New funding model brings promising change as African countries request millions for key populations

3. COMMENTARY
27 Jan 2015

There is mounting evidence that within southern Africa’s generalized HIV epidemic there are under-estimated concentrated epidemics among key affected populations (KAPs) such as sex workers and men who have sex with men (MSM). Recent studies have found HIV prevalence among MSM to be as high as 46.7% in Botswana[1] and 71.1% in Durban, South Africa.[2] Among sex workers, Malawi, Namibia and Swaziland report prevalence rates of 70%.[3] 

Despite these alarming statistics, national AIDS spending in these countries consistently neglects MSM and sex workers. With little to no money coming from governments, KAPs rely on support from funding partners such as the US government and the Global Fund to ensure access to life-saving treatment and prevention services.   

Global Fund support for targeted programming has also been less than adequate. In southern Africa, roughly 2% of total Global Fund investments in HIV prevention were allocated to sex workers.[4] Only 0.07% went towards MSM and transgender (TG) communities.[5]  

Part of the problem is that challenging legal contexts and a lack of political will means countries do not always request funding for these at-risk groups. Of all southern African proposals to the Global Fund (Round 1-10) only three included targeted interventions for MSM, and only 12 had programming designed specifically to reach sex workers.[6]   

To help address these issues, the Global Fund Board approved a Sexual Orientation and Gender Identities Strategy in May 2009. More recently, under the Global Fund’s new funding model (NFM), the Key Populations Action Plan (2014-2017) proposes significant change in the way MSM and sex workers should be prioritized.

With January 30 marking the fifth window of concept note submission for the NFM, are African countries drawing budget lines for MSM and sex worker programming, or is it business as usual?

An analysis of the concept note budgets from Botswana, Malawi and Swaziland suggests a promising change.

Table 1: Proposed KP Programming in Country Concept Notes to the Global Fund

Country

Status of HIV/TB Concept Note Submission

Intervention(s) Targeting Key Populations

Amount requested (USD)

Total Amount Requested for KPs

Botswana

To be submitted in Window 5 (30 January 2015).

Behavioural change for MSM: Needs assessment, training of mobilisers and peers, one-on-one sessions, health talks and focus groups, leaflets on behaviour change and stakeholder meetings.   

$1,479,587

$3,079,174

Condom promotion for MSM and TG: Lubricants along with condoms to MSM and TGs at strategic sites such as BONELA, bars and peers.

$60,000

Behavioral change for sex workers and their clients: Training of mobilisers and peers, health talks and focus groups, leaflets on behaviour change as well as engaging psychosocial support providers to provide counselling and support.

$1,479,587

Condom promotion for sex workers and their clients: Procurement/distribution of lubricants to sex workers.

$60,000

Malawi

To be submitted in Window 5 (30 January 2015).

Prevention programs for MSM: Demand creation & provision of condoms and lubricant, HTC and STI management, MSM-friendly clinical services. Above allocation amount is for expanding HCT and condom supporting activities at community level, specifically targeting MSM.  

$235,000 (allocation)

+

$38,000

(above allocation)

$3,078,000

Prevention programs for sex workers and their clients: Peer-led risk reduction information, routine HTC and STI/TB screening, provision of male & female condoms and lubricant, friendly clinical services, and stigma and discrimination reduction. Above allocation amount is for expanding community HTC & condoms.

$267,000 (allocation)

+

$38,000

(above allocation)

STI services for MSM and SW: Train peer-educators on STI screening and management to enhance the uptake of STI services among MSM & SW, and to boost promotion of youth friendly health services.

$2,500,000 (above allocation)

Swaziland

Submitted in Window 4 (15 October 2014).

Behavioral change for MSM: Peer education & treatment literacy for MSM networks.

$103,965

$157,201

Behavioral change for sex workers: Peer education & treatment literacy for sex worker networks.

$53,236

Botswana’s request of $3,079,174 for key populations programming represents 7% of total funding requested by the country. With half of this for MSM and transgender communities, this far exceeds the regional average in previous rounds.[7]

This is also the first time Swaziland has ever included programming specifically for sex workers and MSM in a Global Fund proposal.[8]

Malawi’s $3,078,000 request is also significant, though the majority of it sits in the above-allocation amount. This means that it is part of incentive funding, which will only be granted if all or part of the allocated funding request is deemed sound by the Technical Review Panel (TRP), and only then after a competitive process and when additional resources become available. This may imply that KAP programming is still not seen as a top priority in Malawi.

It remains to be seen how the amounts requested by these three countries will change or be re-allocated during TRP review and grant-making, but the potential for improved Global Fund commitment to key populations programming in the region is there. There is still a long way to go, particularly towards ensuring that governments dedicate public resources to KAPs to make the HIV response more sustainable. But we’re moving in the right direction.  

 

[1] Baral S.et al. (2009). HIV prevalence, risks for HIV infection, and human rights among men who have sex with men (MSM) in Malawi, Namibia, and Botswana. Plos One, 4(3), e4997.

[2] Cloete, A., Simbayi, L.C., Rehle, T., Jooste, S., Mabaso, M., Townsend, L., Ntsepe, Y., Louw, J., Naidoo, D., Duda, T., Naidoo, P. and the Marang Men’s Project Team. (2014). The South African Marang Men’s Project: HIV bio-behavioural surveys using respondent-driven sampling conducted among men who have sex with men in Cape Town, Durban and Johannesburg. Cape Town: HSRC Press.

[3] According to the 2014 Global AIDS Response Progress Reports

[4] Avdeeva, O., Lazarus, J. V., Aziz, M. A., & Atun, R. (2011). The Global Fund's resource allocation decisions for HIV programmes: addressing those in need. Journal of the International AIDS Society, 14(1), 51.See page 6, Figure 4.

[5] Ryan et al. (2013).  Achieving an AIDS-Free Generation for Gay Men and Other MSM in Southern Africa. amfAR, The Foundation for AIDS Research and Johns Hopkins Bloomberg School of Public Health.

[6] Ryan, O., Macom, J. & Moses-Eisenstein, M. (2012). Demand for programs for key populations in Africa from countries receiving international donor assistance. Journal of Social Aspects of HIV/AIDS, 9(3), 131-136.

[7] Ryan et al. (2013).  Achieving an AIDS-Free Generation for Gay Men and Other MSM in Southern Africa. amfAR, The Foundation for AIDS Research and Johns Hopkins Bloomberg School of Public Health.

[8] Lopez Gonzalez, L. (2012). The First to Go: How communities are being affected by the Global Fund Crisis. Open Society Initiative for Southern Africa (OSISA) and the Open Society Foundations (OSF).Page 2-3.

 

Gemma Oberth is an independent consultant currently supporting the development of several Global Fund concept notes in East and Southern Africa which focus on key populations. She is also a post-doctoral researcher at the Centre for Social Science Research (CSSR) at the University of Cape Town in South Africa. 


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