AIDS 2018 - Debates Over Best Use of Global Funds

Sara L.M. Davis

Steadily growing rates of HIV infection in Eastern Europe and Central Asia (EECA) are at the heart of a debate roiling health aid at AIDS 2018. While US funding for the global HIV response increased in 2017, that trend is unlikely to continue and most other donors cut back, according to a new report from Kaiser Family Foundation and UNAIDS.

The Global Fund to Fight AIDS, TB and Malaria and PEPFAR argue that given the limited global funding for HIV, they should prioritize investing in Sub-Saharan African countries to reach the largest number of people living with HIV. Middle-income countries are increasingly left to “transition” out of aid and foot their own bill. But critics say EECA governments do not fund services for criminalized populations such as people who use drugs. As a result, 39% of new HIV infections are now occurring amongst people who use drugs in the EECA region, says UNAIDS.

“International aid, and the Global Fund in particular, should not behave like development banks. We should fight AIDS wherever it is, and fund what governments are not willing to fund at the time,” said former Global Fund executive director Michel Kazatchkine. While he congratulated a Russian health official sitting beside him at a roundtable, who asserted that Russia had increased its funding for HIV, Kazatchkine countered, “Funding for prevention in Russia is far from where it should be, and still not at scale.”

Harm reduction programs, including provision of opioid substitution therapy (OST) such as methadone, and needle and syringe exchange programs, are proven to have a major impact in preventing HIV. Speaking at the same roundtable as Kazatchkine, Anka Van Dam, director of AFEW International, observed that Russia not only prohibits OST and restricts NGOs through a “foreign agent law”, but it also promotes use of the same laws to neighboring countries, with devastating effect.

The result, says a new report from Harm Reduction International (HRI), is that while globally there is a funding shortfall of 20% overall for HIV, it is a stunning 87% for people who use drugs. An estimated $1.5 billion is needed each year to fully fund harm reduction services in low and lower-middle-income countries, but in 2016, only $188 million was spent. Meanwhile, from 2011-2015 new HIV infections rose by one-third among people who use drugs, most of whom live in middle-income countries.

“This is terrible, it’s incredibly worrying,” said Judy Chang, director of the International Network of People who use Drugs (INPUD). “The report shows that we are increasingly having to rely on the Global Fund. The Fund was one-third of harm reduction funding, and over time it became two-thirds.” This funding is now at risk with the Fund transitioning out of middle-income countries.

Global Fund support for harm reduction peaked in 2010, and has since flat-lined, according to HRI. Global Fund Senior Technical Advisor Palani Narayanan says the Fund’s newest grants suggest the trend will improve. But Catherine Cook, head of research for HRI, warns, “They’ll never reach the 2010 levels.”

PEPFAR is the second-largest funder of harm reduction services, but a US federal ban on needles and syringes places limits on what they can support. Private philanthropies such as Gates Foundation give very little, says Cook.

Chang says that HRI’s analysis fails to capture a further concern: even this limited money is often spent on programs that are expensive and not evidence-based, instead of going to proven harm reduction methods.

While debates over what to prioritize with declining funds continue, the Global Fund Advocates Network (GFAN) launched its own report calling for a 20% increase in donor commitments to the Global Fund for the next replenishment cycle in 2020-2022.

GFAN estimates $14.55 to $18 billion is needed. “We’re sounding an alarm: we are not on track to end the three diseases by 2030,” said Sam Avrett, author of the report.

Timur Abdullaev, a two-time survivor of TB in Uzbekistan, endorsed the call, saying that medicines financed by the Global Fund saved his life. “If it wasn’t for equipment and medicines they paid for, I’d be six feet under. Now we need more resources, that’s the bottom line.”

Calling the report “an antidote to pessimism and a call to action,” Mike Podmore of STOPAIDS said a failure to mobilize these funds would fuel the three epidemics, instead of ending them. “We can’t focus on some countries and leave others behind. When we look back from 2030, we will see 2019 as a turning point, one way or the other.”

Efforts are now beginning to mobilize for the next Global Fund replenishment. France will host the Global Fund replenishment conference later this year.

Sara L.M. Davis, Ph.D. (aka Meg) is an anthropologist and writer. Her forthcoming book is The Uncounted: Politics of Data in Global Health