In April of this year, Dr. Deborah Birx was appointed as Ambassador-at-Large and coordinator of all U.S. government activities to address HIV globally.
As the U.S. Global AIDS Coordinator, Ambassador Birx oversees the implementation of U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) as well as the U.S. government’s engagement with the Global Fund. Together, the U.S. government’s commitments through PEPFAR and the Global Fund account for nearly half of all global funding for HIV and AIDS.
Following her appointment, the Global Forum on MSM & HIV (MSMGF) coordinated with Ambassador Birx’s office over several months to schedule a meeting during her planned visit to the San Francisco Bay Area in October. PEPFAR and the Global Fund represent two of the most important funding streams supporting HIV work among men who have sex with men (MSM) and other key populations worldwide, and it is essential that these funding mechanisms work as well as possible to support the health and human rights of our populations.
With funding from the Elton John AIDS Foundation, the MSMGF was able to support four of our partners to travel to the Bay Area to attend the meeting in person: Dr. Cheikh Traore, co-chair of the Solidarity Alliance for Human Rights (Nigeria); Serge Douomang Yotta, Executive Director of Affirmative Action (Cameroon); Claver Toure, Executive Director of Alternative Cote d’Ivoire (Cote D’Ivoire); and Brian Macharia, Program Coordinator, Ishtar (Kenya).
In advance of the meeting, the MSMGF consulted extensively with each participating partner as well as key staff from African Men for Sexual Health and Rights (AMSHeR) to develop a concrete set of top priority concerns to address at the meeting with Ambassador Birx. Following an introductory presentation by MSMGF Executive Director Dr. George Ayala, participating partners presented the six priority concerns to Ambassador Birx using concrete examples from their own experience. Points are summarized below.
1. More meaningful engagement of civil society, inclusive of MSM and other key populations, in the Country Operational Planning process, and making engagement opportunities more transparent.
Nigeria receives some of the largest amounts of funding from PEPFAR, with funding support for MSM work dating back to 2008. However, MSM and other key populations still face real challenges when trying to engage meaningfully and participate in development of PEPFAR’s Country Operating Plan (COP) in Nigeria.
The COP process itself remains very opaque. We don’t know when it happens or who is involved. Big implementers are often at the table, but they represent a variety of populations and interests that do not necessarily reflect the interest of key populations. Moreover, key population-led civil society groups are often left out of and not consulted in the process. For example, some of the funding and programmatic decisions made through the COP process are very far from what key population communities need or want.
2. Funding comprehensive, rights‐based responses inclusive of programs that are community-, MSM‐, and key population‐led.
In Kenya, key population civil society advocates have done significant work with the government over the last few years focused on HIV interventions targeting MSM. The Global Fund has led the way in supporting these interventions and pushing for greater transparency and accountability. However, it is much less clear what PEPFAR’s mechanisms are for ensuring that funding trickles down to reach smaller community-based organizations, particularly those led by and serving MSM. This makes it difficult for key population civil society advocates to watchdog and hold organizations accountable if things need to be pushed or changed.
Things are further complicated in Kenya by the fact that some key implementers receiving PEPFAR funds are not supportive of advocacy campaigns or efforts to reduce stigma and discrimination for key populations, since most of their work focuses on other prevention and treatment programs. These large recipient organizations are implementing these programs without input from key population civil society organizations.
3. Securing country buy‐in for MSM‐ and key population‐focused work.
We are aware of the new PEPFAR funding targeting key populations through the five year USAID Linkages program, which will be an extremely important funding source for key populations. Moreover, we know that the success of this program will depend on country buy-in as a mechanism for increasing funding to key population programs and interventions.
All civil society participants at the meeting are committed to increasing government buy-in to fund HIV responses with targeted interventions for key populations. Civil society participants and Ambassador Birx’s team discussed numerous options for increasing buy-in, including standardized processes for civil society to inform PEPFAR secretariat staff of exclusion from COP processes; adding staff to review COP processes for civil society inclusion; and adapting the country dialogue processes used in the Global Fund’s New Funding Model to PEFPAR’s COP process. The MSMGF has provided draft language for inclusion in the COP Guidance to facilitate greater civil society participation.
4. Creating mechanisms for getting funds to smaller, community‐, MSM‐, key population‐led organizations, including core funding and funding for leadership development and advocacy.
PEPFAR provides a great deal of support to Cameroon. However, PEPFAR funding is mainly directed to major NGOs and national authorities instead of grassroots organizations. Over a year ago, Affirmative Action applied for a small amount of funding provided by PEPFAR through the Local Capacity Initiative, which only offers funding for activities and not core operating costs. Affirmative Action never received any notice regarding the results of their application.
The HIV work done with key populations by Affirmative Action and similar organizations in Cameroon is very sensitive, and it does not have the support of the government. Cameroonian civil society organizations really need capacity and institutional support to do this work, and we urge more PEPFAR funding be directed to the needs of grassroots organizations.
The Ambassador explained that PEPFAR has had difficulty getting more funding to grassroots groups because there are limited mechanisms through which PEPFAR can do this. The Ambassador committed her office to exploring new and existing funding mechanisms to provide increased funding to civil society organizations, including through the Ambassador’s Small Grants and the Robert Carr Civil Society Network Fund.
5. Ensuring PEPFAR‐funded implementers are human rights‐based and promote key populations.
Access to health cannot be delinked from human rights, even in difficult environments like Cote d’Ivoire. Some of the larger PEPFAR implementers that Alternative Cote d’Ivoire works with as a sub-recipient exhibit homophobic behavior.
For example, when Claver’s office and home were ransacked, he reached out to the main PEPFAR implementer in Cote d’Ivoire to ask for help with personal security and a safe alternative work space. He was told by the implementer that they do not handle these kinds of issues as they are only tasked with working on HIV. They were concerned that they would be accused of promoting homosexuality if they intervened too much. Ultimately, the French embassy provided security to protect Alternative Cote d’Ivoire’s office.
This example and many others like it highlight the need for PEPFAR to develop better mechanisms to respond to human rights emergencies and ensure the security of the people working on the ground. We need a mechanism that allows advocates to report human rights emergencies to PEPFAR secretariat staff, informing them of what is going on in their country. Ambassador Birx pointed out that PEPFAR already has non-discrimination clauses in all contracts with implementers, but enforcement remains an issue. She committed to continuing to work with embassies and State Department staff to respond effectively to human rights emergencies.
6. Facilitating better data collection and utilization to improve targeting of funding and interventions for MSM and other key populations, without sacrificing their safety and security.
Community members must be partners in data collection and research, including monitoring and evaluation activities. These are challenging issues, especially considering the sensitive nature of some of the data and the associated risks. Better systems are needed for south-south exchange, data collection, and data evaluation that protect the rights and safety of key populations involved.
Throughout the meeting, Ambassador Birx and her senior advisors were highly engaged in a very lively discussion and debate with the MSMGF staff and partners. The MSMGF and partners will follow up with Ambassador Birx and her team on each of the issues raised in this meeting, and we welcome additional input on PEPFAR and the Global Fund from our members, who are invited to write us anytime at email@example.com with concerns or requests.
Ambassador Birx continues to prove herself a passionate and committed ally to key populations globally. We look forward to working with her to ensure that issues impacting key populations are recognized and addressed based on evidence and input from the ground.