Historically, programmes financed through the Global Fund usually fail to address the needs of men who have sex with men (MSM), primarily because countries have failed to make this population a priority. This is one of the conclusions of a study on the financing and implementation of HIV programmes targeting MSM.
The study, which examined funding primarily from the Global Fund and the (U.S.) President's Emergency Fund for AIDS Relief (PEPFAR), was conducted by the Foundation for AIDS Research (amfAR) and the John Hopkins Bloomberg School of Public Health. The study focused on grants from Rounds 5-9 in eight countries: China, Ethiopia, Guyana, India, Mozambique, Nigeria, Ukraine and Viet Nam. The study also looked at three regional grants, one in the Americas, one in South Asia and one in West Africa. A report on the study, entitled "Achieving an AIDS-Free Generation for Gay Men and Other MSM," was released in January 2012 and is available here. The researchers caution that the findings from this relatively small sample may not be generalizable to the entire Global Fund grant portfolio.
The study also found evidence that MSM-targeted activities are "deprioritised" during grant negotiations in many countries. The researchers said that in these countries the amount of money earmarked for activities targeting MSM was reduced between the budget included in the proposal (the "requested budget") and the budget approved by the Global Fund Board (the "approved budget"); or between the approved budget and the budget negotiated during the signing of the agreement (the "final budget"). In some cases, the researchers said, reductions occurred at both stages. The researchers referred to these reductions as "attrition."
The most extreme example of attrition in the study was a Round 8 grant from Guyana. The CCM requested $4.6 million; this was reduced to $3.9 million in the approved budget; and it stayed at $3.9 million in the final budget. However, the money earmarked for activities targeting MSM went from $50,072 (requested) to $45,781 (approved), and then to $1,875 (final budget), an attrition rate of 96%.
Similarly, in a Round 6 regional proposal from West Africa, the total budget went from $45.6 million (requested) to $31.4 million (approved), and then $38.8 million (final budget). The amount earmarked for activities targeting MSM went from $1.2 million (requested) to $0.1 million (final budget); the researchers said that it was not clear at which stage the funding for activities targeting MSM was reduced.
[Editor's note: It is important to observe that the researchers were unable to say why this attrition occurs or who is responsible. Therefore, it is not possible to state that the attrition was due to stigmatization of MSM. It may be, for example, that a project was removed from the budget, or downsized, because the project was not well enough developed.]
In addition, the researchers found one case (a Round 9 regional proposal from the Americas) where the amount of money earmarked for activities targeting MSM actually increased (by 68%) between the requested budget and the final budget.
For the purposes of their study, the researchers were provided with final budgets (for most of the countries and regions involved) by the Global Fund Secretariat. The Fund does not normally make final budgets public.
According to the researchers, a previous analysis of Global Fund financing found that only 10% of all Global Fund money was directed to most-at-risk populations (MARPs); and that only one-fifth of the money directed at MARPS was earmarked for MSM.
The report noted that proposals from countries with generalised epidemics rarely address the needs of MARPs. Several reasons were cited, including the limited amount of data on these populations; legal systems that criminalise some or all practices associated with these individuals; and social, economic and political discrimination. Regardless of the specific reasons, the researchers said, "it is clear that although the Global Fund has been associated with a large expansion of HIV prevention, treatment, and care services throughout the last decade, MARPs continue to have the least access to services and support even though HIV prevalence among [these populations], where studied, is often several times higher than among the general population."
The report on the study noted that the Global Fund has made some progress in promoting the inclusion of MSM-related activities in proposals. It cited as examples the adoption of the Sexual Orientation and Gender Identities (SOGI) Strategy, the decision to create a dedicated reserve for MARPs in Round 10, and the decision to "enshrine" prioritisation of MARPs in the Global Fund's Five-Year Strategy. However, the researchers said, it is too early to asses the impact of these measures.