Last year, on November 22, just days before the commemoration of World AIDS Day, the global HIV community was shocked by an announcement from the Board of Directors of the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund). With far less funding available than originally forecast for 2011-2013, the board decided that there was simply not enough to support funding Round 11. While the Global Fund did eventually announce in May that $1.6 billion would be made immediately available, questions remain as to how this money will be spent and what the organisation’s funding model will look like in future.

In over a decade the Global Fund has financed antiretroviral treatment (ART) for 3.3 million people and saved an estimated 7.7 million lives. The organisation is expected to play a central role in placing around half of the nearly nine million people in need of ART on treatment. This could make it possible to reach the United Nations member states’ target of 15 million people on ART by 2015. UN Member states have also committed to reducing the number of new HIV infections by 50% by 2015.

Given that the Global Fund is the largest multilateral funder of HIV treatment, the cancellation of Round 11 threatened programmes that support millions of people who are at risk of contracting, or infected with, HIV, TB or malaria. Now that some money has been made available for immediate release, many programmes in danger of losing their lifeline will hopefully be able to stay afloat. New money may also be made available to scale up programmes so that more people can be reached. But the Global Fund’s November announcement must function as a wake-up call for activists around the world to maintain the pressure for continued financial support of the Fund. Activists must also watch closely as the Global Fund undergoes restructuring, to ensure that grants continue to be disseminated through a demand-driven model. This would allow countries to apply for adequate funding to comprehensively scale up their responses. The new $1.6 billion will be disbursed from 2012-2014; if there are delays in these payments, especially for programmes now facing cuts, life-saving services could be threatened again. Activists must continue to report on the needs that countries have for Global Fund and other monies. It is also vital to ensure such money is distributed in a timely way and used to achieve the maximum possible impact.

States have a duty to provide quality healthcare services to their citizens. Providing health care services is not a favour, but an obligation.

Over the last decade, the humanitarian organisation Médecins Sans Frontières (MSF) has witnessed the impact of the Global Fund and other bilateral and multilateral funding groups on HIV, TB and malaria. MSF has worked in many high-burden countries for over a decade, often as the first provider of HIV treatment. In that time MSF has seen the Global Fund and other grant bodies enable countries to increase their number of new HIV treatment slots. ART has not only transformed HIV from a death sentence into a manageable disease for millions of people, it has also shown itself to be a powerful tool for preventing new infections. A key study released in 2011 demonstrated that early HIV treatment reduces the risk of sexual transmission by 96%. In one area with high HIV prevalence a 1% increase in ART coverage was linked to a 1.7% decrease in HIV incidence.

The Global Fund’s May announcement is just one step among many that are needed to adequately address the HIV, TB and malaria epidemics. The scientific community supports the premise that scaling up HIV treatment and proven prevention can break the back of the epidemic. But this will only become reality if we rapidly expand our response to HIV. We must ensure that more people receive ART, and receive it early in the progression of the disease. Time is of the essence if we are to save lives and prevent costs from ballooning out of control. As Michael Sidibé, Executive Director of UNAIDS has noted, “…either we pay now, or we pay forever”.

And yet donors are pulling back. While the Global Fund was originally envisioned as a $10 billion-a-year fund, over the past several years it has increasingly faced financial shortfalls. Despite a 2007 commitment by the Fund’s board to making $6 to $8 billion available annually—up from the $2 to $3 billion available at the time—at the Global Fund’s October 2010 replenishment conference, donors pledged only $11.7 billion for 2011-2013. The Fund had asked for a minimum of $13 billion, the amount considered essential to maintain existing programmes and to provide limited funds for their expansion.

Reneging on these already weak commitments led to the cancellation of Round 11. While the Global Fund has a new lifeline, donors must step up to further strengthen their commitments to the Fund and to the expansion of its activities.

The cancellation of Round 11 mirrored a global trend of reduced HIV funding. Worldwide in 2010 funds stood 10% lower than in 2009. Yet as we see donors retreat, politicians are ramping up their rhetoric: just weeks before the Global Fund announced the cancellation of Round 11, US Secretary of State Hillary Clinton said that the world could see an “AIDS-free generation” if it expanded its HIV response. Dr. Anthony Fauci, Director of the US National Institute of Allergy and Infectious Diseases, also speaking on the eve of the Board’s announcement, noted, “The fact that treatment of HIV-infected adults is also prevention gives us the wherewithal, even in the absence of an effective vaccine, to begin to control and ultimately end the AIDS pandemic.” We have also seen measurable progress in the HIV/AIDS response, as 2011 brought the first drop in fatalities. But our progress feels seriously threatened, and those words and commitments feel hollow, as donors continue to scale-back.

The crisis could not have come at a worse time. When Round 11 was due for launch, countries began to see other donors reduce their support. They therefore looked to the Global Fund to fill the gap. For example, the World Bank is ending its funding for antiretrovirals (ARVs) in countries such as the Democratic Republic of Congo (DRC) and Mozambique.

The President’s Emergency Plan for AIDS Relief (PEPFAR) also faces potential budget cuts, with Kenya alone confronting a possible 44% slash in funding. Without external support, how will the country achieve goals outlined in the PEPFAR Strategic Framework?

One such goal is to place one million people on ARVs by 2015, up from 500,000 today. How will it be possible to do this, or for Kenya to implement lifelong treatment for all HIV-positive pregnant women, another of the Framework goals?

In Zimbabwe, the Expanded Support Programme—a funding mechanism supported by bilateral donors and the European Commission—has also stopped its financial support for ARVs. The government has had to take on 80,000 people who were receiving treatment through the ESP.

Many African countries are doing their bit to increase their own response to HIV. Between 2009 and 2010 alone, the number of people in sub-Saharan Africa receiving antiretroviral therapy rose by 30%. Since 1997 the rate of new infections has dropped by 26% in the region. This is partly due to improved treatment access. Given the large increase in the number of South Africans now on treatment, UNAIDS expects to see “substantially fewer new infections” in future.

But countries such as Malawi and Zimbabwe, committed to implementing the latest World Health Organization (WHO) guidelines on HIV treatment simply do not have the funds available to put these policies into practice. The WHO guidelines call for the use of tenofovir in all first-line regimens and for ART initiation at CD4 counts of 350.

The implementation of new policies is not the only progress on the line. In the DRC an estimated one million people are HIV-positive and 300,000 need ART. 15,000 patients are currently waitlisted for HIV treatment because funding shortfalls have led to a cap on the number of new treatment slots. In 2011 only 2,000 people were initiated onto treatment.

The DRC is not alone in this predicament. In Guinea, there will be only enough money to place 110 people on ART each month. This amounts to half of the current rate. Uganda had hoped to reach its target of 100,000 people on treatment this year, but the funding squeeze means that the target must be reduced to 50,000-65,000.

While funding mechanisms like the Global Fund and PEPFAR must support the implementation of these policies, African countries also need to spend more of their own money on health. Despite African nations having promised to spend at least 15% of their national budgets on health, few have made this a reality.

While some countries have tried to fill the gap with domestic financing, they still need help. Zimbabwe, for example, plans to increase the proportion of its AIDS levy—a 3% tax on income—that it spends on ARVS. Currently the levy supports 26% of patients who receive treatment. While the Zimbabwean government hopes that the levy can double its support for ARVs by the end of the year, without further funding, large gaps will remain. In fact, by 2014 the country’s treatment gap could balloon to 120,000 people.

Living up to commitments

Now that new money will be made available, we must ensure that it goes to support the programmes most in need. The funds must not only serve as a stop-gap, but also to scale up programmes so that the scientific promise and the rhetoric of the past year can become a reality. While $1.6 billion is a step in the right direction, it is still not enough: activists demanded that $2 billion be made available for the support and scaling up of programmes. And this is based on a low estimate, given that donors only pledged $11.7 billion at the last replenishment conference. Now is the time to boost funding commitments and available funds, not to skimp on essential services.

High-burden countries most affected by Global Fund cuts did not speak out about what the funding crunch could mean for their HIV, TB and malaria programmes. Now that money will be made available, it is important that Global Fund recipient countries make their voices heard as discussions take place on how to distribute Global Fund monies. Money must be made immediately available to programmes facing cuts, and the Global Fund must encourage countries to submit new, ambitious proposals to enable the release of fresh funds.

South Africa has been far too blasé about the crisis affecting the Global Fund and about the wider contraction in donor funding. According to news reports, South Africa’s Health Minister, Dr. Aaron Motsoaledi, said he was “not alarmed” by donors diluting their support because the country has continually expanded its domestic response to the epidemic. But while South Africa has made an impressive job of raising domestic finance to manage HIV/AIDS, poorer countries in the region are unable to match this effort. South Africa only relies on foreign donors to support 10% of its ARV programmes. For other countries in the region this figure is closer to 90%. Although South Africa may be more self-sufficient now, historically the country has relied in part on the Global Fund and other sources such as PEPFAR to develop its response to HIV. As a leader in the HIV response, and a political leader both regionally and internationally, the country must lead the call for demand-driven distribution of Global Fund money. It must also push the international community to expand its financial commitment to dealing with HIV, TB and malaria. At the same time, Motsoaledi and Zuma need to continue their support for domestic leadership in the fight against HIV.

For decades we have seen HIV devastate countries in southern Africa. Yet we have the tools to reverse the epidemic. What we need now are the funds that will turn our vision of an HIV-free generation into a reality. We cannot afford to wait.

Art in Africa

Many African countries are heavily dependent on donor funds to supply antiretroviral treatment. The global funding crisis could spell disaster for these countries and will hinder any progress made in stemming the tide of this epidemic.

People eligible for ART and receiving it (%)

• Democratic Republic of Congo  12%
• Kenya 52%
• Lesotho 66%
• Malawi 67%
• Mozambique 35%
• SA 49%
• Swaziland 78%
• Uganda 44%
• Zambia 68%
• Zimbabwe 63%

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 A united regional strategy

In March 2012 SECTION27 hosted a regional consultation on the right to health, with a specific focus on its implications for health care financing. The meeting was attended by members of civil society from all over Southern Africa as well as the United Nations Special Rapporteur on the Right to Health, Senior Advocate Anand Grover.

The purpose of the meeting was to ensure that financing for health is understood as a key enabler in the progressive realisation of the right to health. Understanding this link is essential because of the continued retreat of foreign sources of funding; instability of vital funding mechanisms (such as the Global Fund) and the failure of governments in the region to prioritise the funding of their health systems, all threaten the lives of millions of people.

The meeting provided an opportunity for civil society to identify prospects for a united regional advocacy stratergy that will help ensure that health care financing can assist in transforming the rhetoric of the right to health into reality. Three key principles were identified which are necessary to achieve this:

1. The right to health mandates that states take primary responsibility in ensuring equitable health care.
2. The state is under a responsibility to identify and eliminate barriers including corruption and lack of accountability, which hinder the realisation of the right to health.
3. Under international law, the responsibility to protect implies that the right to health must be coupled with the obligation of other states to supplement existing resources

Read more about the meeting at www.SECTION27.org.za.

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by Mara Kardas-Nelson is the Access and Innovation Officer for Médecins Sans Frontières South Africa

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