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Many of us are focused on the global—and in most cases very personal—response to the COVID-19 pandemic, but the work in the fight against HIV continues apace. In this update, AVAC shares the essential work of civil society groups and activists who are influencing PEPFAR programming for the coming year. Their continuing advocacy led to important wins, gained over the three weeks spent at the Regional Planning Meetings (RPMs) in Johannesburg. Read on for wins from week three and check out previous posts on wins from week one and week two.
Week three, which wrapped up March 6, focused on Burundi, Ethiopia, Kenya, Malawi, Rwanda, South Sudan, Tanzania, Uganda, and Vietnam. AVAC was there, along with a range of civil society partners including from the Malawian Civil Society Advocacy Forum (CSAF) and Tanzanian partners from COMPASS. Here are some highlights and a look at what was won in week three.
COMPASS in Action in the Malawi and Tanzania Rooms
COMPASS partners came to the week three RPMs with a list of community priorities. In Malawi, these priorities were reflected in the LIU LATHU MU COP20 (“Our Voice Malawi”), developed by CSAF. The final version of PEPFAR’s country operational plan (COP) for Malawi, adopted after strong advocacy by COMPASS partners and others, reflected many of the community COP priorities, including:
- Commitment to launch a T=T (“Tizilombo tochepa = thanzi la bwino” in the local language, or less virus = better health) program, Malawi’s version of Undetectable=Untransmittable or U=U, both are public health campaigns designed to increase viral load suppression and reduce stigma.
- A plan to signficantly increase the number of clients who are trained to help with treatment literacy and adherence, and add over 400 health care workers and lab technicians. These gains are in addition to sustained funding for all current health care workers.
- Commitment to provide an additional 120,000 PLHIV with a preferred TB prevention drug, known as 3HP, in 2020. The term 3HP comes from the regimen’s duration (weekly doses for three months) and the abbreviations of each of the two drugs used, isoniazid (INH) and rifapentine (RPT). Under the commitment, the remaining approximatley 287,000 PLHIV will receive 3HP in 2021.
- PEPFAR to expand cervical cancer screening in 41 additional sites, for a total of 80 facilities in 24 districts.
- Frontline service providers to develop a program of friendly services for key populations (KPs) in districts where PEPFAR is implementing its KP program.
- An increased PrEP target up to 16,000 for the COP in 2020 (COP20), up from 6,700 in COP19. COP20 targets include a communication strategy and supporting materials that were developed through a multi-stakeholder process aimed at improving uptake and adherence.
- Malawi commits to “social network testing” (vouchers for free testing that people can give to partners and social contacts) instead of the more controversial index testing.
The final version of the Tanzania COP was also the result of strong advocacy, and reflected many of the COMPASS partner priorities, including:
- Commitment to make index testing (also known as Partner Notification Services or PNS) client-centered. The commitment addresses safety concerns raised by civil society. There will be no quantitative targets, programs will return to a focus on ensuring safety and informed consent when Index Testing is used. For background on the issue of index testing see AVAC’s FAQ.
- 5,000 additional health care workers will be hired, with the Government of Tanzania agreeing to support recruitment and training of community-based workers to do services like HIV self-testing and PrEP demand creation.
- A PrEP NOW! campaign by COMPASS partners resulted in an ambitious PrEP target of 180,000 in COP20. The activists in the room challenged the premise that slow uptake in a limited pilot in COP 19 should reduce the ambition of the program overall. As a result, the Government of Tanzania presented the PrEP NOW! Campaign at the end of the week to PEPFAR. PEPFAR agreed to expanded rollout starting in June.
- COMPASS activists with other Tanzania civil society continued to push for a more supportive environment for Tanzanian KPs. The Government of Tanzania agreed to review training on sexual orientation, gender identity, and gender expression (SOGIE) for all clinical workers, and to integrate such training into the workplans of Tanzanian implementing partners and law enforcement. This will be reviewed by Tanzania’s Key and Vulnerable Population Forum (KVP-F).
Progress on Testing
As we noted in our week one and two blogs, this year’s PEPFAR COP Guidance, an annual statement of priorities and requirements used by country teams to develop their COPs, directed an aggressive scale-up of index testing. In week three, AVAC and other civil society continued to voice concern about potential harm from how index testing might be applied. There is concern and evidence that high testing targets—in some cases requiring that 80 percent of positive tests be derived from index tests—result in coercive practices, as implementing partners seek to meet high targets. See AVAC’s recent Call to Action. But week three saw some progress. In Kenya, Malawi, Tanzania and Uganda, activists were able to reach agreements with country teams that in addition to community monitoring of sites for harm, index testing targets would not be communicated to implementing partners in those countries.
Partners still have testing goals, now with smaller budgets as PEPFAR seeks to shift resources elsewhere, but they are not required to meet those goals almost exclusively through index testing. In response to pressure from civil society, policy from The Office of the US Global AIDS Coordinator (OGAC) has now shifted, de-emphasizing index testing. Now country programs are required to set targets for HIV diagnoses with a clear strategy for how they'll reach that total. Programs must present a full picture of how they will reach their targets, but that requirement no longer includes the use of index testing per se.
Community Monitoring
COMPASS partners and advocate allies received approval and funding for community-led monitoring in Malawi and Tanzania. These funds will not be released until October 2020. In Tanzania, small grants from PEPFAR will be made available in the near-term to begin the urgent work of developing tools for community-led monitoring.
COVID-19
COVID-19 cast its shadow over the RPM meetings. Ambassador Birx left Johannesburg before week three began to assume her new additional responsibilities as the US White House coronavirus response coordinator, with Deputy Coordinator Angeli Achrekar acting in her stead.
General concerns focused on the impact of COVID-19 on PLHIV, particularly for people with compromised immune systems. In addition, civil society at the RPM began to identify advocacy priorities related to the impact of the pandemic on HIV clinical trials, and on sustaining supply chains and quality services from condoms to voluntary medical male circumsion to antiretrovirals for treatment prevention, and more. Advocates also identified the need to track the rapidly evolving COVID-19 research and development agenda for treatments and vaccines. For an overview, download AVAC’s table of ongoing studies for treatment and prevention of the COVID-19 virus.
Want to learn more about the issues above and engaging with PEPFAR? Check out these resources: