M&E of Gender:

Context of HIV/AIDS
Learning Objectives
 Define gender & related terms
 Identify why gender is important to HIV outcomes &
programming
 Identify criteria for how gender is addressed in
programs
 Identify donor gender M&E donor requirements
 Identify measures of different gender factors
 Apply gender indicators to programs to integrate
gender into M&E
Activity: Vote with your feet!1

 This will help us explore gender

concepts
 Our own beliefs on gender make a
difference
 We need to keep this in mind
when we ask people to address
gender

1 USAID Training of Trainers: Gender and Reproductive Health 101

 Definitions1

 Sex: Biological difference between males &

females
 Gender: What a society believes about the
appropriate roles, duties, rights, responsibilities,
accepted behaviors, opportunities and status of
women and men, in relation to one another
 These beliefs vary between places & change
over time in the same place.
1
WHO 2009: Integrating gender into HIV/AIDS programmes in the health sector
 Definitions1: Gender Equality
 Equal treatment of women and men in laws and
policies, and equal access to resources and services
within families, communities and society at large.
 Comes from written and unwritten norms, rules, laws
and shared understandings.
 Pervasive across societies
 Most prevalent form of social inequality
 Cuts across other forms of inequality such as class,
caste, race and ethnicity.
1
WHO 2009: Integrating gender into HIV/AIDS programmes in the health sector
 Definitions1: Gender Equity
 Stress is on fairness
 Refers to the absence of unfair/avoidable or
preventable differences in health between women
and men
 Different/unequal needs of & barriers affecting
women and men in accessing/benefiting from
health-care programs must be considered in
program resource allocation & design
 Includes and should be inherent to program
monitoring and evaluation
1
WHO 2009: Integrating gender into HIV/AIDS programmes in the health sector
Why do we think about gender &
health?
 High gender equality is associated with:
 Low child mortality, low rates of stunting and wasting
 Higher rates of health care utilization for maternal,
child, and reproductive health services (including
STI/HIV)
 Lower rates of maternal mortality
 Lower rates of gender-based violence
 High gender inequality is associated with lower health
outcomes
 Gender Inequality is a driver of the AIDS epidemic
Gender and HIV/AIDS
 Numerous studies document the relationship
between gender inequality and HIV/AIDS outcomes:
 Increased risk of transmission/higher prevalence
 Less knowledge about HIV/AIDS
 Higher levels of risk-associated behaviors due to
vulnerability
 Association with the incidence of intimate partner
violence, which in turn influences the risk of HIV
 Less utilization of programs & services
 Gender inequalities & HIV/AIDS
Programs1
 Women may not have the power to negotiate condom use
with partners
 So: risk reduction counseling that does not empower women
may be less effective than programs providing skills to
negotiate safer sex
 Women often fear that abandonment or violence would
occur if they disclosed their HIV status to their partners,
and this is a barrier to HIV testing.
 In many societies, women need permission from partners
and families to seek health care, which reduces their
access to health services, including those for HIV.
1
WHO 2009: Integrating gender into HIV/AIDS programmes in the health sector
Gender and HIV/AIDS
Programming
“Gender equality must be at the core of all our actions.
Together we must energize the global response to
AIDS, while vigorously advancing global equality”
-Michel Sidibé, UNAIDS Executive Director
“Gender-related inequalities compromise the health of
women and girls and, in turn, affect families and
communities. Gender-based violence is a serious and
widespread human rights violation, as well as a key
driver of the HIV epidemic.”
-Deborah von Zinkernagel, Principal Deputy Global AIDS
Coordinator (OGAC)
Definitions1: Gender & health
programming
 Gender integration: Strategies applied in
program assessment, design, implementation &
evaluation that take gender norms into account &
compensate for gender-based inequalities
 Gender Mainstreaming: incorporate a gender
perspective into programs, its activities and into
their M&E

1 USAID Training of Trainers: Gender and Reproductive Health 101

Gender and health programming:
Gender integration continuum1

1 USAID Training of Trainers: Gender and Reproductive Health 101

Gender norms: accommodating or transformative?
At a New Delhi bus stop
Gender norms: accommodating or transformative?
 How can health systems address
gender inequality? 1
 Sex-disaggregated data available
 Collected or possible to collect, but not reported or
left out by design
 Quality & ongoing training involved for M&E
system staff
 Gender-focused monitoring & evaluations to
measure progress and impact
 Involvement of stakeholders at all levels

1
Payne, Sarah (2009). How can gender
equity be addressed through health
systems? WHO, policy brief #12
 Gender-based analysis1
 Understanding how experiences of women and men differ
and are similar
 Considers roles and responsibilities of men & women
have in society re: power & decision-making
 Health—differences in
 Health status & determinants
 Care utilization in view of needs
 Ability to pay for services
 Participation of women & men in health management
 Bottom line: GBA reveals influences, omissions &
implications of work in health policy, programming &
planning.

1
PAHO (2009). Guidelines got gender-
based analysis of health data for
decision making. PAHO.
 Data required for GBA1
 Quantitative
 Collecting, reporting & analyzing health indicator and
surveillance data that are disaggregated by sex
 Data on socioeconomic determinants of health, health
status, outcomes , treatments used, incidence of
morbidity & mortality, decision-makers, formal &
informal health providers all collected and reported by
sex
 When possible, further disaggregation by geographic
location, age, income, ethnicity & education

1
PAHO (2009). Guidelines got gender-
based analysis of health data for
decision making. PAHO.
 Data required for GBA1

 Qualitative
 Information about personal experiences and
perspectives
 In depth information about motivations, attitudes,
behaviors, choices etc.
 Gets to the why of what quantitative data shows but
often cannot explain
 In this case, meaning and contextualization of gender
roles & norms and why people act the way they do
within the health system

1
PAHO (2009). Guidelines got gender-
based analysis of health data for
decision making. PAHO.
HIV/AIDS Gender M&E
 Track and evaluate how well gender is addressed in the
program
 Demand for gender integration or mainstreaming as
prerequisite for activity/program planning
 Adhere to donor requirements
 USG Global Health Initiative, gender strategies of USAID,
PEPFAR, UNAIDS, GFATM, World Bank
 Gender should be part of M&E Plan, reflecting how
gender is addressed in the program
 Conceptual Framework, Logic model, indicators, data use
 HIV/AIDS Gender M&E1
 Monitoring
 Indicators that measure gender-specific outputs
 Indicators that track progress and effectiveness of gender-
specific elements of programming
 Disaggregated data collection and analyses
 Data collection in areas such as attitudes and behavior that
reflect gender norms
 Evaluation
 Measuring impact on outcomes that relate to gender-specific
programming
 Elements that address gender equality
 Data used to demonstrate progress and impact, influences
demand for richer data

11
USAID IGWG 2009, A manual for integrating
gender into reproductive health and HIV
programs
 HIV/AIDS, VAW and Gender M&E 1
 Programs should include strong M&E component to
contribute strengthening evidence on intersection between
GBV & HIV
 Monitor gender equality and reducing VAW incidence as
positive process, with outcome indicators related to HIV
risk
 Monitor possible increase in VAW as potential adverse
outcome of HIV-related interventions
 Improve reporting: need systematic way to address extent
and progress or deterioration in type and level of VAW,
including violence against sex workers & other key
populations

WHO 2010. Addressing Violence against

1

women and HIV/AIDS: What works?.

Bilateral & Multilateral Agency Gender
Strategies: USG GHI
 First principle of GHI: women, girls & gender
equality principle
 Gender-related inequalities & disparities
disproportionately compromise women’s and
girls’ health
 Country strategies should include gender
assessments & analysis, and women, girls &
gender equality narrative
Bilateral & Multilateral Agency Gender
Strategies
 PEPFAR: 2 Pronged approach
 Gender integration in all program areas (prevention,
care & treatment)
 Programming along 5 strategic, cross cutting areas:
 Increase gender equity in activities/services
 Reduce violence and coercion
 Address male norms & behaviors
 Increase women’s legal protection
 Increase women’s access to income/productive
resources
Bilateral & Multilateral Agency Gender
Strategies
 WHO guiding principles
 Addressing gender-based discrimination is a prerequisite for
health equity
 Leadership and ultimate responsibility for gender
mainstreaming lie at the highest policy /technical levels of
the WHO
 Programs must analyze the role of gender and sex in areas
of work and for developing appropriate gender-specific
responses in all strategic objectives on a continuing basis
 Equal participation of women and men in decision-making at
all levels of WHO is essential in order to take account of
their diverse needs
 Performance management should include monitoring and
evaluation of gender mainstreaming.
 Bilateral & Multilateral Agency
Gender Strategies
 GFATM gender equality strategy1
 Rationale: gender inequality strong driver of HIV/AIDS,
TB & Malaria epidemics
 Proposals will be funded that:
 Scale up services & interventions that reduce gender-
related risks/vulnerabilities to infection
 Decrease burden of disease for most-at-risk
 Mitigate impact of the 3 diseases
 Address structural inequalities & discrimination

GFATM, Global Fund Gender Equality Strategy

1
 Bilateral & Multilateral Agency Gender
Strategies
 UNAIDS Action Framework for addressing women, girls,
gender equality and HIV1
 Knowing, understanding &responding to the effects of the
HIV epidemic on women/girls.
 Translating political commitments into scaled-up action
addressing rights & needs of women /girls in the context
of HIV.
 An enabling environment for the fulfilment of women’s and
girls’ human rights and their empowerment, in the context
of HIV.

UNAIDS Action Framework: Addressing

1

Women, Girls, Gender Equality and

HIV1. The Action Framework (2009)
 Gender and the Three Ones1
 1 National AIDS action framework that fully integrates
steps towards gender equality
 Commitments, laws, analyses, structural interventions
 1 National AIDS coordinating mechanism-engender roles,
processes and structures
 1 gender-sensitive M&E system
 Gender-responsive budgeting: track gov’t spending & effect
on women, men, girls and boys
 Disaggregate & analyze data by sex to focus on differentials
 Evaluate norms and attitudes supporting gender-power
relations between women and men

1
UNIFEM 2008: Transforming the National AIDS response
Measuring Gender
 Gender differentials in HIV incidence, prevalence, and
service utilization/delivery
 Complex construct unlike many risk factors
 Gender equality measures that have been used for
quantitative analyses in HIV/AIDS studies
 Norms for women and men, including attitudes about
gender-based violence (GBV)
 Beliefs about roles
 Relationship factors
 Women’s autonomy—decision making power in various
areas
 Independent access to economic resources
 Experience of GBV
Example of complex gender equality
measure: GEM Scale
 Objective is to measure attitudes towards gender
norms in intimate relationships among men
 Used to predict multiple partners & IPV in varied
contexts (Brazil, India, China, Uganda etc.)
 24 items, 2 sub scales: Inequitable gender
norms, Equitable gender norms
 Requires asking 24 (can be more or less,
depending on context) items, then performing a
statistical analysis
Areas of measurement:
Gender in the context of HIV
 Prevalence: gender differentials
 Treatment: who gets treatment
 Behavior: risk and care seeking
 Knowledge: differentials in levels and patterns
(what people know)
 Gender Equality Measures (as on previous
slides)
 Programmatic Reach: target populations &
coverage
Areas of measurement:
Gender in the context of HIV
 Gender Based Violence (GBV): prevalence and
health service related
 Stigma/Human Rights: Attitudes, laws and policies
 Humanitarian Emergencies: situation for women and
girls
 Most at Risk Populations (MARPS): people in sex
work
 Orphans and Vulnerable Children (OVC)
 Sample indicators
 Prevalence
% of young women who are HIV infected
 Numerator: # of antenatal clinic attendees (aged 15–24) who test
positive for HIV
 Denominator: # of antenatal clinic attendees (aged 15–24) tested
for HIV
 Treatment
% of adults &children with HIV known to be on treatment 12 months
after initiation of ART. [disaggregated by sex & age] 
Numerator: # of adults and children still alive & on ART 12 months after
initiating treatment
Denominator: Total number of adults and children who initiated antiretroviral
therapy who were expected to achieve 12-month outcomes
Sample indicators
 Behavior: risk
%of young people who have had sexual intercourse before age 15. [disagg.
by sex & age]
Numerator: # respondents (15–24) reproting age at which they first had sexual
intercourse as under 15
 Denominator: Number of all respondents aged 15–24 years
 Knowledge:
% of people who correctly respond to prompted questions about preventing
maternal to child transmission of HIV through ART & avoiding breastfeeding
Numerator: # of respondents who say that HIV transmission from women who
have tested HIV positive can be prevented by the mother taking drugs during
pregnancy &avoiding breastfeeding
Denominator: Total respondents in survey
Sample Indicators
 Gender Equality Measures
Proportion of people who say that wife beating is an acceptable
way for husbands to discipline their wives
Numerator: Number of respondents in an area (region, community, country)
who respond "yes" to any of the following questions:
Sometimes a husband is annoyed or angered by things that his wife
does. In your opinion, is a husband justified in hitting or beating his wife if
 she is unfaithful to him
 disobeys her husband
 argues with him
 refuses to have sex with him
 does not do the housework adequately
Denominator: Total number of people surveyed
Sample Indicators
 Programmatic Reach:
% sex workers reached by HIV prevention programs
[disaggregated by sex & age]
Numerator: #of SWs who replied “yes” to both:
 Do you know where you can go if you wish to
receive an HIV test?
 In the last twelve months, have you been given
condoms (e.g. through an outreach service, drop-in
centre or sexual health clinic)?
Denominator: Total number of respondents surveyed
Sample Indicators
 Gender Based Violence (GBV):
%of health units that have documented & adopted a
protocol for the clinical management of VAW/G
survivors
Numerator: # health facilities in the geographic region
of study (country, region, community) reporting that
they have both documented and adopted a protocol
for the clinical management of VAW/G survivors
Denominator: Total number of health units surveyed
in the geographic region of study
 Sample Indicators
 Gender Based Violence (GBV):
Proportion of people who agree that rape can take
place between a man and woman who are married
Numerator: # of people who agree with the statement:
When a husband forces his wife to have sex when she
does not want to, he is raping her1
Denominator: Total number of people surveyed

1 wording of this question needs to be

carefully developed in order to use
language that conveys the meaning
within the cultural context
Sample Indicators
 Gender Based Violence (GBV):
Proportion of youth-serving organizations that include trainings
for beneficiaries on sexual and physical VAW/G
Numerator: # of youth serving organizations that train
beneficiaries on VAW/G issues. Training curriculums aimed at
youth should include components covering:
 Acts of VAW/G that affect youth along with the health
and social consequences
 How power, coercion and gender issues place youth at
risk for VAW/G
 Where are how youth can get help if they have
experienced an act of VAW/G
Denominator: Total # of youth serving organizations surveyed.
Sample Indicators
 Stigma/Human Rights:
%of people 15-49 expressing accepting attitudes towards people living
with HIV [disaggregated by sex, age, & education
Numerator: Number of women and men aged 15-49 who report
accepting attitudes towards people living with HIV
Denominator: All respondents 15-49 who have heard of HIV
 Humanitarian Emergencies:
# of women & girls reporting incidents of sexual violence per
10,000 population in the emergency area
Numerator: # of incidents of sexual violence reported by
women and girls in the specified period
Denominator: The total camp/area/country population during
the same time period.
Sample Indicators
 Most at Risk Populations (MARPS):
%of female sex workers reporting the use of a condom with every
client in the last month
Numerator: %of FSW respondents who report always using a condom
with every client in the last month
Denominator: Total number of FSW respondents interviewed
 Orphans and Vulnerable Children (OVC)
% children under 18 who are orphans [disaggregated by sex, age,
type of orphan
Numerator: # children under 18 whose mother or father or both
parents have died, as listed by survey respondents
Denominator: All children under 18, as listed by survey respondents
Gender & HIV Indicator resources

 VAW/G compendium
 https://www.cpc.unc.edu/measure/publications/ms-08-30

 HIV indicator Registry (UNAIDS)

 http://www.indicatorregistry.org/
 Go to: browse indicators—need to identify the gender indicators
here

 Gender scales
 http://www.c-changeprogram.org/content/gender-scales-
compendium/index.html
Coming Resource
 Gender and HIV menu of indicator options
 Set of harmonized, agreed-on indicators
 Technical advisory group of global donors &
independent experts, including
 UN: UNIFEM, UNAIDS, WHO, UNFPA
 USG’s GHI: USAID, PEPFAR
 World Bank, GFATM
 Organized by areas of measurement-intersection
ofHIV/AIDS and gender
Activity: Applying indicators

 Using any of the indicator resources listed above

in your group work projects:
 Look at one or two of the resources
 Match an area of measurement that is relevant to
your program
 Select 2-3 indicators that you can use, fill in a
matrix for them
 If time allows, look for another area
MEASURE Evaluation is funded by the U.S. Agency for
International Development (USAID) through Cooperative
Agreement GHA-A-00-08-00003-00 and is
implemented by the Carolina Population Center at the
University of North Carolina at Chapel Hill, in partnership
With Futures Group International, John Snow, Inc., Macro
International Inc., Management Sciences for Health, and
Tulane University. The views expressed in this presentation
do not necessarily reflect the views of USAID or the United
States government.