NEW MODULAR FRAMEWORK RAISES THE PROFILE OF SOME KEY POPULATIONS

Author:

Gemma Oberth

Article Type:

Article Number: 4

Transgender people and prisoners receive greater emphasis than before

ABSTRACT The Global Fund’s new modular framework contains several important changes for the 2017-2019 funding cycle. Transgender populations and prisoners are given stand-alone modules as key populations for HIV prevention. However, key and vulnerable populations for TB and malaria are not given commensurate priority, and some people allege that gender remains side-lined.

In December 2016, the Global Fund published a new Modular Framework Handbook. The modular approach is the Global Fund’s way of organizing programmatic and financial information for each grant, sorting budget lines and performance targets according to set categories. The modular approach was first introduced with the new funding model and was implemented as part of the 2014-2016 funding cycle.

For the 2017-2019 cycle, the Fund no longer requires the modular template as an attachment to the funding request, but applicants must still articulate their requests using the modules and interventions laid out in the framework. The budget template and performance framework, two documents that form part of the funding request, are aligned to the modular approach. The new modular framework came into effect in January 2017, with several important updates and changes. The table below provides an updated list of modules, by component.

Table: Updated modules for the 2017-2019 funding cycle

Component	Module
HIV	Prevention programs for general population
	Comprehensive prevention programs for men who have sex with men
	Comprehensive prevention programs for sex workers and their clients
	Comprehensive prevention programs for people who inject drugs and their partners
	Comprehensive prevention programs for transgender people
	Comprehensive programs for people in prisons and other closed settings
	Prevention programs for other vulnerable populations (please specify)
	Prevention programs for adolescents and youth, in and out of school
	Prevention of mother-to-child transmission
	HIV testing services
	Treatment, care and support
	TB/HIV
	Programs to reduce human rights-related barriers to HIV services
	Program management
TB	TB care and prevention
	TB/HIV
	Multidrug-resistant TB
	Program management
Malaria	Vector control
	Case management
	Specific prevention interventions
	Program management
RSSH	Procurement and supply chain management systems
	Health management information system and monitoring and evaluation
	Human resources for health, including community health workers
	Integrated service delivery and quality improvement
	Financial management systems
	National health strategies
	Community responses and systems
	Program management

Some of the most notable changes are among the key population modules. First, the Global Fund has now separated activities for HIV prevention for men who have sex with men (MSM) and transgender (TG) people into two separate modules. Previously, these were combined into one module called “Prevention programs for MSM and TGs.” The arbitrary lumping together of these two key populations had been criticized (see Lancet article), predominantly for masking or misclassifying epidemics among trans communities. MSM and TG have clear and distinct identities, social and sexual networks and public health needs. The disaggregation of MSM and TG programming (and indicators and targets) in the new modular framework is in line with the latest international guidance that conflation of MSM and TG should stop.

Another key population which is significantly elevated in the new modular framework is prisoners. Under the previous modular framework, activities for prisoners could fall under the HIV module called “prevention programs for other vulnerable populations (please specify).” And the TB care and prevention module had an intervention called “key affected populations” which could include active case finding among groups such as prisoners; displaced people; migrants and ethnic minorities/indigenous populations; miners; children; urban poor; and the elderly.

In the new modular framework, there is a dedicated HIV module called “Comprehensive programs for people in prisons and other closed settings,” which covers a gamut of interventions including community empowerment; addressing stigma and discrimination; behavioural interventions; condoms and lubricant; pre-exposure prophylaxis (PrEP); harm reduction; sexually transmitted infection (STI) services; and prevention and management of co-morbidities. The new framework also updates the TB care and prevention module to include a specific intervention called “Key populations – Prisoners” which goes well beyond active case finding to include infection control; mobile outreach, including regular chest x-rays; TB preventive therapy; linkages to care on exit from detention; and linkages to harm reduction programs for prisoners who use drugs.

Despite these improvements, there are some areas where the new modular framework falls short. Although gender and gender equality is a significant priority in the Global Fund’s new Strategy 2017-2022, there is no stand-alone module that would facilitate countries to budget and program in this area. However, gender-based violence and treatment programs are listed as interventions in the HIV prevention modules for the general population and for adolescents and youth; and fall within the scope of some of the key population interventions.

There is also an intervention under the “Programs to reduce human rights-related barriers to HIV services” module called, “Reducing HIV-related gender discrimination, harmful gender norms and violence against women and girls in all their diversity.” Finally, each TB module has an intervention on removing human rights and gender-related barriers.

Although this is a vast improvement over the modular template used in the previous funding cycle, some people maintain this may not be enough to end the gender inequalities that fuel the three diseases.

“We appreciate that gender and women are highlighted in many modules but given that a key objective of the Global Fund’s new strategy is promoting gender equality, having a stand-alone module on gender, women and gender violence would have been helpful,” said Sophie Dilmitis, Global Coordinator for Women4GlobalFund. “Having its own module could prevent countries from downplaying or sweeping gender under the rug of ‘cross-cutting priorities,’” she said.

Another noticeable shortcoming in the new framework is the absence of specific modules for TB and malaria key and vulnerable populations. Where HIV has seven different modules dedicated to prevention programs for key and vulnerable populations, the other two diseases have none. Given that we have international guidance on who is considered a key and/or vulnerable population for TB and malaria, it is unclear why these are not prioritized commensurately in the new framework.

A third critique centers on why the framework only features prevention modules for key populations. Based on guidance in the latest implementation tools (see MSMIT, SWIT and TRANSIT), key population modules might be better crafted as comprehensive packages of care. The need to scale up treatment access among key populations is particularly glaring, something which the Global Fund’s prevention-focused key population modules may not adequately address. For instance, while 70% of HIV-positive sex workers in Johannesburg know their status, only 24% are accessing life-saving antiretroviral therapy (ART). In Zimbabwe, just one in five young HIV-positive sex workers is on ART.

As countries gear up to submit their funding requests for the 2017-2019 funding cycle, Aidspan will monitor how countries make use of the new framework. Tracking which modules and interventions applicants choose to request funding for is often a good barometer of national priorities. It will be telling to see how countries adapt to the changes in the Fund’s framework.