An Open Letter to the Executive Director of The Global Fund to Fight AIDS, Tuberculosis, and Malaria Dear Dr. Dybul, We were pleased to learn that, as part of the transition to the new funding model, The Global Fund to Fight AIDS, Tuberculosis and Malaria is reviewing its monitoring and evaluation processes, including the indicators used to assess grant performance. This review is welcome, but it is beginning to appear that the Global Fund is going to leave one of the biggest shortcomings of the old M&E approach intact: the failure to use indicators that reflect the experiences and the challenges faced by women in the HIV epidemic. There has recently been a noticeable change—ostensibly for the better—in the rhetoric to recognise that, in the countries with the highest HIV prevalence, HIV and AIDS are disproportionately affecting adult women, and that this is largely due to the discrimination, oppression, and violence experienced by women. In its 2012 Global Report, UNAIDS stated it plainly: "Gender inequality drives the HIV epidemic." In December, the UN entity responsible for compiling the world’s HIV and AIDS data released a report that explored the epidemic from the perspective of women, and a third UNAIDS report focused on progress in Africa, calling for "putting women and girls at the centre" of the response. As is too often the case, the rhetoric is just that. In each of the above-mentioned documents, UNAIDS has demonstrated little real regard for women, consistently making egregious mistakes in reporting data about women and HIV. In the report Update: How Africa Turned AIDS Around, the same critically important statistic about the proportion of women among adults living with HIV in Africa was repeated four times within three pages…and they got it wrong three out of four times. But before I embark on a further examination, allow me to emphasise that the analysis that follows is based on scrupulous desk research done by AIDS-Free World. We conducted our research using grant information available on the Global Fund website between June 15 and June 20, 2013. We based our analysis on the 58 completed grant performance reviews (2002-present) available for the 10 countries with the highest HIV prevalence, all of which are in sub-Saharan Africa. A list of all of the sources can be found on our website. I recognise the Global Fund does not collect statistics nor produce reports of the type that UNAIDS produces; its role is to dispense multi-year grants to countries with specific plans to fight the diseases. But we can get a sense of the Global Fund’s commitment to strengthening the response for women and girls by examining the indicators that grant-receiving countries are encouraged to use when they measure progress at the end of each grant period. Unfortunately, the indicators that have been used in the past do not reflect a commitment to strengthening the response for women and girls. Some of the indicators, such as AIDS-related mortality and adults receiving ARVs, are disaggregated by sex, but many key indicators of progress do not address the differing realities for women and girls versus men and boys. For example, the indicator for new HIV infections is not disaggregated by sex. Since we know that HIV prevalence among girls and young women aged 15-24 in sub-Saharan Africa is over twice that found among men the same age, we might expect to find that new infections are also disproportionately affecting women…but we don’t know, because the indicator is not disaggregated. Similarly, the Global Fund has administered many grants with a focus on orphans and vulnerable children, but few of the programmes use indicators that reflect that the experiences of orphans and vulnerable children who are girls will differ from those of boys, both in the opportunities and obstacles they will encounter. The failure to measure progress in preventing new infections among women, or to measure the effects of OVC programmes on girls, means there is no incentive for countries that receive Global Fund grants to ensure that their efforts are addressing the specific challenges faced by women and girls. Most of the grants we looked at do not directly address women at all, but this might not be obvious at a passing glance. Among the 58 grant performance reviews we examined, 34 of them did not address women in programme objectives or indicators. But in half of those 34 reviews, women are addressed within programmes meant to ensure that women who are already HIV-positive won’t transmit the virus vertically, during pregnancies, childbirth, or breastfeeding; the countries’ plans are explicitly called “Prevention of Mother-to-Child Transmission.” Clearly, those are programmes for children, not for women. The growing number of countries moving toward Option B+ is needed and welcomed, but the fact is that pregnant women living with HIV make up only 0.7 percent of all women aged 15-49 in sub-Saharan Africa. Roughly 94 percent of women in sub-Saharan Africa are in dire need of prevention, but their needs are largely ignored. With its review of monitoring and evaluation processes, the Global Fund has the opportunity to go beyond rhetoric and truly demonstrate its commitment to strengthening the response for women and girls. The current statistical regime, developed by UN agencies such as UNAIDS and WHO and utilised by countries to monitor the epidemic, does not adequately reflect the role that gender inequality plays in putting women and girls at an increased risk of HIV infection. Using its influence as a global leader and major funder of the AIDS response, the Global Fund can have a profound impact on the development of programmes that truly address women’s HIV risk by taking into account such horrors and injustices as sexual violence, child marriage, discriminatory property laws, female genital mutilation, and restrictions on decisions regarding health care and contraception. This will require making women’s experiences central to the development of programmes and to the development of the monitoring and evaluation systems put in place to track progress. We have already seen what can happen when global institutions develop and encourage the use of new indicators: information regarding the populations of men who have sex with men, sex workers, and people who inject drugs has been greatly expanded thanks to the development of indicators meant to track the effects of HIV epidemics on these groups. The development of effective approaches to combating the epidemic among women will require a similar transformation in the ways information is collected about women and AIDS. In some cases, the needed indicators are obvious. For instance, the data on new HIV infections must be disaggregated by sex and age group. But other necessary indicators must be developed by taking stock of the gaps between what we know and what we need to know about the specific effects of HIV and AIDS on women. For example, we need to know about the access to testing, counseling, and treatment among women who are not pregnant. We need to know about the integration of HIV services and contraception provision. We need to know about the violence experienced by all women, not just those who are married or cohabiting. This last item is especially important. Academic research has repeatedly shown that sexual violence puts women and girls at elevated risk of contracting HIV, but we still have no data on the scope of this phenomenon. Institutions ranging from UNAIDS to the Security Council are raising the issue of sexual violence against women, but these constant references without data lead nowhere. We must have a real understanding of the extent of the problem, and not just in cohabiting couples and conflict countries, before we can take steps to solve the problem. The Global Fund can and must force the issue. Simply asking grant recipients to report this data is insufficient because so much of the data is not collected or estimated at all. But the Global Fund is in a unique position to influence countries and the UN on the need to develop new indicators that will provide a more comprehensive account of the challenges still to be overcome in reducing the vulnerability of women and girls to HIV infection. By helping to develop and adopt these indicators, the Global Fund can facilitate the end of the use of data that obscures the devastating effects HIV is having on the world’s women, and can encourage grant recipients to take real and substantive steps to address these effects. Sincerely, Michael Wilkerson, Researcher AIDS-Free World