2019 U.S. PEPFAR COP Reviews: 10 Tips for Advocates

by George Ayala, MPact Executive Director

Several countries funded by the United States President’s Emergency Plan for AIDS Relief (U.S. PEPFAR) are facing significant cuts to their 2019 Country Operating Plans (COP).

In many cases, funding cuts are in response to poor performance or an inability to reach performance indicators set by the U.S. State Department’s Office of the Global AIDS Coordinator (S/GAC), according to S/GAC officials. This places communities living with and disproportionately affected by HIV in a quandary.

First, many ‘poor performing’ countries face serious and persistent structural challenges that undermine HIV responses at the local and national levels. These include; stigma, discrimination, violence and criminalization experienced by gay men and other men who have sex with men, people who use drugs, sex workers, transgender people, and adolescent girls and young women; poorly trained healthcare providers; under-capacitated health systems and broken procurement procedures resulting in stock outs and misdirection of commodities; gross underfunding of community-led programs and organizations; and government officials who lack political will to support and resource modernized, evidence-informed, rights-based, and community-led responses to HIV.

Second, U.S. policies on sexual health and harm reduction also undermine countries’ efforts to reach the right people, in the right places, at the right time. For example, the U.S. ‘Protecting Life in Global Health Assistance’ policy, also known as the Mexico City Policy or global gag rule, prohibits foreign assistance to organizations offering family planning education and services, inclusive of abortion. This policy has led to defunding of clinics that were previously offering antiretroviral medications to treat HIV.

Third, the U.S. has taken a narrow approach to setting performance indicators, which are bio-medically and quantitatively oriented (number of HIV tests and number of people living with HIV identified – referred to as ‘yield’, number of people on treatment). The same expectations are unfairly applied to both clinic/facility-based and peer-led community-based programs, when the nature of the work performed by both sets of actors is fundamentally different.

Fourth, proposed cuts are happening on the heels of PEPFAR’s announcement about a new $100 million to fund faith-based organizations. This new initiative should give advocates pause, especially since announcements about the initiative are short on details about how faith-based organizations will be held accountable to public health principles of using evidence (i.e., normative guidance issued by the WHO), targeting to groups at highest risk, community engagement, and remaining stigma free. Discrimination is not a religious freedom.

It is against this backdrop that MPact has formulated 10 tips for advocates watchdogging the U.S. 2019 COPs processes. They include the following:

  1. Call for proposed budget cuts to be rescinded. Instead, COP budgets should be strategically repurposed to support new contracts with new technically competent/sensitized implementers and capacity strengthening efforts that are aimed at expanding key-population focused, community-led test and start, self-testing, peer-led navigation and adherence programs, drop-in centers, viral load testing and monitoring, and comprehensive prevention programs.
  2. Shout this out during meetings with decision makers: we need comprehensive HIV prevention, inclusive of PrEP NOW! Countries must move beyond PrEP pilot programs towards scale-up of comprehensive PrEP programs – inclusive of demand generation, risk reduction counseling, literacy, adherence and support. In addition, prevention programs beyond PrEP should address upstream factors and support tailored strategies for community mobilization.
  3. Think ‘out of the box’. We should tap high performing and willing DREAMS programs to offer services to young gay men and other key populations through contract amendments with augmented budgets, as a strategy for expanding safe, sensitized, evidence-informed and rights-based services. Alternatively, we should ask for a program that specifically addresses the prevention, care, treatment, safety and security needs of your gay and bisexual men.
  4. Call-out the deleterious impact that the global gag rule is having on a country’s ability to reach its targets, with a focus on targets related to ARVs for cisgender and transgender women and girls, gay men and other key populations;
  5. Insist on better coordination between the U.S. and other bilateral and multilateral funders to ensure clinics and organizations losing funding because of the U.S.’ global gag rule continue to offer HIV prevention, testing, care, and treatment, especially for key populations and women.
  6. Urge governments to keep an unwavering focus on groups at highest risk for HIV acquisition and onward transmission – gay men, people who use drugs, sex workers, and transgender people – and hold faith-based organization to the same standard. The Key Population Investment Fund or KPIF, announced in 2016 and only now being rolled out is not and should not become a substitute for COPS funding for key populations. Treating it as such lets governments off the hook from their responsibilities to our communities.
  7. Tell U.S. PEPFAR missions to hold community-based, key population-led programs harmless to budget cuts, especially because facility-based services (which are being held harmless) have a poor track record engaging and retaining key populations;
  8. Push for expanded technical support and sensitivity training for healthcare workers/providers – stigma and discrimination experienced by key populations continue to undermine performance in facility-based and faith-based programs.
  9. Demand funds for structural and community-level interventions that can help facilitate enabling policy environments. Interventions include advocacy, community mobilization, demand generation, violence prevention and support, and legal services – in addition to sensitization programs for healthcare workers, police, and policy makers.
  10. Vehemently request expanded STI testing, prevention, and treatment for key populations – it’s a shame that basic sexual health services are not a priority.

We shouldn’t settle for business as usual. The ‘if we build it, they will come’ mentality is also a problem. This is a passive posture to take when what we need are proactive, technically competent, and sensitized programs, especially with key populations.

When you hear officials from the U.S. or your government say that they will support ‘maintenance’ of the HIV response, call bullshit and tell them that this shouldn’t mean just keeping people living with HIV on treatment and dropping prevention, sexual health, and programs targeting key populations. And it certainly shouldn’t mean putting up with the indignities of stigma, discrimination and violence.

We deserve and need more.

About MPact

MPact Global Action for Gay Men’s Health and Rights (formerly known as MSMGF or The Global Forum on MSM & HIV) was founded in 2006 by a group of activists concerned about the disproportionate HIV disease burden shouldered by men who have sex with men. MPact works at the intersection of sexual health and human rights, and is linked to more than 120 community-based organizations in 62 countries who are fighting for the sexual health and human rights of gay and bisexual men around the world.


Media Contact: George Ayala, MPact Executive Director, contact@mpactglobal.org