Defining Agency and Vulnerability: PEPFAR and the Role of Women in HIV/AIDS Prevention

• Date: 01 December 2016
• Author: Jaimie Edwards,Sara R. Jordan
• DOI: http://doi.org/10.1002/wmh3.210
• Published date: 01 December 2016

Def‌ining Agency and Vulnerability: PEPFAR and the

Role of Women in HIV/AIDS Prevention

Sara R. Jordan and Jaimie Edwards

Are the responsibilities of women and men in public policies addressing HIV/AIDS represented

differently in policy language? Could these distinctions correlate with different outcomes for female

benef‌iciaries of HIV/AIDS policy programs? Using interpretive policy analysis, this paper examines

gendered responsibility narratives in public policy. We performed a mixed methods analysis of the

publicly available documents from the President’s Emergency Plan for AIDS Relief (PEPFAR), to

determine differences in description of responsibility language around HIV according to gendered

categories. We found that gendered responsibility narratives are pervasive across the body of

PEPFAR documents and that two discourses concerning women’s responsibility—women as

problems and women as vulnerable—and two dominant discourses about male roles—men as violent

aggressors and men as absentee—dominate the policy narratives. Our intent in this analysis is to

deepen understanding of the role of gendered narratives as fostering differences in meaning that

may or may not contribute to disparities in HIV/AIDS policy outcomes.

KEY WORDS: PEPFAR, gender, public policy

Introduction

Is there a difference in the representation of the responsibilities of women

and men in public policies addressing HIV/AIDS? Could these differences

correlate with signif‌icantly different outcomes for benef‌iciaries of HIV/AIDS

policy programs? Proponents of an interpretivist perspective on public policy

f‌ind evidence that the image of women in law and public policy varies by policy

area (e.g., health) and by policy level (e.g., state or local). Other elements of

variability are whether these gendered frames precede or follow from public

policies or whether gender disparities in public policy framing drive different

levels of program success. In this paper, we use the method of interpretive policy

analysis to analyze variation in the image of women in HIV/AIDS policy at the

global level, specif‌ically examining the construction of gender-disparate moral

responsibilities through analysis of publicly available documents from the

President’s Emergency Plan for AIDS Relief (PEPFAR) program.

World Medical & Health Policy, Vol. 8, No. 4, 2016

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1948-4682 #2016 Policy Studies Organization

Published by Wiley Periodicals, Inc., 350 Main Street, Malden, MA 02148, USA, and 9600 Garsington Road, Oxford, OX4 2DQ.

Why PEPFAR? We chose PEPFAR for analysis for three reasons. First, unlike

other health care and or HIV/AIDS policies that may emphasize gender as a

dimension within the implementation or analysis of the program, PEPFAR was

designed with an explicit gendered perspective in the relevant laws incorporating

one of f‌ive key elements: “Increasing gender equity in HIV/AIDS programs and

services, including reproductive health services; preventing and responding to

gender-based violence; engaging men and boys to address norms and behaviors;

increasing women and girls’ legal protection; and increasing women and girls’

access to income and productive resources, including education” (PEPFAR, 2013,

p. 1). The attention to gender equity and to the challenge that HIV/AIDS poses

for women and girls is a feature of this policy program that has stood the political

tests of changing presidential and congressional administrations. Instead of

weakening over time, the gender focus of PEPFAR seems to be increasing, as

illustrated through the establishment of the PEPFAR Gender Challenge Fund

(2012) and the DREAM partnership (2014) almost a decade after the initiation of

the program.

Second, while PEPFAR programs and outcomes have been extensively

studied by a wealth of interdisciplinary scholars, the PEPFAR program has not

been studied as a public policy program per se (see, e.g., Bendavid &

Bhattacharya, 2009; Holmes, Williams-Sherlock, & Bouey, 2009; Homsy et al.,

2009; Kruk et al., 2012; Padian et al., 2011; Rodney, Ndjakani, Ceesay, & Wilson,

2010; Walensky & Kuritzkes, 2010). Further, PEPFAR has not been extensively

studied from the vantage of gender in politics and policy. In this paper, we seek

to close that gap, asking: what gender norms or gendered responsibilities are

being codif‌ied into this policy program via public communications? Are these

norms and responsibilities something that could support or detract from the long-

term goals of HIV/AIDS eradication outlined in the PEPFAR legislation?

Third, PEPFAR is an exceptional policy program because of the number and

variety of actors involved, the geographic and economic spread of the actors, and

the cumulative budget of the program. A review of the PEPFAR quarterly budget

data (submitted per the legislative mandate) shows that the Approved and

Planned funds for PEPFAR programs from 2004 to 2014 is over 5.7 billion

annually, of which almost 90 percent has been allocated to the major funding

departments (Department of State, USAID, Health and Human Services, Defense,

Labor, Peace Corp) and major funding mechanisms (National Institutes of Health

Research and the Global Fund) (PEPFAR, 2015b, p. 4). This funding went to 36

nations or regions for programs as varied as child survival and microf‌inance

credit (PEPFAR, 2015b, p. 3). In comparison, “during the period from 2005

through 2013, the National Cancer Institute budget averaged $4.9 billion per year

(NCI, 2016).”

What Is PEPFAR?

In 2003, then President George W. Bush pressed for the authorization of a

program—PEPFAR—wherein the United States could collaborate with nations

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