Science and real-world experience continue to generate evidence that expanding access to PrEP options and making choice possible, must be the guidestar in HIV prevention.   

Last week, NIAID Director Jeanne Marrazzo joined our Choice Agenda webinar, The More We Know: Evolving our understanding of PrEP for cisgender women, to present a re-assessment of the safety and effectiveness of PrEP options for women—including oral, vaginal ring, and injectable options. She discussed her recent publication in the Journal of the American Medical Association, HIV Pre-Exposure Prophylaxis with Emtricitabine and Tenofovir Disoproxil Fumarate Among Cisgender Women, which provides reassuring evidence that oral PrEP can reliably prevent HIV infection in cisgender women, even if it’s not taken daily. The results challenge the notion that cisgender women need to be “super-adherers” to achieve protection utilizing oral PrEP and that a one-size-fits all approach to prevention will not work. 

Dr. Marrazzo’s research and her comments represent a powerful voice among a chorus of champions for choice. During the same conversation, Joyce Ng’anga’a of WACI Health and the African Women’s HIV Prevention Community Accountability Board, a coalition of women and girls living and working in Africa who are united in calling for continued political and financial support for more choice in HIV prevention, updated on the recently launched Choice Manifesto. This global call to action demands investment in choice and calls for enshrining a woman’s right to choose and for African women and girls to lead the HIV response. 

At the same time, PEPFAR’s Scientific Advisory Board grappled with the potential role of injectables for treatment and prevention, including an update on the current late-stage efficacy trials of injectable lenacapavir, with results anticipated later this year. It’s no secret that scale-up of all current PrEP options (daily oral, vaginal ring and injectable cabotegravir) has been slower than ideal, especially in the countries and communities with high HIV rates that need it most. So as the HIV prevention community awaits the results of the PURPOSE trials for the twice-annual lenacapavir injectable, discussing how an additional injectable option might be introduced and what infrastructure is needed to implement this new product faster than previous PrEP options is critical.  

“We are 12 years since many of us gathered in Washington, D.C., at the international AIDS conference that was just two days after the FDA approved oral TDF/ FTC,” said panel moderator, AVAC Executive Director and PEPFAR SAB member, Mitchell Warren. “Twelve years later, it’s actually an abomination how poorly we have done as a global community, and when we think about equity in this country and around the world, oral PrEP is still only beginning to find its place. The dapivirine ring has struggled for a number of reasons and cabotegravir is struggling still, but I do want to highlight that it is going faster than we saw with oral PrEP, certainly in terms of regulatory approvals. And the question is how might we apply those learnings for lenacapavir in the next months and years?”

As policy, practice and budgets strive to keep up with advances in research, advocacy around choice becomes a cross-cutting priority—so that the promise of new options in HIV prevention won’t be squandered in siloed programs, or by poorly-planned supply chains, or because of disconnected policy decisions. Be sure to watch this space in 2024 as the African Women’s HIV Prevention Accountability Board, the Young Women’s HIV Prevention Council and the Global Key Populations HIV Prevention Advisory Group, amongst others, lay the groundwork to advance efforts to accelerate prevention options that people want and need. 

AVAC is gravely concerned with the Constitutional Court of Uganda’s recent decision to uphold the core provisions of the Anti-Homosexuality Act of 2023 (AHA) that was signed into law nearly one year ago. AVAC stands in solidarity with the LGBTQIA+ community in Uganda, and globally, in calling out this dangerous law. 

“We had hoped that the AHA would be repealed in its entirety, as it is a clear violation of the health, rights and humanity of the LGBTQIA+ community, and will undermine and reverse Uganda’s progress in HIV prevention, destroying community wellbeing and taking lives along the way,” said Angelo Katumba, Senior Program Manager at AVAC. “We’ve seen the direct link between criminalization and stigma and the devastating impact both have on HIV incidence. Even with the partial repeal of four provisions within the law, the AHA remains in place and will continue to drive people underground, discouraging the most vulnerable populations from seeking testing, treatment and prevention, and they will setback the fight against HIV.” 

The Anti-Homosexuality Act of 2023 (AHA) was brought to the Constitutional Court of Uganda for ruling on its legality late last year with advocates challenging the constitutionality of the law before the courts for months. Civil society advocates for LGBTQIA+ and HIV prevention have worked tirelessly over the years to change attitudes and policy in Uganda and around the world. The failure to nullify this law in full intensifies the threats faced by communities that have fought tirelessly for safety and recognition. Advocates are expected to repeal the ruling to the Supreme Court of Uganda.  

Uganda’s Anti-Homosexuality Act is one of the world’s most extreme anti-gay laws, enacted at a time when several other countries, including the US, are seeing the right to health undermined through legal action and anti-LGBTQIA+ laws on the increase. Today, the Uganda’s Constitutional Court even referenced the 2022 United States’ Supreme Court opinion on Dobbs v. Jackson Women’s Health Organization as part of its justification for the legality of the Uganda AHA.  

“It is deeply disturbing to see how Uganda’s attack on human rights and evidence-based public health is influenced by and coordinated with extremist views in the US and on the US Supreme Court,” said Mitchell Warren, AVAC’s executive director. “This is a staggering message that a rights-based approach to healthcare is imperiled in many countries by reactionary movements that are gaining strength from each other.”  

“We must stand up and fight back against these laws everywhere or we will never end any epidemic. We stand in solidarity with all allies and partners committed to turning the tide from hate and fear to global health equity for all,” Warren added. 

Since the Ugandan law was passed last year, the number of clients attending drop-in centres providing HIV prevention and treatment services to key populations, including men who have sex with men, dropped from an average of 40 per week to two.  

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.