Most countries are falling short on HIV prevention targets despite targeted Global Fund investments, report says
Only two of the 26 reporting countries in the Global HIV Prevention Coalition are “virtually on track” to achieve a 75% reduction in new infections by 2020, according to country scorecards in the Coalition’s Second Progress Report published this year. The report presents a detailed picture of progress, achievements and critical gaps related to HIV prevention globally. Although new adult HIV infections have declined between 2010 and 2017, progress is too slow to meet the 2020 targets set in the 2016 Political Declaration on HIV/AIDS – despite targeted catalytic investments from the Global Fund for key populations, human rights and adolescent girls and young women.
The Prevention Coalition is convened by UNAIDS and UNDP and is comprised of over 40 Member States, civil society organizations, key population networks and international organisations such as the Global Fund.
After a consultative process, the Coalition held an inaugural meeting in October 2017 to endorse the 10-point Prevention 2020 Roadmap to improve the delivery of prevention programming at country-level and significantly drive down infections by 2020. The Roadmap was developed for 25 countries with the highest number of new infections among adolescents and adults. Three additional countries were added in April 2018.
The Roadmap focuses on HIV primary prevention and the promotion and provision of effective HIV prevention tools. It also highlights the empowerment of adolescent girls and young women (AGYW) and key populations. Combination prevention packages all include a range of biomedical, behavioural and structural approaches, including testing and linkage to care, and efforts to address policy and human-rights barriers centered around the 5 prevention pillars (see Figure 1).
Figure 1: Five pillars of prevention
The Roadmap includes a 10-point action plan, whose implementation is led by governments. The Prevention Coalition Secretariat has been established within UNAIDS in Geneva to monitor progress and activate a mechanism for rapid technical assistance. The plan is summarized below:
- Conduct a strategic assessment of key prevention needs and identify policy and programme barriers to progress.
- Strengthen accountability for prevention, including all stakeholders.
- Establish or strengthen HIV-prevention program-monitoring systems.
- Assess available resources for prevention and develop a strategy to close financing gaps.
- Develop or revise national targets and road maps for HIV prevention by 2020.
- Strengthen national prevention leadership and make institutional changes to enhance HIV prevention oversight and management.
- Establish or strengthen social contracting mechanisms for civil society implementers and expand community- based programs.
- Develop consolidated prevention capacity-building and a technical assistance plan.
- Introduce the necessary policy and legal changes to create an enabling environment for prevention programs.
- Develop guidance, formulate intervention packages and identify service delivery platforms, and update operational plans.
The Prevention Roadmap aims to address the main gaps that hinder progress on prevention including: political leadership; policy; HIV financing and systematic scale up. To this end, it includes time-bound milestones and targets as well as commitments for governments, civil society, donors and the business community.
The Global Fund’s Role
The Prevention Roadmap does not articulate specific commitments for the Global Fund itself – however, it does list commitments for donor countries, development partners and global philanthropic institutions. These commitments include intensifying support for primary prevention; sustaining funding for HIV prevention across pillars and allowing sufficient transition time to increase domestic financing and management capacity; and placing increased emphasis on HIV primary preventions targets in global and regional fora and conferences.
In the Global Fund’s 2019 Results Report, Executive Director Peter Sands concedes that “while effective diagnosis and treatment are fundamental to the strategy to defeat HIV, it is increasingly clear that we must get better at prevention and in particular, in addressing the underlying drivers of new infections”. The report highlights the Global Fund’s prevention-related achievements such as a five-fold increase in funding for adolescent girls and young women. In 2018, the Global Fund launched the HER Voice Initiative in 13 East and Southern African countries, aimed at driving down infection rates among adolescent girls and young women. The initiative, which was launched with an initial investment of $500,000 from the Global Fund and continued with support from the private sector, is based on the principle that adolescent girls and young women have a vital role to play in driving and shaping the HIV response. HER has provided nearly 200 groups, networks or organizations led by adolescent girls and young women with small grants to facilitate their participation in Global Fund country processes.
Civil society experience: Malawi
Once the Roadmap was endorsed, countries were tasked with developing an accelerated start-up plan for the first 100 days and to prioritize setting national prevention program, financing and impact targets, as these had been missing from the 2016 Political Declaration targets.
Six countries (India, Malawi, Nigeria, Uganda, Ukraine and Zimbabwe) developed civil society shadow reports, with support from Frontline AIDS. “It [the process] started off well, with high levels of energy from all key stakeholders, including civil society. Different meetings were convened in Malawi to discuss priorities. [We agreed] we should revise the [national HIV] Prevention Strategy to align with the 5 pillars and that work is done”, says Malawian civil society advocate Abigail Dzimadzi.
The government also moved quickly to introduce legislation that would create an enabling environment for the response. In February 2018, Malawi passed the HIV Prevention and Management Act, a major step in addressing barriers that hinder prevention efforts. For example, the Act provides for the establishment of the National AIDS Commission, sets the age of consent for voluntary counselling and testing at 13 years old, and outlines the rights and obligations of people affected by and living with HIV.
However, Ms Dzimadzi acknowledges the disconnect between the adoption of enabling policy and the implementation of effective behavioural and structural interventions for key populations and adolescent girls and young women. New adult HIV infections in Malawi declined by a mere 34% between 2010 and 2017. “As I speak [since the adoption of the Roadmap], we haven’t moved. We are now reporting 27,000 new infections. We are still very far from where we thought we would be”, Dzimadzi said. Malawi set a target of fewer than 13,000 new infections by 2020, from a baseline of 34,000 reported in 2017.
In Malawi, the timing of the Prevention Roadmap was not synchronized with the Global Fund’s funding cycle. By the time the Prevention Roadmap was endorsed on October 10-11 2017, the Funding Request had already been submitted. The submission was made in March 2017 and approved on October 20 that year. That said, the Global Fund envelope did allocate $14 million, including $7 million in catalytic matching funds, meant to accelerate progress in prevention for adolescent girls and young women – but those funds had been allocated long before the Roadmap was developed. Advocates felt that they could not modify what had already been written into the grant to reflect the new priorities in the revised National Prevention Strategy.
Additionally, despite the Prevention Roadmap’s emphasis on the critical role of civil society in delivering services to youth and key populations and in advocating for policy change and legal reform to facilitate programme scale up, Malawian civil society feels short-changed. Maziko Matemba, a civil society advocate and vice-chair of the CCM told the GFO, “local civil society are not the ones implementing, just participating [in discussions]. This is an open secret”. Although Malawi has a civil society principal recipient, the funds are allocated to Action AID, an international NGO, not a Malawian organization, and this has become a source of contention among civil society who believe they are not being adequately resourced to respond. Malawi is currently in the midst of revising its National Strategic Plan, and Matemba says, “[civil society] is pushing hard so that support to civil society is well-defined and strategic”.
The Coalition report also states that: “coverage gaps remain substantial across all components of primary prevention”. Despite significant investments from the Global Fund, condom use among adolescent girls and young women remains very low. Matemba says this reflects his observations on the ground. “Most places, the free condoms are not there. I just attended a meeting and even the hotel we were staying in, the bathrooms have no condoms”.
The way forward
Malawi’s experience implementing the Roadmap is far from unique. The Progress Report discusses the six ‘shadow’ reports and notes some of the common gaps. For example, they highlight a lack of data on key populations and inconsistencies in target setting. While official scorecards for all six countries indicate that national targets have been set, in some cases the target-setting process is dependent on finalizing other strategy documents – or, where the targets do exist, they are not comprehensive or exclude certain key population groups. Furthermore, there is a glaring lack of detail across the board for how scaling up prevention will actually be achieved and measured.
This suggests a need to strengthen the accountability framework by meaningfully engaging with civil society and community organizations, by investing, for example, in community-based monitoring tools and initiatives. Additionally, it underscores an urgent need to prioritize and engage key populations and adolescent girls and young women, and fund local civil society organisations and networks that serve them, to ensure that programs meet their needs.
According to the Roadmap, a country prevention programme managers’ meeting will be held in October 2019 to discuss results, management and capacity issues, share experiences and identify changes in technical support needs.
- The Global HIV Prevention Coalition Second Progress Report: April – December 2018.