Reports

Though substantial progress has helped curb the HIV epidemic, high rates of new HIV infections persist among adolescent girls and young women (AGYW) in sub-Saharan Africa, reflecting critical gaps in reaching them with integrated HIV prevention and sexual and reproductive health (SRH) services. The scale-up of oral pre-exposure prophylaxis (PrEP) and multiple novel HIV prevention products on the horizon offer countries a unique opportunity to expand innovative approaches to deliver comprehensive, integrated HIV prevention/SRH services.

This article comparatively analyzes findings from rapid assessments in Kenya, Malawi and Zimbabwe across key themes to highlight cross-country trends and contextual realities around HIV prevention/SRH integration, with a focus on oral PrEP and contraception. In Kenya and Zimbabwe, assessments were completed by Ministries of Health (MOH) and the HIV Prevention Market Manager and include 20 health facility assessments, 73 key informant interviews (KIIs) and six community dialogues. In Malawi, the assessment was completed by the MOH and Georgetown University Center for Innovation in Global Health and includes 70 KIIs and a review of national policies and program implementation in Blantyre. Findings were contextualized through a review of literature and policies in each country.

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This is a pivotal moment for the U.S. Agency for International Development’s vision of global health and development, with the USAID Administrator, Samantha Power, championing locally led and inclusive development, referred to as localization. This approach focuses on making U.S. foreign assistance more accessible, equitable, and responsive by shifting leadership, decision making, and funding to local actors—government, civil society, and the private sector. While previous U.S. administrations promoted greater country ownership, the current discussion has taken on far greater urgency; it is happening amidst a global reckoning around structural racism and social determinants of health, decolonization of global aid, and the power imbalances inherent in donor-driven development. These debates have been accentuated by the COVID-19 pandemic, which has exacerbated inequities while shifting more responsibilities to local actors. Despite challenges ahead in operationalizing localization in compliance with USAID requirements, this vision holds the promise of advancing partner countries’ needs and priorities and transforming the global health landscape through a more inclusive, equitable, collaborative, and sustainable approach.

Most discussion around localization has centered on transitioning health service delivery and procurement to local partners, which is generally standardized and thus easier to measure than localization in the area of health policy. A gap exists in translating the localization agenda to the policy, advocacy, financing, and governance (PAFG) sphere of USAID’s global health programs. This foundational dimension cannot be overlooked: to strengthen health systems, to address health challenges at scale, and to sustain an equitable and inclusive response depends on a strong enabling environment, which reflects the interrelated social, economic, policy, and governance factors that influence the health system. PAFG activities aim to improve the enabling environment for health by strengthening the capacity of governmental bodies (parliaments, ministries, and regulatory agencies), as well as civil society advocacy organizations and the private sector in their stewardship of the health sector (Hardee et al., 2012). Taken together, these components form the foundation for health policy development, advocacy, decision making, civil society engagement, and domestic financing. Indeed, progress in localization will be demonstrated by the extent to which PAFG capacities, skills, and decision making are strengthened and transitioned to local actors. Strong and effective leadership by local actors in health is essential for USAID’s partner countries and local communities to steer toward a healthier future.

As USAID and its partners move forward in implementing localization, the Health Policy Plus (HP+) project seeks to support these efforts by building on its extensive global experience. Specifically, HP+ has partnered with local actors to plan, fund, and implement policy, advocacy, financing, and governance solutions to health challenges aimed at improving health outcomes. These programs have shown the importance of elevating local voices for policy and advocacy, including for marginalized groups and those focused on improving gender equity. HP+ has also shown the value of embedding aspects of localization into the development and implementation of government policies. Informed by HP+ lessons learned at the country level, this brief provides a set of recommendations and illustrative program examples for USAID, its implementing partners, and the global health community to collaborate, implement, and innovate in new ways with local partners to advance localization in the PAFG realm.

By promoting a vision for the way forward, HP+ seeks to further catalyze localization in PAFG and support local partners to achieve sustainable success, aligned with USAID’s commitments and goals. Ambassador Donald Steinberg, expert advisor on localization to Administrator Power, reiterated a guiding principle, often used by HIV advocates, for shifting responsibility to local actors: “Nothing about us without us.”

On December 1, 2014—World AIDS Day—PEPFAR launched a bold initiative called DREAMS—Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe. The goal was to significantly reduce new HIV incidence among adolescent girls and young women in the highest-burden countries in sub-Saharan Africa and in Haiti, where they face a far higher risk for new HIV infection—2 to 14 times higher—than their male peers. Despite the urgency of reducing HIV in this population to reach global goals for epidemic control, Covid-19 and new global efforts around health security threaten to divert the focus on this critical population. DREAMS is now at an inflection point, facing the risk that its progress on girls and young women will be reversed, along with decades of health and development gains for women and girls.

A major new report for the CSIS Global Health Policy Center examines what lessons have been learned in the first five years of DREAMS and what the next five-year approach might be, including redressing the disruptions and costly damage imposed by Covid-19. The report analyzes how DREAMS has evolved and what its impacts have been, including what factors contributed to success or constituted barriers. It also discusses implications for U.S. policy, focused on what is needed going forward if DREAMS is to further drive down HIV infections and increase the health and agency of girls and young women more broadly, with recommendations for the new Biden-Harris administration and Congress. The report argues that DREAMS has been successful in reaching millions of girls and young women with a multisectoral package of services and has catalyzed a global focus on young women and HIV. Although directly attributing the DREAMS impact is complicated, DREAMS has contributed to a decline in HIV incidence among AGYW in all the DREAMS districts. Yet DREAMS represents an expensive model that would be difficult for countries to replicate and sustain and has sparked criticism for operating in parallel to national and local mechanisms. Despite its challenges and critics, DREAMS has proven to be a promising model that is uniquely suited to an adapted and reimagined U.S. strategy that moves toward more integrated approaches and away from siloed, vertical programs.

Click here to download the report.

Sometimes innovation to spur social change arises in unexpected places. In 2011, in Ouagadougou, the capital of Burkina Faso, representatives from nine Francophone West African countries joined with international donors to launch a simple but radical plan. The idea was to expand access to contraception in a region that was dramatically lagging behind the rest of the continent in maternal and child health. What became known as the Ouagadougou Partnership achieved a level of success that was virtually unimaginable at the outset, when even discussing family planning in such conservative societies was perceived to be taboo. Now, almost a decade later, the partnership’s impact and lessons for other regions warrant both celebration and reflection.

The nine Francophone countries of the subregion (Benin, Burkina Faso, Côte d’Ivoire, Guinea, Mali, Mauritania, Niger, Senegal, and Togo) united around an ambitious regional goal—to reach one million additional voluntary users of modern family planning methods by 2015, and 2.2 million more by 2020. The results have been impressive, especially given the low starting point of approximately 2.7 million users: by 2019, over 3.1 million additional voluntary users have been reached, Francophone West Africa has one of the fastest increases in modern contraceptive rates among developing regions, and family planning funding from the core donors has more than doubled. Even more important for future prospects, the partnership has evolved into a dynamic and influential regional platform involving governments, donors, civil society, and implementing partners.

The story of this partnership reflects a unique historical convergence: a group of bilateral and philanthropic donors willing to commit to the subregion, country-level champions from government and civil society, supported by implementing partners, prepared to advance family planning for health and development reasons, and a shared interest in doing business differently to address egregious gaps in women’s health and stalled indicators on family planning. By banding together, fueled by a shared commitment to achieving a regional goal, “friendly” competition among the countries, and grounded in data and evidence, the nine relatively small countries capitalized on their commonalities and made the region a more important geographic space and population size.

Janet was commissioned in 2019 by the William and Flora Hewlett Foundation and the Bill & Melinda Gates Foundation to write this report documenting the history of the Ouagadougou Partnership. She completed her research in January 2020, before the first cases of COVID-19 were confirmed in Francophone West Africa (in Senegal and Burkina Faso) in March 2020. Accordingly, this report does not address the impact of COVID-19 in Francophone West Africa or the challenges it presents to the Ouagadougou Partnership’s activities.

Many of the fastest growing populations are in the world’s poorest countries, putting them at a critical threshold: either they will accelerate economic growth and innovation by investing in their burgeoning youth population or the rapid population growth coupled with a shortage of opportunities for young people will undermine advances in health, development, and ultimately security. These demographic trends, most notable in sub-Saharan Africa, are often referred to as a “youth boom” or a “youth bulge.” Given the enormous implications of these demographic shifts, U.S. assistance should promote young people’s health and development, with particular emphasis on empowering young women. Investments in human capital and gender equality would yield enormous benefits in improving health, reducing poverty, and increasing economic and political stability. Given that these goals align so strongly with U.S. national interests, they benefit from strong bipartisan support.

This agenda constitutes an urgent priority. The magnitude of this demographic transition is evident in sub-Saharan Africa; sixty percent of the population is under the age of 25 and is projected to dramatically increase in the coming years due to decreased under-five child mortality and to continued high fertility, which is often driven by early and closely spaced childbearing. In many of these countries, notably in the Sahel region of West Africa, the population may double as soon as 2030—the year the world community pledged to achieve the Sustainable Development Goals—and possibly quadruple by the end of the century. Overall, the population in sub-Saharan Africa could increase from 1 billion to 4 billion before the end of the century.

Violence against children (VAC) and violence against women (VAW) are public health and human rights crises of global proportions, with damaging consequences to the health and well-being of individuals and their communities. Fueled by gender inequality, social norms condoning violence and harmful traditional practices,1 and exacerbated by lack of commitment to take preventive and protective action and weak protection systems, violence against women and children (VAWC) as well as the magnitude, human toll and societal cost of this violence is increasingly acknowledged by the global community.

Together for Girls (TfG) is a partnership among national governments, UN entities and private sector organizations working at the intersection of VAW and VAC, with special attention to ending sexual violence against girls. Now being implemented in more than 22 countries, the TfG model supports governments to conduct a national household Violence Against Children Survey (VACS) and to use the data to mobilize action through policies and programs that embed violence prevention and response across multiple sectors.

In 2009, the Government of Tanzania, with support from TfG partners, most notably UNICEF, the U.S. Centers for Disease Control and Prevention (CDC), and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), undertook the VACS. Tanzania was the first country to implement a full VACS, surveying both girls and boys (ages 13-24) nationally to assess the prevalence of emotional, physical and sexual violence. It was also the first country to introduce a government-led, multi-sector task force to oversee the implementation of the survey and the ensuing violence prevention and response work catalyzed by the data, which led to the establishment of a multi-sectoral, costed National Plan of Action. Ten years after Tanzania’s landmark research, this case study seeks to consolidate learnings from the national experience of implementing the TfG model.

In many ways, Malawi exemplifies the success of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). Over the last 14 years, new HIV infections have declined by 34 percent. Despite being among the poorest countries in the world, Malawi is approaching its HIV treatment targets. The possibility of controlling the epidemic is within reach.

But Malawi also lays bare major challenges and gaps facing the HIV response, notably how to prevent HIV and address HIV risk for adolescent girls and young women (AGYW) in low-resource settings.

Malawi is 1 of 10 focus countries in east and southern Africa under DREAMS (Determined, Resilient, Empowered, AIDS-Free, Mentored, and Safe), a public-private partnership led by the President’s Emergency Plan for AIDS Relief (PEPFAR) that aims to reduce the number of new HIV infections among 15- to 24-year-old women by 40 percent in geographic “hot spots.” As a prevention program, it is attempting to reach young women and their male partners, populations that have proven very difficult to reach thus far.

This is a moment of heightened focus on the urgency of addressing HIV in adolescent girls and young women by the United States, other international partners, and the government of Malawi. To learn more about the status of DREAMS implementation and lessons for other country programs, CSIS conducted a research trip to Malawi in April 2017.

U.S. leadership through the President’s Emergency Plan for AIDS1 Relief (PEPFAR) has driven remarkable progress in curbing the global AIDS epidemic, raising the possibility of epidemic control in 10 African countries by 2020. But this success masks areas of urgent unfinished business that could derail this momentum, notably preventing HIV infections in adolescent girls and young women ages 15-24 in East and Southern Africa. Addressing the acute risks that these young women face presents unique challenges, especially in the current U.S. budgetary environment, but continued progress against HIV requires that this be a consistent and sustained U.S. priority. The benefits are clear and compelling: empowering these young women and providing access to services to protect themselves from HIV enables them to be healthy and to thrive, which contributes to healthier, more stable and prosperous families, communities, and societies.

Adolescent girls and young women face significantly higher HIV risk than males their age. That, combined with a youth population that has doubled since the start of the epidemic, leads to an inescapable conclusion: if new HIV infections among girls and young women are not greatly reduced, PEPFAR’s enormous investments to achieve an AIDS-free generation are at risk, as is the global response. Focusing on adolescent girls and young women, while also systematically engaging their male partners, provides a critical opportunity to interrupt the cycle of HIV transmission.

In response to these stark realities, in late 2014 PEPFAR launched DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored and Safe), a public-private partnership to reduce HIV in adolescent girls and young women in 10 countries. DREAMS holds notable promise in confronting this critical next frontier in fighting HIV, but faces challenges in demonstrating short-term impact on social and economic realities that directly or indirectly contribute to HIV risk for these young women.

Zambia is a lower-middle-income country struggling with critical health challenges, including high rates of maternal and neonatal mortality, malnutrition, cervical cancer, and a severe HIV/AIDS epidemic that disproportionately affects adolescent girls and young women. The United States is the largest donor to the health sector in Zambia, largely through the President’s Emergency Plan for AIDS Relief (PEPFAR).

Over the past five years, the U.S. has also helped establish several public-private partnerships (PPPs) aimed at advancing the health of women and families. These PPPs provide lessons about the potential impact of these approaches, the challenges inherent in such partnerships, and the importance of PEPFAR support. With future U.S. global health funding likely to be flat-lined, this is an important moment to assess how partnerships with the private sector can amplify the impact of U.S. investments in women’s and family health.

A delegation from the CSIS Task Force on Women’s and Family Health visited Zambia in April 2016 to examine U.S. investments through three partnerships: Saving Mothers Giving Life (SMGL), Pink Ribbon Red Ribbon (PRRR), and DREAMS. The delegation sought to understand these partnerships in Zambia within the context of U.S. support for women’s and family health, which represent the core of functional health systems.

Click here to read the report. You can link to the Zambia page of the CSIS Task Force on Women's & Family Health here.

Senegal is a key country for U.S. investments in women’s and children’s health, demonstrating the impact of support for strong national leadership and targeted U.S. health resources. The U.S.-Senegal partnership has led to significant health gains, notably rises in immunization and contraceptive prevalence rates. However, that progress is still fragile and significant challenges remain, including high maternal mortality, weak health systems, and reaching young people. This is a critical time for the United States to support Senegal in accelerating its momentum and assuming greater control of its health financing and implementation. Success is not only essential to advance women’s and children’s health in Senegal, but also holds important lessons about how U.S. engagement can have a measurable and sustainable impact on women’s and children’s health in other priority countries.

To understand the lessons from Senegal’s recent experience, a delegation from the CSIS Task Force on Women’s and Family Health visited Senegal in February 2016. The delegation focused on the following overarching questions:

1. How have U.S. investments in women’s and family health—through bilateral health programs and engagement in multilateral health partnerships—supported Senegal’s progress in family planning and maternal and child health?

2. What has been the impact of integrating family planning with other maternal and child health services at the facility and community levels?

3. What has been the role of the private sector and public-private partnerships in developing innovative approaches to address Senegal’s persistent health challenges?

4. What are the prospects for family planning and maternal and child health programs in Senegal to transition to sustainable financing?

The report examines the U.S. partnership with Senegal to advance women’s and family health, and finds that the United States can play an important role in furthering Senegal’s capacity to sustain its health gains, build its investment case for international financing, and navigate the complex challenges ahead. To consolidate gains, the report argues that the United States should elevate attention and resources for integrated services to improve access to family planning and child health services. In addition, the report highlights the ongoing challenge of maternal mortality, which will require U.S. support to go beyond program-specific funding in order to accelerate efforts to strengthen health systems and human resources for health. Finally, the report calls for the United States to assist Senegal as it develops plans for a gradual, phased transition away from external support to more sustainable financing of health programs through the government of Senegal, the private sector, and new international financing mechanisms.

The members of the delegation were Julie Becker, senior vice president, Rabin Martin; Janet Fleischman, senior associate, CSIS Global Health Policy Center; Renee Gamela, senior adviser and communications director, Office of U.S. Representative Richard Hanna; Jennifer Kates, vice president and director of global health & HIV policy, Kaiser Family Foundation; and Cathryn Streifel, program manager and research associate, CSIS Global Health Policy Center.

You can find the full report here, and you can link to the CSIS Task Force on Women's & Family Health here.

Voluntary family planning is one of the most transformative interventions in global health, critical to improving women’s health and to saving the lives of women and children in some of the world’s most vulnerable communities. Beyond the direct health benefits, family planning is essential for women’s empowerment and sustainable development, contributing to improvements in education, economic growth, and the prevention of mother-to-child transmission of HIV. As the global leader in supporting family planning, the United States has a vital role to play in helping countries improve the lives of women and families.

To understand the impact of U.S. investments, this report examines U.S. support for family planning in Kenya at a pivotal moment for these issues globally. As a regional leader in family planning and a priority country for U.S. family planning and maternal-child health assistance, and the President’s Emergency Plan for AIDS Relief (PEPFAR), Kenya provides a lens through which to assess the opportunities and challenges in expanding access and transitioning to greater sustainability.

Kenya has made significant progress in family planning, with one of the highest contraceptive prevalence rates in the region at 58 percent, yet faces important challenges in maintaining momentum.

In the polarized U.S. political environment, funding for family planning programs faces persistent challenges. There is a risk that without clear U.S. commitment, these critical interventions could be derailed. Strong, bipartisan leadership is required to depoliticize these issues and to highlight the importance of voluntary family planning and healthy timing and spacing of pregnancies to improve women’s health, prevent unintended pregnancies, increase child survival, avert millions of abortions, and improve economic and social development. U.S. policy toward Kenya is in many ways a laboratory for the region with lessons for other countries.

You can find the full report here, and you can link to the CSIS Task Force on Women's & Family Health here.

The data are stark and incontrovertible: In eastern and southern Africa, girls account for 80 percent of all new HIV infections among adolescents, and HIV/AIDS is the leading cause of death for girls aged 15-19. With 7,000 girls and young women aged 15-24 infected every week, the goal of an AIDS-free generation cannot be achieved without a dramatic new approach to this population. After years of neglect, a global convergence is emerging around the urgency of going beyond biomedical interventions to address the social and economic factors driving HIV risk for adolescent girls and young women. Whether this new attention can catalyze reductions in new HIV infections represents a fundamental challenge for controlling the AIDS epidemic.

In a major shift, the President's Emergency Plan for AIDS Relief (PEPFAR) launched a new initiative on World AIDS Day in December 2014, in partnership with the Bill & Melinda Gates Foundation and the Nike Foundation, to significantly reduce new HIV infections in adolescent girls and young women. With $210 million and highly ambitious goals, the DREAMS (Determined, Resilient, Empowered, AIDS-Free, Mentored, and Safe) Partnership aims to address HIV risks for adolescent girls and young women in high-burden "hot spots" in 10 countries in eastern and southern Africa by identifying where these young women are being infected, what is putting them at risk, and how to target programs accordingly. The partnership's goal is to reduce incidence in high-burden areas by 25 percent in two years, and by 40 percent in three years. Whether these targets are attainable or simply aspirational remains to be seen, but they represent a determined effort to do things differently.

DREAMS and other international partnerships focused on HIV in adolescent girls and young women represent an ambitious effort to go beyond biomedical interventions to address the social and economic factors that put this population at risk of infection. It remains to be seen, however, if these initiatives can demonstrate impact in a short timeframe, and build toward sustainable programs. This is a critical moment to transform a growing global interest in women and girls in a range of sectors into effective HIV programing, and to highlight the results at the July 2016 International AIDS Conference in Durban, South Africa.

Download the report here.

For decades, the United States has been the global leader in supporting voluntary family planning services around the world. The benefits of family planning are numerous, not only for women's health, but also for increasing child survival, nutrition, education, and economic development, as well as preventing mother-to-child transmission of HIV.

This chapter, published in The Mother & Child Project, was adapted from Family Planning and Linkages with U.S. Health and Development Goals, written by Janet and Alisha Kramer.

Topics: Economic development, Ethiopia, family planning, FP-HIV integration, reproductive health, U.S. policy

You can order the book from Amazon.com here. Or, download the paper from which the chapter was adapted here.

The Senegalese minister of health, Dr. Awa Marie Coll-Seck, used a familiar term with us to express her commitment to expanding access to family planning—“yes we can.” That is a bold proposition in such a conservative country, in a region with some of the world’s highest maternal mortality and unmet need for family planning. Her leadership reflects an important moment in Senegal, and prospects for advancing women’s health and family planning in the subregion may depend on its success.

This country leadership has led to strategic partnerships between Senegal and the U.S. Agency for International Development (USAID), the Bill & Melinda Gates Foundation, the United Nations Population Fund (UNFPA), and the William and Flora Hewlett Foundation, among others. The goal is to “reposition” family planning in Senegal and in the francophone West African subregion. Senegal is a main focus of these efforts, since it is seen as the regional hub and is one of the most stable democracies in Africa. Given the current attention to family planning in Senegal, we wanted to see for ourselves what opportunities and challenges are presented by these partnerships, especially related to U.S. policy, and what it will take to build the domestic political support and accountability to ensure further progress.

As Senegal has launched a national family planning strategy and doubled its budget for contraceptives, the donors’ support has encouraged innovative approaches. Early results have been promising—Senegal’s contraceptive prevalence rate among married women increased from 12 to 16 percent (2012 to 2013), after years of stagnation, and new data will be available soon that are expected to show a similar increase for 2013–2014.

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Click here to download the full report.

In 2014, the CSIS Global Health Policy Center led a delegation to Ethiopia to examine the progress made and remaining challenges for expanding access to and demand for family planning services. Congressional staff from the offices of Senator Mark Kirk (R-IL), Representative Charlie Dent (R-PA), and Representative Karen Bass (D-CA) participated. Jennifer Dyer, executive director of Hope Through Healing Hands, and Tom Walsh, senior program officer for the Bill & Melinda Gates Foundation, also participated.

Based on the trip, this report outlines Ethiopia’s health extension program and how health extension workers are providing family planning education and services. The report also gives policy recommendations for future U.S. engagement on issues of family planning in Ethiopia, as well as lessons learned that can be applied in other countries.

Topics: Economic development, Ethiopia, family planning, FP-HIV integration, reproductive health, U.S. policy

U.S. policymakers and private-sector partners increasingly appreciate the importance of targeted U.S. investments in women's health to achieve global health outcomes, especially in sub-Saharan Africa. With budgetary constraints worsening, progress in women's health will require maximizing investment by engaging new partners., identifying program synergies, and aligning with countries' national priorities to meet women's needs. Such strategic coordination--involving maternal newborn and child health, voluntary family planning, and HIV and AIDS services--presents new opportunities to expand the impact of U.S. investments.

In March 2013, the CSIS Global Health Policy Center led a delegation to Zambia to examine the opportunities and challenges related to strengthening U.S. policy approaches to women's global health issues. CSIS chose to visit Zambia because of the new level of political will and leadership on women's health issues in the country; women leaders, in particular, are in an exceptional position to drive forward country ownership, including Zambia's first lady and other high-level government health officials.

In this report by multiple contributors focusing on global health priorities in President Barack Obama's second term, Janet writes a chapter addressing women's global health. In the synopsis, she writes:

Over the past decade, U.S. policymakers have increasingly recognized that advancing women’s global health and gender equality is among the most pressing challenges of the twenty-first century. A growing body of evidence demonstrates that investments focusing primarily on women and girls—maternal health services, voluntary family planning, access to HIV services, education for girls, economic empowerment of women, preventing and responding to gender-based violence— not only are critical to improving health outcomes, but also produce substantial positive returns in poverty reduction, development, and economic growth.

Despite the often-polarized atmosphere in Washington, a number of bipartisan successes have been achieved in support of women’s health. This has been the case under both Democratic and Republican administrations: the George W. Bush administration created the President’s Emergency Plan for AIDS Relief (PEPFAR) and developed gender strategies to reach women and girls; the Obama administration elevated women’s health and gender equality as a key foreign policy goal and accelerated policy development in this area.

Yet significant challenges remain. Administration and congressional leaders will have to navigate around political obstacles, notably the politically polarizing discussion around abortion, which is often erroneously conflated with family planning, and build support for the resources necessary for women’s health and gender programs at a time of severe budget constraints. Despite these challenges, focusing on the health of women and girls heightens the impact, life-saving potential, and cost-effectiveness of U.S. investments.

The health and empowerment of women and girls around the world has been elevated as a priority on the U.S. diplomacy and development agendas. This has been evidenced by a number of actions taken by the Obama Administration, most notably the focus on women, girls, and gender equality (WGGE) as one of seven core principles of the Administration’s Global Health Initiative (GHI). The GHI, announced in May 2009, was intended to promote a more comprehensive approach to U.S. government (USG) global health programs. As part of the GHI process, teams in countries receiving U.S. health assistance prepared GHI strategies, aligning their programs with the GHI’s principles, including WGGE, and have begun to implement those strategies.

To begin to understand how the principle is being applied to programs on the ground, the Kaiser Family Foundation conducted key informant interviews with 15 GHI country teams as well as USG staff in Washington, DC. The findings from the interviews yielded nine central themes and trends related to the response to and implementation of WGGE.

The President's Emergency Plan for AIDS Relief (PEPFAR) is well positioned to serve as a foundation for other global health programs, building on its health infrastructure, training, and systems. To fulfill that potential in the vital area of women's health will require integrating HIV/AIDS services with family planning and reproductive health services. The

results from U.S. health investments in Tanzania indicate that this is a feasible and cost-effective strategy to combat the AIDS epidemic and promote the health of women and girls, and through them their families and communities. The lessons being learned in Tanzania should inform the scale-up of strategic integration under PEPFAR for these critical interventions.

The dual global epidemics of HIV/AIDS and gender-based violence (GBV) exert a destructive and disproportionate impact on women and girls, especially in prevalence countries in Africa. Yet despite bipartisan political consensus on the intersection between HIV and GBV, efforts to address this area have not attracted the attention or resources necessary to drive the program innovation that could demonstrate progress. However, new momentum is now being brought to this agenda with the U.S. President's Emergency Plan for AIDS Relief's (PEPFAR) GBV initiative.

This paper examines how the GBV initiative is being introduced in Tanzania, one of the GBV focus countries, based on interviews in Tanzania in April 2012 with U.S. government officials, nongovernmental organizations, and implementing partners, as well as interviews in Washington, D.C. It describes the importance of this initiative for the work of PEPFAR and the Global Health Initiative (GHI), impediments to progress, why this program has the potential to provide valuable and timely lessons for achieving HIV-related goals and for improving health outcomes for women and girls, and priority steps for getting the best results in the future.

Each day, nearly 800 women die around the world from complications in pregnancy or childbirth. That’s one woman losing her life, every 100 seconds, every day. And while, from 1990 to 2010, global maternal mortality rates declined by roughly 47 percent, from about 546,000 to 287,000, the regional disparities are enormous: 85 percent of all maternal deaths occur in sub-Saharan Africa and South Asia—and more than half of these occur in sub-Saharan Africa. These deaths are largely preventable with interventions and training to address complications such as hemorrhage, infection, and obstructed labor, and more broadly with increased access to reproductive health services.

On June 1 in Oslo, U.S. Secretary of State Hillary Clinton announced the “Saving Mothers, Giving Life” project—an ambitious, dynamic effort by the U.S. government with a new public private partnership to drive efficiencies, spur innovation, and ensure impact in this fundamental area of global health. Maternal mortality is the ultimate health indicator, reflecting both a health system’s strength and how accessible it is to women and girls of reproductive age. If successful, “Saving Mothers” will be an important dimension of Clinton’s legacy as Secretary, lifting the lives of women, families, and communities around the world.

The Obama administration designated Malawi as a GHI Plus country in June 2010, one of the first eight countries selected to implement the Global Health Initiative’s (GHI) more comprehensive approach to global health and serve as learning labs for other GHI country programs. The GHI team in Malawi has identified the health of women and girls, including HIV and family planning (FP)/reproductive health (RH) services, as critical, promising areas for GHI success.

Though still in early stages of implementation, new approaches are emerging in Malawi that leverage resources from the President’s Emergency Plan for AIDS Relief (PEPFAR) to develop greater program synergies for women and girls. Yet Malawi’s weak health system, combined with ever more serious concerns about governance and human rights issues that are undermining donor support, present challenges that may threaten GHI’s ability to achieve sustainable results.

A period of major change is unfolding in health and HIV services in South Africa, carrying opportunities and risks for delivering effective, integrated health services that improve health outcomes and save lives. South Africa is decentralizing HIV services to the primary health are level, paving the way for greater integration to address women's health and to reduce maternal mortality. The United States can find feasible, flexible ways to support this process, even though its health program through the President's

Emergency Plan for AIDS Relief (PEPFAR), is scaling down. As PEPFAR transitions from an emergency to a more sustainable response, this is a crucial moment to demonstrate that it can address HIV-related goals by linking to more comprehensive services for women--notably linking HIV with family planning (FP), reproductive health (RH), and maternal child health (MCH). The stakes are high for PEPFAR and for the Global Health Initiative (GHI) to show results and, most importantly, for the women and children most at risk.

In May 2009, President Obama announced a new U.S. Global Health Initiative (GHI), proposed as a six-year, $63 billion effort to develop a comprehensive U.S. government strategy for global health, acting as an umbrella over most U.S. global health programs. The GHI is guided by seven core principles, the first of which is a “focus on women, girls, and gender equality.” The prominent attention given to this principle,

particularly as the first of the seven core principles, was seen as an indication of the importance placed on the health of women and girls as well as gender equality on the U.S. global health agenda. It is not yet known, however, how this principle will be implemented at the country level, and how its inclusion in the GHI will impact the health outcomes of those women, girls, families, and communities whom the GHI is intended to reach.

The Obama administration’s Global Health Initiative (GHI), announced in May 2009 as a six-year, $63-billion program, has put a strong emphasis on integration of health services, building largely on the work of PEPFAR (the President’s Emergency Plan for AIDS Relief). As implementation of GHI is moving ahead and country strategies are being developed, this is an important moment to bring forward lessons learned from the experience of integration in the U.S. government’s health and development programs. A key example involves U.S. health programs in Kenya over the past five years, notably the APHIA program (the AIDS, Population and Health Integrated Assistance program), which developed an integrated program based on the PEPFAR platform. This paper finds that the APHIA programs in Kenya hold some important lessons that should help inform GHI implementation. Since Kenya has been designated one of eight GHI-Plus countries,the emphasis on program integration in those U.S. government programs is especially relevant.

This paper, which is based on interviews conducted in Kenya in November 2010, as well as with policymakers and implementing partners in Washington, D.C., shows that the APHIA experience illustrates that integration across health sectors is feasible and effective, and that more focused evaluation of the impact of integrated programs would help Kenya and other GHI-Plus country teams and national governments as they develop their strategies. The maternal and child health (MCH) model in Kenya’s Western province is emerging as an innovative example of the benefits of providing women with a comprehensive set of MCH, family planning, reproductive health, and HIV/AIDS services in an integrated setting.

Global health, development, and gender are now understood to be dynamic and interlinked components of U.S. foreign policy. Given the emerging policy and programmatic debates on how these three domains are to be integrated to bring the greatest returns, especially in improving the health and welfare of women and girls, the CSIS Global Health Policy Center hosted a conference, entitled "Linkages between Gender, AIDS, and Development: Implications for U.S. Policy" on June 11, 2010.

This report provides background on the programs represented at the conference, summaries of the speakers' presentations, and U.S. policy options that emerged from the conference. It is intended to help inform the discussion surrounding the implementation of GHI and PEPFAR II and to emphasize the importance of fully utilizing the opportunities to reach women and girls by addressing the health and development challenges that contribute to their risk of HIV.

The imperative to devote specific focus to the multifaceted issues faced by women and girls as a pillar of both global health and HIV strategies has gained increasing prominence in international policy discourse in recent years. Yet the global-level policy changes necessary to operationalize these strategies too rarely filter down to the range of actors at the country level, including to AIDS professionals within national governments, the United Nations and other development partner organizations, and to members of civil society.

This brief describes the new directions in U.S. policy, notably in the President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Health Initiative (GHI), and how these new goals might relate to strengthening national AIDS responses and programs focusing on women and girls.

The interlinked tuberculosis (TB) and human immunodeficiency virus (HIV) epidemics are taking a dramatic toll on women’s lives, notably in countries with high HIV prevalence. While TB is now the third leading cause of death among women aged 15-44, killing some 700,000 women every year and causing illness in millions more, it is particularly lethal for women living with HIV. Yet the burden of the dual TB/HIV epidemic on women, and the

gender-related barriers to detection and treatment, are not being addressed explicitly by global donors, national health systems, or community groups. The urgency of this situation demands that TB be elevated as a key women’s health issue, and that TB screening, prevention and treatment be made a routine part of HIV, reproductive health and maternal and child health services. The lives of millions of women depend on our ability to move this agenda forward.

The world faces enormous challenges in the global health arena, many of which have a disproportionate impact on women and girls. Many key global health priorities revolve in fundamental ways around the gender-related barriers that women and girls face in accessing health-related information, services, and resources, all of which increase their vulnerability to ill health. For success and sustainability, the United States should anchor its global health strategy in a firm commitment to address the gender disparities that affect global health outcomes.

This report proposes that a gender-focused approach to global health build on four cornerstones:

These areas are clearly linked and underscore the importance of an integrated, comprehensive global health policy.

The election of President Barack Obama has fundamentally changed the landscape for the debates around U.S. support for international family planning (FP) programs. The personal engagement of top leadership, notably the president himself and Secretary of State Hillary Clinton, combined with policy and budgetary announcements that make averting unintended pregnancies a priority issue, clearly signal the administration’s intention to promote family planning as part of a comprehensive approach to global health.

Despite the polarization that often surrounds the debates on these issues in the United States, largely over their perceived linkage to the highly charged issue of abortion, an unprecedented opportunity now exists to significantly expand international FP programs based on a common-ground approach.

The core element of this approach is the need to move toward universal access to FP services—defined throughout this paper as education, counseling, and contraceptive commodities—provided on a voluntary basis to females and couples.

Funding for the response to the global AIDS crisis has increased exponentially in recent years, from US$ 260 million in 1996 to almost US$ 10 billion in 2007, nearly a forty-fold increase. While this figure still falls short of anticipated global need in the coming years, it is nonetheless a marked shift in the global response to the AIDS epidemic. At the same time, the new level of resources confers even greater responsibilities on the funding institutions to ensure that the key drivers of the epidemic are being addressed effectively.

This is particularly true in the area of gender and AIDS. While there is now broad international consensus that the gender dimension of the epidemic must be addressed, the three major AIDS financing institutions—the World Bank, the United States President’s Emergency Plan for AIDS Relief (PEPFAR), and the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund)—have not historically focused on ensuring that funding and programs adequately target gender issues. However, recent initiatives in each of the three institutions hold promise for new momentum in this area.

All three major AIDS funding institutions have recently acknowledged the importance of gender and the need to prioritize the gender issues, and each is looking at different approaches toward defining and expanding gender strategies and programs.

The XVII International AIDS Conference in Mexico City sheds a global spotlight on both the progress in combating HIV and AIDS and the failure of our current prevention efforts to stem the epidemic. Despite increased funding for and access to HIV and AIDS treatment around the world, the imperative to vastly increase HIV prevention remains urgent: for every two people put on treatment, five more are newly infected. In the absence of a medical vaccine, the course of the epidemic will depend on how the global community rises to the challenge of prevention.

CARE’s global work on HIV and AIDS in over 40 countries demonstrates that making a real difference in the AIDS epidemic requires more comprehensive, multisectoral approaches to prevention that address the broader context and the factors that are fueling the epidemic. We need strategies that link HIV prevention with development approaches that attack the underlying causes of vulnerability to HIV – such as economic and food security, community empowerment, reproductive health and education – that can build economic and social “vaccines.” A comprehensive approach of this nature means going beyond traditional prevention programming focusing on individual behavior change to also address the social, economic and cultural factors that shape people’s risk of contracting HIV and impede their access to prevention programs.

The AIDS crisis not only represents a threat to the lives of millions of people, particularly in sub-Saharan Africa, but it also undermines hard-won gains throughout the developing world. Through our global field experience, CARE has seen how the AIDS pandemic is linked to deepening poverty, gender inequality and social marginalization. To make a real difference in the fight against HIV and AIDS, our responses must be as interconnected and multidimensional as the AIDS pandemic itself.

This report describes how a comprehensive approach to HIV and AIDS, addressing both the underlying drivers of vulnerability to HIV and AIDS and the broader arenas in which these vulnerabilities play out, is the best use of U.S. HIV funding. Unless the global response to HIV and AIDS addresses these factors, particularly for women and girls, even the best-funded efforts will not achieve lasting impact. Accordingly, this report builds the case for such a comprehensive and sustainable approach by drawing upon CARE’s field experience, focusing on program examples in three key arenas: addressing gender inequality and vulnerability, integrating HIV with economic and food security and supporting community mobilization and engagement.

This report was written by Janet Fleischman, senior associate of the CSIS HIV/AIDS Task Force and chair of the gender committee. It is based on the presentations and discussions at the CSIS conference held on October 30, 2007, “Integrating Reproductive Health and HIV/AIDS Services: Lessons from the Field for PEPFAR Reauthorization,” as well as Fleischman’s visits to Kenya, South Africa, and India in 2007 and her interviews with U.S. administration officials, congressional staff, HIV/AIDS organizations and service providers, reproductive health organizations, and women living with HIV/AIDS.

In the context of reauthorization of the President’s Emergency Plan for AIDS Relief (PEPFAR), and looking ahead to the strategy that will be developed by the next U.S. administration, the conference sought to focus high-level attention on the opportunities and challenges of integrating reproductive health (RH) and HIV/AIDS programs. The proceedings demonstrated that substantial ingenuity and innovation is under way in integrating these services, and highlighted the importance of ensuring that the emerging lessons from the field inform decisions about the next phase of U.S. AIDS policy.

This is a defining moment for U.S. AIDS policy, as Congress and the Bush administration prepare for the reauthorization of the President's Emergency Plan for AIDS Relief (PEPFAR), which expires in September 2008. The reauthorization process offers U.S. policymakers the chance to reflect on the evolution oft he epidemic, to analyze the data collected, and to apply the lessons learned during PEPFAR's first phase, in order to strengthen U.S. AIDS strategy going forward.

Policymakers recognize that gender is an essential component in the fight against the global AIDS epidemic, and PEPFAR has made progress in implementing gender strategies. But the time has come to move beyond consensus statements on the importance of gender and limited programs to develop a stronger, elevated, and comprehensive approach that has real impact on the lives of women and girls in a world of AIDS.

Women account for nearly half of HIV infections worldwide and almost two-thirds of those among young people, with female infections rising in almost every region. Yet twenty-five years into the global AIDS epidemic, there is still no widely available technology that women can both initiate and control to protect themselves from HIV. Due to gender norms and inequalities, many women and girls lack the social and economic power to control key aspects of their lives, particularly sexual matters. As a result, women are in a difficult, and often impossible, situation when it comes to negotiating with their partners over abstinence, fidelity, or condom use.

Given the AIDS epidemic’s disproportionate impact on women, there is a critical need to develop prevention options that women can use with, or when necessary without, their partner's knowledge. Unless women gain greater access to effective prevention tools that they can control, global and national efforts to halt the spread of AIDS cannot succeed. Improving prevention options for women requires both broadening current prevention strategies and developing new technologies that enhance women’s ability to protect themselves.

AIDS, like poverty, has a disproportionate impact on women and girls. Worldwide, of the 1.2 billion people living on less than $1 a day, 70 percent are women. Women own a minority of the world’s land, and yet produce two-thirds of the food in the developing world, are the primary caretakers for children, orphans, and the sick, and represent almost half of those living with HIV globally—nearly 60 percent in sub-Saharan Africa.

In many societies, women are economically and financially dependent on male partners and family members. This dependence can dramatically increase their chances of becoming infected with HIV. Moreover, many women have little control over sexual matters in their relationships, which they often fear might be jeopardized by discussions about sexual issues.

Violence against women is a global health crisis of epidemic proportions and often a cause and consequence of HIV. Violence and the threat of violence dramatically increase the vulnerability of women and girls to HIV by making it difficult or impossible for women to abstain from sex, to get their partners to be faithful, or to use a condom.

Violence is also a barrier for women in accessing HIV prevention, care, and treatment services. That is why the UNAIDS-led Global Coalition on Women and AIDS has made stopping violence against women a top priority. High rates of violence make women more vulnerable Growing evidence from around the world shows that a large proportion of women and girls are subjected to violence by family members, acquaintances, and strangers.

Growing evidence shows that getting and keeping young people in school, particularly girls, dramatically lowers their vulnerability to HIV. By itself, merely attending primary school makes young people significantly less likely to contract HIV. When young people stay in school through the secondary level, education’s protective effect against HIV is even more pronounced. This is especially true for girls who, with each additional year of education, gain greater independence, are better equipped to make decisions affecting their sexual lives, and have higher income earning potential – all of which help them stay safe from HIV. Higher education levels are also clearly correlated with delayed sexual debut, greater HIV awareness and knowledge about HIV testing sites, fewer sexual partners, higher rates of condom use, and greater communication about HIV prevention between partners – all factors that substantially lower HIV risk.

By providing young women with greater economic options and autonomy, education also affords them the knowledge, skills, and opportunities they need to make informed choices about how to delay marriage and childbearing; have healthier babies; avoid commercial sex and other risky behaviors; and gain awareness of their rights.

Recent international initiatives to provide antiretroviral (ARV) treatment in resource-poor countries have changed the landscape of the HIV/AIDS debate and signal an unprecedented new phase in the struggle against HIV/AIDS. With an estimated 40 million people living with HIV/AIDS and 14,000 new infections every day, access to treatment is a challenge of global

proportions. In sub-Saharan Africa alone, almost 4.5 million people need antiretroviral treatment, yet only 100,000 currently receive it. To develop effective treatment programs, national governments, international donors, and community stakeholders should ensure equitable access to HIV treatment and care, notably for acutely vulnerable populations such as women and girls.

The catastrophe of HIV/AIDS (human immunodeficiency virus/acquired immune deficiency syndrome) in Africa, which has already claimed over 18 million lives on that continent, has hit girls and women harder than boys and men. In many countries of eastern and southern Africa, HIV prevalence among girls under age eighteen is four to seven times higher than among boys the same age, an unusual disparity that means a lower average age of death from AIDS, as well as more deaths overall, among women than men.

Abuses of the human rights of girls, especially sexual violence and other sexual abuse, contribute directly to this disparity in infection and mortality. In Zambia, as in other countries in the region, tens of thousands of girls—many orphaned by AIDS or otherwise without parental care—suffer in silence as the government fails to provide basic protections from sexual assault that would lessen their vulnerability to HIV/AIDS.

Through girls’ own testimonies, this report shows sexual assault of girls in Zambia in the era of HIV/AIDS to be widespread and complex. It documents several categories of abuse that heighten girls’ risk of HIV infection, including (1) sexual assault of girls by family members, particularly the shocking and all too common practice of abuse of orphan girls by men who are their guardians, or by others who are charged to assist or look after them, including teachers, (2) abuse of girls, again often orphans, who are heads of household or otherwise desperately poor and have few options other than trading sex for their and their siblings’ survival, and (3) abuse of girls who live on the street, of whom many are there because they are without parental care. All of these situations of abuse must be addressed as part of combating the HIV/AIDS epidemic in Zambia.

During the 1994 genocide, Rwandan women were subjected to sexual violence on a massive scale, perpetrated by members of the infamous Hutu militia groups known as the Interahamwe, by other civilians, and by soldiers of the Rwandan Armed Forces (Forces Armées Rwandaises, FAR), including the Presidential Guard. Administrative, military and political leaders at the national and local levels, as well as heads of militia, directed or encouraged both the killings and sexual violence to further their political goal: the destruction of the Tutsi as a group. They therefore bear responsibility for these abuses.

Although the exact number of women raped will never be known, testimonies from survivors confirm that rape was extremely widespread and that thousands of women were individually raped, gang-raped, raped with objects such as sharpened sticks or gun barrels, held in sexual slavery (either collectively or through forced "marriage") or sexually mutilated. These crimes were frequently part of a pattern in which Tutsi women were raped after they had witnessed the torture and killings of their relatives and the destruction and looting of their homes. According to witnesses, many women were killed immediately after being raped.