Every year the President’s Emergency Plan For AIDS Relief puts together a set of guidelines — a Guidance — on how to turn Country Operational Plans into the realities of setting, reaching and documenting goals to put epidemic-fighting money to use in some of the hardest hit countries.
It is a bureaucratic document with a bland title page that, but the alteration of one digit — 2012 to 2013 — could be indistinguishable from year to year. But before looking at this year’s, leaf through last year’s “COP” Guidance and you will find a shift has taken place. Look for references in last year’s — the 2012 document — to “Men Who Have Sex With Men.” You will find two — one referring you to another document. Look for the acronym MSM — but don’t bother to go past page 18 where it makes its one appearance, and where you also will find the single reference to “PWIDs” (People Who Inject Drugs) and the one mention of “SWs” (Sex Workers) under a bulleted item entitled”MARPS,” (“Most At Risk Populations.”)
In the 2013 document you will find five references to MSM — in a section on HIV testing and counseling, in a section on improving programs for “key populations,” in a section on reaching more men with services, and in a section titled “Cross Cutting Programs and Key Issues.” The document addresses “PWIDs” four times, as well as “FSWs” (Female sex workers) and a new category altogether TGs (transgender persons), four times each. The 2013 COP Guidance also loses an acronym — MARPs have been replaced by “key populations” which has a distinctly more human ring.
The Guidance for this year is longer than last year’s anyway, as it can be in alternate years when reporting requirements are more extensive, and the four-fold increase in mentions of key populations, and enlargement of scope don’t represent change on massive scale. But they are part of a shift in approach that appears throughout the document starting from the introduction. While the introduction of 2012’s COPS Guidance reviews its history, this one begins with a mention of the “powerful new goal” set by Secretary Hillary Clinton in her call for an “AIDS-free generation,” in which “no one infected with HIV ever develops AIDS.”
So, while in the 2012 COPS Guidance — put together in 2011 — suggests that PEPFAR teams in countries with the highest rates of disease, lower levels of treatment coverage and the lowest levels of Global Fund resources “should consider raising their budgetary allocations to diagnosis and treatment over time, as needed, and in discussion with S/GAC [Office of the Global AIDS Coordinator],” the Guidance for 2013 spells out a new policy, saying teams in those countries “must raise their year-over-year proportional and absolute budgetary allocations to treatment,” and that “deviations from this approach will require approval from GAC.” (The bold lettering is their addition too.)
Less concrete, but showing a similar shift in tone is the 2013 COPS Guidance approach to tuberculosis. While the 2012 document reiterates, sadly, that “Tuberculosis (TB) remains the most common cause of death among people living with HIV in sub-Saharan Africa,” before going on to discuss the need to “aggressively expand” intensified case finding, Isoniazid preventive therapy, and infection control. By contrast, the 2013 Guidance acknowledges that HIV-related tuberculosis deaths are preventable, with its assertion that “Ending HIV-associated TB among PLHIV is possible through a combination of widespread ART coverage, early identification and treatment of TB, isoniazid preventive therapy (IPT) and infection control activities.”
There is more of course, and how funding issues will affect all of it remains to be seen. You can find the COPS Guidances, and accompanying technical guidances here.