Describing—and Doing—the Work: AVAC in print and in the streets

In a special issue of Current Opinion in HIV and AIDS, published in January 2019, AVAC staff members Emily Bass, Laura Fitch, Anabel Gomez and Maureen Luba Milambe joined collaborators who work in advocacy and human-centered design to co-author two important articles. Each highlight our core business of bold, evidence-informed advocacy and action. The articles are:

• Demand creation for primary biomedical prevention: identifying lessons across intervention to inform daily oral preexposure prophylaxis programs
• Civil society demand for accountability to achieve 90-90-90 targets: lessons from Eastern and Southern Africa

These articles are behind a paywall for now. If you are interested in obtaining a copy and cannot get access, please contact us here, as AVAC is committed to sharing information and generating discussion without barriers. Publishing work like this in peer-reviewed journals is an advocacy tactic, as it puts critical ideas and histories into the “official” record. The good news is that the content in the articles is robustly reflected in our ongoing work and in our other publications.

In Demand creation for primary biomedical prevention: identifying lessons across intervention to inform daily oral preexposure prophylaxis programs, co-authors Emily Bass, Laura Fitch, Anabel Gomez and consultant Rebecca Loar, make the case that today’s primary prevention programming isn’t yet harnessing the potential of human-centered design, and that lessons from the rollout of voluntary medical male circumcision (VMMC) must be urgently brought to bear on newer strategies like PrEP. To find out more about how and why, check out the 2018 AVAC Report, and the work of the Prevention Market Manager.

In Civil society demand for accountability to achieve 90-90-90 targets: lessons from Eastern and Southern Africa, Maureen Luba and colleagues use case studies from Kenya, Malawi and Uganda, among other countries, to show how African AIDS activism has shaped the global response, and must continue to do so. These case studies capture work that’s opened the PEPFAR process to civil society engagement. These stories demonstrate how, through innovative North-South partnership, civil society has successfully unlocked what had been a closed and relatively unaccountable process for setting goals and allocating resources. This work is ongoing in many forms and on many fronts, including via the Coalition to Mobilize Power, Activism, Strategy and Solidarity (COMPASS) Africa, a multi-country activist effort that AVAC is proud to work on with allies in the global North and South. Learn more about this work and about PEPFAR engagement here.

Key Points from the Articles

From Demand creation for primary biomedical prevention: identifying lessons across intervention to inform daily oral preexposure prophylaxis programs:

• The literature on demand creation for other HIV biomedical primary prevention strategies have much to teach anyone interested in seeing interventions reach the people who need them. For example, one study of the demand creation for VMMC from Zambia and Zimbabwe details the benefits derived from using demand-side thinking to segment potential end-users.
• Studies on condoms suggest the risk failure if demand creation is neglected. The authors note falling investment in demand creation coincided with an increase in new HIV diagnoses in Burkino Faso. And other condom studies described problems such as a lack of market analytics and “inadequate sustained demand creation for targeted segments of the population including young people, men who have sex with men, and sex workers.”
• The urgency behind all of these findings becomes clear when one considers reports like one cited in the article from a Kenyan demonstration project that found high rates of discontinuation of PrEP across key populations groups. But that does not mean people don’t want PrEP. It can’t be emphasized enough, VMMC saw significant gains after efforts at demand creation underwent a process incorporating demand-side thinking.
• Even more chilling, the authors point out, “failure to integrate and act on the lessons learned from VMMC delivery could imperil future investment in PrEP and other key interventions... Indeed, unmerited statements about who will or will not choose to use adherence-dependent methods such as daily oral PrEP or a future microbicide are already being made with some regularity.”
• Demand creation and services for delivering primary prevention must be designed with care, both must address the varied needs of people at risk of HIV. Until then, no one will know what works.

From Civil society demand for accountability to achieve 90-90-90 targets: lessons from Eastern and Southern Africa:

• Relentless work from national and global advocates has resulted in critical gains in access to HIV treatment and prevention but has not been well-documented. This article begins to address that absence with several case studies. Together, they tell the story of advocates turning to innovative methods to gain the attention of decision-makers, mustering evidence and persuasive arguments, and bringing meaningful change.
• This history makes the case for scaling-up the capacity of civil society as a priority to gain control of the epidemic.
• The stories illustrate three unique and vital functions attributed to civil society:
  a) Through innovative North-South partnerships, civil society has unlocked what had been a closed and relatively unaccountable process for setting goals and allocating resources.
  b) Civil society invigorates discussions, replacing status quo assumptions with fresh analysis. This pressure creates new possibilities, improved strategies and greater impact from interventions.
  c) Civil society’s continual demand for accountability and its ability to push an agenda led to institutionalizing a more open process for decisions on policy, programs and funding.
• UNAIDS reports that missing the 2020 fast track targets (fewer than 500,000 new cases and fewer than 500,000 deaths from HIV annually) by only five years will mean a million more deaths and two million more cases by 2030. As the authors make clear, the unique role played by civil society is a matter of life and death. The power of advocacy must be leveraged with a greater commitment to fund and support it.