At the 2006 Annual Implementers’ Meeting of the US President’s Emergency Plan for AIDS Relief (PEPFAR), last week in Durban, South Africa, the “implementers” (the teams working on the ground in PEPFAR’s focus countries) reported success after success and gave numerous examples of just how rapidly effective smart and strategic investments in AIDS care and treatment can be. In a little over two years since disbursements began, PEPFAR has supported antiretroviral treatment (ART) for hundreds of thousands and care for literally millions of people infected or affected by HIV in resource-constrained settings.
And yet a shadow loomed over the meeting, held just ten days after the US delegation to the United Nations (UN) refused to set financial targets for universal access to prevention, care and treatment at UN High Level Meeting on AIDS and just two weeks before the continually cash-strapped Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) will be holding its own “Replenishment Conference,” also in Durban, where the Global Fund board will be begging national, institutional and individual donors for enough money to hold a grant cycle this November — much of which is desperately needed simply to sustain ongoing programmes whose earlier grants will soon be expiring.
This appears to be part of a growing pattern, according to the UN’s Global Report on HIV/AIDS, which notes that after years of funding expansion, “existing pledges, commitments and trends suggest the rate of increase may be declining and that available funds will be US$ 8.9 billion in 2006 and US$ 10 billion in 2007. Those amounts will be far short of meeting the estimated requirements of US$ 14.9 billion in 2006, US$ 18.1 billion in 2007 and US$ 22.1 billion in 2008.”
“The financial shortfalls that we are facing around the response to AIDS are ever more significant and calamitous,” Stephen Lewis, Secretary-General's Special Envoy for HIV/AIDS in Africa said during the UN High Level Meeting.
“We are facing a shortfall overall of $5 billion this year, of $8 billion next year, of $10 billion in 2008. We are facing a minimum overall shortfall of $23 billion dollars which is, quite frankly at this moment in time, a scandalous betrayal of the commitments that the G8 made at Gleneagles in July of 2005.”
In light of such financial uncertainty, a number of participants at the PEPFAR meeting expressed grave concerns about the long-term sustainability and expansion of the scale up of treatment and care globally, and whether there will continue to be reliable ongoing funding for both PEPFAR and the Global Fund. The presence at the PEPFAR meeting of activists from the American religious right, who have been attempting to drive a wedge between the two generally complementary organisations, only heightened worries among some participants that support for one or the other donor agency could be held hostage to American partisan politics.
Yet, the philosophical differences between the two donor organisations seemed relatively minor in light of the importance of their shared objective fighting the pandemic. For the most part, the true implementers (many of whom receive support from both funders) at the PEPFAR meeting appeared more interested in getting the work done than wasting too much time on ideological controversies or religious polemics.
And while some officials, such as South Africa’s Minister of Health Manto Tshabalala-Msimang, openly expressed a desire for PEPFAR to adopt the Global Fund’s country-driven approach to grant-making, (see linked article), representatives from the Global Fund at the meeting recognised the advantages of having PEPFAR around to mobilise non-governmental partners on the ground who can rapidly get the job done and bypass problem local governments.
PEPFAR background
President Bush established the Emergency Plan for AIDS Relief in July 2003 to increase the total US commitment to the effort to combat the HIV across the globe to an $15 billion over a five year period.
Only about $9 billion really represents new money, the lion’s share of which is being directed to efforts in 15 focus countries that are burdened with about half of the world’s HIV infections. Over the first two years, under two billion dollars of the new funds have actually been disbursed but the proposed funding is scaling up rapidly over the next few years, as more programmes come online and develop greater capacity to actually absorb and spend the money effectively.
Nevertheless, the results so far have been impressive. According to statistics put together by the US Office of the Global AIDS Coordinator (OGAC) as of March 31, 2006, PEPFAR has:
- Directly supported ART for 366,800 people and contributed to the support (by strengthening local systems and capacity) making ART possible for 194,200 more.
- Directly supported efforts to prevent mother to child transmission for about 4.5 million women, and preventive therapy for about 340,000 women — preventing HIV transmission to an estimated 65,000 infants.
- Provided HIV-related care and support to nearly 3 million people across the world, including more than 1.7 million people living with HIV/AIDS and more than 1.2 million orphans and vulnerable children.
While the funding has come from the US, these achievements are equally due to the dedication of PEPFAR’s in-country partners — both governmental and non-governmental — implementing the programme on the ground.
Global Fund worries
But efforts supported by the Global Fund are under even more imminent danger of losing support.
“The Global Fund spends an immense amount of time and energy in a yearly begging exercise to get some donors to fulfil their commitments,” Javier Hourcade Bellocq, who serves as an Alternate Board Member to the Global Fund (representing communities living with diseases) said at a press conference held during the UN High Level Meeting on AIDS.
“And even that seems not to be enough,” he continued. “We are now facing the risk of not having sufficient resources to fund the 6th round of proposals that the board needs to approve in November 2006. We immediately need a new round to scale up prevention, treatment, care and support in our countries, and also to renew the first round of grants that’s coming to an end real soon.”
Since its creation in January 2002, the Global Fund has disbursed more than $2.2 billion to public and private recipients in over 127 countries (and promised more than $3 million more, which will be disbursed only after countries reach performance targets).
As of June 2006, according to their own statistics, Global Fund supported programmes have:
- Distributed around 11.3 million insecticide-treated bednets to prevent malaria
- Provided millions of courses of malaria treatment and enabled 53 countries to begin offering artemisinine-based combination therapy (ACT) (rather than older drugs which malaria resistance has rendered ineffective)
- Detected and treated more than 1.4 million TB cases
- Supported HIV care and prevention for hundreds of thousands of people and orphans in resource-limited settings
- Provided ART for 544,000 people
Actually, Global Fund and PEPFAR must share credit for some patients on ART, because often each donor organisation supports different aspects of the same ART programme. For example, PEPFAR may provide support for the laboratory monitoring or staff training, while the Global Fund may purchase the actual medications, or vica-versa.
Speaking at the opening of the PEPFAR meeting, the Global Fund’s Deputy Executive Director, Helen Evans, stressed this sharing of the burden of treatment: “ Together, programmes financed jointly or separately by PEPFAR and the Global Fund have put 875,000 people on ART... this is a more than 40% increase in the last six months and more than a doubling within the last year.”
To do its part to maintain this momentum of scale-up, the Global Fund announced a Sixth Call for Proposals in April this year. But shortfalls in funding commitments are now jeopardising a new round of grants — and even the funding of the second phase of grants for projects already up and running. If there is to be one new grant cycle each year, in 2006 there will be a shortfall of $0.9 billion, and in 2007, a shortfall of $1.2 billion.
“I hate to even begin to imagine the day that the Global Fund will fail to meet its commitments,” said Elizabeth Mataka, Executive Director of Zambia’s of National AIDS Network who also serves as Global Fund board member on behalf of Developing Countries NGOs at the UN press conference. “If round six is not renewed in November, we will lose all the momentum we’ve worked so hard to gain.”
“It is unthinkable that the global fund should have to make this appeal, and is a sad commentary on the G8 countries,” said Ambassador Lewis. “Where is the sense of crisis? What is happening here?”