Every year, MPact advocates and our allies work to ensure that the single largest bilateral source of funding for the global response to HIV – the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) – prioritizes gay men and other key populations in Country programs and budgets.
The COVID-19 pandemic disrupted the usual week-long, in-person Country Operational Plan (COP) Review meeting format and forced the process to move entirely online. While the same stakeholders were invited to participate – civil society, The Global Fund to Fight AIDS, TB and Malaria, UNAIDS, CDC, USAID, Ministries of Health, and philanthropies – negotiations took place entirely over Zoom, over 2 consecutive days of tightly scheduled, 4-hour-long meetings. This lack of face-to-face discussion spaces made the negotiations process more difficult. It drastically changed advocacy entry points, even for seasoned advocates as discussion was often limited to the chat function. In addition, this modality forced more reliance on the Country Chair and limited KP participation in multiple ways.
In preparation for the meeting, MPact issued our Top Tips for Key Population Advocates highlighting the major issues at stake. Now that COP approvals have been signed, we discuss below the major issues that shaped the dialogue on key populations during the COP21 Reviews, as well as our reflections on the path forward.
What’s at Stake
This was the first-ever virtual COPs process, out of necessity due to the COVID-19 epidemic. All stakeholders worked to adapt to the new landscape, most significantly, the extremely shortened timeline for the meeting (2 days rather than a week-long session, with each day lasting only 4 hours).
It was imperative to successfully complete the PEPFAR COPs process and solidify budgets, programs and plans for the upcoming year, especially with on-going uncertainty around the global response to COVID-19 including its impact on PEFPAR.
The lack of “informal spaces” in this new set-up was keenly felt and was a significant barrier for KP advocates. Prior to COVID-19, informal “corridor negotiations” were a vital part of the in-person COPs negotiations process – the ability to hold a quick, informal meeting on a specific issue with PEPFAR leaders and other stakeholders (often during the tea break) to raise concerns, get more information, or to reach an understanding. We call on PEPFAR to develop innovative strategies to ensure the possibility of such informal “check-in” spaces in subsequent virtual PEPFAR meetings – for example, creating spaces for informal meetings in between the “official” meeting days.
The skills and attitude of the COPs Country Chairs were more crucial than ever, as they held the keys to civil society participation in the meeting. Strong Chairs were observed prompting civil society about entry points and soliciting their input on key topics; weaker Chairs became overwhelmed by differing opinions or shortened timeframes, and one even turned off the chat function for the entire group of more than 100 participants. We call upon PEPFAR to implement mandatory facilitation training for all COP Country Chairs, and to provide better support for all meetings (including naming a designated co-facilitator who can moderate the group chat function, respond to questions in the chat, and relay time-sensitive chat messages to the meeting chair).
Human rights violations at odds with PEPFAR priorities and goals
These legal and contextual factors vastly influence and undermine investments in the global health response because they deter key populations from accessing health services for fear of persecution, arrest, or violence.
PEPFAR is housed at the State Department – not at a health-specific institution, such as the CDC – underscoring the political and diplomatic nature, strengths and capacity of the PEPFAR program.
We call upon the State Department to be more assertive and intentional in its engagement with countries that host PEPFAR-funded programs on human rights in the context of global health.
However, that engagement should not take the form of withholding PEPFAR funds, which is a tactic that disproportionately impacts already vulnerable communities.
The Biden Administration’s “whole of government” approach must recognize that laws and policies enacted in a country – including punitive laws against people’s sexual orientation, gender identity, sero-status, drug use, and/or sex worker status – are fundamentally at odds with reaching those most at risk of HIV with U.S. funded global health programs, including PEPFAR.
KPIF (Key Populations Investment Fund) and KP budgets
The $100 million KPIF is coming to an end this fall, and while advocates were assured that KP programs will continue to be prioritized via PEPFAR core budgets, many are concerned that this will not be possible without dedicated funding.
MPact reporting on KPIF revealed some successes, including efforts to strengthen KP organizations, but also shortcomings, including long delays in KPIF program roll-out and a too-large proportion of funding awarded to large international NGOs (rather than to grassroots, KP-led groups)
Cuts to PEPFAR Country programs across the board impacted overall budget levels, making KP budget lines particularly vulnerable to reductions.
As funding for KP priorities is rolled into core PEPFAR budgets, it remains to be seen if structural interventions – including initiatives to address punitive laws and policies targeting key populations – will be de-prioritized, especially if pressure from overall budget cuts results in favoring direct service delivery. We call on PEPFAR to maintain an unwavering focus on addressing the human rights context in which KP programs are implemented.
Budget transparency was a problem throughout the COPs process; several countries did not receive complete budgets from PEPFAR Country Teams before the COP meetings, making it impossible to analyze or engage in budget line advocacy (i.e. to see specific amounts that had been spent on KP prevention the previous year).
There appeared to be underspending on the KP budget line in several countries, but no update or accountability on the circumstances surrounding the underspend. This is significant – if money is underspent, it is usually subject to reprogramming (i.e. being allocated to other priorities) in future budgets. We call on PEPFAR to improve budget transparency and to be consistent for all PEPFAR Countries.
As noted in the MPact KPIF report, fewer funds for KP programs went to organizations led by Key Populations themselves (“KP-led” groups), than flowed to large global partners with national presence. We call on PEPFAR to improve upon these funding flows in alignment with targets to shift in-country funding to national entities.
KP size estimates
PEPFAR’s key populations size estimates have notoriously been too low. These inaccurate estimates in turn lead to disproportionately small KP budgets and inadequate KP programs, which are not nearly enough to drive desired impact.
In what is unfortunately becoming an annual advocacy priority, MPact and other KP advocates refused to accept inaccurately small and misleading population size estimates of key populations, and called for them to be replaced with realistic and reliable KP size estimates.
KP prevention targets were set lower than targets that had been achieved the previous year in several countries.
Several PEPFAR Country teams prioritized the implementation of formal bio-behavioral surveys (BBS) – but these are typically long (and costly) processes – and unless conducted thoughtfully with involvement of local KP communities, they do not necessarily result in credible population size numbers. We call on PEFPAR not to wait for BBS and instead immediately turn to local KP partners for support in crafting more meaningful targets.
Community-led Monitoring (CLM)
Advocates pushed back against “one-size-fits all” approaches to CLM, knowing that this work must be independent and relevant to each specific context and group of people it is designed to serve. Key population communities must be at the helm to define priorities, establish norms, and analyze trends and lessons learned that emerge from CLM data.
Confusion about CLM threatened to lead to inadequate budgets and inappropriate programming (i.e. allocating money to institutions that would be the subject of monitoring efforts, which is a direct conflict of interest).
CLM is a relatively new programmatic area for PEPFAR and there is a tendency to expect a lot of outcomes on a small budget, which inevitably leads to poor project results. To prevent this from happening, experienced advocates in Cote D’Ivoire reviewed CLM budget data from 2020, and were able to push back against proposed cuts for 2021. (Notably, this information didn’t come from officially released PEPFAR budget data, but from budget notes taken by civil society advocates about the previous year’s COPs process). We call on PEPFAR to support robust funding for CLM and to ensure full budget transparency in advance of next year’s COP meetings.
Index testing (or “voluntary 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 reporting revealed that index testing put key populations in danger, increasing their risk of being subjected to violence, stigma, discrimination, and 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.)
Expanded HIV testing targets have again put pressure on several country teams to ramp up index testing, including Malawi. Advocates pushed for implementation of ethics and privacy protocols to protect key populations from known risks associated with this methodology. This is an area that will require close monitoring, and could be a good candidate for CLM. We call on PEPFAR to continue to engage on ethics and privacy issues, especially as testing targets increase.
Continued advocacy to move beyond pilot programs toward scale-up of comprehensive PrEP programs for gay, bisexual, and other men who have sex with men (including demand generation, risk reduction counseling, literacy, adherence, and support).
Push for multi-month PrEP pills dispensation in light of COVID-19 lockdown measures and other policies that restrict movement and make regular access to health services difficult.
In Cote D’Ivoire, implementers were requiring creatinine and Hepatitis B test results before considering PrEP initiation. This was an unnecessary obstacle for many KPs. Advocates in the COPs negotiations shared the WHO recommendations that testing is not needed before starting PrEP, and the government agreed to change that protocol.
Remuneration and equity
The COP processes provided an opportunity for civil society groups to advocate for value-for-money and the issue of remuneration of community field workers.
In many countries. PEPFAR implementers and Global Fund implementers concurrently apply varying and unequal remuneration scales for community field workers. These disparities create tensions between community organizations. CSOs should ask for a harmonization of remuneration across various implementing partners to reduce unnecessary competition and conflict. We call on PEPFAR to prioritize harmonization with the Global Fund that respects the dignity of all stakeholders in the program implementation chain.
These are some of the many priorities that were raised over the course of a very active and intensive virtual COP negotiation period. The shortened timeline for pre-meetings, the meetings themselves, and final approvals all posed challenges for meaningful engagement of civil society – especially key populations – and we urge PEFPAR to carefully consider opportunities to improve upon these entry points in future years. Several countries – notably Nigeria – made significant improvements in their engagement with KP communities compared to previous years, in the form of regular meetings with KP representatives throughout the year, and not just during COP negotiations.
Finally, in addition to PEPFAR COP negotiations, civil society was also juggling many other vital priorities on the global health stage, including submitting applications to the Global Fund’s COVID-19 Response Mechanism (C19RM) and the UN High Level Meeting on HIV. As communities continue to grapple with the financial, social, political, and human rights impacts of the ongoing COVID-19 pandemic, we call on PEPFAR and other global health financing institutions to recognize the toll on civil society, and to seek to prioritize sustainable engagement.