The CHANGE data index grades government agencies on policies and funding impacting family planning, maternal and child health, and HIV & AIDS foreign assistance.
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2019_PEPFAR 2019 Annual Report to Congress
The President's Emergency Plan For AIDS Relief (PEPFAR) Annual Report to Congress provided an overview of PEPFAR’s accomplishments to date and discussed the program’s future directions. This report largely summarized high-level information that was known about PEPFAR programs. The report was responsive to need and based in evidence, as it referenced data that demonstrated the need for and efficacy of PEPFAR programs. The report did not mention human rights principles and was not gender transformative
but demonstrated awareness of gender norms in the discussion of layered packages in DREAMS programming.
2019_PEPFAR 2019 Country Operational Plan Guidance for all PEPFAR Countries
Released annually by the Office of the Global AIDS Coordinator, the Country Operational Plan (COP) Guidance outlines the plan for the global HIV and AIDS activities funded by the President's Emergency Plan For AIDS Relief (PEPFAR) and provides the basis for the approval of annual bilateral HIV and AIDS funding for partner countries. The 2019 COP Guidance was based in evidence and responsive to need. The document provided comprehensive guidance on the implementation of PEPFAR programs for all populations and, within this domain, discussed the importance of integrating cervical cancer screenings into care for women living with HIV as well as into layered DREAMS programming for adolescent girls and young women. However, much of this language could have been stronger and made mandatory. Depending on the program area, the Guidance was based in human rights norms, as it addressed PEPFAR’s role in protecting the human rights of populations that are criminalized or face stigma, such as the LGBTQI+ community. However, in other areas, the COP Guidance was not based in human rights norms, particularly the high targets for index testing within PEPFAR programs, which create an environment where human rights may be violated by grantees in pursuit of high target numbers and to avoid negative performance evaluations. It is critical that the PEPFAR COP Guidance be more specific about the subservience of targets to voluntarism and informed consent, ensure that this human rights mandate reaches the clinic level, and set more realistic targets to avoid harmful outcomes that will ultimately undermine PEPFAR’s goals. Lastly, the guidance was not gender transformative
but demonstrated some gender awareness, as it used “clients” and other gender-neutral language and discussed the impact of gender norms on numerous program areas, including DREAMS, stigma reduction activities, and programs to reach undiagnosed men. Overall, the COP Guidance moderately promoted SRHR through HIV and AIDS programs.
2019_PEPFAR Monitoring, Evaluation, and Reporting Indicator Reference Guide_MER 2.0 (Version 2.4)
The President's Emergency Plan For AIDS Relief (PEPFAR) Monitoring, Evaluation, and Reporting (MER) guidance included the indicators used to monitor and evaluate PEPFAR. All PEPFAR programs were evaluated according to their performance within these indicators and metrics, and this guide helped country teams and PEPFAR implementing partners understand the monitoring and evaluation process. In 2019, some of the MER indicators were updated, but it remains unclear what prompted these changes. The document included many HIV indicators, including indicators that focused on key population (KP) programming and programming for adolescent girls and young women. The updates to the indicators and addition of new indicators provided more detail and definitions about data to be collected, which demonstrated the guide’s responsiveness to need and basis in evidence. The indicators were mostly based in human rights principles, but it is important to note that there is no way to assure that the indicators were implemented in accordance with these norms. For example, all KP-relevant indicators included the "do no harm" mandate, but there was no explicit guidance beyond that. This limitation of the MER Indicators was particularly relevant with the Index testing indicator which reinforced the primacy of testing yield with no measurement for fidelity to human rights. Lastly, the guide was not gender transformative
but was gender aware, as it included a vague consideration of structural factors, such as “living and family situation,” that impact HIV and AIDS treatment and prevention. Measures of gender equity were not included as a required reporting element across relevant indicators.
2019_Protecting Life in Global Health Assistance Frequently Asked Questions and Answers_September 2019
The Protecting Life in Global Health Assistance (PLGHA) FAQ document was updated in September 2019 to provide clarity on the implementation of the May 2019 expansion of PLGHA as well as address questions and confusion from the 2018 Department of State’s PLGHA Six Month Review. The text of this document was similar to the 2018 FAQ document but included additional questions and answers (see questions 33-37). The document did not meaningfully discuss the impacts of the May 2019 expansion on HIV and AIDS. Similar to the 2018 FAQs, this document aimed to provide clarity on the implementation of the policy but left many questions unanswered. This document was somewhat responsive to need as it did include additional questions and answers based on confusion expressed by recipients of U.S. global health assistance, specifically regarding the definition of “financial assistance” and the applicability of the policy to technical assistance. The document was not evidence-based, was not grounded in international human rights, and was not gender transformative
, as it was based on the PLGHA policy which has been shown to be harmful globally, particularly to women and girls. PLGHA has also been shown to decrease access to HIV and AIDS services. Overall, this document provided a substantial hindrance to SRHR.
2019_State and USAID Agency Priority Goal Action Plan_HIV/AIDS
The Agency Priority Goals (APGs) for HIV and AIDS were released by both the Department of State and USAID to hold the President's Emergency Plan For AIDS Relief (PEPFAR) accountable through quarterly reporting that included details around the goals, strategies, milestones, indicators, and progress made towards controlling the HIV epidemic in FY 2019. The 2019 APGs set goals to scale up antiretroviral therapy (ART) services, voluntary medical male circumcision (VMMC) services, and access to HIV and AIDS services for priority and key populations, including men who have sex with men (MSM), sex workers, transgender people, and adolescent girls and young women (AGYW). This plan was responsive to need and based in evidence but did not explicitly mention human rights principles. The APGs were not gender transformative
as gender norms were not discussed. Overall, the document moderately promoted SRHR within this domain.
2019_State and USAID FY 2018 Annual Performance Report_FY 2020 Annual Performance Plan
This document shared the goals and timelines for FY 2020 as well as evaluated and summarized the progress of State and USAID in achieving various strategic goals in FY 2018. These goals included global health and gender-related programs across all three domains. The FY 2020 Performance Plan elements were included throughout the report along with reporting on standard indicators for each Performance Goal under the 4 Strategic Objectives. The Report discussed the joint efforts by the Department of State and USAID to achieve HIV and AIDS epidemic control within the third goal. However, there was very little discussion of the evidence used to inform the President's Emergency Plan For AIDS Relief (PEPFAR) programming or the human rights foundation for such programmatic decisions. The document did not provide a recommendation or detailed plan for the continuation of the success of HIV and AIDS prevention and treatment programming to date. This document was responsive to need but lacked a description of the evidence and human rights frameworks that guided PEPFAR programming. The Plan mentioned the disadvantages of a “gender-blind system” within Strategic Goal 2 but perpetuated such a system by not including a gendered lens throughout the document. As such, this report had little effect on the ability of the Department of State to implement HIV and AIDS programs that promoted SRHR.
2018_DREAMS Report: Dreaming of an AIDS-Free Future
The annual DREAMS report highlights the strengths, challenges, and future directions of the DREAMS program. The report was evidence-based and responsive to need, but lacked a clear gender transformative
stance. The DREAMS program does have concrete gender transformative
components, but they were not reflected in this report in a clear and substantial way. The report described harmful gender norms that affected HIV and AIDS prevention and treatment programs for adolescent girls and young women (AGYW), but did not mention how to address these barriers in a manner informed by human rights principles.
2018_PEPFAR 2018 Annual Report to Congress
The PEPFAR Annual Report to Congress provides an overview of the PEPFAR program to date and discusses future directions. The report was evidence-based, responsive to need, and included a description of how the Department of State will deliver on the mission of PEPFAR moving forward. The report also discussed factors that made HIV prevention and treatment complex for AGYW and for key populations; however, these programmatic concerns were framed within current constructed gender norms. The programming discussed in this report did not include gender transformative
components as a means to provide comprehensive HIV and AIDS services.
2018_PEPFAR 2018 Country Operational Plan Guidance for Standard Process Countries
Released annually by the Office of the Global AIDS Coordinator, the Country Operational Plan (COP) Guidance outlines the plan for PEPFAR-funded global HIV and AIDS activities and provides the basis for the approval of annual bilateral HIV and AIDS funding for partner countries. The 2018 COP guidance was comprehensive and provided updates that were evidence-informed, responsive to need, and based in human rights principles. The 2018 COP Guidance took a holistic approach to PEPFAR programs and discussed intersecting issues, such as: gender-based violence, post-abortion care, contraceptive access, and comprehensive HIV prevention programs. The COP Guidance illustrated gender as a cross-cutting issue within PEPFAR but should have included specific guidance to increase gender transformative
programming across PEPFAR countries.
2018_PEPFAR 2018 Progress Report
The PEPFAR Progress Report is issued annually to provide an overview of programs and illustrate PEPFAR priorities in the future. The report shared a program plan that was responsive to need and based in evidence and human rights principles. However, the document did not discuss gender norms or include a commitment to increase gender transformative
2018_PEPFAR Statement on Potential Safety Issue Affecting Women Living with HIV Using Dolutegravir at the Time of Conception
This press release contains PEPFAR's policy and technical guidance in response to data from a study in Botswana indicating a potential association between women of childbearing potential taking dolutegravir (DTG), an antiretroviral, at the time of conception and the risk of neural tube defects. The statement provided a nuanced overview of the data and concluded by issuing the guidance that all PEPFAR programs continue transitioning to a DTG-based regimen. The release recommended that "HIV-infected women who desire to become pregnant" should remain on efavirenz-based regimens until further data are available. The issuance of this statement was timely and provided an accurate explanation of the Botswana study preliminary findings; however, the Department of State's recommendation took away the choice of treatment from a population based solely on their ability or desire to become pregnant. This was in conflict with a human rights, individual-centered framework. It is also unclear from the press release if PEPFAR consulted with civil society or other relevant stakeholders before issuing this statement.
2018_Protecting Life in Global Health Assistance FAQs_September 2018
The PLGHA FAQs provided detailed guidance on the implementation of the expanded Global Gag Rule for implementing partners as of September 2018. The document was responsive to need in that it clarified areas of the policy that partners had expressed are vague or unclear, but the FAQs were not evidence-based or based in human rights principles. The FAQs included a PEPFAR-specific section that provided detailed guidance on the implementation and monitoring of the impact of PLGHA on PEPFAR programs, specifically within DREAMS. However, this discussion of PEPFAR, aside from the mention of DREAMS, did not discuss gender norms or include gender transformative
language. This section emphasized the importance of minimizing disruption of HIV and AIDS care and treatment and therefore received a higher score within this domain compared to the other two domains, Family Planning and Maternal and Child Health.
2018_Protecting Life in Global Health Assistance Six Month Review
The PLGHA Six Month Review summarized the PLGHA policy and identified solutions to challenges that had arisen in the process of PLGHA implementation. The review was responsive to need in that it addressed concerns expressed by partners who are required to implement the policy, but it was not evidence-based, based in human rights principles, or gender transformative
. The Six Month Review received a higher grade within the HIV and AIDS domain because it discussed the importance of addressing the impact of PLGHA on HIV and AIDS programs and assured that efforts are being made to track the impact of this policy through PEPFAR programming. Still, the Six Month Review substantially hindered the Department of State's ability to support comprehensive HIV and AIDS programs.
2018_State and USAID Agency Priority Goal Action Plan_HIV/AIDS
The Agency Priority Goals (APGs) for HIV and AIDS hold PEPFAR accountable through quarterly reporting that includes details around the goals, strategies, milestones, indicators, and progress made towards controlling the HIV epidemic. Released by both the Department of State and USAID, these reports are useful for government transparency and are responsive to need, and based in evidence and human rights. The 2018 APGs reported on challenges faced by HIV and AIDS programs, but did not provide clear strategies to address them. One such challenge was high HIV and AIDS rates among AGYW and key populations. The APGs mentioned the importance of promoting layered core packages of services for AGYW through the DREAMS program and increasing access to HIV and AIDS services for key populations. However, the APGs did not include indicators specific to either population or data disaggregated by gender as a means to highlight progress made in these areas. As a result, the APGs moderately promoted the ability of the Department of State to support comprehensive HIV and AIDS programs.
2017_PEPFAR Country/Regional Operational Plan (COP/ROP) Guidance 2017
The Country Operational Plan (COP) Guidance is an annual document released by the Office of the Global AIDS Coordinator. It outlines the plan for global HIV and AIDS activities funded by PEPFAR and provides the basis for the approval of annual bilateral HIV and AIDS funding for partner countries. The 2017 COP Guidance was evidence-informed and ensured continued community and government engagement in PEPFAR programs. It also discussed the intersection of gender-based violence with HIV and AIDS and the importance of including contraception and counseling into HIV and AIDS programs. This guidance moderately promoted SRHR because it was responsive to need and addressed the disproportionate impact of HIV and AIDS on adolescent girls and young women, men who have sex with men (MSM), female sex workers, and transgender individuals. The plan was gender accommodating, as it did not seek to dismantle existing gender differences and inequalities. Such guidance should instead outline how to change inequitable gender norms and dynamics and promote gender equity.
2017_PEPFAR Evaluation Standards of Practice (Version 3.0)
The PEPFAR Evaluation Standards of Practice was released to increase the quality of evaluations conducted by all PEPFAR implementing agencies. These standards emphasized the importance of evidence-informed evaluation planning and provided a detailed explanation of the ethics and human rights principles that should be incorporated in all PEPFAR-funded evaluations, particularly for "children, prisoners, pregnant women, and other vulnerable groups." Additionally, these standards laid the groundwork for adaptive programming and the continued commitment of all key stakeholders, including community members and government personnel, in PEPFAR programs. Although the Standards of Practice acknowledged that evaluations should be “context-sensitive” and “culturally relevant,” they did not include a gender transformative
component. There was no mention of the gendered power dynamics and cultural barriers that may prevent people living with HIV, sex workers, or lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI+) persons from participating in evaluations. Despite this, the Standards of Practice were responsive to need and were based in evidence. The Standards moderately supported the ability of PEPFAR programs to promote SRHR.
2017_PEPFAR Monitoring, Evaluation, and Reporting Indicator Reference Guide_MER 2.0 (Version 2.1)
The 2017 PEPFAR Monitoring, Evaluation, and Reporting (MER) Indicator Reference Guide provided guidance for monitoring and evaluating PEPFAR’s HIV and AIDS programs. The indicators were evidence-informed, based on human rights principles, and detailed the importance of sustained “district and community” engagement. The document included an extensive list of indicators for HIV and AIDS program evaluation, including the number of key and priority populations reached with specifically tailored HIV prevention programs, and the percentage of pregnant women living with HIV that receive antiretroviral therapy (ART) to reduce mother-to-child transmission. Though the Reference Guide listed sex workers, MSM, and transgender individuals as key populations, it did not address their distinctive needs when discussing how to evaluate interventions that were tailored for these populations. This lack of clarity can be harmful as evaluators may not understand how to meaningfully engage with these key populations during the evaluation, monitoring, and reporting processes. The indicators were somewhat gender transformative
, as they included a limited discussion of gender norms and related stigma, though this element should be standardized throughout the Reference Guide. The updates within this version of the MER Reference Guide were responsive to need and based in human rights norms and evidence, including WHO and UNAIDS indicators.
2016_Department of State Implementation Plan for the U.S. Adolescent Girls Strategy
The Department of State Implementation Plan for the U.S. Adolescent Girls Strategy was launched in partnership with three other U.S. implementing agencies as part of the first U.S. Global Strategy to Empower Adolescent Girls in 2015. This Plan moderately promotes sexual and reproductive rights (SRHR) because it discussed the importance of incorporating HIV prevention in all adolescent girls' empowerment programs, especially those that address girls’ political, civic, and economic participation and programs that increase peace and security. This Plan specifically acknowledged the relationship between girls who have undergone female genital cutting (FGC) and their increased risk of acquiring HIV. The Plan also mentioned HIV as a barrier to girls’ education and provided examples of existing Department of State programs that are responsive to need and grounded in human rights, including the President’s Emergency Plan for Aids Relief (PEPFAR). However, this Plan did not disclose how to support the needs of adolescent girls and young women (AGYW) who are living with HIV. It only discussed preventing HIV transmission to AGYW. The Plan is gender accommodating, not gender transformative
because it relied on existing gender norms and references unequal gender and age dynamics that put AGYW at a higher risk of HIV incidence.
2016_PEPFAR Country/Regional Operational Plan (COP/ROP) 2016 Guidance
The Country Operational Plan (COP) Guidance is an annual plan that outlines global HIV and AIDS activities funded by PEPFAR and provides the basis for the approval of annual bilateral HIV and AIDS funding for partner countries. The fiscal year (FY) 2016 COP Guidance was responsive to need and addressed the disproportionate impact of HIV and AIDS on AGYW and other key populations such as men who have sex with men (MSM), female sex workers, pregnant women and infants living with HIV, and transgender individuals. The programming was evidence-informed and promoted community and government engagement. Although the Guidance discussed the intersection of gender-based violence (GBV) and HIV and AIDS, it failed to strongly incorporate the positive impact that comprehensive and integrated sexual and reproductive health (SRH) services can have on reducing HIV transmission amongst key populations.