HIV PREVENTION IN GC7 FUNDING REQUESTS IS STILL FAR FROM PROVIDING AN ADEQUATE RESPONSE TO IDENTIFIED NEEDS
Article Number: 7
In spite of global guidance highlighting the need for Global Fund funding requests to pay more attention to HIV prevention, 15 draft applications reviewed under Window 1 showed that prevention is still underestimated when it comes to financial support. Unsurprisingly, far more is spent on health products and treatment. This article looks at a prevention checklist originally designed to help reviewers assess draft funding requests through a prevention lens. But even before the applications reach the review stage, those drafting the funding requests would also find the checklist helpful to ensure adequate attention is given to HIV prevention.
Peer reviews of 15 draft funding requests from 10 countries which submitted under Window 1 were unanimous in their findings that HIV prevention was not given due attention.
Global guidance, from the Global AIDS Strategy 2021-2026 (GAS) to the Global Fund Strategy 223-2028, is clear that greater efforts are needed to bolster HIV prevention interventions within national HIV responses. Unfortunately, however, this has not been evident in the draft funding requests reviewed by the UNAIDS-Technical Support Mechanism (TSM) Virtual Support Desk (VSD). Of the 10 countries reviewed under Window 1, in most cases prevention interventions to address identified gaps in the national HIV response were found to be weak or lacking.
HIV prevention in funding requests appears to be weak
Draft funding requests often failed to provide a good rationale for interventions and there was a lack of consistency in prioritising the most appropriate activities in line with the national strategic plans for HIV (NSPs) and other normative guidance and policy documents. Even when gaps in HIV prevention were apparent from the funding landscape and programmatic gap tables, prioritisation of prevention interventions was poor and/or there was little explanation of how prioritisation was undertaken.
Prevention components were, on the whole, weak. Most countries ‘talked the talk’ regarding the importance of prevention, using the GAS and Global Fund Strategy as the rationale for priority-setting, but failed to back this up with adequate budgets. For example, one country with significant TB/HIV infection among prisoners had allocated only $50,000 over three years to address this. Another country was missing two essential prevention pillars – there were no modules on prevention of mother-to-child transmission (PMTCT) or adolescent girls and young women (AGYW). Moreover, several funding requests failed to address the special needs and issues of young key populations (KPs).
And, where prevention interventions were included, many draft funding requests were guilty of offering a ‘shopping list’ of aspirational prevention interventions using language they presumably assumed the funder wanted to see: but without the financial allocation to deliver them. In other words, the prevention modules’ stated activities were not reflected in the modules’ budget.
Support to encourage greater attention to prevention in funding requests
UNAIDS-TSM developed a guide to assist those who are reviewing Global Fund funding requests for Grant Cycle 7 (2023-2025) with an HIV prevention lens. However, the “Top Ten Checklist” which forms part of the larger, more detailed guide can also be used directly by countries to assess whether they have done enough when it comes to the HIV components of their funding request.
Top Ten Checklist for HIV prevention in GC7 requests
- Is the funding request aligned to national strategies/roadmaps on HIV prevention? If this/these do not exist, are there stated plans to develop one/them through technical assistance or requested funding? In the absence of a plan, is the request aligned to the Global HIV Prevention Roadmap 2025?
- Are the selected HIV prevention modules and interventions appropriate and high-impact in nature given the country context and epidemiology, keeping in mind the new key population-specific modules and new prevention stewardship module? (see Global Fund Modular Framework Handbook).
- Are the four HIV prevention Program Essentials funded at a sufficient scale (condoms, pre-exposure prophylaxis (PrEP), harm reduction, voluntary medical male circumcision [VMMC])? If not, is this because of insufficient resources available or because resources are invested outside the Program Essentials – and, if the latter, is there evidence that the alternative investments will be more impactful? (see page 14 of the HIV Information Note).
- Are the coverage, outcome, and impact targets for HIV prevention ambitious enough, in line country commitments (looking globally to the Global AIDS Strategy and Political Declaration, not only the NSP), considering population sizes and demonstrating the rapid scale-up?
- Is there an explicit analysis of value for money of proposed HIV prevention investments analyzing cost per new HIV infection averted for different populations and interventions? Are the choices made good value for money? Make sure the funding request does not include a range of un-targeted, low-impact, non-specific interventions without differentiation by populations / level of risk.
- Are the HIV prevention packages appropriately focused, comprehensive and differentiated by population (and sub-population), including based on risk categories? (See AGYW decision-making aid [to update], and WHO Consolidated Guidelines on Key Populations – Chapter 5)
- Are the HIV prevention packages scalable and designed in a way that by 2025 all KPs and priority populations can be reached with the packages within available resources or realistically achievable increases in resources? Make sure the funding request does not promote unsustainable packages and delivery modalities, while ensuring quality delivery.
- Is the amount requested for HIV prevention sufficient, keeping in mind past patterns of underfunding prevention? Attention should be paid to the HIV prevention matching funds areas in particular (ensure an increase in the allocation, 1.5:1 match). Consider also domestic and co-financing commitments for HIV prevention in conjunction with the funding request.
- Are the implementation arrangements suitable for the effective delivery of HIV prevention interventions providing trusted access platforms for services, including a role for civil society, community- and KP-led organizations particularly in outreach programs?
When we refer to HIV prevention in this checklist, we primarily refer to prevention among young people and adults. The following priorities are meant:
- Key populations including gay men and other men who have sex with men, sex workers, people who use and inject drugs, transgender people, prisoners (all countries).
- Adolescent girls and young women in settings with moderate to high HIV incidence (countries in sub-Saharan Africa with locations where HIV incidence exceeds 0.3 in 100 person years).
- Adolescent boys and young men (including VMMC and promoting access to testing and treatment) (countries in sub-Saharan Africa with locations where HIV incidence exceeds 0.3 in 100 person years).
- Condom and lubricant programming (all countries with HIV epidemics that reach beyond KPs and their sexual partners, mostly in sub-Saharan Africa and in countries with predominantly KP epidemics where condom programming should be part of KP packages).
- ARV-based prevention (including PrEP, post-exposure prophylaxis (PEP), treatment as prevention including for elimination of vertical transmission) (all countries with sub-populations with very high or rapidly increasing HIV incidence in specific sub-populations).
This HIV prevention checklist is intended to complement other broader checklists that countries may use to determine their HIV interventions and also specific checklists for key populations, paediatrics and PMTCT, HIV testing and treatment. You can also access a short, six-minute video which provides a summary of the above with actual examples from fundng requests at TSM Virtual Tutorial – “Top Ten” Checklist for HIV Prevention in Global Fund Funding Requests.