Supporting community action on AIDS in developing countries
POLICY & CAMPAIGN TOOL
THE RIGHTS COMMITMENT TO HIV Engaging US country missions
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This is a ‘What’s Preventing Prevention?’ Policy and Campaign Tool ‘What’s Preventing Prevention?’ (WPP) is a campaign of the International HIV/ AIDS Alliance, supported by the Stop AIDS Alliance. Its mission is to support community action to prevent HIV infection, meet the challenges of AIDS, and build healthier communities. The WPP campaign calls on donors and governments to guarantee a more effective HIV prevention response that enables key populations to access prevention services and programmes, take active part in the designing and implementation of such programmes and realise their human rights. The campaign has three strands:
BETTER FUNDING Donors need to increase the proportion of their funding for HIV prevention interventions that reach communities at higher risk of HIV.
REMOVE BARRIERS National governments need to remove the political and social barriers that stop people from accessing prevention services.
OUR SAY Communities at higher risk of HIV must be able to participate in decision-making around HIV prevention programmes. This is the best way to ensure services meet their needs. One of the core objectives of WPP is to support the advocacy and campaign work of the Alliance’s Linking Organisations and Technical Support Hubs and their partners. The campaign links up national, regional and global efforts across the Alliance. www.whatspreventingprevention.org
ABOUT STOP AIDS ALLIANCE (SAA) Stop AIDS Alliance (SAA) is a partnership between STOP AIDS NOW!, based in the Netherlands and the International HIV/AIDS Alliance, based in the United Kingdom, with policy and advocacy offices based in Brussels, Geneva and Washington, D.C. Through engaging with EU and US policy makers, EU Institutions, United Nations agencies and other relevant stakeholders, SAA aims to ensure that the HIV response remains a high priority on the global policy agenda to achieve universal access to HIV prevention, treatment, care and support. Its presence in these three main global policy centres, as well as in the Netherlands and the UK, aims to contribute to harmonized HIV policy messages, building linkages between advocacy groups active in the different locations and voicing the concerns and needs of the International HIV/AIDS Alliance’s and STOP AIDS NOW! partners working in the field. www.stopaidsalliance.org Cover image: A couple who are members of an MSM rights organisation in Kenya © Nell Freeman for the Alliance
Stop AIDS Alliance International HIV/AIDS Alliance 1111 19th Street NW Suite 1120 20036 Washington DC Phone: +1 202 327 5015 Email: mhart@stopaidsalliance.org
“LGBT rights are not special rights; they are human rights. My Administration will continue to strongly support human rights and assistance work on behalf of LGBT persons abroad.” US President Barack Obama 27 January 2011
“Now of course, interventions like these can’t be successful in isolation. They depend on institutional and social changes like ending stigma; reducing discrimination against women and girls; stopping gender-based violence and exploitation, which continue to put women and girls at higher risk of HIV infection; and repealing laws that make people criminals simply because of their sexual orientation.” HILARY RODHAM CLINTON US Secretary of State 8 November 2011
“Under PEPFAR’s combination prevention guidance, the engine for all our work must be a deep understanding, fully shared with the country leadership, of the drivers of infection in each country. That includes gathering data on the groups at highest risk, including people living in HIV-discordant relationships, men who have sex with men, people engaged in prostitution, injecting drug users, and others. Some governments are reluctant to engage with these groups, but we are helping them understand, from a public health perspective, the threat to their population at large if they don’t.” Ambassador eric goosby US Global AIDS Coordinator 1 February 2012
“Respect for human rights is another core principle of U.S. health and development efforts – in particular in our approach to the fight against HIV/AIDS. This is reflected in the current PEPFAR Five-Year strategy and is a key part of the work of UNAIDS. Human rights approaches must be linked with evidence-based public health interventions if we are to achieve our goals in combating the epidemic.” DEBORAH VON ZINKERNAGEL Principal Deputy Global AIDS Coordinator, US State Department 23 June 2010
Eric is a treatment support worker and national activist. Amongst other activities, he holds peer education and counselling sessions in several bars and pool halls in Lusaka, Zambia. © Nell Freeman for the Alliance
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A US COMMITMENT TO HUMAN RIGHTS-BASED HIV RESPONSE Under the Obama administration, the US has shown continued strong leadership in the global AIDS response. As of September 2011, the President’s Emergency Plan for AIDS Relief (PEPFAR) has provided antiretroviral treatment to nearly four million people worldwide; prevented 200,000 infant infections; and provided care and support to almost 13 million people. In November 2011, US Secretary of State Hillary Rodham Clinton made the “creation of an AIDS-free generation” the first ever policy priority for the US government. In her speech at the US National Institutes of Health on the next steps in the AIDS response, she confirmed the commitment of the Obama administration to supporting evidence-based approaches, stating that, “we need to let science guide our efforts”. She said that the US would prioritise in the coming years three scientifically proven biomedical interventions within combination prevention: prevention of mother-to-child transmission, voluntary medical male circumcision, and treatment as prevention. However, she also noted the importance of behavioural and structural interventions as crucial components for an effective and sustainable HIV response. She stated that:
Successful HIV responses depend on ending stigma and reducing discrimination, particularly against women and girls, and abolishing discriminatory legislation, such as laws that make people criminals simply because of their sexual orientation. 1
This language reflects the key commitments made by the US and other United Nations signatories in the Political Declaration on HIV/AIDS,2 adopted at the United Nations High Level Meeting on AIDS in June 2011. In the declaration, United Nations member states commit to make progress on addressing human rights issues of importance to key populations. They call on countries to promote and protect “all human rights and fundamental freedoms with particular attention to all people vulnerable to and affected by HIV”. The declaration, unlike the others preceding it, specifically names populations evidence shows are at higher risk, particularly men who have sex with men, people who inject drugs and sex workers.3 Subsequently, in June 2011, the US government made a statement at the UNAIDS Program Coordinating Board Meeting, declaring that:
We strongly believe that the inclusion of the key populations – sex workers, men who have sex with men, and people who inject drugs – [in the declaration4] was critical both to protect their rights and to promote their access to HIV services. We will not win this fight without the meaningful engagement and involvement of all. 5 A human rights-based approach to HIV is essential to achieving universal access to HIV prevention, treatment, care and support. While access to HIV services has expanded among the general population in many countries, access to appropriate HIV and other health services remains woefully inadequate for key populations due to stigma, discrimination, marginalisation and violation of human rights.
This policy and campaign tool is designed for advocates and civil society actors across the world on how to engage with US country missions to ensure that the commitments made on human rights and key populations are effectively funded and implemented in US country programming for HIV and health. It provides an overview of the specific commitments made by the US government in their policies and programming guidances. It also provides you with key messages that you can discuss with the US mission in your country in order to ensure effective implementation of their commitments. 4
HIV testing at a community clinic © Nell Freeman for the Alliance
THE PRESIDENT’S EMERGENCY PLAN FOR AIDS RELIEF The President’s Emergency Plan for AIDS Relief (PEPFAR) is the major US mechanism for supporting the AIDS response in developing countries. PEPFAR was first funded in 2004 and re-authorised with increased funding in 2008.6 In 2009 PEPFAR provided grants to more than 100 countries, including through regional programmes. The PEPFAR Five-Year Strategy, released in December 2009, states that:
In order to make it easier for people with HIV to access all types of care they need, PEPFAR increases access to high-quality, low-cost care and treatment services. These services are responsive to the public health needs of marginalized communities, including injecting drug users, persons in prostitution, and men who have sex with men. PEPFAR also utilizes its services as a mechanism through which to advance the rights of populations that face stigma, and expand equal access to care. 7 All PEPFAR-supported activities in countries are included in Partnerships Frameworks, which are 5-year strategic frameworks guiding US collaborations with these countries on HIV and AIDS. In the US government guidance for PEPFAR Partnership Frameworks it is stated that:
Partnership Frameworks should describe plans to encourage leadership from governments to create non-discriminatory policies and to publicly support People living with AIDS (PLWA) and their inclusion in development of policy, community interventions, and program evaluation. Policies should address causes and consequences of HIV-related stigma, and may support programmatic approaches such as: incorporating Prevention with Positives programs into the training of healthcare workers and lay counselors: utilizing PLWA as lay counselors and peer educators; and employing effective measurement and documentation of stigma in program plans. 8
A sex worker, receives the results of her HIV test. © Nell Freeman for the Alliance
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COUNTRY OPERATIONAL PLANS Country Operational Plans (COPs) are the vehicle for the annual implementation of the Partnership Frameworks and for annual US investments in HIV and AIDS in most countries. The PEPFAR-issued COP guidance for Fiscal Year (FY) 2013 provides instructions to US missions for preparing and implementing COPs. It mentions both technical and programming priorities that should be taken into account in all PEPFAR programming priorities, including one that calls for “increasing coverage and effectiveness of programs for key populations.”9
WHAT CAN YOU DO?
The populations are defined as: Key Populations are persons who are affected by punitive laws, regulations and policies; stigmatized and marginalized in access to and in utilization of services; and disproportionately affected by HIV disease. This includes men who have sex with men (MSM) including male sex workers; transgender persons (TG); people who inject drugs (PWID); and female sex workers (FSW).
It is important to ask questions about the priorities in the COP for your country, and ask the US mission how key populations and human rights are included in the COP.
Besides the COP guidance, there are two additional guidance documents released by the US government that specifically address HIV prevention among most-at-risk populations: a guidance on people who inject drugs and one on men who have sex with men. These guidances include further language on the rights of these populations.
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Sex workers rights protest at the Cambodian Embassy in New York City. © Alliance
GUIDANCE ON PEOPLE WHO INJECT DRUGS The ‘Comprehensive HIV prevention for people who inject drugs: revised guidance’,10 issued in 2010, substantively changes previous PEPFAR policy by indicating that PEPFAR resources can now be used to fund provision of sterile needles and opioid substitution therapy for drug dependence treatment, including methadone, buprenorphine and/or other medications. The guidance further notes that, “PEPFAR programs in countries should be based on principles related to equity, nondiscrimination, and voluntariness… all programs should be conceived with the participation of affected populations.” However, the US Congress, in its report accompanying PEPFAR’s FY 2012 appropriation, enacted in December
WHAT CAN YOU DO?
2011, prevents PEPFAR funds from being used for needle exchange programmes, stating that:
The conferees direct that no funds under this heading may be used for needle exchange programs in fiscal year 2012. (A separate provision in the Labor-HHS bill also reinstated the ban on funding for such programs funded through that account, including domestic programs). Thus, PEPFAR country programmes may not include funds for needle exchange in the FY 2012 COPs. However, all other harm reduction activities can continue to be funded.
It is important to present your programmes on harm reduction to the US country mission and ask them how they are implementing the guidance on people who inject drugs.
GUIDANCE ON MEN WHO HAVE SEX WITH MEN In May 2011, the US government released a guidance addressing prevention programming for men who have sex with men. It calls for, among other things, “scaling up and strengthening of comprehensive HIV prevention programs for men who have sex with men and their sex partners as well as the expansion of laws, regulations and policies that support the human rights of men who have sex with men.”11 It also states that:
PEPFAR supports efforts to further HIV prevention goals through laws, regulations and policies that improve the availability, accessibility and effectiveness of HIV prevention programs for men who have sex with men. Such efforts to further HIV prevention may require a focus on reducing stigma and discrimination experienced by men who have sex with men, promoting the human rights of men who have sex with men, and allowing HIV/AIDS programs to be conducted in a manner that does not put men who have sex with men at risk for discrimination, violence, arrest or prosecution. 12
WHAT CAN YOU DO?
© M.Ramesh/Photovoice/Alliance
It specifically directs PEPFAR country teams to fund programmes that engage in outreach to men who have sex with men, offering them targeted information and communication; condom distribution and promotion; HIV counselling, testing and linkage to care; and sexually transmitted infection screening, prevention and treatment services.
The existence of this guidance provides an opportunity to discuss your programmes for men who have sex with men with the US country mission, as well as the broader activities your organisation is supporting, such as programmes with lesbian, gay, bisexual and transgender people and other work on human rights.
In addition to these two specific guidances for key populations, US commitments on human rights and key populations are further confirmed in a general HIV prevention guidance.
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GUIDANCE ON prevention of sexually transmitted HIV infections The guidance on prevention of sexually transmitted HIV infections, released in August 2011, states that:
Country teams should take steps to ensure that scale-up of prevention programs for MARPs is accompanied by appropriate protections of their rights, including the review of policies and regulations that criminalize or deter MARPs seeking services and training for service providers to reduce stigma and discrimination. 13
WHAT CAN YOU DO?
It is important to highlight to your US mission the work that you do on community mobilisation and the involvement of key populations in prevention activities.
No specific guidance regarding sex workers has been issued. Although sex workers are included in the prevention guidance, this is only in relation to concentrated epidemics. In the PEPFAR guidance on men who have sex with men in Footnote 3, male sex workers are included in the definition of men who have sex with men. In addition, current US law requires all organisations that receive PEPFAR funding to have a policy that explicitly opposes prostitution and sex trafficking. Some organisations have been cut off from funds because of over-interpretation
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Noting the unwillingness of many partner countries to invest in surveillance and programming for these populations, it also specifies, “PEPFAR teams should make breaking down these barriers a priority for both policy and programs in order to most effectively address the epidemic.”14 It also observes that the most effective prevention programmes are those designed, implemented and evaluated with the involvement of the target communities.
of the policy by US country missions, which can happen when the national government has not clearly defined what constitutes a violation of the policy. Fortunately, PEPFAR’s Five-Year Strategy states that services must be responsive to the public health needs of marginalised communities, including sex workers. PEPFAR says it supports countries in the following activities: engaging in targeted prevention, care, and treatment outreach for sex workers; helping governments to support alternatives to sex workers; and working to reduce demand for sex work.
Sex workers chatting to outreach workers. © Alliance
Engaging with US missions on their programming priorities WHAT CAN YOU DO?
When building relationships with US mission staff on country programming, it is important to highlight the progressive language on men who have sex with men and people who inject drugs in the PEPFAR guidance documents, as well as the rights-related language in the prevention guidance.
US country missions have been instructed to take these specific guidances into account when making changes within programme areas.
government and/or local AIDS committee is resistant to addressing the needs of these groups, as your government is required to adhere to the COP guidance if it is to qualify for US funding. The COP Guidance for FY 2012 notes that:
As indicated, the COP guidance itself also explicitly requires attention to specific populations. It states “reaching key populations with effective HIV prevention and treatment services is critical to achieving PEPFAR goals.” And “PEPFAR teams should make breaking down barriers a priority for both policy and programs in order to most effectively address the epidemic.”15 It may be useful to refer to this language in the COP guidance if your own
“PEPFAR country teams should fund activities to support sound legal and policy reform” and “work toward this should occur not only in collaboration with partner governments but also with civil society, and particularly PLHIV organizations”. It adds, “reform that supports HIV prevention, care, and treatment with MARPs is especially critical”. 16
WHAT CAN YOU DO?
On the basis of this language, you can initiate ongoing discussions with the US country mission and national stakeholders involved in programming, about the human rights issues that arise in connection to the provision of services to key populations. The prevention guidance also authorises the use of PEPFAR funds for programming to reduce stigma and discrimination. So it is important to show how your programmes address stigma and discrimination.
Briefings and reports by the International HIV/AIDS Alliance and others17 have include strategies and capacity-building activities that pave the way for more and better civil society involvement in Country Coordinating Mechanisms. Since PEPFAR encourages US staff to participate in the Country Coordinating Mechanisms, these meetings offer additional opportunities for you to interact with, and influence, US country programs.
WHAT CAN YOU DO?
Finally, at Country Coordinating Mechanism and US-convened meetings, you can highlight the need for increased investment in capacity building of civil society and community-based organisations that work with key populations in order to engage more meaningfully in country programming processes. Using the language in PEPFAR guidance documents highlighted above, you can persistently demand a seat at the table where programming is being developed.
Active, meaningful participation in these discussions, presenting your programmes and sharing lessons learned, are essential to improve PEPFAR programming in the field of human rights and key populations.
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Finally, the following key messages can be discussed with US missions: 1. The rights and needs of key populations, as reflected in all relevant US government policies, strategies and commitments (including in the guidance’s on men who have sex with men and people who inject drugs, and the prevention guidance), should be taken fully into account in US HIV and health-related programming. 2. A dedicated, long-term funding mechanism within PEPFAR should be created for the capacity building of local civil society and community-based organisations, including key populations networks, to enable them to play a meaningful role in programming processes and to advocate for their rights. 3. A PEPFAR guidance on sex workers18 should be developed that is comparable in scope and clarity to the guidance on men who have sex with men and people who inject drugs. 4. Targeted surveillance studies should be conducted to develop realistic assessments of HIV prevalence and risk among key populations.19 5. Investment in research should be significantly increased to develop the evidence base for best practice in the delivery of services to key populations. 10
A Mongolian support group for sex workers works to reduce HIV prevalence among this key population Š Alliance
ENDNOTES 1
Clinton, H.R. ‘Remarks on “Creating an AIDS-free generation”’. National Institutes of Health, 8 November 2011. Available at: www.state.gov/secretary/rm/2011/11/176810. htm
PEPFAR, ‘Technical guidance on combination HIV prevention’, May 2011. Available at: www.pepfar.gov/documents/organization/164010.pdf 12 Ibid, pp.9 and 10.
‘Political Declaration on HIV/AIDS: Intensifying our efforts to eliminate HIV/AIDS’. Resolution adopted by the UN General Assembly on 10 June 2011 (point 77). Available at: www. unaids.org/en/aboutunaids/unitednationsdeclarationsandgoa ls/2011highlevelmeetingonaids
PEPFAR, ‘Guidance for the prevention of sexually transmitted HIV infections’, August 2011, p.40. Available at: www.pepfar.gov/documents/organization/171303.pdf
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Ibid, point 29.
‘Political Declaration on HIV/AIDS: Intensifying our efforts to eliminate HIV/AIDS’. Resolution adopted by the UN General Assembly on 10 June 2011 (point 77). Available at: www. unaids.org/en/aboutunaids/unitednationsdeclarationsandgoa ls/2011highlevelmeetingonaids 4
‘Statement on behalf of the United States by Deborah von Zinkernagel, Principal Deputy Global AIDS Coordinator, Office of the U.S. Global AIDS Coordinator, U.S. Department of State, at the 28th UNAIDS Program Coordinating Board Meeting’, Geneva, 21 June 2010. Available at: www.pepfar. gov/press/remarks/2011/166592.htm 5
For more information on PEPFAR, see http://www.pepfar. gov/about/index.htm 6
The U.S. President’s emergency plan for AIDS relief: five-year strategy (December 2009). Available at: www. pepfar.gov/strategy/document/index.htm 7
‘Guidance for PEPFAR Partnership Frameworks and Partnership Framework Implementation Plans’, 14 September 2009. Available at: www.pepfar.gov/documents/ organization/120510.pdf 8
PEPFAR, ‘FY 2013: Country Operational Plan (COP) guidance’, October 12, 2012. Available at: http://www. pepfar.gov/documents/organization/198957.pdf
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Ibid, p.9.
‘FY 2013: Country Operational Plan (COP) guidance’, October 12, 2012, p.21. Available at: http://www.pepfar.gov/ documents/organization/198957.pdf. 15
PEPFAR, ‘Guidance for the prevention of sexually transmitted HIV infections’, August 2011, pp.36–7. Available at: www. pepfar.gov/documents/organization/171303.pdf 16
International HIV/AIDS Alliance, ‘Report on access to Global Fund resources by HIV/AIDS key populations in Latin America and the Caribbean April 2009’. Available at: www.aidsalliance. org/includes/Publication/Report_on_Key_Populations_access_ to_resources_ENG.pdf International HIV/AIDS Alliance, ‘Increased civil society involvement in Country Coordinating Mechanisms in Zimbabwe November 2009’. Available at: www.aidsalliance.org/ newsdetails.aspx?id=247 Global Network of People Living with HIV (2005), ‘Challenging, changing, and mobilizing: a guide to PLHIV involvement in Country Coordinating Mechanisms’. Available at: www.gnpplus. net/cms-downloads/files/handbook-EN.pdf 17
The Office of the Global AIDS Coordinator contends that the United Nations should take the lead on this because of the sensitivity of the issue. However, UNAIDS, issued guidance on this in 2009. This document should inform but certainly should not replace PEPFAR guidance. 18
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PEPFAR, ‘Comprehensive HIV prevention for people who inject drugs, revised guidance’, July 2010, p.8. Available at: www.pepfar.gov/documents/organization/144970.pdf 10
It will be necessary to specify that these data be gathered in a framework protective of human rights, wherein involuntary testing, treatment, confidentiality violation and/or detention are prohibited.
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“The rights and needs of key populations, as reflected in all relevant US government policies, strategies and commitments, should be taken fully into account in US HIV and health-related programming.”
Published by: International HIV/AIDS Alliance (International secretariat) Preece House, 91–101 Davigdor Road, Hove, BN3 1RE, UK Telephone: +44(0)1273 718900 Fax: +44(0)1273 718901 mail@aidsalliance.org www.aidsalliance.org 12 Designed by Progression Design