TRP report on Windows 1 and 2 stresses importance of reaching key populations in funding requests to the Global Fund

4. NEWS
28 Nov 2017
Funding requests contained limited discussion of HIV prevention efforts for young women and girls, TRP says

In October, the Technical Review Panel (TRP) prepared a report on the funding requests it reviewed in Windows 1 and 2 of the 2017-2019 allocation period. The report was divided into three parts: (a) general observations; (b) technical observations; and (c) the review process. In an article in GFO 325, we summarized Part One (general observations). In this article, we provide a summary of what the TRP said in Part Two (technical observations) concerning the importance of reaching key and other high-prevalence populations.

(What the TRP said about key and other high-prevalence populations is just a small portion of Part Two. See the last half of this article for a “table of contents” of what is included in Part Two of the TRP report. See also a separate article in this issue containing excerpts from the report.)

“The Report of the Technical Review Panel on Funding Requests Submitted in the First and Second Windows of the 2017-2019 Allocation Period” is available at https://www.theglobalfund.org/en/technical-review-panel/reports/.

 

REACHING KEY AND OTHER HIGH-PREVALENCE POPULATIONS

The TRP’s comments fall into three areas: (a) data and data use; (b) services tailored to specific populations; and (c) the use of innovative strategies.

Data and data use

The TRP said that funding requests for all three diseases neglected to include important data concerning key populations and general populations with a high prevalence. 

The TRP observed that although TB applications often listed TB key and vulnerable populations, they did not provide any contextual analysis, or estimates of the populations’ size, geographic distribution and ability to access services. Interventions to find missing cases were mentioned, but there was insufficient detail on how proposed interventions for intensified TB case-finding would be carried out. Since the health management information system for TB does not disaggregate treatment outcomes by sex, gender or age, the TRP said, applications did not present gender- and age-differentiated treatment outcomes. 

Although countries are working to identify, estimate the size of, and address the needs and demands of, HIV key populations, disaggregated data for both key and general populations are still infrequently used for prioritization, the TRP stated. Furthermore, many funding requests did not consider epidemiological and qualitative data for HIV prevention programs. “Consequently, the prevention needs of groups in the general population that have higher prevalence and evidence of higher risk were likely not to have been adequately addressed,” the TRP said. For both concentrated and generalized epidemics, funding requests had limited discussion of HIV prevention efforts for young women and girls, and young people at higher risk of HIV. 

Some malaria applicants did not use available empirical data to identify key and vulnerable populations or to design specific activities to reach them, the TRP said. Malaria funding requests should make better use of existing data on age, sex, population mobility and demographics, the TRP stated, to facilitate identification of the most vulnerable populations, understand whether they access services, and design appropriate activities to effectively reach populations in need. “‘General distribution’ of long-lasting insecticide-treated nets does not mean everyone who needs a bed net necessarily has access to one,” the TRP said. 

The TRP cited the national TB program (NTP) of one applicant that acted on data from prevalence surveys showing men of all ages are more at risk for TB, and adapted services to better meet their specific needs.

Although case notifications are disaggregated by gender and age, treatment outcomes are not, the TRP noted.

Recommendations (data use)

For applicants:

  • Plan to provide services to all populations at greater risk of infection and disease, beyond key populations.
  • Systematically assess the needs of all key, vulnerable and at-risk populations. 
  • Use available disaggregated information, from survey and routine data as feasible, to better identify key and at-risk populations for all three diseases.

For partners:

  • Provide technical assistance and support countries to strengthen collection, reporting and interpretation of sex- and age-disaggregated data.
  • Support countries to better analyze and use available sub-national and disaggregated data, qualitative research, and country survey and epidemiological data, to identify vulnerable and underserved populations, make an informed choice of strategic priorities, and design enhanced and sustainable interventions. 
  • Revise data collection methods and reporting tools to include age- and gender-disaggregated treatment outcomes for TB. 

For the Secretariat:

  • Strengthen Global Fund guidance to encourage countries to provide evidence-based services to address the needs of key, vulnerable and at-risk populations. 

 

Tailored services

The TRP noted that some funding requests revealed better key population awareness than in the past, but it said that many others did not mention key populations or propose specific interventions to address their needs. 

For HIV funding requests, these populations included men who have sex with men; transgendered people; prisoners and people in closed settings; indigenous people; lesbians, gays and bisexuals; refugees; people who inject drugs; people with a disability; mobile and internally displaced people; and the military. The TRP pointed out that statements in funding requests affirming that the whole population has access to services often misrepresent situations where specifically targeted interventions matching sub-population needs and demands are absent, denied, prohibited by law or under-funded. 

Often, there was limited discussion of age-appropriate interventions for children in general, and orphans and vulnerable children in particular, the TRP observed. 

Some funding requests proposed strong and equitable interventions for refugees and migrants, the TRP said, but usually they did not address needs on both sides of a conflict; international humanitarian law holds that populations on both sides of a conflict have a right to medical care.

The TRP said that few funding requests proposed interventions for the military or other uniformed personnel in conflict and post-conflict areas.

Recommendations (tailored services)

For applicants:

  • Provide increased domestic financial commitments for key population programming.
  • Include human rights and gender considerations in programming prioritization. 
  • Provide a “service provision landscape” analysis for each key population to identify gaps in service coverage. This is particularly relevant for middle-income countries and countries in transition, where a funding request to the Global Fund is less likely to cover a full package of services for certain key populations. 
  • Use the Global Fund’s human rights baseline studies and legal environment assessments to inform analysis of the needs, demands and rights of key populations. 
  • Place greater emphasis on the HIV test-treat-retain cascade analysis for key populations. Cascade analysis requires identifying where, along the steps of the continuum of care, programs fail to engage and retain people living with HIV in testing, care and treatment; determining the magnitude of the losses and gaps along the continuum; and identifying and analyzing the causes of the losses or gaps. Similar analyses of the pathway of diagnosis, treatment and care for relevant key population groups should inform the choice of interventions in TB and malaria programs.
  • In conflict areas where the government has limited or no control, or cannot reach out to affected populations, make every effort to provide access to services through alternate channels, including international UN agencies, the Red Cross, international non-governmental organizations, or agreements with non-aligned parties, to ensure hard-to-reach populations on both sides of the conflict have equal access to services. 
  • Include sensitization and capacity-building interventions for ministries of justice and police within proposals for people who inject drugs and people in closed settings, with a budget, as per guidelines published by the World Health Organization (WHO), UNAIDS and the United Nations Office on Drugs and Crime. 

For partners:

  • Provide more support to countries with restrictive environments for key populations to overcome political, social or religious barriers to access. 
  • Support countries to develop specific interventions for transgender populations, distinct from men who have sex with men. 
  • Support countries to strengthen outcome measures for reporting on human rights and gender outcomes and consider aligning these with some of the Office of the High Commissioner for Human Rights and PEPFAR indicators. 
  • Support countries to develop and implement comprehensive evidence-based interventions for people in closed settings. Ensure that the relevant global health clusters liaise with country coordinating mechanisms to support inclusion of interventions for internally displaced populations and refugees in funding requests. 

 

Innovative strategies

The TRP noted that innovative strategies could help to fill gaps in HIV and TB coverage. 

HIV applications need more focus to prevent HIV among at-risk populations, the TRP said, and a greater focus on innovative case-finding strategies to meet the needs of hard to reach populations. TB applicants, for their part, should use the matching funds requests to test new approaches to find missing TB cases at the local level before roll-out to the national level. 

Recommendations (innovative strategies)

For applicants:

  • Develop and implement innovative strategies to reach populations with low access to HIV prevention services, taking into account their sex, gender, age, risk, and use of new social networking technologies and products. Consider new testing approaches such as self-testing, index testing, community-based testing, and sexual network testing. 
  • Find and adapt successful examples of finding missing TB cases.
  • Strengthen the role of communities and the private sector, and use information technology for case finding, retention in care and contact management. 
  • Look for new implementers to stimulate and promote innovative ideas. 

 

TABLE OF CONTENTS FOR PART TWO

In Part Two of its report on Windows 1 and 2, the TRP presented technical observations and recommendations. Part Two, which consumed 22 of the 36 pages in the report, covers a lot of ground – far more than we can summarize in one article, or even a few articles. Below is a “table of contents” that we constructed for Part Two. (We covered Item #1 of the TOC in the first part of this article.)

Contents of Part Two of the TRP Report on Windows 1 and 2

  1. Reach the key and other high-prevalence populations who need to be reached.
    1. Improve data and data use.
    2. Provide tailored services for key populations
    3. Use innovative strategies to find and serve missing populations.
  1. Address structural barriers for vulnerable populations.
    1. Women’s and girls’ empowerment.
  1. Provide appropriate, targeted and quality prevention, care and treatment services for malaria, TB, TB/HIV and HIV.
    1. Malaria
      1. Acknowledge malaria upsurges, analyze possible causes using available data, and adjust response if necessary.
      2. Develop appropriate plans for malaria elimination.
      3. Consider rationale and evidence for programmatic decisions on malaria vector-control strategy.
      4. Include essential impact indicators in funding requests.
    2. TB
      1. Set targets that are more ambitious and develop differentiated responses addressing key gaps and barriers.
      2. Optimize use of diagnostic tools.
      3. Provide material and nutritional support to patients who need it.
      4. Expand multi-drug-resistant TB programs.
      5. Prioritize childhood TB.
    3. TB/HIV
      1. Strengthen implementation of TB/HIV collaborative activities
    4. HIV
      1. More focus on prevention is needed.
      2. Prioritize adolescent girls and young women.
      3. Improve the implementation of differentiated service delivery models.
      4. The first 90: Improve HIV testing and linkage to care and treatment.
      5. The second 90: Increase ART coverage.
      6. The third 90: Improving treatment retention and viral load suppression.
  1. Strengthen health systems
    1. Integrate the disease-specific national strategic plan and national health plans.
    2. Strengthen information systems.
    3. Strengthen procurement and supply chain management.
    4. Carry out quality assurance and pharmacovigilance to limit circulation of counterfeit drugs and other sub-standard medicines.
    5. Strengthen human resources for health.
    6. Improve service provision with health systems strengthening and links to reproductive, maternal, newborn, child and adolescent health.
    7. Strengthen community systems.
    8. Involve the private sector in the health response.
    9. Strengthen governance and management of decentralization.
  1. Plan for sustainability

“The Report of the Technical Review Panel on Funding Requests Submitted in the First and Second Windows of the 2017-2019 Allocation Period” is available at https://www.theglobalfund.org/en/technical-review-panel/reports/.


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