by George Ayala, MPact Executive Director
The United States President’s Emergency Plan for AIDS Relief (U.S. PEPFAR) Country Operating Planning (COP) cycle is once again upon us. We were happy to see the 2020 COP Guidance reflect many recommendations advocates offered during the open comment period. However, there are a few new issues reflected in the guidance advocates should carefully track in the lead-up to COP reviews. And although funding is generally expected to remain flat across countries and regions, PEPFAR country teams can also this year submit proposals that include a request for additional funds to support supplementary programs. Only high performing partners are eligible to request funding above the levels determined by U.S. PEPFAR.
In many cases, funding levels are linked to performance. Poor performance can reflect an inability to reach performance indicators set by the U.S. State Department’s Office of the Global AIDS Coordinator (S/GAC). In other instances, country budgets are determined in ways that are not evidence-based, resulting in grossly underfunded community-led services for key populations, women and girls. Budgets and funding decisions should be commensurate with HIV disease burden and other related factors that elevate the risk for HIV for a given population, within a given jurisdiction, within a given country context.
There has been long standing tensions and debates in public health over the need to balance evidence with the ethical imperative to respect and protect human rights. Evidence-informed and rights-based responses to health combine systematically collected data about disease burden, community needs, and intervention effectiveness with unflinching commitments to self-determination, bodily autonomy/integrity, and the acceptability, accessibility, affordability, and quality of services. In addition, evidence-informed and rights-based responses necessarily concern themselves with the legal and policy environments that hinder or help communities most impacted by HIV. For example, about 70 countries still criminalize same-sex sexual behavior. In addition, 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. U.S. policies also continue to prohibit funding to organizations working to decriminalize sex work. These policies have led to defunding of clinics that were previously offering antiretroviral medications to treat HIV and discouraged key populations from accessing services they need.
This year, the U.S. is urgently pushing Index Testing as a strategy for identifying people living with HIV who may not already know their HIV status. The strategy involves working with an individual who newly tested positive for HIV to voluntarily identify sexual and drug injecting partners within the past 12 months, and children in a household. Each listed partner is then contacted, informed that they may have been exposed to HIV, and offered voluntary HIV testing. Although there is good evidence to suggest the effectiveness of this HIV testing strategy, it is not appropriate in countries that criminalize same-sex sexual behaviors, sex work, drug use, and/or HIV transmission, exposure or non-disclosure. Stigma, discrimination, violence, and criminalization complicate the use of interventions like Index Testing. In addition, Index Testing can specifically place cis and trans women, gay and bisexual men, and young people at high risk for gender-based violence and other abuses of power.
It is against this backdrop that MPact has formulated 10 tips for advocates watchdogging the U.S. 2020 COPs processes. They include the following:
- Push back on efforts to scale-up Index Testing without careful consultation with communities most affected by the risk of “adverse events”. “Adverse events” may include (but are not limited to): violations of confidentiality; absence of consent procedures; forced or unauthorized disclosure of sexual history, behavior and/or orientation to partners, family, friends or others; intimate partner violence and/or gender-based violence; ridicule, harassment, or blackmail; failure to link to services; and denial of or delay in service acquisition. Index Testing should be implemented using guidelines published by the World Health Organization and service providers must be regularly trained. Index Testing programs should be independently monitored by communities for which the intervention is meant to serve. Moreover, Index Testing (and all other testing interventions) should be de-linked from donor-imposed performance indicators like HIV positivity rates or ‘yields’. People matter more than targets. And when funding is tied to testing targets like sero-positivity rates, implementers are more likely to sacrifice quality for quantity, especially if quantity will keep funds flowing.
- Advocate for realistic and reliable size estimates of key populations. Size estimates are used by PEPFAR to justify targets, which in turn determine funding. When size estimates are ridiculously low, national programs will underestimate community needs, set low targets, and therefore underfund services. Good news: this year S/GAC has not assigned targets to countries, they only provided national budget levels. PEPFAR country teams are expected to develop and submit their own targets in discussion with national stakeholders, including community advocates. The national budget for that country will then be distributed across priorities based on targets set by country teams. Push for ambitious targets and funding for key populations at levels to ensure the quality, safety, and effectiveness of services to meet those targets.
- Demand a role in monitoring access to and implementation of HIV services for your community. In COP2020, all PEPFAR programs are required to develop, support and fund community-led monitoring for treatment services, in close collaboration with independent civil society organizations. Community-led monitoring can include activities designed to assess the acceptability, accessibility, affordability, quality of services, and client satisfaction. It can also include documenting the impact of punitive laws and policies as well as experiences of stigma, discrimination, coercion, blackmail, and violence on the way to and/or at HIV service organizations and clinics.
- 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 for gay, bisexual and other men who have sex with men– 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.
- Ask country teams to include supplementary funding for support services tailored to the needs of young gay and bisexual men and other key populations. Services tailored to young gay men and other key populations are urgently needed to expand safe, sensitized, evidence-informed and rights-based services. This would be a good way to make country programs more ambitious.
- 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; and 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.
- 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, transgender people – and ensure that all services delivered by faith based groups are evidence-based and respect the needs of all populations.
- Tell U.S. PEPFAR missions to hold community-based, key population-led programs harmless to budget cuts AND urge them to take full advantage of additional or supplementary funds to support community-led programs. Programs led by and for gay men and other men who have sex with men, people who use drugs, sex workers, and transgender people remain dreadfully under-funded.
- Push for expanded technical support and sensitivity training for healthcare workers/providers, involving communities in the development of curricula and provision of those – stigma and discrimination experienced by key populations continue to undermine performance in facility-based and faith-based programs.
- 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; provided by communities to communities – in addition to sensitization programs for healthcare workers, police, and policy makers.
When you hear or see officials from the U.S. or your government settling for business as usual, or flatline funding, or interventions ‘done to’ instead of ‘done with’ our communities, call bullshit! This is not the time to abandon a vision for evidence-informed, rights-based, comprehensive, community-led HIV and other sexual health services. It is certainly not the time to abandon our efforts to eliminate stigma, discrimination, and violence from the global fight to end AIDS.