Pepfar Watch

Community Alert: PEPFAR’s Technical Guidance for COVID-19

The original blog is available on the MPact website here.

MPact is closely following developments regarding COVID-19, and particularly its impact on gay, bisexual and other men who have sex with men. MPact has provided short info notes with resources on a variety of topics, including: tips for LGBTI advocatessex and sexual healthstaying healthy under physical distancing and self-isolationtips for health professionals serving LGBTI communities during COVID-19Human Rights Advocacy & COVID-19: Considerations for LGBTI Advocatesa joint statement with UNAIDS on discrimination in the age of COVID-19 and Inclusion of LGBTI People in COVID-19 Response Efforts. Stay tuned for updates and check out all our resources on COVID-19 here.

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The COVID-19 pandemic has changed every facet of our world. We are only just beginning to understand how this will impact the communities we serve, including the ability to receive funds from bilateral and multilateral institutions such as the United States President’s Emergency Plan For AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, TB and Malaria (the Global Fund). MPact is committed to regularly informing partners during this rapidly evolving situation by providing up to date information about key decisions made by these two main funders in the global response to AIDS, Tuberculosis and Malaria.

Both PEPFAR and the Global Fund are aware of the extraordinary challenges that countries are facing due to the COVID-19 pandemic. The impact of the virus is widespread; however, individuals from marginalized or disadvantaged groups who already experience poorer outcomes in healthcare are often disproportionally affected by the wider implications of the pandemic. Prevention and rapid containment of COVID-19 is a priority in order to minimize the negative impact on health systems, as well as services for people living with HIV (PLHIV) and people who need HIV prevention services, especially key populations (KPs). PEPFAR is committed to supporting governments’ responses to COVID-19 by leveraging existing PEPFAR resources so that people living with HIV (PLHIV) have the best possible outcomes within the context of stretched healthcare systems.

MPact has conducted an in-depth analysis of the PEPFAR Technical Guidance. We highlight in the below brief the top 10 updates for Key Populations working to ensure access to PEPFAR HIV treatment, care and support during COVID-19 – including PEPFAR’s recommendations, as well as missing elements that KP communities should monitor.

PEPFAR’s “Technical Guidance in Context of COVID-19 Pandemic”

PEPFAR is the United States’ biggest global health program, and implementers and program beneficiaries alike have questions about PEPFAR’s approach to sustaining the HIV response while adapting to the new COVID-19 pandemic landscape.

To provide clarity during this rapidly changing time, the program has published the “PEPFAR Technical Guidance in Context of COVID-19 Pandemic.” It affirms that PEFPAR is committed to continuing essential HIV prevention and treatment services, while providing a safe environment for clients and staff. (Note that this document is being continuously updated, so keep checking back for new updates – this analysis corresponds to the version that was last updated on 05/15/2020).

PEPFAR has committed to 4 “Guiding Principles” for the provision of services in PEPFAR-supported countries during COVID- 19 pandemic, as follows:

  • Protect the gains in the HIV response;
  • Ensure the safety of PEPFAR-supported staff, including by adapting client services so that they can be performed safely;
  • Reduce risk of transmission of COVID-19 among clients served by PEPFAR and PEPFAR-supported staff;
  • Enable PEPFAR Operating Units (OUs) the flexibility to determine how best to continue to serve clients with HIV prevention and treatment services in areas affected by COVID-19.

Top 10 Updates for Key Populations:

1.    Decentralize KP services

What: KP services should be decentralized by relocating out of health facilities and into community platforms as much as possible. This will ensure that KPs can continue to access treatment, PrEP, viral load testing and other care during COVID-19[1].

Why: Visits to health care facilities should be limited to only those that are medically essential. Minimizing patient contact with health facilities during COVID-19 reduces risk to recipients of care and reduces the burden on these facilities[2].

How: PEPFAR is committed to giving KP programs flexibility to determine how best to continue to serve clients with HIV prevention and treatment services in a decentralized manner[3] (see section below on leveraging the use of technology). Certain other services, such as distribution of medication, will require specific adaptations. PEPFAR offers suggestions including: home deliveries through peer-run groups; scheduled pick-up times at pharmacies; automated lockers as additional pick-up infrastructure outside of hospitals; and community pick-ups organized by KP groups[4] (see p. 9-10 of the Technical Guidance for more information).

2.    Make use of technology and virtual approaches

What: PEPFAR KP programs should use virtual approaches, including social media, phone, SMS and alternative methods of communication by health care and peer outreach workers to ensure critical services for KPs are continued[5]

Why: Moving KP programming into online spaces helps reduce risk during COVID-19. Social distancing practices help ‘flatten the curve’ of the pandemic by reducing spread of the pandemic and lessening the burden on healthcare systems.

How: KP communities have been immensely creative in creating supportive online spaces in the HIV response, long before COVID-19. Though it’s impossible to completely replicate the warmth of in-person KP community support groups and peer-to-peer networks, digital platforms such as Facebook, Instagram, SMS, WhatsApp and others can be used to maintain connections within the KP community, and between providers, peer outreach workers and the KP community they serve. Digital platforms are also key for sharing timely updates about changes to services as implementers continue to adjust and adapt the HIV response during COVID-19.

3.    Use PEPFAR’s feedback mechanisms to report KP experiences

What: PEPFAR is committed to getting feedback from KPs about their experiences as PEPFAR makes adjustments to the HIV response during the COVID-19 pandemic.

Why: COVID-19 is disrupting normal ways of working all across the HIV response. Yet any interruption to HIV services among key populations has an exponential impact, pushing already vulnerable groups even further into economic instability, and elevating risk of stigma and personal violence. For example, as traditional peer outreach models are temporarily paused in favor of digital approaches (see above), there is risk that KPs will fall through the cracks.

How: Any instances of KPs being left behind, especially any barriers to HIV service delivery, should be documented and reported. Tracking these issues will enable PEPFAR to better understand and address problems.

  • File a civil society report directly to OGAC via the PEPFAR CSO input/feedback mechanism here.
  • Consult your S/GAC chair
4.     Link KPs to violence prevention and services

What: KP programs should ensure that there is a system in place to track instances of KP-related violence, and to link clients with violence prevention, reporting and shelter services[6].

Why: Social distancing, lockdown protocols, and other physical confinement measures that are intended to contain the spread of COVID-19 could also increase the potential for KPs to find themselves isolated among homophobic, transphobic, and/or violent individuals.  COVID-19 may elevate risk for key populations communities in several ways, including economic uncertainty, HIV service interruption, scapegoating of the LGBT and key population communities for spreading COVID-19, and potential for increased stigma and personal violence (read MPact’s presentation on this topic here). Disruptions to regular routines (work, school, etc.), reduced economic opportunities (including sex work), and reduced geographic mobility leave few outlets, options and agency for KPs to protect their own physical safety, placing them in elevated risk environments. Interpersonal violence, including violence catalyzed by stigmatization of sexual orientation and gender identity, is a legitimate risk factor, and it further elevates risk-taking behavior as a result of economic insecurity.

How: As an initial option, PEPFAR recommends sharing local contacts of responders who can address gender-based violence (GBV) related concerns[7]. MPact recommends that where these resources don’t yet exist in an appropriate manner for KP individuals, community networks can start by developing communications protocols for individuals to safely reach out and alert others that their safety is at risk. Community-based organizations and individuals facing human rights violations can also report cases online directly to MPact using our Incident Assessment and Documentation Tool.

Learn more here:

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5.    Scale-up Multi-Month Dispensation (MMD) of medication (PrEP and Treatment)

What: PEPFAR is scaling-up multi-month dispensing (MMD) and decentralized delivery of anti-retroviral treatment (ART) and Pre-Exposure Prophylaxis (PrEP)[8]. Individuals on HIV treatment will receive a 3-6 month supply of ART, while individuals on PrEP will receive a monthly or 3-month supply of PrEP medication[9].

Why: MMD is directly in line with PEFPAR’s priorities for the COVID-19 response, including reducing congestion at health facilities and maintaining the gains of the HIV response (including avoiding any HIV treatment interruption).  MMD is good news for key populations, especially those for whom economic insecurity, social instability, and fear of stigma at clinics make recurring, short-term medication refills challenging. Accessing multiple months of medication at one time helps reduce the risk of treatment interruption, especially for mobile populations. PrEP is a vital intervention for all key populations, and uninterrupted access is essential for safety and effectiveness.

How:  As the MMD program begins to scale-up in your setting, ensure that KP communities are included and can access multiple months of treatment and/or PrEP medication at one time.  This includes virtual options for meetings with healthcare providers, using SMS technology for refills, and community delivery of medication. PrEP demand-creation, dispensation and adherence support activities should continue, but in-person gatherings should be paused, moving instead toward “no-contact” or “limited contact” platforms (see the above section on making use of technology)[10].

6.    Keep an Eye on New Testing Protocols (Index Testing ban lifted and self-testing kits)

What: PEPFAR has made two major updates to testing as it relates to key populations:

  • PEPFAR has lifted the previous halt on Index Testing for key populations[11].

Index Testing, also called “assisted partner notification services”, is an HIV case-finding strategy that tracks the contacts of people who test positive for HIV, and ensures they are also tested. MPact previously issued a community advisory and wrote an open letter to PEPFAR, raising ethical concerns about rights violations under Index Testing, including reports of heath facilities withholding HIV medication until individuals diagnosed with HIV disclosed their sexual partners. In response, PEPFAR temporarily halted Index Testing for KPs.

  • PEPFAR is encouraging HIV self-testing kits be given to newly diagnosed individuals, which they can pass on to their sexual partners[12]. Partners can use the kit to self-screen, and then only those most likely to have HIV will come to the clinic for confirmatory HIV testing[13].


  • Index Testing has been re-instated for KPs because PEPFAR is now satisfied that minimum standards for HIV Testing Services (HTS) are in place, and they are working with country teams to ensure that either:

(a) HTS provision at sites is meeting minimum standards or

(b) Sites are brought up to HTS standards.

  • Distribution of HIV self-testing kits supports on-going HIV testing efforts, while avoiding unnecessary crowding at clinical sites during the COVID-19 period of risk.

How: HIV testing is essential to any effective HIV response, and it’s important that modifications are being made to keep testing going during the COVID-19 response.  However, KP programs should carefully monitor Index Testing among KPs and track adverse incidents.

If you have questions or concerns about Index Testing or have an incident to report to PEPFAR:

  • File a civil society report directly to OGAC via the PEPFAR CSO input/feedback mechanism here.
  • Consult your S/GAC chair
7.    Safeguard the role of community in KP programming

What: KP community networks are essential to safe and effective KP programs, now more than ever. The PEPFAR Technical Guidance recommends that programs should make use of existing KP community-based networks and programs to keep essential services flowing to the KP community, including: PrEP initiation and refills; delivery of HIV self-testing kits; and pickup or delivery of services[14].

Why: As decentralization moves HIV programs and services outside of clinical settings, KP-led networks are best placed to understand the specific needs and considerations for making these modifications work for KP communities. Centering this work around the people is vital.

How:  PEPEFAR has stated that OUs should prioritize keeping KP community programs safe and effective. Equip community health workers and peer outreach workers with adequate supplies of condoms, lubricants and self-test kits[15]. OUs can consider introducing a bag, uniform, or other marker to help identify community health workers to law enforcement and community members as persons providing essential duties and provide them with documentation of their role and authorization to continue to work[16]. At the same time, all PEPFAR programs must be mindful of privacy concerns as KP programs and services become decentralized:  OUs should review and set up standard processes to make sure all staff are mindful of client privacy and safety during remote patient contact[17] (for example: confirm client preference on receiving calls, receiving voicemails, and receiving SMS messages. For more information and guidance, refer to the PEPFAR Technical Guidance, page 6). KP-led organizations should offer insights and recommendations for the best ways that PEPFAR programs can serve and protect KP communities.

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In addition to explaining the above recommendations in the PEPFAR Technical Guidance, MPact has identified a handful of questions that remain outstanding at this time. Here is what is missing and therefore needs your attention and advocacy:

8.    Funding: additional resources or reprogramming?

Implementing the adjustments recommended in the PEPFAR Technical Guidance (i.e. decentralization, scale-up of multi-month dispensation, etc) can help support HIV program continuity and safety during COVID-19[18].  However, no new PEPFAR funds have been allocated by the U.S. Congress at this time,[19] and the Technical Guidance is not clear about what funding can be used to enable these changes to take place[20].  Other funders have been more explicit about how much money is available, and how it is being directed: for example, The Global Fund to Fight AIDS, TB and Malaria has announced up to US$500 million in grant flexibilities and up to US$500 million for a COVID-19 Response Mechanism.

MPact recommends that KP program implementers keep track of the resources they need to make these adjustments to their KP programming work during COVID-19 and report their needs to PEPFAR.

9.    Targets: uncertainty about changes and evaluations

There will almost certainly be disruptions and adjustment periods as KP programs move their programmatic work into alignment with the new Technical Guidance (for example, moving from direct services to online platforms). Yet it is not clear whether KP programs will continue to be evaluated on their original prevention, treatment and retention targets.

The Technical Guidance’s only apparent reference to targets comes in the context of HIV testing. It acknowledges that overall HIV testing “target achievement may be impacted by COVID-19.[21]” Yet despite a clear directive to scale-up and expand HIV self-testing, the Technical Guidance also states that self-testing targets should not be “adjusted prospectively,” but rather discussed with Chairs and PPMs[22].

For KP implementers and advocates, it’s a challenge to know how best to prioritize program adjustments (especially in a time of limited resources) without a sense of how target achievement will be evaluated.

MPact recommends that KP programs undertake quarterly reviews of their target data, and request meetings with PEPFAR country teams to update them on the state of the response among KPs. This will enable feedback in real time and ideally allow for course-corrections without delay.

10.    Mental Health Programming

Currently, there is only a passing reference to mental health in the Technical Guidance (on page 10), but nothing specifically about the impacts on mental health for gay men and key populations during the COVID-19 pandemic. Moving to self-testing during social distancing and other public health measures that limit in-person contact raises questions about appropriate wrap-around support and counseling for newly diagnosed individuals, including for KP communities who may be facing other forms of social isolation at this time. It would be prudent for PEPFAR to address this topic in more detail, because although it’s valuable to track service barriers and ensure violence prevention, we also need explicit sensitization of providers about the unique psychosocial and mental health needs of KPs.

MPact recommends that KP programs report gaps in mental health support for KPs to PEPFAR country teams and suggest program initiatives that would be beneficial for bridging the gap.

Please feel free to report to us (MPact Director of Policy Nadia Rafif at any problems or obstacles you may experience, which we can document and report to PEPFAR.

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COMMUNITY ADVISORY: Index Testing Could be Harmful to Your Rights and Well-Being.” February 2020, MPact.

COVID-19 and Its Impact on Key Populations: A Community Reflection. April 2020, Mpact.
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Ensuring Gay Men’s Needs Are Addressed in the 2020 PEPFAR COPs. March 30, 2020, MPact.

Frequently Asked Questions – Index Testing.” January 2020, AVAC.

Global Fund Guidance Notes on Responding to COVID-19

Global Fund Funding Request Instructions Global Fund COVID-19 Response Mechanism

Open Letter to PEPFAR: Index Testing.” January 2020, MPact.

USAID / PEPFAR Guidance on KP Programs.

[1] p.28, PEPFAR Technical Guidance in Context of COVID-19 Pandemic. Updated as of 05/15/2020.

[2] p.3 PEPFAR Technical Guidance in Context of COVID-19 Pandemic. Updated as of 05/15/2020.

[3] p.3 PEPFAR Technical Guidance in Context of COVID-19 Pandemic. Updated as of 05/15/2020.

[4] p. 9-10 PEPFAR Technical Guidance in Context of COVID-19 Pandemic. Updated as of 05/15/2020.

[5] p. 28 PEPFAR Technical Guidance in Context of COVID-19 Pandemic. Updated as of 05/15/2020.

[6] [6] p.22, 29. PEPFAR Technical Guidance in Context of COVID-19 Pandemic. Updated as of 05/15/2020.

[7] p.22 PEPFAR Technical Guidance in Context of COVID-19 Pandemic. Updated as of 05/15/2020.

[8] p.3 PEPFAR Technical Guidance in Context of COVID-19 Pandemic. Updated as of 05/15/2020.

[9] p.7, p.22 PEPFAR Technical Guidance in Context of COVID-19 Pandemic. Updated as of 05/15/2020.

[10] P. 23-24.  Note, however, that the PEPFAR Technical Guidance does also state that “community distribution and adherence support in small groups (less than 10 people present at any time) for PrEP may help support people and would not be a burden on the health care system.”

[11] P.29, PEPFAR Technical Guidance in Context of COVID-19 Pandemic. Updated as of 05/15/2020.

[12] P.14, 15, 28. PEPFAR Technical Guidance in Context of COVID-19 Pandemic. Updated as of 05/15/2020.

[13] P.15, PEPFAR Technical Guidance in Context of COVID-19 Pandemic. Updated as of 05/15/2020.

[14] P.28, PEPFAR Technical Guidance in Context of COVID-19 Pandemic. Updated as of 05/15/2020.

[15] p. 28 PEPFAR Technical Guidance in Context of COVID-19 Pandemic. Updated as of 05/15/2020.

[16] p.5, PEP FAR Technical Guidance in Context of COVID-19 Pandemic. Updated as of 05/15/2020.

[17] p.6, PEPFAR Technical Guidance in Context of COVID-19 Pandemic. Updated as of 05/15/2020.

[18] World Health Organization. “Q&A: HIV, antiretrovirals and COVID-19.” 22 March, 2020.

[19] Kaiser Family Foundation. “COVID-19 & PEPFAR: Implications for the Future.” May 20, 2020.

[20] The guidance does explicitly state that laboratory costs dedicated for HIV and TB testing should not be reallocated for COVID-19(p.35); that additional funding to roll out MMD at a broad scale will need to be considered by S/GAC before any medication is procured (p.7);

[21] p.14 PEPFAR Technical Guidance in Context of COVID-19 Pandemic. Updated as of 05/15/2020.

[22] p.15 PEPFAR Technical Guidance in Context of COVID-19 Pandemic. Updated as of 05/15/2020.

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