Last month, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) finalized its Country Operational Plans (COPs) for 2018—with a formal signing ceremony on the plans that will direct U.S. funding for HIV in the next fiscal year, starting October 2018. Health GAP and other allies from around the world have been witnessing, interrogating, engaging, and pushing this process to ensure the 2018 COPs invest much more in the most urgent community-level HIV treatment and prevention priorities. Here is a round-up of some of the top takeaways and victories.

1. Transparency at PEPFAR has been improving

This year reflected the highest level of transparency seen to date from PEPFAR—providing national and global civil society groups an opportunity to engage with multiple cycles of accountability in recent months. In December 2017, civil society groups began pushing to shape the U.S. government guidelines for the COPs and set minimum standards for civil society engagement. By January 2018, the COPs planning cycle was under way and activists worked transnationally to prepare for COP development and finalization in over a dozen countries. Strong coalitions of activists reviewed PEPFAR’s 2017 country plans and outcomes, and analyzed data to generate new ideas and demands for expanding what showed impact and shifting away from failing strategies. By February 2018, civil society demands were solidified and shared with PEPFAR teams around key areas where people living with HIV, key populations, and community activists prioritized major issues on a country-by-country basis. The process wasn’t perfect, but it showed that pressure on powerful actors in the AIDS response can deliver real impact.

2. Activists are getting better at wielding PEPFAR data in their advocacy

Activists were able to use data and evidence from PEPFAR’s programs to formulate their demands, this year more than ever before. This made the resulting demands sharper, and the proposals—aimed at addressing the key drivers of HIV mortality and new infections—more specific. With this level of specificity, the top priorities this year were more varied than ever before between countries—with some country coalitions prioritizing specific, urgent investment in new or improved cadre of human resources, for example, while others focused on improving the lagging performance of key populations programming. Still, others challenged PEPFAR to expand investments to new, under prioritized geographic areas. There were also some themes throughout—insufficient investment in front-line services and in indigenous organizations, for example, or the damage of unrealistic undercounting in key populations size estimates.

3. Opening up closed places is critical to exacting accountability

This year—for the first time—civil society representatives participated in what, in previous years, has been a closed “Management Meeting”, between national governments and PEPFAR, where much of the priority-setting was done without civil society present. Pushing our way into this meeting ensured demands were less often met with the response, “That has already been decided” (although that response did persist in some countries). Finally, the approval meetings that just concluded in April took a very different turn from what had been planned—with PEPFAR focusing on gathering implementing partners and challenging them with data about their own performance. Here, too, civil society was able to push the envelope and ensure civil society demands were heard and considered up to the moment before U.S. Ambassador Deborah Birx signed the PEPFAR COPs.

4. When we win, we should pause to celebrate and then keep pushing on the unfinished agenda

Again this year, activists were able to win concrete shifts that will advance the AIDS response in PEPFAR-recipient countries. We detailed a few of these in our previous blog but there were many more. However, not everything was won. Here a few examples of outcomes from the COP finalization meetings that remain unfinished business from activists’ agendas:

• • For Malawi, civil society called for a bold campaign alongside the roll-out of dolutegravir for first-line treatment, in which every person with HIV would get access to viral load testing and information about the prevention and health benefits of viral suppression along with community led treatment literacy—“U=U” for Malawi. Government, PEPFAR, Global Fund and Gates Foundation all agreed to support this exciting effort, but the actual resources to make this happen have not yet been committed.
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  • For Mozambique, activists challenged the far-too-low targets for MSM programming and sex workers and the PEPFAR team in Maputo and in Washington, D.C. together promised that the program would be held to reaching 150% more people with critical prevention services than they originally proposed.  Meanwhile, a promise of an expanded cadre of community health workers openly living with HIV, in order to drastically improve retention of people with HIV in care, still needs to be developed into a concrete costed plan.
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  • For Uganda, a critical question remains as to how community health workers can be better remunerated to help professionalize and sufficiently equip this critical but under-performing cadre.
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  • For South Africa, the language regarding PEPFAR will do to ensure access to condoms in schools was too vague, lacked specific targets. At the COP approval meeting, officials agreed to a clear target that PEPFAR will ensure 100% of schools in DREAMS districts have real and adequate access in fiscal year 2019. We now need to watch to make sure this is implemented.  

5. There is still a lot more to be done

The work doesn’t stop now, but there is a global network of activists holding PEPFAR to account that is stronger than ever. The stakes are higher than ever, too. With just two years left to achieve the 90-90-90 goals and progress toward epidemic control, many countries are dangerously off track. Over the past few months some incredibly important victories were had—some shared here and others in our previous post. Turning these victories on paper into reality over the coming months will take intensified advocacy and accountability measures.

Wondering what’s next?

Over the coming months, we at Health GAP will be turning our attention to some new cross-cutting priorities that stood out to us this year. First, we will be working to ensure that country transitions to use of superior quality first-line dolutegravir containing treatment (tenofovir-lamivudine-dolutegravir or “TLD”) regimens happen without delay, with sufficient support for treatment literacy, and with adherence to core technical guidelines—in particular ensuring people with HIV have access to viral load testing and their results before a shift in treatment regimen is made. TLD transition across the PEPFAR portfolio is a critical opportunity to secure high quality treatment programs that include differentiated service delivery, lay health worker leadership, and high-impact HIV drug resistance prevention efforts.

Secondly, we will be digging into national-level program data to ensure that the proposed solutions, such as changes to PEPFAR implementing partners in COP 2018 in regions and countries that are underperforming, are actually accelerating the pace of treatment and prevention scale up and not repeating mistakes for another year.

Finally, we will be focused on pushing the U.S. Congress to increase funding for PEPFAR. It is critical to note just how evident the impact of insufficient funding is having during this COP year—as we noted in our recent report on the deadly effects of flat funding of U.S. global AIDS programming. With mortality still unacceptably high among people with HIV, there are reports across countries that there is no room in the budgets for life-saving interventions like treatment for opportunistic infections or monitoring CD4 counts because it is being crowded out by testing and ARV budgets that have to expand. Advocates have pushed for more and better funding to expand high impact DREAMS programming for young women, yet expansion in COP 2018 was to far too few districts in only a handful of countries instead of that program being taken to scale. In Malawi, it’s still not clear who will cover voluntary medical male circumcision (VMMC) efforts in key high prevalence regions when World Bank funding comes to an end this year and neither PEPFAR nor the Global Fund have sufficient funding to expand their reach.

May 2018 signals the “end” of the PEPFAR Country Operational Planning cycle, but our advocacy is far from over. Now we must shift to watchdogging the implementation of the commitments we won—something we know is always a far trickier part of the equation. Over the coming months, we’ll be embarking on the growing coalitions of brilliant, bold activists who are making important strides in holding PEPFAR to account for achieving the best possible outcomes for people living with and affected by HIV.