(Header photo from PEPFAR COP civil society debrief, Johannesburg March 2020)
MPact Global Action for Gay Men’s Health & Rights advocates for better policies that will serve gay, bisexual and other men who have sex with men, as well as proportionate funding to adequately address the unique challenges experienced by our communities. This blog describes in detail key issues in the 2020 U.S. PEPFAR planning process, as well as highlights from some countries to achieve a more equitable and effective HIV response for gay men.
For the last several weeks, MPact advocates have been working to influence the single largest bilateral source of funding for the global response to HIV – the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) – and ensure that its money and programs are tailored and targeted to effectively reach gay men and other men who have sex with men.
This strategic advocacy opportunity takes place once a year, when PEPFAR hosts regional gatherings with all of its Operating Units to review data, specify targets, and set budgets for the coming year. Known as the COP (Country Operational Plan) Reviews, this year PEPFAR hosted three consecutive week-long meetings in Johannesburg, South Africa, from February 17 through March 6, 2020. Notably, civil society is invited to the table to elevate their priorities alongside power players that include The Global Fund to Fight AIDS, TB and Malaria, the Joint United Nations Programme on HIV/AIDS (UNAIDS), the Centers for Disease Control (CDC), the U.S. Agency for International Development (USAID), Ministries of Health, and philanthropists.
In preparation for these meetings, MPact worked alongside a transnational coalition of advocates[i] to gather community priorities and advocate for those priorities while in Johannesburg. Several country civil society coalitions wrote shadow reports, known as The People’s COP, that couple grassroots information with specific demands for budget lines, policy changes, and programmatic priorities. In addition, MPact issued 10 tips for advocates based on our past experiences at the COP Reviews to guide gay men and other men who have sex with men on how to make significant changes to ensure programs are answering to their specific needs.
MPact staff attended every week of the COP Reviews, supporting national-level key populations advocates and working in solidarity with global civil society, fighting to change harmful policies, and pushing for robust budget commitments to gay men and other key populations.
Here are the major issues that shaped the dialogue on key populations at the COP20 Reviews – issues that MPact and our fellow advocates will continue to track going forward:
Index testing (or “assisted partner notification services”) is an HIV case finding methodology in which people who test positive for HIV are asked to disclose their sexual and/or needle sharing partners, as well as name their biological children, to provide a linkage for subsequent HIV testing. But community-level reports reveal that index testing has put key populations in danger, increasing their risk for violence, stigma, discrimination, as well as many other human rights abuses. (MPact previously shared a community advisory on index testing, warning constituents that they should never be coerced into sharing information on their sexual or needle-sharing partners).
Ahead of the COP review, MPact joined civil society partners in an open letter to PEPFAR calling for the immediate cessation of Index Testing, and to de-link any case-finding targets from the Index Testing methodology. In response, the PEPFAR 2020 COP Guidance temporarily halted index testing for “FSW, MSM or any other key population group” and required all facilities to comply with the WHO’s Self-Testing and Partner Notification guidelines.
Nonetheless, there was a gap between PEPFAR 2020 COP Guidance and country-level understanding and implementation. In the Cote d’Ivoire and Tanzania negotiations, advocates were successful in removing proportional case finding targets for index testing, thus reducing the pressure that facilities and providers will face in identifying cases thru index testing. In addition, advocates continue to push hard for index testing not be resumed until certification processes and new guidance can be put in place regarding the monitoring of adverse events. MPact is currently working with country teams, CDC, and USAID to strengthen these processes.
Key Population Size Estimations, Targets, and Budgets
For years, PEPFAR’s population size estimations for key populations (KP) have been too low. KP size estimations inform the size of KP-dedicated budgets, and consequently, KP programming; so low estimates lead to small budgets and tiny programs which are not nearly enough to drive impact. The PEPFAR COP20 Guidance itself acknowledges these challenges, noting that the “estimated KP size [must be] large enough to reach a given target sample size sufficient for the measurement of viral load suppression and the treatment cascade.”
As MPact advocates and allies worked to challenge these low population size estimates at the COP20 reviews, some advocates from PEPFAR-supported countries asked for the implementation of formal integrated bio-behavioral surveillance (IBBS) surveys. However, IBBS surveys these are typically long (and costly) processes, and unless conducted thoughtfully with involvement of local KP communities to ensure safety and confidentiality, they do not necessarily result in more credible population size numbers. MPact and allies urged PEFPAR not to wait for IBBS survey results and instead immediately turn to local KP partners for support in crafting more meaningful targets. Where PEPFAR’s own data indicated that KP targets had been met and exceeded – such as the case for Malawi – advocates pushed for higher and more robust KP targets, as well as the first-ever disaggregation of data on Male Sex Workers, who had previously been invisibilized by being grouped under the larger MSM umbrella. In Eswatini, PEPFAR committed to launch studies (IBBS survey and size estimation) for the transgender and PWID populations in the 2020 COP.
Advocates protected and pushed forward KP budgets as well. In Kenya, advocates were able to gain commitment to fulfill the KP funding amount promised from the COP19, and pushed for an increase to the KP budget for COP20 (reaching $20.5 million) – though, notably, budgets will not be finalized until the COP agreements are officially signed.
PrEP for Gay Men
MPact and allies pushed PEPFAR country programs to move beyond pilot programs to immediate scale-up of comprehensive pre-exposure prophylaxis (PrEP) programs for gay, bisexual and other men who have sex with men. Importantly, the work needs to include demand generation, risk reduction counseling, literacy, adherence and support.
Multiple countries secured new commitments to scale-up PrEP during the COP20 review, even though the road to universal PrEP access remains long. Among our lessons learned, however, is that close attention to budget lines remains vital: several country proposals prioritized PrEP commodities above all else, without due consideration for the support required to fund the wrap-around services to enable proper PrEP implementation and effectiveness. Other country proposals failed to adequately budget for PrEP commodities within the context of PrEP scale-up, suggesting that programs would not be able to reach proposed PrEP targets. In Cote D’Ivoire, for example, the overall budget of the entire PrEP program was initially presented as $900K with only $300K for commodities, aiming to reach 9000 individuals. “Hallway advocacy” enabled advocates to push up the commodities budget, and to find more money in the overall budget for PrEP program set-up and demand generation.
Additional areas for follow-up for MPact and partners with regard to PrEP for gay men include the creation of targeted messaging campaigns that sensitively reach and communicate to gay men and other men who have sex with men. These messaging campaigns need to be developed with communities and monitored on their effectiveness.
The PEPFAR COP20 Guidance mandated all PEPFAR programs to “develop, support and fund community-led monitoring for treatment series in close collaboration with independent civil society organization and host country governments.” Community-led monitoring (CLM) is an accountability mechanism in which community members design their own process for reviewing and rating the quality of HIV services. Community feedback on the accessibility, quality, and any adverse events can be a powerful tool for shifting policy and program implementation. The People’s COP reports prepared by civil society in advance of the PEPFAR COP20 Reviews are one such example of community monitoring. Another powerful example of community-led monitoring used by many MPact partners is the “secret client” methodology, which empowers community members to record instances of stigma, discrimination, and other inappropriate behavior while seeking health services, and then report it back to facilities anonymously.
While PEPFAR Country teams generally demonstrated an openness to supporting CLM, advocates were quick to point out that the funding mechanisms matter. In particular, the main funding channel needs to be a step removed from PEPFAR itself to ensure independence in the review process. Second, advocates were clear about the need for a single, well-resourced grant to support this work. Some PEPFAR Country Teams proposed multiple funding sources to support CLM, including a small grants initiative to provide seed support to several civil society organizations in a given country. Seasoned CLM advocates, however, noted the importance of a single unifying framework and single large grant for maximum impact, with one standardized community checklist and coordination across all districts being surveyed (rather than multiple small initiatives, each with different CLM tools and surveys, potentially collecting data that did not align across a variety of overlapping districts). Of course, this approach would only be acceptable if gay-led organizations are actively and meaningfully engaged in the process of developing the survey tools.
Key Populations Investment Fund (KPIF)
The $100 million Key Populations Investment Fund announced by PEPFAR in 2016 is now finally moving forward in earnest after a delayed start, with the intention to support KP-led organizations. The funds are intended to ensure not only tailored HIV services for key populations, but additionally, to support organizational and financial management capacity strengthening among KP-led organizations, as well as to “address specific structural barriers that inhibit access to and the effectiveness of HIV services, including violence, legal, law enforcement, policy, economic, and educational barriers.”
Unfortunately, in some countries “KP-competent” agencies have been prioritized as the conduit through which KPIF funds will flow, rather than KP-led organizations. Despite KPIF guidelines to channel at least 70% of funds to communities, we have observed in Zimbabwe that large amounts of funds are dedicated to staffing a new local KPIF technical support unit within the structure of an international NGO, rather than directly supporting KP-led organizations. MPact will continue to monitor which organizations are being supported by the KPIF.
What comes next?
Each COP Review negotiation culminated in an outbrief presentation to PEPFAR leadership at the end of each week, but plans (and budgets) are not finalized until the COP agreement is signed in April. Time remains for advocates to follow up with PEPFAR Country Teams and the State Department Office of the U.S. Global AIDS Coordinator and Health Diplomacy (S/GAC) in Washington D.C. to secure the budgets, targets, and plans that civil society envisions. This is particularly important in consideration of the fact that many COP review meetings did not include detailed presentations of budget allocations, making it challenging for civil society to effectively gauge PEPFAR’s level of commitment.
In addition, a vital part of the on-going work in this space is holding PEPFAR Country Teams accountable to the promises made during the COP20 review meetings. Each PEPFAR Country Team should debrief civil society at the country level following the Johannesburg meeting, and civil society asks should be reviewed in tandem with PEPFAR and host government commitments. For example, in Tanzania a commitment was made for quarterly briefings with key population constituencies in country.
These were an exciting few weeks for MPact and partners, and the work is just beginning! Please continue to follow our work to learn about developments on the topics above.
Please feel free to report to us any problems or obstacles you may experience, which we can document and report to our contacts at OGAC and with PEPFAR country teams. Please write to the MPact Director of Policy Nadia Rafif at firstname.lastname@example.org with any questions or problems you may have.
At the time this blog is issued, PEPFAR just released Technical Guidance in Context of COVID-19 Pandemic, to remind everyone that PEPFAR remains committed to supporting the provision of care and treatment of individuals with HIV while maintaining a safe healthcare environment for clients and staff. Deaths due to HIV and other co-morbidities must continue to be prevented during this time. In order to meet our commitment to continued care and treatment for PLHIV and the prevention of deaths among PLHIV due to HIV associated co-morbidities, PEPFAR is committed to supporting the host government response to the COVID-19 pandemic by leveraging existing PEPFAR resources, such that PLHIV have the best possible outcomes within the context of stretched healthcare systems. Overarching principles as well as specific technical guidance is provided for PEPFAR operational issues; prevention, testing, clinical services, supply chain, and laboratory activities; infection prevention and control; and budget guidance. This document will be updated routinely as the situation evolves. A more detailed update will follow.
This blog has been developed by Krista Lauer, consultant for MPact, with the contribution of Cheikh Traore (consultant), Stephen Leonelli (Senior Policy Advisor at MPact) and Johnny Tohme (Community Mobilization Manager at MPact), and reviewed by Nadia Rafif (Director of Policy at MPact)