(PULL QUOTE) “In the event of a decline in GFATM funding or should GFATM exit at some point, there would still be life for the HIV programmes in Guyana. But drawing on the experiences of Peru, the Government of Guyana through the Ministry of Health must provide adequate direction on HIV and put in place accountability mechanisms. Indeed, placing HIV and AIDS activities within the national budget would show political commitment to addressing HIV and AI
What can we say about HIV and AIDS today? In 2010, the UNAIDS update(1) summed up the story of HIV and AIDS thus: The HIV and AIDS epidemic has achieved some stability; since the late 1990s, annual new HIV infections have dropped, but the rate is still high; over the last few years, the AIDS-related death rate has slowed down, due to increased use of antiretrovirals, indicating that more and more people are now living with HIV. But as we view this startling progress made to turn the tide on the epidemic, we must not forget the work of the AIDS activist movements of the 1980s that formed people’s understanding of HIV and the responses they extracted from governments to address the HIV epidemic ; from the era of these activist movements to activist countries, and then to global HIV governance, many activists have now been domesticated into becoming experts in governmental as well as non-governmental organisations (NGOs); where they now merely impose a sanitised attention on managing the epidemic, solely involving a technocratic transmitting of drugs into bodies, thereby neglecting the social conditions of the HIV infection and the survival of the those living with HIV (2). The global HIV governance architecture may be the perpetrator of this stark negligence.

The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and the President’s Emergency Plan for AIDS Relief (PEPFAR)are two major components of the global HIV governance architecture, with donor-driven agendas; and highly supportive of strong doses of pharmaceutical and biomedical treatment to the subservience of a social contract and a social safety net for people in resource-constrained contexts (2). The GFATM, a major funding agency for HIV programmes since 2004 and the PEPFAR are contestants in a race to prevent and treat HIV in resource-constrained countries, resulting in a scale-up where donors and agencies are expected to develop health system capacity to implement treatment regimens; the cut in GFATM funding in many countries will hurt the treatment program, resulting in a scale-down (2).
Today in Guyana, however, with GFATM in a scale-down mode, the local competition to maintain the existing HIV response is well underway. Within this context, though, there are two scenarios that require addressing: (i)What present HIV activities will be maintained? And (ii) is there life for the HIV programmes after GFATM, or even now during a decline in its funding?
The first scenario has to do with concerns about global health activities: where there is increasing awareness that pharmaceutical and biomedical treatment alone does not make an individual whole; and where health activities should not be replacements for the non-existence of social contracts and social safety nets in resource-constrained countries (2). In addition to maintaining prior activities, a critical area will be developing strategies to respond to new evidence, resources, and need (3).
Let me now look at the second scenario and use the case of Peru to see whether there is life for HIV programs after GFATM exits. Overall, in the battle against HIV, Peru has done well in the absence of GFATM funding. One of the lessons from the Peru case, however, is that under GFATM funding, the powerful NGOs which made unilateral decisions jeopardised a coherent programme response and weakened the coordinating work of the Ministry of Health’s HIV office (3). In fact, during the era of GFATM funding in Peru, there was inadequate governmental direction on HIV.
In the event of a decline in GFATM funding or should GFATM exit at some point, there would still be life for the HIV programmes in Guyana. But drawing on the experiences of Peru, the Government of Guyana through the Ministry of Health must provide adequate direction on HIV and put in place accountability mechanisms. Indeed, placing HIV and AIDS activities within the national budget would show political commitment to addressing HIV and AIDS.
References:
1. UNAIDS J. Global report: UNAIDS report on the global AIDS epidemic 2010. UNAIDS Geneva. 2010.

2. Kenworthy NJ, Parker R. HIV scale-up and the politics of global health. Global public health. 2014;9(1-2):1-6.

3. Amaya AB, Caceres CF, Spicer N, Balabanova D. After the Global Fund: Who can sustain the HIV/AIDS response in Peru and how? Global public health. 2014;9(1-2):176-97.
By Dr. Prem Misir