Georgia’s concept notes for both HIV and TB are closely reflecting the priorities identified in their national strategic plans, a recent WHO evaluation has found, but must ensure that more interventions focus on improving case detection rates for the two diseases.
The country submitted its HIV proposal in April and its TB proposal on 15 July, in anticipation of disbursement of the country allocation of $56.4 million. The HIV concept note is proceeding to grantmaking, while the TB proposal will be reviewed in the next window by the Technical Review Panel.
The HIV concept note prioritized interventions targeting key populations. Georgia’s HIV burden is concentrated in key affected populations, such as people who inject drugs (PWID), men who have sex with men (MSM) and female sex workers (FSW). Conducting representative surveys of PWID has been challenging, resulting in estimates of HIV prevalence ranging fom 0.4 – 9.1%. Among MSM, infection rates rose to 10% in 2012 from 7% two years earlier.
Improved care and treatment for people living with HIV was also identified as a top priority. There are currently 3,714 registered cases of HIV in Georgia – yet estimates included in the NSP (for 2016-2018) suggested the number of infections was nearly double that figure, at 6,580, suggesting that more than 40% of the target community is unaware of their status.
Among the recommendations included in the WHO review of the HIV program was the need for tandem testing with Hepatitis-C, which could significantly increase the number of tests administered to key populations. Georgia has one of the world's highest rates of Hep-C infection, also concentrated among key populations. In a new pilot program sponsored by Gilead Pharmaceuticals, free testing and treatment will be made available to at-risk groups. Those who enrol in the program will also be tested for HIV, which will help to improve HIV case detection rates.
The approved HIV concept note aligned with review recommendations to emphasize leadership, governance and advocacy to open policy discussions on health and social issues to a wider complement of institutions. This would include reinforcement of the Ministry of Labor, Health and Social Affairs as a leader in HIV-related policy debates, and better-definition of the roles of HIV partnership members including the National Center for Disease Control and Public Health: a principal recipient under the new HIV and TB grants.
Also at the heart of the concept note is more concerted engagement with the private sector – particularly in terms of sensitizing health service personnel to reduce stigma – which is in line with recommendation of WHO evaluators. Some 95% of health facilities in Georgia are privately operated.
Loosening the currently restrictive policy environment would also contribute to an improved outlook on the expansion of harm reduction including OST and needle and syringe exchange programs. The HIV CN envisions scaling these programs both geographically and in terms of reducing structural barriers to access to existing programs, such as the currently banned “take-home” practice.
In the TB portfolio, the WHO review noted that control activities beginning in 2016 align closely with recommendations made in 2014 during a high-level WHO mission. Among these are improved case detection, treatment adherence and success rates; MDR/XDR treatment; and the strengthening of the TB control system, which suffered under the rampant privatization of health care facilities including TB outpatient services in 2012.
Widening the space for civil society to participate in decision-making for TB will continue to be a priority in Georgia, as it is relatively immature compared to civil society engagement in HIV. How this will translate beyond the life of the Global Fund’s engagement in Georgia, however, remains to be seen. The state already covers more than half of the national outlay on TB, including, by late 2015, the entire cost of first-line TB medication. According to the NTP notifications data, a total of 3,850 TB cases (all forms and including penitentiary sector), were registered in the country in 2014, rougly 103 per 100,000.
While Georgia can rely on Global Fund support through 2018 for its TB program, there is a risk that a funding gap will accompany the presumptive end of Fund grants in 2019. There are growing concerns that the spread of MDR/XDR TB and the growing disease burden will strain existing TB budgets, leaving a gap in some elements of the program. Collaborative work has begun between the CCM and MolHSA to plan the transition to avoid any vacuum in access to TB diagnostics and treatment.
The HIV program review was performed in March 2015 prior to the submission of the concept note, aiming to review the key components of the program and the draft NSP for 2016-2018. An extensive review of TB prevention, control and care system in Georgia was done in November 2014 to inform the development of both the NSP and the TB concept note. The reviews are expected to be published by the WHO in coming months; near-final drafts were shared privately with Aidspan.