Global Fund: errors of interpretation and possible omission

(English translation posted on behalf of Javier Hourcade Bellocq, who writes for Corresponsales Clave, the website of the KC team in Latin America. Follow this link to read the original Spanish version.)

Since the launch of the 11th round of Global Fund to Fight AIDS, Tuberculosis and Malaria great confusion remains regarding the application of the concept of ‘most at risk populations’ (MARPs). This has resulted in the exclusion of some from recent Round 11 proposals.

As mentioned and explained in previous articles, especially that detail the new policies of Round 11, the new eligibility criteria defines specific interventions. These new policies have evolved out of Round 10 and follow a technical definition of disease burdens in a concentrated epidemic. In these new policies, the concentrated epidemic within a MARP is considered low if the prevalence is less than 2.5%, moderate if prevalence stands between 2.5 and 5%, and high if prevalence stands as 10% or more.

What makes a country eligible for the Global Fund is the HIV prevalence in at least one MARP. For example, many countries have around 20% prevalence in gay men / men who have sex with men and about 30% prevalence in transgenders. However, other MARPs should not be excluded from proposals simply because they have a prevalence of less than 10 or 5%.

An emblematic case is that of female sex workers. The few countries with recent serious data show a reduction in the prevalence and incidence of HIV in this population, attributable to many interventions and increased access to condoms. Nowhere is this prevalence below 2%, and around half show a conservative 3.5% prevalence.

But what makes sex workers a MARP is not only current prevalence rates but the work this population engages in. It is a serious technical error to exclude from a Global Fund proposal a key population due to a matter of percentages. And the consequences may be that in a few years down the line, while waiting to “qualify” again as a MARP, neglecting this group will see prevalence again return to high values, which would be a tragedy.

The new politics of the Global Fund for Round 10 and 11 is to issue so-called MARP grants of up to 12.5 million dollars across five years as a way to fund high-impact interventions in these populations. Nowhere does it say that you should only include interventions in populations with more than 5 or 10% prevalence. This interpretation is due to confusion or lack of reading by members of the MCP. It is a confusion that could be cleared up by asking questions – but in order to ask first you have to read.

The more I work with the Global Fund, the more it confirms my theory that many officials of CCMs and Principal Recipients do not read or ask. I include in this group some representatives of the agencies of the United Nations and international NGOs that do the “homework”. I seem to recall that all agencies of the system are technical partners of the Global Fund, and are responsible for support and advice to the PR, SR and MCP in our countries. Finally, also contributing to this phenomenon, are authors of ‘literary industry proposals’; consultants who write proposals for various CCM and regional networks and give incorrect or outdated information. Regardless of this, it is always the CCM’s responsibility to inform themselves before deciding.

Nor should we underestimate the effect of bias and conflict of interest in some CCM members representing community MARPs, as excluding another MARP would result in more resources for their own cause.

This never was the spirit of whoever came up with CCM and Global Fund policies. This should be a matter of solidarity, morality and ethics that goes beyond the technical dimension.

Using a little common sense does not mean we will try to allocate resources among a long list of MARPs. No one argues that women, housewives, young people, truck driver among others are in a state of vulnerability to HIV and sexually transmitted infections, but this unfortunately does not make a MARP. There is plenty of literature and documents on the recommendations of UNAIDS, Pan American Health Organisation and other agencies. And a door to door campaign, television ads or workshops in schools are not considered high-impact targeted interventions for MARPs. Common sense dictates that you can not get high-impact interventions to a significant number of young people with a strategic fund of 12.5 million.

Exclusion of sex worker organisation in Bolivia

Among several examples, we use a recent one: the CCM in Bolivia. This mechanism is a technical committee structure, and now in addition to supervising other grants, is working on a proposal for Round 11. The Organization of Women Sex Workers (ONAEM) applied for inclusion in the Technical Committee and at the last meeting, according to the minutes, it was decided that: “… It shall be convened as special guests including the OTN, making note that no epidemiological grounds serve on the Committee.” The Committee is the driving force behind the development of the proposal, even if an interested network of decentralized mechanisms known at the Departmental Coordination (MCD) also contribute.

Here female sex workers may not be considered a relevant population based on epidemiology. This decision regarding the degree of inclusion of adequate interventions for this population in the proposal has generated understandable anxiety in the community. This is just one example – there are many more – the same fate befell female sex workers in the recently approved proposal to PEMAR Uruguay.

We asked Daniel Ruiz Diaz, CCM President of Bolivia, during his recent tour, pointing out that part of the document mentioned should not be the domain of the CCM but the Technical Committee. Subsequently, ONAEM have been invited to be part of the drafting committee of the HIV proposal Round 11.

Unless those who provide technical support do so in a timely and appropriate manner, and CCM members make non-biased decisions based on evidence and information, we will lose credibility inside and outside our countries and will witness a high rate of rejection by the Panel of the Global Fund Technical Reviewer. Going down this road poses a serious risk of error in response to the epidemic for which we will pay a high price in the near future.