When the Technical Review Panel (TRP) assessed Ethiopia’s TB/HIV funding request last Fall, it considered the request to be technically sound, but expressed concerns related to coverage of key populations.
“While the request does build on results and impact of previous periods to guide implementation for sex workers and their clients and other vulnerable populations, [it] does not address how HIV prevention, care and treatment services will be provided to the key populations of men who have sex with men (MSM) and people who inject drugs (PWID),” the TRP said. In addition, the TRP said, the request did not fully describe the TB/HIV situational analysis by sub-populations, gender, age and geographical locations.
The TRP recommended that the funding request proceed to grant-making with some issues to be cleared by the TRP and the Secretariat. The request successfully completed grant-making and, on 1 December 2017, the Global Fund Board approved the two grants emanating from the request as part of the third batch of grant approvals for 2017–2019 (see GFO article).
The Board approved $239.8 million for the within-allocation portion of the funding request. Ethiopia also asked for $113.8 million in a prioritized above-allocation request (PAAR), of which $90.7 million was deemed to be quality demand and was added to the Unfunded Quality Demand (UQD) Register. The two principal recipients (PRs) are the Federal Ministry of Health (FMOH) and the Federal HIV and AIDS Prevention and Control Office.
EPI SITUATION AND CURRENT STRATEGIES
Ethiopia has a low intensity HIV epidemic (prevalence was estimated at 1.2% in 2016), with disproportionately high infection rates among key populations (e.g. 23.0% for female sex workers; 6.0% among PWID; 4.9% among truck drivers; and 4.2% among prison inmates). There are no formal published reports on HIV prevalence among MSM.
Ethiopia is a high burden country for TB, TB/HIV and multi-drug-resistant TB (MDR-TB), with estimated TB incidence at 192 per 100,000 and a mortality rate of 26 per 100,000. The treatment success rates among drug-sensitive TB patients and drug-resistant TB (DR-TB) patients are 89% and 70%, respectively.
Global Fund–supported strategies and activities planned under the Ethiopia HIV program include the following:
- implementation of a prevention program for female sex workers (FSWs), migrants and other vulnerable populations;
- intensification of targeted HIV testing and counselling services to perform eight million tests per year and increase the proportion of people living with HIV tested from 72% to 90% by 2021;
- virtual elimination of mother-to-child transmission of HIV; and
- increasing antiretroviral therapy (ART) coverage to 83% (from 423,000 in 2017 to over 626,000 by 2021).
Global Fund–supported strategies and activities planned under the TB program include the following:
- improving case notification and access to quality TB, DR-TB and TB/HIV services so that 473,000 additional TB cases and 4,850 MDR-TB cases are notified over 3.5 years;
- increasing enrolment on MDR-TB treatment from 730 in 2017 to 1,590 in 2021;
- increasing the proportion of TB cases with drug susceptibility testing from 9% to 40% in 2021; and
- increasing the proportion of TB cases with documented HIV status to 96% in 2021.
The GAC acknowledged the ambitious targets of the HIV and TB programs. However, considering the context of a paced reduction in the allocation, and given that the Global Fund currently supports 100% of the cost of antiretrovirals (ARVs) and first- and second-line anti-TB drugs, the GAC said, there is a risk that funding for ARV and MDR-TB treatment will not be sustainable beyond the current implementation period without increased country ownership and significant additional domestic contributions. The GAC expressed concern about the discrepancy between the number of patients to be covered by ART by 2021 in the Global Fund-supported budget (500,000) and the national target for this period (626,000). The GAC said there are risks that further scale-up would create financial gaps in Years 2 and 3 of the program. This is an issue in many countries, not just Ethiopia; Aidspan reported at length on this issue in GFO 327.
The mention of “paced reductions” in the previous paragraph refers to the fact that when the 2014–2016 allocations were announced in March 2014, Ethiopia’s HIV component was categorized as being “significantly over-allocated.” Ethiopia was told to expect that future allocations for its HIV component would be gradually reduced until such time as the component was no longer over-allocated.
STRENGTHS OF THE FUNDING REQUEST
The TRP said that the funding request is aligned with national priorities and most international normative guidance. The TRP noted that the request covers a significant percentage (68%) of the estimated TB care and treatment gap. As well, the TRP applauded the fact that differentiated care models are being piloted in six “high-load” hospitals.
The TRP observed that the funding request demonstrated linkages between TB and other services, such as integrated management of neonatal and childhood illness and routine maternal and child health services contributing to improved TB care.
In addition, the funding request reflects good coordination amongst donors and government, with planning undertaken to maximize impact, the TRP said. Examples include the Federal Ministry of Health annual resource mapping exercise to align and harmonize donors’ investments.
ISSUES AND CONCERNS
The TRP identified nine issues which it said should be addressed during grant-making and one issue to be taken up during grant implementation. The Review and Recommendation Form for Ethiopia’s TB/HIV funding request describes each issue as well as the actions recommended by the TRP. For some of the issues, sources provided Aidspan with information on how the issues were addressed in grant-making.
For space reasons, we have had to be selective concerning which issues we include in this article.
Issue #1 –– Lack of targeted programming for key populations that are not accepted by society
The TRP said that the funding request did not make any reference to the key populations of MSM and transgendered people (see separate article in this issue), and made only a passing reference to PWID.
The TRP suggested that the CCM assess the extent to which PWID are accessing services and develop an action plan to enhance access. The TRP also suggested that a mechanism be established to ensure that PWID are able to provide meaningful input to the development of the action plan, while protecting their privacy and safety.
In response, we understand that the CCM outlined an action plan that contained interventions to prevent substance abuse, and to provide social, counselling, rehabilitation and HIV services to victims of substance abuse, including PWID. The CCM said that the interventions will include establishing or strengthening anti-drug clubs in schools and institutes of higher education; developing educational posters and brochures; and scaling up services for substance users in health facilities. There were no harm reduction interventions planned. Nor was there any information on whether and how PWID provided input into the development of the action plan.
According to our sources, the TRP pointed out that the action plan did not include opioid substitution therapy (OST). However, the TRP said, OST could be considered in the future when health structures and personnel and law enforcement agents are more able to address the needs of PWID.
Issue #2 –– Lack of a human rights and gender framework
The TRP said that the funding request lacked a human rights and gender analysis of barriers and opportunities to enhance access to, and use of, HIV and TB services. The TRP explained that the barriers include social barriers, such as stigma and discrimination, as well as legal barriers. Examples of legal barriers are laws limiting political, civil, economic or social rights of groups affected by HIV; laws that criminalize and penalize key and vulnerable populations and, therefore, foster stigma and discrimination; and laws that fail to protect the equality of women, as well as protect them from violence.
The TRP requested that the CCM (a) identify the key barriers that impede access of key populations to HIV and TB services; and (b) in consultation with the affected communities, develop an action plan with practical steps to remove the barriers or mitigate their impact. These steps may include changing laws, the TRP said, but that does not imply that that legal change is the only or primary option.
We understand that in its response, the CCM identified barriers such as stigma in health facilities, fear of stigma, and fear of non-confidentiality (based on a study of most-at-risk populations). The CCM also listed factors that contribute to gender inequality and gender-based violence.
The CCM listed several interventions that it said are incorporated in the funding request –– such as conducting a national survey of most-at-risk populations to produce estimates of population size and service utilization, and to help understand the barriers; scaling up services in drop-in centers and clinics; providing training to law enforcement personnel on stigma and discrimination and gender issues; and providing female sex workers with human rights literacy training.
The TRP was said to be satisfied with these clarifications.
Issue #3 –– Gaps in HIV prevention for female sex workers (FSWs) and their clients
The TRP said that proposed prevention interventions targeted to FSWs and their clients were under-resourced in the current funding request, while prevention interventions targeted at the general population were unduly prioritized. The TRP recommended that the CCM consider reprogramming resources from prevention aimed at the general population to activities targeting FSWs, their clients, and other sub-populations at risk. The TRP also recommended that these groups receive “enhanced coverage” with an essential package of services. Finally, the TRP recommended that the CCM provide a one-page summary that includes targets designed to achieve at least 65% coverage of combination prevention services for sex workers and their clients.
We understand that in response, the Ethiopian CCM noted that the country’s investment case gives high priority to combination prevention interventions for FSWs. There is a national package for provision of combination prevention services to FSWs being implemented through the support of the Global Fund, PEPFAR and other partners, the CCM said. Services include social mobilization and demand creation, mainly using group discussion approaches; condom distribution and education; HIV testing and counselling; referral and linkage of community-level interventions to health facilities that provide other health services; and care and treatment services. The CCM said that these initiatives, when combined with other activities, will enable Ethiopia to reach at least two-thirds of FSWs and their clients with combination prevention services.
We understand that the TRP was satisfied with the clarifications provided.
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Issue #4 –– HIV testing not optimized
The TRP said that the funding request does not adequately prioritize HIV testing and counselling (HTC) for sub-populations at risk, in particular FSWs, MSM, transgendered persons, PWID, prisoners and other priority populations with higher HIV prevalence. The TRP recommended that Ethiopia consider reprioritizing HTC resources towards interventions that identify key and priority populations and link them to treatment services. The TRP requested that the CCM provide a two-page summary of key targeted testing approaches.
We understand that in response, the CCM said that one of the objectives of the national HIV strategic plan for 2015–2020 is intensifying targeted HIV testing services that are designed to identify the majority of new infections and link patients to care and treatment. To achieve this, the CCM said, Ethiopia designed and implemented a national Catch-Up Campaign starting in November 2016. Thirteen key populations were identified, including FSWs and their clients, inmates, truck drivers and orphaned and vulnerable children (but not MSM, transgendered persons or PWID). The CCM listed several prioritized interventions, including:
- strengthening targeted demand creation for HIV testing services through community peer support groups among partners of index cases;
- strengthening facility-based and outreach HIV testing services;
- strengthening partner notification; and
- integrating HIV testing services in social support settings of selected health facilities established to support victims of substance abuse, including those who inject drugs.
The TRP indicated that it was satisfied with the clarifications provided.
Issue #6 –– List of key populations for TB care incomplete
The TRP said that although Ethiopia plans to implement targeted interventions addressing the needs of prisoners, children, health workers, (some) refugees, pastoralist communities and urban poor – there is limited information on how the needs of other high-risk groups will be addressed, including South Sudanese and Somali refugees, internally displaced persons and miners. The TRP requested that the CCM provide a more robust description of key affected populations for TB and provide strategies to enhance case finding among these groups. We are not aware of how this issue was addressed in grant-making.
Issue #8 –– Targets for TB care and prevention and MDR-TB not ambitious enough
The TRP said that the targets for case notification for drug-susceptible and DR-TB were conservative and unambitious. It recommended that the CCM work with the Secretariat during grant-making to revise the targets. We do not know if this issue was resolved.
Issue #10 –– Insufficient planning to increase domestic financing
The TRP said it was concerned that there has been insufficient planning to support increased investment from government and other country-level sources of finance for national HIV, TB and malaria programs. The development of innovative financing approaches and increased government commitment were mentioned in the funding request as alternate sources of financing in an increasingly constrained external assistance environment, the TRP said. However, there weren’t many details. The TRP recommended that the CCM further clarify how government, insurance, private sector, household, and innovative financing approaches will support key interventions. This issue is to be addressed during grant implementation.
CO-FINANCING AND THE FISCAL CYCLE
The GAC said that the Ministry of Finance and Economic Cooperation has made an indicative commitment to increase the funding for the disease programs by $38.4 million, which exceeds the minimum co-financing requirement.
According to the GAC, in order to align Ethiopia’s HIV and TB grants duration with the country’s fiscal cycle, the grants will have an implementation period of three years and six months, from 1 January 2018 to 30 June 2021. In light of this, the GAC said, and to mitigate potential programmatic disruption, “Ethiopia will also benefit from a one-time flexibility to facilitate financing of commodities arriving in country after the end of their current allocation utilization period.”
(Translation: Ethiopia is being given a one-time waiver from the rule that says that funding from a given allocation period [e.g. 2017–2019] for a given country must be used within the three-year allocation utilization period established for that country. When Ethiopia received its allocation letter for 2017–2019, it was informed that its allocation utilization period was 1 January 2018 to 31 December 2020, a period of three years. But the implementation period for Ethiopia’s HIV grants extends beyond 31 December 2020 (to 30 June 2021). Without the waiver, Ethiopia would have had to finance the last six months of its HIV grants from its allocation for the 2020–2022 allocation period.)
Some of the information for this article was taken from GF-B38-ER02 (Electronic Report to the Board: Report of the Secretariat’s Grant Approvals Committee) and the Funding Request Review and Recommendation Form for Ethiopia’s TB/HIV application. These documents are not available on the Global Fund’s website.