The Global Fund Board has approved Phase 2 funding for two Round 9 HIV grants in Pakistan. Funding of $7.1 million was approved for one of the grants, for which the principal recipient (PR) is the National AIDS Control Programme. Funding of $11.3 million was approved for the other grant, for which the PR is the Nai Zindagi Trust. In approving the Phase 2 funding, the Board was acting on recommendations from the Grants Renewal Panel in the Secretariat.
According to the Global Fund, Pakistan continues to face an expanding concentrated epidemic among people who inject drugs (PWIDs). The HIV prevalence in this population is 38% across major urban centres and up to 52% in some communities. Sexual and injection-related risk behaviours have also increased among PWIDs between 2008 and 2011. It is estimated that there are 130,000 people living with HIV in Pakistan, 31,000 new cases annually, and 4,800 deaths from AIDS in 2011. The number of people eligible for antiretroviral therapy (ART) based on the World Health Organisation 2010 guidelines is estimated to be 25,000.
The Secretariat’s assessment of the first phase of both grants was that there was insufficient coverage and quality of key high impact interventions, including less than 20% of eligible people receiving ART by the end of 2011. The Secretariat noted that three-quarters of the way through Phase 1, only 47% of budgeted funds had been spent. In addition, the Secretariat said, opioid substituting therapy (OST) was not available due to legal barriers.
The Secretariat said that as a result of a comprehensive dialogue with in-country partners in provinces and at the central level, the request for continued funding reflects a reprogramming of the grants.
Phase 2 of the grants will focus on investments that can demonstrate the highest impact, including scaling up the coverage and quality of combination prevention programmes for people who inject drugs and their families. Programmes will target high-transmission urban centres – Karachi, Peshawar, Quetta and Turbat – in order to rapidly increase coverage of harm reduction services, including needle and syringe programmes and OST. In Karachi, the goal is to expand coverage of harm reduction services from 26% of PWID (currently) to more than 60%.
Phase 2 will also attempt to reduce barriers to ART for PWID, transgender people and other key affected populations. The goal is to put all PWID living with HIV and eligible for ART on OST; and to put an additional 10% of PWID living with HIV (but not eligible for ART) on OST. The programme also aims to increase ART coverage from 2,000 (currently) to 6,500 by the end of Year 5, which would constitute 26% of the people currently eligible for ART.
The Grant Renewals Panel recommended that the country team exercise vigilance to ensure that Phase 2 achieves its targets. In addition, while acknowledging that current levels of Global Fund investments in Phase 2 will not achieve optimal national coverage, the Panel said that efforts should be intensified to leverage investment by government and other partners (including the World Bank) and to remove legal barriers to OST.
The Secretariat said that given the size of the country, its administrative and political challenges, and notably the legal impediments around OST, achieving significant impact during Phase 2 will be a challenge.
The Secretariat said that while it has confidence that the National AIDS Control Programme should be capable of handling the complex management task of devolving the programme to the provinces, it recommended that that the PR be required to prepare a work and transition plan to cover this task. It also recommended that the plan include improvements in risk management and procurement capacities. The Board made the preparation of this plan a condition of its approval of Phase 2 funding.
Information for this article was taken from Board Decision B28-EDP-14 and from B28-ER-11, the Report of Secretariat Funding Recommendations for February. These documents are not available on the Global Fund website.