For the first time, gender equality is included as a top-line strategic objective in the Global Fund’s Strategy (2017-2022). HIV prevention among adolescent girls and young women (AGYW) in sub-Saharan Africa will be a strong focus for the Global Fund in the coming funding cycle (2017-2019). This is something that the African constituencies strongly pushed for. The number of new HIV infections among AGYW remains exceptionally high, especially in sub-Saharan African countries. UNAIDS estimates that there were 450,000 new HIV infections among AGYW (15-24) in 2015 – that’s 8,600 new infections each week. In East and Southern Africa – the hardest hit region – HIV prevalence is 3.3% among young women (15-24), compared to 1.6% among their male peers. This disparity is strongly linked with social and structural factors, including gender inequality and gender-based violence. New and ambitious global targets require greater HIV prevention efforts among AGYW. The 2016 United Nations Political Declaration on Ending AIDS sets a specific target to reduce new HIV infections among AGYW to fewer than 100,000 by 2020 – a 75% reduction from 2010. “We are at a pivotal moment for women and girls everywhere,” said Heather Doyle, Senior Technical Advisor on Gender at the Global Fund. “In this environment, it is imperative that we in the global health community demonstrate measurable progress in our work to target women and adolescent girls.” The Global Fund’s strategy is aligned to global targets. It embraces the UNAIDS Fast-Track target (among others) that by 2020, 90% of women and girls will live free from gender inequality and gender-based violence, mitigating the risk and impact of HIV. Two specific sub-objectives in the Global Fund’s strategy aim to scale-up programs to support women and girls and reduce health inequalities marked by age and gender (Figure 1). Reducing HIV incidence among AGYW (15-24) by 45% over the life of the strategy (2017-2022) is a key corporate target.

Figure 1: Two specific sub-objectives on gender equality in the Global Fund’s 2017-2022 strategy

Specific approaches under these two sub-objectives include working with countries to develop appropriate initiatives in funding requests and grants to address gender-related barriers to services; and to support the development and implementation of gender-responsive national health strategies. In addition, the approaches include linking reproductive, maternal newborn, child and adolescent health interventions with HIV, TB and malaria programs; supporting programs to keep girls in school; and supporting programs that aim to eliminate human rights barriers to services, including legal and policy barriers, particularly for women living with HIV, transgender women, women who inject drugs, and sex workers. While the sub-objectives in the Global Fund Strategy are new, the Global Fund has historically prioritized women and girls, increasing investments over recent years. The Fund reported that in 2015, 55-60% of its spending was directed to women and girls, up from about 46% in 2010. In several high-burden countries, current grants (from the 2014-2016 funding cycle) dedicate significant portions of their allocations directly towards HIV prevention activities among AGYW (Table 1).

Table 1: Investments in targeted HIV prevention activities among adolescent girls and young women in selected high-burden countries, as part of current grants (2014-2016 funding cycle)

Country	Amount ($ million)
Botswana	$6.0 m
Cameroon	$1.8 m
Kenya	$3.5 m
Lesotho	$2.6 m
Malawi	$12.0 m
Mozambique	$4.5 m
Namibia	$3.0 m
South Africa	$67.0 m
Swaziland	$5.0 m

Source: Global Fund presentation delivered at the Strategy Meeting to Explore Engagement of Women’s Funds in the Global Fund’s AGYW work. Nairobi, Kenya. 6-7 December 2016

In Malawi, for example, the current Global Fund program aims to reach 80% of girls enrolled in 322 schools in three target districts (Mangochi, Mulanje and Lilongwe). The package of interventions includes: life skills and sexuality education; codes of conduct; girls’ clubs; linkages, referral systems and services; HIV awareness, testing, and counseling; hygiene and sanitation; social asset building; women’s rights; and empowerment and addressing gender-based violence. In addition, the program also aims to reach 80% of out-of-school girls in the three target districts, located in 20 traditional chiefdoms. The package of interventions for this group of girls is slightly different, incorporating economic empowerment, condom distribution and family planning, couples counselling and legal clinics. The economic empowerment activity includes village savings and loans programs, as well as basic vocational skills such as local production of sanitary pads. A similar package is being provided through the Global Fund's support to AGYW in 880 schools in Swaziland. In addition, the Swazi Global Fund grant is providing social protection “dignity packs” to 4,800 adolescent girls aged 15-19, including a conditional cash transfer (cash incentive). To qualify for the conditional cash transfer, the girls must be enrolled in school and attending more than 80% of their classes each school term. In addition, for a randomly selected sub-sample of the girls, incentives are provided to girls who test negative for two curable STIs (trichomonas vaginalis and syphilis). Depending on which arm of the trial the girl is in, the cash transfers may be conditional on one or both of these criteria. A two-year evaluation (the Sitakhela Likusasa Impact Evaluation) of the effectiveness of these incentives is currently ongoing. Cash transfers are also being piloted as part of the Global Fund program in South Africa, in high HIV prevalence districts in two provinces: Western Cape and KwaZulu-Natal. South Africa is engaging approximately 30,000 young women with a “cash plus care” program, a combination of cash incentives and social support. The cash transfers are conditional rewards-based incentives that serve to stimulate health-seeking behavior and behavior change to minimize the risk of HIV infection. The “care” element includes linking eligible young women to the appropriate health services as well as linking the young women and their families to social protection, such as government welfare grants, as appropriate. Combining cash transfers with additional care components has been shown to be even more effective at reducing HIV incidence than programs which offer cash alone. In a fourth example, the Kenya Red Cross is also implementing a cash transfer program for AGYW as part of its current Global Fund grant. The Fund told Aidspan that this includes transfers for about 7,000 girls in Homa Bay, the county with the highest HIV prevalence in Kenya. Homa Bay accounts for about 10% of all HIV infections in the country. In a recent interview, Doyle told Aidspan that the Global Fund’s approach to supporting cash transfers as an HIV prevention intervention for AGYW is focused only in high-burden areas and adapted to the specific epidemiological and social context. Doyle said that understanding social contexts is key, noting that “cash transfers, like any intervention for AGYW, need to sit within a well thought-out, comprehensive package of services that speak to the lived realities of AGYW.” Along with being location-specific, the Global Fund’s support of interventions like cash transfers in Kenya, South Africa and Swaziland is also strategically targeted based on age-related infection patterns. According to UNAIDS, in Kenya, South Africa and Swaziland, a large number of new HIV infections are estimated to occur among adolescent girls aged 15-19, while in other African countries (such as Nigeria, Uganda and Zimbabwe), new infections are more common among women in their late twenties. UNAIDS recommends cash transfers as an intervention for AGYW aged 10-24 in hyper-endemic countries with low rates of female secondary school enrolment. For the coming funding cycle (2017-2019), the Global Fund is stepping up its investments in AGYW even further. Eligible countries can access an additional $55 million on top of country allocations to address HIV among AGYW (Table 2) as part of the matching funds included in the catalytic investments. To be awarded the matching funds, a country must increase its allocation amount dedicated to AGYW, as well as its program targets for this group, compared to its previous Global Fund grant (see GFO article for more information on how matching funds work).

Table 2: Matching funds available to address HIV in adolescent girls and young women (2017-2019 funding cycle)

Country	Amount ($ million)
Botswana	$1.0 m
Cameroon	$1.9 m
Kenya	$5.0 m
Lesotho	$1.5 m
Malawi	$7.0 m
Mozambique	$6.0 m
Namibia	$1.0 m
South Africa	$5.0 m
Swaziland	$1.5 m
Tanzania	$8.0 m
Uganda	$5.0 m
Zambia	$4.0 m
Zimbabwe	$8.0 m

Source: Global Fund website - http://www.theglobalfund.org/en/fundingmodel/process/catalytic-investment/

For some countries, to access the full amount of matching funds available will mean significantly scaling up programs and targets for AGYW. In Mozambique, for example, the country is currently spending about $4.5 million of its Global Fund allocation on HIV programs for AGYW (recall Table 1). To access the $6 million in matching funds available, the country will need to increase its current budget by about one-third (to at least $6 million) and increase current targets by nearly two-thirds (corresponding to at least $12 million worth in investments) for this population. “For sub-Saharan African countries where you have a disproportionate burden, the Global Fund is working to ensure scale and quality of programs,” said Doyle. “Understanding gender-related barriers is critical as a strategic investment strategy.” As many of the 13 countries in Table 2 are submitting funding requests in the first half of 2017, Aidspan will continue to monitor how AGYW are prioritized in these Global Fund programs. Editor’s note: This article, originally published on 28 January, was updated on 7 February to correct a few errors. The amounts in Table 1 for Kenya and Mozambique were altered. The new number for Mozambique required, in turn, some adjustments to the text in the paragraph immediately below Table 2.