The Coalition to build Momentum, Power, Activism, Strategy & Solidarity in Africa (COMPASS) has finalized a transformative and power-sharing approach to the governance and leadership of South-North coalitions. This new approach represents innovation that harnesses the power of the coalition. It is redefining and strengthening South-North relationships, and it offers a model for a field seeking to decolonize global health. The effort was built on a founding principle of power-sharing, and a commitment that COMPASS would ultimately be led by an African-based organization. Pursuing this vision has involved a multi-year, member-led process for creating a participatory governance framework. And it has resulted in reimagining COMPASS leadership, with African organizations in control.  

This case study explores the COMPASS approach that made these changes possible, the growing pains that informed the process for instituting change, and what others can learn from this experience.

Tune in for a podcast from AVAC!

Hear from COMPASS partners on the pioneering approach to power sharing, and from Dr. Madhukar Pai on the global context.

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What is COMPASS?

COMPASS was founded in 2017 as a data and evidence-based South-North civil society coalition. The coalition from its beginnings has been dedicated to advancing strategic advocacy campaigns to influence policies, programs and funding for the HIV response in East and Southern Africa, with a particular focus in Malawi, Tanzania, and Zimbabwe, and at the global level. In December 2023, Pangaea Zimbabwe signed a new two-year, $4.9 million grant agreement with the Bill & Melinda Gates Foundation as the new secretariat of COMPASS Africa, a role previously served by AVAC. In recent years, AVAC was part of a coalition-wide effort to develop a clear transition plan for COMPASS to be led by African civil society organizations.

Since 2017, with a grant from the Bill & Melinda Gates Foundation, 29 COMPASS partner organizations have launched dozens of campaigns and logged 31 significant advocacy wins, with many multi-year campaigns still in progress. To name just a few of the wins from COMPASS campaigns:

• Tanzania has changed the legal age of consent to access HIV services from age 18 to 15 and uptake has since seen a marked increase in testing, and increased awareness of HIV status among people 15 and older from approximately 60% to 82%.
• Zimbabwe and Tanzania piloted community-led monitoring (CLM), which funds communities to track data on HIV services and report back on progress toward country targets, and whether services are meeting community needs. CLM was so successful, PEPFAR expanded the program in Zimbabwe and rolled it out globally.
• Malawi’s once marginalized civil society now serves on technical working groups, influences the allocation of PEPFAR dollars and has become an essential partner to the national government in planning for HIV policies and programs. All three countries have secured funds for key population programs.

In the initial three years, results like these were delivered from a coalition with centralized leadership. Africa-based partners identified priorities, activated strategic relationships, navigated in-country challenges and executed co-created campaigns. US-based COMPASS partner organizations shared expertise on data and other technical assistance and leveraged access to global-level decision makers, with AVAC holding the primary grant and coordinating the coalition Secretariat. Coalition guidelines, partnership agreements and a robust process for co-developing strategy kept the coalition on track, but with success came challenges. 

Partners wanted more opportunities to share lessons learned from each other’s campaigns and to lend capacity to one another. Roles and responsibilities needed more clarity. Partners sought broader participation and transparency in coalition decision-making, in selecting new members, and having a more formalized governance. Partners also sought to improve the existing channels for sharing feedback and resolving conflicts transparently and equitably. 

Coalition members were ready to see power structures rearranged, redistributed, formalized and documented.

Ulanda Mtamba, a COMPASS member based in Malawi, put it this way: “For us partners in the South, it could feel like someone else is driving the vehicle from afar, while all the work is happening here.” 

These sentiments reinforced the founding plan to shift management of the primary grant to an African-based partner. Just as important, these considerations informed an effort to re-shape the coalition and create structures to support an African partner-led, multi-country, multi-continent coalition. 

Coalition Governance: Transparency, Participation and Trust

To create the needed structures and support for greater transparency and power-sharing among all partners in the coalition, COMPASS spent one year developing a governance manual that increases accountability and consistency, formulates the coalition structure, clarifies roles and responsibilities, and establishes a process for determining who holds the Secretariat. 

Thirty-six volunteers from across the COMPASS Africa responded to an open call to develop a comprehensive, participatory governance framework. The volunteers selected a two-chair leadership team and a steering committee to run the development process. 

“Partners were given a chance to select the leaders of the process. It was important that the process was community-led and participatory, so coalition members truly felt ownership of COMPASS. That itself was something very important,” said Francis Luwole, COMPASS country coordinator in Tanzania. 

As four working groups tackled issues such as sub-granting protocols, new membership and definition of roles and responsibilities, the steering committee focused on overall goals to be reflected in the governance manual: prioritize transparency; ensure accountability to COMPASS values; maximize opportunities for members to participate in decision-making; and ensure the country coalitions had ample opportunity to review, provide feedback and validate the manual. Through regular in-person and remote meetings, anonymous surveys and country visits, the co-chairs fostered a shared ownership of the coalition’s structure, purpose and future.

“Before now… there were no guidelines to answer questions such as ‘who we are, why we’re here, or who are we doing this for—there was no clarity in some of the roles and responsibilities of members in the coalition, especially for new members. The expectation now is for the governance manual to provide an outline of what the structure of the coalition is and the roles and responsibilities of all coalition members,” said Ulanda Mtamba.

The case study found that the participatory nature of the process ensured that diversity and inclusivity were at the forefront of the new COMPASS governance structure by allowing the opportunity for as many voices as possible to have their opinions and inputs considered. It also fostered a shared sense of ownership that empowered many coalition members to invest and believe in the change to create an African-led coalition. 

The 63-page governance manual now covers, among other things: member obligations and benefits; a protocol for conflict resolution; a selection process for new members; guidelines for meetings; sub-grant management; an M&E framework; a process for ending coalition membership and terminating the secretariat; and defined principles and core values. It also establishes a governance committee to serve as a decision-making and strategy-setting body with representatives from every COMPASS country, global partners, and key constituencies such as adolescent girls and young women, key populations and people living with HIV. The governance committee will be the primary leadership structure of COMPASS going forward, with coordination support from Pangaea Zimbabwe as the coalition secretariat.

“It speaks to inclusion. It speaks to equity. Our core values and principles have been reflected in the way we have structured the coalition. I’m very optimistic that, once we fully operationalize the governance manual, we are going to come up with something really beautiful, something that other partners or other coalitions may want to adapt,” said Maureen Luba, Malawi-based COMPASS member.

For more on the colonial legacy of global health, The Choice Agenda held a discussion examining the historical legacies and power dynamics that continue shaping global health. Watch the recording.

Shifting the Secretariat

As of December 2023, coalition member Pangaea Zimbabwe became the primary grant-holder and COMPASS Secretariat. In this role, Pangaea Zimbabwe will make sub-grants, convene the coalition, and be the primary point of contact for the coalition with its donors, support campaign tracking & evaluation, and administer the process that selects coalition leadership and new members. Dedicated teams comprised of in-country partners with expertise on data analysis and monitoring & evaluation will provide technical assistance across the coalition. AVAC is now a sub-grantee partner of COMPASS, continuing to coordinate the team that provides strategic and technical support to partner campaigns, provide status updates and background on the R&D pipeline for HIV prevention, support COMPASS partners in their engagement with PEPFAR and the Global Fund, and link the coalition to global platforms and advocacy initiatives. 

“From our earliest conception, we outlined a vision of collective power and shared decision-making that has been central to COMPASS’s success. For that success to be sustainable, AVAC and the COMPASS coalition at large pursued a future in which governance would be centered among African-based partners,” said Mitchell Warren. 

“Since 2017, we’ve been breaking new ground under COMPASS. We’ve expanded our networks and brought together the superpowers of seasoned advocates with diverse strengths to develop and share technical expertise and winning strategies,” said Imelda Mahaka, Executive Director of Pangaea Zimbabwe. “COMPASS has built a strong foundation based on collaboration, knowledge-exchange and trust that can and will accelerate innovative advocacy under African leadership.” 

Putting in the Time: Sustaining the partnerships 

The development of the manual and Pangaea Zimbabwe’s assumption of the Secretariat involved a phased, transparent multi-year transition plan to guide the handover of the secretariat and sub-grants management. AVAC and Pangaea Zimbabwe held weekly calls on the process, COMPASS partners contributed feedback to the plan, and the entire coalition was able to track milestones defined for the transition process.    

“Partners stressed to us repeatedly the importance of not rushing the process. All coalition partners needed time and opportunity to meaningfully participate in designing the new governance framework. Integrating this input into the governance manual was more important than finding quick solutions. We found the same was true in the process of transitioning the secretariat. Pangaea Zimbabwe wanted an appropriate on-ramp to get comfortable in their new role, with plenty of support and other partners also wanted to know how AVAC was supporting the relationship between Pangaea Zimbabwe and the project’s donor. We all invested time in building trust and confidence. For those in power who are now looking for a sustainable way to shift that power to others, my message to you is that you can’t just throw the bag and run,” said Justine MacWilliam, AVAC’s senior program manager. 

“This process has showed how to share power and take away the dominance of power. The desire for social justice has underpinned these values, the desire to equalize power, and the desire to contribute to something that is a legacy,” said David Kamkwamba of the Network of Journalists living with HIV (JONEHA) in Malawi. 

As COMPASS campaigns continue apace with a freshly inked grant from the Gates Foundation, coalition members, and Pangaea Zimbabwe are referencing the manual, testing its strength, making changes and sharing their insights. It is bold, careful and imperative work to build and use structures for collective power and effective action. 

“AVAC and COMPASS have set new benchmarks in effective civil society mobilization, advocacy and collaboration between global North and South. AVAC’s commitment to empowering African leadership within the coalition reflects a profound dedication to ensuring sustainability and maximizing impact. Coalition members are beginning a new chapter, founded on their inspired, tireless commitment to deepening the impact of COMPASS under African leadership,” said Uganda-based COMPASS member, Kenneth Mwehonge.

“This is giving hope, especially to global south partners, especially in these times when we are talking about decolonizing global health. It’s timely and strategic. It’s proving to each other our readiness to say ‘This is possible. We can have leadership in the Global South where the work is happening, where the epidemic is being fought,” said Luba.  

The COMPASS Coalition understands that doing business as usual will not advance HIV prevention or global health equity. And this new power-sharing model cannot turn the tide all by itself. But COMPASS partners hope fellow travelers who see the necessity of decolonizing global health will be interested in this model and will follow its progress. The work will certainly change and evolve based on what is learned in the months and years ahead, but there’s no going back.

Yesterday’s second full day at CROI 2024 in Denver included several studies presented on biomedical prevention, and the sum total of the message is clear: PrEP works, and choice works! Advocates have long called for choice—and now the science shows it works for individuals and supports declines in population-level incidence. Whether we’re talking about a daily pill of PrEP, injectable cabotegravir, or the dapivirine vaginal ring (DVR), from the US to Kenya, Australia to Uganda, people deserve choice! 

There was also more conversation about DoxyPEP, and how researchers and public health programs are balancing the public health benefits of reduced syphilis and chlamydia rates, with the threat of antimicrobial resistance, especially for gonorrhea.  

Here are highlights of the research!  

Tuesday’s Community Breakfast Club message, Living with HIV for a Lifetime—It’s Complicated, rang loud and clear.  

Allison Agwu from Johns Hopkins and Judith Currier from UCLA, talked about strategies presented on cross cutting health issues from cardiovascular disease to HPV that are affecting quality of life for PLHIV. And they talked about advances in treatment, such as the progress of long acting injectables, combination therapy with broadly neutralizing antibodies (bNAbs), and a long-acting pill—all of which are in the pipeline. 

But the advocacy around these field-changing issues echoes the very same priorities for HIV prevention, and the same priorities needed for global heath equity at large. Once new products are approved, they simply don’t reach the people who need them most, and offering choice is the key to reaching impact.  

“We are learning we have to figure out access in parallel with delivery. Clinics just can’t operationalize these innovations; we have to focus on this more and fund implementation science,” said Currier.    

“We need the a la carte of options. Something that fits in someone’s life now may not fit later,” said Agwu. 

The Breakfast session moderator, Annette Sohn from amfAR, talked about the advocacy still needed to ensure research is inclusive and data is gathered for all the populations that carry a disproportionate burden of HIV — another issue of great importance in HIV prevention.  “We still routinely have to tell researchers to stop combining data on men who have sex with men and transgender women.” For more on inclusive research for transgender people check out the The Transgender Manifesto.  

Evidence for making the most of prevention tools and the power of choice! 

Studies from three different continents delivered the message: enriched programs that support coverage and choice of prevention options will yield dramatic results.  

PEPFAR representatives pledged to take the findings of the SEARCH Dynamic Choice study into their programming decisions. Why? Just look at these results: Conducted in Kenya and Uganda, the study offered oral PrEP, PEP or injectable cabotegravir to both men and women, and an option to switch products. Prevention services were person-centered, including access to a clinician by phone at any time, clinic and community access to services, and counseling to develop personalized adherence plans. Coverage among study participants increased to 69.7% compared to 13% in the standard of care. Among people who self-reported HIV risk, coverage was 76%. Of the 56% who chose injectable CAB, 42% were not on any prevention product in the prior month. And perhaps most intriguing of all, 28% of participants used two different products during the study and the study arm ended with zero incidence of HIV compared to 1.8% in the control group—these numbers show why adding to the method mix expands the number of people who continue with prevention, even as their needs change. “CAB-LA is not simply replacing oral PrEP. It’s expanding the pie,” said Moses Kamya of Kampala’s Makerere University, who presented these data.  

Data from the INSIGHT cohort looked at PrEP uptake and continued use among more than 3,000 adolescent girls and young women in six African countries over six months. Participants who were shown test results measuring protective levels of PrEP in their bodies had higher adherence. The results: uptake was greater than 90%, at least 64% showed evidence of recent use. Investigators reported that “real time feedback” from these tests motivated adherence. 

In the US, a study conducted by Emory University suggests a direct link between population PrEP coverage and decreased HIV incidence. Between 2012-2021, PrEP coverage in the US ranged from 3.8% in West Virginia to 22% in New York, and rates of new diagnoses fell in association with increased coverage by state.  

Data from Australia analyzed HIV incidence among all people prescribed PrEP in Australia’s national PrEP program by tracking government subsidized PrEP prescriptions and antiretroviral therapy (ART) between 2018 and 2023. ART was used as a proxy for HIV acquisition, because both testing and treatment among PLHIV are high across the country. The data showed that low PrEP usage among gay men and other men who have sex with men, along with younger age and hepatitis C treatment was predictive of HIV incidence. Nicholas Medland who presented the data said “the overall incidence rate is low. As long as you can get PrEP out the door, it works at the population level.” 

The Deliver Study investigating efficacy of the dapivirine vaginal ring (DVR) among pregnant and lactating people (PLP) provided data from people in the second trimester of pregnancy. Building on earlier findings in later stages of pregnancy, investigators reported no increased rate of adverse outcomes compared to pregnancy outcomes in the community, and that “data support using DVR” as an HIV prevention option for PLP.  At this time, 11 countries have approved DVR, but this data is needed for regulators to approve its use for people who are pregnant. See our PrEP tracker for the latest on DVR initiations, regulatory approvals and more.  

DoxyPEP rollout: Ready? Or not? 

Yesterday we reported on DoxyPEP research, which showed reduced syphilis and chlamydia rates among MSM and TGW (though limited reductions in gonorrhea). There’s cautious optimism among researchers and public health programs about DoxyPEP, but questions remain about antimicrobial resistance (AMR) and whether expanding this intervention to cisgender women (where more research is urgently needed!) would further increase AMR globally. A round table discussion featured many angles.  

Chase Cannon from the University of Washington started with a history lesson—prophylaxis for STIs isn’t new. It was a program of the military in the mid-20th century for American soldiers but ultimately ended. Current data shows the clinical benefits of DoxyPEP. It reduces STI incidence significantly, it’s cost-effective and well-tolerated.  While concerns about AMR are real, taking DoxyPEP is less exposure to doxycycline than taking a full course to treat an STI. Alongside the clinical benefits, Cannon made the case that the community interest and uptake is hard to ignore. He pointed to qualitative research that DoxyPEP has played a transformative role in reducing stigma, sexual stress and anxiety in MSM.  

Beatrice B.S.L. Bercot countered with a more sober look, warning that AMR is already a problem in many European and African countries, and she’s cautious about wider global rollout. Her solution? “The damage is done” with gonorrhea drug resistance, the world has an urgent need for a gonorrhea vaccine. She also noted that while DoxyPEP is promising for syphilis and chlamydia, we need more surveillance and monitoring to better understand AMR spread. 

Stephanie E. Cohen from San Francisco’s Department of Public Health focused on implementation questions. She said DoxyPEP research and implementation is making the same mistakes made with PrEP—a lack of research for cisgender women and people assigned female at birth, and similar racial disparities in DoxyPEP use as seen with PrEP. Cohen cautioned that focusing on “risk categories” in marketing DoxyPEP may exacerbate disparities just as it did with PrEP.  

Cohen urged training for providers, marketing strategies that are non-stigmatizing, and new surveillance tools to monitor AMR. She called for better clinical guidance on STI screenings of people using doxy-PEP to identify other STIs. 

The rich data presented on Tuesday made clear the connection between science and the real-world. But Sunday’s opening session reminded advocates that many researchers who lead the science fail to understand that fundamental truth. During the Martin Delaney Lecture given by Frank Mugisha of Sexual Minorities Uganda, those who listened learned about the impact of draconian homophobic and transphobic legislation that is imperiling the lives LGBTQI+ communities in countries across Africa and in the US. To our dismay, many researchers attending the opening plenary chose not to listen. To learn more, please read this statement from the CROI Community Educator Scholars and Mentors, advocates and others who stand in solidarity.  

The 31st annual Conference on Retroviruses and Opportunistic Infections (CROI) kicks off this weekend, and runs from March 3-6 in Denver, Colorado. CROI is the go-to forum for groundbreaking science in the HIV field, and this years’ program is full of exciting new research.

At AVAC, we’re tracking data and discussion on long-acting, injectable PrEP; the dapvirine vaginal ring (DVR) in pregnancy; doxycycline as post-exposure prophylaxis (DoxyPEP) to prevent sexually transmitted infections (STIs); and the latest in HIV cure and control. We’re also very excited for this year’s Martin Delaney Presentation—Unveiling the Power of Uganda’s LGBTIQ Advocacy in Shaping HIV Response and Health Care Access—that will be delivered by Frank Mugisha of Sexual Minorities Uganda (SMUG) in Uganda and couldn’t be more timely. Be sure to check out the conference program.  

AVAC and partners have worked to follow and explain the research presented at CROI for many years, making the science more accessible, connecting the findings to community priorities, and ensuring civil society and affected communities are represented within the program, and ultimately the research. For those attending or not, this email shares ways to follow along and join in the discussion and debate. 

Follow Along

Be part of the conversation by following AVAC on X (Twitter) at @hivpxresearch for real-time updates using the conference hashtag #CROI2024, and be sure to sign up and follow our partner, Aidsmap, who will be reporting from the conference.

Community Breakfast Clubs

Join the CROI Community Liaisons, AVAC, the European AIDS Treatment Group, and partners for daily Community Breakfast Clubs. These virtual webinars feature researchers and advocates discussing some of the most consequential science being presented at CROI. They are open to all, CROI registrants and non-registrants alike. CROI registration not required.

Monday, 4 March, 7:00am – 8:00am MT (Click here to determine the time in your location.)
Spotlight on Social and Behavioural Science at CROI 2024
 
Tuesday, 5 March, 7:00am – 8:00am MT (Click here to determine the time in your location.)
Living with HIV for a Lifetime – It’s Complicated
 
Wednesday, 6 March, 7:00am – 8:00am MT (Click here to determine the time in your location.)
Research Roundup: Scientists and Advocates Offer Fresh Perspectives and Seasoned Analyses of CROI 2024 Research
 
Looking forward to seeing you at the daily Breakfast Club sessions and to working together to unpack the research and be sure it is applied! 

AVAC joins allies around the world to condemn in the strongest possible terms this week’s actions by Ghana’s lawmakers, who have passed legislation to further criminalize LGBTQ+ people.  

Homosexuality was illegal in Ghana before the passage of the so-called “Human Sexual Rights and Family Values Act”, which now furthers the criminalization of this community, making it a crime to identify as LGBTQ+, to form or fund LGBTQ+ groups, to advocate for LGBTQ+ rights or distribute advocacy materials, with multi-year jail terms attached. The new law also encourages communities to report LGBTQ+ people to authorities. Find more background on Ghana’s legislation here. 

“With these actions, Ghana is joining a hyper-fundamentalist global movement that uses anti-queer propaganda to strip away fundamental rights of citizens in a free society,” said Richard Muko, AVAC’s Senior Program Manager of Policy Advocacy, and member of the Key Populations Transnational Collaboration (KP-TNC).  

It is with grave alarm that AVAC re-states our concerns and demands from May 31, 2023—when Uganda’s President Yoweri Museveni signed into law the Anti-Homosexuality Act, a similar assault on citizens’ rights. 

“This is a growing, global tsunami. As with Uganda’s hateful AHA law, these anti-gay laws threaten lives and livelihoods, and the ability to connect key populations with the resources they need and deserve to prevent and treat HIV and to live their fullest lives. But the danger runs deeper than any one health threat. These actions represent a profound attack on free societies. We must unite to oppose these laws.  LGBTQ+ communities and other minorities must enjoy the full rights of citizenship, or these protections, which include access to healthcare, may well be imperiled for everyone,” said Mitchell Warren, AVAC’s executive director.  

Amnesty International has tracked a surge of intensifying hostility and discriminatory bills across 12 African countries in the last year, and in the US, 25 states passed anti-trans bills in 2023. Political leaders in the US and in countries across Africa are openly calling for LGBTQ+ people to be driven from public life, while US-based hate groups are providing support to proponents of this anti-civil rights agenda on the continent.  

“Singling out vulnerable communities as scapegoats, exposing them to violence and incarceration, is integral to instilling a climate of terror that enables divisive forces to consolidate power. It is imperative to stop these laws,” said Manju Chatani-Gada, Director of Partnerships & Capacity Strengthening  

AVAC urgently calls on Ghanaian President Nana Akufo-Addo to reject this bill. We are not alone. Here are statements from UNAIDS and The US Department of State. To add your voice, see guidelines here, prepared by LGBTQ+ activists working in Ghana.