Visualizing Multisectoral Prevention: The DREAMS program theory of change

This is PEPFAR’s own visualization of how its AGYW programs can effect change. It’s notable for the definition of a care package that touches on the individual and her community, and for the way it defines a range of outcomes. There isn’t anything comparable for PEPFAR’s Key Population Investment Fund, which is infusing resources into a range of countries. Some of that funding is going for ART; for primary prevention, a theory of change linked to incidence is a must. AVAC is working with allies in KPIF countries to make this demand.

Excerpted from AVAC Report 2019: Now What?

Universal Test and Treat (UTT) Trial Results

As this table shows, the two trials that offered community-wide testing in both arms (SEARCH, TasP) did not find a difference in incidence between the arms. One explanation may be that the expanded access to testing and linkage in both arms had an impact in both intervention and control communities. The two trials that only provided universal testing in the intervention arm identified differences in incidence between that arm and the control arm.

There were other differences between the four UTT trials. As described below, PopART was the only trial with urban and peri-urban communities.

Excerpted from AVAC Report 2019: Now What?

AVAC Report 2019: With 2020 targets sure to be missed, we ask Now What?

Today, AVAC released Now What?, our 2019 annual report on the state of the HIV prevention field. Each year, the AVAC Report frames the most pressing advocacy issues facing the HIV response. At the threshold of 2020, it’s clear that global goals for HIV prevention will miss the mark by a long shot.

Though important progress has been made, the crisis UNAIDS called out in 2016 persists today with new infections around 1.7 million annually, a far cry from the 2020 target of fewer than 500,000.

So, we asked ourselves, Now What?, and answered with cross-cutting analysis and an advocacy agenda to match.

FIRST, we call for leadership that is bold, visible and activist, from the new head of UNAIDS, to houses of parliament to civil society coalitions: take uncompromising stances, demand accountability, speak out for intersectional issues of race, gender, class and climate. This work needs to be funded, full-throttle and fearless.

SECOND, we call for the use of today’s most recent evidence to guide new prevention targets that will pave the way for epidemic control. Clear milestones for the prevention research pipeline must be set. Investments over the past decades have provided us with the prevention options we have today, and much-needed new strategies are under now investigation. The field needs targets for prevention research that people can understand and influence.

THIRD, we call for multilayered prevention approaches that are centered around the person, not the virus. Since last World AIDS Day, we’ve learned again, perhaps most strikingly from the ECHO trial, about the dynamic needs of women for HIV and pregnancy prevention. The complexity of translating results into policy, bring renewed urgency to the need for comprehensive HIV prevention and reproductive health approaches. Multilayered prevention incorporates multipurpose strategies (i.e., products that prevent both pregnancy and HIV) within programs designed to address structural barriers (i.e., policy reform, transforming community norms, facilitating educational empowerment).

2020 will be a pivotal year—join us in calling on leaders, from the grassroots to global capitals, to make 2020 a turning point, when siloes come down, crises are transformed by innovation, and prevention is center stage in the fight against HIV.

Happy reading, and we’d love to hear how you answer Now What?

Follow the Money: HIV R&D Resource Tracking Reports 2018

Two new reports tracking resources for investment in HIV research and development are hot off the presses. The Resource Tracking for HIV Prevention R&D Working Group, a collaboration among AVAC, IAVI and UNAIDS, has launched its 15th annual report, HIV Prevention Research & Development Investments: Investing to end the epidemic, detailing overall 2018 investment and analysis of funding trends. And the Cure Resource Tracking Group, a collaboration between AVAC and the International AIDS Society, has also released its annual report, Global Investment in HIV Cure Research and Development in 2018.

These two reports represent powerful tools for advocacy. Both reports can be used to advance advocacy for a host of issues directly impacted by financial investments: the prevention crisis in the global HIV response is insurmountable without cutting-edge research and development and the scale-up of existing interventions, while cure research spearheads crucial innovation, and offers hope and inspiration to the millions affected by the epidemic.

Read on for links to downloads and key findings from each report:

Key Findings in Prevention R&D Funding

The report indicates an uptick after five consecutive years of declining investment. In 2018, funding for HIV prevention R&D increased by a modest 1.2 percent or US$13 million from the previous year, growing to US$1.14 billion. While the increase is encouraging, it’s the smallest net increase since 2003. This incremental growth impacted the various prevention categories differently. Investment increased for pre-exposure prophylaxis (PrEP), female condoms and prevention of vertical transmission (PMTCT) but decreased for voluntary medical male circumcision (VMMC), preventive vaccines, microbicides and treatment as prevention (TasP).

Despite the significant variation among these categories, donor trends remained more or less the same. Public sector (79 percent of overall or US$900 million) and philanthropic sector (14.4 percent of overall or US$164 million) investments remained mostly unchanged from 2017, while the private sector saw a 30 percent surge in investment, rising to at least 6.6 percent of overall funding or US$74.7 million in 2018. Actual commercial investment levels are higher as not all private companies responded to the Working Group’s request for data.

While US and European investment remained steady in 2018 compared to 2017, these figures are still the lowest in over a decade at US$829 million and EU$57.5 million, respectively. Outside the US, increases came from Australia, Canada, the European Commission, Germany and the UK, while declines were observed from Brazil, France and Japan. Global philanthropic levels also saw no change in 2018 and the Bill & Melinda Gates Foundation (BMGF) remained the preeminent funder in that category at US$149.7 million or 91 percent of all philanthropic sector investment.

In 2018, the US public sector and BMGF accounted for 86 percent of all funding. Citing the promise of the current R&D pipeline, the report cautions against this funding imbalance and the resulting impact on the longevity and sustainability of the field. Much hope can be drawn from the latest scientific strides: the ongoing efficacy trials for long-acting injectable PrEP and antibody mediated-prevention; the planned Phase III trial of a novel HIV vaccine regimen; and the dapivirine vaginal ring – another potential option for women. All of the above is contingent on sustainable financing and a diverse donor base that cushions against priority shifts from large donors.

Key Findings in Cure R&D Funding

The report estimates global investments in HIV cure research, which includes therapeutic HIV vaccines (for treatment) shows US$323.9 million in 2018, representing a 12 percent increase over the US$288.8 million invested in 2017. Compared to the US$88.1 million invested since tracking began in 2012, this is a 268 percent increase. The public sector accounted for the majority of funding, with the remaining US$19.7 million invested by philanthropies such as Aidsfonds, amfAR, the Bill & Melinda Gates Foundation, CANFAR, Institut Pasteur, Sidaction and Wellcome Trust.

We hope these reports will serve as tools for advocacy and inform public policy that accelerates scientific progress. We thank all of the individuals who contributed data to the report and who gave time and effort as trial participants.

If your organization is a funder or recipient of HIV prevention grants and we don’t know you already please contact us at avac@avac.org!

Activists on the Frontlines of the PEPFAR Planning Process: Week 2

Emily Bass is AVAC’s Director of Strategy & Content.

The three-week PEPFAR Regional Planning Meetings (RPM) wrapped up last week. Each week two included a fresh group of countries, some familiar patterns and some new ideas. You can check out a write-up of the first week here. One of the most important takeaways to consider is the need for ongoing attention to this work. It can’t be contained within these few weeks—PEPFAR engagement is a 365-day effort, and the wins at the RPM are sometimes fragile. Just one week removed from their COP review, Tanzanian activists went into action after language in the government’s circular on forced anal exams didn’t have a clear prohibition, as promised at the RPM, of the practice. And in Malawi, once activists, government and PEPFAR got home, conversations about seemingly settled issues continued. This isn’t a problem—it’s how the process works, and it’s why the work continues after the RPMs. Here are some additional areas to celebrate and watch with vigilance.

A View from the Zimbabwe Room: Preserving primary prevention, speeding TLD transition

Going into the RPM, Zimbabwe’s lean US$145 million program – as compared to, say, Kenya’s US$350 million program – wasn’t facing any cuts, but its funds were largely consumed by antiretroviral treatment and programming for orphans and vulnerable children (OVC). Growth seemed off the table, and by the end of the week both DREAMS and voluntary medical male circumcision (VMMC) – both key prevention strategies for AGYW and men respectively – faced US$2 million cuts. Zimbabwean civil society, represented by Diana Mailosi of Advocacy Core Team (ACT) and Walter Chikanya of Zimbabwe Community Health Intervention Research (ZiCHIRe) presented priorities developed via in-country consultations—many previously shared with PEPFAR. [The ACT is a key Zimbabwean partner in the Coalition to build Momentum, Power, Activism, Strategy and Solidarity (COMPASS Africa)—learn more about this work here]. These priorities included expanding the coverage of viral load testing; protecting and expanding VMMC; differentiated service delivery and accelerated transition to dolutegravir for treatment, also known as TLD transition. Advocates also pushed for the cuts to DREAMS and VMMC to be rescinded, and those dollars were restored to the programs.

After a week of public negotiation in the Zimbabwe room and in side-discussions, civil society also ensured a commitment to include screening for intimate partner violence (IPV) in all index-testing programs, a PEPFAR intervention to increase identification of people living with HIV. IPV screening is a key step to protect individuals who are asked to disclose their sexual contacts, biological children and needle-sharing partners as part of index testing.

In these meetings, other stakeholders make commitments, too, in response to advocates calling out gaps. This year, the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) stepped in with approximately US$5.5 million for viral load reagents. This became a priority as it became clear that without such a commitment, viral load testing would cover only 60 percent of those eligible. Activists also helped to win accelerated TLD transition, now set to occur in nine months rather than one year, and the Ministry of Health representative from Zimbabwe outlined an approach that centers on women’s choice—so that women of childbearing age who wanted to opt for DTG can do so whether on contraception or not. These are big wins and require ongoing vigilance from in-country advocates to ensure that providers, women and all PLHIV have robust treatment literacy and that the shelves carry the options for contraceptives and antiretrovirals needed to make informed choice a reality.

A Return to Treatment Literacy: It’s about time

The discussion of the Zambia program looked at many issues—including struggles with retention in treatment among certain age groups, persistently low rates of HIV testing within key population programs, and the need for programs to deliver condoms, lubricant, oral PrEP and more while protecting human rights, safety and security. For many in the room—which included Enock from Friends of Rainka and Fred from Network of Zambian People Living with HIV—one key win was the strong commitment to expand treatment literacy at antiretroviral treatment (ART) sites and in the community, led by and for people living with HIV. So many of today’s programmatic interventions, from index testing to TLD transition to PrEP uptake are best delivered with the support of peers who can provide correct, comprehensive information. This “treatment literacy” was once a mainstay of AIDS treatment—but funding for it fell by the wayside as ART clinics got medicalized, and it seemed a matter of just prescriptions and refills. It was never this simple; and today, countries and programs are finally returning to a fundamental element of truly effective public health programs: information from, by and for the people who are the true experts.

What’s Next

COMPASS coalitions in Malawi and Zimbabwe are following up and nailing down the fine points; in Uganda, HEPS, a longtime AVAC collaborator, is finishing up a report on how civil society can participate in PEPFAR’s site-level monitoring work, known as “SIMS”—a critical way to keep tabs on what is actually happening on the ground. Look for that report in the coming months. We’ll announce it on the P-Values blog, and you’ll be able to find it on avac.org/high-impact-prevention.

We’ll also be closely following developments in so-called “reboot” countries, where the Office of the Global AIDS Coordinator (OGAC) is demanding wholesale overhauls of the programs before any money gets spent. Mozambique, South Africa and Tanzania are all in this category; likewise, the transition to “indigenous” partners—local organizations versus international NGOS—will be something to track to ensure that resources go to groups with ground-level expertise, proven track records and the ability to deliver.

We’ll be watching—will you?

Describing—and Doing—the Work: AVAC in print and in the streets

In a special issue of Current Opinion in HIV and AIDS, published in January 2019, AVAC staff members Emily Bass, Laura Fitch, Anabel Gomez and Maureen Luba Milambe joined collaborators who work in advocacy and human-centered design to co-author two important articles. Each highlight our core business of bold, evidence-informed advocacy and action. The articles are:

These articles are behind a paywall for now. If you are interested in obtaining a copy and cannot get access, please contact us here, as AVAC is committed to sharing information and generating discussion without barriers. Publishing work like this in peer-reviewed journals is an advocacy tactic, as it puts critical ideas and histories into the “official” record. The good news is that the content in the articles is robustly reflected in our ongoing work and in our other publications.

In Demand creation for primary biomedical prevention: identifying lessons across intervention to inform daily oral preexposure prophylaxis programs, co-authors Emily Bass, Laura Fitch, Anabel Gomez and consultant Rebecca Loar, make the case that today’s primary prevention programming isn’t yet harnessing the potential of human-centered design, and that lessons from the rollout of voluntary medical male circumcision (VMMC) must be urgently brought to bear on newer strategies like PrEP. To find out more about how and why, check out the 2018 AVAC Report, and the work of the Prevention Market Manager.

In Civil society demand for accountability to achieve 90-90-90 targets: lessons from Eastern and Southern Africa, Maureen Luba and colleagues use case studies from Kenya, Malawi and Uganda, among other countries, to show how African AIDS activism has shaped the global response, and must continue to do so. These case studies capture work that’s opened the PEPFAR process to civil society engagement. These stories demonstrate how, through innovative North-South partnership, civil society has successfully unlocked what had been a closed and relatively unaccountable process for setting goals and allocating resources. This work is ongoing in many forms and on many fronts, including via the Coalition to Mobilize Power, Activism, Strategy and Solidarity (COMPASS) Africa, a multi-country activist effort that AVAC is proud to work on with allies in the global North and South. Learn more about this work and about PEPFAR engagement here.

Key Points from the Articles

From Demand creation for primary biomedical prevention: identifying lessons across intervention to inform daily oral preexposure prophylaxis programs:

The literature on demand creation for other HIV biomedical primary prevention strategies have much to teach anyone interested in seeing interventions reach the people who need them. For example, one study of the demand creation for VMMC from Zambia and Zimbabwe details the benefits derived from using demand-side thinking to segment potential end-users.
Studies on condoms suggest the risk failure if demand creation is neglected. The authors note falling investment in demand creation coincided with an increase in new HIV diagnoses in Burkino Faso. And other condom studies described problems such as a lack of market analytics and “inadequate sustained demand creation for targeted segments of the population including young people, men who have sex with men, and sex workers.”
The urgency behind all of these findings becomes clear when one considers reports like one cited in the article from a Kenyan demonstration project that found high rates of discontinuation of PrEP across key populations groups. But that does not mean people don’t want PrEP. It can’t be emphasized enough, VMMC saw significant gains after efforts at demand creation underwent a process incorporating demand-side thinking.
Even more chilling, the authors point out, “failure to integrate and act on the lessons learned from VMMC delivery could imperil future investment in PrEP and other key interventions… Indeed, unmerited statements about who will or will not choose to use adherence-dependent methods such as daily oral PrEP or a future microbicide are already being made with some regularity.”
Demand creation and services for delivering primary prevention must be designed with care, both must address the varied needs of people at risk of HIV. Until then, no one will know what works.

From Civil society demand for accountability to achieve 90-90-90 targets: lessons from Eastern and Southern Africa:

Relentless work from national and global advocates has resulted in critical gains in access to HIV treatment and prevention but has not been well-documented. This article begins to address that absence with several case studies. Together, they tell the story of advocates turning to innovative methods to gain the attention of decision-makers, mustering evidence and persuasive arguments, and bringing meaningful change.
This history makes the case for scaling-up the capacity of civil society as a priority to gain control of the epidemic.
The stories illustrate three unique and vital functions attributed to civil society:
a) Through innovative North-South partnerships, civil society has unlocked what had been a closed and relatively unaccountable process for setting goals and allocating resources.

b) Civil society invigorates discussions, replacing status quo assumptions with fresh analysis. This pressure creates new possibilities, improved strategies and greater impact from interventions.
c) Civil society’s continual demand for accountability and its ability to push an agenda led to institutionalizing a more open process for decisions on policy, programs and funding.
UNAIDS reports that missing the 2020 fast track targets (fewer than 500,000 new cases and fewer than 500,000 deaths from HIV annually) by only five years will mean a million more deaths and two million more cases by 2030. As the authors make clear, the unique role played by civil society is a matter of life and death. The power of advocacy must be leveraged with a greater commitment to fund and support it.

One Timeline, Two Stories, One Message: Putting trials and targets together

One problem with HIV prevention agendas is that they either live in an eternal present or in a far-off future. It’s “work with what we’ve got, which is condoms and VMMC and a little bit of PrEP”, or it’s “nothing can change without an AIDS vaccine”. The future depends on using what’s available, better and more widely, without ever losing sight of what’s in the pipeline.

As the figures below show, in the very same timeframe that the world will miss its critical target for incidence reduction and scale-up of primary prevention, several trials will release results that could change the future. 2020 will be a time of hope and reckoning. But only if the two stories start to be told as one.

Global HIV Prevention R&D Investment by Technology Category, 2000-2017

In 2017, reported funding for HIV prevention R&D decreased by 3.5 percent (US$40 million) from the previous year, falling to US$1.13 billion. The full report, HIV Prevention Research & Development Investments 2017: Investing to end the epidemic, is available for download. And all the graphics are available as well.

HIV Prevention R&D Trial Participants by Region in 2017

Participation of volunteers and the engagement of communities in which trials take place is essential to conducting HIV prevention research. In 2017, there were nearly 600,000 participants in HIV prevention research trials globally, mostly originating from sub-Saharan Africa, Europe, North America and Asia. A majority of participants were enrolled in research investigating TasP and PrEP, and while there are trials aimed specifically at men who have sex with men (MSM), transgender individuals and people who inject drugs, most of the studies do not specify the need to include members of key populations.

The full report, HIV Prevention Research & Development Investments 2017: Investing to end the epidemic, is available for download.

Investment in HIV Prevention R&D by Top Philanthropic Funders in 2017

Global philanthropic funding increased by 4.1 percent from 2016 levels and amounted to US$164 million, or 14.6 percent of overall funding. The Bill and Melinda Gates Foundation (BMGF) remained the largest funder and increased its contribution by 6.6 percent, to US$150.2 million. Wellcome Trust investment fell for the fifth consecutive year to an annual US$2 million.