Men's limited understanding of family planning (FP) and harmful cultural gender norms pose obstacles to women's FP use. Thirty-two model men called 'Emanzis' were recruited from the community in Kabale, Uganda to lead men from their peer group through a 10-session curriculum designed to transform gender norms and motivate men to engage in FP and HIV services. Cross-sectional surveys were conducted before (n = 1251) and after (n = 1122) implementation. The Gender Equitable Men (GEM) Scale was used to assess the effect on gender attitudes. The intervention achieved negligible changes in responses to GEM items. Improvements in some gender-influenced health-seeking behaviours and practices in men were noted, specifically in visiting health facilities, HIV testing, and condom use. For future application, the intervention should be adapted to require higher peer educator qualifications, longer intervention duration, and more frequent supervision. Practical guidance is needed on where to direct investments in gender-transformative approaches for maximum impact.

Male involvement for increasing the effectiveness of prevention of mother-to-child HIV transmission (PMTCT) programmes.

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IssuesThe recently launched “Global Plan towards the Elimination of New HIV Infections among Children by 2015 and Keeping their Mothers Alive” sets forth ambitious targets that will require more widespread implementation of comprehensive prevention of vertical HIV transmission (PMTCT) programmes. As PMTCT policymakers and implementers work toward these new goals, increased attention must be paid to the role that gender inequality plays in limiting PMTCT programmatic progress.DescriptionA growing body of evidence suggests that gender inequality, including gender-based violence, is a key obstacle to better outcomes related to all four components of a comprehensive PMTCT programme. Gender inequality affects the ability of women and girls to protect themselves from HIV, prevent unintended pregnancies and access and continue to use HIV prevention, care and treatment services.Lessons LearnedIn light of this evidence, global health donors and international bodies increasingly recognize that it is critical to address the gender disparities that put women and children at increased risk of HIV and impede their access to care. The current policy environment provides unprecedented opportunities for PMTCT implementers to integrate efforts to address gender inequality with efforts to expand access to clinical interventions for preventing vertical HIV transmission. Effective community- and facility-based strategies to transform harmful gender norms and mitigate the impacts of gender inequality on HIV-related outcomes are emerging. PMTCT programmes must embrace these strategies and expand beyond the traditional focus of delivering ARV prophylaxis to pregnant women living with HIV. Without greater implementation of comprehensive, gender transformative PMTCT programmes, elimination of vertical transmission of HIV will remain elusive.

South Africa has some of the highest levels of both HIV and gender-based violence (GBV) worldwide. The international literature has highlighted the importance of tackling GBV in the fight against AIDS. Although the link between these epidemics is acknowledged by South Africa's medical and NGO communities, government response has largely dealt with them separately. PEPFAR is South Africa's largest HIV/AIDS donor, representing significant funding potential for programmes seeking to tackle these twin epidemics. Using a combination of policy document analysis and key informant interviews at national and provincial level (Western Cape), we examined PEPFAR's response to the GBV-HIV link, the extent to which PEPFAR is aligned to national policies and the extent to which implementing agencies have felt able to work with PEPFAR funding. A number of PEPFAR-South Africa's positions (e.g. on condoms and abortion) stand in contradiction to South Africa's own laws. While PEPFAR-South Africa officials are adamant that PEPFAR addresses the GBV-HIV link, it does not form an explicit strategic goal and there are no indicators for this work. Although some agencies receiving PEPFAR funding do address the links between GBV and HIV, this appeared incidental rather than the reason for their receipt of PEPFAR funding. Not one implementing agency interviewed agreed with PEPFAR's ideological stance, perceiving it unhelpful and inappropriate in a social context defined by violence and HIV. Nevertheless, many organizations were prepared to apply for funding. Those awarded it found creative ways to work with-or around-PEPFAR's restrictions to ensure delivery of an appropriate range of much needed services to those facing the twin epidemics of HIV and GBV. The recent change in the US administration offers an important opportunity for broader links between HIV and GBV to be supported through PEPFAR. This paper makes recommendations for building a more systematic approach on the current ad hoc experience of PEPFAR in South Africa.