Impact and implications of the GFATM crisis

Impact and implications of the GFATM crisis

Sharonann LynchMédecins Sans Frontières (MSF)

Context

• In November 2011 at its 25th meeting the Board of the GFATM took the unprecedented decision to cancel Round 11 (which was opened August 2011).

• Round 11 was replaced with a Transitional Funding Mechanism to help countries that otherwise face disruption of existing services (no new ART or DR-TB treatment slots)

• Grants from the next funding window to be available only in 2014.

• At its 26th meeting in May2012 the Board agreed on "opening new funding opportunities starting in late September 2012 to allow for Board funding decisions to be made no later than the end of April 2013."

International funding contextInternational AIDS Assistance from Donor Governments: Commitments, 2002-2011

Source: Kaiser/UNAIDS July 2012

GFATM 2010 3-year replenishment (2011-2013) conference:

• Called for USD 20 bn needed to scale-up programs

• Failed to reach even the minimum scenario of USD 13 bn

• Pledges amounted to USD 11.7 bn

GFATM context: Contributions, Commitments and Disbursements (2002-2012)

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Q1-2012

0

5,000

10,000

15,000

20,000

25,000

Contributions

Commitments

Disbursements

Annual Contributions

Annual Commitments

Annual Dis-bursements

In U

SD m

illio

ns

Source: Trustee, May 2012

Contributions: $22.2b

Source: GFATM

3.6 million people currently on antiretroviral therapy260 million people treated for malaria9.3 million people treated for TB64,000 people treated for DR-TB

GFATM context: rationing and new reform

• The blunt rationing tools of the GFATM– 10% efficiency cuts across all grants– Funding history rule: recent grants make countries Ineligible to

apply for another round– Cuts to phase 2 renewal grants of middle-income countries

• Policy reform: from bottom up to a top down model?– Allocating country resource ‘envelopes’?– Countries applying by invitation only for specific interventions

• Reform could jeopardize core principles– Demand-driven and focused on people in need– Interventions that match country demands and country

contexts

The costs of inaction

Sources: Schwartländer B et al. Lancet, 2011, 377:2031–2041; John Stover, Futures Institute, personal communication, May 2012.

3-year delay = 5 million new HIV infections

3-year delay = 3 million AIDS deaths

2011 20202011 2020

3

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2.5

Peo

ple

(mill

ions

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Peo

ple

(mill

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)

Accelerated treatment

Modeled for Kenya an additional 323,000 on ART including: • CD4 <500 cells/µl already on

waiting lists for ART or in pre-ART care

• Pregnant and breastfeeding women

• Active tuberculosis (TB)• HIV+ partners in serodiscordant

couples regardless of CD4 count -

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

900,000

1,000,000

Base CaseAccelerated Scale-Up

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

New Annual Infections, base case and acceler-

ated scale-up

Accelerated Scale-upBase Case

SO

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: CD

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31% reduction in HIV incidence within 5 years

The size of the Rounds has been shrinking over time

• Round 8– launched March 2008, board approved November 2008– $2.8 billion

• Round 9– launched October 2008, board approved November 2009– $2.4 billion

• Round 10– launched May 2010, board approved December 2010– $1.7 billion

• New funding window– 2011 was effectively a gap year– September 2012: 2 years and 3 months since the last

successful Round was launched– April 2013: 16 months since the last approval of scale-up

applications

Implications: country perceptionUNAIDS survey findings

Intention to apply

Of the 78 reporting countries:• 55 countries (71%) intended

to apply for Round 11. – 51% ART focus– 45% PMTCT coverage focus

• 9 (12%) would not apply. • 10 (13%) were not eligible• 4 countries (5%) were

undecided

Perceived risk• Nearly 71%: moderate to high

risk of ARV treatment service disruption.

• Almost 60% concerned about PMTCT service disruptions.

• Over 68% anticipated a disruption in TB related services for people living with HIV.

Source: UNAIDS

Malawi• Threats/risks

– GFATM• 100% of ARVs from GFATM (would represent 2/3 of health budget if

had to be absorbed nationally)• Last approved GF funding was Round 7

– SWAp fund & PEPFAR: no ART support– UNITAID/CHAI: funding for pediatric HIV commodities ending in

2013• Programmatic ambitions: what is at stake?

– ART initiation at CD4 < 350– TDF-based first-line (full rollout deferred)– VL monitoring (rollout deferred)– PMTCT Option B+ (full implementation delayed)– Scale up of diagnosis and ART for children (under threat)– Facility coverage 600 sites (full implementation delayed)– 52% salary top-ups ended

Mozambique• Threats/risks

– GFATM• Round 9 funding not released on time (emergency request of $16M

in Sept => only $10M arrived to date)• Round 10 proposal rejected• Not eligible for Round 11 or TFM

– World Bank: funding ending 2013– UNITAID/CHAI: funds for pediatric HIV commodities ending

2013• Programmatic ambitions: what is at stake?

– ART initiation at CD4<350 – TDF-based first line (under review, funding-dependent)– PMTCT Option B+ (under review, funding-dependent)– Scale up of diagnosis and ART for children (under threat)– VL monitoring (in current guidelines, but implementation deferred)– 80% coverage target, compared with 53% today (full rollout delayed)

DRC• Threats/risks

– GFATM: main source of funding for ARVs but major disbursement and management problems

– PEPFAR, World Bank, UNITAID/CHAI: limiting or phasing funding for ARVs

– EU, Sweden, UK: no concrete plans in coming years to invest in HIV/AIDS treatment

• What we’re seeing– ART scale-up (now at 12%, not expected to reach 25% by

2015)– Further rationing of ART (treatment slots already limited,

patients’ waiting time has increased)– Implementation of WHO guidelines (350, TDF) (full

implementation delayed)– PMTCT Option B or B+ (full implementation delayed)– Further decline in operational capacity (govt and NGOs) – Decreased HTC (less than 10% the target)– Facilities are charging patients for ART

Guinea• Threats/risks

– GFATM• Heavy reliance on the GF: funded 50% of ARVs in 2011• Current GF grant (Round 6, phase II) ends Dec 2012 => purchase

of ARVs foreseen under Round 10 but major disbursement delays• Ineligible for Round 11 and TFM: earlier ART proposals too modest

in terms of treatment slots (Round 6 for 11k patients, Round 10 for less than 2k)

• What are we seeing?– Initiation rates halved from the previous year– Potential gap for continuity of ART for 11K patients due to late

disbursements– Patients presenting late stage – Treatment slots (already capped) would need to be cut further– Patients being turned away/added to waiting lists – Patients pay for OI treatment since September 2011

Spotlight on TBGFATM and TB• 79% of donor funding • 11% of total funding• Largest DR-TB funder

• Malawi – Planned to expand TB treatment to 15,000 children over 5

years (on hold until more funding becomes available– Planned to use Round 11 to purchase 16 GeneXpert

• Mozambique– Planned to use Round 11 for TB drugs and reagents

(World Bank has since covered) and DR TB drugs– Dependent on R7 for 1s/2nd line drugs

• Myanmar – Planned to use Round 11 to expand MDR-TB detection and

treatment (ambition was to use Round 11 to start 10,000 new patients on treatment over 5 years)

– No other known donor prospects for TB/DR TB• Uzbekistan

– Planned to scale-up MDR-TB testing and treatment with Round 11

• Zambia: – Planned to use Round 11 to help improve case finding,

scale up TB diagnosis using mobile technology in remote areas, and increase the number of people on IPT

Implications: HIV and TB services, TB, civil society and health systems support

GFAN: Impacts of the Global Fund’s Round 11 cancellation and funding shortfalls

Wednesday 25 July. 3:3opm-6:30pm

VENUE: Booth #820, Opposite Global Village Session Room 2

MSF – Losing Ground: How funding shortfalls and the cancellation of the Global Fund's Round 11 are jeopardising the fight against HIV & TB

RESULTS – The Global Fund: Progress at risk - Opportunities and obstacles in the fight against TB and TB-HIV

HIV/AIDS Alliance – Don’t Stop Now – How underfunding the Global Fund to fight AIDS, Tuberculosis and Malaria impacts on the HIV response

Eurasian Harm Reduction Network – Global Fund’s retrenchment and the looming crisis for harm reduction in Eastern Europe and Central Asia

Open Society Foundations – The First to Go: How Communities are being affected by the Global Fund Crisis  

What's next: treading water or gaining ground?

• Model of the GFATM: the September Board meeting will make a decision

• New funding window: opened by end of September and the decision on applications by the end of April 2013

• Funding the GFATM• In September 2012 UN General Assembly Fundraising

event hosted by UN SG • 3-year replenishment cycle (2014-2016) - a pledging

conference in September or October 2013 to raise an estimated USD 20 billion needed

• Financial transaction tax

Conclusion• To reach with HIV treatment and

help retain as many people as possible as quickly as possible and as early in their disease progression as possible…

…we need a fully funded and functioning Global Fund

• We need governments to pick up the pace of scale-up and funding levels.

• We can’t beat this plague with the same funding levels we’ve had for the past 4 years.

State of ART: tools, strategies, & policies dashboard

Report & survey results in 23 countries:www.msfaccess.org