Andrey Rylkov Foundation
for Health and Social Justice

Quitting While Not Ahead



Quitting While Not Ahead

Executive Summary

The Global Fund’s General Manager firmly stated to the media: “Discontinuing programs is not an option. […] There is an ethical responsibility that is well understood by the donor countries, and we are very proud of keeping those populations with a good quality of life.”

Over the last decade, the Global Fund has played a unique and indispensable role in responding to the HIV epidemic among people who use drugs in Eastern Europe and Central Asia (EECA).

From 2002 to 2009, it approved $263 million for harm reduction in EECA alone—more than all other international sources combined. This enabled the steady expansion of harm reduction programs in the region. The Global Fund supported not only syringes and medicines, but also programs to reduce stigma, mobilize communities, and build the service and advocacy capacity essential to the establishment of sustainable, nationally supported programs. In a region where people who use drugs have traditionally been criminalized and excluded, the Global Fund pushed for their human rights and full inclusion.

In 2011, a sharp reduction in donor support forced the Global Fund to halt new funding and impose cost-cutting measures. EECA, which is home to a fast-growing HIV epidemic concentrated among people who inject drugs (PWID), has already been affected and will be hit particularly hard by these changes in the near future. The Global Fund’s decision to reduce funding availability based on country income ignores the fact that income is not the determining factor for the availability of HIV services for PWID; rather, the decisive factor is political will. With few alternate funding sources available, there is the risk of the growth of the region’s concentrated HIV epidemic, and loss of the many gains made in the last decade with Global Fund support.

Global Fund changes in 2011 included:

Cancellation of Round 11, scheduled to begin its support in 2013 (originally planned to begin in 2012). At least eleven Round 11 HIV/AIDS applications from EECA were being prepared that focused on harm reduction. Eight planned to focus on key populations and high-impact interventions through the Global Fund’s Targeted Pool funding stream.3 Moldova’s proposal was for the second wave of National Strategy Applications (NSAs).

When they began developing Round 11 proposals, Albania, Azerbaijan, Belarus, Moldova, and Tajikistan all foresaw potential interruptions of harm reduction services previously funded by the Global Fund. Since the Round 11 proposals were to finance services starting from 2013 at the earliest, the affects of cancellation will become apparent only in the longer term.

EHRN planned a regional proposal covering nine countries with a high burden of HIV and a severe burden of TB. It would have been the region’s first large scale advocacy and technical support initiative to address key regional barriers to an effective and sustainable HIV response.

Replacement of Round 11 with a Transitional Funding Mechanism (TFM) available only “to provide for continuation of essential prevention, treatment and/or care services by current grantees.”5 Essential services were defined as HIV ‘prevention and treatment targeted at key populations with high levels of incidence,’ including people who inject drugs. The emergency TFM aimed to prevent disruptions of services but not disruption of community systems strengthening and advocacy work. In EECA, few of those planning to submit Round 11 proposals were able to apply to the TFM and even those applying could only do so for the very basics: services, but not advocacy work. Compared with the ten national and one regional HIV/AIDS proposals originally planned for Round 11 and the second wave of NSAs, only Russia (2 NGO grants, including the Russian Harm Reduction Network/ ESVERO after a special decision by the Global Fund Board to allow it to apply), Serbia, and Tajikistan applied for HIV TFM support by the 31 March 2012 deadline.

A new rule that 55% of all funding should go to low-income countries, thus limiting the funding for middle-income countries. This rule affects the EECA region particularly, since more than 95% of people living with HIV there live in middle-income countries.7 During Phase 2 grant renewals in 2012 most of the ongoing HIV projects funded by the Global Fund will have to create savings of 25% or more, compromising the quality and scope of activities.8 Following the adoption of the 55% rule, the Global Fund’s Secretariat defined the indicative levels for savings and cuts in renewal processes, which are differentiated for low-income countries (and lower lower-middle income countries) and for others. PWID and community groups are frequently bearing the largest share of the cuts, and the bulk of the PWID-focused HIV prevention cuts fall on activities such as NGO development, service capacity building and other types of community systems strengthening.

Armenia, Azerbaijan, Belarus, Bosnia and Herzegovina, Georgia, and Montenegro can now implement only 75%9 of the activities in Phase 2 that they had identified as necessary in earlier plans. In Armenia, the biggest HIV-related funding cuts foreseen are to prevention services for PWID, though this is the population in which HIV prevalence is the highest (about 10%) and harm reduction coverage is only 15%. The budget for NGO capacity building has been cut by 96%.

2011 changes, outlined above, took place in the context of previous developments in the Global Fund policies:

Tight eligibility requirements: as of 2012, Albania, Bosnia-Herzegovina, Croatia, Kazakhstan, Macedonia, Montenegro, and Romania are no longer able to apply in future due to low HIV prevalence among key populations.

  • Romania offers one example of what can happen to harm reduction when Global Fund support is no longer available. It has been ineligible since Round 7, and its Global Fund grant stopped disbursing in 2010. No government funding has ever been made available for NGO harm reduction programmes. Harm reduction coverage of PWID fell from 76% in 2009 to 49% in 2010. In 2011, the number of newly reported HIV infections among PWID was higher than in previous years, and PWID as a share of newly reported HIV cases was larger.
  • In Albania, which in 2012 became ineligible due to increased income level, two NGOs have already shut down their NSPs and another is in imminent danger of closing due to lack of funding. (OST is still funded, through the Continuity of Services mechanism.)

NGOs from Bulgaria, Lithuania and Russia could apply for the Global Fund funding within Round 11, despite the fact that these countries have upper-middle income status and are part of EU or G8. This NGO rule presented a unique opportunity for countries like Lithuania and Russia, where the political will is lacking to fund harm reduction, in order to sustain and scale up programs for PWID. Preserving the NGO rule for countries with high HIV prevalence among PWID in the new Global Fund funding model is absolutely essential.

With increasing, sustained domestic engagement — particularly from governments — EECA has made a number of notable achievements in the response to HIV, including reduction of vertical transmission according to goals. Unfortunately, national governments are far more reluctant to support targeted prevention and treatment services for people who inject drugs, and they are unlikely to fill the gap left by the Global Fund’s changes. Evidence from around the world has shown that harm reduction programs—including needle-syringe programs (NSPs), opioid substitution treatment (OST), anti-retroviral treatment (ART) for PWID, and peer outreach and counselling—can curb the spread of HIV and increase ART access in this highly vulnerable population. Yet only 10% of PWID in Eastern Europe and 36% in Central Asia access NSPs, and only 23% of people in need of ART in the region were receiving it at the end of 2010–the second lowest rate in the world. People who inject drugs comprise 62% of those living with HIV in the region, but only 22% of those receiving ART. Since ART not only saves lives but also reduces the risk of HIV transmission,10 this has an impact on prevention as well. As a result, EECA is the only region in the world where the HIV epidemic continues to grow. Continued advocacy is needed to support sustainable national funding for harm reduction; until this is achieved, the Global Fund is indispensable to the HIV response in the region.

There is no substitute for the Global Fund in EECA. Other donors in the region operate on a far smaller scale than the Global Fund, and are often much more restricted in their scope of work. While EU institutions embrace harm reduction as one of their drug policy principles at the highest political levels, their tools to support harm reduction, even within their own territory, remain limited. Through its European Social Fund, the EU can provide structural funds for HIV responses in its member states. However, these are primarily accessible to large, established NGOs, rather than to the smaller, community-based groups that often provide harm reduction services.

As a result of sharply decreased funding, harm reduction services in EECA will be unable to reach many of those in need, imperilling the health of people who inject drugs and threatening the gains of the last decade. The HIV epidemic will likely continue to grow in countries with large epidemics. Given the rapidity with which HIV can spread through shared injecting equipment, there is also the risk of new, fast-growing epidemics in countries that have succeeded in averting HIV epidemics among PWID so far, through wise use of Global Fund support. Funding cuts could also mean that EECA harm reduction organizations will lose experienced, well-trained staff. In short, many of the hard-won gains of the last decade will be lost if the Global Fund, its donors, the European Union institutions, and other actors do not act quickly to restore support to harm reduction in the region.

The Global Fund and donor governments, as well as the European Commission and other funders, must recognize that given its large, concentrated epidemic among people who inject drugs, who are highly stigmatized, further investments in EECA are the most strategic choice. Donors have an ethical and moral imperative to restore funding to desperately needed HIV programmes in the region.

Summary Recommendations

Governments and other donors must increase their contributions to and fully fund the Global Fund. Only then will it be possible to get EECA’s HIV epidemic under control.

The Global Fund Board should:

  • Ease restrictions on engagement in middle-income countries with epidemics concentrated among PWID, especially where other sources of funding are unavailable. Eliminate the rule that 55% of funding per year must go to low-income countries.
  • In new Global Fund funding model, strengthen Targeted Pool to generate more focused investment in PWIDs, along with other marginalized and highly affected populations.
  • More comprehensively ground funding decisions in the UNAIDS Strategic Investment Framework for the global AIDS response proposed in 2011, which prioritizes increased and sustained involvement by civil society and communities, including community mobilization, advocacy, capacity building and human rights programming.
  • Preserve the multi-country funding channel for Regional Coordinating Mechanisms and regional organizations to provide a less politicized and safer platform than at a country level through which to advocate for the needs of key affected populations.

The European Union institutions should:

  • Honour existing pledges and scale up support for the Global Fund in the context of the on-going negotiations on the new EU multi-annual financial framework (MFF) 2014-2020 and 11th European Development Fund.
  • Actively promote harm reduction at the global level and through political dialogue with partner countries in EECA.
  • Provide financial and technical support for sustaining harm reduction activities in EECA, including through long-term investment to support the work of NGOs in the region.

Other donors, including bilaterals, should:

  • Devise strategies to maximize their engagement in harm reduction as part of broader health and development programming.

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