Activism in Action: Week 2 reporting from the frontlines of the PEPFAR planning process

In late February, we reported back from week one of the Regional Planning Meetings (RPM) in Johannesburg where representatives from programs under the US Government’s President’s Emergency Plan for AIDS Relief (PEPFAR) meet to make plans, set targets and define approaches, ultimately captured in Country Operational Plans (COPs) for more than 50 countries around the world. At the RPMs, PEPFAR country staff, PEPFAR Washington staff, national ministry of health representatives, national and international civil society organizations (CSOs), WHO, UNAIDS and Global Fund gather for three weeks to lay out the priorities for the PEPFAR program for the next year, which starts the following October.

Week two, which wrapped up the last week of February, focused on Angola, Botswana, the Dominican Republic, Haiti, Namibia, Mozambique, South Africa, Zambia and Zimbabwe. AVAC was there, along with civil society partners from the Advocacy Core Team—the Zimbabwe country team from COMPASS as well as GALZ and other activists from Zimbabwe. Here are some highlights, issues and what was won in week two.

COMPASS in Action in the Zim Room

COMPASS partners came to the RPMs with a list of community priorities, reflected in the Community COP20 Zimbabwe. These demands were informed by over 50 Zimbabwean CSOs. The final version of the Zimbabwe COP, adopted in week two, reflected many of the Community COP priorities, including:

• Increased staffing and scale-up of viral load testing, and new approaches to connect clinics and laboratories to improve the coverage of viral load testing from the current 44 percent coverage to 85 percent.
• Increased PrEP targets by 177 percent by delivering PrEP to 28,600 people in 22 districts with a focus on key populations and adolescent girls and young women with supporting communications and PrEP literacy efforts to increase demand, normalize PrEP and improve continuation.
• Commitment to continue funding human resources for health, such as lab technicians, community adolescent treatment supporters (CATS), data clerks, peer and lay workers, nurses and pharmacists in PEPFAR priority districts.
• Elimination of all formal and informal user fees for HIV and related services in the public sector by September 2021.
• Increased Community ART Refill Groups (CARGS) as an option in up to 50 percent of treatment facilities to increase retention of treatment among PLHIV.
• A buddy-system as a model for key and vulnerable populations to access HIV related services, and the expansion of drop-in centers.
• Beginning scale-up of 3HP, the more tolerable and preferred TB preventive therapy, as the current TB therapy, is expanded cover to 100 percent of PLHIV by end of COP20.
• CSOs won US$1m for community-led monitoring of services at 200 facilities in 40 districts in Zimbabwe. The focus will be on services for young people and key populations.
• Rollout of electronic medical records to over 500 sites.

Coverage for viral load testing was a top priority for civil society. Last year, COMPASS partners worked with PEPFAR staff to develop a US$6.8m plan to expand coverage. Power outages greatly impact the stable functioning of the labs that are critical to measure viral loads. Activists pushed for staff hirings and backup solar power to avoid lab processing delays. Since it had no funds this year to commit, PEPFAR agreed to request those funds from Global Fund, and the Global Fund agreed to consider the request at the country level in the next few weeks. Activists will follow up on this.

Wither Testing?

This year’s PEPFAR Country Operational Plan (COP) Guidance, an annual statement of PEPFAR priorities and requirements used by country teams to develop their COPs, continued ambitious scale-up of index testing. In week two, AVAC and other civil society continued to voice their concern about harm from index testing. See recent Call to Action. Current index testing in the Guidance still stands, but there’s movement to allow community monitoring of index testing programs, funded by PEPFAR, to test compliance with WHO testing guidelines. Still, the continuation of high targets for index testing remained. As Naïké Ledan from Haiti said at the closing plenary, “Failing on targets [should be] more acceptable than failing on human rights.”

In 2018, PEPFAR tested 95 million people in provider-initiated testing centers (PITC) such as hospitals or clinics, and through modalities such as self-testing and index testing. According to PEPFAR leader Ambassador Birx, PEPFAR programs have significantly overspent on testing with an investment in COP19 of US$401m against a budget of US$285 million. (In contrast, PEPFAR underspent on prevention by 10 percent, spending US$475m from a budget of US$520m.) As countries approach over 80-95 percent of PLHIV on treatment, those testing positive for HIV from provider testing have fallen. The implication of these data came to the fore in different country plans as index testing was scaled up and funding for PITC testing was signficantly cut. COMPASS partners voiced concerns about the 90 percent reduction in PITC testing in Zimbabwe in COP20. PITC testing repesented half of all of new HIV positive diagnoses in Zimbabwe, so advocates pushed for and were able to retain PITC testing targets in the final COP plan.

Another Virus Steals the Spotlight

In week two, another virus was consuming public attention, and Ambassador Birx was appointed to be the White House Coronavirus (COVID 19) Response Coordinator, in addition to her PEPFAR role. The PEPFAR program, and the US$900m in labs that PEPFAR has built across Africa will help prepare the continent from this new threat. As Birx noted, COVID-19 represents a challenge that PEPFAR understands, surveillance, finding asymptomatic patients and working with community.

Zambia Moves on Prevention

As a number of countries approach their 90-90-90 targets, they have been encouraged by PEPFAR to look to investments in treatment retention and HIV prevention. For Zambia, discusions focused on how to push PEPFAR funded programs beyond the 90-90-90 fast track targets set by UNAIDS, which have now been met. Zambian CSOs, along with COMPASS partners AVAC and amfAR, pushed for communities to lead the way on closing long-standing gaps in primary prevention. A strategy of pushing an agenda early in the week worked well, getting changes included before budgets were locked down. By the end of the week, PrEP targets for the Zambia program went from 44,000 to 110,000, including increases for KPs.

Stay tuned for week three! We’ll provide updates on Tanzania and Malawi, where COMPASS Africa worked to implement the Malawi Community COP.

Want to learn more about the issues above and engaging with PEPFAR? Check out these resources:

• AVAC’s Frequently Asked Questions (FAQ) - Index Testing on index testing.
• For PrEP programming, targets and more by country, check out PrEPWatch’s PrEP Tracker.
• Health GAP’s PEPFAR Watch page includes the updated 2020 Rough Guide to Influencing and Monitoring PEPFAR Country Programs (also in French) as well as copies of several countries’ People's COP documents.
• amfAR has created user-friendly databases to understand what’s happening with PEPFAR programming at the country level. Check out their database on performance (mer.amfar.org), which is part of the COMPASS initiative, and don’t miss amfAR’s database on country plans and budgets (copsdata.amfar.org). You can download country fact sheets in English, French and Portuguese.
• CHANGE’s Prevention Goals Brief for CSOs is available here.
• MSF Access Campaign, 20 Point Checklist for diagnosis, treatment and prevention of AIDS.