A regional workshop in Western and Central Africa (WCA) to build the capacity of national consultants and experts working on Global Fund grant applications was held in Saly, Senegal, from 25 to 27 November 2019.
The workshop, organized by UNAIDS, the Global Fund and other partners such as WHO, UNICEF, UNFPA, UNDP, Expertise France, and the Civil Society Institute (Institut de la société civile), brought together 140 people from over 20 countries in the WCA region - country delegates, national and international consultants and UN representatives - who will support the development of funding requests to the Global Fund in the coming months.
The workshop had several objectives:
- To provide an overview of the guidelines and priorities for a more effective response to HIV that should be factored into 2020-2022 funding requests;
- To review approaches and tools related to programmatic priorities around HIV, TB and resilient and sustainable systems for health (RSSH) in WCA;
- To share the latest thoughts on prioritization principles, the investment approach and the central role of civil society;
- To discuss specific issues relating to challenging operating environments (COE)
- To enable experts to share their experience (across countries) and create a (virtual) regional technical working group relating to the 2020-2022 grant cycle.
Challenges in the West and Central Africa region
Preventing new infections
The various presentations given during the three-day workshop all highlighted the significance of the challenges the region is facing, particularly in terms of preventing new infections, more than 60% of which occur among key populations and their sexual partners. Adolescents and young adults (240 new infections daily in WCA) are also particularly vulnerable. In light of delays in treatment (only 51% of people who know their HIV status are currently on treatment in the region), activities raising awareness of the importance of HIV prevention are also crucial, as is condom provision.
As part of this response, partnerships with the United Nations Populations Fund (UNFPA) and with sexual and reproductive health Directorates within Ministries of Health are essential. Pinpointing geographical pockets of new infections and having a good understanding of adolescents and young adults are also important: UNFPA has launched a vibrant advocacy campaign targeting young people, who require a response tailored to their needs and who need to be involved in developing these interventions.
Missed opportunities for prevention of mother-to-child transmission
Tangible progress has been made towards preventing mother-to-child transmission, but it is not enough. UN agencies, including UNICEF, WHO and UNAIDS, have played a considerable role in this area, through developing strategies to reach women during pregnancy, to help them disclose their HIV status, to put them on treatment and keep them on it until their child reaches 18 months. Despite this, half of the children living with HIV become infected during this period, which demonstrates the challenge of retaining mothers in care beyond delivery. There are also missed opportunities during pregnancy (90% of pregnant women go to the health center at least once during pregnancy; it should therefore be possible to test them when they attend the health facility) and after childbirth, both of which present many windows of opportunity to reduce infections. Participants from Unicef said that it is necessary to think about how to move forward so that these opportunities are not missed and that those working most closely with mothers at community level encourage this link during pregnancy and following childbirth.
The relevance of differentiated approaches
Many interventions appear to have been successful, in the current and previous Global Fund cycles, at expanding the implementation of differentiated approaches, i.e. approaches that are diversified as well as tailored to meet specific, identified needs. Many different testing strategies were presented and discussed, from family testing and index testing to self-testing, which have been put in place as part of the ATLAS project run by SOLTHIS (relating to self-testing for HIV) and funded by Unitaid. They all bring benefits, associated investments and costs, and present opportunities to speed up the region's delays in achieving the first ‘90’ (knowing one’s HIV status) in UNAIDS’ 90-90-90 combined target.
It has been the same for starting people on treatment and retaining them in care, which is done through many differentiated approaches nowadays: for adult patients who are stable, once treatment has been initiated at the health center, follow-up care can be done in the community. There are many options: community ART distribution points managed by organizations of people living with HIV, adherence support groups, fast-track channels in health facilities, community-based distribution. These strategies have helped to unclog health centers, bring services closer to users (while lowering the cost and time spent seeking treatment), and have enabled a new form of collaboration between organizations of people living with HIV and patients. These approaches are all the more important given that a number of patients are lost to follow-up after 24 months and there are further difficulties ensuring retention beyond that. These community strategies tailored to the needs of patients must be strengthened, it was discussed, and put to scale.
Viral-load testing seems to be the only area where there have been no major innovations in intervention strategies. An overview of the basic principles was given at the workshop: training of health-care providers, stimulating demand, checking the transport route for samples (the study carried out in Senegal to send dried blood spots to Dakar from regional level to carry out early infant diagnosis tests, called Emprise, was mentioned), and results returned within a reasonable timeframe. But there were not enough differentiated strategies relating to the patient's place of residence, and the proximity of viral-load testing centers, and there were few reflections on the cost, or on the analysis of results and moving to second-line treatment.
In addition to the lack of data on key populations, vulnerability of these groups to stigma, discrimination, violence and exploitation and their limited access to the appropriate health services were also highlighted.
Activities targeting key populations tend to focus on prevention and awareness-raising campaigns. For homosexuals and sex workers, the major gaps relate to limited condom and lubricant distribution, awareness-raising methods, access to services for sexually transmitted infections and mental health services, and linkages between testing and treatment services. To date there has been little focus on services for drug users, prisoners and transgender people. There are few needle- and syringe-exchange and opioid-substitution treatment programs and overdose prevention is not included in most national strategic plans in the region. There is also a lack of disaggregation by sex, gender, and age in key-population-size estimations, in epidemiological surveillance, and in programs, from the design stage all the way up to service monitoring.
One of the recurring themes of the meeting was the fact that we will not be able to achieve the three ‘90s’ without involving civil society (CS). The ongoing regional initiatives presented at the workshop, be it community treatment access watchdogs, the Regional Civil Society Coordination Institute (Institut Régional de coordination de la Société Civile) or the Global Fund communication platforms, have shown that in a large number of areas, from prevention to monitoring and evaluation, civil society has a unique comparative advantage that goes above and beyond solely advocacy.
UNAIDS outlined the way forward to ensure that civil society plays a central role: each country should to take stock of policies that enable civil society to take action, identify civil society organizations that could work on specific issues, set out an action plan for civil society organizations in these areas, including institutional and technical capacity building, and ensure funding request-writing committees factor these civil society plans in. In this regard, UNAIDS has carried out an exercise to map civil society and plans to accelerate civil society's contribution in more than 10 countries in the region.
Human rights and gender
UNAIDS said that programs to overcome human rights issues and gender-related barriers that hinder access to HIV services should be identified, integrated, costed, budgeted, implemented and evaluated on a sufficient scale to make a difference. These programs must now be described in a comprehensive way in concept notes. Practical steps were presented by the GF, UNAIDS and UNDP to enable integration and strengthening of human rights principles and programs in national AIDS responses, in order to facilitate access to health care and to maximize the chances of them being adopted and adhered to, to ensure that nobody is left behind. It was mentioned that there are examples of programs that have proven successful in reducing human rights issues and gender-related barriers that hinder access to HIV services.
An overview of risk mitigation policy in grant management was presented. The WCA region is particularly affected by additional safeguard measures, especially in ‘challenging operating environments’ (13 countries in the region fall into this category). However, studying risk is not limited to the risks related to sound financial management of grants. Risk management also relates to program governance (inadequate governance of the national program, monitoring of grants by the principal recipient, compliance with Global Fund requirements), quality of health commodities, risks related to human rights and gender equity, macroeconomic factors that impact, in particular, honoring co-financing commitments, and political instability in the country.
This analysis is crucial, it was noted, and must be included in the concept note following a comprehensive, focused dialogue to identify all risks and mitigation measures. Although some risks cannot be avoided as they relate to macro political and economic issues over which health stakeholders have little or no control, they must still be taken into account to guide operational decisions (operating in risk areas requires original and adapted intervention methods) and strategic decisions (which priorities to achieve optimal impact?), it was agreed.
Strengthening health systems
Finally, the topic of priorities for strengthening health systems and for integrating TB, hepatitis and sexual and reproductive health into HIV prevention and treatment activities was raised by the Global Fund's RSSH department and by WHO. Selecting the amounts allocated to health system strengthening (HSS) activities is left to the discretion of each country, as well as choosing to draft a specific HSS request or to build it into one of their grants (when preparing grants in the current cycle, most HSS activities were built into countries’ malaria grant). For the Global Fund, following the last report of the Technical Review Panel (TRP), the challenge lies in moving from supporting the system to strengthening it and ensuring it is sustainable. This involves strategic investments that are intelligently thought out and identified through an improved understanding of the context of the different pillars of the system, involving all stakeholders in this system (public, private, civil society organizations).
The main priorities identified by the Global Fund have not fundamentally changed since 2017. They relate to: service delivery (especially for adolescents’ sexual and reproductive health services; integrated care and support for children and how that translates at community level); human resources for health (in particular establishing systems for career development and for deployment of human resources across the country, plans for funding, and motivation for professionals from the Ministry of Health); support to the pharmaceutical and laboratory sector; and health management information systems. Given the competing urgency in this area, the long-term nature of efforts to achieve the expected results and the number of partners involved, it is necessary to have an inclusive dialogue. This needs to happen as quickly as possible at country level to bring together all stakeholders and technical and financial partners. This will allow identifying the priorities of an HSS roadmap and the funding gaps that are usually covered by Global Fund grants.
Sustainability, transition and co-financing
It was broadly agreed, and emphasized by the Global Fund, that sustainability considerations must be integral to the planning and implementation of programs for all countries, regardless of whether they are developing countries or not. The first step is having a robust and costed national strategic plan, developed with significant involvement of all stakeholders (including communities most affected and civil society).
In the WCA region, based on lessons learned from previous concept notes, the Global Fund’s RSSH team would like to see funding requests that include: clear sustainability analysis: understanding of current challenges and plans / proposals to address them; considerations around allocative and technical efficiency, linked to existing national studies and strategies; increased focus on integration (including community activities); national funding: evidence of national efforts to mobilize funds for the three diseases and health systems at the national level - partners, private sector, national budget; focus on co-financing commitments for some interventions (including human resources for health); clarity on expenditure tracking and reporting at national level; a clear vision for developing human resources for health, with coordinated and standardized approaches managed by governments and co-financing commitments; and greater clarity on strategic investments into health systems to improve sustainability, including data, performance-based management, and supply chains.
Various orientation workshops on the three diseases are taking place during the current preparation period for the new cycle. The allocation letters, which have been sent to countries starting during the week of December 12, will kick off the country dialogue process, although a number of countries have already initiated a schedule to monitor funding requests, have designated a chair for the proposal committee, and have submitted requests for technical assistance to different providers (UNAIDS Technical Support Facility, WHO, 5% Initiative). This is why updating and preparing consultants and country experts is so crucial, participants affirmed. In the words of one participant, this workshop “enabled us to share experiences between the various stakeholders involved in the HIV response, making innovative strategies tangible, especially those advocating differentiated services. We can see that it is through coordination and ensuring synergy between all stakeholders (health delivery and civil society) that these strategies are effective.”
The presentations and reference documents from the Western and Central Africa workshop are publicly available in a shared folder on UNAIDS’ Sharepoint site.