Sex and the Global Fund: How sex workers, lesbians, gays, bisexuals, transgender people, and men who have sex with men are benefiting from the Global Fund, or not

Susana T. Fried and Shannon Kowalski-Morton

Health and Human Rights 10/2

Published December 2008

Abstract

The Global Fund to Fight AIDS, Tuberculosis and Malaria has allowed countries to bring their response to HIV/AIDS to an unprecedented scale, resulting in innovative projects that reach otherwise underserved communities with HIV prevention, treatment, and care. But in regions and countries where sex workers, men who have sex with men, or lesbian, gay, bisexual, and transgender persons are criminalized or stigmatized, organizations that are led by or work with these groups face challenges participating in Global Fund processes and accessing funding. This article explores the potential of the Global Fund to create space for the participation of these groups in decision-making and to increase their access to resources; examines barriers that hinder their participation; and proposes measures to overcome them.

Introduction

During a trip to Botswana in July 2006, we asked a group of representatives of community-based non-governmental organizations (NGOs) that were receiving, or hoped to receive, funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria if any of them worked with sex workers or men who have sex with men (MSM). “Sex work is illegal, so it’s difficult to work with these groups,” one replied. Others said that they would not submit projects targeting sex workers or MSM for fear that conservative government officials would reject their proposals, or even worse, that the stigma attached to sex workers and MSM would become attached to these NGOs.

Like many countries, Botswana does not collect data about HIV prevalence rates among sex workers, MSM, or people who identify as lesbian, gay, bisexual, or transgender (LGBT), so it is difficult to know with certainty whether HIV prevalence is higher in these communities than it is in the general population. But if Botswana is similar to the few African countries where data are available, it is safe to assume that specific HIV prevention and treatment services for these groups are lacking or non-existent. Sex workers, LGBT individuals, and MSM are criminalized and highly stigmatized in Botswana. Lesbians, Gays and Bisexuals of Botswana (LeGaBiBo), the only organization in the country that works to promote the rights of the LGBT community, has been barred by the government from registering as a legal entity, which also prevents it from receiving donor funding. In this cultural and political context, accessing Global Fund resources or participating in country-level decision-making processes that set priorities for proposals and oversee Global Fund grants is near impossible. Unfortunately, the situation in Botswana is not unique.

The Global Fund has allowed many countries to bring their response to HIV and AIDS to an unprecedented scale — and has used its money in a highly unconventional way. Unlike some other international and bilateral donors, the Global Fund is designed to respond to local demand, and ties project selection and funding to evidence and performance. Partnership with civil society and people living with or affected by the three diseases is key. In many cases, these partnerships have resulted in innovative projects that reach otherwise underserved or invisible communities with HIV treatment, care and, increasingly, prevention.

Given these operating principles, the Global Fund has the potential to cut through the political discomfort with sexuality that has stymied the flow of funding to communities that are often most in need of HIV information and services: sex workers, MSM, and LGBT. In a number of countries, such as China and Moldova, the Global Fund has opened up space for policy dialogue and funding on issues that governments and other donors had previously ignored or downplayed. These issues include harm reduction and treatment for injecting drug users, and evidence-based interventions for and by sex workers, MSM, and other vulnerable groups.

But in regions and countries in which sex workers, LGBT persons, or MSM are criminalized or highly stigmatized, where they are prevented from organizing or from claiming a public presence, organizations that are led by or work with these groups face significant challenges when it comes to participating in country-level Global Fund processes and accessing funding. As the Global Fund’s 360° Stakeholder Evaluation in 2006 found, addressing the needs of vulnerable and marginalized populations remains one of the Fund’s biggest challenges.¹

Experiences with other socially marginalized groups show that this does not need to be the case. Since the Global Fund started operating in 2002, countries with epidemics driven by injecting drug use have grappled with and overcome many of the barriers that previously had restricted the involvement of drug users in designing HIV services and limited the funding for harm reduction programs. For instance, although drug use is illegal in countries of the former Soviet Union, every country in the region that receives funding for HIV and AIDS has included programs that provide harm reduction services for injecting drug users. In Kyrgyzstan and Ukraine, drug users or their advocates have used their positions as members of the Global Fund’s country coordinating mechanisms (CCMs) to ensure that grant proposals address their needs. Moreover, in Russia and Thailand, coalitions of NGOs that are led by and work with drug users have bypassed CCMs that excluded them and have successfully sought direct funding from the Global Fund for HIV prevention and treatment services. Clearly, the barriers are not insurmountable.

This article outlines the particular need for specific HIV programming for sex workers, LGBT individuals, and MSM. It explores the potential of the Global Fund to create opportunities for the participation of these groups in country-level decision-making and increase their access to resources, examines some of the key barriers that hinder their participation, and proposes measures to help overcome these barriers.

The information in this article comes from multiple sources, including a desk review of key documents related to the Global Fund, as well as news sources and other relevant reports; a desk review of documents related to Global Fund grants in a randomly selected sample of 65 countries, including the composition of CCMs, coordinated country proposals, grant agreements, and progress reports (where available); results of 45 responses to a confidential survey; and open-ended interviews with 36 key informants.²

Sex workers, MSM, and HIV and AIDS: Ignored and under-funded

[I]n many countries there is limited willingness or capacity to focus on the legal, social, economic and cultural issues that drive the epidemic. Groups known to be most at risk of infection — such as sex workers, injecting drug users and men who have sex with men — rarely receive targeted services, resulting in ineffective responses. Overt and covert stigmatization and discrimination against these groups is a significant factor impeding data collection and targeted funding and programming.

— Declaration of Commitment on HIV/AIDS and Political Declaration on HIV/AIDS: Focus on Progress over the Past 12 Months, Report of the UN Secretary-General, May 2007

There are major gaps in epidemiological surveillance of HIV prevalence in MSM, LGBT, and sex worker communities, including in countries where HIV epidemics are concentrated among these groups. Even when HIV prevalence is high in the general population, available data show that prevalence among these populations is often much higher.³ Studies in Kenya, for example, show HIV infection rates among MSM of 40% or higher, compared to 6.1% for the general population.⁴ In Guyana, limited studies have found HIV prevalence rates of 31% among sex workers in Georgetown and 21% among MSM in the Demerara-Mahaica region, compared to 2.4% for the general population.⁵

In South Africa, national HIV epidemiological surveys do not collect sufficient data on high-risk populations such as MSM or sex workers.⁶ However, independent studies estimate that prevalence among self-identified gay men may be as high as 30%, while the rates for transgender individuals may be even higher.⁷ Available data from 2000 show that slightly over 50% of sex workers were HIV-positive.⁸

The concentration of HIV/AIDS among these populations in South Africa should be a national priority, and interventions to address their needs should be built into the country’s Global Fund grant proposals. However, only limited steps have been taken in this direction. In May 2007, South Africa recognized and included these groups in its new national AIDS strategic plan. But to date, not a single Global Fund HIV grant currently being implemented in South Africa has program components that specifically focus on meeting the needs of these communities.

In many countries, discrimination and hostile legal and political environments seriously impede efforts to protect the sexual health and rights of sex workers, LGBT individuals, and MSM and hinder access to the HIV prevention, treatment, care, and support services that they need. In particular, access to health services is often curtailed because of discrimination or violence in health care settings or because receiving health care requires disclosure of stigmatized behavior.⁹ Moreover, a lack of knowledge among health care providers about the specific sexual health needs of sex workers, LGBT individuals, and MSM means that the care they do receive is often inappropriate and fragmented.¹⁰

In addition, social marginalization and experiences of stigma, discrimination, and violence further increase the vulnerability of sex workers, LGBT individuals, and MSM to HIV infection. Organizations that are led by or work specifically with these communities are often targets of harassment.¹¹

UNAIDS pointed out in 2006 that programs that focus on HIV prevention, treatment, and care for sex workers and MSM are still neglected and under-funded and fall far below community need. In 2005, only 22.5% of sex workers in Africa and 35% in Latin America and the Caribbean had access to targeted prevention programs, while just 9% of MSM globally had access to HIV prevention and treatment services. UNAIDS rightly notes that this represents “a serious mismanagement of resources and a failure to respect fundamental human rights.”¹² Reaching sex workers, MSM, and LGBT communities and individuals with appropriate and accessible prevention and information as well as care, treatment, and support is clearly essential to halting and reversing the spread of the HIV pandemic.

The potential of the Global Fund

Apart from its general focus on AIDS, tuberculosis, and malaria and a requirement that middle-income countries submit proposals that meet the needs of poor or vulnerable populations, the Global Fund does not define priority areas for each disease or attach conditions to its funding. Rather, it requires that programs that it funds be based on evidence and international best practice. The quality of proposals is assessed by an independent technical review panel.

A core principle of the Global Fund is that its funding should be driven by need and demand. As such, control over priorities and program implementation is anchored in country processes that are supposed to be transparent and inclusive. A broad range of stakeholders, including governments, the private sector, NGOs, and perhaps most importantly, people living with and affected by the three diseases, is required by the Fund to be involved in setting country priorities, writing country-coordinated proposals, and overseeing grant implementation through a CCM. Further, each constituency participating in CCMs is required to have a transparent, documented process for selecting its own representatives. Given these requirements, it would stand to reason that individuals and communities that are most affected by HIV — including sex workers, MSM, and LGBT individuals — should be integrally involved in Global Fund country-level processes and programs. But whether sex workers, LGBT individuals, and MSM can take advantage of this opportunity depends heavily on countries’ social, political, and legal context, and the existence (or lack thereof) of supportive allies in national, international, and intergovernmental agencies.

The Global Fund’s inclusive and participatory structures do have the potential to expand opportunities for broad participation in decision-making. In Honduras in 2004, for example, the government allowed three NGOs working on LGBT rights and HIV prevention to legally register after a 10-year struggle to do so, largely due to advocacy by CCM members to ensure their participation on the CCM and in grant implementation. One seat on the 16-member CCM is now held by a representative of Comunidad Gay Lesbica, and new indicators have been added to the grant agreement for the second phase of the grant, signed in January 2005, to specifically measure the impact of HIV prevention efforts among MSM and sex workers.¹³ In Kyrgyzstan, representatives of organizations that work with drug users and sex workers have been participants on the CCM since its inception and have helped to ensure that country proposals address the needs of, and direct funding to, community-based organizations that are led by or work with drug users and sex workers.

Funding provided by the Global Fund also has the potential to help correct resource shortfalls for projects and organizations that are led by or work with sex workers, LGBT individuals, and MSM. In its first five years, the Fund has committed almost $7 billion to addressing the three diseases, with almost 60% going toward programs aimed at increasing access to HIV prevention, treatment, care, and support.¹⁴ In Eastern Europe and Central Asia, for example, funding from the Global Fund has been used to introduce and expand services for sex workers in every country where HIV grants are being implemented.¹⁵ In Latin America, sex workers and MSM are targeted beneficiaries of most Global Fund HIV grants.

Despite the barriers to greater participation in Global Fund decision-making and access to resources for HIV prevention and treatment for sex workers, LGBT individuals, and MSM, change has proven possible.

Barriers to increasing sex worker, LGBT, and MSM participation and funding

The barriers to these organizations are the laws that prevent the open expression of sexual orientation of the individuals within African countries and particularly in Ghana. There is also what is called the harassment of the police which force most of these groups to go underground.

— M. C., Ghana

In a number of notable cases, the sexual health and rights of sex workers, LGBT individuals, and MSM have been bolstered by funds made available through the Global Fund. However, in too many other cases, groups led by or working with and for sex workers, MSM, and LGBT individuals and communities have confronted persistent barriers to participating in Global Fund processes and benefiting from its resources.

Some barriers are rooted in country-level processes that — despite the rhetoric and appearance of civil society engagement — are still anchored in government control. It is important to note that increases in funding do not necessarily mean that drug users or sex workers were involved in the processes that set these programmatic priorities. Those who have been involved note that their opinions are not always taken into account.

Other barriers are related to capacity: many sex worker, LGBT, or MSM organizations are small and technically ill-equipped to prepare the detailed and complex applications required to gain access to Global Fund resources or to navigate the bureaucracies that are set up at the country level. Their social marginalization compounds these difficulties by limiting their connections to national HIV/AIDS networks or movements and reducing their access to needed information for their engagement.

Outright discrimination presents an additional obstacle to overcome. The overarching barrier is general social exclusion: in places where sex work and/or homosexuality are highly stigmatized, open participation can be extremely difficult and even dangerous. Where sex work and/or homosexuality are subject to criminal penalties, participation may be entirely foreclosed. Consequently, many governments, and even non-governmental HIV/AIDS service organizations, do not recognize or address the scale of the epidemic among sex workers, MSM, and LGBT individuals and communities. Instead, they direct their efforts, if any, at the general population or at less “controversial” targets.

These experiences of general exclusion are frequently exacerbated by outright harassment. In a recent article in Medical News Today, Anjali Gopalan of the Naz Foundation India Trust, an organization working on HIV care and prevention with diverse communities, commented, “The police harass health outreach workers working on HIV prevention among the gay community. Volunteers are prevented from distributing condoms among prisoners by officials who cite these antiquated laws.”¹⁶ In such contexts, discriminatory, hostile, and punitive national legal and policy environments present fundamental, and often insurmountable, obstacles — not only to funding but, in a larger sense, to effectively reversing the epidemic. As a respondent from Senegal stressed, “Our main challenges are the law which is used by corrupt policemen to harass MSM [and women who have sex with women] and arrests of adults for engaging in what others call ‘unnatural.’”¹⁷

Barriers to participation

The CCM does not respond to our needs because it did not include us in the development process of the proposals presented to our population. In this case, they did it with what they thought were our needs. The CCM cannot represent us, nor speak for us, without including us.

— Representative of a sex worker organization in Peru

Our analysis of a representative sample of 65 CCMs found that, while some organizations that work with sex workers and MSM as part of their overall portfolio of activities are members of CCMs, few organizations that focus exclusively on these issues or that are led by sex workers, LGBT individuals, or MSM are represented.¹⁸ Just 5 of the 65 CCMs we reviewed — Bolivia, Bosnia, Ecuador, Honduras, and Turkey — have representatives of easily identifiable LGBT organizations as members.

In most of the 136 countries where the Global Fund has made grants, governments and civil society are still struggling to establish mechanisms that allow them to work together on an equal footing. The underlying power differentials among these Global Fund-mandated “partners” often mean that CCMs are government-dominated and that even “mainstream” civil society representatives have limited capacity or power to ensure that the issues they feel are most pressing are adequately addressed in proposals and programs. Since groups led by or working with or for sex workers, MSM, and LGBT individuals and communities are often marginalized, or intentionally operate “below the radar” because they fear the consequences of a more public presence, their capacity to engage in these processes can be even more limited.

These issues [LGBT and MSM] are too sensitive for the official members of the CCM. They aren’t ready to speak about them openly.

— M. N., Russia

In many countries, CCM decisions about what to include in their Global Fund proposals often reflect political imperatives rather than objective, community-informed assessments of what is really needed. CCM members we spoke with also noted that many of the same NGOs that are on the CCMs receive funding through the Global Fund and may feel constrained to speak critically about politically difficult issues, such as the needs of sex workers, MSM, and LGBT individuals. As a result, issues that are controversial and communities that are marginalized or criminalized may be left out. A study commissioned by the Global Fund on the proposal development and review process in seven countries in Africa, Asia, Latin America, and the Caribbean, released in early 2006, found that “marginalized groups were seldom discussed as an issue per se of particular relevance” by CCMs.¹⁹

Although CCMs are required to have a documented and transparent process for ensuring the input of a broad range of stakeholders, including non-CCM members, in proposal development procedures, a recent survey by the Global Fund found that only 31% of CCMs do so.²⁰ Accessing information about ways to participate in or influence these processes remains a major barrier for many sex worker, LGBT, and MSM organizations. Many of these groups fall outside the “information loop” because they are not members of national AIDS networks or do not have ties with government bodies, such as the National AIDS Councils, that take responsibility for disseminating this information in many countries.

Barriers to funding

In India, MSM groups and sex worker communities haven’t received grants or benefited directly from the Global Fund. Not as sub-recipients even. The sub-recipients tend to be [people living with HIV/AIDS] programs or the State, but not marginalized groups.

— A.Y., India

CCMs are responsible for choosing the organizations or entities that will become principal recipients of Global Fund grants. In most cases, however, it is the principal recipients that are responsible for selecting the sub-recipients, which do most of the grant implementation. Hence, the principal recipient’s sensitivity to working with organizations led by or working with sex workers, MSM, and LGBT individuals and communities strongly influences whether these organizations receive Global Fund resources.

The number of civil society principal recipients is increasing; however, 68% of Global Fund grants still go to government principal recipients, 13% go to multilateral institutions and UN agencies, and just 19% go to NGOs or other non-governmental bodies.²¹ Where sex work and homosexuality are criminalized, it is rare that a government principal recipient will seek the active participation of sex worker and LGBT organizations, or MSM projects, in the implementation of the grant. Indeed, because of the illegal — and often hidden — nature of sex work and homosexuality in many countries, organizations that are led by or that work with sex workers and MSM may choose not to seek funding from government sources because of the inherent conflicts and risks involved in doing so.²²

Where the principal recipient is an NGO or a UN agency, however, or where key NGOs — whether they be led by sex workers, LGBT individuals, MSM, or allies — play a strong role in the process of selecting a principal recipient and deciding on funding priorities as CCM members, sex worker and MSM projects can fare better. In Thailand, for example, an NGO principal recipient, RAKS Thai Foundation, was able to direct funding to EMPOWER, a sex workers’ rights group, to implement a grant component focusing on HIV services for migrant sex workers from Burma, Cambodia, and Laos. In Kyrgyzstan, the United Nations Development Program (UNDP) has close ties to groups working with marginalized populations and has also been closely involved in building the capacity of the Global Fund principal recipient, the National AIDS Council, to perform its role. In this capacity, UNDP has been able to facilitate access to greater support from the government principal recipient for groups working on HIV/AIDS with sex workers and MSM than might have otherwise been the case.

The Global Fund Board recognizes that the criminalization or stigmatization of certain vulnerable groups may make it difficult to work within the structures of CCMs. In such cases, these groups may apply directly to the Global Fund by submitting non-CCM proposals or regional organization proposals. In reality, the eligibility criteria for non-CCM and regional organization grants are difficult to meet, and few groups that work with marginalized populations have been able to use this mechanism effectively to receive Global Fund grants. The Naz Foundation International, based in Lucknow, India, for example, attempted to submit a regional organization proposal focusing on meeting the needs of MSM in five South Asian countries during the Global Fund’s sixth funding round in 2006. Yet, the proposal was screened out because the Foundation was not able to demonstrate that it had attempted to seek endorsement for the proposal from the CCMs in each country, which is a requirement for regional proposals.

As noted above, groups that work with injecting drug users have had more success than those working with sex workers, LGBT individuals, and MSM because they have been able to demonstrate that a hostile political climate to harm reduction services was preventing the country from adequately addressing concentrated epidemics in drug-user communities. Coalitions of NGOs in Russia and Thailand, for example, have successfully received funding for non-CCM grants to deliver a comprehensive set of prevention and treatment services for active and former injecting drug users. However, implementing non-CCM grants brings its own set of challenges. As the groups working with injecting drug users in Thailand have found, scaling up HIV prevention and treatment programs in the absence of government support can be an arduous and politically perilous process.

Organizational challenges

The LGBT movement in South Africa is still relatively small and there is a great need for services which the current organizations do not have the capacity to provide, for example, in rural areas.

— T. K., South Africa

Many organizations that are led by or work with and for sex workers, LGBT individuals, or MSM are small and grassroots. While this gives them strong connections to the communities that they serve, it also means that many of them have limited capacity for large-scale advocacy and program implementation.²³

For some, this limited capacity translates into difficulties navigating the often-complex bureaucracies that are established in countries to manage Global Fund monies or preparing technically strong proposals for consideration by the CCMs and principal recipients.

In other cases, these organizations simply may not be able to meet criteria established at the country level to participate on a CCM or to be a sub-recipient, such as being legally registered or being in existence for a certain number of years. A recent analysis of LGBT organizations based in the global south or working internationally found that one-quarter are not legally registered, most of them because authorities either refused to register them or established barriers to registration that they could not overcome. It also found that LGBT organizations are relatively young, with 34% of them having been established within the last three years.²⁴ As Sunil Babu Pant, from Blue Diamond Society, explained about the process in Nepal, the priorities established by the CCM (migrants and people living with HIV/AIDS) and the criteria set (applicant organizations must have been in existence for at least five years) limited the possibilities for projects focusing on sex workers and MSM to apply.²⁵

Recommendations

To overcome these obstacles, there is much the Global Fund and its partners can do to increase the participation of communities that are most affected by HIV and AIDS in the design and implementation of Global Fund projects.

Recent decisions adopted by the Fund’s Board of Directors aimed at leveraging civil society involvement should go a long way to increase the involvement of sex workers, LGBT individuals, and MSM. These decisions require the inclusion of the most vulnerable groups or affected communities in CCMs and encourage the selection of dual principal recipients, with at least one from the non-governmental sector, to administer grants.²⁶ Another recent Board decision expands its eligibility criteria to include upper-middle income countries with concentrated epidemics among vulnerable groups, including MSM, sex workers, and injecting drug users.²⁷ In November 2007, the Board adopted a decision calling for the round 8 proposal guidelines and application form to be modified to encourage countries to address the needs of women, girls, and sexual minorities; the hiring of high-level staff at the secretariat to champion gender issues; and the development of strategies on gender and sexual minorities for the Global Fund.²⁸

In order for these measures to be successful, the representation of vulnerable groups on CCMs and in the development of Global Fund policies needs to be real, not rhetorical — in other words, sex workers, MSM and LGBT individuals, should be given the space to speak on their own behalf, and they should be supported in doing so.

The Global Fund Board should also consider developing a more accessible and open non-CCM application process for countries where the social or political environment precludes the active participation of organizations that work with or are led by sex workers and MSM, to ensure that these communities can benefit from funding.

The delegations on the Board of the Global Fund that represent developing country NGOs, developed country NGOs, and communities living with HIV and TB or affected by malaria, should seek to include organizations and individuals that represent or work with sex workers, MSM, or LGBT individuals on their delegations. They should also increase their efforts to communicate with and seek feedback from such groups to better represent their views and concerns in Board discussions.

The Global Fund Secretariat can be more proactive in enforcing the requirements on NGO participation and transparency in country-level processes that already exist and in informing the Board when countries are falling short. The Secretariat might also help to facilitate participation by marginalized groups by disseminating more user-friendly and accessible information about Global Fund processes, procedures, and requirements at a global level and supporting CCMs to do the same. For example, the Secretariat might provide space on the Global Fund’s country web pages to share more information about CCMs, such as notices of upcoming meetings, meeting minutes, terms of reference for CCM members, calls for proposals, and other opportunities for participation.

CCM members can work to increase the openness and inclusiveness of grant preparation processes and disseminate information about deadlines and participation opportunities beyond their immediate networks.

Recipient governments should repeal national laws and policies that criminalize sex work and same-sex sexuality — both for human rights and public health purposes.

Global Fund partners, including UN agencies, donors, international NGOs, and national partners should provide support, technical assistance, partnerships, and networks for local and national organizations working with and for sex workers, MSM, and LGBT communities. Such support should compensate where national governments are unable or unwilling to provide funding. It should also seek to build capacity so that these groups can access Global Fund resources in future rounds.

Organizations that are led by or work with or for sex workers, LGBT individuals, or MSM need to actively engage in Global Fund processes at the country and global levels, advocate the inclusion of programs focused on sex workers, LGBT individuals, and MSM in country proposals, and raise alerts about barriers or challenges to such inclusion. Where these organizations are not receiving Global Fund financing directly, they need to monitor the effectiveness of Global Fund programs that focus on meeting the needs of their communities.

Over time, changing discriminatory, hostile, and punitive national legal and policy environments will be crucial to effectively reversing the HIV/AIDS epidemic, especially among marginalized groups who face stigma, discrimination, and abuse that hinder their ability to secure their rights and health.

Conclusion

The Global Fund offers more potential than many other donors to open up space for participation in country-level decision-making by sex workers, LGBT individuals, and MSM, increase resources for HIV services that meet their needs, and break some of the taboos around funding HIV programs that deal with “controversial” issues of sexuality. It is the responsibility of all partners to create an environment where sex workers, LGBT individuals, and MSM can reap the benefits that the Global Fund can bring.

Ultimately, the Global Fund must negotiate a difficult dilemma: on the one hand, sex workers, LGBT individuals, and MSM (as well as women who have sex with women, who are entirely invisible in HIV programming) are at risk of contracting HIV and AIDS. In some cases, they are at high risk, especially (but not solely) in those countries in which HIV is concentrated within these very groups.²⁹ Reaching these individuals and communities — with appropriate and accessible prevention tools and information as well as care, treatment, and support — is essential to addressing the pandemic, even where the HIV epidemic is a generalized crisis. Moreover, including them in the design and implementation of programming is the best way to ensure that interventions targeted toward them promote their rights as well as their health.

On the other hand, the Global Fund relies on a country-driven model of funding. Since these groups are marginalized, their ability to influence funding priorities, program design, and other aspects is often quite limited. Most countries have failed to prioritize the needs of sex workers, MSM, and LGBT individuals, even when HIV/AIDS is concentrated in these communities. If the Global Fund aims to help fill resource gaps to stem the HIV and AIDS pandemic, it must come to terms with this dilemma.

Susana T. Fried is Gender/HIV Advisor at the United Nations Development Programme (UNDP), Bureau of Development Policy, New York, NY, USA. At the time of writing, she was an independent consultant and an Adjunct Assistant Professor at the Columbia University School of International and Public Affairs.

Shannon Kowalski-Morton is Program Officer in the Public Health Program at the Open Society Institute, New York, NY, USA.

skowalski@sorosny.org

References

1. The Global Fund to Fight AIDS, Tuberculosis and Malaria, 360° Stakeholder Evaluation: Perceptions and Opinions of Stakeholders of the Global Fund (Geneva: The Global Fund to Fight AIDS, Tuberculosis and Malaria, 2006).

2. This research was conducted in 2006 and early 2007 and does not take into account the results of the Global Fund’s seventh round of funding.

3. Therapeutics Research, Education, and AIDS Training in Asia, MSM and HIV/AIDS Risk in Asia: What is Fueling the Epidemic among MSM and How Can It Be Stopped? (Bangkok: Therapeutics Research, Education, and AIDS Training in Asia, 2004), p. 10; C. Johnson, Off the Map: How HIV/AIDS Programming Is Failing Same-Sex Practicing People in Africa (New York: International Gay and Lesbian Human Rights Commission, 2007), pp. 36-37; UNAIDS, Report on the Global AIDS Epidemic 2006 (Geneva: UNAIDS, 2006).

4. Johnson (see note 3), pp. 36-37.

5. UNAIDS, 2006 AIDS Epidemic Update (Geneva: UNAIDS, 2006).

6. Indeed, the only national data on MSM mentioned in the 2004 UNAIDS/WHO epidemiological fact sheets are from 1986.

7. L. Samelius and E. Wågberg, Sexual Orientation and Gender Identity Issues in Development (Stockholm: Swedish International Development Agency, Health Division, 2005), p. 41.

8. European Commission, UNAIDS, UNICEF and WHO, Epidemiological Fact Sheet: South Africa 2006 Update (December 2006). Available at http://www.who.int/GlobalAtlas/predefinedReports/EFS2006/EFS_PDFs/EFS2006_ZA.pdf.

9. J. W., interview by author, April 25, 2005; A. Parivudhiphongs, “Dare to CARE,” Bangkok Post (August 8, 2005).

10. Therapeutics Research, Education, and AIDS Training in Asia (see note 3), pp. 22-23.

11. S. Fried, “Case Study — India” (unpublished document on file with authors, 2006).

12. UNAIDS, Report on the Global AIDS Epidemic 2006 (Geneva: UNAIDS, 2006), pp. 103 and 110.

13. UNDP, Shifting Perspectives and Taking Action: UNDP’s Response to HIV/AIDS in Latin America and the Caribbean — The Answer Lies Within (New York: UNDP, 2005); The Global Fund to Fight AIDS, Tuberculosis and Malaria, Program Grant Agreement between the Global Fund to Fight AIDS, Tuberculosis and Malaria and the United Nations Development Programme. Available at http://www.theglobalfund.org/search/docs/1HNDH_937_45_ga2.pdf.

14. The Global Fund does not provide information about grant sub-recipients, and as such, it is impossible to determine how much funding is being directed toward groups that work with sex workers, LGBT communities, or men who have sex with men.

15. U. Weber, “Harm Reduction is Established in Eastern Europe,” presented at The 18th International Conference on the Reduction of Drug Related Harm (Warsaw, Poland, May 13-17, 2007).

16. Medical News Today, “Gay Rights Groups in India Protest Arrest of MSM, HIV/AIDS Advocates Say Antiquated Laws Hinder Prevention.” Available at http://www.medicalnewstoday.com/medicalnews.php?newsid=36093.

17. D. H., survey response to authors, April 19, 2005.

18. This represents almost 50% of all CCMs in countries where the Global Fund has grants.

19. D. Wilkinson, R. Brugha, S. Hewitt, et al., Assessment of the Proposal Development and Review Process of the Global Fund to Fight AIDS, Tuberculosis and Malaria (Soborg, Denmark: Euro Health Group, 2006). Available at http://www1.theglobalfund.org/en/files/links_resources/library/studies/integrated_evaluations/EHG_Final_Report_Executive_Summary.pdf.

20. Technical Evaluation and Reference Group of the Global Fund to Fight AIDS, Tuberculosis and Malaria, Assessment of the Country Coordinating Mechanisms: Performance Baseline (Geneva: The Global Fund to Fight AIDS, Tuberculosis and Malaria, 2005), p. 11.

21. The Global Fund to Fight AIDS, Tuberculosis and Malaria, Distribution of Funding after 6 Rounds. Available at http://www.theglobalfund.org/en/funds_raised/distribution/#sector_recipients.

22. Johnson (see note 3); J. Dorf, Sex Worker Health and Rights: Where is the Funding? (New York: Open Society Institute, 2006). Available at http://www.soros.org/initiatives/health/focus/sharp/articles_publications/publications/where_20060719/where.pdf.

23. Therapeutics Research, Education, and AIDS Training in Asia (see note 3); Dorf (see note 22); Redfern Research, A Snapshot of LGBTI Organizations in the Global South, East and Those Working Internationally, 2006 (New York: Funders for Lesbian and Gay Issues, 2007).

24. Redfern Research (see note 23).

25. S. Pant, interview by author, April 2006.

26. The Global Fund to Fight AIDS, Tuberculosis and Malaria, 15th Board Meeting Decision Points. Available at http://www.theglobalfund.org/en/files/boardmeeting15/GF-BM15-Decisions.pdf.

27. Ibid.

28. The Global Fund to Fight AIDS, Tuberculosis and Malaria, 16th Board Meeting Decision Points. Available at http://www.theglobalfund.org/en/files/boardmeeting16/GF-BM16-Decisions.pdf.

29. In some cases, lesbians are also at high risk, especially where they are specifically targeted for rape, as, for example, in South Africa. Y. Ertürk, Integration of the Human Rights of Women and the Gender Perspective: Violence against Women, Report to the UN Commission on Human Rights, UN Doc. No. E/CN.4/2005/72 (2005), para. 27.