The Global Fund and UNAIDS have expressed concern over a new law in Nigeria imposing harsh penalties on people who engage in or support same-sex activities, and have asked the  government to reconsider in order to ensure access to essential HIV services for LGBT people.

Country ownership is a core principle of the Global Fund model. But as is often the case, the ideal has been complicated by political realities, namely, who owns country ownership? Too often it is the loudest voice, not the best harmony of a variety of voices, which drives the process away from the ideals of the Fund into potentially uncomfortable territory.

The work of the Grant Approvals Committee has expanded the influence of the Global Fund over the contents of programmes financed through requests for continued funding.

Côte d’Ivoire is known throughout West Africa as the most tolerant country, where gay, lesbian and transgender people from all backgrounds do not have to fear the same kind of systematic violence or opprobrium that plagues them elsewhere in the region. Yet for all this openness, the country is hardly an oasis: sex workers and men who have sex with men continue to encounter often violent stigmatization, the manifestation of a culture of ignorance and suspicion, particularly within the security and defense forces.

The Office of the Inspector General says that it has found evidence of attempted misappropriation, misuse of grant funds, misrepresentation and anti-competitive and collusive practices related to the implementation of HIV grants to Kazakhstan.

A Georgia-based NGO has launched an online petition it hopes will attract regional support for a greater push by governments to fill the anticipated vacuum that will be left once the Global Fund no longer commits significant financial support to a majority of EECA countries.

Donor support has enabled Malawi to scale-up its ART services to reach 67 percent of Malawians in need of treatment, but this success is under threat because of an acute shortage of trained health personnel in the public sector.

Aidspan is pleased to launch the following research paper highlighting some of the main areas of conflict of interest within country coordination mechanisms that can compromise the process of principal recipient selection or grant implementation.

The law passed the Nigerian national assembly in May 2013 but President Goodluck Jonathan resisted signing it until early January, doing so with little fanfare as he knew the likely firestorm it would provoke among Nigeria’s development partners.

Governments including the US and the UK released strongly worded statements that matched the urgent request by the Global Fund and UNAIDS for Nigeria to review the constitutionality of the law, which will impose stiff jail sentences of up to 14 years for those entering into same-sex unions and restricts public association by gay and lesbian Nigerians.

In a 14 January statement, the two organizations said the new law “could prevent access to essential HIV services for LGBT people who may be at high risk of HIV infection, undermining the success of the Presidential Comprehensive Response Plan for HIV/AIDS which was launched by President Goodluck Jonathan less than a year ago”.

Nigeria should put comprehensive measures in place to protect the ongoing delivery of HIV services to LGBT people without fear of arrest or other reprisals, the Global Fund/UNAIDS statement added.

Estimates from 2012 suggest there are some 3.4 million people in Nigeria living with HIV, a national prevalence rate of around 4%. Prevalence among men who have sex with men is estimated at 17%.

“The provisions of the law could lead to increased homophobia, discrimination, denial of HIV services and violence based on real or perceived sexual orientation and gender identity. It could also be used against organizations working to provide HIV prevention and treatment services to LGBT people,” they said.

The law may have serious public health and human rights implications for Nigeria and could be a bellwether for similar repressive legislation across West Africa.  

There are already more than 30 countries in sub-Saharan Africa that have criminalized homosexual activity: most of which are recipients of Global Fund support. The implications of the new law are already evoking concerns among civil society groups that work specifically with men who have sex with men. The Global Fund Secretariat told Aidspan that it did not know yet what the law meant for the programmes it supports in Nigeria, but that contact with government was continuing.

However, the adverse implications for outreach programmes to the MSM community could be considerable. In the administrative capital Abuja, the International Center for Advocacy on Right to Health (ICARH) established a clinic in 2011, providing condoms and ARVs to slow the spread of HIV in this population.

“This law will be very harmful to our work,” Ifeanyi Kelly Orazulike, ICARH’s Head of Programmes told Aidspan. “The primary beneficiaries of our programmes are men who have sex with men. Over 600 people are benefitting from our services, and 200 of them are receiving ARVs. What will happen to these people who are on ARVs? There is a real possibility that they will drop out of the programme as MSM will henceforth fear coming out in public to receive the services.”

Mr Orazulike said that anecdotally, he has heard from many men preparing to flee the country once the law is fully implemented because due to the way it is written, it creates an atmosphere that encourages targeting of people on the basis of their sexual orientation. As part of an intensive year-long campaign to keep the bill from being passed, ICARH delivered a paper to the Nigerian senate about the potential implications for public health. The paper, he said, was ignored.

“The international community should put pressure on the Nigerian government to understand the negative impact of this law in terms of financing for programmes targeting key populations,” he said, noting that the support by the Global Fund and other donors is crucial.

The Global Fund has disbursed about $1 billion to Nigeria since 2002, some two-thirds of which supports HIV programming including the provision of anti-retroviral therapy for more than 520,000 people.

Speaking by telephone to Aidspan, Ibrahim Umoru, coordinator of Nigeria’s Network of People Living with HIV/AIDS, which has been a sub-recipient (SR) of Global Fund grants since 2006, called the law  inconsistent with the country’s need to slow the spread of HIV transmission and infection. Tackling AIDS is not just about providing anti-retroviral treatment; it’s about sensitizing people about prevention and changing behaviours to avoid infection. So the grey areas not yet clarified in the application of the new law could make his job decidedly more complicated.

“For instance, in my work, I come across situations where I may need to offer counselling to MSM people who are HIV positive. Since the new law criminalizes the public display of same-sex activities, will such counselling be prevented?” he asked. “As a person living with HIV, my concern is not about people’s sexual orientation but rather about sexual health. Treatment must be given to all people without discrimination.”

Discouragement with the passage of the bill that they spent a year fighting will not make AIDS activists in Africa’s most populous nation complacent, Mr Umoru vowed; instead, they will continue to agitate for government to ensure a conducive environment for the implementation of HIV/AIDS programmes for all people, including those engaged in same-sex activities.

Yakasai Umar Tanko, the national coordinator of Network of Youth on HIV/AIDS in Nigeria (Nynetha), a sub-recipient of Global Fund grants for Round 9, said the government should be prepared to fill the void if donors who have been funding LGBT programmes are unable to operate because of the new law.

“The government must have been aware of the implications of coming up with that law and should be ready for the consequences that the law will have on donor funding for HIV/AIDS programmes,” he said.

Read the article in French. Lire l'article en français.

by Kate Macintyre

A mere $28billion later and the Global Fund’s dedication to country ownership as a guiding principle is still intact, bolstered, reinforced, reinvented or reemphasized at almost every opportunity. 

It’s a sound foundation, predicated on the notion that countries themselves know how to solve their own problems and can tailor their responses to AIDS, TB and malaria to their own political, cultural and epidemiological context.

And that’s right, and good, and as it should be, and the Global Fund is not alone in promoting this as the basis of its development investment: people living in the midst of the epidemics are considered most knowledgeable about what they need, when they need it and even how the interventions should be developed.

Ownership also, the argument goes, breeds responsibility for management, implementation and oversight. So by stating ownership by a country of the programmes that its cheque-book supports, the Global Fund is saying that the country should be accountable for the success or failure of those programmes.   

Underlying this commitment to country ownership is also a motivation from many donors: that if a country owns a programme, it is more likely to sustain it after donors’ funds have finished. So, in basic terms, “country ownership” from the donors’ perspective is an exit strategy. Moreover, it is seen as an exit strategy with a lower risk of failure in the long term.  

The cracks in this foundation of ‘good’ notions of country ownership only appear when what a national government wants jars with the vision of what a donor or other voices in the country desire.  

Many definitions of country ownership ascribe a degree of fairness to democratic processes that are simply not evident.   Nascent democracies in many parts of the world do not have systems set up to hear and deal with the multiple voices that the principle of “country ownership” assumes they do.  The systems also, importantly, don’t have protective policies in place to ensure there are safe spaces for vulnerable individuals or groups to speak their mind. 

Even in a mature democracy like America, where freedom of speech and civil society has a protected space, it took a seriously angry movement of gay men (ACT UP), with a sustained and brilliant campaign of about five years in the 1980’s, to draw serious government and societal attention to the problem of access to treatment for AIDS. 

This disconnect between the assumptions of the principle of country ownership and the realities of the political spaces in many countries heavily affected by the epidemics, is at the root of many of the tensions that can compromise the Global Fund model, and can seriously interfere in the process of grants applications and approvals.  An airing of the differences this disconnect produces is needed.

In its eagerness not to be too prescriptive, and to promote country participation, the Global Fund at its genesis allowed too much latitude in defining ownership. This meant problems from the word ‘Go’: who owned what? Does owned mean government-led, or does it allow for a diversity of voices to guide a country’s priority-setting? In the early days, gentle suggestions about the importance of  including civil society voices were met with silence.

The reality was, and in many cases continues to be, that the loudest voices are the well-established ones: government, its agencies, its technical partners. Representation on the country coordination mechanisms (CCMs) remains a challenge for women, for young people, for all people living with the diseases.  Too many groups ‘represented’ in CCMs are merely tokens, window-dressing to meet the quotas and criteria for eligibility demanded by the Fund.

One friend of mine put it simply: “No one listens to any voices outside the formal government channels. I only sit here in the hope that the funds that come in will trickle down to some groups that fight the epidemic that is mowing down my friends.” 

We, my friend and I, very much hope that the new country dialogue model envisioned under the new funding model will counteract that bias, and provide spaces to some of the CCM members who until now have sat in silence.

What we have also seen is the Global Fund itself increasing asserting its role as “technical corrector” via more recommendations from the TRP and the Grant Approvals Committee (see article). These recommendations range from concept notes being asked to incorporate more targeted programmes for human rights, a greater emphasis on harm reduction, wider attention to gender issues and key populations to demands that principal recipients be changed or entire programmes being excised from proposals.

There is a risk that some of these recommendations – most, if not all, of which have a very sound basis in public health – cross the fine line between technical support and the core principle of country ownership: and the risk is calibrated depending on where you sit.

As to be expected, with the roll-out of the NFM, as in so many donor-recipient models, there has been unease expressed as grumblings about more control coming from Geneva. And for some in implementing countries, those grumbles have translated into concerns about just how prescriptive the Fund has the potential to become in comparison to the Rounds system.

Today, the Fund asks that countries demonstrate their knowledge of their epidemics, their contexts, and the supporting data-based evidence for both their strategies and planned interventions in order to qualify for grants. Much of the quality of the exchange within the country dialogue should come from the quality of those national strategic plans. So better plans should equal more country ownership.  But how far will the national plans be willing to implement decent strategies that reach key populations? And how far will the Global Fund be prepared to go to ensure that those strategies, and those targets, are in place?

It comes down to the kind of working relationship countries are prepared to have – both with the Global Fund and with the civil society voices no longer prepared to stand in silence, but instead to stand with the full weight of Global Fund support behind them. This will be the critical challenge in making sure that country ownership is evenly distributed among all those who want to ensure the best possible impact of strategies to fight AIDS, TB and malaria.

Sadly, many governments remain nervous about power- and resource-sharing when it comes to civil society.   

Proof of that nervousness, that fear, has come this month from Nigeria, where President Goodluck Jonathan signed into a law the latest anti-gay legislation to terrorize the affected communities in sub-Saharan Africa (see article).  This is a classic, and not rare, clash between the Fund’s strategy for key populations and the national right to self-determination by a country’s elected officials.  What the Fund chooses to do next will have enormous repercussions both for Nigeria and all future discussions about its guiding principle of country ownership.

Kate Macintyre is the executive director of Aidspan. Opinions expressed in this commentary are her own.

Read the article in French. Lire l'article en français.

The Global Fund has become more prescriptive about what should be included in submissions for funding for the next phase of a grant. While this trend began under the Grant Renewals Panel, the formation of the Grant Approvals Committee (GAC) in the second quarter of 2013 brought with it a noticeable upswing.

The GAC, comprised of senior Secretariat officials and non-voting representatives of technical partners, reviews all requests for funding and makes recommendations to the Board.

When a continued funding request is under review, the GAC recommends or suggests changes to workplans and budgets – which are ultimately requirements that countries must adopt for funding to be approved.

Although the reports of the GAC are not posted on the Global Fund website, they are seen by members of the Board delegations and the people consulted by the delegations. Aidspan has access to the reports and has been reporting on their content in GFO.A list of recently approved requests was published here.

Aidspan has observed a number of trends emerging from the GAC recommendations, including the modification of programme elements, either adding them or eliminating them and shifting the resulting savings towards programming that targets key populations. Cost-cutting and switching to new principal recipients are also typical GAC requirements.

On occasion the GAC requires countries to revise and resubmit requests for continued funding. A Round 8 TB request from Guinea-Bissau required a change in PR from the ministry of health to the United Nations Development Programme as well as a programme review that could lead to further revision and validation of the most recent draft national strategic plan.

India was told which objectives should be prioritised in itsrequest for continued funding for three single-stream-of-funding grants: the expansion of TB notification rates and multiple-drug-resistant TB diagnosis and treatment; TB–HIV co-infection; and urban care models to reach more vulnerable and marginalised people.

In several cases, the GAC “recommended” actions that went beyond the grants themselves and targeted national programmes. When it reviewed the India TB grants, for example, the GAC said that a high-level inter-agency task force should be established to convince India’s political leadership to pick up a greater share of the costs of providing TB treatments.

Aidspan understands that a multilateral task force was subsequently established among technical partners including the WHO, the Stop TB Partnership and USAID. Additional input from Path, the Clinton Health Access Initiative (CHAI) and the Bill and Melinda Gates Foundation contributed to the group’s mandate, which emphasises new strategies for structuring of Global Fund investment to get out in front of the TB epidemic in India, which is proportionally the world’s largest.

In the case of two HIV grants from Namibia, the GAC asked for the country dialogue to include a district-by-district assessment of high HIV transmission areas, focusing on the most vulnerable groups.Namibia was also required to expand TB–HIV collaborative interventions to acknowledge gender issues including gender-based violence.

When it reviewed a renewal request for a Colombia HIV grant, the GAC said that the PR must implement activities targeting transgendered people to try and bring down the high HIV prevalence rates in that community. Activities targeting people who inject drugs were also added to the grant.

There are also notable consequences for countries that fail to implement GAC recommendations. In May 2013, the Board approved Phase 2 funding for a regional HIV grant in Latin America and the Caribbeanon the condition, set by the GAC, that the grant be completely reprogrammed. The grant was to be refocused away from the regional military and security forces and towards activities to reduce stigma and discrimination affecting populations such as sex workers, men who have sex with men, and transgendered people. Several months later, when the applicant had done little to re-work the grant, the GAC recommended it be discontinued and the Board agreed (see article here).

Under the old Grant Renewals Panel, also known as the Phase 2 Panel, the Global Fund also set conditions for the next phase of a grant, but it was less likely than the GAC to require the addition or removal of entire programme elements.

The requirements of the GAC with respect to the inclusion of certain key populations in programmes funded by Global Fund grants is clearly an attempt to ensure that marginalised and stigmatised populations – such as transgendered persons, people who inject drugs, and men who have sex with men – receive prevention and treatment services. In many countries, these populations are not covered by government-funded programmes. The focus on key populations is consistent with the objective of the Global Fund to concentrate on the hot spots of the HIV, TB and malaria epidemics.

Similarly, by requiring the addition in grant renewals of activities related to human rights and gender, the GAC is forcing countries to address issues that have not received enough attention in the past. For several years now, the Global Fund has been promoting the idea that programmes must include a greater focus on human rights and gender. The recent actions of the GAC indicate that the Global Fund’s initiatives have not borne enough fruit and that the Fund feels it must go beyond promotion – at least in some countries.

Another trend that Aidspan has observed is that when the GAC requires the removal of some programme elements, it is usually because the GAC believes that these elements will not have a major impact on the epidemics. Reinvesting the savings from these discontinued elements into initiatives that will have a greater impact is consistent with the value-for-money approach that the Global Fund has adopted.

From comments from the Global Fund Secretariat, Aidspan understands that these requirements are the direct result of a new, more strategic approach to funding embodied by the NFM that demands greater engagement by the Secretariat itself in the process of developing concept notes and grant proposals.

The GAC, according to the Secretariat, ensures that partners are present at the table to make sure that investments are better targeted, part of a better process that will ultimately maximize the impact of Fund investment at the country level.

It is too early to tell whether the actions of the GAC will have the desired outcomes, including improving the quality and impact of programmes targeting key populations. But these prescriptive requirements should, at their core, do more to expand the number of people, particularly among vulnerable populations, who are accessing services supported by the Global Fund.

Côte d’Ivoire is known throughout West Africa as the most tolerant country, where gay, lesbian and transgender people from all backgrounds do not have to fear the same kind of systematic violence or opprobrium that plagues them elsewhere in the region. Nor is there any legislation banning homosexual activity as in other countries, including Nigeria which in January passed a jarring bill into law that imposes 14-year penalties on same-sex unions or gatherings by sexual minorities in public.

Yet for all this openness, the country is hardly an oasis : sex workers and men who have sex with men continue to encounter often violent stigmatization, the manifestation of a culture of ingnorance and suspicion, particularly within the security and defense forces.

The response to an announcement made in June 2013 by the French embassy that it would fund the local human rights group Alternative to fight anti-gay discrimination was met with virulent opposition, manifest in the pages of the country’s  daily newspapers.

While some of the papers reported on the news without comment, others lambasted the announcement as “encouraging this vomit-inducing phenomenon designed to destroy the human race”.

A report released in October 2012 by a consortium of human rights organizations revealed a number of instances of violence meted out by defence forces.

Violence is not the only form that stigmatization can take ; other groups working in the country to battle the effect of an 3.7% prevalence rate of HIV often take exception to the money allocated specifically for outreach to this population.

“They think, why should those people get extra money, when there are other people also suffering?”  said Dr Aidara Coulibaly, director of a community outreach NGO, Alliance Côte d’Ivoire.

In support of its global objectives to target funding to the populations most in need, the Global Fund in November 2013 approved support for two HIV programmes targeting both sex workers and men who have sex with men (see article). Until September 2016, some $3.9 million of an $18.8 million grant (CIV-910-G13-H) has been specifically allocated to target the needs of these vulnerable populations.

Administered by the national anti-AIDS alliance, the money will be spent on free distribution of male and female condoms, lubricant and outreach campaigns on prevention of HIV infection. Additional funds under Phase 2 of a second grant (CIV-910-G12-H) will boost the Fund’s contribution to anti-retrovirals from 30% to 50% of the national need. There are currently nearly 18,000 people on ARV therapies supported by the Global Fund.

These programmes are an effort, in line with the national strategic plan developed by Côte d’Ivoire for 2012-2015, to bring the high rate of HIV infection in key populations under control.

In line with the objectives established by the Global Fund to reach out to key populations, even in the face of marginalization, the country coordination mechanism (CCM) has begun bringing representatives from sexual minority groups into decision-making.

Despite noticeable reluctance by some CCM members to share the table with them, gay voices are making themselves heard.

Dr Coulibaly said that gay advocacy groups were directly responsible for ensuring that lubricants were included in the commodities requested under Phase 2 of the recently-approved grant.

Other proposals, including human rights sensitivity training for security forces, were not as enthusiastically received – a position perhaps attributable to the fact that the Ivorian justice ministry refuses to believe that security forces have ever committed violent acts against gay men, said Franck Amani of the national association of people living with HIV (RIP+).

Still, even within the CCM, there is stigma, couched in terms of morality. 

Yvette N’Tamon, who represents a religious alliance that has a seat on the CCM says that while all populations should be represented at the table, “really integrating them into decision-making means accepting homosexuality as a good moral value. And that is simply not the case. We don’t have much of a choice, though.”

According to a survey conducted in 2012-13 by the national HIV programme, HIV prevalence among sex workers is 28.7 percent nationally. For men who have sex with men, there are no good data from the national level, but sero-prevalence in Abidjan is estimated at close to 18%.

Results from a more comprehensive Integrated Bio-Behavioural Survey, partially funded by the Global Fund, are expected in 2014, with a second phase survey to be launched in 2016. The results generated by these two surveys will help to fill the yawning national gaps in survey data while also helping the PR to further refine its strategies for programmes targeting the two populations.

But while these programmes are considered by many in the country to be vital to the success of the national fight against AIDS, they don’t go nearly far enough, said one sex worker who asked to be identified only as Chimène.

 “When they beat us in the street, we have no way to pay our medical bills, and only in Abidjan can we even find someone to defend us; elsewhere in the country, no one has the means or the interest,” she said.

For some groups, it’s not a want of funds that prevents successful programming. According to Dr Marguerite Thiam, head of the national AIDS commission’s outreach to vulnerable populations, religious and traditional prejudice, to say nothing of the prejudice and stigma perpetuated by the armed forces, means that outreach can be compromised. “Our work can most definitely be compromised by fear, and widely misunderstood,” she said.

The opinions about HIV, sexuality and social mores are as varied in Abidjan as the people from across the region who flock to what remains the most metropolitan capital in all of francophone Africa despite more than a decade of on-and-off conflict and strife.

In Blockhauss, a densely populated working-class neighbourhood in Abidjan, Florence, a businesswoman, and Chantal, an aesthetician, shared a similar outlook on the necessary response to AIDS in the country.

“Everyone deserves to be treated [for HIV], no matter if they are sex workers, gay or straight. You can get AIDS accidentally, but it’s also true that gay men should kind of expect it – it’s their fault that they get AIDS,” they said.

Just a few blocks away, Rodrigue N’Choko is closing the private clinic where he works as head nurse. For him, external funding that targets sexual minorities including sex workers is critical, even if that targeting is resented by the wider population. “If that money were not available, how would these people get treatment?” he asked. “Even when they know their status, they need to seek treatment in secret.”

M N’Choko may have a nuanced view of the importance of providing access to treatment for all people living with HIV, but his is not a position shared by most health providers in the country. Only three clinics in Abidjan are considered safe places where HIV+ gay men can feel confident seeking treatment. Many doctors are anecdotally known to refuse to provide treatment because of their sexual orientation.

For many working in the HIV field, that sort of exclusion and marginalization is the most dangerous, because it perpetuates stereotypes and misunderstandings among the very people whose code of conduct demands that they first do no harm. To overcome it, they say, Côte d’Ivoire must be innovative in implementing a public health approach to HIV – instead of a cultural one.

“We are trying to establish in the public perception that men who have sex with men are often also in relationships with women; many are married, for example. So this means that everyone should be aware of how to prevent HIV. And in some ways, we are making headway, but it is a huge task.”

Just how huge a task it is was manifest in an interview with Roger Koffi, a popular radio presenter on the Muslim radio station Al Bayane. Insisting that his opinion was informed by secular, rather than religious teaching, he said : “In Africa, it’s difficult to accept homosexuality. I do not agree that we should be helping them, and think that those funds would be better served elsewhere, like subsidizing more antiretrovirals for the poor who aren’t gay.”

*Voir l'article original in French. See the original article en français.

An investigation by the Office of the Inspector General (OIG) into three HIV grants in Kazakhstan administered by the principal recipient, the Republican Center for Prophylactics and Control of AIDS (RCAIDS), has found evidence of attempted misappropriation, misuse of grant funds, misrepresentation and anti-competitive and collusive practices.

A report was released by the Global Fund on 13 December: one of five on “separate subcases” that the OIG is investigating. There has been no further elaboration of the nature of the other cases or when those conclusions will be released.

In 2006, RCAIDS procured $149,172 worth of the antiretroviral drug Viracept from manufacturer Hoffmann La-Roche, which subsequently issued a global recall due to alleged contamination. Most of the supply purchased by RCAIDS was returned.

In 2009, Hoffmann La-Roche agreed to reimburse the cost of the recalled drugs, initially estimated at $101,957, to RCAIDS. According to the OIG, the financial manager of RCAIDS, acting on instructions from the then-director general, requested that the reimbursement be made through a transfer to the bank account of a company in New Zealand without informing the Fund.

The company had no apparent relation to Fund-financed activities. To justify the transfer, the financial manager provided a false statement to Hoffmann La-Roche, asserting that the company in question delivered ARV drugs and test systems to RCAIDS in 2010.

Since no reimbursement was made at that time, the OIG characterised this as “attempted misappropriation”.

The reimbursement came in 2012 when $105,227 was paid into the bank account of RCAIDS. A new director general was now in place, and the OIG said that the reimbursement was classified as a “grant” to RCAIDS and subsequently earmarked for an anti-HIV information campaign: an unauthorised activity that was tendered in a non-competitive procurement process.

Evidence of collusive practices in the award of the three contracts was also uncovered by the OIG; one of bidders was a friend of the director general of RCAIDS. Law enforcement authorities in Kazakhstan have separately launched a criminal investigation into procurement irregularities related to the HIV grants.

RCAIDS committed in September 2013 to reimburse the full amount to the Global Fund Secretariat.

The investigation appears to have already influenced recommendations for future disbursements of grant money to Kazakhstan. As pre-conditions for Phase 2 grant signing, an oversight procurement strategy in place since January 2013 will remain in effect for the foreseeable future, and the director of RCAIDS has effectively been banned from any involvement in, or responsibility for, implementation of Global Fund grants. The Global Fund’s country team was also keenly monitoring the recruitment of a new financial manager RCAIDS, following the resignation in July 2013 of the official involved in some of the irregularities uncovered by the OIG.

The report of the OIG investigation can be found on the Global Fund website here.

A Georgia-based NGO has launched an online petition it hopes will attract regional support for a greater push by governments to fill the anticipated vacuum that will be left once the Global Fund no longer commits significant financial support to a majority of EECA countries.

The regional initiative spearheaded by the Georgia Union of People Livin with HIV “Real People, Real Vision” group will also include advocacy targeting governments in Armenia, Azerbaijan, Belarus, Moldova, The Russian Federation and Ukraine. The campaign, ‘Health can be purchased, put the price in the budget’ seeks to ensure that government provides stable, quality and free treatment for all people living with HIV.

EECA remains the only region where generalized HIV prevalence is rising, according to a 2012 report from UNAIDS. However, because of a shift in the Global Fund’s approach towards high impact, low income countries, many of the states in the region that are classified by the World Bank as middle-income may see a precipitous drop in the amount of financial support they get from the Fund, from 2015. And while governments have committed to provide funding for treatment and care programming, it is prevention and harm reduction activities, specifically targeting key populations, that are especially vulnerable.

The Georgia-led campaign has emphasized a number of potential challenges that may occur during the transition period, even before states are ready to take financial responsibility for all of the services and programmes currently supported by the Global Fund.

Critical attention must be paid to procurement, the group said, as Georgian legislation is narrowly tailored in order to restrict what sort of drugs are allowed in the country. Currently, state funds may only be used to purchase officially registered medicines; however, because Georgia has enrolled in the Fund’s voluntary pooled procurement (VPP) mechanism, anti-retroviral drugs are being allowed in the country as humanitarian aid and without the need for local registration.

This has brought prices for anti-retroviral drugs down considerably, allowing greater numbers of the estimated  1,730 people living with HIV in Georgia – according to data generated by the National AIDS Centre in 2013 – to begin ARV treatment. Real People, Real Vision is urging a change in legislation from parliament in order to make registration more flexible and simplify the tendering process: a move that would bring Georgia in line with many other countries in the region.

Other components of the group’s advocacy campaign include promoting a new working group on HIV as the credible leader in helping Georgia transition out of Global Fund financing into full domestic support for HIV prevention, treatment and care as a model for other countries in the region. A treatment support working group has been convened under the parliamentary committee on health and social affairs, to bring stakeholders and decision makers in HIV/AIDS together to plot the transition from Global Fund to state funding of ARV treatment in Georgia.  There is not, however, currently any plan in place to finance or develop programming that targets high-risk groups for prevention activities after 2016. 

 “It is a critical moment for us to consolidate the approach by community representatives and governmental institutions to meet the challenge of transition and ensure fundamental right of every person–access to the continues vital lifelong treatment,” Giorgi Soselia, a spokesman for the East Europe Central Asia Union of People Living with HIV –ECUO, told Aidspan.

Nearby in Belarus, a similar advocacy campaign is in its infancy in the wake of mounting concern that the epidemic in that country is expanding unfettered. As in Georgia, there are concerns about state funds being used to support HIV-related prevention programming for injected drug users, sex workers and men who have sex with men: three key populations that receive considerable targeted support through grants from the Global Fund.

Civil society organizations have requested urgent changes in approach and policy in order to ensure sustainability of HIV prevention work in the country. While popular opinion and state policy in Belarus is lining up against him, the chairman of  “BelNet AntiAIDS”  – a network of HIV service NGOs– Oleg Eryomin has expressed confidence that the science linking prevention activities to reduced risks of infection will help change people’s minds.

His group has launched a campaign to incorporate all Global Fund-supported services for HIV prevention into the state budget from 2015, but the dialogue with government is not easy: Eryomin says that it might be possible to benefit from a state social demand programme that is to support local NGOs, but in reality there are many legal and policy barriers for NGOs to benefit from the state support unless some policy changes are not implemented.

Other potential sources of revenue to fill the gap that will be left by the Global Fund’s investment in Belarus include other donors, who have made unofficial commitments worth about 15% of the current Fund expenditures.

According to Eryomin, the state has committed to cover treatment costs and even support production of ART medicines in the country, but funds for prevention remain under negotiation.

Malawi’s health sector is grappling with a serious lack of trained health care staff that could have an impact on its Global Fund-supported programming to enroll a greater number of HIV-positive Malawians on antiretroviral therapy (ART).

Fund support to the Malawian health sector for ARV purchases began in June 2004. Prior to that Round 1 application, only nine public sector facilities offered ART, reaching just 3,000 people – or 1% of the national need.

According to UNAIDS figures, Malawi has a generalized HIV epidemic with an estimated HIV prevalence of 10%. About 910,000 people are living with HIV and 44,000 AIDS-related deaths were reported in 2011.

With donor support, Malawi has scaled-up its ART services. As of June 2011, 449 clinics were reaching 276,987 (67%) out of the 411,574 of Malawians in need of treatment.

But those successes are under threat because of the acute shortage of trained health personnel in the public sector. World Health Organization recommendations encourage a ratio of seven health care workers for every 1,000 patients on ARVs. As of 2010, Malawi’s ratio was about half: 3.54 health workers/1,000 ART patients. Malawi has only two doctors and 37 nurses and midwives for every 100,000 people.

Low pay and poor working conditions, particularly in remote areas, are some of the factors inhibiting Malawi’s ability to reach the recommended ratios. However, the sector has also been badly hit by the AIDS epidemic.

“The shortage of health workers has an impact on health care delivery,” Henry Chimbali, a spokesman for the Ministry of Health’s HIV prevention and behaviour change unit, told Aidspan. “Government is making efforts to increase their numbers, and we have seen significant improvements.”

With one of the world’s lowest ratios of health care professionals per population and low laboratory capacity, Malawi has relied on a “public health approach” to ARV scale-up.

With support from the Global Fund, the ministry has developed national ART guidelines that provide health care workers with a standard approach to patient assessment, initiation and reporting. Almost all patients are given the same low-cost, fixed-dose combination first-line therapy. Due to the shortage of physicians, lower cadres of health care workers provide care to people living with HIV at most health facilities.

Of the more than $777 million in Global Fund grants signed for Malawi since 2002, some $44 million was allocated for health system strengthening.

To address the staff shortage, the Global Fund and DFID pooled resources to initiate the Emergency Human Resources Programme (EHRP) in 2005. The 6-year, $272-million programme provided a 52% salary increase for all health workers, an expansion of pre-service training and recruitment of expatriate volunteer doctors and nurses. The EHRP also included incentives to attract health care workers to underserved regions of the country.

According to an analysis of the EHRP by the World Health Organization (WHO), the salary “top-ups” helped stem the flight of health care workers from the public sector. The expanded pre-service training boosted the number of health professionals trained annually to 1,000 in 2008 from just 400 in 2004.

Despite this success, however, Malawi is still far from achieving the right ratio of health care professionals to patients to effectively confront HIV with a full slate of prevention, treatment and care activities. According to the District Implementation Plan (DIP) in the capital Lilongwe for fiscal 2011-12, the doctor to patient ratio is 1:110,195, with staff retention and remaining a serious challenge.

Aidspan is pleased to launch a research paper (available here) highlighting some of the main areas of conflict of interest within country coordination mechanisms that can compromise the process of principal recipient selection or grant implementation.

The survey of 33 CCM members from seven countries will serve as a baseline from which future examinations about the extent of conflict of interest within CCMs will be derived.

Principal concerns about COI relate to representation within the CCM architecture of those who receive Global Fund money; others concern what survey respondents considered to be a dominating presence of government representatives, technical partners and multinational bodies within the CCM.

The paper, Conflict of Interest in Country Coordinating Mechanisms: An Aidspan Survey, was co-authored by David Garmaise, Aidspan senior analyst, Arnold Wafula, Kersten Reisdorf and Angela Kageni, Aidspan senior programme officer for outreach.

veuillez patienter: cette article sera disponible prochainement.

Le Fonds mondial et l'ONUSIDA expriment leur inquiétude concernant une nouvelle loi du Nigéria qui prévoit des sanctions sévères à l'encontre des personnes qui ont des rapports homosexuels ou qui les soutiennent. Ces institutions demandent au gouvernement de réexaminer la question afin d'assurer l'accès des lesbiennes, gays, bisexuels et transgenres (LGBT) aux services essentiels de lutte contre le VIH.

The lobbying group Women4GF Africa is developing a new strategy to promote equality and inclusion of women and girls in Global Fund processes, to ensure the most effective impact of programming that targets them.

En Côte d’Ivoire, le Fonds mondial a approuvé le financement de $92,5 millions pour la phase 2 de deux programmes VIH, tournés notamment vers les prostitué(e)s et les homosexuels. Si cette annonce est saluée positivement par certains, elle se heurte à l’incompréhension et aux préjugés d’une partie de la population et des décideurs.

South Africa’s progress in the fight against AIDS has been compromised by continued stockouts of drugs in health facilities nationwide, a national activist group charges.

A group of civil society organisations in Uganda have launched a campaign to urge the Chinese government to contribute at least $1 billion to the Global Fund.

The Global Fund has released a partial calendar of events related to the new funding model.

The Ethics Official deals with matters such as improper conduct by governance officials and potential conflicts of interests.

This is issue 235 of the GLOBAL FUND OBSERVER (GFO) Newsletter.

We welcome suggestions for topics we could cover in GFO. If you have a suggestion, please send it to the Editor of GFO (see contact information below).

Author: Articles 1: Karanja Kinyanjui (Karanja.kinyanjui@aidspan.org), Aidspan’s Senior Editor. Articles 3 and 5: David Garmaise (david.garmaise@aidspan.org), Aidspan’s Senior Analyst. Article 8: Lauren Gelfand (lauren.gelfand@aidspan.org), Aidspan’s Editor-in-Chief. Article 4: Aurelie Fontaine, Article 6: Tinatin Zardiashvili, Article 7: Owen Nyaka (Aidspan correspondents).

GFO Newsletter is an independent source of news, analysis and commentary about the Global Fund to Fight AIDS, TB and Malaria (www.theglobalfund.org). GFO is emailed to nearly 10,000 subscribers in 170 countries at least twelve times per year.

GFO Newsletter is a free service of Aidspan (www.aidspan.org), a Kenya-based international NGO that serves as an independent watchdog of the Global Fund, and that provides services that can benefit all countries wishing to obtain and make effective use of Global Fund financing. Aidspan finances its work through grants from foundations and bilateral donors.

Aidspan does not accept Global Fund money, perform paid consulting work, or charge for any of its products. The Board and staff of the Fund have no influence on, and bear no responsibility for, the content of GFO or of any other Aidspan publication.

GFO Newsletter is currently provided in English only. From March 2014, the French language version, Observateur du Fonds Mondial, will be available to subscribers.

Aidspan Editor-in-Chief: Lauren Gelfand (lauren.gelfand@aidspan.org)

Aidspan Executive Director: Kate Macintyre (kate.macintyre@aidspan.org)

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