Participation of Women and Transgenders in GF Processes in Latin America and The Caribbean

Participation of women and transgenders in Global Fund Processes in Latin America and the Caribbean
MAKE YOUR VOICE HEARD
A publication of
A Program of
With the technical and financial support:
Make your Voice Heard: Participation of women and transgenders in Global Fund Processes in Latin America and the Caribbean
Regional Researcher
Alexandra Lamb Guevara
Copy-Editor
Maya Briggs Translation into Spanish Damian y Bibi Hager
Review of Spanish document

Lidice Lopez Tocon Enrique Chavez
Design
Rommel Gonzales Cruz
Fundacin AID FOR AIDS - Lima Peru

Observatorio Latino Program Calle Tupac Amaru 698, Pueblo Libre Lima Peru 2010
Executive Director: Teresa Ayala Advocacy Director: Enrique Chavez General Coordinator of Study: Lidice Lopez Tocon
We specially thank local researchers who collected and analised the data used in the regional study: Viviane Ramel (Ecuador), Ximena Salazar Lostaunau (Peru), Violeta Ross (Bolivia), Veronica Daz (El Salvador), Amarili Mora (Nicaragua) y Patricia Watson (Jamaica); and fixers that colaborated with the regional researcher organising interviews and focus group in semi-focus countries: Desire Diez Portela (Dominican Republic)); Rubn Pecchio (Panama); Mirtha Ruiz (Paraguay); Cecilia Davila (Argentina), Kenneth van Emden (Suriname), Lucrecia Leal (Guatemala) y Erica Colindres (Honduras). This study and its publication have been possible with the technical and financial support of UNAIDS and International HIV/AIDS Alliance and the support of HIVOS to Observatorio Latino work.
The photos used in this document have been compiled from different sources and are autorized to be disseminated under Creative Commons License. Front Page photo: flickr.com (Photographer: Isidro Cea) Photos are only referential and are not related to the text
Acknowledgements
We would like to thank to all study participants, including Country Coordinating Mechanism members and in particular, women leaders of community-based organizations, women living with HIV, female sex workers and transgenders that shared their experiences and perceptions so as to enrich our understanding of their realities
LATIN AMERICA AND THE CARIBBEA
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List of abbreviations
AIDS CCM HIV IEC LAC LGBT NGO PLHIV PR REDCA+ SR UNAIDS WLHIV : Acquired immune deficiency syndrome : Country Coordinating Mechanism : Human immunodeficiency virus : Information, education and communication : Latin America and the Caribbean : Lesbian, gay, bisexual and transgender : Non-governmental organisation : Personas que Viven con el VIH/Sida : Principal Recipient : Red Centroamericana de personas viviendo con VIH (Central American Network of People living with HIV) : Sub-Recipient : The United Nations Joint Programme on HIV/AIDS : Women living with HIV
Participation of women-in-general, women living with HIV, female sex workers and transgenders in Global Fund processes in Latin America and the Caribbean
Contents
Executive summary .............................................................................................................. Introduction ........................................................................................................................... Conceptual Framework ................................................................................................. HIV/AIDS in Latin America and the Caribbean .......................................................... The Global Fund .............................................................................................................. The Global Fund and Gender .................................................................................... Participation in Health ................................................................................................. What is participation? .................................................................................... Participation, gender and HIV/AIDS ....................................................................... Target populations ................................................................................................. Women-in-general ................................................................................................. Women living with HIV .................................................................................... Female Sex Workers .................................................................................... Transgenders .............................................................................................................. The Global Fund and the participation of women and transgenders in Latin America and the Caribbean ....................................................................... Goal and objectives of the study .................................................................................... Methodology .............................................................................................................. Results ........................................................................................................................... Representation and Participation in the CCM .......................................................... Current representation of women and transgenders in 15 CCMs across Latin America and the Caribbean ............................................. Gaining access, representation and participation in the CCM ................... The role of legitimacy and accountability in effective CCM participation ................................................................................................. Communication between CCM representatives and their constituencies ................................................................................................. Factors that have contributed to improving access and participation in the CCM ....................................................................... Barriers that reduce effective participation in the CCM ................................ Participation in Global Fund Grant Proposal Development ................................ Process(es) employed to develop a country-level grant proposal ................................................................................................. Participation challenges common to all proposal development processes .................................................................................... Access to Resources as Global Fund Sub-Recipients ................................ Challenges to Accessing Resources as Sub-Recipient Organisations ................... Conclusions .............................................................................................................. Recommendations .............................................................................................................. Annex ........................................................................................................................... 8 12 13 13 14 14 15 16 16 17 17 18 19 20 21 22 22 26 26 26 28 33 35 36 37 39 39 43 44 46 48 50 52
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Executive Summary
The existence of a Country Coordinating Mechanism (CCM), required to access resources from the Global Fund to Fight AIDS, Tuberculosis, and Malaria (the Global Fund), has substantially modified the dynamics of national responses to the three diseases, enabling the integration of civil society, and especially those populations most affected by the epidemics, into key HIV/ AIDS decision-making spaces. Nevertheless, the weak participation of some affected populations in the CCMs has resulted in a general dearth of activities directed towards these populations in many Global Fund grants throughout the region. This situation prompted Observatorio Latino, a programme of AID FOR AIDS, to evaluate the participation of women and transgenders in Global Fund processes, where participation is understood to mean involvement in the development, implementation and monitoring of Global Fund HIV/ AIDS country or regional grants. The report describes and analyses the characteristics and effectiveness of womens and transgenders participation in CCMs, and in the elaboration of national or regional proposals, and outlines the situation for these populations with regard to access to Global Fund resources. Additionally, the report identifies factors which have facilitated or limited their participation. With technical and financial support from UNAIDS and the International HIV/AIDS Alliance, 178 in-depth interviews and 42 focal groups were carried out in fifteen countries in Latin America and the Caribbean, in order to gather perceptions on the participation of women and transgenders in Global Fund processes.
Key Findings
The effective participation of women and transgenders in the CCM should be reflected in a countrys proposals, as well as in the extent to which these groups are able to access resources as sub-recipients. There is little evidence of this to date; in part, because many of the representatives of these groups have difficulties participating effectively, but also because many CCMs do not create opportunities to debate nationallevel HIV/AIDS policies or programming. Representatives are unsure of how to put forward their groups specific agendas in meetings which are often operational and reactive. Women hold a significant number of CCM seats in Latin America and the Caribbean; however, this has not translated into effective representation of the needs and realities of women with regards to HIV/ AIDS. There is little evidence that womens organisations have shown interest in Global Fund grants or in participating in the CCMs; Honduras, Jamaica, the Dominican Republic and Suriname, countries with higher HIV prevalence rates among women than other parts of the region, are the exceptions. Direct representation in a CCM is the most effective way of being able to represent the needs and realities of population groups, whereas shared representation has been shown to offer less possibilities of efficient communication between representatives and their constituencies.
The findings show that 13 out of the 15 CCMs studied include a woman living with HIV (WLHIV) representative among its members, but only one of these seats is specifically designated for WLHIV; in the 12 remaining cases, the woman delegate represents the wider sector of people living with HIV (PLHIV). This has limited the opportunities to insert a specific agenda that responds to the needs of WLHIV; instead, the wider PLHIV agenda has been prioritised, often focusing on the pressing need of access to antiretroviral treatment. In recent years, sex workers and transgenders have achieved more seats on the CCMs throughout the region as a result of the persistent advocacy carried out by their organisations. Additionally, the Global Funds strong recommendations on the inclusion of the most affected and vulnerable populations in the CCM have been a key factor in this achievement. The regional networks of sex workers (RedTraSex) and transgenders (RedLacTrans) have played an important role in presenting to their members the importance of being involved in Global Fund processes, and strong advocacy by these two networks has contributed to placing the needs and realities of their population groups on the regional agenda.
Issues of legitimacy and accountability of representatives have affected the effective participation of women and transgenders in the CCMs as election processes are not necessarily democratic or inclusive; the represented group may be limited to members of just one organisation instead of the wider sector. Additionally, whereas open and transparent communication between representatives and their sectors can contribute significantly to strengthening participation in the CCM, the study found no evidence of systematic communication systems which would guarantee that information and decisions taken in the CCM are communicated to the respective sectors, and that constituents opinions are reaching their representatives. To date, participation in the development of country-level grant proposals for submission to the Global Fund has largely depended on the nature of the proposal development process undertaken in each country. Some efforts have been made to include WLHIV, sex workers and transgenders within these processes; however, the overwhelming perception held by the population groups is that this inclusion has been limited to rubber-stamping the proposal, rather than fostering participation which allows involvement in decision-making.
Moreover, effective participation in these processes has been made difficult by limited technical capacity, limited time and above all, limited opportunities to access the decision-making spaces related to the proposal. On the other hand, a lack of epidemiological and social research focusing on WLHIV, sex workers and transgenders has meant that these groups are unable to support their positions with evidence. Access to funds as sub-recipients is limited for these population groups. Although the majority of projects in Latin America and the Caribbean include proposals for work with WLHIV, sex workers and transgenders, their organisations have rarely received direct funding as sub-recipients; for the most part, funds are assigned for the implementation of specific activities. A significant obstacle to receiving direct access to funds as sub-recipients is the weak organisational capacity to administer and implement grants.
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Key Recommendations
CCMs should designate a specific seat for each of the population groups most affected by the epidemic, according to epidemiological evidence in each country, while emphasising the importance of inclusive, open and transparent elections of representatives. They should also create opportunities for engagement with and debate of national-level HIV/ AIDS policies and programming in CCM meetings, in order to facilitate bringing to the table the needs and realities of population groups which have not yet been addressed. CCMs should develop systematic induction processes for new members, supplemented by other strategies, such as mentoring. They also need to develop an action plan for integrating a gender focus into CCM structure and operations, building the capacity of members in gender awareness and sensitivity. National-level proposals should therefore integrate interventions that address gender inequalities and respond to a solid gender analysis of the HIV epidemic in the applicant country. Womens organisations should be supported to mobilise around the issue of HIV/AIDS. In light of the trend towards shared representation, especially for PLHIV, there is a need to construct transparent and systematic communication systems between representatives and their constituencies. WLHIV need to work more closely with PLHIV representatives on the CCM in order to ensure that their specific needs and realities are understood and that they are able to present these with clarity in the CCM. Regional community networks should examine the possibility of providing training and mentoring for their members to improve their participation, a) in the CCM and b) in grant proposal development. It is important for these populations to define the political agenda which they wish to defend in spaces related to Global Fund. In the cases of shared representation, there is a need to work more closely with the existing representative to build understanding of the diverse agendas which need to be presented in the CCM. The Global Fund and its partners should provide clear and practical guidance to CCMs on ways to increase the effective participation of communities involved in CCM and other Global Fund processes. CCMs should also be encouraged to integrate organisational development activities with community-based organisations of WLHIV, female sex workers and transgenders within national proposals as part of community systems strengthening. International agencies and other donors should continue and increase support to strengthen regional and national community networks be it in election processes and representation, definition of a national and regional agenda, or organisational strengthening to build their capacity to be sub-recipients. Finally, more investment is needed to carry out new and broader research into womens lack of mobilisation around HIV/AIDS in Latin America and the Caribbean. Additionally, this study should be widened to include all the countries in the region as well as other populations affected by HIV/AIDS, tuberculosis and malaria.
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I. Introduction
The financing provided by the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) has substantially modified the way in which the response to these three diseases is being coordinated in many countries in the world. In particular, the Global Funds setting up of a Country Coordinating Mechanism (CCM), which integrates governmental authorities with grassroots organizations, affected populations, and the private sector, has been a decisive factor in this change. This new body has evolved differently in each country, depending on existing dynamics between the state and its citizens, and its experience with citizen participation, social regulation and accountability. In Latin America and the Caribbean (LAC), to a greater or lesser degree, civil society and affected populations have been part of CCMs since their inception. However, other populations that are more exposed or vulnerable to the diseases have had little experience with these mechanisms, and therefore, their needs have frequently not been incorporated into Global Fund approved and financed proposals. In 2007, AID FOR AIDS Per, through its programme Observatorio Latino, drafted a survey to gather information on womens participation in CCMs across Latin America, in order to ascertain the extent to which participation is balanced between men and women1. The results of the survey indicated that 40% - 70% of CCM members are women, yet despite this significant figure, individuals felt that the presence of women on the CCM did not guarantee the promotion or defense of their needs, and that female sex worker and transgender participation was minimal or nil. Furthermore, CCM performance reviews cite the lack of mechanisms for assuring a gender approach is incorporated into proposals2. These results motivated Observatorio Latino to broaden the study and to gather information on the participation of women in general, female sex workers, and transgenders in CCMs, understanding participation to mean involvement in the development, implementation, and monitoring of Global Fund projects in their countries. These population groups are linked to Observatorio Latinos particular interest in womens participation, and its more general interest in the participation of affected and most vulnerable populations. The findings of this study may also reflect the realities of gay men, lesbians, vulnerable adolescents and young people, indigenous people, and others. However, the methodology of the study focuses on womenin-general, women living with HIV/ AIDS, female sex workers, and transgenders. With technical and financial support from UNAIDS and the International HIV/AIDS Alliance, data was collected on 15 CCMs throughout Latin America and the Caribbean, through interviews and focus groups with women living with HIV, female sex workers, and transgenders. This study aims to analyse the representation, legitimacy, and accountability of these populations representatives in Global Fund processes, as well as the perception of other CCM members of their levels of participation in drafting proposals and implementing activities. It also aims to promote reflection on the composition of CCMs in Latin America and the Caribbean, and on effective and legitimate participation by women and transgenders. It is, furthermore, designed to be used as a tool: for advocacy in obtaining resources, technical support and training; to increase effective participation; and to improve relations between representatives and their constituencies, in such a way that the former are able to convey needs that have not yet been met.
1. The survey was answered by seven CCM members. 2. UNAIDS, An Analysis of the Gender Policies of the Three Major AIDS Financing Institutions, July 2008, available at: http://womenandaids.unaids.org/documents/Analysis_Financing_Mechanisms.pdf
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II. Conceptual Framework

HIV/AIDS in Latin America and the Caribbean
Home to primarily concentrated and low-level epidemics, the regional HIV prevalence rate in Latin America remains relatively stable at 0.6%3. The Caribbean, on the other hand, has been more significantly affected and continues to have the second highest level of HIV prevalence (1.0%) outside of Southern Africa4. Prevalence rates in the Caribbean range from as low as 0.1% in Cuba to as high as 2.2% and 3% respectively in Haiti and the Bahamas5. In Latin America, the epidemic is concentrated primarily among gay and other men who have sex with men (MSM), transgenders6, female sex workers and, in certain parts of the region such as the Southern Cone, also among injecting drug users. Recent studies suggest HIV prevalence rates range from between 10-25% among gay and other MSM, and as high as 35-40% among transgenders7. Reported prevalence rates are lower among female sex workers: recent data from Guatemala, El Salvador and Argentina report prevalence rates of 4.4%, 3.2% and 1.8% respectively among this population group8. However, in the Caribbean, prevalence rates among sex workers are significantly higher, with recent data suggesting 9% and 27% respectively in Jamaica and Guyana9. In 2008, the male to female ratio of people living with HIV in Latin America was reported as 3:1, whereas in the Caribbean the ratio stood at 1:110. Despite the significantly higher number of men living with HIV in Latin America, recent data from Central America and other studies in Argentina, Peru, Brazil and Paraguay suggest that HIV prevalence among women is increasing11 12.
3. UNAIDS, Latin America Fact Sheet 2009, available at: http://data.unaids.org/pub/FactSheet/2009/20091124_FS_latinamerica_en.pdf 4. UNAIDS, Caribbean Fact Sheet, 2009, available at: http://data.unaids.org/pub/FactSheet/2009/20091124_FS_caribbean_en.pdf 5. ibid 6. The term transgenders in this study is used to refer to individuals who identify as women yet were born as biological males. Transgenders have often been grouped together with men who have sex with men in HIV/AIDS related research. However, because their gender identity is female, they often share more commonalities with women than with gay men in the context of HIV/AIDS. 7. International HIV/AIDS Alliance, The Hidden HIV Epidemic, Transgender Women in Latin America and Asia, 2008, available at: http://aidsportal.org/Article_Details.aspx?ID=9528 8. UNAIDS, Latin America Fact Sheet 2009, op.cit. 9. UNAIDS, Caribbean Fact Sheet, 2009, op. cit. Data has not been disaggregated by male, female or transgender sex workers. 10. ibid 11. UNAIDS, Latin America Fact Sheet 2009, op. cit. 12. UNAIDS, Report on the Global AIDS Epidemic 2008, available at: http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/2008_Global_report.asp
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The Global Fund

The mechanism currently having the largest effect on national responses to HIV/AIDS is the Global Fund for AIDS, Tuberculosis and Malaria (the Global Fund). Founded in 2002, the Global Fund acts a funding mechanism that channels financial resources to developing countries for the implementation of programmes that respond to one or more of the three diseases. The Global Fund is unique, in large part due to its governance structure which brings together governmental, non-governmental, private sector and community stakeholders all with an equal vote on the organisations board. The organisations commitment to transparency and community participation within its highest decision-making structure is, in turn, reflected within its guidelines for the establishment of Country-Coordinating Mechanisms (CCMs) in each country. CCMs are responsible for developing and submitting proposals to the Global Fund, selecting the Principal Recipient (the organisation which manages the resources required for grant implementation) and overseeing implementation after grant approval. CCMs are, according to the Global Fund, central to its commitment to local ownership and participatory decision-making13. The Global Funds CCM guidelines strongly encourage that membership include representation of all key stakeholders that are relevant in the fight against the three diseases in the national context14. Moreover, the most recently updated version of the guidelines encourages a gender-balanced composition and the representation of a gender perspective by its members. In keeping with its principles of local ownership and local governance, while the Global Fund Secretariat may recommend, it does not impose these guidelines on CCMs, and so the structure and composition of this mechanism vary from country to country. What is consistent throughout most countries is the key role played by the CCM as the decision-making body in the development of national-level Global Fund proposals and their subsequent monitoring. Participation by people living with HIV and other key populations (gay and other MSM, female sex workers, transgenders and drug users) can contribute to ensuring that these groups needs and realities are heard in this vital space. In Latin America and the Caribbean, where such groups are significantly affected by HIV/AIDS, their participation in this key decision-making space is crucial to the development of an appropriate, high-quality and sustainable national HIV/AIDS response. Recently, participation in the CCM has taken on even more significance as this decision-making space is being employed not only to discuss the use of Global Fund resources, but as an appropriate multi-sectoral forum to debate national HIV/AIDS policies and strategies.
The Global Fund and gender

In 2008, UNAIDS published a report that analysed the gender policies of the three major AIDS financing institutions: the World Bank, the Presidents Emergency Plan for AIDS Relief and the Global Fund15. The report suggests that the Global Funds commitment to local ownership has not provided the necessary mechanisms to ensure that grant proposals are gender-sensitive. UNAIDS quotes a 2004 report by the International Centre for Research on Women that partly attributes the Global Funds lacklustre performance on women to monitoring and evaluation guidelines and processes that are not as strong as they could be to assess the gender-related impacts of country programs16. Additionally, the UNAIDS report clearly states that most proposals have lacked a gender perspective due to the limited involvement of women in CCMs which, in turn, presents challenges for womens groups to access Global Fund resources. Since 2007, the Global Fund has begun to take action to address gender inequality in its work, evident for example in its recent Fact Sheet, Ensuring a gender sensitive approach, in which the Global Fund acknowledges that men and women do not enjoy the same level of access to health care services17. In November 2008, the Global Fund further consolidated its position on gender by adopting a Gender Equality Strategy that explores how the Global Fund can encourage a positive bias in funding towards programs
13. The Global Fund, Country-coordinating mechanisms core structures available at http://www.theglobalfund.org/en/ccm/ 14. The Global Fund, Guidelines on the Purpose, Structure, Composition and Funding of Country Coordinating Mechanisms and Requirements for Grant Eligibility, available at: http://www.theglobalfund.org/documents/ccm/Guidelines_CCMPurposeStructureComposition_en.pdf 15. UNAIDS, An Analysis of the Gender Policies of the Three Major AIDS Financing Institutions, July 2008, available at: http://womenandaids.unaids.org/documents/Analysis_Financing_Mechanisms.pdf 16. UNAIDS, op. cit. 17. The Global Fund, Fact Sheet: ensuring a gender sensitive approach, March 2008, available at: http://www.theglobalfund.org/documents/rounds/8/R8Gender_Factsheet_en.pdf
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and activities that address gender inequalities and strengthen the response for women and girls18. A separate but complementary strategy focusing on MSM and transgenders (Sexual Orientation and Gender Identities Strategy, or SOGI Strategy) was approved by the board in May 200919. Both the Gender Equality and the SOGI Strategies provide concrete recommendations on how to address gender issues in the response to HIV/AIDS, tuberculosis and malaria in the context of Global Fund operations. In acknowledgement that the CCM serves as the most significant decision-making body at a national level, the Strategy documents make significant recommendations that seek to address gaps in the understanding and capacity of CCM members with regards to the health and rights of women in
particular, men who have sex with men, female sex workers and transgenders. In addition, there are concrete recommendations that seek to encourage CCMs to increase the participation of these groups in all relevant Global Fund processes. These strategies, however, are new and their recommendations have yet to be implemented at national levels. Nonetheless, in Latin America and the Caribbean, there are examples of these population groups participating in CCMs and other Global Fund processes. It is the experience and effectiveness of this participation to date by women-in-general, women living with HIV, female sex workers and transgenders that this study seeks to explore and, by doing so, provide further recommendations for how such participation can be improved.
Participation in Health
The concept of community participation in health was first formally articulated by the World Health Declaration in the context of primary health care within the Alma-Ata declaration in 1978. The WHO asserted that quality primary health care requires and promotes maximum community self-reliance and participation in the planning, organisation, operation and control of primary health care []; and to this end develops through appropriate education the ability of communities to participate20. Over 30 years later, effective community participation is considered an essential cornerstone of any welldesigned development project. Yet the use of the term participation has become so prolific that it can be considered a buzzword which is too readilyused, without enough thought being given to its meaning or function21.
18. The Global fund, The Global Funds strategy for ensuring gender equality in the response to HIV/AIDS, tuberculosis and malaria (The Gender Equality Strategy) 19. The Global Fund, The Global Fund Strategy in Relation to Sexual Orientation and Gender Identities, 2009 available at: http://www.aidsportal.org/repos/GF-B19-4%20Report%20of%20Policy%20and%20Strategy%20Committee%20Attachment3.pdf 20. International Conference on Primary Health Care, Alma-Ata, 1978, Alma-Ata Declaration available at http://www.who.int/hpr/NPH/docs/declaration_almaata.pdf 21. Andrea Cornwall and Karen Brock, What do Buzzwords do for Development Policy? A critical look at participation, empowerment and poverty reduction, Third World Quarterly, Vol. 26, No. 7, pp 1043 1060, 2005
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What is participation?
In a 1998 article, Zakus and Lysack reviewed many different interpretations of community participation in health. They combined these definitions and articulated participation as the individual or collective process by which members of the community a) develop the capability to assume greater responsibility for assessing their health needs and problems, b) plan and then act to implement their solutions, c) create and maintain organisations in support of these efforts and d) evaluate the effects and bring about necessary adjustments in goals and programmes on an ongoing basis22. Using this definition, participation in health can be understood as a strategy that provides people with the skills and opportunities to significantly contribute to developing, implementing and monitoring solutions to their health issues.
Participation, gender and HIV/AIDS

In the last 20 years, this notion of participation has driven not only health development, but international development in general. Efforts have been made to involve local stakeholders in the development of projects, programmes and policies which affect them. However, such initiatives have rarely been gender-sensitive, often disregarding those who are most marginalised and vulnerable23. It is important to acknowledge here that the term gender should not be equated with the term women. Nonetheless, within the context of participation it is more often women who are marginalised and excluded as equal participants. According to Cornwall (2003), womens involvement is limited to implementation rather than participation24. Yet, the equal participation of women in decision-making spaces is vital, in order for them to directly represent their needs and realities when it comes to deciding on policies and strategies that affect and benefit them. Ensuring an equal number of men and women in any decision-making space does not ensure a gender-sensitive approach. Power plays an important part in conceptualising and achieving community participation and, in many cases, women have to struggle twice as hard to participate in spaces already dominated by those in power, ie, men. Participatory initiatives must be developed with an approach that actively seeks to encourage the participation of women in a meaningful way. This means that, in addition to ensuring an equal number of men and women participants, women must be provided with the necessary tools and skills in order to engage in such spaces effectively. This is particularly relevant in the context of HIV/AIDS where gender inequality fuels the HIV epidemic, as discussed in more detail in the next section.
22. J. David L. Zakus and Catherine L. Lysack, Revisiting Community Participation Health Policy and Planning, Vol. 13, No. 1, Oxford University Press, 1998 23. Andrea Cornwall, Whose voices, whose choices? Reflections on Gender and Participatory Development, World Development, Vol. 31, No.8, 2003 24. Cornwall, op.cit
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Target populations
Women-in-general
HIV prevalence rates in Latin America suggest that, to date, women have been less affected than men by HIV (see HIV/AIDS in Latin America and the Caribbean, p. 13), and yet numbers of women recently diagnosed with HIV are increasing, particularly in Central America25. In some parts of the region there is even discussion concerning the feminisation of the HIV epidemic26. By including women-in-general in this study, the Observatorio Latino acknowledges the need to engage more effectively with women as a population group at large. It should be noted that the term women-in-general is used throughout this report to indicate women from the general population who are not affected by HIV to the same extent as women living with HIV or female sex workers. Nonetheless, they do experience a complex set of factors, rooted in the gender inequalities that are predominant throughout Latin America and the Caribbean, which make them vulnerable to HIV. Recent studies carried out respectively in Chile, Colombia and Mexico emphasise that traditional gender roles within predominantly Catholic and conservative societies are a key determinant that contributes to increasing womens vulnerability to HIV27 28 29. In their 2008 study, Urza and Zuiga discuss how women are economically, socially and culturally subordinate to men in Latin American societies and the impact this has had in increasing vulnerability to HIV. For example, this subordination can have a direct impact in increasing HIV transmission through sexual violence or difficulties in negotiating condom use. Women believe they must conform to traditional roles as mothers and wives, within which they have minimal capacity and opportunity to negotiate sexual relations. Yet, it is not only gender inequalities in the context of sexual relations which contribute to increasing risk to HIV among women. In both Latin America and the Caribbean, women have less access to education and consequently, fewer opportunities for employment. Low-levels of education among women perpetuate a cycle in which men dominate both the public and the private agendas. A 2009 study carried out in Colombia30 indicates that as part of conforming within the traditional roles of mother and wife, women tend to place their own needs last, particularly where their health is concerned. Many only access health services for gynaecological reasons and so only discover their HIV status once pregnant. This situation has been compounded by lack of access to information and education concerning sexual and reproductive health and rights. In fact, this lack of information, combined with HIV programmes and strategies that have prioritised more-at-risk population groups (such as gay and other men who have sex with men, or female sex workers) has resulted in the common perception that HIV is not a priority issue for women in Latin America31, (although this is less true in the Caribbean where the male to female ratio of HIV prevalence is 1:1, see HIV/AIDS in Latin America and the Caribbean, p. 13). Many women believe that because they are in a stable relationship, they are not at risk of HIV transmission, and yet the UNAIDS 2008 report combines data from various studies which indicate that most women living with HIV in the region reported transmission from their long-term male partner32. That HIV is primarily being transmitted to women by their partners indicates that for HIV prevention efforts to be effective, the focus should continue to be on those groups most key to the dynamics of the epidemic (gay and other MSM, female sex workers and transgenders). Nonetheless, the increase in numbers of women testing positive for HIV demonstrates that a comprehensive national HIV response must also address why more women are testing HIV-positive. For this reason the Observatorio Latino has chosen to include women-in-general as a study group, while acknowledging that throughout Latin America and the Caribbean, HIV is still concentrated within very specific population groups.
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25. UNAIDS, Latin America Fact Sheet 2009, op. cit. 26. Garibi Gonzlez, C., The Complex Relationship Between HIV/AIDS and Violence, Sexualidad, Sociedad y Salud, 2009, no.3, pp.82-95 (Spanish only). Available at http://www.e-publicacoes.uerj.br/index.php/SexualidadSaludySociedad/article/view/27/247 27. Urza Morales, A., Ziga Barreda, P., HIV Vulnerability in Women at Social Risk, Revista Sade Publica, 2008; 42 (5); pp.822-9 (Spanish only) 28. Garibi Gonzlez, C., op. cit. 29. UNFPA, Colombian Ministry of Health, National University Colombia, Vulnerability Factors to HIV infection among Women, 2009, available at: http://www.unfpacolombia.org/home/unfpacol/public_htmlfile/VIHmujeresWeb.pdf (Spanish only) 30. Ibid 31. Ibid 32. UNAIDS, Report on the Global AIDS Epidemic 2008, op. cit.
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Women living with HIV
In addition to the challenges that people living with HIV often face in accessing both anti-retroviral treatment and treatment for opportunistic infections, they are also frequently subjected to high levels of stigma and discrimination in the workplace, in healthcare settings and even within their own families33. Women living with HIV, additionally, face other specific considerations that arise as a result of the unequal position that they occupy within society (see previous section). Many women living with HIV in the region have only had a minimal level of education, and as a result work in the informal sector34. In cases where a woman is too ill to work, her income source ends. Those who work in the formal sector may experience a similar situation when their employers find out about their positive diagnosis and they are forcibly dismissed. In healthcare settings, women often experience more discrimination than men. Upon receiving a positive diagnosis, they may be told by the doctor that they must no longer engage in sexual relations and they must not have children35. These judgements have no basis and yet, after a positive diagnosis, many women will believe what they are told by their doctor, as they have no other point of reference36. Similar discrimination may also be experienced within the family. As stated in the previous section, many women do not per-
ceive themselves at risk to HIV and so, often, their first HIV test is during pregnancy37. This being so, women learn about their HIV status before their partners even in cases when HIV transmission has occurred through their long-term partner. Upon disclosing their HIV status at home, they are often subject to discrimination by their partners and family who associate an HIV-positive diagnosis with an immoral lifestyle - the implication is that this is evidence that the woman has been unfaithful and so is not fulfilling her role as a dedicated wife and mother. Women living with HIV are rarely informed of their reproductive rights. Some may decide that they do not want to have children after receiving a positive diagnosis, for fear that they may not be well enough to care for the child. However, access to birth control and safe abortion is often difficult38. In cases where a woman living with HIV decides to have a child, she may not be given the necessary information to help reduce the possibility of mother-to-child transmission. Undoubtedly, both women and men living with HIV share many similar challenges upon receiving and living with a positive diagnosis. However, as described above, women experience a complex set of additional challenges; these need to be specifically addressed in any national HIV/AIDS response which seeks to provide integral care and support to all PLHIV.
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33. ICRW, Common at its core: HIV-related stigma, across contexts, 2005, available at: http://www.icrw.org/docs/2005_report_stigma_synthesis.pdf 34. ICW, Visibility, Voices and Visions, 2004, Spanish version available at: http://www.icwlatina.org/imagenes/biblioteca/visibilidad...pdf 35. UNFPA, Colombian Ministry of Health, National University Colombia, op. cit. p.20 36. Ibid 37. Gemetro, F., Bacin, G., Women living with HIV in Argentina, 2007 (Spanish only) 38. Abortion is illegal in most of the region apart from in cases of rape or when there is a threat to the life or health of the woman
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Female Sex Workers
In the context of HIV/AIDS, sex workers (female, male or transgender) are often labelled as a vulnerable population. This term, however, is misleading as it suggests that vulnerability is inherent to sex workers, rather than clarifying that it is the nature and context within which sex work takes place that create factors of vulnerability to HIV. Most countries in Latin America do not explicitly address sex work within national legal frameworks39. Legal systems rarely prohibit an individual from selling sex, but exploitation and/ or management of a brothel is often penalised. Local municipalities are free to develop norms and codes that sanction activities related to selling sex (loitering, indecent exhibition and exposure, managing an es-
tablishment for the purpose of sex work). Police are able to use these codes as an excuse to harass sex workers (particularly those working on the street). Many sex workers are forced to work in precarious conditions, thus exposing them to greater risks, exploitation and violence by pimps and/or clients. Sex workers are often subjected to high levels of stigma and discrimination from their family, friends and neighbours. Many also report similar levels of stigma from healthcare professionals (particularly those female sex workers who are also HIV positive) and consequently are reluctant to seek frequent health check-ups40. In Latin America, HIV prevalence rates among female sex
workers in the region tend to be lower than among gay and other MSM or transgenders, often just under 5%41. Some studies in the region suggest that condom use among female sex workers has increased significantly42. Certainly, in Latin America there are many organisations of female sex workers who work to defend their rights, and also carry out HIV prevention activities with their peers. By contrast, in the Caribbean, it has been more difficult for sex workers to organise themselves, not least because sex work is illegal throughout most of the region. It is important to note, that HIV prevalence rates among female sex workers in the Caribbean are far higher than in Latin America, reaching 9% and 27% in Jamaica and Guyana respectively43.
peru21.pe
39. International HIV/AIDS Alliance, Regional Consultation on HIV/AIDS and Sex Work in the Andes and the Southern Cone, 2006 40. Ibid 41. UNAIDS, Report on the Global AIDS Epidemic 2008, op. cit. 42. Ibid 43. UNAIDS, Caribbean Fact Sheet, 2009, op. cit.
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El trmino trans es empleado The term transgenders is used in this study to refer to individuals who identify as women, but were born as biological males44. Among the population groups included in this study, transgenders face the most unique and complex set of vulnerability factors to HIV. The few studies that have disaggregated HIV prevalence rates between men who have sex with men and transgenders (the latter ranging between 35-40%) clearly support this claim45. Lack of formal education among transgenders is often more prevalent than among female sex workers. Many transgenders left (or were thrown out of) home at an early age when their behaviour began to differ from the expected norms that conform with Latin American and/or Caribbeans societies expectations of gender identity and expression. As a result, transgenders often sell sex from a very early age46. Transgenders experience high levels of violence and not just in the context of selling sex47. Their gender identity and gender expression is constantly visible. In societies that place greater importance and value on men, as is the case in Latin America and the Caribbean, many people do not tolerate a biological man who chooses to identify as a woman. Unlike women living with HIV or female sex workers who may be
Transgenders
stigmatised for their HIV status or their profession, transgenders are stigmatised for who they are. Discrimination against transgenders is constant and in all settings (health, workplace, education, religion, family). In the context of HIV, transgenders have until recently been rendered invisible by their frequent public health categorisation as men who have sex with men. Many transgenders choose not to, or do not have the resources to have sex reassignment surgery. Biologically they are males, and public health studies and interventions have treated them as such. HIV prevention programmes have targeted gay men together with transgenders, but often they have little in common. As more transgender organisations have formed over the last few years, it has become clearer that many transgenders feel a stronger connection with female sex workers than with gay men. The Observatorio Latino believes it is pertinent to include transgenders in a study which is predominantly about women, because many of the vulnerabilities experienced by transgenders are rooted in their expression and identity with the feminine gender. As such, some of these vulnerabilities are shared with women-in-general, but particularly with female sex workers.
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44. The term transgender can also be used to refer to individuals who identify as men but were born as biological females. Female-to-male transgenders do not experience the same of level of risk to HIV transmission as male-to-female transgenders. This study only refers to the latter population group. 45. In 2008, the International HIV/AIDS Alliance published a report The Hidden Epidemic: Transgenders in Latin America and Asia which compiles HIV prevalence data among transgenders from Latin America and Asia. The report indicates that in Latin America and the Caribbean, only Peru, El Salvador and Argentina had carried out studies which disaggregated HIV prevalence data between MSM and transgenders. Available at: http:// www.msmgf.org/documents/LA_res_transepi.pdf 46. International HIV/AIDS Alliance (2008) The Hidden Epidemic: Transgenders in Latin America and Asia 47. Agniva Lahir, Vulnerability of male and transgender sex workers to STIs/HIV in the context of violence and other human rights violations, presentation given at the 8th International Congress on AIDS in Asia and the Pacific, Sri Lanka, 2007
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The Global Fund and the participation of women and transgenders in Latin America and the Caribbean
Considering the recently approved Global Fund strategies on Gender Equality and Sexual Orientation and Gender Identities, it is important to determine the extent of the participation of women and transgenders in Global Fund processes throughout the LAC region. It is hoped that the results will serve to feed into actions encouraged by the Global Fund to ensure a gender sensitive approach throughout Latin America and the Caribbean. The study also aims to highlight the existing challenges and barriers that serve as constraints to achieving effective participation. The report can be used as a baseline that both highlights current good practices throughout the region, and as an indication of where improvements and changes are needed. In this study, the term participation has been employed as defined earlier: the involvement of the community in developing, implementing and monitoring health-related solutions. As such, participation in Global Fund processes does not refer just to womens or transgenders participation on CCMs (monitoring and developing), but also to their participation in grant proposal development (developing) and in their subsequent access to Global Fund resources as sub-recipients (implementing). Only if women and transgenders are seen to be participating in all three of these processes, can they be judged to be participating at all local levels of the Global Fund. In addition to assessing the nature of the participation of women and transgenders in CCMs, grant proposal development and as Global Fund sub-recipients, the study seeks to identify whether participation has been effective. In determining how to characterise effective participation, it has been useful to rely on Andrea Cornwalls analysis of effective participation by women in forest protection committees, described in her 2003 article, Whose voices, whose choices? Reflections on Gender and Participatory Development. Cornwall suggests that womens opportunities to influence decision-making in these spaces rested not only on being present on these committees, but also on how and whether women represent womens interests, whether they raise their voices, and when they do, whether anyone listens48. So, participation can be considered effective if it is a) representative, b) when participants have the capacity to engage with other stakeholders, and c) when other stakeholders are open to listening and taking action on what is being said. This understanding of effective participation can be applied in the context of this study particularly when assessing participation of the target groups in CCMs and in national grant proposal development. However, at the level of implementation (access to Global Fund resources as sub-recipients) this definition is less useful. In this case, effective participation can be viewed in mostly quantitative terms the extent to which women and transgender organisations have been able to access Global Fund resources as sub-recipients, and whether this access bears any relation to their participation in CCMs and/or grant proposal development.
48. Andrea Cornwall, Whose voices, whose choices? Reflections on Gender and Participatory Development, World Development, Vol. 31, No.8, 2003
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III. Goal and objectives

Goal
Assess the participation of women (women-in-general, women living with HIV and female sex workers) and transgenders in Global Fund processes in Latin America and the Caribbean.
Objectives
1. Describe and analyse the characteristics and effectiveness of the participation of women (women-in-general, women living with HIV and female sex workers) and transgenders in country coordinating mechanisms (CCMs) throughout Latin America and the Caribbean49. Describe and analyse the characteristics of the participation of women (women-in-general, women living with HIV and female sex workers) and transgenders in the development of country-level proposals (or regional in the case of REDCA+) to the Global Fund throughout Latin America and Caribbean. Review the extent to which sectors of women (women-in-general, women living with HIV and female sex workers) and transgenders have been able to access Global Fund resources as sub-recipients. Identify the barriers that restrict women (women-in-general, women living with HIV and female sex workers) and transgenders from effectively participating in Global Fund processes in Latin America and the Caribbean.
2.
3.
4.
IV. Methodology
Design
The design of the methodology was guided by a number of key considerations: In seeking to analyse the nature of womens and transgenders participation in Global Fund processes in Latin America and the Caribbean, the study should prioritise their voices and perspectives. The study should seek to gain a comprehensive regional perspective of the different trends in participation evident among these population groups. The results of the study should include a map of the current situation regarding participation in CCMs across the region, and a description of how this participation has been gained, in order to provide practical information which will be useful for womens and transgenders groups when advocating for increased participation in Global Fund processes. As a result of these considerations, the study is predominantly qualitative in its approach. It emphasises the perspectives of women and transgenders and their own analysis of the quality of their participation. Data collection was guided by a number of qualitative variables with a small selection of quantitative variables to provide information on current levels of participation. The full list of variables is included in Annex 1. The study gathered data from 15 countries in Latin America and the Caribbean and one regional Global Fund grant - REDCA+ in Central America. In order to gather data from a significant number of countries throughout the region and make the most of available resources, three sets of research methods were designed, as detailed in Graphic 1. Regardless of the research method employed, data-collection took the form of individual in-depth interviews, using a semi-structured interview guide, and/or focus groups. The different interview guides are included as Annex 2. A total of 178 interviews and 42 focus groups were held in the 15 countries and one regional grant included in this study. It is important to emphasise that focus groups were exclusive to members of a population group in order to generate a safe space where participants felt comfortable to discuss individual perceptions
49. On average, the Global Fund opens a call for proposals once a year, this is called a round. The study includes Global Fund Round 5 to Round 9 (approved between 2005-2009) HIV/AIDS proposals only. In the absence of an HIV/AIDS proposal approved during that time period, the study reviewed the most recent HIV/AIDS proposal to have been submitted by the country.
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of their groups participation in Global Fund processes. In cases where a population group enjoys direct representation in the CCM, this representative was not invited to participate in the focus group, so as not to affect the discussions of other members; rather, she was interviewed separately. It is worth noting that identify-
ing women to participate in the focus groups of women-ingeneral was challenging. Participants in the women-in-general focus groups were selected based on whether they work in womens organisations implementing interventions related to HIV/AIDS and/or promote and defend womens interests in relation to HIV/AIDS. The major dificulty was to ascertain
whether the women promote and defend womens interests in relation to HIV/AIDS; which suggests that women who work in HIV/AIDS do not necessarily address the issue within a wider context of womens rights and realities. This issue is given further consideration later in the report.
Graphic 1: Countries included in the report, disaggregated by research method
First Research Method: Focus Countries (6)50
A local researcher was responsible for data-collection over a two-month period between July and September 2009 in each focus country. An average of 20 individual interviews and four focus groups (one with each population group) were carried out.
Second Research Method: Semi-Focus Countries (7)
Data-collection was carried out by the regional researcher over the period of a week in each country between September and October 2009. An average of 10 individual interviews and 3 focus groups (priority was given to population groups currently participating in the CCM) were carried out in semi-focus countries.
Third Research Method: Non-Focus Countries (2 and 1 regional grant)
The regional researcher was responsible for data-collection in two non-focus countries and 1 regional grant. Data was collected in the form of telephone interviews. Up to 5 phone interviews were carried out in each country, and with key stakeholders involved in the implementation of the regional grant. No focus groups were carried out under this research method.
Countries were selected according to the following criteria:

Countries that are implementing, have implemented or have presented HIV/AIDS grants to the Global Fund; Countries that have had their HIV/AIDS grants extended through the Rolling Continuation Channel mechanism (RCC); For focus countries in particular, countries with organisations of women living with HIV, female sex workers or transgenders who have a strong relationship with the Observatorio Latino. This criterion was used in order to facilitate the support and follow-up of recommendations that arise from the study.
50. The data collected in focus countries for this study has also been analysed separately and published in an in-depth country-specific report which follows a similar structure to the regional report. 51. Rolling Continuation Channel is a mechanism employed by the Global Fund to facilitate the continuation of grants which are coming to an end. CCMs are invited to submit a proposal outside of the traditional Round process.
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Ethical Considerations
Informed consent forms were developed for use with all study participants (face-to-face and phone interviewees, and focus group participants). Participants were informed of the studys objectives and their own role within the study and neither interviews nor focus groups took place without the explicit consent, supported by the signature of the relevant informed consent form, of the participants. They were given the right to remain anonymous. Informed consent forms (for individual interviews and focus groups) are included as Annex 3. The report uses quotes from interviews and focus groups, as relevant. In order to preserve the anonymity of study participants, the quotes are attributed to the respective population group and country. When the quote is from a CCM member who represents a specific population group, this is clearly stated. In cases where identifying the country may compromise an individuals anonymity, only the region is stated (Central America, South America or the Caribbean); this is particularly relevant to cases where the quote is by an individual representing a specific population group in the CCM.
Studys Limitations
The information included in this report is restricted to the 15 countries and the regional grant from where data was collected. The Observatorio Latino acknowledges that for a comprehensive regional overview of participation, data-collection would have been required from all the countries in the region. Nonetheless, it is hoped that the data analysed in this report is sufficient to provide an accurate understanding of the participation trends prevalent in the region and the challenges faced by women and transgenders in achieving effective participation. Moreover, it is believed that some of the experiences and examples of good practice included in the report are relevant across the region. The study acknowledges that for both women and transgenders there are significant structural barriers, not least socio-economic and political factors exacerbated by gender inequalities, that can play a critical role in determining access and effectiveness of participation in Global Fund processes. However, it is important to emphasise that this study was not designed to focus on these structural barriers. Instead, it highlights practical barriers to participation that in many cases are applicable to other population groups beyond women and transgenders (such as gay and other men who have sex with men or drug users). In this way, it is hoped that the reports recommendations are realistic and relevant to the context within which organisations of women living with HIV, female sex workers and transgenders currently operate. Women-in-general were included in this study in recognition of the increasing numbers of women testing HIV positive. However, once data collection began it became clear that womens organisations are neither participating in CCMs nor in the implementation of Global Fund resources. This may indicate that HIV/AIDS is not a priority issue for womens organisations in Latin America and the Caribbean. As a result, the report contains very little information about the participation of women-in-general in Global Fund processes.
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Partnerships
The overall study was coordinated by the Observatorio Latino, and has benefited from financial and technical support from UNAIDS and the International HIV/AIDS Alliance. Research was carried out by one regional researcher and 6 local researchers (one in each focus country). The regional researcher was responsible for designing the research protocol, data-collection tools, informed consent forms, and providing support to local researchers. Data analysis was carried out by the local researchers and the regional researcher, in close coordination with the Observatorio Latino. UNAIDS and the International HIV/AIDS Alliance provided key inputs and feedback during the development of the protocol and during the drafting of the regional report. The Latin American and Caribbean Network of Female Sex Workers (RedTraSex), the Latin American and Caribbean Network of Transgenders (RedLacTrans), and the Latin American Network of Women living with HIV (ICW Latina) supported the study by recommending study participants among their respective population groups in each country.
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V. Results
Va.Representation and Participation in the CCM
Current representation of women and transgenders in 15 CCMs across Latin America and the Caribbean
A review of the CCMs in 15 countries in LAC indicates that women-in-general, women living with HIV, female sex workers and transgenders are represented in the CCM in one of three different ways. 1. Direct representation refers to instances in which a CCM representative is responsible for representing the specific interests of her own constituency. For example, a transgender CCM representative who occupies a seat specifically assigned for transgenders. She is responsible for representing the interests of the transgender community. Shared representation refers to instances in which a population group is represented in the CCM through a shared seat. The representative does not necessarily belong to the population group in question, but may be responsible for representing various constituencies at a time. Examples include female sex workers being represented by a seat that is allocated to a wider coalition of civil society organisations, or transgenders who are represented by a seat designated to an LGBT coalition. Diluted representation is a form of shared representation. It refers to situations in which a member of a population group is a CCM member but her mandate goes beyond the specific representation of her own population group52. An example of this is when a woman is acting as representative for People Living with HIV (PLHIV); her mandate is to represent the larger group of PLHIV rather than the specific needs of Women Living with HIV (WLHIV). Table 1 depicts the current state of representation in the 15 countries included in this study. Colours have been used to depict the type of representation in place for each population group in each country.
3.
2.
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52. There is a recent example of this in El Salvador where a female sex worker has been elected to a civil society coalition seat.
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Table 1: Representation of women and transgenders in 15 CCMs in Latin America and the Caribbean (December 2009)
Country Women-in-general Women living with HIV
Central America Costa Rica El Salvador Guatemala Honduras Nicaragua Panama South America Argentina Bolivia Colombia Ecuador Paraguay Peru Caribbean Jamaica Rep. Dominicana Surinam
1 Mid - 2007 2 Mid - 2009 3 Late 2008 4 Mid - 2008 5 2008 6 2007
Female sex workers
Transgenders
5 5
4 6
Direct representation
Shared representation
Diluted representation
The following section has initially been divided by population group. It focuses on a) their different experiences with regards to gaining access to the CCM; and b) the different perceptions held by population representatives, their constituencies and other CCM members of the effective-
ness of their participation once in the CCM. The results of the study showed that while there are differing experiences between the population groups with regard to gaining access and participation once in the CCM, there are also
many shared factors (including communication, legitimacy etc.) that can contribute to improving or reducing their access and effective participation. These will be reviewed together at the end of the section.
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Gaining access, representation and participation in the CCM

Women-in-general
Although women constitute a considerable proportion of CCM members across the region, only the CCM in Honduras has designated a specific seat for the representation of women-in-general. In Suriname, the CCM member list includes a womens organisation. However, this organisation was invited to participate in the CCM on behalf of community-based organisations rather than in representation of women-in-general. In the Dominican Republic, the NGO Forum (a coalition of civil society organisations) includes two womens organisations. The Forum has its own seat on the CCM in representation of its civil society member organisations. Not satisfied with shared representation on the CCM, perceiving it does not adequately represent their needs, both of the womens organisations have unsuccessfully requested their own seat on different occasions. Their petitions have been denied; government representatives in the CCM explain that the current representation mechanism in the form of the shared civil society seat occupied by NGO Forum eliminates the need for a specific seat for women-in-general. In Ecuador, the National Council for Women (CONAMU by its acronym in Spanish) held a seat in the CCM until May 200953. Although the CONAMU representative brought a womens agenda to the table, it should be noted that the occupant of the CONAMU seat was appointed by her organisation and not by a wider sector of women-in-general. Despite the noticeable lack of representation of womenin-general in over 85% of the CCMs reviewed, many of the individuals interviewed for the study felt that women are strongly represented in their respective CCMs. When asked for more information about womens representation, many explained that their claims are based purely on the high proportion of women members in this mechanism. Some CCM members went on to acknowledge that despite the high proportion of women members, this had not translated into the strong defence of womens needs and realities in the CCM. Instead, international organisations such as USAID or UNDP were often credited with raising womens needs. In these instances, it was acknowledged that although these international organisations raise womens issues during CCM meetings, the representatives of these organisations are neither leaders nor members of womens organisations. Womens issues are raised but without the legitimacy of an elected representative accountable to her constituency. It may be that the lack of representatives of women-ingeneral in the CCM reflects the absence of HIV/AIDS as a priority issue within the agenda of womens organisations and movements across the region. This study did not explore the reasons for which womens organisations are not engaging in HIV/AIDS interventions. Arguably, the perception that women are not a high-risk group in the context of HIV could have hindered any efforts to mobilise around this issue. However, this explanation is not adequate in the context of the Caribbean, where the male to female ratio is 1:1. Additional research is required to explore the absence of womens organisations from national responses to HIV/AIDS. The lack of women-in-generals participation in the CCM extends to participation in proposal development and access to resources. As such, it should be noted that the remainder of this study focuses on women living with HIV, female sex workers and transgenders (see Study Limitations, p. 24)
53. In May 2009, the CONAMU ceased to exist following a presidential decree. It will be replaced by the National Council for Gender Equality. It remains to be seen whether the CCM in Ecuador will designate a specific seat for this newly created government body.
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Women living with HIV
Representatives of people living with HIV participate in all of the 15 CCMs included in this study. Women living with HIV are present, either as voting or alternate members, in 13 of the CCMs. However, in 12 of these, they sit on the CCM in representation of PLHIV, rather than WLHIV (diluted representation). Only the CCM in Guatemala has allocated a specific seat for this particular population group (direct representation). In a few countries, including Ecuador, Peru and Costa Rica, either the community of people living with HIV or the CCM has requested gender balance among PLHIV representatives. However, the female representative is not elected at an assembly of only women living with HIV, but rather at a wider assembly of PLHIV during which both men and women vote for each representative. The remaining CCMs do not request a gender-balanced representation among PLHIV representatives. Nonetheless, despite the frequent lack of a formal requirement that both men and women living with HIV participate in the CCM, there are only two CCMs in the region, Colombia and Panama, where PLHIV are represented by men alone (shared representation). Despite the presence of women living with HIV in 13 CCMs, many individuals interviewed argued that this has rarely translated into the insertion of a WLHIV agenda in CCM meetings.
Even though the PLHIV representative on the CCM is a woman, she fights on behalf of PLHIV in general (Principal Recipient. South America) Some female representatives explained that their PLHIV mandate on the CCM provides neither the opportunity nor the right to highlight WLHIV-specific issues: My job is to put a PLHIV agenda on the table, not a specific one of women living with HIV. I defend the rights of PLHIV in proposal development and in any decisions that are made on the CCM, I always try to ensure that PLHIV needs are put first. (Female PLHIV CCM representative. Caribbean) In some countries, the dominance of the PLHIV agenda was explained in the context of the pressing and urgent needs related to access to treatment. PLHIV advocacy agendas have prioritised access to treatment and services and against this background, WLHIV organisations have struggled to develop their own agenda. Nonetheless, some of the women who were interviewed identified sexual and reproductive rights, minimal employment opportunities, gender-based discrimination and violence, as some of the WLHIV-specific issues that they feel are not be-
ing addressed in existing PLHIV agendas. When asked about the level of their participation in CCM meetings, the women living with HIV who are CCM members and other CCM members agreed that although it can vary slightly depending on the personality and capacity of the individual, on the whole, women representatives of PLHIV tend to be active and vocal members who are quick to articulate and defend the needs of the PLHIV community, particularly on treatment-related issues. In summary, although there are women living with HIV actively participating in most CCMs, representation of this population groups needs and realities is overshadowed by those of a wider community of people living with HIV.
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Female Sex Workers
Female sex workers are represented in 11 of the 15 CCMs. However, they benefit from direct representation in only 5 CCMs (see Table 2), most of which are in South America and all of which have been created in the last three years. In the remaining CCMs, they are represented by a shared seat which is designated to a civil society coalition of NGOs (Costa Rica, El Salvador and Paraguay), or vulnerable populations (Peru), or they are indirectly represented by an organisation that works with sex workers (Suriname and Jamaica). In El Salvador, a sex worker has recently been elected onto the CCM, but in representation of the national forum of NGOs rather than in direct representation of her population group. This last instance is the only example of a female sex worker whose mandate on the CCM goes beyond her own population group and at the time of datacollection it was still too early to assess the implications of this diluted representation. In some of the countries where female sex workers are directly represented on the CCM, gaining access to this space is acknowledged to have been a long and challenging process. In Argentina and Ecuador, the respective national organisations of female sex workers advocated directly with CCM members, the National AIDS programme and international agencies, while also frequently sending letters to the CCM to request a sex worker-specific seat. In Guatemala, the lack of a legally-registered female sex worker organisation had acted as a barrier from participating in the CCM. A sex worker-specific seat was created in mid2007 when OMES, an organisation of female sex workers and a member of RedTraSex, finally received its legal registration. The studys results indicate that the work carried out by the regional network of female sex workers was a key factor in gaining the 5 sex worker specific CCM seats, thanks to their persistent advocacy for the direct representation of female
sex workers in CCMs across the region. The five sex worker seats that now exist in the region are all occupied by members of RedTraSex. Additionally, the sex worker CCM representatives have participated frequently in training workshops organised by the regional network as part of the latters mission to build the capacity of its member organisations and their leaders. In some countries where shared representation is currently the only way for female sex workers to have their voice heard on the CCM, organisations of female sex workers have requested a sex worker-specific seat (El Salvador, Peru). They believe the existing form of representation does not adequately reflect their needs in this space. We still dont have our own space as sex workers on the CCM, but we need it because our realities are really different from those who supposedly represent us in that space (Female sex worker. Peru) We dont feel represented by [two civil society coalition seats] even though theyre supposed to also represent us in that space, but they never ask us our opinion or tell us whats happened. We havent been given the chance to participate on the CCM. (Female sex worker. El Salvador) Their petitions for a sex workerspecific seat have not yet been successful; other CCM members explain that there has to be a limit to new seats on the CCM otherwise the mechanism will become unmanageable and decision-making even more difficult. In contrast, in those countries (Argentina, Ecuador, Guatemala, the Dominican Republic) where female sex workers are directly represented in the CCM, female sex workers concerns are less related to representation and more to the quality and effectiveness of
their participation. In particular, female sex worker representatives mentioned 1) their own confidence and capacity to participate, and 2) their perception that the CCM provides limited opportunities to raise their populations issues. A few of the interviewed sex worker representatives on the CCM described how their confidence to raise their hand or ask for a clarification during meetings is often related to how well they know the other CCM members present. I tend not to ask when I dont understand, I think its a confidence issue. I feel more at ease with some CCM members than others because I have participated in other spaces or because I know theyre our allies. If they arent there, I tend to keep quiet (Female sex worker. CCM representative. Caribbean) Level of Global Fund knowledge and amount of advocacy experience was also quoted both by sex worker CCM representatives themselves and other CCM members as important variables that affect the quality of their participation. They raise their voice but not in a strategic way, I believe that there is a steep learning curve to knowing how to participate in the CCM. Female sex workers are not yet participating effectively. I think this is directly related to their lack of understanding of the political importance of the CCM. (Other CCM member. Caribbean) The participation of female sex workers is weak on the CCM. Despite having their own seat their needs and position arent really visible in the CCM. [] Their plans and policy positions arent really clear. (Other CCM member. Central America) It is worth noting that the sex
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worker representatives in Ecuador and Argentina are members of large national sex worker organisations. These organisations have significant experience in advocacy work and have successfully sourced funding from a diverse range of donors. The (internal and external) perception of the quality and effectiveness of their participation in the CCM is stronger than in those where sex worker representatives belong to weaker and less-experienced organisations. Their concerns regarding the effectiveness of their participation are not linked to their own capacity, but to a perception that CCM meetings rarely provide an opportunity to advocate on behalf of their population group.
This is a common perception shared by WLHIV, female sex worker and transgender CCM representatives alike. As such, it is analysed in more detail in the section on CCM-level Barriers on p. 37. The direct representation of female sex workers is still a relatively new phenomenon in the region and there are still too few instances. Shared representation is more common, but female sex workers believe that this scenario rarely allows their needs and realities to be accurately represented on the CCM. Once in the CCM, the quality of the participation of female sex workers is closely related to the strength and advocacy experience of their organisations.
The [RedTraSex] regional proposal is a clear example of the benefits of us being on the CCM. We were able to present it directly to other CCM members and they listened. In countries where were not on the CCM, our peers had to fight to get the CCM to invite them to a meeting and put the issue on the agenda. (Female sex worker. CCM representative. South America) RedTraSexs country focal points were responsible for presenting the networks regional proposal to their respective national CCMs for approval (a Global Fund requirement when presenting a regional proposal). They believe that as CCM voting members, it was a far quicker and easier process to place the RedTraSex regional proposal on the CCM agenda (in some instances, an extraordinary CCM meeting was called for the sole purpose of reviewing the proposal). This is in marked contrast to other countries where there is no direct representation of female sex workers on the CCM. Sex worker representatives said that as CCM members they felt confident when presenting the proposal and requesting CCM approval.
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Transgenders are represented in 12 of the CCMs in this study. Although this figure is higher than for female sex workers, it is important to note that they are directly represented in only 3 CCMs (Argentina, Guatemala and Nicaragua)54. They are indirectly represented in the remaining 9 by an LGBT seat (Bolivia, Colombia, Ecuador, Honduras, Panama and the Dominican Republic), a civil society coalition seat (El Salvador, Paraguay), or a vulnerable population seat (Peru). The three transgender-specific seats on CCMs are relatively new; the first seat was created in Argentina in late 2008, and the remaining two in 2009 in Central America (Guatemala and Nicaragua). The Caribbean does not have a transgender representative in any of the CCMs included in this study55. There is a fourth transgender representative in Colombia; however she represents a wider LGBT coalition (diluted representation)56. Transgender representation on CCMs has, until recent years, been gained almost by default, in the form of a seat for gay and other men who have sex with men (MSM). Transgenders have frequently been categorised for public health purposes using the epidemiological term of MSM; their gender identity is rendered invisible under such terminology. While theoretically enjoying widespread representation throughout a region where most CCMs have a seat representing gay and MSM (in recognition of high HIV prevalence rates among this population group), for transgenders this has led to passive participation in the specific context of participation in CCMs. In the majority of instances, it is a gay man who has been elected (or
Transgenders
appointed) to fill the LGBT seat, and who has the responsibility to represent not only the gay male community but all other members of the diverse LGBT population. Transgenders, however, as a result of their gender identity and expression, experience very different needs and realities to gay men (see section on Transgenders, p.20). The former often reject the notion that gay men can accurately represent them in the CCM. I dont feel that I have a voice [on the CCM]. When we do go to meetings, it is always about MSM, HIV-positive people and other vulnerable groups. The needs of the transgender group never come up. Worse, we are never consulted about our needs (Transgender. English-speaking. Caribbean) We dont feel represented by a gay man on the CCM. How can he know our needs? (Transgender. Ecuador) In recent years across Latin America, a larger number of transgenders have organised their own groups, and have mobilised around issues of gender identity rights, gender-based discrimination and violence and particularly HIV/AIDS, in light of recent studies that estimate HIV prevalence rates as high as 40% among transgenders. Ive told the CCM, there arent enough specific studies on transgenders. Were fighting to stop being classified as MSM. Our reality is hidden under that term. We are transgenders and need to be considered differently from gay men (Transgender. CCM representative. Central America)
As with female sex workers, gaining direct representation in the CCM has, in each case, been a long process. Again, similarly to female sex workers, this process has been closely supported by the Regional Network of Transgenders (RedLacTrans) with regional-level advocacy. All three current transgender CCM representatives agree that gaining direct access to the CCM was made possible by their persistent national and regional advocacy work, coupled with the Global Funds most recent CCM guidelines that encourage the participation of those populations most affected by HIV in the CCM. Similar processes to those which have taken place in Argentina, and particularly Guatemala and Nicaragua, are also happening in other countries around Latin America and the Spanish-speaking Caribbean, so it is likely that there will be more transgenderspecific seats in CCMs in the near future. The situation is far more challenging in the English-speaking Caribbean where transgenders experience high levels of stigma and discrimination and where there are very few organised groups of transgenders.
54. The Nicaraguan CCM is being restructured and the transgender seat is set to be integrated into a wider LGBT seat in the near future. 55. Transgenders are not directly represented in any CCM in the Caribbean, not just those Caribbean CCMs (the Dominican Republic, Jamaica and Suriname) included in this study. 56. The transgender who is in the CCM in Colombia is not included in the figures quoted as direct representation of transgenders as the seat is not specific to transgenders. At the next election, the seat may be filled by a gay man, lesbian or transgender.
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The role of legitimacy and accountability in effective CCM participation

The Global Fund recommends that CCM members be democratically elected by their respective constituencies. This should result in a CCM representative who is acknowledged, both by his or her constituency and other CCM members, as having the legitimacy to represent a wider group. Moreover, the representatives accountability should be to all population group members (or wider constituency members in cases of shared representation) and not just to the small number of individuals who voted in the election. The reality is often very different; most representatives have been elected by members of their constituency, however, elections are not always considered to be open or transparent. In some cases, often when an organisation played an instrumental role in advocating for the creation of a seat for a specific population group, CCM seats are informally perceived as belonging to an organisation and not to the wider constituency. In such instances, it is common for the director of the organisation to be named as the CCM representative, without having been first elected by a wider constituency. Lack of legitimacy (be it real or perceived) plays a key role in reducing the effective CCM participation of all of the population groups included in this study. In turn, a lack of legitimacy can affect the chain of accountability between a representative and his or her constituents. Most women representatives of PLHIV in the CCM have been elected at an assembly of PLHIV. In some countries, the assembly will include members from a national network of PLHIV, members from different PLHIV organisations (national or local-level) and members from different PLHIV support groups. In CCMs where the PLHIV seats have been assigned to specific networks or organisations (such
as Argentina and Guatemala), representatives will be elected by members of their own organisation or network. In both scenarios, there are concerns related to the legitimacy of representatives. In elections held at large assemblies, there are concerns that the stronger PLHIV organisations are able to dominate elections and effectively select the representatives they choose. Members from smaller organisations feel that they are invited to the elections in order to legitimise the election process, but that they have little opportunity to influence the election outcome. WLHIV participants in a focus group in El Salvador explained that two of them had unsuccessfully attempted to stand for election as candidates for one of the four PLHIV seats on the CCM. Their perception is that the election candidates had been pre-selected by the stronger organisations present at the PLHIV assembly and that, as a result, the election was neither fair nor transparent. In instances such as these, the legitimacy of CCM representatives is undermined, as members of the population group who feel that their election vote did not count subsequently dissociate themselves from the representative. The study illustrates other examples of PLHIV assemblies in the region that are organised at short notice, or where invitations are not widely distributed, thus limiting the level of participation in the elections. Some of the women living with HIV who participated in the focus groups claimed that they had not participated in the elections for the current PLHIV representatives on the CCM, and some did not know who their representatives are. When representatives are not perceived to have been elected in a transparent fashion, their accountability may also be compromised. In such instances, representatives may prior-
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itise only the needs and realities of those who elected them in the CCM, and do not seek to consult the wider constituency who they have a responsibility to represent. This is particularly relevant in cases where representatives have been selected rather than elected, often when CCM seats are organisation-specific. Such examples are more frequent among seats allocated to the PLHIV community where the CCM seat has historically belonged to one organisation/network/coalition of PLHIV. However, as the community of PLHIV has grown and become more diverse, the form of electing (or selecting) the CCM representative is no longer representative of the wider PLHIV community. Those most affected by this situation are women living with HIV who have traditionally organised themselves within larger groups of PLHIV. In cases where WLHIV are CCM members, they perceive their accountability to be toward their organisation or, at best, to the wider PLHIV community. Rarely do women representatives of PLHIV recognise that their CCM participation can be used to specifically benefit WLHIV, believing either that this would detract from representation of PLHIV needs, or that their accountability is not to WLHIV (see WLHIV section on Gaining Access, Representation and Participation in CCM). Issues around legitimacy and accountability affect female sex worker and transgender representatives equally, but for different reasons. Most female sex worker and transgender representatives have been elected by their respective constituencies, but the election process is often different to the larger assemblies organised among the PLHIV community. Unlike PLHIV seats in the CCM (a Global Fund requirement rather than recommendation), female sex worker and transgender seats have been largely gained thanks to consistent
advocacy on the part of their specific respective organisations. As a result, although the seats represent a population group, they are perceived as belonging to the organisation that advocated for their inclusion in the CCM. Representative elections take place with the involvement of organisation members only. The opinions of female sex workers and transgenders who participated in focus groups regarding the legitimacy and accountability demonstrated by their representatives tends to be more positive than the perceptions held by WLHIV. This positive bias may, of course, be due to the fact that the majority of female sex workers and transgenders who participated in the focus groups belong to the same organisation as their CCM representative. In some cases, the representatives belong to the only organisation of female sex workers or transgenders in the country, and so it is natural that elections take place only with members from the respective organisation. In other cases, the organisations have a nation-wide reach, and sex workers or transgenders from around the country participated in the election of their representative, thus ensuring national-level representation. Nonetheless, despite nationallevel democratic elections, representatives are still chosen within one entity (be it an organisation or a network of organisations). Accountability may not yet be an issue in countries with a small number of organised groups of female sex workers and transgenders, but this may change as these movements strengthen and increase in number. Aside from legitimacy issues specific to the different population groups, certain legitimacy issues are shared by all. Due to economic and logistical challenges, CCM representative elections tend to be held in the capital city. This limits the participation of individuals and/or
organisations from other areas and establishes a capital-centric representation on the CCM. There are few examples of CCM members who do not live in the capital city (with a few exceptions, for example in Argentina and Guatemala). Certainly, a number of participants in focus groups from outside the capital felt that existing representatives do not represent their local reality, and that communication between the representative and the constituency was even more challenging because of the distance. (The following section provides more detail and analysis on communication flows.) Other CCM members interviewed as part of the study expressed their own concerns regarding their perception of representatives legitimacy. Although the Global Fund recommends that representatives be democratically elected by respective constituencies, this is not explicitly stated in all CCM bylaws. Some CCM members expressed their concerns that the mechanisms used to elect representatives are not clear and that their participation on the CCM does not necessarily reflect the voice of a wider constituency, but rather individual representation. it suggests that CCM representatives need to ensure that election processes are documented and that they share the documentation with other CCM members.
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Communication between CCM representatives and their constituencies

Communication plays a fundamental role in contributing toward effective representation in any mechanism that brings together elected representatives. The latter should communicate information gained and decisions made at CCM meetings to their respective constituencies, while also providing the opportunity for their constituencies to respond to the new information and raise any issues or concerns as relevant. Effective communication between representatives and their constituencies contributes toward more informed and Methods of communication representative decision-making in the CCM. Women living with HIV, female sex worker and transgender representatives in the CCM, and members from their respective constituencies were asked to describe the different types of communication that are used to share information. The results indicate that most representatives have sought ways to disseminate information learnt in the CCM down to their constituencies; however, this happens using a variety of informal systems. No evidence was found of formal, documented systems developed by representatives or their organisations that describe mechanisms that WLHIV, female sex workers or transgender CCM representatives should use to communicate with their groups. The research discovered three principal methods of communication that are used on an informal basis by representatives to share CCM-related information with their constituencies, detailed in the next chart:
Description and analysis of the effectiveness of each method

After CCM meetings, representatives write a report summarising meeting outcomes and send this by e-mail to members of their constituency. Generally, the recipients are members of the representatives own organisation. In cases where there is shared representation, reports are disseminated to all members of the wider coalition or NGO forum. Individuals who have received reports by e-mail explained that they often find the reports difficult to understand because they rarely know the context surrounding the decisions made, or information discussed at CCM meetings. Most individuals interviewed have e-mail addresses, but many do not access their accounts frequently and said that when they do see the report it is often quite a few weeks after it was sent. Representatives who write these reports (particularly female sex workers and transgenders) described how challenging they found it to draft reports that accurately describe what happens at CCM meetings in a way that makes them relevant and interesting to their constituency. Although the electronic dissemination of written material is a widely accepted method of sharing information, it is important to consider that women living with HIV, female sex workers and transgenders do not all share similar levels of literacy. Many find it considerably challenging to understand the content of reports. This can be demotivating which, in turn, means that they will be unlikely to provide feedback. Information is often shared at weekly or monthly organisational meetings. In cases where there is shared representation, there may be monthly or bimonthly meetings of a group of organisations and the CCM representative may be invited to share what happened at the most recent CCM meeting. This often happens on an ad hoc basis. It tends to be the representatives responsibility to put the Global Fund and CCM meetings on the meeting agenda. This method of communication has advantages over the electronic dissemination of reports by allowing individuals present to ask questions for clarification, and provide immediate feedback. However, many individuals interviewed also expressed frustration with this method as they feel that CCM representatives, by presenting in person at such meetings, believe that it relieves them of the responsibility of writing a report which can be more widely disseminated. Information flows, therefore, to a very reduced number of people through such a method. Those who do not live in the capital, or are unable to attend the meeting, lose the opportunity to find out what happened at CCM meetings. Face-to-face meetings are least effective in cases of shared representation, where absence from a meeting means that there is no further opportunity to access information. In the case of direct representation, constituency members are often in more frequent contact with their representative, and are more likely to be able to receive information informally in other spaces (see one-to-one exchanges below). Many individuals (WLHIV, female sex workers and transgenders alike) who participated in focus groups mentioned one-to-one exchanges with CCM representatives as the method most likely to allow them to fully understand the information shared at CCM meetings and its relevance to their population group. One-to-one exchanges tend to happen on an informal and spontaneous basis. They are also considerably dependent on personal relationships. Several participants explained that they do not access Global Fund and CCM-related information from their own representatives on the CCM, but from other CCM members with whom they have a better relationship and whom they feel they can approach more easily. This method of communication is neither an effective way of disseminating information nor of gathering feedback or evidence of a population groups needs. However, the fact that this method was mentioned by many individuals in the focus groups suggests that it has served as a means of generating interest and sharing Global Fund and CCM-related information. This confirms the claim put forward by a female sex worker in Central America: Its not that we cant write reports about what happens, its just that we find it easier to talk about it, explain it, and we know that our compaeras find that easier to understand too.
Written reports shared by e-mail
Organisation-wide meetings
One-to-one exchanges
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It should be noted that in instances where a population group is not represented in the CCM (by neither direct nor shared representation), communication with this group is virtually nonexistent. In such cases, there are examples of organisations who have attempted to access CCM meeting minutes. However, the latter are rarely distributed beyond CCM members (with the notable exception of
Honduras, where the CCM has a website that provides access to all relevant documentation). It is also important to acknowledge that participants frequently stated (with the exception of Paraguay) that in cases of shared representation, it is far more difficult to access CCMrelated information from their representative. Representatives tend to share information with
their own population group and their own organisation, even in cases where their representation goes beyond their specific population group. It is important to understand this in the context of the earlier discussion of accountability, and the perception that a representatives accountability is limited to those who were individually responsible for the election, rather than the wider constituency.
Factors that have contributed to improving access and participation in the CCM
Global Fund recommendations that the populations most affected by HIV should be represented on the CCM. Female sex workers and transgenders who participate in the CCM in direct representation of their respective population group explained that despite persistent advocacy to gain access to the CCM, in most cases their insistence was unsuccessful. This situation changed once the Global Funds recommendations to include population groups who are most affected by HIV in the CCM became stronger (towards the end of 2007). Those interviewed believe that the Global Funds recommendations created an environment where it was perceived that female sex workers and transgenders, in particular, had to be represented in the CCM in order to meet Global Fund eligibility requirements. In some cases this has translated into direct representation, in others into shared representation; what is clear is that the representation of both these population groups in the CCM is very recent. Advocacy by strong and respected organisations who have been or are starting to play a key role in the national response. Having recognised the importance of the Global Fund, organisations of female sex workers and transgenders in particular have advocated for direct representation on the CCM. Their petitions have been taken more seriously in countries where the organisation is already well-known and where their work is respected. Support, advocacy and increased visibility resulting from the work carried out by regional networks. Regional networks have, and can continue to play a significant role in building the capacity of their member organisations. Specifically, RedTraSex and RedLacTrans have emphasised the importance of the Global Fund to their members and encouraged them to advocate at a national level for direct representation in the CCM. At a regional level the networks have played an important part by raising awareness of the needs and realities faced by the different population groups and advocating that these same populations play a central role in HIV/AIDS responses.
flickr.com (Photographer: nanettesol)
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Barriers that reduce effective participation in the CCM

Lack of recent epidemiological data and other HIV/AIDS-related studies focusing specifically on women-in-general, women living with HIV, female sex workers and transgenders. In Latin America and the Caribbean, there is least specific data related to transgenders as they have often been grouped together, or even hidden within, the category of men who have sex with men. The Global Fund emphasises the importance of evidence-based HIV programming, decision and policy making. Limited data does not allow CCM representatives from the population groups in this study to support their claims in CCM meetings, claims which they often have direct experience of. Other CCM members explained that this lack of data has made it difficult for certain population groups to negotiate effectively in the CCM.
General Barriers
When there are opportunities to discuss issues that are relevant to certain population groups, the representatives are rarely able to support what they say with data or other information that consolidates their stance. This limits their participation and doesnt allow them to be heard (Other CCM member Honduras)
Barriers at the CCM level
Lack of a systematic induction process to CCM participation. The study only found evidence of one CCM (El Salvador) that has established a formal induction process for new members. Representatives in the CCM from the studys population groups emphasised the importance that a comprehensive induction can make to their participation in this decision-making space. In response to the lack of a formal induction, many representatives explained that they had relied on alliances with existing CCM members, whom they had asked for access to recent CCM meeting minutes and other relevant information (grant proposals, recent principal recipient reports etc). It was often difficult to get hold of this documentation, and so new representatives were unable to understand much of the context surrounding issues raised in CCM meetings. Lack of gender expertise among CCM members. The Global Funds recent Gender Equality Strategy underlines the importance of gender expertise among CCM members and recommends sex parity among membership and leadership57. Certainly, the majority of CCMs in the region have achieved sex parity among membership; however, this does not immediately translate into a CCM that is either gendersensitive or knowledgeable about gender issues in HIV/AIDS programming. When interviewed, various CCM members put forward the sex parity among CCM membership as evidence that their CCM is gender-sensitive, demonstrating a limited understanding of gender issues. This has a direct impact on the participation of representatives of women, women living with HIV, female sex workers and transgenders (and also, of course, gay men and other men who have sex with men) as their contribution to CCM discussions are not considered within a wider gender analysis and understanding of the national HIV/AIDS epidemic. CCM meetings are either reactive or too operational minimal opportunity for political or programmatic debate. CCM members (both those belonging to the population groups included in this study, and other government or civil society members) expressed frustration with their current CCMs way of working. Many believe that the CCM does not fulfil its remit of effectively overseeing grant implementation. In some countries, women living with HIV, female sex worker and transgender representatives feel that the CCM convenes solely for the purpose of developing national proposals, or responding to a request from the Global Fund secretariat. Some interviewees suggested that, in the context of proposal developI often feel that we waste time at CCM meetings. Nothing ever seems to get resolved. Sometimes it feels like some decisions have been taken before the meetings, and were just there to approve them (WLHIV. Caribbean)
57. Gender Equality Strategy, GFATM, http://www.theglobalfund.org/documents/strategy/TheGenderEqualityStrategy_en.pdf
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ment, the CCM does not create sufficient opportunities to discuss the wider national HIV/AIDS response, and how Global Fund resources will complement existing efforts. For this reason, they are unsure how best to insert their populations agenda in CCM meetings. Their participation in the CCM centres instead on operational discussions (reviewing indicators and targets, monitoring financial expenditure). As a result, some representatives felt that their participation in the CCM does not go beyond rubber-stamping. Shared representation is promoted. In CCMs where certain population groups are already represented in the form of shared representation, it has been particularly challenging to advocate for direct representation. In some CCMs, members have argued that if they increase the number of civil society seats, they should also increase the number of government seats in order to ensure parity. Other CCMs have suggested that increasing membership will make it difficult to make decisions. The population groups in this study argue that by being among the groups most affected by HIV, there is a strong rationale for them to be directly represented on the CCM, and furthermore, that direct representation is the only way to ensure that their voices are heard on the CCM. Some CCMs require representatives to be members of legally registered organisations. There are only a few examples of CCMs in the region where members are required to belong to legally registered organisations (for example, Guatemala and Nicaragua). Nonetheless, in such instances this is a considerable obstacle, particularly for community-based organisations of female sex workers and/or transgenders, which often encounter challenges and delays when registering their organisations.
Barriers at the level of representatives and their constituencies
Global Fund and CCM-related knowledge. Many WLHIV, female sex workers or transgender CCM members described their most significant challenge to effective participation as simply understanding what is discussed in CCM meetings. Knowledge and understanding of the Global Fund, its core structure and way of working, and the specific role of the CCM in that structure, is certainly limited among CCM representatives from all the population groups included in this study. Not surprisingly, this lack of knowledge is more evident among individuals who are not in the CCM and have had minimal, if any, contact with the Global Fund grant(s) in their country. In the case of female sex workers and transgenders, their awareness of the Global Fund was gained from information shared at regional meetings organised by either RedTraSex or RedLacTrans. Various individuals quoted such meetings as key to understanding, not only what role the Global Fund plays in the HIV/AIDS response, but also how this is relevant to their population group and why it is important for them to participate in the CCM. Womens organisations and/or movements do not include HIV/AIDS on their political agenda. HIV/AIDS is not a priority issue for womens organisations in the LAC region. There is minimal evidence of these organisations showing interest in the Global Fund, and even less of them advocating to participate in CCMs. What little movement there is around the issue of HIV/AIDS has occurred in those countries in the region with higher HIV prevalence rates, such as Honduras, Jamaica and Suriname. The predominance of low prevalence epidemics throughout the region has naturally prioritised programming that targets the most affected population groups. This has compounded womens dissociation from HIV/AIDS related issues. Limited political capacity. Women living with HIV, female sex workers and/or transgender CCM representatives, who are still in an incipient phase as leaders, often mentioned their political experience and capacity as a key barrier that reduces
There are often situations where I just dont understand what was said during the CCM meeting, so how am I supposed to then tell my community about it if Im still struggling to get to grips with it myself (WLHIV CCM representative. Caribbean)
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the effectiveness of their participation. For some, it is the first time they have participated in a national-level decision-making space as a voting member. They have limited experience of how to make use of such a space, how to form allies within the CCM, or how to avoid or even engage with existing conflicts. It is important to clarify that this does not mean that they do not actively participate in meetings; rather, they recognise that their contributions are not often strategic. Lack of a strong political agenda. As mentioned earlier, many representatives state that CCM meetings rarely provide an opportunity to insert their populations agenda on the table. Other CCM members have noted that even in instances where this might be possible, many representatives have not raised concrete proposals from their population groups as expected. Although this may be related to the previous barrier regarding weak political capacity, some CCM members believe that it is because some population groups have yet to develop an agreed political agenda to push in spaces such as the CCM.
Vb.Participation in Global Fund Grant Proposal Development

Process(es) employed to develop a country-level grant proposal
Graphic 2: Process(es) followed to develop a Global Fund grant proposal
CCM decides to submit proposal to Global Fund
The chart outlines the overall proposal development process. Blue boxes have been used to describe the steps which are followed in most, if not all countries. The green boxes demonstrate different mechanisms used to promote civil society participation.
A) Open call for proposals published in the media
B) Large workshop(s) to agree on proposal goal and objectives (variety of stakeholders invited external to ccm)
Small technical committee / working groups + lead consultant(s) draft proposal using inputs from a) submitted proposals or b) large planning workshop
C) Large workshop to review draft proposal (particularly indicators and targets)
Validation of proposal with CCM members
Proposal submitted to Global Fund
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In developing a country-level grant proposal for submission to the Global Fund, countries in Latin America and the Caribbean have all followed similar processes. The CCM decides to submit a proposal, after which the development of the actual proposal is generally led by a small technical team which may, in turn, delegate specific tasks to different working groups. The technical team and/or working groups are made up of CCM members, and occasionally staff from the Principal Recipient in cases where the latter has already been identified. Frequently, a consultant, or team of consultants, is contracted to coordinate the different inputs, draft the narrative and develop the budget. The main variations in this process are evidenced in the different
levels of civil society participation in the development of the process. The study reveals that there are three different mechanisms which have been somewhat arbitrarily employed by CCMs throughout the region, as a way of seeking civil society inputs into the proposal. Most CCMs have opted for the use of one mechanism alone, and have not sought to integrate opportunities for civil society participation throughout the proposal development process. This has led many civil society members to suggest that the CCM only seeks civil society participation in order to comply with the Global Fund requirements (rubber-stamping), rather than because it believes such inputs and participation are integral to the development of an evidence-based, high-quality proposal.
I dont feel there are real opportunities for us [women living with HIV] to participate in the development of the proposal. I feel that our participation is just so that they [CCM] can say we were there (Woman living with HIV. Central America)
Mechanism A
Open Call for Proposals
After deciding to submit a national-level proposal to the Global Fund, the CCM publishes an Open Call for Proposals, inviting organisations from any sector to submit proposals which, if successful, will be used to feed into the national-level proposal. CCMs which have employed this method suggest it is an open, democratic and transparent way of ensuring that any interested party can participate in the development of the Global Fund proposal. In reality, it is a very passive participation with no opportunity to partake in the decision-making concerning the content of the proposal. A small technical committee (composed of CCM members) generally decides which proposals are relevant to the national proposal. Frequently, the national HIV/ AIDS strategy is used to guide the selection of the proposals. In the absence of a national strategy, selection is based on decisions previously made by the CCM on the nature and strategy of the Global Fund proposal to be submitted. The call for proposals provides little detail or guidance, and so, on occasion, proposals have been immediately discarded for their lack of relevance to the National Strategic Plan, as has been the case in recent rounds in Suriname. Certainly, the method allows population groups that are not directly represented in the CCM to submit a proposal, which may be taken into account in the development of the national proposal. However, without the support and advocacy of a CCM representative, it is unlikely that the proposals content will be taken into consideration. Moreover, an important prerequisite in the call for proposals is for the applicant organisation to be legally registered. This serves as a significant barrier for many civil society organisations. This method provides little opportunity to actively influence the strategies included within the national proposal. Decisionmaking is limited to a small number of members in the technical committee and to a lesser degree to the CCM. It should be noted that in many countries, decision-making is delegated to the technical committee, and the CCMs role is restricted to ratifying decisions that have already been taken.
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Case study: Sex worker participation in developing Global Fund proposal in Argentina Sex workers have been directly represented in the CCM in Argentina since Dec 2008. They consider their participation in the development of the Round 9 (2009) proposal to have been a significantly more positive experience than previous rounds. The national organisation of female sex workers, AMMAR, employs technical staff who have considerable proposal development experience. These staff members have in-depth knowledge of the issues and realities experienced by female sex workers. The sex worker CCM representative from AMMAR delegated her participation in any of the meetings related to technical aspects of the proposal (for example, log-frame development, and monitoring and evaluation plan) to the technical staff in her organisation, but not without previously having sourced programmatic inputs from all of the members of AMMAR throughout Argentina. The technical staff member(s) participated in all of these meetings to ensure that their needs and realities (as previously agreed by AMMARs members, and already raised in prior discussions by the CCM sex worker representative) were integrated and accurately reflected throughout the proposal. This strategy overcomes two of the most significant challenges to effective proposal development participation: lack of technical capacity and lack of time. The technical staff member has training and experience in proposal development and is a full-time staff member of AMMAR. Thus she is able to dedicate the necessary time to contribute to the development of the proposal. It should be noted that Argentina employs a variation of Strategy B, an initial workshop with civil society stakeholders to generate inputs for the proposal.
Mechanism B
Initial workshop to generate inputs with different stakeholders
At first glance, the second strategy favoured by many CCMs in Latin America and the Caribbean appears to offer a more active opportunity to participate in the development of a national proposal to the Global Fund. After deciding to submit a proposal, the CCM organises a large workshop (in some cases, a series of workshops) to which it invites a wide range of civil society stakeholders and other actors (private, governmental and academic sectors). The workshop(s) is generally facilitated by the lead consultant responsible for drafting the proposal, or by members of the technical committee in charge of the proposal. Participants may be divided into thematic groups during the workshop where they are encouraged to present their populations needs and realities. These inputs are, in turn, documented for use in the development of the proposal. The greatest criticism of such workshops is that participants do not have an opportunity to participate in the process of deciding the proposals goal, objectives, target groups or implementation strategies. Participants feel that these decisions are taken behind closed doors by a select group of CCM members. Our experience has often been that the consultant, CCM and/or the National AIDS Programme decide whats actually going to be in the proposal. Quite often, the end product does not seem to include the inputs we gave during the planning workshop (Transgender. South America) This participation strategy is not dissimilar to the previously described strategy of publishing an open call for proposals. By creating a space where participants can present and defend their needs and realities, participation is certainly more active, but without access to decision-making, it is not any more effective.
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Mechanism C
Validation workshop with different stakeholders
The third strategy used by CCMs seeking civil society input also involves organising a large workshop with a variety of different stakeholders. The significant difference is the timing. This workshop is organised much later in the proposal development process, once the first or even second draft has been written. Unlike the initial workshop which seeks to generate inputs which can be used in the drafting of the proposal, this workshop is seen by the CCM and the technical committee as a way of gaining stakeholder validation. In some cases, participants are asked to review indicators and targets and confirm that they are realistic. Many individuals who have participated in such workshops stated that the experience was very frustrating. All they do is to have workshops that dont even reflect what our needs are. They have their own agenda where they are supposedly helping us, but all they are doing is helping themselves (Female sex worker. Caribbean) The proposal was often presented as a fait accompli and participants felt that raising their hand to challenge an aspect of the proposal would not lead to anything. Those interviewed believe that the supposedly participatory objective of the workshop was not reflected in the discourse and actions of those facilitating the space. Rather than being encouraged to provide feedback and critique the proposals content, participants felt their participation was limited to minimal issues. They showed us a PowerPoint presentation which included the proposals key strategies. We were encouraged to ask questions if we didnt understand. We gave some feedback around the usage of some of the terminology related to sex work and our input into the proposal amounted to no more than that. (Female sex worker. South America) Once again, participants have no access to any of the decision-making related to the development of the proposal, a situation further compounded by their only being invited to participate in the last stages of the process, once key decisions had already been taken. At this late stage of the process, civil society members have minimal opportunities and even less time to advocate for changes or improvements to the proposal.
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Participation challenges common to all proposal development processes

None of the three strategies described above are used in a way that creates an opportunity for real and effective participation in Global Fund proposal development. Rather than being considered as the main actors both in the development and the implementation of the proposal, we are instead considered as beneficiaries (Transgender CCM representative. South America) Yet the strategies do allow civil society input from individuals beyond those who are CCM members. It is, in fact, for this reason, that many of those interviewed did not identify a relationship between the representation of their population group in the CCM and the effectiveness of their subsequent participation in proposal development. Many recounted occasions when their organisations had participated in an open call for proposals (mechanism A) or they had been invited to participate in an initial proposal development workshop (mechanism B); most of these examples of participation had taken place without the presence of a direct or indirect representative in the CCM. However, when asked to describe the benefits of having representation in the CCM, most agreed that having a representative in the CCM has allowed them to provide closer follow-up to the proposal development process, as well as being able to participate in some of the key decision-making opportunities related to proposals which were not previously accessible through the participatory mechanisms chosen by each CCM. For example, in cases where an initial workshop was held to generate civil society inputs, the presence of a CCM representative provided an insider who could subsequently push for these inputs to be integrated into the proposal. Despite the expected, and in some cases proven benefits of having a CCM representative when it comes to effective participation in Global Fund proposal development, most women living with HIV, female sex workers and transgenders identified a series of additional challenges to effective proposal development participation, which are not overcome by the presence of a representative in the CCM. These challenges are common to all of the population groups in this study and as a result have not been disaggregated by group in the list below.
Lack of technical capacity
Those women living with HIV, female sex workers and transgenders who have participated to any degree in Global Fund proposal development highlighted their lack of proposal development experience as the principal barrier to their effective participation. Few have experience in developing a log-frame, large budgets, or a monitoring and evaluation plan. Those who are CCM representatives identified this weakness as the principal
reason they have not actively sought to participate in the technical committee or working groups that lead the proposal development process, thus excluding themselves from the key decision-making spaces. In some cases, CCM representatives volunteered to participate in these committees, in recognition of the importance of representing their population groups needs. However, they felt that other CCM members discouraged them.
They [other CCM members] think we cant add anything useful to the discussion or process (Woman living with HIV. Ecuador)
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Proposal development is time-consuming

The process of developing a proposal for the Global Fund requires that participating individuals dedicate substantial amounts of time to developing, drafting and reviewing all versions of the proposal. Women living with HIV, female sex workers and transgenders can only allocate this amount of time to the detriment of their daily organisational activities, advocacy work and other ac-
tivities. Unlike government, or staff at large NGOs who benefit from a full-time salary, few women living with HIV, female sex worker and transgender activists receive a regular salary through their organisation; they supplement their income with other income-generating activities. As such, it is difficult for them to commit to the time-intensive proposal development process.
Participating in those working groups that lead the development of the proposal, takes up so much time. Meetings go on late into the night, sometimes 8 to 10 hours a day for a month, if not longer. Our work in our organisation suffers as a result. We need to prioritise our organisations activities; we have to earn a living (Female sex worker. Dominican Republic)
Other challenges
In acknowledging that the CCM is the key entity responsible for decision-making in the process of developing a national proposal for submission to the Global Fund, it is clear that the challenges identified in the previous section related to CCM participation
specially, lack of recent epidemiological data specific to a population group, limited political capacity, and lack of a strong political agenda- will have a direct impact on effective participation in proposal development.
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Vc. Access to Resources as Global Fund Sub-Recipients

The majority of this study has focused on the participation of women and transgenders in Global Fund decision-making mechanisms (the CCM) and processes (national grant proposal development). As described in the previous sections, their participation in these spaces has sought to raise the needs and realities of these population groups so that they may be taken into account in the allocation of Global Fund resources. By accessing and managing their own resources as sub-recipient organisations of the Global Fund, these population groups are not just monitoring and developing but also implementing, thus achieving a more effective participation in Global Fund processes (see Conceptual Framework, p.13) A Global Fund grant is managed in-country by one or more Principal Recipient(s), which is responsible for distributing resources to sub-recipients; in turn, the sub-recipients are responsible for the implementation of the grants activities.
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This last section reviews the extent to which organisations of women, women living with HIV, female sex workers and transgenders have been able to access Global Fund resources as sub-recipients. The selection of sub-recipients is a process which is usually jointly developed by the CCM and the Principal Recipient after grant signature with the Global Fund. More recently, however, the Global Fund has encouraged CCMs to include a tentative list of sub-recipients in the original grant proposal. Regardless of whether a CCM chooses to identify sub-recipients during the development of the national proposal or after grant signature, the process is very similar. An open call for proposals is widely published, and organisations are encouraged to submit proposals for the implementation of specific interventions as outlined
within the grant proposal. Proposals will only be considered from organisations that are legally registered. Although the CCM plays an active role in developing the selection criteria, once prospective subrecipients have submitted their proposals, these tend to be reviewed by the Principal Recipient alone. The Principal Recipient makes the initial selection of sub-recipient organisations and presents this to the CCM for approval. Some CCMs have developed conflict of interest policies to respond to the common situation whereby a CCM member belongs to a prospective sub-recipient. Throughout the region there are very few instances of organisations of women, women living with HIV, female sex workers or transgenders who have received Global Fund resources as official sub-recipient organisations. However, there
are many examples of these population groups receiving resources and/or commodities for their peer outreach work or to implement specific activities. Table 2 describes the access to Global Fund resources of the population groups as either sub-recipients, or as beneficiaries of an intermediary sub-recipient. The table uses green to indicate when an organisation of a specific population group has been able to access resources as a sub-recipient. Yellow has been used to indicate when an organisation or a specific population group has received Global Fund financial resources through an intermediary organisation. In cases where organisations have only received commodities, such as condoms or IEC materials, no colour has been used, but it is indicated in text.
Table 2: Access to Global Fund resources as either sub-recipients or implementing organisations of women and transgenders in 15 CCMs in Latin America and the Caribbean (December 2009)
Country Women-in-general Women living with HIV
Central America Costa Rica El Salvador Guatemala Honduras Nicaragua Panama
No successful proposal to date
Female sex workers
Transgenders
South America Argentina Bolivia Colombia Ecuador Paraguay Peru Caribbean Jamaica Rep. Dominicana Surinam
Access to resources as Sub-Receipient Access to resources through an intermediary organization Commodities only Commodities only Round 2 Focus on young people and displaced populations Commodities only
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The data presented in Table 3 demonstrates that Global Fund resources allocated to specific population groups are rarely or never, as is the case of transgenders, directly managed by these same groups. There are only 6 instances of direct management of funds by the population groups in the 15 countries included in this study, of which none were in the Caribbean, and only one in Central America. This study did not review the amount and proportion of resources that women and trans-
genders have been able to access as sub-recipients. However, a recent report published by the International HIV/AIDS Alliance suggests that the proportions are very low58. Only 4.6% (just under US$8million out of a total of over US$170million) of the resources allocated to subrecipients have reached organisations of people living with HIV, gay men, and female sex workers in the form of sub-recipient grants directly managed by these population groups; similarly to this study, there were no transgender sub-recipients.
Challenges to Accessing Resources as Sub-Recipient Organisations

Those interviewed for this study, particularly individuals from organisations of female sex workers and transgenders (El Salvador, Argentina), cited their lack of legal registration as a key barrier to having their proposals considered. These two population groups typically encounter more challenges than womenin-general or women living with HIV when legally registering their organisations, particularly in parts of the Caribbean where sex work and homosexuality is illegal. In the absence of legal registration, organisations made up of these population groups have formed alliances with intermediary organisations, so that the latter may act as the legal entity which officially presents the proposal to be included as a sub-recipient. In some instances, this alliance has been actively sought by the organisation lacking legal registration, and the intermediary (or umbrella) organisation plays a purely administrative role. In other cases the group of female sex workers or transgenders has played a more passive role, while other NGOs have developed proposals (in some cases without consulting the former) that include activities to be implemented by these population groups. In such cases, individuals interviewed often felt they were being used as cheap labour by the sub-recipient NGO, and that their opportunities for participating in decision-making in the allocation of resources were minimal. In the case of organisations of women living with HIV, such groups have been sub-recipients only in Costa Rica and Peru. The population has occasionally benefited from Global Fund resources in the remaining 13 countries, but the resources have been allocated for more general PLHIV activities, rather than WLHIV-specific activities, in accordance with the strategies in the original grant proposal. There are even fewer examples of organisations of women-ingeneral which have acted as sub-recipients. The study reveals one such instance, in Ecuador, where an organisation of women received approx 1% of the total amount allocated to subrecipients in Ecuadors Round 2 HIV/AIDS proposal. In other countries, HIV/AIDS NGOs have received resources to work with women, most often in the context of programmes preventing mother-to-child-transmission.
58. International HIV/AIDS Alliance, Report on Access to Global Fund Resources by HIV/AIDS Key Populations in Latin America and the Caribbean, April 2009. Available at: http://www.aidsalliance.org/includes/Publication/Report_on_Key_Populations_access_to_resources_ENG.pdf
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Aside from the lack of legal registration, many individuals who participated in this study also highlighted their organisations capacity limitations in the areas of programme and financial management as another key barrier. They believe these weaknesses have contributed to what they perceive as a lack of donor confidence in their abilities to effectively manage their own resources. However, as was often said by many of those interviewed: How will we ever be able to manage our own resources, if donors are not willing to invest in strengthening
our financial and administrative capacity? Lack of donor confidence, combined with minimal investment in capacity-building in grants management, appear to be the most significant longterm barriers limiting women and transgenders (and many other civil society groups) from acting as Global Fund subrecipients, and thus playing a larger role in managing and making decisions around the investment of resources for their own population groups.
We need to strengthen organisations of female sex workers, transgender and other key populations. If we content ourselves with working with big NGOs just because they have the capacity to manage the grant, then our interventions will not be sustainable in the long-term and we will not be strengthening the grassroots groups (Principal Recipient. Paraguay) Paraguays Round 6 and 8 HIV grants both include interventions that target key populations, including female sex workers and transgenders. Round 8, in particular, seeks to strengthen organisations of key populations so that they may directly implement relevant prevention activities with their peers. However, in Paraguay there are few organisations of these population groups that have the organisational capacity to be sub-recipients. In response, CIRD, the principal recipient (a civil society organisation with considerable experience in community strengthening) has developed a simple yet effective methodology which allows groups to implement activities from the outset, while also preparing them to become sub-recipients. In years one and two, funds are channelled through an NGO; this organisation is also responsible for providing support and training in basic book-keeping, financial reporting, programme reporting, monitoring and evaluation, and general grant management to the incipient group. After two years of support from the intermediary organisation to the potential sub-recipient, a direct grant is signed between the principal recipient and the small group, removing the need for an intermediary organisation and allowing the new subrecipient to take complete control of the management of the project and its funds. Thanks to this methodology, UNES, an organisation of female sex workers, recently signed its first direct grant with the Principal Recipient, and is now one of only three female sex worker sub-recipient organisations in the region.
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VI. Conclusions
Participation in Country Coordinating Mechanisms
Women make up a significant, and in some cases dominant, proportion of members in CCMs in Latin America and the Caribbean. This has not translated into the effective representation of womens HIV/AIDS related needs and realities in CCMs. HIV/AIDS is not a priority issue for womens organisations in the LAC region. There is minimal evidence of these organisations showing interest in the Global Fund and even less of them advocating to participate in CCMs. What little there is has occurred in those countries in the region with higher HIV prevalence rates, such as Honduras, Jamaica and Suriname. The predominance of low prevalence epidemics throughout the region has naturally prioritised programming that targets the most affected population groups. This has compounded womens dissociation from HIV/AIDS related issues. However, due to their multi-sectoral nature, CCMs have begun to play a role in the national HIV/AIDS response that goes beyond the development and oversight of Global Fund grants. Occasionally, CCM meetings are being used to discuss and debate national HIV/AIDS policies and strategies. For this reason, it is imperative that the realities and needs of women-in-general in the context of HIV/AIDS are represented in this space. 85% of the CCMs (13 out of 15) in this study include a woman living with HIV among its members. Only one of these seats is specific to WLHIV. The remaining 12 seats are PLHIV seats to which a woman has been elected. The perception that their accountability is to the wider PLHIV community has compromised the effective representation of a WLHIV agenda by WLHIV CCM members. Despite the strength and experience of a number of WLHIV leaders across the region, the emergence of a political agenda specific to this population groups needs is, in most countries, still in its nascent stage. This has added to the challenges faced by WLHIV CCM members when seeking to prioritise the issues and needs of their specific population group in the CCM. An increasing number of female sex worker or transgender specific seats have been gained in CCMs across the region since mid-2007. The persistent advocacy carried out by organisations of these population groups was a strong contributing factor in securing direct representation. However, the majority of those interviewed believe that the decisive factor was the Global Funds own strong encouragement that CCM membership include representatives of those groups most affected by the epidemic, according to the local context. Women living with HIV, female sex workers and transgenders maintain that direct representation in the CCM is the most effective form of having their needs and realities represented in this space. The experience of shared representation in CCMs throughout the region has demonstrated that communication between representatives and their constituencies tends to favour those who belong to the exact same sub-constituency as the representative (be that an organisation or a population group). In the specific case of the traditional grouping together of transgenders with gay and other men who have sex with men, this shared representation in the CCM has served to hide the very particular realities and vulnerabilities faced by transgenders, not often shared by gay and other men who have sex with men. The regional networks of female sex workers (RedTraSex) and transgenders (RedLacTrans) have played an important role in raising the importance of engaging with the Global Fund among its members. Moreover, they have supported their members local advocacy work in gaining CCM representation with regional-level advocacy work. This has served to strengthen the reputation of their country focal points, while also ensuring that the needs and realities of these two population groups maintain a central position at a regional level. The effective participation of women and transgenders in CCMs is affected by a variety of different factors, among which legitimacy, accountability and communication emerge as the strongest. Despite the Global Funds recommendation that CCM members be democratically elected by their constituency, this does not always occur. Moreover, constituency may be interpreted to mean a specific organisation, rather than a wider population group, and so rather than elections, representatives may in fact be selected (and in a few rare cases self-selected) from within an organisation. This affects the legitimacy of the representative vis--vis members of his or her community. In turn, the accountability of a CCM member is perceived to be limited to whoever was responsible for the s/election. Open and transparent communication between representatives and their constituencies can significantly contribute to strengthening participation in the CCM. However, the study only uncovered evidence of informal communication systems employed by CCM representatives. There are no systematic methods, as such, for ensuring that information and decisions made in the CCM are communicated to respective constituencies, nor are there clear systems to feed information up to CCM representatives.
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Systematic induction and support to new CCM representatives can play an important role in improving participation, particularly for individuals who may not have participated in a national-level key decision-making space before. The structural barriers which affect the participation of women and transgenders should not be disregarded. Although this study has chosen to focus on the practical barriers to participation, it is clear that some of these have their roots in gender inequalities, gender-based discrimination, poverty and legal obstacles that directly affect participation (lack of formal education among female sex workers and transgenders, inability to register organisations of female sex workers or transgenders in parts of the Caribbean, lack of resources to dedicate time to proposal development or participate in CCM meetings). Effective participation in the CCM by women and transgenders in the CCM should be reflected in national-level proposals that address the needs of these population groups, and in the extent to which these population groups access resources as sub-recipients. This has not been the case to date. In part, because many CCM representatives for women and transgenders are struggling to participate effectively for many of the reasons already described, but also because many CCMs do not provide the opportunity for real engagement with programmatic and political HIV/ AIDS debates. Representatives are unsure how to position their constituencys agenda in meetings which are operational and reactive.
Participation in the development of country-level grant proposals

Participation in the development of country-level grant proposals is dependent on the proposal development process. The current processes encourage the participation of WLHIV, female sex workers and transgenders, but only to a limited degree. This has resulted in womens and transgenders perception that current participatory mechanisms amount to mere rubber-stamping. Effective participation in these processes is hindered by capacity, time and most importantly, by the lack of opportunities to participate in the decision-making aspects related to the proposal. There is a significant lack of epidemiological studies that focus on WLHIV, female sex workers and/or transgenders. This lack of information does not allow these groups to support their claims with relevant evidence-based data.
Access to Resources
To date, there is no evidence of a relation between CCM representation and access to resources as sub-recipients. In the case of female sex workers and transgenders, it is too early to assess the effect of their participation in the CCM and to be able to draw a relation between that and subsequent access to resources (the first female sex worker and transgender seats date to mid-2007). Although most grants in the region include a component of work with WLHIV, female sex workers or transgenders, organisations of these population groups have only very rarely received resources in the form of sub-recipient grants. In most cases, these population groups receive Global Fund resources as beneficiary organisations (sub sub- recipients) to implement one-off activities or to carry out peer outreach work. These small resources do not contribute to their organisational strengthening, nor are the organisations able to take part in the decision-making of how best to allocate the use of these resources with their own population group. Another significant barrier to accessing resources as sub-recipient organisations is the weak grant management capacity of these groups, many of which are not legally registered.
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VII. Recommendations
For CCMs
As recommended by the Global Fund, CCM membership should reflect the dynamics of the national epidemic. In most of the LAC region, this means including representatives of gay and other men who have sex with men, female sex workers, transgenders, and in the case of the Southern Cone, drug users. In Latin America, significant steps have been made in the last two years toward increasing representation of these population groups. However, the trend is still towards shared representation. This study highlights that current manifestations of shared representation tend to favour only the immediate constituency of the current representative. Direct representation allows the most affected population groups to speak for themselves. In countries with high prevalence rates (over 5%) among female sex workers and transgenders, the CCM should designate a specific seat for each of these population groups, to allow direct representation. Gender-sensitive approaches are interpreted by many CCM members to mean an equal number of male and female participants. Its important to develop an action plan for integrating gender into CCM structure and operations. It is necessary to build the capacity of their members in gender awareness and sensitivity. When developing proposals for submission to the Global Fund, integrate interventions that address gender inequalities and respond to a solid gender analysis of the HIV epidemic in the applicant country. Emphasise the importance of open and transparent elections in CCM bylaws and insist on receiving relevant supporting documentation on the election process of each of its members. This will avoid seats being perceived as belonging to specific organisations. Seats should belong to a sector (be it a specific population group, or a coalition of organisations working on HIV/AIDS). Develop systematic induction processes for new members and consider using other strategies, such as mentoring, to strengthen the participation of community representatives. In CCM bylaws, clarify representatives responsibility to share CCM related-information and decision-making with their constituencies. Create opportunities for engagement with and debate of national-level HIV/AIDS policies and programmes in CCM meetings. This will allow representatives to bring their constituencies agendas to the table in a more systematic and less reactive fashion. Take advantage of the resources available at the level of the Global Fund to support CCM operations. A portion of these resources could be used to facilitate: (a) Frequent and systematic communication between representatives and their constituencies. (b) Transport costs for representatives from outside the capital city, thus allowing constituencies to elect representatives who do not live in the capital.
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For women-in-general, WLHIV, female sex workers, transgenders

Womens organisations should consider placing HIV/AIDS in their political agendas and seek to engage with Global Fund processes at national levels. In light of the trend towards shared representation, particularly between PLHIV and WLHIV, community groups should work towards making existing representative mechanisms more accountable to all their constituents. Transparent and systematic communication systems should be developed between existing representatives and their constituencies. This should be an explicit requirement of representatives, laid out within the CCM bylaws. WLHIV organisations and networks need to work more closely with PLHIV representatives on the CCM to ensure that the latter understand their specific needs and realities, and are able to clearly represent them on the CCM. Female sex workers and transgenders should continue to advocate for direct representation. Hold their CCM representatives accountable for representing the whole constituency; this is relevant both in situations of direct and shared representation. Regional community networks should continue to raise Global Fund awareness among their members, and encourage increased engagement with local Global Fund processes. Regional community networks should explore the possibilities of providing training and mentoring to their members to improve participation in CCMs and grant proposal development. Clarify the political agenda to be presented and defended by representatives in Global Fund-related spaces. In cases of shared representation, work closely with the existing representative to build his/her understanding of the diverse agendas that s/he must represent in the CCM.
For the Global Fund

Meet with WLHIV, female sex worker, transgender community leaders during Global Fund country missions, even if they are not CCM members. Encourage them to engage with local Global Fund processes. Provide clear and practical guidance to CCMS on ways to increase the effective participation of communities in the CCM and other Global Fund processes. Community systems strengthening should include building the organisational and grants management capacity of community-based organisations. CCMs should be encouraged to integrate such technical support actions with potential sub-recipients in national-level proposals.
For International Donors and Agencies

Continue and increase support to strengthen regional and national community networks. Provide funding and technical support for organisational strengthening to community groups with the aim of building their capacity to be sub-recipients. For international agencies with national-level presence, provide technical support to population groups in how to organise transparent and democratic elections for CCM representatives.
Recommendations for further study

Additional research is needed into womens lack of mobilisation around HIV/ AIDS in Latin America and the Caribbean. This study should be widened to include every country in the region as well as other populations significantly affected by HIV, tuberculosis and malaria.
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Annex 1
Variables considered in the study
Variables have been divided by each objective from 1 to 3. The variables for objective 4 are cross cutting and are included in the other three objectives. Some of the variables were considered for the analysis at a local level and others at a regional level. However, it is of Observatorio Latino interest to list them all here.
Objetive 1: Describe and analyse the characteristics and effectiveness of the participation of women and transgenders in country coordinating mechanisms (CCMs) throughout Latin America and the Caribbean. Quantitative variables CCM structure
Percentage of CCM members representing different sectors (government, private sector, international organisations, civil society and others) # and % of civil society CCM members # and % of CCM female members # and % of female and transgender CCM members who directly represent women and/ or transgenders. # of CCMs with specific policies or processes that promote a gender-balance among members
CCM member selection process

# of CCMs with process guidelines for the election of members onto CCM # of female and transgender CCM members democratically chosen by their respective constituencies # of occasions in which women and/or transgenders are represented on the CCM, but indirectly, by a mechanism that represents various different sectors (eg. NGO coalition or LGBT coalition)
Participation in CCM
# of CCMs which have, or have had, a woman or transgender president or vice president who directly represents her population group. # of female and transgender CCM members who directly represent their population group and have participated in a CCM committee, working group or other similar sub-structure # of CCMs with guidelines or ToRs that describe members roles and responsibilities.
Correlation among factors that may or may not increase the participation of women and transgenders in CCMs
Relation between % of women and transgender CCM members who directly represent their population group, and a civil society principal recipient or two principal recipients Relation between % of women and transgender CCM members in direct representation of their population group, and a president or vice-president from civil society
Qualitative variables
Perception of the participation of women and transgenders in CCMs in direct representation of their population group. Researchers will primarily seek the perceptions of women and transgenders but also those of other CCM members, other civil society members and representatives from the principal recipient(s) Perception of the participation of women and transgenders in CCMs when represented by a mechanism that represents various groups together (eg. NGO coalition, LGBT coalition). Researchers will primarily seek the perceptions of women and transgenders but also those of other CCM members, other civil society members and representatives from the principal recipient(s) Perception of the openness and readiness on the part of other CCM members to listening to what women and transgenders have to say. Researchers will primarily seek the perceptions of women and transgenders but also those of other CCM members, other civil society members and representatives from the principal recipient(s) Perception of women and trangenders in relation to ease of access to CCMs as a population group Frequency in communication between women and transgender CCM members and their respective constituencies Communication methods employed by women and transgender CCM members to exchange communication with their respective constituencies CCM member election processes Knowledge of CCM functions and operations, and CCM members roles and responsibilities. CCM induction and training procedures for new members Coordination between CCM member and alternate member Clarity of roles and responsibilities between CCM member and alternate member Factors that facilitate the participation of women and transgenders in CCMs Barriers and challenges that restrict women and transgenders from effectively participating in CCMs.
Objetive 2: Describe and analyse the characteristics of the participation of women (women-in-general, women living with HIV and female sex workers)
and transgenders in the development of country-level proposals (or regional in the case of REDCA+) to the Global Fund throughout Latin America and Caribbean.
Quantitative variables
# of proposals presented to the Global Fund (approved or not) in which the development of the proposal included the direct participation of women (women in general, women living with HIV, or female sex workers) and/or transgenders. Data disaggregated by population group and whether the proposal was approved or not. The study will focus on Global Fund HIV/AIDS proposals betweens Rounds 5 and 9. If no relevant proposal was submitted during this period, then the most recent HIV/AIDS proposal will be reviewed. Relation between # of proposals presented to the Global Fund in which the development of the proposal included the direct participation of women and/or transgenders, and the direct representation of these population groups on the CCM. Disaggregated by population group. The analysis of this variable can only be done at a regional level, but data will be gathered in each country.
Process of developing country-level proposals to the Global Fund Process of participation of women and transgenders in developing the country-level proposal Systems and mechanisms used to gather data on womens and transgenders needs and realities which are then subsequently used to feed into proposal Factors that facilitate the participation of women and transgenders in the development of proposals for the Global Fund Barriers and challenges that restrict women and transgenders from effectively participating in the development of proposals for the Global Fund
Objetive 3: Review the extent to which sectors of women (women-in-general, women living with HIV and female sex workers) and transgenders have been able to access Global Fund resources as sub-recipients. Quantitative variables
# of occasions in which organisations of women (women in general, women living with HIV and female sex workers) and transgenders are subrecipient organisations # of occasions in which organisations of women and transgenders are beneficiary groups as outlined within the Global Fund proposal, but funds are received via an intermediary organisation and not directly managed by the beneficiary organisation: disaggregated by population group and Round. Relation between the amount received and directly managed by organisations of women and/or transgenders as Global Fund sub-recipients, and the direct representation of these population groups on the CCM.
Perception of the level of access that organisations of women and transgenders have to Global Fund resources. Factors that facilitate direct access to Global Fund resources by organisations of women and/ or transgenders Barriers and challenges that limit organisations of women and transgenders from directly accessing Global Fund resources
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Annex 2
Interview Guide
This interview guide provides examples of standar questions that cover the qualitative variables of the study. This guide was adapted to local context and the condition of the interviewee (member of CCM, women-in-general, female sex workers, WLHIV, transgender, other leaders that do not participate int he CCM, representant of principal recipient or representant of international organizatios) agencies.
Semi-structured Interview Guide Date: Country: Interviewee name: Organisation: Population Group: CCM participation
What do you know about the Global Fund in general and its programmes in your country? What do you know about the Global Funds country-coordinating mechanisms (CCMs)? What knowledge do you have of the role of the CCM within the Global Fund structure? Describe how the CCM operates in your country: Structure, membership, frequency of meetings What is/was your role/title on the CCM? How long did you/have you occupied this role? Describe the process of how you became a CCM member (how was this achieved? How were you selected/elected? Etc) Describe the induction process? Handover with previous member? Was there an specific training? Describe how the needs and realities of your population group are represented on the CCM. Participation via a representative from same population group, or participation via shared representation with other groups, eg. NGO coalition or LGBT coalition. To what extent do you feel that the needs and realities of your population group are being listened to and taken into account on the CCM? Do you feel confident to raise your voice in CCM meetings? Describe the changes you have noticed in your own participation in the CCM since the day you first gained access to this space. If you have noticed changes describe the factors (external and internal) that have motivated them. Describe the communication between you (your population group) and the individual who represents your population group on the CCM. (Frequency, method of communication) How do you access information regarding the discussions and decisions taken in the CCM? Describe any examples of instances in which your population groups needs and realities have been taken into account by the CCM. (Request description of particular instances/examples) Describe the factors that have facilitated the participation of your population group on the CCM. Describe the barriers or challenges that have limited the access and participation of your population group on the CCM.
No.
Participation in the development of country-level proposals

What do you know of the process by which Global Fund country-level proposals are developed in your country? Who leads the process? Who participates? How is the process and proposal content validated with the community? Have you or your organisations participated in the development of one of the recent HIV/AIDS country-level proposals to be submitted to the Global Fund? Were you invited to participate? How was the process? Were there meetings with the individuals responsible for drafting the proposal? Describe the opportunities to review and provide feedback on the sections that refer to your population group? Describe the factors that have facilitated the participation of your population group in the development of country-level proposals to the Global Fund. Describe the barriers or challenges that have limited the participation of your population group in the development of countrylevel proposals to the Global Fund. How would you describe the participation of your population group (both positive and less positive aspects)?
Access to Resources
Who is/are the Global Fund principal recipient(s) in your country? Describe what you know about the principal recipient(s). (role, responsibilities, tasks) What do you know of the process by which sub-recipients are identified and selected to implement a Global Fund grant? Which organisations are currently acting as sub-recipients for a Global Fund HIV/AIDS grant? Which population groups are represented by these organisations? Do you know of any organisations of your population group that have received Global Fund resources to implement specific activities? What process did these organisations have to go through to access these resources? How do they receive the resources? (direct contractual agreement with the principal recipient, or small funds to implement specific activities without a contractual agreement, or via a sub-recipient that acts as an intermediary organisation) In cases where the answer is no: Why do you think the proposal was rejected? What is your opinion on the matter? Describe the feedback or comments that were given following the rejection of the proposal. In instances where your population group has participated in the development of a successful country-level proposal to the Global Fund, describe how this has contributed to your populations access to resources as sub-recipients. Describe the process. Describe the factors that have facilitated the access of your population group to Global Fund resources as sub-recipients. Describe the factors that have limited access to resources as sub-recipients. How would you assess the general participation of your population group in the Global Fund HIV/AIDS grants being implemented in your country? Would you like to add anything else?
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Anexo 3
Study on the effective participation of women-in-general, women living with HIV, female sex workers and transgenders in Global Fund processes in Latin America and the Caribbean
INFORMED CONSENT FORM

This consent form must be used with all the individuals that participate in the studys focus groups and interviews, including: Women in general, women living with HIV/AIDS, female sex workers and transgenders Global Fund Country Coordination Mechanism (GF CCM) members Global Fund Principal Recipient (GF PR) representatives Researcher: ........................................................................................ Organisation in charge of study: AID FOR AIDS, Observatorio Latino Programme The consent form is divided into 2 sections: Fact sheet (provides detail on the study) Consent to participate (to be signed by the individual if s/he chooses to participate) You will receive a full version of the Informed Consent Form.
Section I: Fact Sheet

Purpose of the Study The purpose of this study is to collect data on the participation of women-in-general, women living with HIV, female sex workers, and transgenders in Global Fund processes in Latin America and the Caribbean. The study will assess their participation in the following two Global Fund processes: Global Fund Country Coordinating Mechanisms The development of country-level proposals to the Global Fund The study will also assess the degree of access to Global Fund resources that organisations of these groups have achieved as sub-recipients. The study will take place in 15 countries around the region, including [] Selection of participants in the study You have been invited to take part in this study because we believe you can contribute to improving our knowledge and understanding of the participation of women-in-general, women living with HIV/AIDS, female sex workers and transgenders in Global Fund processes in your country. Voluntary participation Your participation is completely voluntary. The choice is completely up to you. You may choose to withdraw from the study at any time without having to provide a reason. Procedure Data will be collected through a series of face-to-face interviews and focus groups. Focus group questions will centre on your experience, be it direct or indirect, of the participation of women-in-general, women living with HIV/AIDS, female sex workers, and transgenders in Global Fund processes. If a question makes you uncomfortable, you may refuse to answer. There is no consequence for not answering. Your name will NOT appear in any report without your permission. Length Data gathering is scheduled to last from August 2009 to October 2009. Your participation shall be limited to just one (01) focus group which will last no longer than 2 hours /one interview which will last no longer than 1 hour. Benefits for participants Focus group participants /interviewees will not receive financial compensation. Yet, it is expected that the studys results will benefit women-in-general, women living with HIV/AIDS, female sex workers and transgenders and help to improve their participation in GF processes. Transportation expenses You will be reimbursed for any transportation costs incurred by participating in this focus group. Confidentiality Participating in a study may entail a loss of privacy. Although individual researchers will be able to attribute you answer to you, we assure you that any information you provide will be confidential. Nothing you say during the focus group shall be communicated to any person outside the research team. Your name shall NOT appear in any report without your permission. As stated above, you may refuse to answer any question or to provide any type of information. You may also withdraw from the focus group /interview at any time, turn off the recording, or delete anything that has been recorded. All focus group participants are asked to maintain their peers answers confidential and not to talk about what has been discussed within the group outside of it. Nevertheless, it must be made clear that those coordinating this study cannot guarantee that other participants will maintain the same level of confidentiality. Dissemination of Results The final regional report will be shared with you and your community. Each participant will receive their own copy of the final report. The results of this study will be widely disseminated throughout Latin America and the Caribbean as well as in other regions with a particular emphasis on dissemination at relevant regional conferences and fora. How to contact us If you have a question, please do not hesitate to ask it now. If at a later date you have any further queries, do feel free to contact: [Name of local/regional researcher, e-mail address, telephone number] Participants Rights You have the right to read the consent form (or have it read to you, if necessary) and to have its contents thoroughly explained to you. You also have the right to a copy of it.
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Section II: Consent to Participate

I hereby declare that I have read the fact sheet (or it was read to me) concerning the study on the effective participation of women-in-general, women living with HIV/AIDS, and female sex workers and transgenders in Global Fund processes in Latin America and the Caribbean, led by AID FOR AIDS, Observatorio Latino Programme. I furthermore declare that I had sufficient opportunity to ask questions and that all my questions were answered in a satisfactory manner. Moreover, I understand that my participation is completely voluntary and that I have the right to withdraw from participating at any time during the study. Consequently, I hereby declare my willingness to participate in one (01) focus group related to the abovementioned study and my consent that discussions taking place therein be recorded. Lastly, I herein make known that I received a copy of this consent form.
PARTICIPANTS NAME AND SIGNATURE
DATE
In the event that the individual cannot read nor write: I hereby declare that I witnessed the fact sheet concerning the study on the effective participation of women-in-general, women living with HIV/AIDS, and female sex workers and transgenders in Global Fund processes in Latin America and the Caribbean, which shall be conducted by AID FOR AIDS, Observatorio Latino Programme, being read to the abovesigned and that the abovesigned had sufficient opportunity to ask questions. I herein make it known that I witnessed the abovesigned freely grant consent to participate in the study.
WITNESSS NAME AND SIGNATURE
DATE
PARTICIPANTS FINGERPRINT
I hereby declare that I explained the study to the participant and answered any of his or her related questions. I believe the individual has understood all of the information provided in the fact sheet and that s/he freely gave consent.
RESEARCHERS NAME AND SIGNATURE
DATE
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Participation of Women and Transgenders in GF Processes in Latin America and The Caribbean

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MAKE YOUR VOICE HEARD

Review of Spanish document

Fundacin AID FOR AIDS - Lima Peru

LATIN AMERICA AND THE CARIBBEA

flickr.com (Photographer: ronnie44052)

LATIN AMERICA AND THE CARIBBEA

flickr.com (Photographer: Memo Vasquez)

flickr.com (Photographer: Daniel Zanini H.)

LATIN AMERICA AND THE CARIBBEA

LATIN AMERICA AND THE CARIBBEA

flickr.com (Photographer: Daniel Zanini H.)

II. Conceptual Framework

LATIN AMERICA AND THE CARIBBEA

The Global Fund

The Global Fund and gender

flickr.com (Photographer: Brocco Lee)

LATIN AMERICA AND THE CARIBBEA

Participation, gender and HIV/AIDS

Rommel Gonzales Cruz

flickr.com (Photographer: stereocity)

LATIN AMERICA AND THE CARIBBEA

Women living with HIV

flickr.com (Photographer: jorgemejia)

Female Sex Workers

LATIN AMERICA AND THE CARIBBEA

flickr.com (Photographer: freakyman)

Rommel Gonzales Cruz

LATIN AMERICA AND THE CARIBBEA

flickr.com (Photographer: NeoGaboX)

III. Goal and objectives

Graphic 1: Countries included in the report, disaggregated by research method

First Research Method: Focus Countries (6)50

Second Research Method: Semi-Focus Countries (7)

Third Research Method: Non-Focus Countries (2 and 1 regional grant)

Countries were selected according to the following criteria:

LATIN AMERICA AND THE CARIBBEA

Rommel Gonzales Cruz

Rommel Gonzales Cruz

LATIN AMERICA AND THE CARIBBEA

flickr.com (Photographer: Libertinus)

Female sex workers

flickr.com (Photographer: J.C. Rojas)

LATIN AMERICA AND THE CARIBBEA

Gaining access, representation and participation in the CCM

flickr.com (Photographer: Daniel Zanini H.)

Women living with HIV

Rommel Gonzales Cruz

LATIN AMERICA AND THE CARIBBEA

Female Sex Workers

Rommel Gonzales Cruz

LATIN AMERICA AND THE CARIBBEA

The role of legitimacy and accountability in effective CCM participation

LATIN AMERICA AND THE CARIBBEA

Communication between CCM representatives and their constituencies

Description and analysis of the effectiveness of each method

Written reports shared by e-mail

LATIN AMERICA AND THE CARIBBEA

flickr.com (Photographer: nanettesol)

Barriers that reduce effective participation in the CCM

Barriers at the CCM level