Certain policy reforms are essential for effective HIV/AIDS responses, and Partnership Frameworks offer a unique opportunity to engage governments in these areas. Across all countries, evidence indicates that progress in these areas is tied to success in prevention, treatment and care of HIV/AIDS. Thus, the expectation is that all Partnership Framework Implementation Plans will explicitly address the policy issues outlined below and demonstrate government policy commitments to achieve progress.
In certain policy areas, governments have demonstrated outstanding leadership and are robustly implementing the relevant policies. In such cases, country teams need only communicate to OGAC why the issue is not a concern. Partnership Framework Implementation Plan policy baselines need not refer to all of the following areas, although they should all be discussed during the situation assessment. Partnership Framework Implementation Plans should prioritize policy reforms that can be achieved during the 5-year timeframe and that are considered to be most important to the advancement of programmatic goals and objectives within the country.
PEPFAR funding is intended to provide HIV/AIDS prevention, treatment and care services to target populations, and should not become a source of general revenue to the host government through customs duties, taxes (including VAT) or similar charges. If arrangements with the government do not routinely provide exemption from such charges for PEPFAR commodities, including pharmaceuticals, the USG team should explore with the government whether policy reforms are needed to ensure exemption.
- Address Human Resources for Health (HRH): Developing a sustainable health worker system is critical to addressing the HIV epidemic and strengthening the health care system as a whole. While there are common HRH challenges across countries, each country needs a unique human resource development strategy reflecting its own context, resources, and constraints. In considering a strategy, four critical components should be considered: (1) policy and financial requirements; (2) human resource management; (3) partnerships; and (4) leadership. In all cases, Partnership Frameworks should specifically address policies around task-shifting and innovative approaches to health worker training and retention. Quantifiable targets and results concerning new health workers (including professionals and paraprofessionals) trained and retained are essential.
- Address gender issues: Evidence demonstrating the special vulnerability of women and girls to HIV/AIDS is well established. In addition, there is a growing body of evidence that the gender dynamics of health-seeking behavior may adversely affect treatment and care outcomes for HIV-infected men. Partnership Frameworks provide a unique opportunity to advance policies that address these issues. Specific policy areas for consideration include:
- Addressing policy factors placing women and girls at greater risk for HIV infection, including policies related to concurrent partners, male norms, gender-based violence and high-risk behaviors of male partners. The approach should take a comprehensive view of these factors and strive to address facilitators and barriers unique to the country context in order to decrease the risk of HIV infection among women and girls.
- Addressing policy factors that influence men, including the role of men in terms of gender norms, access of men to treatment and, if applicable, opportunities for medical male circumcision.
- Addressing policy and legal reforms needed to increase gender equity in land and property inheritance rights. The following are strategies to increase women's legal rights generally, and property and inheritance rights specifically:
- Legal and policy interventions to safeguard the inheritance rights of women, particularly women in African countries, due to exponential growth in the number of young widows, orphaned girls, and grandmothers becoming heads of households.
- Institutional capacity-building of government ministries, universities, NGOs, and civil society to improve women's legal rights and indigenous women's access to justice.
- Legal and policy interventions that inform lawyers, prosecutors, law enforcement, and service providers on the legal rights of women, and encourage these groups to enforce these rights through the judicial and legal process.
- Working with governments and civil society to eliminate gender inequalities in the civil and criminal code.
- Addressing policy and legal reforms related to Gender-based Violence (GBV). The following are relevant to addressing GBV:
- Existence of National Anti-GBV/Sexual Violence Laws.
- Attention to GBV within National HIV/AIDS Policies.
- Policies related to provision of comprehensive health care services for victims/survivors of sexual violence, including post-exposure prophylaxis (PEP).
- Capacity-building of government ministries, institutions (education, health, legal, etc.), NGOs and civil society to prevent and respond to GBV.
- Policies and laws that address norms that perpetuate GBV.
- Address issues that impact children: Addressing the unique vulnerabilities of children infected and affected by HIV/AIDS is central. Key policy interventions that should be incorporated in Partnership Frameworks include those that address access of children to care and treatment, and those that provide protection for orphans and vulnerable children for a range of issues from inheritance rights to protection against violence to access to education, shelter, food and social support. Policies should also support efforts to scale up antiretroviral therapy for children, including integrating HIV prevention, care, and treatment for children into both existing antiretroviral therapy sites focused on adult care and into maternal, newborn and child health services.
- Ensure the implementation of policies that improve uptake of counseling and testing: Knowledge of HIV status is central to prevention, care, and treatment. Yet evidence-based practices to increase uptake are still not widely implemented. Counseling and testing policies should: enable voluntary and informed consent for all populations, including youth; enable the promotion of confidentiality and beneficial disclosure and guard against inappropriate disclosure; ensure non-discrimination in service provision, facilitating access for a range of population groups; and establish a monitoring and evaluation system that promotes an enabling environment. As epidemiologically appropriate, policies should include:
- Implementation and promotion of provider-initiated opt-out counseling and testing, especially in PMTCT settings;
- Task-shifting to allow appropriately trained and supervised lay workers to provide counseling and testing services; and
- Use of point-of-care rapid HIV testing.
- Improve access to high-quality, low-cost medications: Country policies have a dramatic impact on the availability of drugs and other commodities essential to the care and treatment of PLWA. Access begins with appropriate registration of antiretroviral and other important drugs and commodities. The national drug regulatory authorities (NDRAs) of partner countries should make every effort to work with drug manufacturers and assist in the timely registration of antiretroviral drugs, drugs for opportunistic infections, drugs for care and treatment, rapid HIV test kits, and other essential HIV/AIDS commodities that are purchased by PEPFAR. In the event that HIV/AIDS pharmaceuticals that can be purchased by PEPFAR are NOT registered in country, the country should provide import waivers to allow products that are available for purchase by PEPFAR to be imported without NDRA registration. For drugs receiving import waivers, PEPFAR should maintain due diligence to assure quality standards. Strengthening forecasting, procurement and logistics systems within the context of a strong partnership with country and other international partners to ensure a coordinated response is also critical.
- Address stigma and discrimination: Partnership Frameworks should describe plans to encourage leadership from governments to create non-discriminatory policies and to publicly support PLWA and their inclusion in development of policy, community interventions, and program evaluation. Policies should address causes and consequences of HIV-related stigma, and may support programmatic approaches such as: incorporating Prevention with Positives programs into the training of healthcare workers and lay counselors; utilizing PLWA as lay counselors and peer educators; and employing effective measurement and documentation of stigma in program plans.
- Strengthening a multi-sectoral response and linkages with other health and development programs: The HIV/AIDS epidemic requires a broad multi-sectoral approach. As a starting point it is essential that government policies support linkage of HIV/AIDS programs with other health programs including maternal and child health, safe motherhood, malaria and TB programs. Policies should also support linkage with other development efforts, for example food and nutrition, economic strengthening, and education, and relevant ministries should also be involved in Framework development. Secondly, the Partnership Framework should support policies to include civil society, including faith- and community-based organizations and groups of PLWA, in the development and implementation of HIV/AIDS programs. Finally, country ownership should be inclusive of the local private sector, whether in service provision or as a resource contributor in public-private partnerships (PPPs). The Partnership Framework should address where PPPs can play a role in leveraging both the resources and core competencies of local business, and should identify plans to seek PPP opportunities. Country teams are encouraged to consider offline consultations with headquarters on PPP opportunities as appropriate.