Sexual and reproductive health in HIV-related proposals supported by the Global Fund to Fight AIDS, Tuberculosis and Malaria
Manjula Lusti-Narasimhan a, Camille Collin a & Michael Mbizvo a
a. Department of Reproductive Health and Research, World Health Organization, 20 avenue Appia, 1211 Geneva 27, Switzerland.
Correspondence to Manjula Lusti-Narasimhan (e-mail: firstname.lastname@example.org).
(Submitted: 15 December 2008 – Revised version received: 11 July 2009 – Accepted: 26 August 2009.)
Bulletin of the World Health Organization 2009;87:816-823. doi: 10.2471/BLT.08.059147
In recent years, advocacy efforts have been targeted towards promoting the support of sexual and reproductive health within HIV-related proposals submitted to the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). In 2008, the independent Technical Review Panel of the Global Fund recommended that technical assistance to countries for proposal development place greater emphasis on potential opportunities for integration and synergy between sexual and reproductive health and HIV/AIDS, since HIV infection is acquired and transmitted largely through unprotected sexual intercourse or during pregnancy, childbirth and breastfeeding.1 Promoting sexual and reproductive health is therefore important for ensuring that people have the knowledge and ability to protect themselves against not only sexually transmitted infections (STIs), including HIV infection, but also, importantly, against unintended pregnancies. Moreover, people living with HIV who have access to antiretroviral therapy are leading longer, healthier lives and require services that meet their sexual and reproductive health needs while respecting their rights.
The Global Fund, which is one of the largest supporters of HIV/AIDS programmes worldwide, is committed to country ownership of programmes that evolve from national plans and priorities. Thus, investment by the Global Fund in sexual and reproductive health is essential in helping countries control their epidemic of HIV infection. Although HIV/AIDS programmes receive substantial funding from various initiatives and agencies, including the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the President’s Emergency Plan for AIDS Relief (PEPFAR), the Global Fund alone disbursed over 4 billion United States dollars (US$) between December 2002 and November 2008 to fund HIV control programmes. By the end of 2008, it had committed a total of 13.2 billion US$ for HIV control at the country level.2
We performed an in-depth analysis of the sexual and reproductive health elements contained in HIV-related proposals approved by the Global Fund. Our overall objective was to assess which of the interventions and activities being proposed by countries in the area of sexual and reproductive health would enable them to attain internationally agreed goals and targets for universal access to care for HIV and sexual and reproductive health. As the Global Fund model is country-driven, the knowledge base acquired through this analysis will provide a clearer understanding of the extent to which countries are prioritizing sexual and reproductive health initiatives to tackle their HIV epidemics. We also reviewed selected grant agreements to assess whether sexual and reproductive health is still featured among the main programme activities. Finally, we analysed the sexual and reproductive health indicators appearing in proposals and grant agreements to find out how countries monitor and evaluate such activities and whether the Global Fund evaluates their results for performance-based funding.
The process of submitting yearly proposals to the Global Fund began in 2002 (round 1), and rounds 2 to 9 have followed since. During such rounds, countries are invited to submit proposals to combat HIV/AIDS, tuberculosis and malaria. All proposals are evaluated by the Technical Review Panel, an independent body that recommends a selected few to the Board of the Global Fund, which then approves or rejects them.3 Once a proposal is approved, the grant process begins. This process is divided into two phases: phase 1 is the initial two-year period for which a grant agreement is signed with the principal recipient(s) in a particular country (usually the minister of health or finance), who will manage the implementation of the activities under the grant; phase 2 comprises from the third year to the end of the approved proposal and could last an additional one to three years. Towards the end of phase 1 a comprehensive review of programme performance is conducted and the Global Fund decides whether to fund or not fund the remaining proposal term (phase 2). To implement performance-based funding and to facilitate grant management throughout the life of a grant, the Global Fund tracks programme performance against targets by using a set of indicators. These indicators are selected based on the activities proposed by countries and are listed in the performance framework that is part of the formal and legally binding grant agreement.4
The Global Fund’s performance-based approach to providing grants is designed to ensure the efficient use of funds. Progress towards the objectives of a given programme and the use of grant funds are monitored by independent organizations contracted by the Global Fund to ensure that its funding is proving effective in the fight against the three diseases being targeted. A grant agreement5 negotiated between the Global Fund and the principal recipient establishes the terms and conditions under which the Global Fund may provide funding to the principal recipient to implement the activities described in the proposals. The principal recipient implements the programme as described in the programme implementation description included as Annex A of the agreement. The attachment to Annex A, also called the performance framework, sets forth the main objectives of the programme and its key indicators, intended results and targets.
For this analysis, the content of each HIV-related proposal and selected grant agreement was screened for the inclusion of sexual and reproductive health in accordance with the elements described in the WHO global reproductive health strategy to accelerate progress towards the attainment of international development goals and targets.6 This strategy includes five priority aspects: antenatal, intra-partum, postpartum and neonatal care; family planning, including infertility services; elimination of unsafe abortion; control of STIs, including HIV infection, reproductive tract infections, cervical cancer and other gynaecological conditions; and promotion of sexual health. Other cross-cutting elements listed in this strategy that were also considered for analysis included adolescents’ exposure to risk, access to sexual and reproductive health services, prevention of mother-to-child transmission (PMTCT) of HIV, gender-based violence, male involvement in sexual and reproductive health and the promotion of human rights.
We analysed a total of 214 original HIV-related proposals from rounds 1 to 7 submitted by 134 countries and approved for funding. Fig. 1 shows the distribution of the proposals that were approved, by Global Fund region. When more than one proposal from the same country was submitted in one round, all were integrated into a single analysis for the country. This resulted in a total of 210 analyses.
Fig. 1. Regional distribution of HIV-related proposals approved by the Global Fund in rounds 1 to 7
Our analyses focused on proposed programmes and activities, specifically on each proposal’s executive summary, goals, objectives, service delivery areas, activities and indicators. They did not include the background information provided in the proposals, such as the description of the national situation or of other strategies, initiatives and programmes targeting sexual and reproductive health.
We also selected a sample of 35 grant agreements. Nearly half (18) of them pertained to the three most highly-funded HIV-related portfolios for the African and Asian regions (the latter included eastern Europe and central Asia); the others (17) were picked at random. In this context, an HIV-related portfolio includes all HIV-related proposals submitted by a particular country in different rounds of funding. For example, the HIV-related portfolio for Ethiopia consists of three proposals (submitted in rounds 2, 4 and 7), worth almost US$ 950 million, for which three grant agreements were signed. The 18 grant agreements selected according to the described criteria were signed with Ethiopia, India, Malawi, the Russian Federation, Uganda and the Ukraine. The remaining 17 grant agreements were signed with Bangladesh, Cambodia, Cuba, Haiti, Kazakhstan, Nepal, Niger, Peru and the Sudan. When there was more than one grant agreement for the same country proposal in one round – this being the case when multiple principal recipients existed – a single analysis was conducted for all the grant agreements. Similarly, when a grant agreement for phase 1 and an amended and restated grant agreement for phase 2 existed, a single analysis was carried out for both.
The analysis of the grant agreements focused on the programme descriptions (Annex A) and on performance framework indicators (in the attachment to Annex A). The proposals and grant agreements were accessed on the Global Fund’s web site.7
Due to time restrictions, we did not analyse unfunded proposals, which may provide further insight into proposed sexual and reproductive health activities. We were also unable to analyse the percentage of the total proposal budget allocated to these activities. This information is not readily available in HIV-related proposals or grant agreements on the Global Fund’s web site.
At least one element related to sexual and reproductive health was included in 99% of the HIV proposals and 88% of the selected grant agreements. Within the proposals and grant agreements, different wording was used to refer to the five priority aspects and related elements of sexual and reproductive health featured in the WHO global reproductive health strategy to accelerate progress towards the attainment of international development goals and targets. For example, antenatal, intra-partum, postpartum and neonatal care were not always referred to using these terms but were found under descriptions of PMTCT programmes and activities. Nevertheless, we tried to categorize such information in an objective and consistent way.
The proportion of funded HIV-related proposals that included elements of sexual and reproductive health was remarkably consistent across all rounds (Fig. 2). Table 1 shows the number and percentage of funded HIV-related proposals that included broader and more specific sexual and reproductive health elements. At least 70% of the HIV-related proposals included one or more of the four broad elements of sexual and reproductive health: information, education and communication; condom promotion/distribution; diagnosis and treatment of STIs, and PMTCT. A lower percentage included the more specific elements of sexual and reproductive health within these broader categories. Of the HIV-related proposals, 20–30% included elements such as sexual health counselling, gender-based violence, and linking of voluntary HIV counselling and testing with sexual and reproductive health services; fewer than 20% of them focused on adolescent sexual and reproductive health, the rights and needs of people living with HIV in terms of sexual and reproductive health, and safe abortion services. Overall, most elements of sexual and reproductive health were contained in fewer than 40% of the HIV-related proposals.
Fig. 2. Percentage of HIV-related proposals approved by the Global Fund containing elements of sexual and reproductive health, by Global Fund round
Table 1. Sexual and reproductive health elements featured within 214 HIV proposals approved by the Global Fund, 35 proposals selected from among them, and the 35 corresponding grant agreements, rounds 1 to 7
Table 1 also compares the integration of elements of sexual and reproductive health in the selected HIV-related proposals that were funded and in the grant agreements signed for these proposals (n = 35). More elements of sexual and reproductive health were present in the HIV-related proposals than in the grant agreements. For example, the diagnosis and treatment of STIs were mentioned in 69% of the HIV-related proposals but in only 54% of the grant agreements.
In addition, many elements of sexual and reproductive health that were present in the HIV-related proposals were not included at all in the selected grant agreements. This was true, for example, for the promotion of male involvement in sexual and reproductive health, condom promotion/distribution for dual protection, and syphilis screening and/or treatment. Although we analysed a limited number of grant agreements, a consistent trend was noted.
Family planning, a key component of sexual and reproductive health, was poorly represented, although it was mentioned under different sections, such as information, education and communication on PMTCT and/or family planning, condom promotion/distribution for dual protection, and family planning consultations within PMTCT. Family planning consultations were described in only 11% of HIV-related proposals and in 6% of grant agreements.
A possible reason for the discrepancies observed between HIV-related proposals and grant agreements in terms of the inclusion of elements of sexual and reproductive health may be that grant agreements provide information that is disease-specific, concise and not detailed. Further study at the country level may help clarify some of these issues and reveal how countries prioritize their interventions after a proposal is approved. One might, for instance, interview principal recipients or members of the Country Coordinating Mechanism (CCM) who are responsible for proposal development and oversight.
A preliminary analysis showed that sexual and reproductive health indicators were present in most of the HIV-related proposals and in 83% of the grant agreements reviewed. HIV-related proposals included indicators related to all of the broader elements of sexual and reproductive health mentioned in Table 1. However, many indicators were either too broad or too narrow. For example, the one pertaining to the number of young people reached with HIV/AIDS education in school settings does not specify whether HIV/AIDS education deals with safe sex, the prevention of unintended pregnancy, the prevention of STIs or condom promotion. Conversely, indicators for PMTCT were too narrow. They included, for example, an indicator related to prong 3 of the global PMTCT strategy,8 namely a complete course of antiretroviral drugs given prophylactically to HIV-positive pregnant women. However, there was no indicator related to prong 2 of the PMTCT strategy, which is to prevent unintended pregnancy in HIV-positive women. To systematically measure and evaluate a comprehensive PMTCT programme at the country level, indicators for all elements of the PMTCT programme are needed. This example illustrates the more general problems involved in monitoring and evaluating HIV control programmes. Although countries may include PMTCT as a key activity in HIV-related proposals, in essence they will only be reporting on a few aspects of the broader PMTCT strategy.
This is the first comprehensive and systematic analysis of the sexual and reproductive health elements included in HIV-related proposals supported by the Global Fund. The Programme of Action of the1994 International Conference on Population and Development9 defined the prevention, diagnosis and treatment of HIV infection and AIDS as a core element of sexual and reproductive health services. In 2004, the 57th World Health Assembly adopted a comprehensive Global Reproductive Health Strategy10 that is firmly based on the Programme of Action from the International Conference on Population and Development. It called for rapid progress in improving sexual and reproductive health, including the control of HIV infection. Although fragmentation in funding for sexual and reproductive health and HIV control programmes has unfortunately occurred, this study clearly demonstrates that CCMs and national level stakeholders see the opportunity for funding programmes in sexual and reproductive health as a means to combat HIV in their respective national settings. The inclusion of sexual and reproductive health elements within HIV proposals provides opportunities to reduce unsafe sexual behaviour; promote dual protection for the prevention of STIs and unintended pregnancies; reduce STIs, including HIV; reduce maternal and neonatal mortality and morbidity; help people find out their HIV status, and ensure respect for the sexual and reproductive health and rights of people living with HIV.
In this study, 99% of HIV-related proposals and 88% of the selected grant agreements reviewed included at least one element related to sexual and reproductive health. Most of the HIV-related proposals and more than 80% of the grant agreements also include indicators related to sexual and reproductive health. At least 70% of the HIV-related proposals included one or more of the four broad elements of sexual and reproductive health: information, education and communication on sexual and reproductive health; condom promotion and/or distribution; diagnosis and treatment of STIs, and PMTCT.
Despite the above, certain important aspects of each of these elements were found to be missing or were under-represented in HIV-related proposals and grant agreements. For instance, within PMTCT, family planning, which is one of the four pillars of the global PMTCT strategy, was poorly represented. So were many of the other elements, such as preventing unintended pregnancy and STIs through the promotion of dual protection, preventing unsafe abortion, and preventing and managing gender-based violence. These areas have very important implications for HIV control programmes; they must all be at the heart of HIV-related proposals to ensure the rights and needs of people living with HIV, meet their fertility needs, prevent forced pregnancy termination, or provide services for victims of violence. Moreover, the absence of indicators for measuring such activities in most proposals and grant agreements points to a great missed opportunity and to the risk that these activities will not be implemented or pursued.
One must not assume that when proposed HIV-related programmes rate low in sexual and reproductive health elements, programmes related to such elements do not exist at the country level. The Global Fund is one partner among many that work with countries; other agencies or initiatives could be addressing gaps in this area. Nonetheless, the Global Fund has a crucial, catalytic role to play by helping countries integrate sexual and reproductive health in their HIV control programmes and by collaborating with partners who can further support countries in their efforts to stem the HIV epidemic and reach universal access targets.
The Global Fund could develop new proposal guidelines and include in its proposal forms questions that will lead CCMs to consider sexual and reproductive health when developing disease control programmes. For example, direct reference to sexual and reproductive health could be made in the questions on programme goals, objectives, service delivery areas, activities, cross-cutting interventions for health systems strengthening, and monitoring and evaluation. The Global Fund already encourages CCMs to conduct their own analyses on sexual and reproductive health. The generic guide for the rapid assessment of sexual and reproductive health and HIV linkages is listed on the Global Fund’s web site.11 In addition, the Global Fund should consider including more indicators on sexual and reproductive health in its monitoring and evaluation toolkit and make it clear that such indicators are acceptable within the performance-based funding framework.
Initiatives such as the Advocacy Summit on Global Fund round 7: Integration of Sexual and Reproductive Health (Geneva, Switzerland, December 2006)12 and the Mobilizing for RH/HIV Integration Initiative13 have provided countries with important support in preparing HIV-related proposals for the Global Fund that integrate sexual and reproductive health, as well as in advocacy efforts to get stakeholders at the national and global levels to prioritize sexual and reproductive health and HIV integration as a critical component of scaling up access to HIV/AIDS prevention, treatment and care.
Our analysis can boost advocacy efforts and further help countries in strengthening interventions for sexual and reproductive health within programmes that address HIV/AIDS prevention and care. It is critically important to focus on the sexual and reproductive health needs of those living with HIV or at risk of acquiring HIV infection and to invest resources and energy where they are most needed: not on the virus, but on human beings. ■
Competing interests: None declared.
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