Andy Seale, Anurita Bains, and Sam Avrett

Health and Human Rights 12/1

Published June 2010

Abstract

After almost three decades of work to address HIV and AIDS, resources are still failing to adequately address the needs of the most affected and marginalized groups in many societies. In recognition of this ongoing failure, the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) has approved a sexual orientation and gender identities (SOGI) Strategy. The Strategy is designed to help its investments more effectively reach men who have sex with men; transgender populations; male, female, and transgender sex workers; and women who have sex with women. The Global Fund financing model is unique and based on ideas of broad partnership. It emphasizes the importance of country-ownership while ensuring that work is appropriately targeted, evidence-based, and rooted in principles of human rights. The classic international development tension of pursuing a rights-based agenda while also supporting strong country ownership has moved the Global Fund into a more substantive technical, advocacy, and policy arena, resulting in the creation of the SOGI Strategy, which emphasizes the needs of marginalized groups. A strong commitment to participation and consultation was crucial during the development stages of the Strategy. Now, as the Strategy goes live, it is clear that progress will only be achieved through continued and strengthened partnership. The diverse partners — in particular the governments and other stakeholders in recipient countries that helped develop the Strategy — must now commit to stronger collaboration on this agenda and must demonstrate bold leadership in overcoming the considerable technical and political challenges of implementation that lie ahead.

Introduction: The importance of partnership

The Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) is an international financing institution, established in 2002 to intensify the fight against HIV and AIDS, tuberculosis, and malaria by providing large-scale supplemental financing to countries. This multilateral funding partnership between governments, civil society, the private sector, and affected communities, though still a relatively young initiative by most standards, has grown quickly to become a key source of health and development finance with more than US$19.2 billion approved and US$10 billion disbursed in more than 140 countries.1 Additionally, the Global Fund plays a leading role in financing the drive toward the realization of the Millennium Development Goals and the HIV/AIDS-related targets set by the United Nations in 2001 and 2006.2

From the start the Global Fund has emphasized its role as a “financial instrument, not an implementing entity,” relying on technical and implementing partners to ensure quality and effectiveness in the programming it supports.3 The Global Fund’s framework document states that it “will base its work on programs that reflect national ownership and respect country-led formulation and implementation processes.”4

The Global Fund is one of the few funding mechanisms that truly allow countries to determine their own priorities, in that it is designed to support proven interventions as identified by the recipient countries rather than by donors. Recipient countries are usually far better positioned to know what types of interventions are needed, feasible, and culturally appropriate.5

The Global Fund finances programming that is country-driven, evidence-based, rights-based, performance-based, and delivered in a spirit of multisector partnership, mirroring its own key processes, governance, and management structures. The Global Fund Framework Document establishes that priority will be given to “the most affected countries and communities, and to those countries most at risk” and will include efforts to “eliminate stigmatization of and discrimination against those infected and affected by HIV/AIDS, especially for women, children and vulnerable groups.”6

The Global Fund promotes its “country-level demand driven” model by ensuring the meaningful inclusion in country processes of those most vulnerable to infection and most in need of services. For example, basic eligibility for funding requires that representatives from infected or affected communities be present on the country-level, multi-stakeholder partnerships known as Country Coordinating Mechanisms (CCMs).7 These partnerships are central to the Global Fund’s commitment to local ownership and participatory decision-making. They develop and submit grant proposals to the Global Fund and oversee progress during implementation following grant approval. CCMs include representatives from the public and private sector (including governments), multilateral or bilateral agencies, non-governmental organizations (NGOs), academic institutions, private businesses, and people living with HIV/AIDS, malaria, and/or tuberculosis.

In recent years the Global Fund has recognized that its combined country-driven and rights-based approach needs further clarification to ensure that key affected groups have access to decision-making processes and resources. Additional support is needed to effectively deliver on the more sensitive and contentious gender and sexuality-related aspects of health and development. Challenges in this area typically stem from marginalization, limited capacity, and lack of evidence, access, power, and representation. The Global Fund partnership recognizes that addressing the needs of marginalized and previously overlooked groups brings public health and societal benefits to a wider population.

This paper explores the importance of partnership in delivering on this agenda and describes the process of Global Fund stakeholders in developing its sexual orientation and gender identities (SOGI) Strategy. The paper begins by describing the broad context of these public health issues and the key challenges to involving minorities. It briefly outlines the Global Fund model, role, history, and structures. It then explores key discourses inside and outside of the idea of “partnership” as it relates to financing, sexual orientation, and gender identities. It concludes with a discussion about how sustained, strong, and committed partnership may best achieve success.

Context and challenges

HIV/AIDS disproportionately affects and infects certain populations, including sex workers, men who have sex with men (MSM), transgender persons, and other sexual minorities. These populations often face considerable challenge accessing healthcare and other services. The marginalization, and in some cases criminalization, of people due to their sexual orientation or gender identity severely compromises their ability to negotiate health-related services. This paper does not attempt to review the evidence and arguments for targeting these groups; this is comprehensively described elsewhere, such as in the SOGI Strategy itself and in publications of technical partners and civil society groups.8 Yet it is still important to emphasize that in many countries a dire lack of investment — combined with laws, religion, social institutions, and cultural traditions related to sexual orientation and gender identity — result in the denial of access to life-enhancing and life-prolonging services for groups most affected by HIV/AIDS. Sex between consenting adults of the same sex is criminalized by more than 80 UN Member States, including 34 African countries. Ten states go so far as to impose the death penalty for homosexual relations between consenting adults.9 In addition, nationally collected data that could inform HIV prevention targeting these populations is often scarce or non-existent. For example, 49 out of 52 African countries failed to report data reflecting the level of understanding among MSM of HIV prevention as part of the country progress reporting for the 2008 UN High Level Meeting on AIDS.10 Evidence from Southeast Asia and Latin America indicates that suboptimal care and targeting has led to a worsening of HIV/AIDS epidemics in many contexts.11

MSM, transgender persons, and sex workers also face serious challenges accessing Global Fund resources, despite considerable efforts on their own behalf as well as those of the Global Fund Board, Secretariat, and technical partners. Even when funding has been allocated to address HIV vulnerability in these communities, its impact is often limited by ongoing human rights abuses, poorly designed interventions, and the absence of a broader supportive environment.12 The Global Fund’s SOGI Strategy challenges country and regional implementing partners to better demonstrate how they will address gender diversity and sexual orientation in their processes, proposals, and programs.13

The Global Fund’s journey to a position that more explicitly asserts the importance of addressing sexual orientation and gender identities is also, in part, a story of the organization’s evolution and growth. The Global Fund’s Secretariat, Board, and partners have increasingly been challenged to address the need to secure quality, equity, and increased resource efficiency in efforts to fight HIV/AIDS, tuberculosis, and malaria. Simultaneously Global Fund decision-makers must grapple with classic development tensions as programs walk the “impossible tightrope” of promoting national values and ownership while ensuring the incorporation of internationally established rights-based approaches and principles.14

Discourse and strategy development: Questions of evidence

According to Rosemary McGee, attention to policy and strategy development processes, their contextual history, and an understanding of the tactics and discourse used by key stakeholders during the development process can be as important to a strategy’s successful implementation as the technical or “scientific” evidence and public policies that inform it.15

The SOGI Strategy builds on a dialogue dating back many years prior to the establishment of the Global Fund itself. An examination of the discourse that preceded the Strategy’s development offers useful insight to those keen to support its implementation. A central theme reinforced by many stakeholders during consultation stages was the importance of operating within the Global Fund’s country-driven, evidence-based, rights-based, and performance-based approach, and always in strong partnership. Consequently, the Strategy seeks to reinforce these elements, while recognizing that this focus can expose tensions at the country level, underlining the considerable challenges that face partners working to expand access to marginalized groups. The experience also serves as a reminder that politics and socio-cultural issues influence health programming — particularly HIV-related programming — as much as technical and scientific debate and evidence. These two influences are inter-related in an often complex manner. Whatever the need for evidence-based policy, perhaps what is needed most is an improved evidence-based understanding of the policy process that takes account of political and social realities on the ground. By identifying multiple entry points and pressure points in the policy process, such an evidence-based understanding of the policy process would offer ways for a range of actors and their diverse expertise to explode the usual myths of legitimacy and rationalization, and to counter and contest the usual enactment of politics.16

A shared understanding among stakeholders of the policy process and the issues raised could enhance successful partnership. For example, the political and social dynamics played out in the discourse around the development of the SOGI Strategy often touch on structural barriers that need to be addressed in moving forward. The Global Fund Board Communities Delegation, and participants at the key consultation meetings in Nepal and Senegal, sought to ensure that the final Strategy addressed the political and social realities on the ground, including constraints of criminalization and other legal barriers. One recommendation made by the 2008 Global Fund Partnership Forum discussed the “enabling environment” necessary for success:

The Board should ensure that the Global Fund shows leadership in recognizing the importance of decriminalization as an essential element in responding to the three diseases. The Board is requested to create more scope for human rights based proposals that seek to influence the enabling legal and policy environment for successful outcomes for the three diseases in relation to criminalized and vulnerable groups. Proposals should require an analysis of legal and policy barriers to implementation of effective programs for sexual minorities and a plan to address those barriers. Indicators should be developed to track the impact of these interventions.17

The Global Fund seeks to adhere to a number of key principles to support strong partnership, including a commitment to transparency. Considerable time is taken to document the step-by-step processes of grant decisions and management, and of the development of key strategies and policy positions. Understanding how dynamics conspire to keep various discussions at the margins of development debates can be empowering to groups struggling to be heard.

The inclusion of community voices can help resolve “catch-22” debates about evidence that often arise, debates that can blight programming for marginalized groups. Since credible development organizations seek to demonstrate that planned activities are based on a strong evidence base, it is not unusual for discussions about direction to be diverted by a critique of whether available evidence is robust enough to warrant action. Taking time to examine and critique the power dynamics and structural environment that have influenced the availability of evidence may be more useful. This approach is vital in contexts where dominant power dynamics have resulted in scant evidence related to marginalized populations. The Global Fund’s commitment to consult broadly with key groups was undertaken in order to ensure that the final SOGI Strategy properly considered the realities of groups on the ground, recognizing and compensating for the lack of evidence in some countries.

In 2008, only 37 of 128 countries reporting on the UN Declaration of Commitment on HIV/AIDS provided any detail on five indicators related to sexual minorities and HIV.18 In most countries, there is a lack of data that is recognized at the government level that describes population sizes, HIV prevalence, and related social and behavioral trends.19 This unacceptable absence of the very type of information that can inform government policy makers presents a major implementation barrier for the Global Fund. As a result of this common deficiency, community groups worked hard during the consultation process to ensure that contexts experiencing a lack of data were explicitly addressed within the Strategy. In turn, the SOGI Strategy encourages Global Fund partners to build and strengthen the country-specific evidence base related to sexual minorities by requesting support for national surveillance and operational research when applying for funding.20

The Global Fund funding process

The Global Fund provides grants to technically sound and cost-effective interventions on a discretionary basis following independent review.21 To date, the Global Fund has primarily relied on a mechanism that begins with an open call for proposals, although other funding models have been explored, including direct funding of a small number of national strategies. After the open call for proposals, Country and Regional Coordinating Mechanisms prepare proposals and submit them for review. Proposals are screened using published eligibility criteria; selected eligible proposals are subsequently submitted to an independent Technical Review Panel that evaluates proposals and assigns them to one of four categories: 1) recommended for approval without changes; 2) recommended for approval with minor changes; 3) not recommended in current form, but strongly encouraged to re-submit following major revision; and 4) rejected. The panel’s recommendations are then submitted to the Global Fund Board, which approves the final grants based on technical merit and availability of funds. The Secretariat contracts one Local Fund Agent per country or region to certify the financial management and administrative capacity of the nominated principal recipients of funding. If the principal recipients require capacity strengthening, other development partners may contribute. The Secretariat and principal recipients then negotiate the formal grant agreement, which identifies specific, measurable results to be tracked using identified indicators. Once the approved grant agreement is signed, the first disbursement is made and the principal recipients then make further disbursements to sub-recipients. As the program and services begin, the CCM monitors progress throughout the implementation process and during the production of annual reports and reviews. After two years the CCM must submit a request for continued program funding support, and this subsequent request is either approved or denied based on progress and availability of funds.

In order for funds to reach the key affected populations, the Global Fund recognizes the need to address potential barriers within its somewhat complex funding processes. Normative attitudes, assumptions, and power dynamics that marginalize issues and groups can be easily and unintentionally reproduced inside processes and systems. To combat this tendency, a number of safeguards and additional opportunities are built into the process to expand access and create an environment in which effective programs can be funded and flourish. One such flexibility in the SOGI Strategy allows, in exceptional circumstances, for proposals to be submitted without the involvement of either Country or Regional Coordinating Mechanisms. This may prove vital in contexts of severe marginalization. For example, in countries where communities are actively criminalized and subject to violence and murder, Country or Regional Coordinating Mechanisms may refuse to engage with communities.22

Discourse and strategy development: Consultation and mobilization

In developing the content of the SOGI Strategy, a number of Board-level decisions, discussions, and consultations were held with technical experts, community representatives, and other stakeholders throughout 2008. Additional feedback was solicited and received from regional experts.23 These included initial discussions at the Global Fund’s 16th Board Meeting in November 2007, where the need for a two-part strategic approach to gender was first explored. This two-part approach emphasized, first, the need to address gender inequality, and, second, the need to address sexual minority groups and issues, with particular emphasis on lesbian, gay, bisexual, transgender and intersex (LGBTI) communities, MSM and sex workers. The 2007 meeting built on discussions among Global Fund donor countries who had met four months earlier in Germany for the G8, at which time they had agreed to encourage the Global Fund to respond to growing evidence suggesting increased feminization of the AIDS epidemic.24

Later in 2007, the Global Fund Board was given an opportunity to comment on and discuss the G8 Summit Declaration. Community and civil society representatives on the Board worked hard to ensure that the proposed new “gender” focus of the Global Fund was not limited to women and girls, and secured agreement for it to also address sexual minorities, a group often missed by development organizations’ considerations and understandings of gender.

The move to include sexual minorities in a new organizational understanding of gender was positive and promised to facilitate the brokering of some common ground in a policy debate around gender issues that had, at that time, become somewhat divisive, with different interest groups working globally, presenting different perspectives on their understandings of gender, HIV-related risk, stigma, and discrimination. Many organizations, UNAIDS included, had previously referred to groups who were most vulnerable to HIV infection by using shorthand phrases and acronyms such as “MARPS” (“most at risk populations”). Over time the MARPS label had become associated with groups of individuals who were in many communities viewed as “bad people,” particularly to mean sex workers, sexual minorities, and drug users. However, in some contexts — for example in hyper-endemic epidemics where HIV incidence is largely heterosexually driven — the demographic at highest risk was, and remains to be, a young woman in a steady relationship with a man (or two).25 Sensitivities and heated policy discussions about sex work and sexual/reproductive health rights contributed to the debate over “which women are MARPS?” One particular issue was the desire to clearly differentiate between women who are sex workers and those who are not.26 An unfortunate side effect of this controversy was an increasing tendency for development agencies to restrict their understanding of gender to “gender equality,” thereby missing opportunities to address broader themes that encompass socially constructed ideas of masculinity and femininity, which often hold the key to successful interventions for both sexual minority groups as well as women and girls.

In March 2008 the Global Fund approved a Strategic Framework for Ensuring a Gender-Sensitive Response, and the Gender Equality (GE) Strategy was agreed on eight months later at the 18th Board Meeting.27 The GE Strategy makes explicit that gender equality is only one aspect of a comprehensive understanding of gender. The SOGI Strategy was designed to complement the GE Strategy and was subsequently approved at the May 2009 Board meeting. Its approval followed extensive discussions by the Board’s Policy and Strategy committee; these discussions resulted in 19 clear action points being added to the draft SOGI Strategy, with an emphasis on flexible implementation in varied country-specific contexts.

Discourse and strategy development: Participation and representation

The rationale for a special focus on the inclusion of civil society organizations and marginalized communities within the Global Fund model was evident even before the organization’s founding in 2002. For example, a global multisector partnership conference in Winterthur, Switzerland in October 2000 was one of several events that helped set the stage and tone for the establishment of the Global Fund. The Massive Effort Advocacy Forum called for unprecedented global mobilization against AIDS, tuberculosis and malaria and emphasized the importance of private sector, community and civil society involvement, noting that “[w]hen people with vastly different backgrounds come together with a shared purpose, new energy can be released and expertise used in innovative ways.”28 The document also noted that “[i]ncreased spending should be combined with new methods of health delivery — drawing on the new information technologies, the schools, and the communities.”29

Throughout the process of establishing the Global Fund, consistently strong opinions were expressed about donor conditionalities that might impede the ability to reach and involve the most affected groups. For example, the first recommendation listed from a series of non-governmental organization discussions about the possible design of the Global Fund in 2001 noted that:

[a]ny conditions for donation/earmarking of resources to the Fund should not support, promote or tolerate stigma and/or discrimination on the basis of race, gender, health status or specific behaviors.30

The establishment of the Global Fund was celebrated as a refreshing move toward creating space for all, in accord with the spirit of the celebrated cry, “nothing about us without us,” the philosophy behind the AIDS activist principle of “greater involvement of people living with HIV” (GIPA). The idea that personal experiences should shape the AIDS response was first voiced by people living with HIV and AIDS in Denver in 1983.31 The GIPA Principle was later formalized at the 1994 Paris AIDS Summit when 42 countries agreed to “support a greater involvement of people living with HIV,” ensuring that all infected and affected communities and individuals were central to key decision making and implementation.32 The principle was subsequently adopted and championed by UNAIDS. Specifically in the context of the Global Fund,

The Global Fund was created based on values such as transparency, effectiveness, and inclusiveness of all groups of society. These values can only be attained by the active participation of civil society in Global Fund processes at all levels including governance and implementation.33

In addressing the important issues of marginalization the Global Fund model would challenge what Robert Chambers described as the “delusionary symbiosis” taking place between the “self-deceiving” state and “self deceiving” donors that had dominated much development assistance in the 1980s and 1990s. This symbiosis resulted in top-down projects driven by the need of the two dominant powers (donors and recipient governments) engaged in the development “project” to promote and demonstrate “success.” 34

In other words, the Fund’s design would help ensure that multiple stakeholders — from grassroots community-level to global technical partners as well as donors and recipient governments — had the opportunity to work together to create better programs by creating more space for marginalized populations. The Global Fund did not commit to participation for the sake of “participation”; it did so because it made sense both programmatically and economically. This, in turn, tested some of the traditional male and elite-dominated relationships that had previously characterized much development decision-making, which often resulted in programs with limited reach and impact as far as marginalized groups were concerned.

Partnership: The key to success

Clearly the key to success in delivering on the SOGI Strategy lies in the ability of the partnership model to deliver in the real world for and with real people. In order for it to succeed, there needs to be a shared understanding across all partners in the Global Fund definition of “country ownership” as a concept requiring multistakeholder engagement — not just high-level government or political support. Much emphasis is placed on the Country Coordination Mechanism as a structure, supported by technical partners, to help deliver on this commitment to multisectorality. Indeed, the first two action points of the Strategy describe how to strengthen the CCM in order to deliver more effective programming addressing HIV, sexual orientation, and gender diversity.35 Other action points focus on improving guidelines for proposals submitted to the Global Fund; strengthening the expertise of the Technical Review Panel, which now includes those with expertise on gender and sexual diversity issues; how to ensure monitoring, evaluation, and reporting is improved and strengthens programming for sexual minorities; how to mobilize and harness supportive and strategic partnerships; the use of advocacy, communication and leadership to promote the values, principles and expectations of the Global Fund in this area; and finally, strengthening the capacity of the Secretariat to encourage and support more effective programming.36

All of these actions suggest that, without this additional level of support, the core Global Fund model of country-driven, evidence-based, rights-based, performance and partnership will not necessarily deliver optimal outcomes for the Strategy’s target populations. While the Secretariat needs to ensure these principles are respected, it must also recognize that progress will be made more quickly in some contexts than in others. However it will also need to ensure that Secretariat-supported efforts to improve technical capacity and expertise are kept distinct and separate from implementation and proposal development, with partners taking on an enhanced role:

In accordance with its principle of country ownership, the Global Fund does not engage in proposal preparation or country programming. Extending and deepening strategic partnerships with international and local organizations, NGOs and networks focused on women’s rights and empowerment is therefore key to developing and implementing health programs that address gender issues. This should include partnerships with networks of men who have sex with men and other vulnerable groups.37

Access, rights, and country realities

The SOGI Strategy realizes the unique placement of Global Fund partnership as key to catalyzing country-level ownership in programming. However, as the reality on the ground is more nuanced and complex than the concepts and theories often presented in toolkits, policy, and strategy documents, the Secretariat has committed to an ongoing process of analysis of its own processes and investments. The Secretariat also recognizes that many lessons in the recent past have been learned by development and country partners with a longer history of engagement on these issues.

Clearly it has always been a challenge to ensure that donor aid and investment successfully reaches groups most affected by HIV/AIDS. In a chapter entitled “No Money For Bad People,” Tania Boler and David Archer explore how development aid for HIV has always “been politicized but in ways which make it less — rather than more — likely that countries will provide HIV prevention services to those in need.”38 It is next to impossible to avoid power, politics and access issues when seeking to strengthen health outcomes for key affected groups. One of the key inhibiting factors often described is that established institutions in many countries, including large NGOs, remain inaccessible to minority groups.39

In terms of being able to access or benefit from Global Fund grants, MSM, transgender persons, and sex workers face serious challenges. They face limited access to decision-making or control in CCMs, principal recipient organizations, or sub-recipient organizations, and widespread inaction against social and structural barriers to the realization of health and rights.40

Some external commentators argue that donors have government-centric tendencies, the Global Fund included, which have impact on the way partners understand and interpret “country ownership”:

This state-centric understanding of political leadership is manifested in the grant criteria and procedures of the Global Fund. The postcolonial African state has typically tried to direct and control the development process. African state officials have perceived the recent trend whereby donors channel funding to NGOs instead of the state has undermined state authority. The language of the Global Fund reflects an awareness of these concerns about African state sovereignty. “The Fund will base its work on programs that reflect national ownership and respect country-led formulation and implementation processes.” The Global Fund attempts to distance itself from being an intrusive international organization by stating that it is “a financial instrument, not an implementing entity.”41

Amy Patterson and David Cieminis identify the politics of interference with African governments, which are facing some of the greatest challenges in developing effective programming for sexual minorities, as a key influence in the Global Fund’s decision to promote country ownership and distance itself from “prescribing” programmatic solutions that should instead be developed at the country level. Interestingly they also describe a debate around human rights that took place during the 2001 United Nation General Assembly Special Session on HIV/AIDS, the session that resulted in the establishment of the Global Fund. During the session, heads of state from many developing countries called for a rights-based approach to secure HIV treatment for their citizens, a call which was resisted by the United States administration of the time, concerned that it would undermine intellectual property rights and consequently research and development into new HIV treatments.

It is interesting to note that many African states were part of the call for a rights-based approach to HIV in 2001 with their arguments clearly based on principles of equity — yet these same principles of equity have yet to be extended to many LGBTI Africans who are still denied adequate health and social care and protection.42 The heightened temperature around sexuality across the continent in recent years, combined with heated discussions in the Anglican Church, contributed to the decision of all states in English-speaking Africa to reject a statement on human rights, sexual orientation, and gender identity at the United Nations General Assembly during the 60th celebrations of the Declaration of Human Rights in December 2007.43 These examples show that government and state-level organizations in all regions hold the greatest power in determining what and whose rights are recognized and protected in their own national contexts — which makes them critical partners to the success of delivering on the Global Fund’s SOGI Strategy.

Patterson and Cieminis miss the point when they say that the Global Fund does not want to be seen as an “intrusive international organization” because recipient countries constitute the Global Fund themselves.44

The Global Fund’s 360° Stakeholder Evaluation confirmed that properly addressing the needs of marginalized and at risk populations remained a major challenge.45 Clearly the response must be mobilized across the wider Global Fund partnership and not just inside the Secretariat. Fried and Kowalski-Morton’s 2008 analysis of the Global Fund’s lack of success in its early years in reaching sex workers, lesbians, gays, bisexuals, transgender people, and men who have sex with men highlights the “difficult dilemma” facing the Global Fund of reconciling the need to prioritize these groups with a country-driven model of funding: “If the Global Fund aims to help fill resource gaps to stem the HIV and AIDS pandemic, it must come to terms with this dilemma.”46

The analysis points out that some barriers are connected to processes in-country that “despite the rhetoric and appearance of civil society engagement… are still anchored in government control.” This issue is addressed directly in the SOGI Strategy, which notes that

men who have sex with men, transgenders, and female, male, and transgender sex workers face challenges in being able to access or benefit from Global Fund grants. They have limited access to decision-making bodies of the Global Fund, and face social and structural barriers to the realization of their health and rights.47

The Strategy makes it clear that issues, particularly around access, are long-term challenges that will not be solved overnight and, importantly, need to be solved through close collaboration among all key in-country partners. The Strategy encourages action to be “gradual, careful, built upon current positive efforts and good intents, and respectful of the varying contexts in which the Global Fund operates.”48

Despite the access and other challenges described in the Strategy, it is important to note that many countries have been able to use the Global Fund to secure funding for MSM and other groups well before the Strategy was agreed. Some regions, including Eastern Europe, parts of Asia, and Latin America have used Global Fund money to fund work with sex workers and men who have sex with men at a scale never previously experienced. During the eighth round of Global Fund funding, 72.4% of proposals identified men who have sex with men and other sexual minorities for targeting with 52.6% proposed explicit interventions.49 Nevertheless the Global Fund has recognized that it can and should do more to secure greater access and participation of the target populations described in the SOGI Strategy.

Quality, complexity, and terminology

In-country partners have a major role in maximizing the opportunities presented by the SOGI Strategy. Global partners, including the Global Fund Secretariat, have a responsibility to work sensitively with partners at country level to meet their technical support, resource and convening needs — in addition to helping clearly identify what can work programmatically. The Secretariat can do more to encourage countries to address issues of quality in their programs, in addition to monitoring the appropriate handling of funds — what Elizabeth Pisani described as “bean-counting.”50 Indeed much of the Strategy describes an enhanced role for the Secretariat. It describes how the Secretariat can support strengthened capacity and processes to ensure better outcomes at country level, ensuring that the Secretariat plays an important role in seeing that country partners access appropriate technical assistance needed from a range of specialized partners. For example, it stresses the importance of clear measurement criteria to assist in grant monitoring and evaluation, while at the same time acknowledging that developing universally acceptable tools presents considerable challenges:

Attempting globally comparable definitions of populations and their behaviors will always be an approximate task. It is understood that an important dynamic in overcoming the marginalization of sexualities and gender identities is for people to define and claim the names by which they are discussed. Therefore, unlike many other fields of human rights or health where terms can be found for universal application, in the topics of sexual orientation and gender identity, there is value in maintaining a diversity and fluidity to terminology.51

Nevertheless, any global effort to address the health and rights of sexual minorities needs to use consistently applied definitions of, and data about, those sexual minorities for sound strategy and monitoring and evaluation.52

A two-day discussion at the 2008 Global Fund Partnership Forum in Senegal to strengthen the draft Strategy for “sexual minorities” recognized the term as a potentially problematic “catch-all” phrase favored by many organizations. The discussion group, which included many LGBTI community activists familiar with the arguments around terminology, insisted on the following text being read as a preamble to the group’s report back to the Forum’s plenary session:

The discussion group assumes that in taking this important work forward the Global Fund will ensure that terminology is inclusive, in other words, ensuring that ‘sexual minorities’ refers to all people whose sexual orientation, gender identity and/or sexual behaviors do not conform to majority norms and values including: men who have sex with men, women who have sex with women, individuals who are transgender, transsexual and intersex. Sexual minorities can also include marginalized heterosexual behaviors and gender roles including non-monogamous sex and sex work.53

A similar level of pragmatism, care, and accuracy with language will also be needed during the implementation of the Strategy. Despite years of trying, advocates and academics have been unable to find satisfactory terminology that meets the needs of all groups engaging in sexuality discourse. This is most evident when discourse moves from the comfort of the margins to the mainstream arena, where terms are employed as a strategy to claim rights and visibility and ground. In these contexts, the catch-all phrases of MSM, LGBTI, and sexual minorities are re-exposed as problematic to non-heteronormative discourse and throw up barriers to mainstream AIDS practitioners. This may result in reinforcing marginalized positions. Programs must neither be held hostage to semantics nor diluted as a result of clumsy or non-inclusive language.

Discussion and conclusion

The SOGI Strategy aims to address barriers within the Global Fund’s own processes rather than prescribe what needs to be done. Through this approach, it hopes to catalyze and support strong, positively biased country programming. The Secretariat has already taken several actions related to the Strategy, such as modifying how funding is made available to support the functioning and capacity of Country Coordinating Mechanisms, and amending Round 10 proposal forms and guidelines to include references to key affected populations.54 A new “MARPS Reserve” of USD 200 million over five years was agreed upon by the Global Fund Board in May 2010 for Round 10 only. This reserve aims to ensure that key affected populations from all regions of the world have a chance to be funded, even if the demand for Global Fund resources in Round 10 exceeds available finances.55 The Secretariat has also met regularly with key technical and community partners to identify and progress key actions needed both internally for the Secretariat and externally for partners, so that they can maximize the opportunities presented by the Strategy. It has elaborated flexibilities for regional and country proposals as well as proposals in countries where national and local governments find themselves unable to act.56 These actions are an important start. As a major international funding entity working to address challenges to health from frameworks of evidence, human rights, and measurable outcomes, however, the Secretariat and key partners must and can do more to accelerate their actions on this agenda.

The Global Fund is increasingly interested in using the midterm grant review milestone within the typical funding cycle to strategically strengthen programs for marginalized and most at risk populations, and to request that Principal Recipients are accessing appropriately disaggregated data and technical support.57 Building on this will take trust, patience, and a strong “can do” approach from key partners in country, together with bold leadership within the Country Coordinating Mechanism.

The Global Fund acknowledges that work in this area is difficult and sometimes controversial in many parts of the world, with no single approach applicable to every situation. In mapping a way forward, this paper emphasizes the importance of recognizing the Global Fund as a dynamic multisector partnership initiative — in other words an initiative that is much larger than its Geneva-based Secretariat. It also attempts to reflect the spirit of openness and transparency valued at the Global Fund. Finally it argues that transparency and openness are crucial for successful partnership. As the Global Fund is a funding agency, not a normative or technical agency, it simply cannot move on this agenda alone.

The Global Fund offers considerable potential for opening spaces for participation by sex workers, lesbian, gay, bisexual and transgender individuals, men who have sex with men, and women who have sex with women in country-level decision-making. It also offers an unprecedented opportunity to increase resources for HIV services that meet community needs and break some of the taboos around funding HIV programs that deal with the “controversial” issue of sex and sexuality.

It is the responsibility of all partners to create an environment where populations most at risk can reap the benefits that Global Fund investment can bring. As the work moves forward, there is a need for care during implementation in order to secure a “do no harm” approach, so that the communities, particularly in countries where they are criminalized, are able to engage in any new spaces safely and with confidence. It is also vital that funding reinforces strong community effort and strives to achieve the difficult partnership challenges of ensuring that communities are at the heart of decisions and impact. The challenges require sensitivity to different national and regional contexts and the need to resist attempts to impose “one size fits all” approaches developed at the global level. Each context will be different and demand a different level of engagement, with considerable emphasis on supporting a proactive and constructive response among recipient governments and enhanced commitment from national and technical partners to work more closely with sexual minority groups in their countries. Understanding the unique political, social, and cultural contexts of each country is critical if this strategy is to be effective.58


Andy Seale is Senior Advisor for Sexual and Gender Diversity at the Global Fund Secretariat, where he is responsible for coordination of the Global Fund’s work to strengthen its support focused on sexual orientation and gender identities.

Anurita Bains is Senior Advisor in the Office of the Executive Director at the Global Fund Secretariat.

Sam Avrett is an independent consultant who supported the development of the Global Fund Sexual Orientation and Gender Identities Strategy.

Please address correspondence to the authors c/o Andy Seale, The Global Fund, chemin de Blandonnet 8, 1214 Vernier, Geneva, Switzerland, email: andy.seale@theglobalfund.org.


References

1.    The Global Fund to fight AIDS, Tuberculosis and Malaria, The Global Fund 2010: Innovation and impact (Geneva: April 2010), p. 3. Available at http://www.theglobalfund.org/documents/replenishment/2010/Global_Fund_2010_Innovation_and_Impact_en.pdf.

2.    In 2006, a “Political Declaration on HIV/AIDS” was adopted unanimously by UN Member States at the close of the United Nations General Assembly 2006 High Level Meeting on AIDS. It provides a strong mandate for scaling up national AIDS responses toward universal access to HIV prevention, treatment, care and support. It also reaffirms the goals set out in the 2001 Declaration of Commitment and the Millennium Development Goals, in particular the goal to halt and begin to reverse the spread of AIDS by 2015. Political Declaration on HIV/AIDS, G.A. Res.60/262 (2006). Available at http://www.unaids.org/en/AboutUNAIDS/Goals/default.asp.

3.    The Global Fund to fight AIDS, Tuberculosis and Malaria, The framework document of the Global Fund to fight AIDS, tuberculosis and malaria: Title, purpose, principles and scope of the Fund (Geneva: The Global Fund, 2003), p. 1. Available at http://www.theglobalfund.org/documents/TGF_Framework.pdf.

4.    The Global Fund (see note 3), p. 1.

5.    T. Boler and D. Archer, The politics of prevention: A global crisis in AIDS and education (London: Pluto Press, 2008), p. 125.

6.    The Global Fund (see note 3), pp. 2–3.

7.    Definition and description of the Global Fund’s country coordinating mechanisms (CCM) are available at http://www.theglobalfund.org/en/ccm/?lang=en.

8.    The Global Forum on MSM and HIV (http://www.msmgf.org/aboutMSMGF.htm) and the Network of Sex Work Projects (http://www.nswp.org) are two examples of civil society initiatives offering technical and advocacy support at the global level. Additional references are available as an Annex in The Global Fund, Sexual orientation and gender identities strategy, (Geneva: The Global Fund, 2009), pp. 21–23. Available at http://www.theglobalfund.org/documents/publications/other/SOGI/SOGI_Strategy.pdf.

9.    The Global Fund (see note 3), p. 3, section 1.7.

10.  amfAR, The Foundation for AIDS Research, Special Report: MSM, HIV,

and the road to universal access: How far have we come? (New York: amfAR, The Foundation for AIDS Research, 2008). Available at www.amfar.org/WorkArea/DownloadAsset.aspx?id=170. See also UNAIDS, UNGASS 2008 reporting analysis (Geneva: The Global Fund, 2008). Available at http://www.unaids.org/en/KnowledgeCentre/HIVData/CountryProgress/2007CountryProgressAllCountries.asp.

11.  amfAR, The Foundation for AIDS Research, the MSM Initiative, Ensuring universal access to comprehensive HIV services for MSM in Asia and the Pacific: Determining operations research priorities to improve HIV prevention, treatment, care, and support among men who have sex with men (August 2009). Available at www.amfar.org/WorkArea/DownloadAsset.aspx?id=7825, p. 4. See also International HIV/AIDS Alliance, Report on access to Global Fund resources by HIV/AIDS key populations in Latin America and the Caribbean (April 2009), p. 5. Available at http://www.aidsalliance.org/includes/Publication/Report_on_Key_Populations_access_to_resources_ENG.pdf.

12.  The Global Fund’s Sexual orientation and gender identities strategy (Geneva: The Global Fund, 2009), p. 4, section 1.9. Available at http://www.theglobalfund.org/documents/publications/other/SOGI/SOGI_Strategy.pdf.

13.  Much of the strategy focuses on future rounds of funding recognizing that there are challenges in the realignment of existing programs, but it also signals changes that can be made now to improve in-country processes and programmatic reach.

14.  M. Crewe and V. Reddy, “There are a thousand ways to wear a veil” (presentation at Gender Conference, Lima, Peru, July 29, 2007).

15.  R. McGee, “Unpacking policy: Knowledge, actors and spaces” in K. Brock, R. McGee and J. Gaventa (eds), Unpacking policy: Knowledge, actors and spaces in poverty reduction in Uganda and Nigeria (Kampala, Uganda: Fountain Publishers, 2004), p. 25.

16.  Ibid.

17.  The Global Fund, Listening to the voices: Recommendations from The Global Fund partnership forum, Dakar, Senegal, 8–10 December 2008 (Geneva: The Global Fund, 2008), p. 3. Available at http://www.theglobalfund.org/documents/partnershipforum/2008/PF2008_Recommendations.pdf.

18.  UNAIDS (see note 10).

19.  The Global Fund (see note 13).

20.  Ibid., p.6.

21.  The usual rounds-based funding process at the Global Fund follows a series of stages outlined in The Global Fund, The Global Fund’s proposals process in brief (n.d.). Available at http://www.theglobalfund.org/en/rounds/applicationprocess.

22.  The Global Fund, Non-country coordinating mechanisms information note, (Geneva: The Global Fund, 2010). Available at http://www.theglobalfund.org/documents/rounds/10/R10_InfoNote_Non-CCM_en.pdf.

23.  In February 2008, in Geneva, the Gates Foundation and the International AIDS Society hosted a Global Summit that focused on MSM. The Open Society Institute and Population Services International (PSI-Nepal) organized the Kathmandu consultation. Further consultations took place at the International AIDS Conference in Mexico and at the December 2008 Global Fund Partnership Forum.

24.  G8 Summit Declaration, Growth and responsibility in Africa (June 8, 2007), p. 15. Available at http://www.g-8.de/Content/DE/Artikel/G8Gipfel/Anlage/Abschlusserkl_C3_A4rungen/WV-afrika-en,property=publicationFile.pdf.

25.  Hyperendemic scenarios refer to those areas where HIV prevalence exceeds 15% in the adult population driven through extensive heterosexual multiple concurrent partner relations with low and inconsistent condom use. UNAIDS, Practical guidelines for intensifying HIV prevention: Towards universal access (Geneva: UNAIDS, 2007), p. 1. Available at http://data.unaids.org/pub/Manual/2007/20070306_prevention_guidelines_towards_universal_access_en.pdf.

26.  The UNAIDS response to the debate was to move away from the controversial “MARPS” label altogether and toward the use of the more neutral term “key populations.” “Key populations” terminology is described and available at www.unaids.org/en/PolicyAndPractice/KeyPopulations/default.asp.

27.  The Global Fund, The Global Fund’s strategy for ensuring gender equality in the response to HIV/AIDS, tuberculosis and malaria: The gender equality strategy (Geneva: The Global Fund, 2008). Available at www.theglobalfund.org/documents/strategy/TheGenderEqualityStrategy_en.pdf.

28.  G. H. Brundtland, Director-General of the World Health Organization, Opening Dinner Address, Massive Effort Advocacy Meeting, Winterthur, Switzerland (October 3, 2000). Available at http://www.winterthurhealthforum.ch/HtmlDoc/SpeechBrundtland031000.html and http://www.winterthurhealthforum.ch/PDF/ME4Report.pdf.

29.  J. D. Sachs, Address, Massive Effort Advocacy Forum, Winterthur, Switzerland (October 5, 2000). Available at http://www.winterthurhealthforum.ch/HtmlDoc/SpeechSachs031000.html.

30.  The Global Fund, Key recommendations from the NGO consultation meeting, Brussels, 12–13 November 2001 (Geneva: The Global Fund, 2001). Available at http://www.theglobalfund.org/documents/twg/NGO_consult_GFATM_recommendations.pdf.

31.  The Denver Principles: Statement from the Advisory Committee of People with AIDS  (Denver, CO: 1983). Available at http://www.denverprinciplesproject.com.

32.  UNAIDS, The greater involvement of people living with HIV and AIDS policy brief (2007). Available at http://data.unaids.org/pub/Report/2007/JC1299-PolicyBrief-GIPA_en.pdf.

33.  The Global Fund, Participation and transparency (Geneva: The Global Fund, 2007). Available at http://www.theglobalfund.org/documents/publications/other/D2H/2_Participation.pdf.

34.  R. Chambers, Whose reality counts? Putting the first last (Rugby, UK: ITDG Publishing, 1997).

35.  The Global Fund (see note 13) p. 7.

36.  Ibid., pp. 7–19.

37.  The Global Fund, Scaling up a gender-sensitive response to HIV/AIDS, tuberculosis and malaria by the Global Fund, Sixteenth Board Meeting, Kunming, China, November 12–13, 2007, GF/B16/13, Board Input (Kunming, China: The Global Fund, 2008). Available at http://www.theglobalfund.org/documents/board/16/GF-BM16-13_ScalingUpGenderSensitiveResponse.pdf.

38.  Boler and Archer (see note 5), p. 105.

39.  C. Johnson, Off the map: How HIV/AIDS programming is failing same sex sex practicing people in Africa (New York: IGLHRC, 2007); S. Fried and S. Kowalski-Morton, “Sex and the Global Fund: How sex workers, lesbians, gays, bisexuals, transgender people, and men who have sex with men are benefiting from the Global Fund, or not,” Health and Human Rights: An International Journal 10/2 (2008), pp. 127–136. Available at http://hhrjournal.org/blog/perspectives/sex-and-the-global-fund.pdf; amfAR (see note 11) and International HIV/AIDS Alliance (see note 11).

40.  The Global Fund (see note 8).

41.  A. Patterson and D. Cieminis, “Weak and ineffective? African states and recent International AIDS policies in the African state and the AIDS crisis,” in A. Patterson (ed), The African state and the AIDS crisis (Farnham, UK: Ashgate, 2005), p.175.

42.  Johnson (see note 39), p. 103, describes how African same-sex-practicing people are “under-counted, under-researched and under-funded.”

43.  L. M. Mute, “Africa’s hypocrisy on human rights, sexual orientation and gender identity,” Pambazuka News, Pan-African Voices for Freedom and Justice (January 8, 2009). Available at http://www.pambazuka.org/en/category/comment/53072.

44.  Patterson and Cieminis (see note 41), p. 175.

45.  The Global Fund, 360° stakeholder evaluation: Perceptions and opinions of stakeholders of the Global Fund (Geneva: The Global Fund, 2006).

46.  Fried and Kowalski-Morton (see note 39).

47.  The Global Fund (see note 8).

48.  Ibid., p. 1.

49.  The Global Fund, Gender analysis of Round 8 HIV/AIDS proposals (Geneva: The Global Fund, 2009). Available at http://www.theglobalfund.org/documents/rounds/9/CP_Analysis_R8_Gender%20Responsiveness_en.pdf.

50.  E. Pisani, The wisdom of whores: Bureaucrats, brothels and the business of AIDS (New York: W. W. Norton, 2008), p. 309.

51.  The Global Fund (see note 8), p. 14, section 2.43.

52.  Ibid.

53.  The Global Fund (see note 17), p. 3.

54.  The Global Fund, Apply Now — Round 10, Online Round 10 Application Support (Geneva: The Global Fund, 2010). Available at http://www.theglobalfund.org/en/applynow/?lang=en.

55.  The Global Fund, Dedicated reserve for Round 10 HIV/AIDS Proposals for most at risk populations (MARPS), information note (Geneva: The Global Fund, 2010). Available at http://www.theglobalfund.org/documents/rounds/10/R10_InfoNote_MARP_en.pdf.

56.  The Global Fund, The Global Fund Multi Country Applicants Information Note (Geneva: The Global Fund, 2010). Available at http://www.theglobalfund.org/documents/rounds/10/R10_InfoNote_Multi_en.pdf. See also The Global Fund (see note 22).

57.  The usual rounds-based funding process at the Global Fund follows a series of stages (see note 21).

58.  The Global Fund (see note 8), p. 4, section 1.11.

 
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