Gender Dynamics and HIV in Vulnerable Populations: a call to action

1. Gender Dynamics and HIV in Vulnerable Populations: a call to action Juliette Bynoe-Sutherland Head, Policy Analysis Division PANCAP for Caribbean HIVAIDS Alliance November 12th 2010 St. Kitts & Nevis

2. GENDER: 30 years on…

3. Can you describe your organization's gender response? Classic Responses: • We are really please to report that we are able to share with you the number of girls and boys who are…. • We have established a programme for women and girls in ….. • Our Mens’ Health clinic provides services each Wednesday …

4. Gender Responses are more than ….. • Counting numbers of men and women in activities or programmes. • Designing programmes focused on women are CRITICAL but gender based responses requirement engagement with this issue of masculinity and the incorporation of masculinity in women's programmes. • Doing Men’s heath programming without routinely addressing the range of male sexual and reproductive issues including the needs of Most at Risk Groups: gay, bisexual, transgendered men, sex workers.

5. Why don’t some of us get it? • Clouded by views of feminism and female empowerment. • Gender Advocates challenged to translate analysis into pragmatic programmes of action. • Gender outcomes seen as vague, immeasurable, illegitimate. • Biomedical model/medicine/science - training has not dealt well with the social dimensions of ill health.

6. Why do some of us get it e.gCHAA & Local partners in SISTA • Treatment acts on the symptoms – what about the cause? (UNAIDS: For every 2 persons on treatment - 5 new infections). • Research: some persons to be more vulnerable to HIV (or ill health) than others? (St. Kitts – epidemic concentrated in Most at Risk Populations/MARPS & generalized epidemic has not taken route) • Research & Experience: Social factors influence health status, health seeking behavior, and allocation of resources e.g poverty/social class, age, sexual orientation and gender. • Without addressing causal issues: gender and sexual determinants of HIV transmission – frustration & futility • We can’t all do the same thing and expect different results!

7. GENDER & VULNERABILITY

8. Who am I? Who are you? My Labels • Barbadian • Graduate • Attorney • Human Rights Advocate • Regional Advisor • Black • Married Woman • Mother • Heterosexual • Christian

9. What can I share with you? The keys to understanding Gender & Vulnerability as it operates in relation to the HIV epidemic

10. What can I share with you? Information to shape and mould a call to action!

11. 1. Gender is socially constructed • Sex = male and female (hormones/chromosomes) • Gender refers to the roles that men and women play and the relationships that arise out of these roles which are socially constructed and not biologically determined (PAHO 1997) • Perceptions of Gender (masculinity & femininity) are deeply rooted in socio-cultural factors – underlying beliefs about how society should be. • However, dominant ideology/perception is that gender roles in our society are hierarchical. • Generally : There is an unequal power relationship between men to women - favoring men. • NO ABSOLUTES: Gender roles are learnt and can be affected by class, education and economics AND can evolve over time.

12. 2. Sexuality impacted by gender • The unequal power balance between men and women directly impacts sexuality - who one has sex with, in what ways and why and under what circumstances and with what consequences • Power plays a role in how sexuality is expressed in heterosexual, homosexual or transgendered relations – whose pleasure is given priority. • Sexuality compounded by social and moral norms about “right and wrong” leading to stigma, discrimination, criminalization and its resulting marginalization and isolation of groups. • Social stigma makes it difficult for sexual minorities, commercial sex workers, transactional sex practitioners to be open, drives them underground, or into risky behavior. • Upshot: Our societies institutionalize inequality – individuals and groups can’t access services OR services not reaching them

13. 3. Vulnerability • Vulnerability to HIV – the likelihood that some groups are at greater risk of exposure to HIV due to biological, structural and infrastructural . Most at risk populations are /can be economically marginalized women and girls, MSM, sex workers, drug users, migrants - country specific! • Biology of women, young girls, anal sex • Socio-cultural – lack of autonomy of some women, multiple partnering, unprotected marital sex, hidden sexuality, cultural stigmas & taboos, religious principles & moral views, gender based violence against women & men e.g direct transmission/ reduced ability to negotiate • Economic: poverty, migration e.g a woman /person who lacks access to resources/ economically dependent could fear and loss of financial support if they seek to negotiate safe sex. • Political: laws and policies reinforce social norms – ignore discrimination, criminalize sexual behaviors and actions of consenting adults, refusal to provide social protection, condone abuse by law enfocement • Access to prevention treatment care and support : gender shapes content and quality of programmes, scaled up targeted interventions increase visibility of stigmatized groups

14. 5. Gender & Vulnerability applied to Health • All players in the health sector have gender roles and views. The processes and environments in which people work and receive care can also be gendered: • Are we adequately meeting individual needs - exploration of the different roles that masculinity and femininity play in health behavior e.g women as “vectors of disease” in PMTCT • Do providers acknowledges the ways in which both the sex or gender of the provider impacts on the health care event e.g attitudes to HIV positive women with repeat pregnancies • Does training and education identify the gendered nature of medical and nursing knowledge/education/texts/teaching styles and environments • Are we researching clinical practice to address the way in which the sex or gender of the patient impacts on clinical testing, diagnostics, treatment and outcomes e.gadhearance

15. 4. HIV: a national development issue • Gender factors underlie vulnerability to HIV and AIDS • Response cannot be medicine or public health driven – need to address the social –cultural, economic political and legal factors that create vulnerability. • PRECONDITION - Refine epidemiology to better identify at risk communities. (Not rocket science!) • Underlying prejudices and inequalities must be address through national leadership, dialogue, specially designed health and social service responses and engagement of community actors e.gCBO, FBOs

16. A call to action – A R I S E Adapted from AIDS WOMEN CAUCUS & Caribbean Regional Strategic Framework on HIV and AIDS 2008 - 2012

17. A: ACCESS • Effective Partnerships – can reduce barriers to universal access to a comprehensive set of INFORMATION & SERVICES in prevention, treatment care and support. • Policies & Systems - to improve the socio-economic conditions and reduce the risk circumstances of MARPS – moral and political imperative – we are all potentially vulnerable • Service provision premised on OUTCOMES rather than judgment based on Sexual & Reproductive Health models

18. R: RIGHTS • Promote and guarantee human rights as a conditionality of the rule of law in a country. Human Right for ALL must be at the centre of a national HIV response: • Low hanging fruits – legal literacy of women, girls, children, MARPs, Human Rights awareness raising, • Litigation strategies – push from below • Constitutional interpretation and law reform – leadership from above to declare otherwise legal laws: bad law • Model Policies & Legislation – advocacy for implementation! • Zero tolerance for state sponsored violations and in the private sphere – gender based violence.

19. I: Investment • “I hear the thunder but feel no rain” – investment is the best evidence of interest and commitment. • Investment in HIV prevention are investments in gender based programmes, poverty alleviation, micro-finance, legal literacy. • Increased funding needed by public, private, NGOs on harm reduction, social protection, needs of women and girls. • Invest based on comparative advantage – role for the State and community based organizations e.g churches

20. S: Security • The mental, physical, psychological and financial security of ALL human beings should concern us . • Shifting locus of vulnerability in an interdependent globalized environment. (African-American & Caribbean American infection rates in the USA) • Interventions/activities should promote choice, control, personal autonomy and empowerment. • Social mobilization (i.e active engagement & organization into sustainable responses) of at risk communities should be a pillar of all initiatives.

21. E: EQUITY • Education, Empowerment, Resources for MARPs • Equality and Equity: MARPs do not need an equal allocation of resources – their circumstances require d MORE resources – an equitable response. • To do otherwise endangers national gains made. • Promote community participation and dialogue particularly the involvement of women – community leaders, faith based leaders, opinion leaders must be champions for change

22. References • International Council of AIDS Service Organizations CASO – Gender, Sexuality, Rights and HIV (2007) • UNAIDS – Handbook for Legislators in HIV/AIDS law and human rights (1999) • PANCAP - Caribbean Regional Strategic framework on HIV and AIDS 2008 - 2012 • Inter Agency Coalition on AIDS and Development: Gender Analysis for Project Planners. (2007)

23. Thank-you! For full text of presentation: www.pancap.org www.caribbeanhivaidsalliance.org