TECHNICAL GUIDANCE FOR GLOBAL FUND HIV PROPOSALS

HUMAN RIGHTS AND LAW

Country and regional consultations on universal access in 2005 and 2006 showed that stigma and discrimination
against people living with HIV, marginalization of most-at-risk groups and gender inequality are major barriers to
universal access to HIV prevention, treatment, care and support, and are undermining the effectiveness of
national responses to HIV. In the Declaration of Commitment on HIV/AIDS (2001) and the Political Declaration on
HIV/AIDS (2006), governments committed themselves to overcoming legal, regulatory or other barriers that block
access to effective HIV prevention, treatment, care and support, medicines, commodities and services. They also
committed to intensifying efforts to enact, strengthen or enforce, as appropriate, legislation, regulations and other
measures to eliminate all forms of discrimination against and to ensure the full enjoyment of all human rights and
fundamental freedoms by people living with HIV and members of vulnerable groups, in particular to ensure their
access to education, inheritance, employment, health care, social and health services, prevention, support and
treatment, information and legal protection, while respecting their privacy and confidentiality; and to developing
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strategies to combat stigma and social exclusion connected with the epidemic .

The 2008 Global Report on AIDS showed that, whilst some progress has been made in addressing HIV-related
human rights issues, there is great need to do more. Whilst many national strategic plans acknowledge human
rights issues as critical, national responses are failing to address these obstacles through concrete programmes
of sufficient scale to have an impact. Programmes to support human rights and gender equality in the context of
HIV should be seen as an integral part of programming to achieve universal access to HIV prevention, treatment,
care and support. Where such programmes are not part of a national HIV funding proposal (or are only included
as a small scale programme), the proposal should be queried. It has become increasingly clear that responses
which ignore human rights are not effective from a public health point of view, are not acceptable from a human
rights point of view, and are not in line with the commitments of national governments in the Declaration of
Commitment (2001) and the Political Declaration (2006). National responses to HIV must change in terms of their
content, coverage and approach. How they should change is more clearly defined in three concepts promoted by
UNAIDS as follows:

Know your epidemic and your response and act on it, that is, tailor the response, through a
participatory process, to the specific epidemiological realities of the national and local epidemics. This
means no more generic national plans and responses, and most importantly shifting funding and
programming to the address the vulnerabilities and needs of the most affected by HIV. Depending on the
epidemic, this might mean women (including those in ongoing relationships), young people - particularly
young women and girls, men who have sex with men, drug users, and sex workers and their clients.

Address the drivers of the epidemic, that is, spend a sufficient proportion of HIV funding and
programming to try to change the structural causes of peoples vulnerability to HIV infection and impact.
This means finding an appropriate balance among programmes in the health sector, programmes to
empower communities and programmes aimed at social change. These might include those aimed at
empowerment and social change around male sexuality, gender equality and reduction of gender-based
violence, knowing your rights and laws, the reduction of stigma and discrimination against key
populations, and social and ecomonic empowerment of those affected (orphans, caregivers, families).

Achieve universal access to HIV prevention, treatment, care and support, that is, determine who is
in need of HIV prevention, treatment, care and support and put in place programmes to overcome the
obstacles to accessing these such as poverty, age, sex, sexual orientation, legal status, geography. It
also means governments can no longer avoid the controversies associated with gender equality, access
of young people, men who have sex with men, drug users, sex workers and prisoners, migrants, refugees.

1 th
United Nations (2006). Political Declaration on HIV/AIDS. United Nations General Assembly, 60 Session, 2 June 2006.
New York.
 This also means giving greater support to a wide array of HIV prevention programmes, depending on the
epidemic, for both general populations but also for most at risk populations.

These concepts and frameworks for action align with the priorities of the Global Fund on AIDS, Tuberculosis and
Malaria (the Global Fund). The Technical Review Panel proposal review criteria include consideration of the
soundness of approach of each proposal. This includes whether the proposal addresses issues of human rights
and gender equality, including contributing to the elimination of stigmatization of and discrimination against those
infected and affected by tuberculosis and HIV/AIDS, especially women, children, and other vulnerable groups2. In
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addition, at the 16 Board Meeting of the Global Fund (November 2007) the Board recognized the importance of
addressing gender issues, with a particular focus on the vulnerabilities of women and girls and sexual minorities,
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in the fight against the three diseases.

Addressing issues of human rights (including specific programmes to strengthen the rights of vulnerable
populations) in the context of HIV entails three things. First, human rights principles of non-discrimination,
participation and accountability must guide all HIV planning and service delivery, with the result that those
affected participate and HIV services are made available, accessible, acceptable and of quality to everyone in
need regardless of their sex, age, ethnic origin, and social, economic or legal status. Secondly, national HIV
responses must include specific programmes to support human rights and an enabling legal and social
environment. Thirdly, a human rights approach calls for a particular emphasis on ensuring that the most
marginalised and most at risk populations benefit from the national HIV response.

1. Evidence of continuing gaps

g aps in the response
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(a) Evidence from the 2008 Report on the Global AID S Epidemic
Countries are failing to implement basic programmes to remove HIV-related human rights obstacles to effective
HIV responses:

1/3 of countries still do not have legal protection for people living with HIV against HIV-related
discrimination. Of those countries that report that they do have such laws, most reports indicate that they
are not sufficiently enforced to offer real protection.

Only 44% of countries report that they have amended policies and legislation to be consistent with
national HIV/AIDS control strategies/policies.

15 countries in sub-Saharan Africa have adopted overly-broad laws that criminalize HIV transmission and
provide for mandatory testing and disclosure. Such laws can also be found in other regions.

74% of countries report having policies to ensure equal access to HIV-related services for populations at
risk. However, 57% of these still report laws or policies that impede access to HIV services for vulnerable
groups.

Coverage of prevention activities for most-at-risk groups remains particularly low in countries with
concentrated epidemics.

Only 22% of countries report using performance indicators or benchmarks to measure compliance with
human rights standards in the context of their HIV efforts.

Of the 136 countries that completed the UNGASS National Composite Policy Index (NCPI) in 2008:

45% of countries report having trained/sensitized members of the judiciary (including labour
courts/employment tribunals) to HIV and AIDS and human rights issues that may come up in the context
of their work

46% of countries report legal aid systems for HIV and AIDS casework available in the country

40% of countries report that private sector law firms or university-based centres provide free or reduced-
cost legal services to PLHIV

Where countries report some sort of programme, there is little or no information on whether they have actually
been budgeted, costed and implemented, or on the scale and quality of the reported programmes. These
responses suggest that concrete prorgammes to support human rights in the context of HIV are not being
sufficiently implemented.

2
TRP Proposal Review Criteria, available at: http://www.theglobalfund.org/en/files/about/technical/TRP_TOR.pdf
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http://www.theglobalfund.org/en/files/boardmeeting16/GF-BM16-Decisions.pdf
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Available at: www.unaids.org
(b) Evidence from recent analyses of Global Fund pr oposals:
A recent review by AIDSPAN of successful Global Fund proposals from rounds 1-7 in Sub-Saharan Africa found
that programmes to address the underlying vulnerabilities of women were the least frequent activities of those
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identified activities which were gender responsive . More specifically, only 3 proposals (one percent) included
activities promoting the legal and human rights of women. This analysis suggests that countries are failing to
respond to the guidance of the Global Fund in developing sound proposals which address issues of human rights
and gender equality.

2. Elements to be considered
considered in the situation analysis (both of the ep
epidemic and the response)

Whether the proposal focuses on integrating human rights principles across different service delivery areas or on
specific programmes to support human rights and law, or both, the following elements should be considered in the
analysis of major constraints and gaps:

Epidemic
Does the analysis of the epidemic in terms of vulnerability to infection and to impact focus on population
groups based on sex, age, income, ethnic and racial background, location, marital and legal status and
identify their needs in terms of prevention, treatment, care and support?
Does the analysis of the epidemic identify (through a participatory approach) the reasons for the
occurrence of HIV infections among these different groups (e.g. inability to reach them with prevention
information, services, commodities due to geography, legal status, age, sex, discrimination, mobility, or
resource constraints; lack of social mobilization and support to change/avoid risky behaviours)?
Is lack of confidentiality and/or HIV stigma and discrimination preventing people from:
o Getting tested and counselled for HIV
o Disclosing their status to their sex or drug using partners
o Adopting safer sex behaviours and/or measures to prevent mother to child to transmission?
Is the status of women preventing women and young girls from:
o Having sufficient access to HIV information, sexual education, life skills training
o Having independent access to HIV prevention testing, counselling, and commodities and to
reproductive health services
o Being able to negotiate abstinence, fidelity or safe sex in relationships
o Being able to avoid sexual violence or coercive sex inside or outside marriage?

Response
Are the groups most affected by the epidemic being reached by current HIV programmes (e.g. women,
men who have sex with men or other sexual minorities sex workers, drug users, young people, mobile
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workers or migrants, prisoners, orphans )?
Does law and policy support the achievement of universal access (laws and policies on non-
discrimination based on HIV; equality of women inside and outside marriage and protection from violence;
decriminalisation of sexual acts between consenting adults; allowing harm reduction, etc.)?
What steps are being taken to overcome the human rights related barriers to the roll-out and uptake of
HIV prevention, treatment, care and support (e.g. campaigns and laws against stigma and discrimination
and violence against women, campaigns against harmful gender norms, legal aid, training of service
providers on non-discrimination, law reform, integration of HIV into primary care and reproductive health
services, elimination of school fees, implementation of HIV education and life-skills in schools,
programmes on social mobilization and education around HIV-related rights and law)?

5
Aidspan report (2008) Do Global Fund Grants Work for Women? An Assessment of the Gender Responsiveness of Global
Fund-Financed Programmes in Sub-Saharan Africa. Available at: http://aidspan.org/documents/aidspan/aidspan-gender-
paper-en.pdf
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UNAIDS Practice Guidelines on HIV Prevention identifies 14 key audiences for prioritized HIV prevention measures. These
audiences are: (i) general population, (ii) injecting drug users, (iii) healthcare workers, (iv) men, (v) men who have sex with
men, (vi) people living with HIV, (vii) populations of humanitarian concern, (viii) pregnant women, (ix) prisoners, (x) recipients
of blood or blood products, (xi) sex workers. (xii) transport workers and commercial drivers, mobile populations, uniformed
services personnel and clients/non regular partners of sex workers, (xiii) women and girls, and (xiv) young people.
 Has a plan been developed to measure/secure equity between women and men, rich and poor, young
and old, urban and rural, ethic and racial groups in access to HIV prevention, treatment, care and support?

If data on these issues is not available, this is itself an indication that human rights issues are not being
addressed in the context of the response to the HIV epidemic. Lack of data on the above issues also strongly
suggests that the country response is not appropriately matched to the epidemic. Matching and prioritizing the
response entails identifying the populations that are most at risk and vulnerable to HIV by measuring the extent to
which new HIV infections are occurring within these populations. Responding to the epidemic also requires
identifying the extent to which vulnerable populations are consulted and engaged in tailoring the response for their
communities. Where key data regarding prevalence and access to HIV prevention, treatment, care and support is
not available for vulnerable sub-populations, the proposal should include activities to improve collection of
information as a matter of priority, including information on human rights and law related issues, that is
disaggregated according to vulnerable populations.

3. Rationale for including

including support to human rights and/or in the proposal

Support for HIV-related human rights should be included in the proposal because HIV-related human rights issues
have been identified by most countries as an obstacle to achieving universal access to prevention, care,
treatment and support. Responses to HIV that are based on respect for human rights and enabling legislation
both serve to help fulfil national human rights obligations and are more effective as they ensure a response
targeted to the national and local particularities of the epidemic in the country. For example, evidence from the
2008 Report on the Global AIDS Epidemic suggests that countries that have non-discrimination laws against most
at risk populations have achieved higher HIV prevention coverage.

The Technical Review Panel is also looking for evidence of coordination with multilateral and bilateral initiatives
such as the WHO/UNAIDS initiative to achieve universal access to prevention, treatment, care and support by
2010. This is one of the criteria for assessment of proposals under the general heading of potential for
sustainability and impact. The Global Fund is again encouraging applicants in Round 9 to consider expanding
their work on and/or introducing programmes focused on alleviating barriers to universal access to services by
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key affected populations . These barriers often take the form of stigma and discrimination, criminalization, or law
enforcement that impedes access.

4. Link between human rights and law and the proposal

proposal objectives
bjectives

The overall objectives of the proposal may or may not explicitly mention human rights or law. However, attention
to human rights is essential for the achievement of any objective, whether explicitly human rights related or not.

If the proposal objectives do not explicitly mention human rights, the proposal should still demonstrate how
attention to human rights will help achieve the overall objectives. This may include:
making the legal and policy environment more supportive (e.g. reforming/enforcing legislation to protect
womens property rights, equality in marriage; de-criminalising homosexuality; revising drug laws to allow
for harm reduction, etc.)
training service providers on issues such as confidentiality, informed consent and non-discrimination.
inclusion of target group in programme design, implementation and evaluation.

Example: if the proposal objective is to improve the access of sex workers to HIV services, the proposal could
include the following human rights related activities:
inclusion of sex workers in the design, implementation, monitoring and evaluation.
social mobilisation among sex workers to empower them regarding their human rights, including rights to
freedom from violence and trafficking and right to health services, including HIV services
training for law enforcement officers on the rights of sex workers to non-discrimination and non-violence

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women and girls, youth, men who have sex with men, injecting and other drug users, sex workers, people living in poverty,
prisoners, migrants, people in conflict and post-conflict situations, refugees and displaced persons. See Global Fund Round 8
Guidelines for Proposals, which are unchanged for Round 9.
 law review/reform with a view to improve the legal status of sex workers, and
provision of legal assistance to sex workers.

Example: if the proposal objective is to increase access and uptake of PMTCT, the proposal could include the
following human rights components:
activities to ensure informed consent and confidentiality of care (training of health care workers), to
reduce stigma and discrimination (e.g. around breast-feeding), support for couples counselling, support
for referral services, (e.g. services that address violence against women).
activities to make PMTCT available, accessible, acceptable and of quality for women from most at risk
groups through their participation in programme design and implementation (e.g. sex workers and
injecting drug users).

Proposals may also include explicit human rights related objectives which may include, among other things:
reduce stigma and discrimination against people living with HIV in different settings (e.g. health care
setting, school, workplace, general public).
increase the knowledge of people living with HIV and/or most at risk of infection of their human and legal
rights in the context of the response to the epidemic.
The proposed activities should in this case include programmes directly addressing these issues.

5. How to define and quantify the target population(s) (also

(also consider gender and equity issues)

Rights-based approaches to HIV call for a particular emphasis on ensuring that the most marginalised and most
at risk social groups benefit from the national response. The situation analysis should identify these groups.
Round 8 proposals often failed to include an adequate analysis of the epidemic, its drivers, how the current
response is addressing these, remaining gaps and how (in concrete terms) the proposal addressed gaps in the
response. A rights-based approach provides a framework for addressing these issues through attention to the
principles of participation, information, non-discrimination, and accountability.

The Global Fund is asking applicants to describe how the proposal adheres to the principles of equality and
fairness in the prioritisation and selection of target populations. Non-discrimination and substantive equality
require that programmes be tailored to the specific needs of different groups (rather than adopting a blanket
approach) in order to address underlying causes of inequality in terms of access to services or impact of
programmes. The proposal should also cite data regarding the levels of access to services of different populations,
identify discrepancies or gaps in access, and articulate objectives and activities to address unequal access. The
proposal should also state whether particular groups should receive prioritised access to services and, if so, the
rationale for this.

6. Main (important) activities to be considered

Integrating human rights into other service delivery areas

In order to uphold the human rights principles of participation, accountability, and empowerment, and the
inclusion of people living with HIV and other affected groups (such as women, youth, sex workers and
people who use drugs) in programme design, implementation, and evaluation are essential.
Integrate HIV-related human rights and gender training (non-discrimination, confidentiality, informed
consent) into the curricula of healthcare and social workers. Specific activities and funding for technical
assistance and capacity building on human rights may also be warranted, particularly for Principal
Recipients and Sub-Recipients who will be responsible for implementing human rights-based
programmes.
Expand or implement comprehensive prevention programmes, including positive prevention strategies
by and for people living with HIV.
Ensure that prevention and PMTCT programmes include empowering messages that emphasise joint
sexual decision making and responsibility for sexual outcomes (pregnancy, health) and engage men in
couples counselling and testing.
Integrate treatment and human rights literacy initiatives by networks of people living with HIV into HIV
treatment scale-up.
 Integrate human rights messages into behaviour change communication programmes, including mass
media, school-based, and community outreach programmes.

Examples of specific programmes to support human rights in the context of HIV. These can be additional activities
under several service delivery areas, including policy development and civil society capacity building
Know your rights/laws campaigns and social mobilisation. These can be targeted to people
affected by HIV and/or for specific populations such as women, sex workers, MSM and mobile
populations. These programmes are an effective way to capacitate community to draw down their rights
into concrete demands for access to prevention, treatment, care and support, and to compel changes and
improvements in laws and policies.
Law review and reform, and work with police and judges to address barriers to HIV prevention.
Review and reform of legislation and enforcement practices by police and judges particularly those that
impede (a) the distribution of sexual health education and information, (b) access to HIV testing and
counselling services (which may be impeded by fear of prosecution under laws that criminalise HIV
transmission or fear of privacy violations and discrimination), (c) the provision of condoms, sterile injection
equipment and other harm reduction measures, and (d) work with members of vulnerable populations,
including sex workers, men who have sex with men, drug users and prisoners.
Legal aid/assistance in the context of HIV response. An important means by which individuals affected
by HIV or vulnerable to HIV can enforce their rights through formal and informal dispute resolution processes,
including strategic litigation to compel legislation to protect people from HIV-related discrimination in different
contexts, and/or to provide access to prevention, treatment, care and support.
Campaigns for rights of women in relation to property, inheritance, and freedom from sexual violence.
Public information and community campaigns that explicitly link womens vulnerability to inequality under the
law and to sexual coercion and violence to help both empower women and change harmful gender norms.
These programmes may also include programmes to reform or better implement laws (customary or otherwise)
relating to property ownership and inheritance.
Involving National Human Rights Institution or the Office of Ombudsman in the response. National
Human Rights Institutions have a mandate to monitor the national human rights situation, take individual
human rights complaints, and carry out human rights education activities. More information on how to involve
National Human Rights Institutions in the HIV response can be found in the Handbook on HIV and Human
Rights Institutions (UNAIDS, 2007) (http://data.unaids.org/pub/Report/2007/jc1367-handbookhiv_en.pdf).
Programmes to address the impact of HIV, the burden of care on women and girls and the situation of
orphans. Specific programmes for women, girls and orphans around economic empowerment and social
assistance, as well as provision of training and community engagement that shifts the burden of care from
women and girls to the broader community, including men and boys.
Programmes to address HIV-related stigma and discrimination. The most promising approaches to
stigma and discrimination reduction feature a combination of: empowerment of people living with HIV and
vulnerable groups (both in terms of programme objectives and through meaningful involvement in
programme design), accurate education about how HIV is and is not transmitted, and activities that foster
direct or indirect interaction between people living with HIV and key audiences. Multi-faceted
programmes promoting a combination of social mobilization, human rights and legal activism turn
victims of stigma and discrimination into empowered groups engaged in self-determination and social
change. The Stigma Index, developed by GNP+, ICW, IPPF and UNAIDS, is an example of a recently-
developed tool that countries can support the use of in order to empower people living with HIV and to
find out more about HIV-related stigma and discrimination in their locality (www.stigmaindex.org).

7. Approach to (or tools for) costing these activities (including what to cost and how)

Many Round 8 proposals did not include specific costing and budget lines for human rights and gender related
programmes. Please see UNAIDS publication Resource Needs for HIV/AIDS: Model for Estimating Resource
Needs for Prevention, Care, and Mitigation.

8. Some key indicators (outcome, coverage/output)

When relevant, all indicators, both output and outcome, should be disaggregated, at minimum, by sex and age.
In many cases, indicators should also be disaggregated by vulnerable populations, to measure the extent to
which programmes are impacting on target populations for maximum effect. As far as practical, each indicator
should also be disaggregated by marital status, legal status, urban/rural, income, ethnicity and race. Qualitative
indicators on the quality, availability, accessibility and acceptability of services should also be collected.

Indicators listed in the Monitoring and Evaluation Toolkit may not adequately reflect the human rights issues.
Therefore, specific human rights indicators can be used. These could include:

Output
Number of people living with HIV involved in the programmes forming part of the proposal (including
involvement in design, implementation and evaluation phases)
Number and coverage of programmes to train health care workers in non-discrimination, confidentiality
and informed consent
Number and coverage of sensitivity training programmes for law enforcement staff
Number and coverage of national and community campaigns to reduce HIV stigma and discrimination
Number and coverage of income-generation schemes for women care-givers and families caring for orphans
Number of young people and children receiving age-appropriate life-skills and sexuality education (in
schools and in informal settings)
Number and coverage of legal and social support services for women affected by HIV, including care-
givers and victims of sexual violence
Number and coverage of legal support services for people living with HIV
Number of information and education materials produced that incorporate human rights messages

Outcome
Percentage of service users and/or providers who are aware of patients rights to confidentiality, informed
consent and non-discrimination
Existence of laws on violence against women (including within marriage); statistics on prevalence of
violence; statistics on complaints and convictions on sex crimes
Indicators on attitudes towards girls education, violence against women, etc. (e.g. DHS indicators on
womens status and empowerment and on domestic violence)
Indicators on attitudes towards people living with HIV

9. Key implementing partners to be considered

Ministries of Interior, Justice, Labour, Gender, etc.

National Human Rights Institutions
Human rights and legal organisations
Womens groups
Networks of people living with HIV, including networks of women living with HIV
Community groups
Religious and community leaders
Media organisations
Prisoners groups
Migrants groups

Where necessary, proposals should include human rights training and other capacity building activities for
implementing partners.