Will a New Funding Strategy Leave Behind HIV’s Most Vulnerable?

The dynamics of HIV are changing, and our approach to financing the response must change with it.

This year, World AIDS Day might be best spent reflecting on how we can make sure that socially excluded groups don’t get left behind in the global HIV response.

The Global Fund to Fight AIDS, Tuberculosis, and Malaria is allocating $12 billion from donors to address the three diseases. The tricky part? How to spend it wisely. The dynamics of HIV are changing, and our approach to financing the response must change with it. It’s important that we reflect and make adjustments in real time if our funding strategies aren’t keeping up.

In March, the Global Fund did something that, on the surface, sounds logical: it approved a new funding model that prioritizes the poorest countries with the highest levels of disease. Countries with little money but lots of people living with HIV would get the biggest share of the funding, while countries with higher income and fewer people living with HIV would get less.

Makes sense, right? Actually, there are two problems here.

The first is that the best way to turn the tide of HIV may not necessarily be as simple as targeting the largest number of people. And the second is that the poorest people on the planet do not necessarily live in the world’s poorest countries.

Let’s start with the first problem. The Global Fund’s new funding model goes for sheer volume, targeting countries that have the most people living with HIV. But there are countries that have low overall HIV prevalence rates across the general population, yet suffer from devastating, highly concentrated epidemics within specific groups—for example, among people who use drugs, sex workers, transgender people, or men who have sex with men.

Targeting these smaller epidemics is crucial, especially because members of these groups often can’t easily access HIV treatment and services. People who use drugs, sex workers, and men who have sex with men may face imprisonment simply for the work they do, for who they love, or for the substances they use. They don’t necessarily think of the health system as a place of support. Simply accessing health care can risk exposing them to the criminal justice system.

Then there’s the second issue: that the poorest people don’t always live in the poorest countries. Research shows that the “new bottom billion”—or 72 percent of the world’s poorest people—today actually live not in poor countries, but within the borders of middle-income countries—the very countries the Global Fund’s new funding model would withdraw money from.

Today, some of these middle-income countries have become epicenters of the HIV epidemic. In the year 2000, 70 percent of all HIV cases were found in poor countries. By 2020, a mere 13 percent of HIV-positive people will live in countries that are defined as “poor.”

What’s more, while the Global Fund says that middle-income countries are rich enough to pay for HIV services, the reality is that when national governments are asked to take over the responsibility of funding such services, politically unpopular measures like providing clean needles to people who use drugs—even though that’s proven to be one of the most effective ways of fighting HIV—fall by the wayside. Romania is a prime example. After it stopped receiving Global Fund support in 2010, it witnessed a stunning spike in the share of HIV cases among people who inject drugs, from three percent in 2010 to 33 percent in 2013.

The Global Fund is developing a new five-year strategy next year, and understanding the impact of the new funding model is of paramount importance. If there are elements of the model that need to be corrected, this is a prime opportunity for strategic review, and to make any necessary course corrections.

As this review takes place, the Global Fund must remember that where you spend the money, and who you spend it on, is all-important. This is exactly the thinking that guided the Global Fund’s attempt to design a better funding model. But it may have guided it in the wrong direction. As it evaluates its funding strategy going forward, the Global Fund needs to remember that the most vulnerable populations aren’t always where you’d assume they are, and that sometimes the most difficult epidemics to treat are the smallest. 

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I agree de program

It is a big opportunity and good work for poorest countries. And these diseases are cause of death.

This sounds right. Does the Global Fund strategy really not address vulnerable populations and hot spots? If not, yes they should!

We have not been funded yet. Hopefully next year you will consider our NGO as well

Another couple of problems with the Global Fund's strategy are that the highest levels of HIV are usually found in wealthier quintiles, and in the wealthier countries in Africa (where the vast majority of HIV positive people are). HIV has never been a disease of poverty. Nor has it ever been widely distributed in most African countries. It has always affected disproportionate numbers of people in a few hotspots, with low prevalence outside of those hotspots in many African countries. Gold mining areas in Zambia and other southern African countries, areas around Lake Victoria, cities and a few other environments suffer from particularly high prevalence, whereas most rural areas, where a lot of poor people live, have not been hit by HIV so much.

I urge Global Fund to work with local NGO s so as to reach the target beneficiaries.Avoid alot of midlemen consultancies that end up increasing the administrative costs and very little resouces reach the ground.

That is really the whole situation, Evans. HIV and other disease initiatives are simply money makers for the countries politicians and Global Fund politicos. Here in Indonesia 60% of any aid monies disappears before getting to a location where it can be of value.

As Simon said, above, it is not the economics that dictates where HIV and other diseases are. It is a human behavior that is not even effected by education.

$12 billion can certainly help eradicate many diseases, but, as with the case of gangrene, sometimes the only way to save the rest of the body is to cut off the infected area. Maybe some research into behavior modification drugs would be helpful. We do it with our children, why not with people who are predators?

In Africa and especially the Sub- Saharan Africa, a high level of people living with HIV/AIDS tend to smoke tobacco more due to stigma and to catch up with stress. This funding can assist the civil society in tobacco control to change the behavior by home visits of people affected by the epidemic.

Good analysis, the Global Fund once again stumbles over his own lack of professionality and lack of capacity to collect and assess data. Despite the fund regularly utters otherwise: There is no control and there is a gross lack of ethics and self-criticism.

Neither governments nor NGOs are a good tool to success, although the latter - often equally corrupt and unprofessional - often display themselves to be better than governments.

The Global Fund itself the biggest NGO and money distributing system is not able to show the right use of their funds.

Statements of directors that only very few % of the "investigated" (!) funds were not used accordingly are at minimum unethical and uneducated - if not intentionally misleading.

The GFATM has a geuinly political job: To stand with the needy and oppressed whose human rights are violated. It does not.

It became a root cause of the problem and not it's solution and there is no proof for the benefit of it's work. The GFATM lack transparency and professional asessment.

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