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Monitoring and Evaluation of Gender and HIV

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This presentation discusses monitoring and evaluation of gender and HIV.

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Monitoring and Evaluation of Gender and HIV

  1. 1. Monitoring and Evaluation of Gender and HIV MEASURE Evaluation
  2. 2. Before we begin… This presentation assumes a basic knowledge of monitoring and evaluation (M&E) principles and practices. If you need a refresher on this information, visit: • ining/online-courses-and-resources/courses • fundamentals
  3. 3. Outline 1. Define gender and related terms. 2. Identify why gender is important to HIV outcomes and programming. 3. Review measures and indicators for gender progress in HIV programs.
  4. 4. Activity: Vote with your feet! • 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. Source: USAID Training of Trainers: Gender and Reproductive Health 101
  5. 5. Definitions Photos do not indicate HIV status. A young man in Uganda. 2018. Kato James, Courtesy of Photoshare
  6. 6. Definitions SEX GENDER Biological difference between males and females: • Universal for all human beings • Unchanging • Determined at birth Beliefs about the appropriate roles, duties, rights, responsibilities, accepted behaviors, opportunities, and status of women and men, in relation to one another: • Constructed by society • Differs between cultures and over time • Acquired *Source: World Health Organization (WHO). (2009). Integrating gender into HIV/AIDS programmes in the health sector.
  7. 7. Definitions Gender gap Adherence to rigid gender roles can create a gender gap: • Unequal access to and participation in opportunities and realities that women and men experience Source: WHO, Why Gender and Health Women Men
  8. 8. Sexual orientation and gender identity Sexual orientation is a way to describe who a person is attracted to romantically and sexually, and whether this person is of the same or different gender. Gender identity is the personal experience of oneself as a boy or man, girl or woman, as a mix of the two, as neither, or as a gender beyond woman or man.
  9. 9. For more information MEASURE Evaluation’s Sexual Orientation and Gender Identity online course (download Flash to access): resources/non-certificate-courses-and-mini-tutorials/sogi/sogi
  10. 10. Definitions Gender equality: The state or condition that affords women and men equal enjoyment of human rights, socially valued goods, opportunities, and resources. Genuine equality means more than parity in numbers or laws on the books; it means expanded freedoms and improved overall quality of life for all people Gender equity: The process of being fair to women and men, boys and girls. To ensure fairness, measures must be taken to compensate for cumulative economic, social, and political disadvantages that prevent women and men and boys and girls from operating on a level playing field. *Source: Interagency Gender Working Group (IGWG) training resources
  11. 11. Definitions Source: Kuttner, P. (2015). Available at equality-graphic/
  12. 12. Gender and HIV An HIV-positive mother holds her HIV-negative daughter in Tanzania. 2016 Zacharia Mlacha, Courtesy of Photoshare
  13. 13. Why does gender matter in HIV? Gender inequality is a driver of the HIV epidemic.  Gender inequality is associated with higher HIV prevalence and incidence.  Gender inequality is also associated with: • Higher risk of transmission/higher prevalence • Higher risk of intimate partner violence, which in turn increases the risk of HIV • More risk-associated behaviors because of vulnerability • Less knowledge about HIV/AIDS • Less use of programs and services
  14. 14. A middle-aged man contracts HIV from injecting drugs with a dirty needle after a stressful day at work because societal norms prevent him from seeking emotional support. Gender and HIV A woman contracts HIV because societal norms prevent wives from insisting on condom use with husbands, and yet tolerate husbands’ extramarital sex. A transgender woman defaults from her HIV medication because she is stigmatized when accessing health care. She is afraid to return to get her next supply of ART. Source: WHO,
  15. 15. Gender and priority populations • Certain populations, because of their gender, are particularly vulnerable to HIV. • Adolescent girls and young women (AGYW) • Men who have sex with men (MSM) • Transgender people • Female sex workers (FSW) • Gender intersects with other factors (such as age, race, ethnicity, socioeconomic status) to compound risk.
  16. 16. Gender-based violence and HIV Violence and HIV are mutually reinforcing epidemics USAID. (n.d). Violence and HIV. Available at ER_-_16_Days_Violence_HIV_Infograph_508.pdf
  17. 17. How does gender effect HIV programming? • Women or marginalized populations may not have the power to negotiate condom use with partners. o Simply providing condoms is not enough; providing skills to negotiate safer sex helps empower people. • Women often fear that abandonment or violence would occur if they disclosed their HIV status to their partners. o This is a barrier to HIV testing. • In many societies, women need permission from partners and families to seek health care. o Permission reduces their access to health services, including those for HIV. Source: WHO, 2009: Integrating gender into HIV/AIDS programmes in the health sector
  18. 18. • International push led by the United States government, the United Nations, and other donors to address gender in programs Source: Gender and HIV policies
  19. 19. “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) Gender and HIV
  20. 20. Gender M&E Photos do not indicate HIV status. A protest rally for gender equality and transgender equal rights organized by the LGBTQ community in Kolkata, India. 2017 Debarshi Banerjee, Courtesy of
  21. 21. Why integrate gender in M&E efforts? • Ensure that gender is addressed in HIV programs in a measurable way • Provide evidence to: o Raise awareness about gender inequity o Work for change o Address the gender dimensions of health and HIV • Demonstrate program progress and HIV impact • Ensure that M&E practices are not contributing to inequalities
  22. 22. Gender M&E considers the impact of gender on the health program, target population(s), and results. • Data are collected by sex (or gender) and use gender-sensitive methods and sampling • Analyzed with an eye to potential gender differences • Used to improve programs and policy for all people Gender M&E
  23. 23. Monitoring: • Measures gender-specific outputs • Tracks progress of gender-specific elements of programming • Disaggregates data collection and analyses • Collects data on attitudes and behavior that reflect gender norms • Considers gender in data analysis and use Gender-integrated monitoring Are programs adequately addressing gender?
  24. 24. Evaluation: • Measures impact on outcomes that relate to gender-specific programming • Identifies elements that address gender equality • Uses data to demonstrate progress and • Generates demand for richer gender data Gender-integrated evaluation Are gender-integrated programs and policies making a difference?
  25. 25. Sex-disaggregated data • HIV indicators that are presented both for men and women or boys and girls 0 20 40 60 80 100 120 June 2017 June 2018 June 2019 Thousands Number of adult patients on ARV treatment after 1 year 0 10 20 30 40 50 60 70 June 2017 June 2018 June 2019 Thousands Number of adult patients on ARV treatment after 1 year Female Male
  26. 26. Sexual and gender identity data Source: PEPFAR Monitoring, Evaluation, and Reporting Indicator Reference Guide 2.0 (Version 2.3), Appendix A: Key Population Classification
  27. 27. Gender-sensitive data • Indicators that address gender directly and go beyond sex disaggregation alone—for example: • Gender-based violence • Gender attitudes and norms • Power differences • Female autonomy • Access to educational and economic opportunities
  28. 28. Gender-sensitive data
  29. 29. Gender-sensitive data • To know if we have increased women’s and men’s participation in and benefits from interventions, especially in areas where they have been historically under-represented • To know if we have reduced gender inequality (e.g., barriers to access ) or unintentionally exacerbated gender inequalities • To generate evidence on how attention to gender in programs makes outcomes more equitable and sustainable Source: MEASURE Evaluation. (2013). Facilitating data use for gender-aware health programming: Guidance for workshop facilitators. Retrieved from
  30. 30. Systems and processes Consider: • Logistics: Timing? Who is the interviewer? Location? • Questionnaire administration o Gender biases that may affect data  E.g., male over-reporting of # sexual partners, underreporting of GBV • Ethical issues, particularly for GBV and other sensitive topics and marginalized populations o Review relevant international guidelines Data collection
  31. 31. Systems and processes • Protocols and procedures • Stakeholder engagement • Quality and ongoing training for M&E system staff People, partnerships, and planning
  32. 32. Gender M&E in HIV programs Photos do not indicate HIV status. Public Health Ambassadors Uganda, 2016 David Alexander/Johns Hopkins Center for Communication Programs, Courtesy of Photoshare
  33. 33. Asking the right questions Monitoring questions and data Question: Are there gender differences in the use of/access to HIV services/treatment? o HIV testing o Referral for treatment o Use of and adherence to ART Data needed: Sex- and age-disaggregated data from the health information systems (data collected at multiple points in time)
  34. 34. Asking the right questions Monitoring questions and data National Guidelines on Medical Management of Rape and Sexual Violence Question: For rape cases presenting within 72 hours, is appropriate medical care provided, including post- exposure prophylaxis (PEP), according to National Guidelines on Medical Management of Rape and Sexual Violence? Data needed: Sex- and age-disaggregated data from routine health information systems on the number of rape survivors presenting at the facility within 72 hours who receive services, including PEP. This would need custom data collection if information cannot be obtained from a review of medical records. See also MEASURE Evaluation’s work on data quality for PEPFAR’s GEND_GBV indicator: review/gend_gbv-rapid-data-quality-review
  35. 35. Question: Are GBV programs and services inclusive of men and the lesbian, gay, bisexual, and transgender (LGBT) community? Is everyone able to access health services or do service providers turn people away because of stigma and discrimination? Data needed: Qualitative data on client experiences and provider attitudes; data disaggregated by sexual orientation and gender identity Asking the right questions Evaluation questions and data
  36. 36. Asking the right questions Evaluation questions and data • Has the removal of gender-based constraints contributed to improved HIV outcomes? o Do transgender people feel more comfortable accessing health services and are they therefore adhering to their medication? • Has the program reduced power differences in relations between men and women? o Is decision making more equitable? o Do men and women have more equal opportunities? o Has HIV-related stigma changed in the community?
  37. 37. Measuring Gender Photos do not indicate HIV status. A family after participating in a workshop on “Gender Awaren for Family Life” in Bangladesh, 2010. Sumon Yusuf, Courtesy of Photoshare
  38. 38. Areas of measurement • 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 (discussed on upcoming slides) • Programmatic reach: Target populations and coverage Gender and HIV
  39. 39. Areas of measurement • Stigma and discrimination/human rights: Attitudes, laws, and policies • Humanitarian emergencies: How gender plays a role in access to HIV care and treatment, violence, etc. • Priority populations: People in sex work, men who have sex with men, transgender people, people who inject drugs • Orphans and vulnerable children (OVC) Gender and HIV
  40. 40. Measuring gender • No “gold standard” for measuring gender norms and attitudes or women’s empowerment • Use multiple measures Photo: Promundo o You cannot use a single measure. Gender is a complex construct and operates in multiple spheres. o A scale combining several items is more valid than a single scale item used alone.
  41. 41. Gender-sensitive data Gender-Equitable Men (GEM) scale: Measures attitudes toward gender norms in intimate relationships • Respondents: Men and women; boys and girls • Applied in multiple countries; culturally sensitive • Topics covered: • Sexual relationships • Homophobia • Domestic chores and daily life • Reproductive health and disease prevention • Example items: • “If someone insults a man, he should defend his reputation with force if he has to.” • “A man needs other women, even if things with his wife are fine.” Norms Source: Compendium of Gender Scales. Retrieved from
  42. 42. Gender-sensitive data Measure household decision making • Respondents: Men and women, separately • Applicability in multiple settings? Decision making Source: Demographic and Health Survey Program. Retrieved from • Example items: • Who usually makes decisions about major household purchases? • Who usually makes decisions about whether to take your child for health care? Photos do not indicate HIV status. Photo Credit:
  43. 43. Gender-sensitive data Demographic and Health Surveys (DHS) have standard questions on economic empowerment • Respondents: Men & women, separately • Example items: o Knowledge/use of microcredit programs o Having a bank account, asset ownership o Control over money for different purposes Economic empowerment Source: Golla, A. M., et al. (2011) Understanding and measuring women's economic empowerment: Definition, framework and indicators. International Center for Research on Women (ICRW). Retrieved from
  44. 44. Gender-sensitive data Women’s leadership and political participation • Example items: Women in parliament o Women in science technology, engineering and math (STEM) Male engagement in family planning • Example items: o Men as clients o Men as supportive partners o Men as agents of change Increased engagement Photo © Gabriel Cohen, courtesy of Photoshare
  45. 45. Gender-sensitive data Sexual Relationship Power Scale (SRPS): Measures power within sexual relationships • Respondents: Men and women, separately • Applied in multiple countries and settings • Example items: o Relationship control  “Most of the time, we do what my partner wants to do.”  “My partner always wants to know where I am.” o Decision-making dominance  “Who usually has more say about whether you have sex?”  “Who usually has more say about what you do together?” Power Source:
  46. 46. Gender-sensitive data Conflict Tactics Scale: Measures the extent to which specific tactics, including acts of physical, psychological, and sexual violence, are used • Respondents: Men or women, intimate partners • Applied in multiple countries and settings • Example items: o Suggested compromise to an argument o Used knife or gun on partner o Used force to make partner have sex Intimate partner violence (1) Source: Strauss, M. A., Hamby S. L., Bonney-McCoy S., & Sugarman, D. B. (1996). The revised Conflict Tactics Scales (CTS2). Journal of Family Issues, 17(3), 283-316. Retrieved from
  47. 47. Gender-sensitive data It is critical to have someone with research expertise on the team when looking at intimate partner violence. Following international ethics and safety guidelines for research on violence is imperative! Intimate partner violence (2) ations/violence/9241546476/en/ Compendiums of indicators are available (see the “Resources” slides at the end).
  48. 48. Gender-sensitive data • Demonstrate removal of gender barriers. • Capture quality, not just quantity. • Demonstrate change in inequality. • Use what you’ve got! Selecting indicators Photo: International Fund for Agricultural Development
  49. 49. Gender-sensitive data Quantitative measures are limited in their ability to capture: • Complexities of power and relationship dynamics • Unintended consequences of shifting norms Importance of qualitative data
  50. 50. Example Indicators Two siblings in Madagascar, 2017, Samy Rakotoniaina/MSH, Courtesy of Photoshare
  51. 51. Sample gender and HIV indicators Gender equality measures Percentage (%) 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
  52. 52. Sample gender and HIV indicators Gender-based violence Percentage (%) of health units that have documented and adopted a protocol for the clinical management of GBV survivors Numerator: Number of 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 GBV survivors Denominator: Total number of health units surveyed in the geographic region of study Percentage (%) of people who believe that gender-based violence can take place between same-sex couples Numerator: Number of people who believe that GBV can occur between two men, two women, or gender nonconforming couples Denominator: Total number of people surveyed
  53. 53. Sample gender and HIV indicators School-based life skills for young people The number or percentage (if denominator is available) of young people ages 10–24 years reached by life skills–based HIV education in schools. Numerator: Number of young people reached through any school- based effort, including peer education, classroom, small group, and/or one-on-one information, education and communication, or behavior change communication to promote change in behavior in a school setting Denominator: Number of young people attending targeted schools
  54. 54. Sample gender and HIV indicators Priority population: Female sex workers Percentage (%) of female sex workers (FSWs) reporting the use of a condom with every client in the past month Numerator: Number of FSW respondents who report always using a condom with every client in the past month Denominator: Total number of FSW respondents interviewed
  55. 55. Sample gender and HIV indicators Avoidance of health care among key populations because of stigma and discrimination: Percentage (%) of key populations who have avoided health services in the past 12 months owing to stigma and discrimination Ask: Have you ever avoided seeking (i) health-care, / (ii) HIV testing, / (iii) HIV medical care* or (iv) HIV treatment* in the past 12 months because of any of the following: 1. Fear of or concern about stigma? 2. Fear or concern someone may learn you [insert behavior, e.g., have sex with men]? 3. Fear of or concern about or experienced violence? 4. Fear of or concern about or experienced police harassment or arrest? Numerator: Number of people who report avoiding healthcare owing to stigma and discrimination Denominator: All respondents Disaggregated by gender, age, and priority population
  56. 56. • Integrating Gender in the Monitoring and Evaluation of Health Programs: A Toolkit: 122- en • The Importance of Gender in HIV and AIDS Data: • Sexual Orientation and Gender Identity Mini Course: resources/non-certificate-courses-and-mini-tutorials/sogi/sogi • Guidelines for integrating gender into an M&E framework and system assessment 16-128-en MEASURE Evaluation gender M&E HIV Resources
  57. 57. MEASURE Evaluation gender M&E HIV Resources • Compendium of Gender Equality and HIV Indicators: • Violence against women and girls: A compendium of monitoring and evaluation indicators: 30 • Gender M&E eLearning Course • GEND_GBV Rapid Data Quality Review review/gend_gbv-rapid-data-quality-review MEASURE Evaluation Gender Resources:
  58. 58. Gender integration in programming References and resources • Caro, D. (2009). A manual for integrating gender into reproductive health and HIV programs: from commitment to action. USAID and IGWG. Retrieved from • Communication for Change (C-Change). (n.d.). Compendium of gender scales. Retrieved from scales-compendium/index.html • Doggett, E., Krishna, A., Robles, O.J., & Betron, M. (2016). Gender and sexual and reproductive health 101. Retrieved from reproductive-health-101
  59. 59. Gender integration in programming References and resources • Gender Practitioners Collaborative. (n.d.). Minimum standards for mainstreaming gender equality. Retrieved from • Global AIDS Indicator Registry: indicators/27 • IGWG. Gender analysis and integration. Retrieved from • It’s Pronounced Metrosexual. (2018). The Genderbread Person V4. Retrieved from 2018/10/the-genderbread-person-v4/
  60. 60. Gender Integration in Programming References & Resources • Kuttner, P. (2016). The problem with that equity vs. equality graphic you’re using. Cultural Organizing. Retrieved from problem-with-that-equity-vs-equality-graphic/ • PEPFAR Monitoring, Evaluation, and Reporting Indicator Reference Guide 2.0 (Version 2.3) (2018). • Strauss, M. A., Hamby S. L., Bonney-McCoy S., & Sugarman, D. B. (1996). The revised Conflict Tactics Scales (CTS2). Journal of Family Issues, 17(3), 283-316. Retrieved from • USAID. (n.d). Violence and HIV. Retrieved from _16_Days_Violence_HIV_Infograph_508.pdf
  61. 61. Gender Integration in Programming References and Resources • USAID. (2012). USAID Gender equality and women's female empowerment policy. Washington, DC, USA: USAID. Retrieved from .pdf • WHO and PATH. (2005). Researching Violence against women: A Practical guide for researchers and activists. Retrieved from • WHO. (2009). Integrating gender into HIV/AIDS programmes in the health sector: tool to improve responsiveness to women’s needs. Retrieved from • WHO. (2016). A tool for strengthening gender-sensitive national HIV and SRH monitoring and evaluation systems. Retrieved from systems_en.pdf
  62. 62. This presentation was produced with the support of the United States Agency for International Development (USAID) under the terms of MEASURE Evaluation cooperative agreement AID-OAA-L-14-00004. MEASURE Evaluation is implemented by the Carolina Population Center, University of North Carolina at Chapel Hill in partnership with ICF International; John Snow, Inc.; Management Sciences for Health; Palladium; and Tulane University. Views expressed are not necessarily those of USAID or the United States government.
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