New Funding for South African Grants Will Target Key Populations

4. NEWS
20 Sep 2013
New grant to be signed to implement BCC activities for young women
$55 million in TB funds will be added to an existing HIV grant

As announced in previous GFO articles (here and here), South Africa has been awarded up to $307.3 in renewal and interim applicant funding. See the table for details.

According to the Grant Approvals Committee (GAC), South Africa has a generalised HIV and AIDS epidemic, with a 17% prevalence rate among 15 to 49 year-olds and the highest number of persons living with HIV in the world (estimated at 6.4 million). The epidemic is compounded by the high rate of TB/HIV co-infection: About 60% of TB patients are infected with HIV (one of the highest rates in the world).

The GAC said that South Africa has a very high TB burden with 1% of the population developing TB disease annually, as well as high rates of TB/HIV co-infection and multiple-drug-resistant TB (MDR-TB). South Africa’s TB prevalence and incidence rates rank second and first, respectively, in the world. With an estimated 13,000 cases of MDR-TB, South Africa has the highest burden of drug resistant TB in Africa.

The South Africa country coordinating mechanism (CCM) submitted one funding request combining renewal funding for existing grants with interim applicant funding under the new funding model (NFM). The request had two components: HIV and TB. When the NFM was launched, South Africa was invited to apply for $37 million for HIV and $55 million for TB. Most of the NFM funding will be added to existing HIV grants, including the $55 million earmarked for TB (see the section at the end of this article).

Table: Interim applicant and renewal funding awards for South Africa HIV grants

Grant Number
Principal recipient
Approved funding ceilings ($ million)
Renewals
Interim applicant
Total
SAF-H-RTC
Right To Care
$31.5
$2.0
$33.5
SAF-910-G09-H
National Religious Association for Social Development
$19.4
$2.0
$21.4
SAF-304-G04-H
Western Cape Provincial Department of Health
$25.6
NIL
$25.6
SAF-H-NDOH
Department of Health
$107.1
$55.0*
$162.1
SAF-H-NACOSA
Networking AIDS Community of South Africa
$33.1
$25.0
$58.1
TBD
TBD
NIL
$6.6
$6.6
TOTAL
 
$216.7
$90.6
$307.3

* Although the $55 million is being added to an existing HIV grant, the money will be spent on TB activities.

The GAC said that the request for HIV funding was aligned with the current National Strategic Plan for 2012–2016.

On the treatment side, the CCM proposed to expand the efficiency and success of larger programmes, including adherence support, pharmacovigilance and resistance monitoring. On the prevention side, the CCM placed the emphasis on expanding combination prevention programmes for underserved populations.

According to the GAC, the new funding will target the following key populations: (a) low socio-economic populations; (b) victims of gender based violence; (c) sex workers; (d) men who have sex with men, lesbians, gays, bisexuals, transgenders and intersex; (e) prisoners; (f) people living with MDR-TB; (g) miners and adjoining communities; (h) uncircumcised men; and (i) youth.

Although most of the new funds will be added to five existing grants, a new grant will be signed with a principal recipient (PR) yet to be identified in order to implement behaviour change communication activities for young women aged 15–24, who accounted for 34% of new infections in 2010. A call for proposals for the sixth PR will be launched shortly with the goal of signing the grant by January 2014. Of the total funding approved, $6.6 million will be used for this new grant.

The GAC noted that although TB notification has been increasing, about 30% of TB patients are undetected; and that although HIV testing among TB patients is high, only 44% of those infected are on antiretroviral therapy (ART). One of the primary thrusts of the CCM’s TB request is an aggressive expansion and phased decentralisation of MDR-TB services in all 52 districts in South Africa. The plan is to achieve this through innovative nurse-initiated MDR-TB treatment.

The TB request also calls for (a) expanding TB programmes in correctional facilities, including providing TB/HIV services in all 242 prisons; and (b) scaling up services among miners and adjoining communities with high TB rates. The goal is to reach 400,000 miners in six mining districts.

The GAC said that improving the quality and success of MDR-TB treatment services is particularly important in South Africa given the comparatively low MDR-TB treatment success rate (40%) as compared to the World Health Organization recommended target of 75%.

When it reviewed the request from the CCM, the Technical Review Panel (TRP) expressed concerns about the proposed approaches for both TB and HIV components.

On HIV, the TRP noted that the HIV request proposes significant expansion of services to a number of key populations using innovative approaches for both prevention and treatment. Therefore, the TRP said, it will be critical to monitor the effectiveness and impact of these approaches.

Specifically, the TRP recommended that close attention be paid to ensuring that there is a strong M&E system at the PR level; that relevant data be obtained from sub-recipients; and that achievements using the new approaches be well documented. The TRP also said effective implementation of activities in the grant designed to create an enabling environment will be critical to success of the programme.

Further, the TRP stressed the need for programme implementation to be closely monitored, so that that mid-course corrections can be made as required.

The TRP identified two other issues for the Secretariat to follow up during grant-making: (1) the need to ensure linkages between the prevention programmes and care and treatment, including both TB and HIV screening and treatment services; and (2) the need to ensure that the coordination, management and M&E efforts of the PRs and the CCM are well defined, and that efforts are made to find synergies in these systems to reduce duplication and administrative costs. 

The GAC endorsed the TRP’s recommendations regarding the HIV component. The Secretariat will ensure that these issues are covered in final grant-making before the revised grant agreements are signed, and in the implementation of the grants.

Regarding TB, the TRP said that the planned expansion of MDR-TB treatment services needs to be monitored very closely, as does the quality of the services provided. The TRP stressed the need to carefully design the monitoring and management feedback systems that accompany service expansion. In addition, the TRP said, a detailed plan for quality assurance and technical assistance for nurse-led sites should be in place prior to the initiation of activities.

The GAC endorsed the TRP’s recommendations regarding the TB component. In addition, the GAC said that the rapid scale-up of the decentralisation of MDR-TB services also requires careful monitoring. The GAC said it was concerned about the fact that the data on MDR-TB that the CCM was using is based on a TB prevalence survey from 2002. The GAC recommended that a new TB prevalence survey be undertaken as soon as possible.

The Secretariat will ensure that the issues raised by the TRP and the GAC concerning the TB component are covered in the final grant-making before the revised grant agreements are signed, and in the implementation of the grants.

The GAC noted that people who inject drugs (PWID) were not included as a key population in the request. The Secretariat’s country team for South Africa informed the GAC that the CCM had decided to include only a sub-set of key populations in the request and that it did not prioritise PWID for this proposal.

The GAC said that although community systems strengthening (CSS) activities were included in the funding request, work needs to be done to define a clear CSS strategy.

Finally, the GAC observed that despite the fact that there exists some solid HIV epidemiological data for South Africa, more information is needed on key geographical hot stops.

Decision to add TB funds to existing HIV grant

Aidspan asked the Secretariat whether the decision to add $55 million in TB funding to an existing HIV grant might not create problems for people tracking commitments, disbursements, expenditures and results by disease. The Secretariat responded that while there might be some risks of this happening, the benefits of adding the funds to an existing HIV grant outweigh the risks.

The Secretariat explained that (a) the PR for the new TB activities will be the Ministry of Health, which is already the PR for the HIV grant; (b) there is a lot of overlap between HIV and TB activities anyhow; (c) administratively, this is the simplest arrangement; (d) and the TB funds can still be tracked separately.

The Secretariat said that there could be more of this kind of co-mingling of funds in future.

Information for this article was taken from Board Decision GF-B29-EDP9 and from GF-B29-ER5, the Report of Secretariat Funding Recommendations. These documents are not available on the Global Fund website. Additional information was obtained from the Secretariat.


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