Key recommendations for the Global Fund Strategy 2023-2028
The International Network of People who Use Drugs and Harm Reduction International welcome the Global Fund Strategy Framework, which puts people and communities at the centre by maximising health equity, gender equality, human rights, people-centred public health and community leadership and engagement. As the largest donor for harm reduction in low-and middle-income (LMI) countries, the Global Fund is pivotal to efforts to end AIDS among people who use drugs by 2030. With a 95% funding gap for harm reduction in LMI countries and with people who use drugs stigmatised, criminalised and discriminated against in a majority of countries, it is critical that the new Global Fund strategy reflects on what needs to change, articulatesthe strategic shifts needed to leave no-one behind and defines how its new objectives will be translated into action. We call on the Global Fund Board to consider the following seven areas when writing the strategy narrative.
1. Meaningfully engage communities, including people who use drugs, in all Global Fund programmes and processes at all levels.
Programmes cannot simply be imposed on communities but have to both acknowledge and draw on the experience and expertise of people and communities, particularly of the most affected, marginalised and hardest to reach. In order to deliver on the objective to maximise engagement and leadership of the most affected communities, it is crucial that communities are involved in decision-making about Global Fund work at all levels (Board, Secretariat, regional, country, local, CCM), including development of the strategy from drafting stage to implementation and monitoring. This will require a clear definition and commitment in the Strategy, well-defined pathways of engagement (the ‘how’), followed by funding to build the capacity of communities and providing technical assistance for effective engagement and representation. In return, meaningful engagement and leadership will contribute to smarter programme design, efficient allocations, effective oversight of programmes for people who use drugs, better accountability and provide community feedback on implementation of Global Fund programmes.
2. Increase investment in HIV prevention, including for harm reduction and data revolution.
The Global AIDS Strategy 2021-2026 calls on governments and donors to significantly increase resources for prevention and harm reduction. Key populations and their sexual partners accounted for 65% of HIV infections worldwide in 2020 and 93% of HIV infections outside sub-Saharan Africa. New HIV infections among people who inject drugs increased in some regions. At the same time the coverage of harm reduction interventions is critically low and funding for harm reduction is in crisis.
It is therefore crucial that the Global Fund strategy uses all mechanisms possible to ensure that quality harm reduction services receive due priority within country grants, including dedicated funding for key- population-led programming. This will require a data revolution. Many governments still deny the existence of key populations, including people who use drugs and therefore do not collect, update or ensure the quality of data. This lack of current, quality data prevents the initiation and scale up of essential harm reduction services. It is critical that the Global Fund strengthens the collection, availability and use of disaggregated data for people who use drugs. This involves formally acknowledging that existing data from governments often underestimates the size and needs of people who use drugs. If governments cannot provide accurate, disaggregated data, other sources of data (civil society/community/academia) must be used and efforts to fill data gaps or improve available data must be supported financially.
3. Strengthen and fund community and key population-led service delivery.
Directly impacted communities cannot continue to be treated as ‘vectors’ of disease but must be valued, and therefore invested in, as key partners in the response. According to UNAIDS, as of 2019, community and key population-led HIV prevention programmes that exceeded 80% coverage in many countries were among the most effective. However, Harm Reduction International’s research found that less than 7% of the total international donor funding for harm reduction goes to community-led organisations. It is critical that the Global Fund supports and sustainably funds the delivery of services that work, are of good quality and are effective. We recommend that the Global Fund strategy adopts and operationalises the following 2025 Global AIDS targets:
- 30% of testing and treatment services to be delivered by community-led organisations;
- 80% of service delivery for HIV prevention programmes for key populations and women to be delivered by community-, key population- and women-led organisations;
This will require ensuring strong key population representation within CCMs and that key populationled organisations are grant recipients. Additionally, the Global Fund must expand its support to key population-led programmes in challenging political environments by increasing technical assistance, adapting implementation and financing approaches (e.g. boosting use of non-CCM applications), and supporting capacity development initiatives with a greater focus on community systems strengthening.
It is also critically important that the Global Fund improves its ability to track its own investment and expenditure in all aspects of key population funding, including tracking progress in funding community-led programming.
4. Establish a dedicated funding stream for key populations.
The Global Fund must commit to establishing a dedicated funding stream for key populations and grassroots organisations, with representatives from networks and communities involved in the discussions and development at all steps. Such a key population-specific funding stream would allow people who use drugs’ organisations and networks to determine how funds are used for community-led programming while strengthening community leadership and ownership in Global Fund processes. Funds could be facilitated through global key population networks, existing smaller funding mechanisms, or other means – as long as key populations are fully involved in the design and implementation of this funding stream.
5. Mainstream communities, human rights and gender and provide funding for advocacy.
Access to harm reduction, health and social services for people who use drugs is often thwarted by widely prevalent stigma, discrimination and punitive laws and policies, including criminalisation. Special attention must be paid towards removing human rights barriers, primarily decriminalisation, which drives people away from health services further compounding health inequities. It is imperative that the Global Fund Strategy mainstreams and scales up work on communities, human rights and gender across the Global Fund and at global, regional and national levels and adequately invests in long-term community-led and civil society advocacy for gender equality and to remove legal and policy barriers, including through multi-country and regional grants. We recommend that the Global Fund strategy supports the achievement of the global 10-10-10 targets and that 60% of the programmes support the achievement of societal enablers to be delivered by community-led organisations.
6. Reassess the sustainability, transition and co-financing policy.
The challenges and complexities of transitioning from international donor funding to domestic financing are particularly pronounced for harm reduction. Governments often lack the political will to fund harm reduction and, even where domestic funding is present, they may lack technical expertise in harm reduction programming and/or mechanisms for social contracting necessary to fund civil society, community and key population-led programmes. It is therefore crucial that the Global Fund does not reduce or withdraw funds from countries until domestic support for harm reduction is secured, rolled out and committed to for the foreseeable future. Additionally, the Global Fund must continue to fund civil society, community and key populations-led advocacy under transition grant applications and more broadly. This is crucial to driving domestic investment in high quality, humanrights based harm reduction approaches.
7. Keep focus on the three diseases.
Wide disruptions in services have been reported globally in HIV prevention and care as the result of national responses to COVID-19, such as lockdowns, transformation of service delivery points and even more limited access to services by key populations. A Global Fund survey assessing COVID-19- related disruptions in 38 countries found that services for sex workers and people who inject drugs had been reduced by approximately 20%. The new Global Fund strategy must stay focused on its primary goal: ending the three diseases. Additionally, there should be no diversion of resources from existing funds to respond to COVID-19, and this programme of work should only be expanded when new funds become available and should continue to focus on key populations and marginalised communities.
Harm Reduction International (2021), Failure to Fund: The continued crisis for harm reduction funding in low- and middleincome countries. London. Available from: https://www.hri.global/files/2021/07/06/HRI_Report_Failure_to_Fund.pdf
UNAIDS (2021), Global AIDS Update, Geneva. Available from: https://www.unaids.org/sites/default/files/media_asset/2021- global-aids-update_en.pdf
New research from HRI identified US$131 million in funding for harm reduction in LMI countries in 2019 – just 5% of the US$ 2.7 billion UNAIDS estimates is required annually by 2025 for an effective HIV response among people who inject drugs. Available from: https://www.hri.global/files/2021/07/06/HRI_Report_Failure_to_Fund.pdf
UNAIDS (2021), Global AIDS Strategy 2021-2026: End Inequalities. End AIDS. Geneva. Available from: https://www.unaids.org/en/resources/documents/2021/2021-2026-global-AIDS-strategy
Harm Reduction International (2020), The impact of multi-country harm reduction advocacy grant in South-East Asia. London. Available from: https://www.hri.global/files/2021/03/10/HRI-SE-ASIA-REPORT-PAGES.pdf