services in a VCT clinic, the
odds of reporting violence was
ten times higher among HIV-
positive young women than
similarly aged HIV-negative
women (Maman, Mbwambo et
al. 2002). 
a178 Access to Services:
Sociocultural norms that 
define male and female roles 
and responsibilities also affect
women?s and men?s access to
and use of health services,
including HIV/AIDS services. 
In countries in which ?son pref-
erence? is the norm, in times 
of scarcity, families allocate
resources for men and boys
first and women and girls later
or not at all. For example, in
Pakistan, lower income house-
holds seek health care more
often for boys than girls and
are more likely to use higher-
quality providers for boys
(Alderman and Gertler 1997).
Women themselves continue
this pattern because of being
socialized to sacrifice their own
interests. They often put the
health of their children and
families first and do not seek
medical attention until they 
are seriously ill (Buvinic and
Yudelman 1989). 
a178 In some regions of the
world, women are further con-
strained from using services
because of gender norms sur-
rounding their mobility.
Practices such as purdah, com-
mon in Islamic and Hindu soci-
eties, where women are con-
fined to their homes, prevent
women from travelling to use
services. Such practices also
demand that health care servic-
es employ women care-givers,
and provide the privacy, mod-
esty, and seclusion necessary
for women to feel comfortable to
use the service (Mehra, Bruns
et al. 1992). For example, many
women feel uncomfortable
interacting with male health
care providers or being forced
to expose themselves in semi-
public wards (Auerbach 1982).
Moreover, services often lack
characteristics that women find
essential, such as emotional
support.
a178 The barriers that men 
face in using services are often
related to sociocultural norms
that ascribe reproductive
responsibilities entirely to
women and shut men out of
parenting or nurturing roles.
For example: family planning,
prenatal, and child health clin-
ics are typically not designed 
to reach men or meet men?s
needs. Because, in many coun-
tries, HIV/AIDS information
and services are provided pri-
marily in such clinics, men are
less likely to benefit from those
services and are thus less likely
to be fully informed about
HIV/AIDS prevention, care and
support, and treatment options
17
Integrating Gender into HIV/AIDSProgrammes
(Mane and Aggleton 2001;
UNAIDS 2001). This has signifi-
cant implications for men?s
ability to protect themselves
from infection and cope with
the epidemic.
3.3 Economic
Factors:
Poverty and
Dependency
a178 Poverty and economic
dependency greatly increase
both women?s and men?s vul-
nerability in the HIV/AIDS epi-
demic. Overall, economic
growth has noticeably
decreased the numbers of indi-
viduals living in absolute pover-
ty worldwide. Women?s econom-
ic status has also shown signif-
icant improvements over the
last decade. The gender gap in
education is significantly lower
and there are more women
earning an income today than
ever before. Yet, it is also true
that the majority of these
women are in insecure jobs in
the informal sector and those
that are employed in the formal
sector continue to earn less 
than men (UNIFEM 2000).
Within certain countries, there
are also sharp differences
between women based on eth-
nicity, race, and socioeconomic
status. Labor market challenges
such as unemployment, wage
gaps, and occupational segrega-
tion are greater for poor women
of color and of indigenous
descent (Inter-American
Development Bank 1998).
a178 A review of women?s eco-
nomic status is important 
in order to assess their vulnera-
bility to HIV because we have
strong evidence to establish a
direct link between women's
low economic status and their
vulnerability and exposure to
HIV. Research from the U.S.
shows women who have lower
incomes and less than a high
school diploma were less likely
than higher income women who
had a high school diploma to
use condoms (Pearson, Grinstead
et al. 1992; Anderson, Brackbill
et al. 1996). Other ways in
which women?s economic status
affects their vulnerability in 
the HIV/AIDS epidemic are
described below.
a178 Sex as a Marketable
Commodity: Studies from
across the developing world
indicate that poverty is over-
whelmingly the root cause 
of women bartering sex for eco-
nomic gain or survival (Weiss,
Whelan et al. 2000). When sex
?buys? food, shelter, or safety, it
is very difficult to follow preven-
tion messages that call for a
reduction in the number of sex-
ual partners. Although com-
mercial sex work is the most
well-known way for women to
exchange sex for money, there
is a range of other types of
18 Integrating Gender into HIV/AIDSProgrammes
?transactional? sexual partner-
ships that women use as a
rational means to make ends
meet. For example, in Haiti,
faced with trying to balance the
multiple demands of family and
economic survival, single moth-
ers often enter into a series of
sexual relationships, called
plasaj, in order to obtain food
and housing for themselves 
and their children. Alarmingly,
research has shown that
women in this setting who
entered a sexual relationship
out of economic necessity had
increased odds of having
syphilis and HIV infection
(Fitzgerald, Behets et al. 2000).
a178 Lack of Economic
Leverage: Women who are eco-
nomically vulnerable are less
able to negotiate the use of a
condom or fidelity with a non-
monogamous male partner and
less likely to leave relationships
that they perceive to be risky
because they lack bargaining
power and fear abandonment
and destitution (Mane, Rao
Gupta et al. 1994; Heise and
Elias 1995; Weiss and Rao
Gupta 1998). There are data to
show that women in high-risk
relationships perceive the 
short-term costs of leaving the
relationship much higher than
the potential long-term health
costs. 
a178 Lack of Access to
Information: Women and 
men who are economically dis-
advantaged are less likely 
to have information about
HIV/AIDS than those from
higher income levels, and are
therefore more vulnerable to
infection. A recent analysis
showed that knowledge of
HIV/AIDS prevention is dis-
tinctly higher among the better-
off than among the economical-
ly disadvantaged in almost
every country with available
data (Gwatkin and Deveshwar-
Bahl 2001). It is important to
note that the analysis showed
that the gender gap in knowl-
edge (which favours men) per-
sists at all income levels.
a178 Impact of Migration:
Poverty and the lack of econom-
ic opportunity make it more
likely that both women and
men will migrate in search of
income and employment, which
can disrupt stable social and
familial relationships and
expose both men and women 
to increased risk of infection.
Moreover, in most settings,
migrant populations are more
likely to be socially marginal-
ized, with restricted access to
economic assets, information,
and services (UNAIDS 1999).
a178 Research from Africa 
has shown that rural-to-urban
migration of men leads them 
to form new sexual networks in
areas where an unequal ratio 
of men to women and a higher
seroprevalence rate is likely to
make them more vulnerable to
19
Integrating Gender into HIV/AIDSProgrammes
infection (Bassett and Mhloyi
1991; Sanders and Sambo
1991). When men are engaged
in seasonal migration for work,
and often return home to their
community of origin, the vul-
nerability of their female part-
ners who are left behind is sig-
nificant. The situation is often
further exacerbated by the fact
that wives and other long-term
sexual partners of migratory
workers find it extremely diffi-
cult to insist on the use of con-
doms when their men have
been away for so long working
hard to send money home.
Migratory women workers face
similar risks. Being away from
home makes it likely that they
will establish new sexual net-
works or engage in multiple
partnerships for economic gain
or security.
a178 Impact of Ethnicity,
Caste, and Race: Gender inter-
sects with ethnicity, caste, and
race to create multiple vulnera-
bilities for those who belong to
marginalized ethnic, caste, and
racial minorities, who have
borne a long history of discrimi-
nation and disadvantage. In
almost every region of the
world, there are large gaps in
terms of schooling and employ-
ment between those who belong
to racial, caste, and ethnic
minorities and those who do
not. Ethnic, caste, and racial
minorities are also disproportion-
ately represented among the
poor in every region of the world. 
a178 With less economic
opportunity and hope, individu-
als from minority or disadvan-
taged groups are more likely to
resort to risky behaviour such
as injecting drug use or
exchanging sex as a means of
survival. Socially and economi-
cally marginalized populations
also typically have less access
to health information and serv-
ices, increasing their vulnera-
bility of contracting illness and
reducing the chances that their
illnesses will get adequately
treated. Unfortunately, HIV
prevalence rates among minori-
ties are usually politically sen-
sitive data and as a result very
few countries disaggregate such
data by race, caste, or ethnici-
ty.
a178 Coping with the
Socioeconomic Impacts of
the Epidemic: Gender also
affects the way in which women
and men are affected by the
economic impacts of the epi-
demic. Research has shown
that women are generally more
vulnerable to the consequences
of AIDS morbidity and mortali-
ty, whether they themselves are
HIV-positive, or they are living
with and caring for others who
are HIV-positive within the fam-
ily, or both ? a situation whose
prevalence is on the rise.
Because women are more likely
to wait longer periods of time
before seeking services and
treatments during the course 
of an illness, they are more
20 Integrating Gender into HIV/AIDSProgrammes
likely to be at an advanced
stage of HIV infection and pres-
ent related opportunistic infec-
tions before they actually seek
out treatment and services.
Thus, they are far less likely to
take advantage of whatever
treatments are available. They
are also more likely than men
to serve as the primary caretak-
ers of others who are infected
and to remain silent about their
own health problems when
other family members are in
need of caring ? whether ill or
not. From data in high preva-
lence settings in Africa it is
known that the combined phys-
ical and emotional burdens of
caring for sick family members
and ensuring their food security
under harsh economic condi-
tions often takes a toll on
women?s own health and well-
being (Danziger 1994).
a178 The economic vulnerabili-
ty of women also exposes them
to graver consequences when
faced with the stigma and dis-
crimination typically associated
with being infected or affected
by HIV/AIDS. When faced with
the social ostracism and aban-
donment that often result,
women frequently face tragic
consequences because they
lack the necessary economic
resources to cope (Nyblade and
Field-Nguer 2000).
a178 Access to and Use of
Services: Economic factors
also affect women?s access to
and use of services. Economic
constraints such as the lack of
money to pay for services or
transportation, or the high
opportunity costs of lost time,
create significant barriers for
women?s use of health services
(Leslie and Rao Gupta 1989;
Moses, Manji et al. 1992). 
a178 The larger workloads of
women who live in poverty or 
in low-income settings make it
more difficult for them to take
the time to access services.
Worldwide, women spend
between 10 and 16 hours a 
day doing housework, collecting
water and firewood, caring for
children, and producing their
family?s food (Buvinic and
Yudelman 1989). This daily
burden of work is significantly
larger than men?s. For example,
African women perform about 
90% of the work of hoeing,
weeding, processing food, and
providing water and firewood, 
80% of food storage and trans-
port and 60% of harvesting and
marketing (World Bank 1989).
Taking time to use services is
particularly difficult for rural
women because they also have
to take time to travel to urban
areas or village centers where
services are located.
a178 Women?s economic vul-
nerability further constrains
their time. Women are concen-
trated in more insecure jobs
with longer hours, poorer pay,
and little or no benefits (United
21
Integrating Gender into HIV/AIDSProgrammes
Nations 2000). These long
hours are added to women?s
already large burden of domes-
tic work, leaving less time in
the day to use health services.
Additionally, in such jobs
women have little control over
the hours or conditions of work,
making it difficult to take time
off. Further, smaller incomes
make the cost of services more
prohibitive for women and the
insecure and small, but critical
income make the opportunity
cost of missing work larger for
women. Thus, reducing waiting
times in clinics and ensuring
that the timings during which
services are provided are con-
venient for women?s work
schedules are key to increasing
their access to those services.
a178 In families where income
and resources are pooled from
multiple individuals, women are
still at a disadvantage in access-
ing funds for health services
because families typically allo-
cate resources for men and
boys first and women and girls
later or not at all (Buvinic and
Yudelman 1989; International
Center for Research on Women
1989). As a result of these fac-
tors, the formidable cost of
HIV/AIDS treatments in most
developing countries are more
likely to constrain women?s
access than that of men. 
a178 Experience of providing
free and universal access to
antiretroviral therapy for treat-
ment of HIV/AIDS in Brazil,
shows that even when services
are free there are noticeable
gender differences in the seek-
ing and use of services. One of
the challenges that remains in
Brazil?s treatment programme is
that, despite a large network of
anonymous voluntary coun-
selling and testing units
throughout the country, women
are not being diagnosed until
the late stages of infection
(Bastos, Kerrigan et al. 2001;
Luppi, Eluf-Neto et al. 2001).
One of the explanations offered
is that for women, testing is
offered in prenatal clinics, even
though many poor women do
not typically use prenatal care
until late in their pregnancy
(Bastos, Kerrigan et al. 2001).
Another possible explanation is
that women do not perceive
themselves to be at risk of HIV
and therefore do not seek test-
ing. Other data suggest that
women?s lack of use of services
could also be the result of the
discrimination they face at the
hand of health workers, who
treat them as if they were pros-
titutes or injecting drug users
(Ventura-Felipe, Bugamelli et
al. 2000).
a178 In summary, gender-
related factors increase
women?s economic vulnerability
and dependency, which in turn
increases their vulnerability to
being infected, restricts their
access to much-needed infor-
mation and services, and
22 Integrating Gender into HIV/AIDSProgrammes
exposes them to severe conse-
quences when infected or
affected by HIV/AIDS. For men,
gender-related norms and eco-
nomic need force them to
migrate without their families
in search of work, creating situ-
ations that foster multiple sexu-
al relationships that may lead
to HIV infection. Overall, pover-
ty greatly exacerbates both
women?s and men?s vulnerabili-
ty by restricting access to infor-
mation and services and mak-
ing it more difficult to cope with
the impact of the epidemic.
3.4 The Special
Vulnerabilities
of Adolescents
and Youth
a178 This section presents the
ways in which gender plays a
particularly significant role in
the experience of adolescents 
in the HIV/AIDS epidemic and
affects their sexual risk and
vulnerability. Because age
intersects with gender in deter-
mining the distribution of
power in any society, younger
members of a society, typically,
have less power than older indi-
viduals and younger women or
girls have less power than
younger men or boys.
a178 Moreover, the power
imbalance characteristic of gen-
der relations among women and
men ? within and outside rela-
tionships ? has many of its
roots in adolescence. At the
same time, in most societies
adolescents are no longer fully
under the protection and guid-
ance of their adult parents, yet,
they are also not endowed and
entrusted with the rights and
responsibilities of adult men
and women. As they enter a
new world of social relation-
ships, young people face the
challenge of reconciling cultural
and family-based expectations
and norms of behaviour with
their own emerging sexual feel-
ings and desires (Weiss, Whelan
et al. 2000). When the chal-
lenges of adolescence occur
concurrently with emerging
gender-related norms and
expectations, a set of special
vulnerabilities arise for youth 
? vulnerabilities that are espe-
cially salient for the design and
implementation of youth-orient-
ed HIV/AIDS policies and pro-
grammes.
a178 Most statistics on adoles-
cent sexual health tend to focus
solely on age of sexual initia-
tion, the incidence of sexually
transmitted infections (STIs),
and the health, social and eco-
nomic consequences of early
motherhood. What these statis-
tics do not reveal is the context
in which risk behaviour takes
place, including the factors that
contribute to early sexual initia-
tion and unprotected sex, and
how these factors differ for
23
Integrating Gender into HIV/AIDSProgrammes
young males and females
(Weiss, Whelan et al. 2000).
a178 Among the most impor-
tant factors are gender differ-
ences in socialization of young
people. Early in adolescent life,
roles are assigned to boys and
girls in matters regarding free-
dom of mobility, time use, types
of education, and decision-mak-
ing responsibilities within the
home (Weiss, Whelan et al.
2000). This includes the early
assignment of sexual ?privileges?
for young men, including those
that introduce and subsequent-
ly reinforce the idea that sex is
a male ?necessity?. In contrast, a
set of sexual ?responsibilities?
are assigned to young women,
including the maintenance 
of virginity, responsibility for
birth control, or exhortations
that passivity and ignorance
about sex is the best ?protec-
tion? a girl can have from sexual
interactions.
a178 Although delayed sexual
debut is a legitimate core ele-
ment of many HIV prevention
efforts for adolescents, it is
important to note that the
severe negative social sanctions
associated with the loss of vir-
ginity, paradoxically, increase
young women?s risk of infection
in many ways. It restricts young
unmarried women?s ability to
ask for information about sex or
reproductive health out of fear
that they will be thought to be
sexually active. Also, in cultures
where virginity is highly valued,
some young women practice
alternative sexual behaviours,
such as anal sex, in order to
preserve their virginity, regard-
less of the fact that these
behaviors may place them at
increased risk of HIV (Weiss,
Whelan et al. 2000).
Particularly strong norms that
reify virginity and a culture of
silence about sex makes access-
ing treatment services for sexu-
ally transmitted diseases highly
stigmatizing for adolescent and
adult women (de Bruyn,
Jackson et al. 1995; Weiss,
Whelan et al. 2000). 
a178 Recent data on the norm
of virginity notes a shift in
young people?s attitudes toward
premarital sex. Studies on the
attitudes and behaviors of ado-
lescents found that there is 
a ?rupture in the salience of vir-
ginity? as a normative ideal 
for adolescent girls (Dowsett,
Aggleton et al. 1998). The
researchers attribute this
change to an increasing sexual
assertiveness by young women
and the acceptance by some
young men of more equitable
gender roles for women. It is
notable, however, that these
changes have not created a
dent in other attitudes about
gender roles, such as women?s
?natural? inclination to get mar-
ried and have children, and
men?s ?natural? need to be sexu-
ally assertive.
24 Integrating Gender into HIV/AIDSProgrammes
a178 Data also indicate that
despite the norm of virginity,
young women and men are hav-
ing sex prior to marriage and
early in their teens. The per-
centage of adolescent girls who
have had sex before the age of
18 years varies greatly between
countries, ranging from 66% in
Ghana to 20% in Mexico (Alan
Guttmacher Institute 1998;
PAHO, WHO et al. 2001).
a178 Young people?s risk of
infection is also greatly affected
by their lack of economic
options. Frustrated youth with
few economic opportunities are
more likely to engage in a range
of risk behaviours, such as 
using drugs and engaging in
unprotected sex in exchange for
gifts, money, or favours
(Mathur, Malhotra et al. 2001).
A notable trend is the number
of young women who are having
sex with older men for money,
material goods, or gifts (Rao
Gupta and Weiss 1993;
National AIDS Programmes of
Trinidad and Tobago 1995;
Zelaya, Mar?n et al. 1997). This
is a troubling trend because
older men are likely to have had
more previous sex partners and
therefore are more likely to have
been exposed to HIV or other
sexually transmitted infections.
a178 While the lack of econom-
ic opportunities increases the
risk of transmission of HIV, the
converse is also true. AIDS 
fuels youth?s lack of economic
opportunities because of the
overall economic impact of the
epidemic in weakening local
economies. Yet, often, youth?s
need for economic options is
greatest in the epidemic. When
parents or other family mem-
bers become ill or die, adoles-
cents become providers and
even heads of households,
forced to take on the economic
responsibility for themselves 
and their families.
a178 Increasingly, programmes
have attempted to respond to
this situation by creating
?linked? services that attempt to
meet both the reproductive
health and livelihood needs 
of young people. Such pro-
grammes have clearly emerged
in response to community need
and frequently adopt innovative
and creative strategies to serve
youth?s needs (Esim, Malhotra
et al. 2001). However, these
linked programmes face formi-
dable challenges. Currently,
there are no ?model? programmes
and optimal methods for ?link-
ing? in a way that provides addi-
tional value are still unclear
(Esim, Malhotra et al. 2001). 
a178 As this section under-
scores, adolescence is a partic-
ularly vulnerable time. But it is
equally true that the adolescent
years provide a window of
opportunity to bring about
changes in levels of knowledge,
attitudes and behaviours before
they are fully formed. In order
Integrating Gender into HIV/AIDSProgrammes
25
for HIV/AIDS interventions to
use this window of opportunity
to reduce young people?s vul-
nerability to HIV and address
their needs within this epidem-
ic, it is critical not only to
ensure that boys and girls get
accurate information and skills
but that interventions also help
them develop more equitable
and respectful gender norms of
behaviour.
26 Integrating Gender into HIV/AIDSProgrammes
Gender norms that pres-sure women and men
ideals of femininity and mas-
culinity and restrict women?s
access to economic resources
fuel the spread of HIV/AIDS
and negatively affect individu-
als? experience when infected or
affected by the disease. By cur-
tailing women?s sexual rights
and autonomy, encouraging
irresponsible and risky sexual
behaviour among men, restrict-
ing women?s access to and use
of economic resources and fos-
tering homophobia, gender
norms have contributed to cre-
ating a culture of silence and
shame that surrounds sexuality
and an unequal balance of
power between women and
men. Together these pose a sig-
nificant challenge for policies
and programmes that seek to
contain the spread of the
HIV/AIDS epidemic.
a178 To meet this challenge,
WHO is committed to integrat-
ing gender considerations into
all HIV/AIDS programming.
This is in keeping with WHO?s
overall goal of integrating gen-
der into all aspects of its broad
mandate to assure health for all
(World Health Organization
2002). This goal includes ana-
lyzing and addressing gender
issues in planning, implementa-
tion, monitoring and evaluation
of policies, programmes, proj-
ects and research. WHO recog-
nizes that integrating gender
considerations is essential for: 
a69Increasing coverage, effective-
ness and efficiency of interven-
tions;
a69The promotion of equity and
equality between women and
men, throughout the life
course, and ensuring that
interventions do not promote
inequitable gender roles and
relations;
a69The provision of qualitative
and quantitative information
on the influence of gender on
health and health care; and
a69Supporting Member States in
undertaking gender-responsive
planning, implementation and
evaluation of policies pro-
grammes, and projects.
a178 Gender integration in
HIV/AIDS programming, as in
all development programming,
has two aspects:
a69 technical/substantive; and
a69 structural.
4. Integrating
Gender into
HIV/AIDS
Programming
and Policies
4. Integrating
Gender into
HIV/AIDS
Programming
and Policies
27
Integrating Gender into HIV/AIDSProgrammes
The technical/substantive
aspect of gender integration
refers to the specific approaches
or strategies used to address
gender differences and con-
straints in HIV/AIDS pro-
grammes and policies. But
these technical approaches are
unlikely to be adopted without
attention to the structural
aspects of gender integration;
to fully integrate a gender per-
spective into all programming
within an institution requires
institutional systems, process-
es, and structures that routine-
ly, continuously, and compre-
hensively identify and respond
appropriately to the different
ways in which gender affects
programming (see Box 1). The
different technical and structur-
al approaches to integrating
gender in HIV/AIDS program-
ming within institutions are
described in the sections below.
4.1 Technical
Approaches
for Gender
Integration
a178 The HIV/AIDS epidemic is
highly complex in its reach and
impact. These complexities are
magnified when we examine
them through the lens of gen-
der. A conceptual framework
that sorts through the different
types of gendered responses to
the epidemic and differentiates
one approach from the other 
can greatly facilitate the devel-
opment of guidelines to assist
programme managers and poli-
cy makers to integrate gender
in HIV/AIDS programming. 
a178 Existing approaches to
address gender in HIV/AIDS
programming fall along a con-
tinuum from ?harmful? (i.e.,
making discriminatory distinc-
tions between men and women
that actually negate any real or
potential programme successes)
to ?empowering? (i.e., fostering
the ability of men and women to
become free of gender-related
constraints and power imbal-
ances, and improving women?s
capabilities to organize, make
choices and decisions, take
positions of leadership, and
shape their own destinies).
While this continuum may in
many cases seem ?linear?, some
interventions may be success-
fully gender-integrative in one
aspect, yet more harmful in
another. It is therefore impor-
tant to consider the full range
of activities in each intervention
and assess them in terms of the
following levels.
4.1.1 ?DO NO HARM?
a178 The most basic and fun-
damental aspect of a gendered
set of policies and programmes
requires the elimination of those
assumptions, suppositions and
stereotypes that are damaging
Integrating Gender into HIV/AIDSProgrammes28
Box 1: Is Schooling A Risk?
A recent study carried out in a government-run, co-educational secondary
boarding school in Kampala, Uganda demonstrated that even a well-designed
and implemented HIV/AIDS education programme can be thwarted by the over-
all gender-discriminatory environment within which the programme is conduct-
ed. This evidence was corroborated by data collected from 21 other schools
around the country.
The main finding of the study showed the school to be a site of an extensive
set of gendered practices, which constituted a risk in themselves in terms of
sexual health. In particular, four patterns or forms of ?control? emerged from the
study: hegemonic masculinity; gendered discipline patterns, sexual harassment,
and ?compulsory'?heterosexuality. 
In the first instance, the AIDS education curriculum addresses the power dis-
parities between male and female but the mechanisms used to gain power
within the school ? defining ?leadership? as a male preserve, for example 
? compromises that part of the curriculum that seeks to change gender norms. 
In terms of gendered discipline patterns, school officials defined differential 
levels of discipline for boys and girls, for example, by reinforcing the idea of
girls as ?victims? ? where rules and regulations for them were designed ?for their
safety?. Thus girls were more ?policed? than boys, including treating girls as if
they might ?tempt? boys sexually. Girls were urged thus to be ?obedient? in a
manner not required of boys. These practices negated parts of the curriculum
designed to encourage boys and girls to ?question? gender role stereotypes 
as a means of empowerment.
Sexual harassment in this environment meant that boys controlled the lan-
guage space and physical space of the girls, forcing them into silence.
Harassment of the girls ranged from having to put up with verbal slights 
and insults to actual physical abuse ? even adult female teachers experienced
verbal abuse from boys in their classes. 
In Uganda, social and sexual interaction within a co-educational setting is the
norm ? students do not self-segregate. In some cases, there were reports by
girls of ?forced relationships?, that they conformed in order to ?be safe? despite
their dislike of the situation. The boys were pressured by their peers to take on
girlfriends, lest they be teased. Boys were also expected to ?prove? themselves
and often dared to ?do something? with a girl. Failure to conform can lead to 
disciplinary measures by peers.
All these findings suggest that even well-designed, ?Best Practice? school-based
prevention programmes for youth may fail if the gendered environmental 
context is not taken into account.
Source: (Mirembe and Davies 2001).
29
Integrating Gender into HIV/AIDSProgrammes
to women?s and men?s ability to
benefit from interventions and
policy responses to HIV/AIDS. 
a178 Programming sometimes
provides women and men the
same interventions when their
needs are different and/or pro-
vides women and men different
interventions when their needs
are the same. The most impor-
tant lesson for doing no harm is
that in order to be gender sensi-
tive health programmes must
offer different services for
women as compared to men
when their needs differ but
must ensure that services 
do not treat women and men
differently when their needs are
the same. This does not mean
that supporting programmes for
women exclusively when it is
appropriate to do so must pres-
ent a ?trade-off? that excludes
the necessity of programming
exclusively for men.
a178 Many of our past, and
unfortunately, current HIV pre-
vention efforts have fostered
violent, predatory and irrespon-
sible images of male sexuality,
while at the same time portray-
ing women as powerless and
passive ?victims? of male power
and domination. In addition,
women are often seen as ?repos-
itories? of infection and disease,
responsible for bringing illness
and death into their households
and communities. Particularly
vivid examples of these stereo-
types are prevention efforts that
portray sex workers as harbin-
gers of death, and condom pro-
motion efforts that employ
macho stereotypes of male viril-
ity in order to promote condom
sales. Although such efforts
may result in short-term gains
through, for example, an
increase in condom sales, in 
the long-term they erode the
very foundations upon which
HIV prevention activities are
based, namely responsible,
respectful, consensual, and
mutually satisfying sexual part-
nerships.
a178 Another common mistake
made in HIV/AIDS program-
ming that seeks to be gender-
sensitive is when women and
men are provided different
interventions or information
based on stereotypes of
women?s and men?s roles when,
in fact, their needs and respon-
sibilities are the same. A com-
mon example is when basic
information about the preven-
tion of perinatal transmission of
HIV is provided only to women,
with the assumption that it is
women who are mothers and
must therefore be the only ones
informed about ways to prevent
MTCT of infection. This has
many harmful outcomes. First, 
it undermines any efforts to
encourage parenting as the
responsibility of both mother
and father. Second, it makes it
more likely that men will block
their female partner?s use of
MTCT prevention services
30 Integrating Gender into HIV/AIDSProgrammes
because they are not fully
informed about the value of the
intervention. Third, it reinforces
the stereotype of women as ?vec-
tors of disease?. Finally, it con-
tributes to the social (and
sometimes physical) harm that
women experience as a result of
being the ?first? to ?take home?
an HIV-positive test result. 
Thus, providing women and
men with different interventions
and information when their
needs and responsibilities are
the same is just as deleterious
as providing women and men
with the same interventions
when their needs and con-
straints are different. 
a178 In order to avoid doing
harm or further reinforcing the
very norms that a gendered
response to HIV/AIDS must
change, it is important to
design interventions based on
data on women?s and men?s
lives in a particular community
or setting, rather than presum-
ing to know the reality based on
stereotypical notions of gender
roles. Box 1 provides an example
of how an overlooked contextual
aspect of an intervention can
totally negate any gains made
in the intervention, and ulti-
mately can destroy an interven-
tion?s credibility entirely.
a178 Data on the inequalities
and injustices that women face
can sometimes lead to another
harmful practice that could
undermine the ultimate success
of HIV/AIDS efforts. Blaming
men for perpetuating injustices
against women is not a produc-
tive way to resolve the unequal
balance of power in gender rela-
tions. Such an approach runs
the risk of shutting men out of
the process of finding feasible
solutions and significantly con-
strains the ability of pro-
grammes to work with women
and men as equal partners in
promoting reproductive and
sexual health. Statements that
see men as the major or sole
problem to deal with in
HIV/AIDS programmes run the
additional risk of oversimplify-
ing social, economic and politi-
cal structures. They fail to
acknowledge that gender, class,
race, sexuality and age (among
other factors) oppress men as
well as women ? albeit in differ-
ent ways and with different con-
sequences (Mane and Aggleton
2001).
a178 Although the idea that
policies and programmes must
do no harm may seem like sec-
ond nature to those working at
the programme and field levels,
it may be the most pervasive
shortcoming of many existing
programmes. More comprehen-
sive efforts cannot succeed
unless HIV/AIDS programming
first and foremost does no
harm. It is important to remem-
ber, however, that the elimina-
tion of damaging assumptions
and stereotypes about women
and men does not constitute
31
Integrating Gender into HIV/AIDSProgrammes
the only way to respond to gen-
der considerations in program-
ming. Although necessary,
?doing no harm? is only the first
step along a continuum. 
4.1.2 ?GENDER-SENSITIVE?
PROGRAMMES
a178 A second approach recog-
nizes that the prevention, care,
treatment and support needs of
men and women are often dif-
ferent, not only because of their
distinct physiology, but more
importantly, because the con-
text of gender roles and rela-
tions substantially influences
how women and men will
respond to initiatives designed 
to reduce risk or vulnerability
or to alleviate the impact of
AIDS.
a178 Programmes that foster
the development of female-con-
trolled prevention technologies
are one example of this type of
programming. Another example
would be educational messages
about prevention that recognize
the unequal power balance
between men and women that
is prevalent in all contexts and
settings. Programmes that rec-
ognize the unique vulnerabilities
that men face ? such as the
Healthy Highways Project in
India ? represent another
important and often overlooked
aspect of gender-sensitive pro-
gramming. In this case, the
project seeks to lower the risk
and vulnerability to HIV infec-
tion of truck drivers, their
young crew members, and their
paid sexual partners (see Box 2).
Another example of this type of
programming is the integration
of STI diagnosis and treatment
interventions into family plan-
ning clinics to help women
access such services without
fear of social censure. Providing
women with a female condom
or advocating for the develop-
ment of microbicides are other
examples of gender-sensitive
interventions. Such efforts rec-
ognize that the male condom is
a male controlled technology
and take account of the imbal-
ance in power in sexual interac-
tions that makes it difficult for
women to negotiate condom
use, by providing them with (or
advocating for) an alternative 
? a woman controlled preven-
tion technology.
a178 An adaptation of the tra-
ditional model of prevention 
of MTCT is another example of 
a gender sensitive approach. 
The traditional MTCT preven-
tion package consists of volun-
tary counselling and testing of
pregnant women, the provision
of antiretrovirals for pregnant
women who are infected in
order to protect the unborn
child from infection, and the
provision of breast milk substi-
tutes to reduce the risk of infec-
tion to the baby once it is born.
This standard protocol treats
the woman as merely a carrier
Integrating Gender into HIV/AIDSProgrammes32
Box 2: Addressing Male Vulnerability in India
The Healthy Highways Project was planned and implemented by the
Department for International Development, UK (DFID) and the Government of
India's National AIDS Control Programme (NACO). The project aims to reduce
the number of new HIV infections among inter-city truck drivers, their crew and
paid sexual partners. Two regional units manage the work, which has been
mainly implemented through more than 30 NGOs, 18 transport companies and
a number of transport-related associations.
In 1999, estimates suggested that almost 3.5 million people in India had
become infected with HIV. Although there have been no studies to determine
seroprevalence among truck drivers, there have been alarming increases in
HIV infection among antenatal women in the areas where high concentrations
of truck drivers live. There are up to five million truck drivers in India, and
behavioural surveys show that 75% of truck drivers report extramarital sex,
mostly with sex workers (among whom HIV infection is up to 60% in the worst
affected areas). Truck driving involves long periods of separation from spouses
and families, dangerous and exhausting work, and relatively high earnings.
Commercial sex partners are usually extremely poor and are mobile rather than
brothel-based, making them difficult to reach with HIV prevention messages
and technologies. Since condoms are usually associated with family planning,
this type of ?recreational sex? is usually unprotected. 
The Healthy Highways Project offers STI care and counselling, condom promo-
tion and distribution, dissemination of educational materials and face-to-face
behaviour change communication. While the mobility of drivers made conven-
tional peer education impractical, training has been given to some who come
into close contact with truckers, including petrol attendants, tobacco retailers
and tea-shop owners. Beyond the 3.5 million men who have been reached
through the project's activities, work has taken place with more than 33,000 
sex workers, more than 2,000 of whom have been treated for STIs.
Men have reacted positively, welcoming services and expressing eagerness 
to obtain more information. The NGOs working with the men have established
excellent networks and links with gatekeepers, but have not always had prior
experience working specifically with men. 
This should be kept in mind in any attempts to replicate this kind of intervention
elsewhere.
Source: (UNAIDS 2001).
33
Integrating Gender into HIV/AIDSProgrammes
or vessel for the baby, giving no
importance at all to the baby?s
need for its own mother or the
woman?s own right to treat-
ment, care, and support. Cost
considerations, among other
factors, are cited as the reason
for not including antiretrovirals
for the infected mothers as part
of this traditional regimen. 
Increasingly, however, program-
mers are including treatment
for opportunistic infections,
care, and support for the infect-
ed mother as additional ele-
ments to the standard regimen,
to help the mother through the
pregnancy and to maintain her
health and well-being, not just
that of the baby (see Box 3).
Such an adaptation responds to
women?s needs and treats them
as equally important as those of
the child.
a178 The bulk of HIV/AIDS
programmes that have success-
fully addressed gender have
done so by acknowledging gen-
der differences and designing
services to meet the different
needs of women and men.
Although effective, it is impor-
tant to remember that gender-
sensitive programmes do very
little to change those conditions
that create gender-related barri-
ers in the first place. If we are
to think in terms of a long-term
set of goals for the creation of
successful and sustainable
HIV/AIDS programmes, we
must recognize that gender-sen-
sitive interventions, while criti-
cally important for meeting the
needs of women and men in the
epidemic, cannot be the ?end of
the line?.
4.1.3 ?TRANSFORMATIVE?
INTERVENTIONS
a178 Programmes that seek to
transform gender roles and cre-
ate more gender-equitable rela-
tionships are more advanced
than gender-sensitive approaches
because they seek to change
the underlying conditions that
cause gender inequities. They
also transform HIV/AIDS initia-
tives by reaching both women
and men and recognizing both
as critical players in ensuring
the effectiveness of HIV/AIDS
programming.
a178 Transformative interven-
tions use a variety of methods
to work with men and women to
facilitate an examination of
gender and sexuality and its
impact on male and female sex-
ual health and relationships, as
well as to reduce gender-related
violence against women. One
example is Stepping Stones, a
well-known life skills training
programme that uses transfor-
mative methods to address
HIV/AIDS as well as broader
community issues (see Box 4).
Through a curriculum that
includes group participation,
ways to change, and examina-
tion of why people behave the
way they do, participants are
Integrating Gender into HIV/AIDSProgrammes34
Box 3: MTCT Interventions
While prevention of MTCT has advanced significantly in recent years, care and
support services for HIV-infected women have not moved forward with sufficient
emphasis, despite the burden of HIV disease borne by women of reproductive age.
Programmes for prevention of HIV infection in infants and young children (MTCT
prevention) allow identification of HIV-infected women and delivery of short course
antiretrovirals and other interventions to prevent HIV transmission to infants. They
also offer an opportunity to provide care and support to HIV-infected women, chil-
dren and their families. For the large part, MTCT prevention programmes have
tended to focus only on children, offering very limited direct benefit to HIV-infected
women.
There is increased recognition and increased attention of the need for interventions
for women who are identified as HIV-positive through such programmes. In particu-
lar, recent treatment breakthroughs and their application in resource-constrained
countries have led to demand for expanded care and support interventions that
can benefit the health of  the women themselves during and after pregnancy, as
well as the health of their children and families. 
We must face many challenges in ensuring care of HIV-infected women identified
through MTCT prevention and other service. The complex interactions between
HIV prevention and care, treatment and support interventions point to shortcom-
ings inherent in offering a single intervention, such as ARV drugs alone, to 
HIV-infected women. To date, however, there is very little normative and strategic
guidance on the comprehensive HIV-related care, treatment and support needed
by women in resource-constrained settings. 
Some progress has been made that will require continued advocacy and support.
Advances have been made in highly active antiretroviral therapy (HAART) with
simpler regimens and lower prices. The World Health Organization and its 
collaborative partners are developing guidance on a comprehensive approach to 
HIV-related care, treatment and support of HIV-infected women and their children
in the context of Reproductive Health and Maternal and Child Health Services in
resource-constrained settings. This guide will assist policy-makers and programme
managers of HIV/AIDS and reproductive health programmes. The manual will 
present a menu of key interventions that includes medical, nutritional, and psy-
chosocial interventions, based on an inventory of existing recommendations, a
review of evidence, and experience of what works in different settings. It will also
provide related norms and standards, highlight information gaps and establish
research priorities. Several countries are proposing programmes for extending
MTCT prevention efforts to care and support for women, to improve their own sur-
vival. Health workers are encouraged to recognize the needs of HIV-infected
women and refer HIV-infected mothers and infants for related services, as avail-
able.Timely and adequate referring not only includes relevant care and medical
services, but fostering of partnerships between maternal and health care pro-
grammes and social, psychological, legal, and community based support systems. 
Integrating Gender into HIV/AIDSProgrammes
35
Box 4: The Challenges and Opportunities of Changing Gender
Norms: The Stepping Stones Curriculum
Stepping Stones is a life skills training package that encourages participants to
find their lives, and those of others, worthwhile enough to look after themselves
and each other. The original Stepping Stones package was designed as 
18 sessions over 3-4 months, for at least four parallel groups of older and
younger women and men, meeting simultaneously. Sessions were grouped
around four main themes: 
a69group cooperation; 
a69why we behave in the ways we do; 
a69HIV and safer sex; and 
a69ways in which we can change.
During workshop sessions, participants explore the range of factors that deter-
mine the quality of their lives and discuss their hopes and fears. Through this
process, participants are encouraged to take control and responsibility for their
own lives and form a strong bond by recognizing the equal value and contribu-
tion of each part of the community. It is on this basis that behaviour change 
? not only for HIV prevention, but a wide range of other community develop-
ment issues?can begin to take place.
Experience has shown that Stepping Stones requires time, good training,
skilled facilitation, care, negotiation, prolonged follow-up and more time. A wide
range of factors can prevent the successful transfer of Stepping Stones from
one context to another. Strategies to promote its success include:
a69Ensuring high quality implementation. 
a69Promoting regular attendance.
a69Reducing barriers to attendance for poor men. 
a69Bringing peer groups together.
a69Meeting special requests.
a69Challenging gender and age norms.
a69Working with issues of difference within the community.
a69Including ongoing participatory monitoring.
Ongoing challenges ? and potential programmes failures ? include familiar 
concerns about condoms among participants and non-participants, in addition
to objections about the ?open? discussion of sexuality and family planning, par-
ticularly with young, unmarried people. However, the most important obstacle 
is achieving sustainability. As Baron Oron from Uganda stated, ?[when follow up
is lacking, and the community expects it] it leaves a gap and may destroy all
that has been created?. 
Source: (Gordon and Welbourn 2001).
36 Integrating Gender into HIV/AIDSProgrammes
encouraged to take responsibili-
ty for themselves and others to
promote safer, more productive,
behaviour in the future. What is
novel about projects like
Stepping Stones in particular 
is that they actively target men
for something other than pro-
moting condom use or generic
?safer sex? messages. These
projects foster an environment
that works with both men 
and women to redefine gender
norms and encourage healthy
sexuality.
a178 Programmes such as 
these have grown out of a belief
that the dominant form of mas-
culinity can be changed and
replaced with more gender equi-
table models of malehood.
Research conducted by Gary
Barker (2000) in Brazil and by
others was influential in estab-
lishing that alternative, more
equitable masculinities do exist
(Necchi and Schufer 1998; Yon,
Jimenez et al. 1998). Each of
these studies identified young
men who showed some degree
of gender equity in their inti-
mate and sexual interactions
with young women. Barker
(2000) went a step further and
also identified the factors asso-
ciated with gender equitable
attitudes among the young men
who were different. The key fac-
tors he isolated include acknowl-
edgement of the costs of tradi-
tional masculinities to their own
health and well being, access to
adults who do not conform to
traditional gender roles, rejec-
tion of domestic violence within
their families, and the presence
of a gender equitable male peer
group.
a178 In addition to Stepping
Stones, examples of other pro-
grammes that seek to foster
constructive roles for men in
gender relations are the Men as
Partners (MAP) programme in
South Africa; the interventions
that target young men, men in
prisons, and a wide range of
professional and working class
men, designed and implement-
ed by Salud y Genero, a small
nongovernmental organization
based in Mexico; and Project
Papai in Recife, Brazil that tar-
gets young men on themes
related to fatherhood. 
a178 Transformative approach-
es with youth attempt to shift
the gender-power imbalance
during a time when many pat-
terns of adult behaviors are
being formed. Some initiatives,
such as the Mid-Peninsula AIDS
Prevention Programme (see Box 5)
have been piloted or field tested
with promising initial results.
This transformative approach
was used in a school-based pre-
vention programme on HIV for
youth in California. The intent
of the programme was to
encourage youth to examine
and challenge culturally pre-
scribed expectations and norms
that lead to behaviours that fos-
ter risk of HIV infection.
Integrating Gender into HIV/AIDSProgrammes
37
Box 5: Challenging "Sexual Scripts" with Youth in
California, USA
The Mid-Peninsula AIDS Prevention Programme, a project supported
by the Center for AIDS Prevention Studies (CAPS) in San Francisco,
recently tested an innovative school-based programme with more
than 500 racially-diverse ninth graders (average age = 14 years).
The programme educated youth on HIV and its transmission and
worked to empower youth by teaching them to think critically about
?sexuality scripts? (sets of ideas and norms that prescribe ways 
of thinking and acting in terms of sex and sexuality) and how enact-
ing these scripts can result in self-damaging behaviour. Many of
these scripts prevent the empowerment of young women, and dis-
empower young men in ways that they are not consciously aware of
but which they assume to be normal and natural. Students participat-
ed in the programme for one hour each day for a week. Activities
included an interactive game on HIV facts, discussions of how sexu-
al scripts affect experiences and expectations in sexual and romantic
relationships, and brain-storming about strategies to resist 
internalization of such scripts in sex-specific groups. 
In an evaluation, researchers found that knowledge on HIV and
STDs had increased significantly after the programme, but they were
unable to demonstrate significant change in sexual behaviour. This
lack of significant behaviour change was partially due to the low level
of risk behaviour at baseline and the relative short time period of
three months from baseline to evaluation. However, there was some
change for sexually inactive girls; more of those in the study group
delayed sex compared to those in the control group. Additionally, the
evaluation demonstrated that the approach could have significant
behavioural impacts in future. In the baseline study, there was a
strong correlation between risky sexual behaviours with stereotypical
beliefs about sex and gender, especially for boys. After the pro-
gramme, the majority of participants said that the workshop helped
them become more aware of gender pressures and better able to
protect themselves from HIV and pressure to have sex.
Source: (Somera and Laub 1998).
38 Integrating Gender into HIV/AIDSProgrammes
a178 Other programmes that
seek to transform gender rela-
tions include efforts to work
with couples as the unit 
of intervention, rather than 
with individual men and
women.  Couple counselling in
HIV testing clinics to help cou-
ples deal with the results of
their tests and in family plan-
ning programmes to promote
dual-protection against both
unwanted pregnancy and infec-
tion are recent examples of
efforts that seek to reduce the
negative impacts of the gender
power imbalance by including
both partners in the interven-
tion. The challenge these pro-
grammes face is not being able
to recruit couples who are will-
ing to participate. Although
many couples who do partici-
pate describe couple coun-
selling as a positive experience,
so far the numbers who partici-
pate have remained low (Becker
1996). Further research is
needed to identify ways to over-
come barriers to couple coun-
selling and to test the effective-
ness of this method in creating
more gender-equitable relation-
ships between women and men.
4.1.4 INTERVENTIONS THAT
EMPOWER
a178 At the other end of the
continuum from damaging poli-
cies and programmes are those
that empower women and girls.
These types of interventions
seek to equalize the balance of
power between women and men
in order to reduce their vulnera-
bility in the epidemic.
Interventions that see empower-
ment as an end goal also tend
to treat HIV/AIDS within a larg-
er context of social and eco-
nomic development. Once
example of this is a project car-
ried out in Sonagachi, a red-
light district in Calcutta, India.
Initially designed as an inter-
vention to reduce the level 
of STDs and increase condom
use among sex workers, the
programme has expanded to
empower sex workers by
enabling them to control their
own lives and solve their own
problems, as both a goal in and
of itself and as a way to prevent
the spread of HIV (see Box 6).
a178 To design interventions
to empower women requires us
to first deconstruct the sources
or components of power that
are amenable to project or
policy intervention. The first,
most fundamental source of
power for individuals in society
is access to information, educa-
tion, and skills. We must give
women and men basic informa-
tion about their bodies, sexuali-
ty, disease, and reproduction.
Access to information is vital for
individuals to protect themselves
in the HIV/AIDS pandemic and,
more importantly, it is a basic
human right. In addition, pro-
viding women with basic skills
such as increasing their con-
Integrating Gender into HIV/AIDSProgrammes
39
Box 6: Sonagachi: Empowering Sex Workers to Prevent HIV/AIDS
in India
In 1992, the All India Institute of Hygiene and Public Health (AIIH&PH) in 
consultation with the National AIDS Control Organization (NACO) of India, 
the Ministry of Health and Family Welfare of West Bengal, and WHO initiated an
HIV intervention targeting sex workers in Sonagachi, a red light district in
Calcutta. In the beginning, the project was largely directed towards reducing the
level of STDs and increasing condom use among sex workers. However, the
programme has expanded to empower sex workers by enabling them to control
their own lives and solve their own problems, as both a goal in and of itself and
as a way to prevent the spread of HIV. 
As of 2000, the programme had reached over 8,000 street-based sex workers,
out of an estimated 12,000 living in Calcutta, in a wide variety of activities.
Several health care clinics have been built and staffed to provide ongoing health
care, distribution of condoms, HIV testing and counselling, and the like. Many
women also participate in peer education during six-week training sessions
where they learn about health issues and where and when to go for health care.
Through the peer education groups, an acting group developed that performs
plays about STD and HIV prevention, as well as additional sex work issues. The
group has performed at many venues, including the Twelfth World AIDS
Conference in Geneva. In 1998, the sex workers initiated a Positive Hotline for
counselling and support for HIV-positive individuals,including both sex workers
and the larger community. Perhaps most significantly, in 1995, the sex workers
began a registered cooperative where they save money, provide loans and small
investment schemes for members, and market condoms. With the profits, mem-
bers have started a cr?che for sex workers? children and purchased land for a
training center outside of Calcutta where older sex workers produce handicrafts.
Other activities have included legal aid and training and literacy classes for the
sex workers and sensitization training for police.
Despite challenges, including police raids and internal adjustments with the
close integration of project staff and sex workers, the project has become a well-
known success. Evaluations have consistently found significant improvements in
knowledge of AIDS, condom use, and even STD and HIV incidence. For exam-
ple, in 1992, 1.1% of sex workers surveyed reported always using condoms. By
1995, this rose to over 50%. Similarly, while HIV prevalence rose dramatically
among sex workers in most parts of India, only 5.5% of randomly sampled
women at Sonagachi were HIV-positive in 1998. 
While Sonagachi continues to expand and grow, complete with ongoing chal-
lenges, they attribute their continuing success to placing the control of the inter-
vention with the community, building capacity among both staff and sex workers,
treating sex workers as whole persons, and meeting the sex workers? felt needs.
Source: (UNAIDS 2000).
40 Integrating Gender into HIV/AIDSProgrammes
dom literacy and providing
them with the skills to commu-
nicate with their partners about
sex helps to reduce their risk
and vulnerability to infection.
a178 Another important source
of power for women is access to
economic resources and assets.
Ensuring the implementation
and protection of women?s prop-
erty and inheritance rights;
ensuring their access to sources
of credit; ensuring equal pay for
equal work; fostering the provi-
sion of business, financial and
marketing skills necessary for
the success of their enterprises;
providing access to agricultural
extension services to ensure the
highest yield from their land;
promoting access to formal sec-
tor employment; and ensuring
their rights to be free of abuse
and exploitation in the informal
employment sector are all ways
by which women?s access to
economic resources can be
facilitated.
a178 Social capital is another
critical source of power.
Increasing social support for
women who are struggling to
change existing gender norms
and helping them to expand 
their social networks by provid-
ing them opportunities or meet-
ing in groups and raising
awareness in communities is
yet another important ingredi-
ent for building social capital
and empowering women.
Strengthening grass-roots
women?s organizations by pro-
viding them with adequate
resources also helps build
social capital for women.
a178 In the final analysis,
empowered women have the
political agency to make deci-
sions and shape their own des-
tinies. Providing women with
leadership opportunities, the
opportunity to problem-solve 
and organize are well-tested
ways of increasing women?s
political power and could go a
long way toward empowering
women to cope with the varied
demands that the HIV pandem-
ic burdens them with. Beyond
direct interventions, we need to
pay attention to the contextual
factors of empowerment as well.
Working to protect women from
violence and moving the prob-
lem of gender-related violence
out of the personal sphere and
into the public sphere are other
ways to facilitate their political
empowerment.
a178 In the ultimate analysis,
reducing the imbalance in 
power between women and 
men requires policies that are
designed to empower women.
Policies that aim to decrease 
the gender gap in education,
improve women?s access to eco-
nomic resources, increase
women?s civic and political par-
ticipation, and protect women
from violence are key to empow-
ering women. HIV/AIDS pro-
gramme experts and
41
Integrating Gender into HIV/AIDSProgrammes
researchers must advocate
strongly for creating a support-
ive policy and legislative context
for women because such a con-
text is crucial for containing the
spread of HIV/AIDS and miti-
gating the impact of the epi-
demic.
4.2 Structural
Elements for
Gender
Integration
a178 Since the mid-1990s, pro-
gramme designers and imple-
menters have struggled with
turning knowledge about the
gender-related determinants of
risk and vulnerability to
HIV/AIDS into effective pro-
grammatic interventions.
Beyond the constraints that are
part and parcel of addressing
gender within any particular
public health programme, the
very nature of the epidemic 
(i.e., its economic, social, cul-
tural and political dimensions)
has meant dealing with another
set of constraints ? those that
are deeply structural. If integra-
tion of gender concerns at the
technical level is to succeed,
these structural constraints
and barriers have to be
addressed as well.
a178 First and foremost is the
need to foster and develop the
political will and leadership at
the level of state institutions
that is necessary to create a
policy environment amenable to
the wholesale integration of
gender into HIV/AIDS pro-
grammes. This requires, among
other things: directly engaging
policy makers with the tools
and materials that make a case
for the value of integrating gen-
der (especially the use of sound
research data that demonstrate
the incontrovertible evidence 
of the gender dimensions of
HIV/AIDS), and providing them
with guidelines on how to make
that possible, supported by
evaluation-based evidence from
the field that demonstrates that
addressing gender increases the
effectiveness of HIV/AIDS pro-
gramming.
a178 There are many rationales
in making a case for gender
integration into HIV/AIDS pro-
grammes. In particular, initia-
tives to integrate gender can
and should rely on equity and
efficiency rationales, or at least
be willing to alter rationales to
meet the needs of those to
whom advocacy for integrated
programming is targeted. By
equity, we are referring to advo-
cacy based on human rights,
appeals to justice, or other fair-
ness-related arguments. The
more instrumental efficiency
approach maintains ? and right-
fully so ? that gender integra-
tion maximizes the effectiveness
of programmes by reaching
more people and reducing con-
42 Integrating Gender into HIV/AIDSProgrammes
straints to accessing and using
information, technologies and
services for all. It yields more
sustainable long-term results in
terms of lowering the incidence
of infection and mitigating the
negative consequences of AIDS.
Both rationales should be used,
as appropriate for particular
settings or audiences, to justify
integration.
a178 The allocation of financial
resources is clearly a key struc-
tural determinant of the suc-
cess of any integration effort.
However, this goes beyond sim-
ply providing money for ?gender
initiatives?, which often is fund-
ing that is sporadic and nar-
rowly targeted at a highly spe-
cific project or programme.
Successful integration of gender
requires that funding for all
programme areas be increased
to match the overall program-
matic goals of an HIV preven-
tion, care and support, or treat-
ment programme, with gender-
analysis and gender-disaggre-
gated goals and indicators for
evaluation woven in through-
out.
a178 Successful integration
requires that technical knowl-
edge and understanding of and
expertise on gender-analysis
and the gender-specific realities
of women and men exists at all
levels and departments of the
institution, not merely at the
level of service provision.
Gender must not be seen as an
add-on or appendage, but
rather a core element to be
addressed in order to maximize
the effectiveness of the pro-
gramme. To ensure that the
response to gender considera-
tions is integrated not grafted
on, it is critical that all institu-
tional gender expertise not
remain centralized in one
department or with one ?key?
gender ?point-person?.
Integration must extend out-
ward to ensure that all pro-
gramme staff understand the
gender-differentials related to:
risk factors of HIV infection;
access to information, educa-
tion, services and technologies;
differences in progression of
HIV infection and distinctions
between men and women as to
the type and severity of oppor-
tunistic infections; the different
roles that men and women play
as formal and informal care
providers; and the differential
social and economic burdens of
AIDS morbidity and mortality.
The training used to promote
such knowledge and under-
standing should be hands-on,
practical, related to a specific
type of intervention, and pre-
sented in the context of maxi-
mizing a programme activity?s
effectiveness.
a178 As with almost any kind
of programmatic activity, the
need for data that provide direc-
tion to an institution as to
where funds should be priori-
tized and what kind of response
Integrating Gender into HIV/AIDSProgrammes
43
would be best is crucial. While
the data gap on women and HIV
infection has more or less been
bridged, there is still a need for
sex-disaggregated data on a
host of other socioeconomic
indicators of women?s status
that are essential in order to
understand the direction, scope
and impact of the epidemic in
different parts of the world.
Therefore, sex-disaggregated
data collection and analysis is
an important element for
understanding and addressing
gender.
a178 Part and parcel of data
collection is the effective moni-
toring and evaluation of integra-
tion into programmatic activi-
ties. Again, this cannot be an
?add-on? or secondary goal of
the project. Sound monitoring
and evaluation criteria and
tools need to be integrated into
programme design from the
outset, to ensure that the wide
variety of gender-specific ele-
ments ? technical and structur-
al ? is being addressed. 
a178 In order to ensure that
gender is integrated compre-
hensively throughout a pro-
gramme, there should be an
institutional incentive system
that rewards employees who
pay attention to gender issues.
Without such incentives, pro-
grammes are likely to continue
treating gender as a marginal
aspect of ?mainstream? projects
and programmes and pay lip-
service to the issue rather than
treat it as important for the effi-
ciency and effectiveness of 
projects.
Integrating Gender into HIV/AIDSProgrammes44
As with most areas ofpublic policy and action,
relationship between gender and
the HIV/AIDS pandemic is far
ahead of our knowledge ? and in
many instances, capabilities and
commitments ? about how to
respond effectively. Since the
mid-1990s, programme planners
and implementers, policy mak-
ers, and donors have recognized
the gender dimensions of the
HIV/AIDS pandemic. It has
been recognized that for effective
results, the incorporation of
gender considerations must per-
meate programmes and policies
at all levels. Integrating gender
into existing and new HIV/AIDS
programmes and policies must
not be considered to be a ?side
show?, luxury ?accessory? or a
second-thought ?add-on?.
Consideration of gender must
form the very centerpiece of all
policies and programmes aimed
at slowing the spread of HIV and
mitigating the impact of AIDS.
a178 However, to date the
majority of initiatives to inte-
grate gender into effective pro-
gramming have been small and
experimental. Where pilot initia-
tives seemed to show promise,
navigating the uncharted waters
of ?scaling-up? remains a signifi-
cant challenge to overcome. 
a178 The acknowledgement of
how deeply gender permeates
the enormous scope of the
HIV/AIDS pandemic has forced
many to admit that this is more
than a ?health matter?. The
incorporation of a comprehen-
sive gender framework to
address HIV/AIDS issues goes
far beyond the standard or tra-
ditional set of HIV/AIDS inter-
ventions to include a wide range
of social and economic interven-
tions. The realities of gender
inequalities within the social
and economic context of any
given country can prevent or
negate even the best HIV/AIDS
interventions. These contextual
factors cannot be ignored.
Ultimately, to address economic
and social gender inequities that
lie at the root of the pandemic
requires a multisectoral
response that must increase
women?s and girls? access to
productive resources such as
education, employment, land,
and credit, end the culture of
silence and shame that sur-
rounds sexuality, and protect
girls and boys from the corrosive
effects of gender stereotyping.
a178 This recognition that
HIV/AIDS is more than a health
matter is a critical step forward
in addressing the pandemic.
5. The
challenges
that lie
ahead
5. The
challenges
that lie
ahead
45
Integrating Gender into HIV/AIDSProgrammes
However, the questions of who
should implement such non-
health interventions and how it
should be done naturally arise.
Should institutions with health
mandates engage in non-health
interventions to address health
outcomes, or should health
institutions partner with non-
health institutions through
linked programmes and other
mechanisms? Or should entire-
ly new methods be used? These
are not easy questions to
address, yet the countries that
have been the most successful
in reducing the number of new
infections (e.g. Senegal,
Thailand and Uganda) are those
that have used a multisectoral
approach to HIV/AIDS. In the
case of Uganda, programmatic
and policy foci that included
elimination of gender-damaging
programmes, a commitment to
gender sensitive HIV prevention,
gender-transformative innova-
tions and efforts to empower
women (especially in the area of
women's human rights) have
been cited as key to the success
of Uganda?s approach to
HIV/AIDS (Garrett 2000;
Sittitrai 2001).
This review of issues andapproaches to address
in the HIV/AIDS epidemic rein-
forces the conclusion that suc-
cess is contingent upon integrat-
ing gender considerations.
Clearly, if gender issues are
ignored, programmes run the
risk of minimizing their effective-
ness or even causing harm.
However, it is also clear that
there is no single way to address
gender, nor is there one
approach that can guarantee
success. Programmes must
address individuals? vulnerability
in a variety of ways within both
short and long term timeframes.
In the short term, gender-sensi-
tive programmes are our best
hope. We must continue to
address women and men?s vulner-
ability by continually adapting to
and meeting women?s and men?s
gender and age-specific needs
within the current social and cul-
tural context. But we must also
plan for the long term. Gender-
sensitive programming will not
change the gender-based realities
that fuel the epidemic and make
women and men vulnerable.
Transformative and empowering
programmes must be implemented
alongside gender-sensitive pro-
grammes in the hope of ultimately
challenging the very foundation of
the epidemic. This is the broad
direction we must take, but to fol-
low this road map there is a great
need for building the capacity of
programmes and policy experts in
integrating gender and for provid-
ing them with specific program-
matic guidelines that specify ?how?
gender considerations can be inte-
grated into different types of
HIV/AIDS policies and pro-
grammes. This is the next impor-
tant step that WHO will take with
others in order to ensure that gen-
der norms and gender inequality
do not continue to fuel the
HIV/AIDS epidemic.
46 Integrating Gender into HIV/AIDSProgrammes
6. conclusion
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