This study presents evidence linking the spread of Human Immunodeficiency Virus (HIV) with gender inequality in law and in custom in Pacific Island countries and territories. The subject of HIV and gender is sensitive and cannot be discussed without the use of explicit language and without plainly stating the facts. This study suggests recommendations based on the findings in five areas, proposing policy responses and programme approaches which can and should be fundamental to fighting the spread of HIV in Pacific Island countries and territories. Among the key issues identified through this work, gender still does not get adequate attention in HIV programming, despite the fact that it has long been recognised as being fundamental to understanding and addressing HIV and AIDS. The spread of HIV is closely associated with the different and unequal circumstances of women and men, and the power imbalances between them which result in different forms of gender-based discrimination against women. The Pacific Platform for Action for the Advancement of Women identified HIV as an area of concern to Pacific women in 1994. It was pointed out thirteen years ago (in 1996), in a UN report, that stopping the spread of HIV in the Pacific demands attention to the different social and cultural determinants of HIV infection among men and women. However, even in the new (2009-2014) Pacific Regional Strategy on HIV and other Sexually Transmitted Infections (STIs), gender is still referred to as one of many issues to be addressed to halt and reverse the spread of HIV, rather than as a central, cross-cutting consideration. Similarly, few countries have developed gender-responsive national HIV strategic plans and policies. One notable exception is Papua New Guinea which provides an example of best practice in formulating a national gender policy for HIV and AIDS, albeit major challenges remain in its implementation.