Since entering the New Funding Model (NFM) as an early applicant in 2013, Zimbabwe has been a unique case for Global Fund investments. The country submitted a single HIV concept note in April 2013 (before integrated HIV/TB concept notes were encouraged), was granted $311.2 million, and began implementation in January 2014. Then, the country was granted an additional $126.1 million in HIV funding in 2015, based on tweaks to the Fund’s allocation methodology. In another unusual move, Zimbabwe was invited to submit an extra HIV concept note in May 2015, this time for incentive funding only. Subsequently, another $25.3 million was awarded. Zimbabwe has one of the world’s highest HIV prevalence rates at 14.7% and is home to 1.4 million people living with HIV. After a one-year costed grant extension, Zimbabwe’s current HIV grant is set to run until the end of 2017. It is now aligned with the regular grant cycle (instead of being a year early), and aligned with the country’s TB grant (making an integrated funding request possible). Now, the country is gearing up to prepare its HIV/TB funding request for the 2017-2019 grant cycle, likely to be submitted in the 23 May 2017 window. Building on the momentum from the NFM, civil society and communities are proactively engaging, analysing program gaps and setting priorities for the next three years. Aidspan spoke to several of these stakeholders to get a sense of the emerging themes for the country’s upcoming funding request. “Zimbabwean civil society from all perspectives – key populations, criminalized populations, networks of people living with HIV and their allies – are all acutely cognizant that the new grant cycle presents a crucial opportunity for them to push forward a comprehensive agenda for higher quality service delivery,” says Asia Russell, the Executive Director of Health GAP. Russell has been working with partners in Zimbabwe to prepare for the next Global Fund grant cycle. Zimbabwe’s previous experience with concept note development underscores the need for an actively engaged civil society. In a report which reflects on Zimbabwe’s NFM experience as an early applicant, a key lesson learned is that specific community needs often risk being sidelined. The report recommends a minimum funding set-aside for community responses, so this is not overshadowed by health systems strengthening and other biomedical priorities. One of the top priorities that civil society is pushing for in the next Global Fund request is universal access to immediate HIV treatment for all people living with HIV, regardless of CD4 count. Commonly referred to as “test-and-treat”, the World Health Organization began recommending this approach back in September 2015. More than a year later, Zimbabwe has yet to adopt these guidelines as national policy. Many other countries in the region have already done so: Malawi (as of April 2016), Lesotho (as of June 2016), Botswana (as of June 2016), Kenya (as of July 2016), Rwanda (as of July 2016) South Africa (as of September 2016), among others. Stakeholders told Aidspan that the Zimbabwe government is apprehensive about the cost implications of offering HIV treatment to all. As a compromise, seven (out of 59) districts have rolled out test-and-treat on a pilot basis, supported by the  United States President’s Emergency Plan for AIDS Relief (PEPFAR) and the Zimbabwe Ministry of Health and Child Care. However, activists charge that this is not good enough. “Why on earth is a person living with HIV in one geographic area more deserving of the latest science?” asks Russell. Treatment access is human rights issue in the country, with some provinces achieving much higher coverage levels than others (Figure). For instance, 74% of people living with HIV in Matabeleland North have access to antiretroviral therapy (ART), compared to just 44% in Manicaland. Part of the reason for this are sub-optimal HIV testing strategies, which often miss those who are most at risk. The next Global Fund funding request is an opportunity to close these gaps and move closer towards treating all.

Figure: HIV treatment coverage in Zimbabwe (Zimbabwe’s HIV Investment Case, 2015)

Another civil society priority that is emerging is the need to roll out pre-exposure prophylaxis (PrEP) for HIV prevention. Unlike many others, the country has published PrEP guidelines. However, there is no additional funding in the prevention budget to invest in PrEP, beyond some important demonstration projects with female sex workers. HIV prevalence among female sex workers in Zimbabwe is 57.1% and has been increasing over the last three years. Alongside PrEP, other new prevention technologies are being discussed for inclusion in the upcoming funding request. Civil society is also pressing upon the need to invigorate other areas of sexual prevention, such as building up the resiliency of communities. They say this is particularly important for adolescent girls, young women, and men who have sex with men (MSM). In Zimbabwe’s recent People Living with HIV Stigma Index, 77.8% of MSM living with HIV reported experiencing stigma and discrimination, which can act as a human rights barrier to accessing vital services. A third and critical priority being tabled by civil society for Zimbabwe’s next funding request is a strong focus on key populations and community responses. Civil society is demanding that the long overdue size estimation studies of key populations to be made available in time to inform the funding request. In addition, while the country has embraced the 90-90-90 targets, activist in the country urge that reaching these goals will not be possible without improving quality service delivery and improving the environment in which services are provided – especially for MSM, sex workers and transgender people. Differentiated delivery and bringing services to communities are also key priorities, including providing formal support for a cadre of lay workers. Civil society say this should be guided by Zimbabwe’s task shifting policy, but that there is a need to cost out what it would take to train these people. Stakeholders in-country began consolidating these priorities in mid-October, with consultation meetings ongoing among key populations, civil society and government, and with technical and development partners. So far, AVAC and EANNASO have been supporting civil society leadership on the Zimbabwe country coordinating mechanism (CCM) to spearhead these processes. “It went beyond my imagination,” says Donald Tobaiwa, a CCM member representing civil society and Chair of the TB Committee. “The key populations, they all came in their numbers. You know the Zimbabwean situation – we never thought that all the groups would come.” According to Talent Jumo, a new CCM member representing the women’s sector, the challenge moving forward will be to secure resources and technical assistance so that key populations groups and women's organizations can continue to coordinate and monitor progress. “We need to ensure that key recommendations are mainstreamed into the National Strategic Plan, and the implementation framework in general.” Zimbabwe’s mid-term review of its 2015-2018 National HIV and AIDS Strategic Plan is currently underway. This process will be critical for informing the country’s 2017 funding request to the Global Fund.