Stigma indices and gender assessments have generated critical evidence
There is increased recognition that removing human rights- and gender-related barriers to accessing HIV- and other health services by populations living with and affected by HIV, is a prerequisite for ending AIDS, reaching Universal Health Coverage, reducing inequalities, and achieving many other Sustainable Development Goals by 2030.The 2016 Political Declaration on HIV and AIDS notes that "urgent consideration should be given to the promotion, protection and fulfilment of all human rights" and commits countries to "achieving gender equality and the empowerment of all women and girls." Similarly, the Global Fund's Strategy 2017-2022 has among its four strategic objectives to "promote and protect human rights and gender equality".
Despite this high-level acknowledgement and commitment, addressing human rights and gender barriers in Global Fund grants has been a challenge. In 2016-2017, nine baseline assessments conducted in the Fund's 20 human-rights focus countries found evidence of insufficient programs to reduce human rights-related barriers. On average, countries scored 2.08 out of a possible 5.00 (with 4.00 representing the threshold for comprehensive human rights programming).
In May 2019, the Global Fund projected that if recent trends continue, it will achieve only three quarters of its target for reduced HIV incidence among adolescent girls and young women (42% compared to the 58% strategy target). (See separate article in this GFO on HIV prevention for this target group.)
Several initiatives aim to accelerate progress on human rights and gender equality. These include the Global Fund's Breaking Down Barriers Initiative, Community, Rights and Gender Strategic Initiative, and HER Initiative, as well as UNAIDS' Technical Support Mechanism (TSM). This article provides an overview of the latter.
UNAIDS has established a technical support mechanism to enable high-quality technical support provision to accelerate the AIDS response, towards achieving the Fast-Track targets and the commitments in the 2016 Political Declaration on HIV and AIDS. As a means to these ends, the TSM has a particular focus on effective and efficient Global Fund grant implementation.
Jointly managed by Oxford Policy Management and Genesis Analytics, the UNAIDS TSM provides short-term (3-6 months) technical support in over 100 countries, primarily in Africa, Asia, and the Pacific. Its main focus is to reach those who are underserved and at higher risk of HIV, thereby reducing inequities and strengthening the sustainability of effective programmes.
Since 2018, UNAIDS' has supported 32 human rights and gender assignments in 18 countries, making up approximately 15% of the TSM's overall portfolio. These assignments have mostly been geared towards achieving the Fast-Track targets on eliminating gender inequalities, eliminating stigma and discrimination, ensuring access to HIV-sensitive social protection, and ensuring access to HIV combination prevention services for key populations (Table 1).
Table 1. Overview of UNAIDS' human rights and gender technical support since July 2018
Assignment Type Countries
People living with HIV Stigma Index studies Burkina Faso, Eswatini, Lesotho, Namibia, Indonesia, the Philippines, Rwanda and Sierra Leone
HIV and social protection assessments Lesotho, Malawi, Mali, Uganda and Zimbabwe
Gender assessments Benin, Côte d'Ivoire, Malawi, Morocco, Sierra Leone, South Africa and Tanzania
Law and policy reviews Asia Pacific (regional), Indonesia, Lao, Uganda, West and Central Africa (regional) and Vietnam
Development of five-year national human rights plans Côte d'Ivoire and Ghana
Removing barriers to access faced by key populations Estonia, Democratic Republic of Congo, Indonesia and Papua New Guinea
Helping countries to roll out the People Living with HIV Stigma Index has been a core focus of UNAIDS' recent technical support. Assignments in Burkina Faso, Eswatini, Lesotho, Namibia, Indonesia, the Philippines, Rwanda and Sierra Leone employed the new Stigma Index 2.0 methodology, which includes a broader range of health issues (beyond HIV), and better captures intersectional stigmas faced by key populations. While the Index itself is led by national networks of people living with HIV, UNAIDS works in partnership with the Global Network of People Living with HIV (GNP+) to provide quality assurance, adapt tools, and do in-country capacity building.
The Stigma Index studies have helped countries build the necessary evidence to make effective use of Global Fund catalytic investments, especially matching funds. For instance, Eswatini's Stigma Index pointed to disclosure issues and limited treatment literacy among young people. This helped guide implementation of the country's $1.5-million matching funds grant for adolescent girls and young women, a portion of which is dedicated to increasing access to care and treatment for adolescents living with HIV.
In South Africa's Stigma Index, the report showed that internalized stigma is still a major challenge, with more than 40% of people living with feelings of internalized stigma. Based on this finding, the country dedicated $1.9 million of its $5-million human-rights matching funds to support community-level anti-stigma champions, and invest in community-led research initiatives to measure and track improvements in self-stigma.
Gender assessments, too, contribute critical strategic information to guide national Global Fund decision-making. "When countries use data from qualitative gender assessments, such as UNAIDS' Gender Assessment Tool, there is better prioritization and design of interventions to address gender-related barriers, particularly for women and girls," said Heather Doyle, Senior Coordinator for Gender at the Global Fund. Doyle highlighted this point in a recent consultants' training in Senegal (see story in GFO 370).
UNAIDS is currently supporting gender assessments in Benin, Côte d'Ivoire, Malawi, Morocco, Sierra Leone, South Africa and Tanzania. Results from the assessment in Malawi will help the country respond to the Global Fund's Office of the Inspector General December 2019 audit report of Global Fund grants to Malawi, which largely focused on weakness in the design and implementation of interventions targeting adolescent girls and young women. (See also the GFO article on the audit report.)
At the global level, UNAIDS technical support has also been invested in operationalizing the Global Partnership for Action to Eliminate All Forms of HIV-Related Stigma and Discrimination, developing a reference document with the latest evidence on what works for ending discrimination in six settings (healthcare, education, household, justice, workplace, and emergencies and humanitarian; forthcoming). This document will further guide country-level programming on human rights, including in their Global Fund grants.
UNAIDS human rights and gender technical support is particularly critical in light of the Technical Review Panel's (TRP) Observations on the 2017-2019 Allocation Cycle. The TRP found that there were information gaps in some funding requests on the impediments to health services faced by key populations.
In Indonesia, UNAIDS supported a mobility study which revealed that 34.3% of sex workers in Denpasar and 28.1% in Manado had moved in the past six months, and that mobile sex workers were more than twice as likely to experience discrimination when accessing health services. In Papua New Guinea, UNAIDS technical support responded to a lack of demand-creation strategies by delivering training and field coaching for outreach workers on how to implement a "yes to test" calculator, with a focus on ensuring informed consent among key populations.
Human rights and gender are also mainstreamed in much of UNAIDS' other technical support provision, including national strategic planning and policy-making, as well as developing Global Fund funding requests. With technical support from UNAIDS, Congo's new National HIV Strategic Framework 2019-2022 includes legal education and information ("know your rights") for people living with HIV, key populations and survivors of gender-based violence, coupled with HIV-related legal services. In revising Sierra Leone's HIV Policy, UNAIDS technical support ensured that healthcare workers who provide information and services to key populations would not be considered in contravention of the law, which still criminalizes some of these groups.
In the Global Fund's upcoming 2020-2022 funding cycle, UNAIDS aims to supply human rights and gender experts to support national funding-request development processes. UNAIDS works in close collaboration with the Global Fund Secretariat to ensure this technical support is well-coordinated and strategically targeted. "We recently undertook a detailed mapping of available human rights-related technical assistance to countries, including that from UNAIDS, UNDP, Frontline AIDS and others," said Ralf Jürgens, Senior Coordinator for Human Rights at the Global Fund. "The partnership between the Global Fund and UNAIDS is critical for scaling up programs to remove human rights-related barriers to health services in the 20 priority countries and beyond," he said.
To request technical support through UNAIDS, prospective applicants are encouraged to approach their UNAIDS Country Director, or write to email@example.com.
Gemma Oberth and Kitty Grant are the focal points for human rights and gender assignments with the UNAIDS TSM. Andrea Boccardi is a Senior Community Support Adviser with the Human Rights and Gender Team and human rights and stigma & discrimination technical lead for the TSM at the UNAIDS Headquarters in Geneva.
Disclosure: Both Gemma Oberth and Kitty Grant also consult directly with the Global Fund, supporting the Global Fund's Breaking Down Barriers Initiative and the Community, Rights and Gender Strategic Initiative. This was declared to Aidspan and was not considered a conflict of interest in light of the authors' unpaid contribution to the GFO in order to share information about the UNAIDS TSM.