By Dr. Prem Misir

WHAT can we say about HIV and AIDS today amid a context of reduced donor funding globally? UNAIDS summed up the story of HIV and AIDS, thus: in 2012, 35.3 million people were living with HIV, due to the life-saving antiretroviral therapy; 2.3 million new infections globally, a 33% decline in new infections from 3.4 million in 2001; a fall in AIDS deaths of 1.6 million in 2012 compared to 2.3 million in 2005 (1). In presenting its post-2015 agenda for consultation, UNAIDS indicated that the virus was the primary cause of death for girls and women aged 15-39 (17%) and the principal cause of death for boys and men aged 15-39 (12%); and in 2011, 7 million people entitled to HIV treatment were not reached (2).

“…in 2012, 35.3 million people were living with HIV, due to the life-saving antiretroviral therapy; 2.3 million new infections globally, a 33% decline in new infections from 3.4 million in 2001; a fall in AIDS deaths of 1.6 million in 2012 compared to 2.3 million in 2005.”

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 (3). 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. 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 programme, resulting in a scale-down (3).
Against this background of the story is the stark and harsh reality of the massive cutbacks in donor funding. For instance, with AIDS being a chronic condition implying the need to meet treatment costs for the life of the patient as well as prevention costs as AIDS is an infectious disease, UNAIDS will require an annual budget of US$16 billion to US$22 billion between 2011 and 2020 to fight AIDS (4). After huge initial bouts of funding, the financing started to fizzle out within the range of US$6.9 billion to US$7.9 billion annually between 2008 and 2012 (5).
For a few years now, an implicit strategic goal of The Global Fund is to develop country-led sustainable AIDS, Tuberculosis and Malaria programmes. To commence activities leading to this goal, The Global Fund in 2011 presented entitlement and counterpart financing guidelines wanting recipient countries to match its grant with a contribution from the government on the basis of the country’s income level; for instance, low-income countries have to match 5% of The Global Fund financing, 20% for lower low middle-income countries, 40% for upper lower middle-income countries, and 60% for upper middle-income countries (6).
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 programs 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-existing social contracts and social safety nets in resource-constrained countries (3). In addition, sustainability after The Global Fund is not only about maintaining programmes, but also developing strategies to respond to new evidence, resources, and need in relation to economic growth and growing social inequality (7).
Let me now look at the second scenario and use the case of Peru to see whether there is life for HIV programmes 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 jeopardized a coherent programme response and weakened the coordinating work of the Ministry of Health’s HIV office (7). 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.
In any country, any discussion on life for HIV programmes after The Global Fund should not start when the donor funding is fizzling out, but at the beginning point, when negotiations are underway to institute donor funding. And perhaps, even at the commencement of donor funding, focus should be on prioritization of services, cost efficiency measures, and accountability mechanisms; solid foundations for sustainability when donor funding ends.

References
1. UNAIDS. Global report: UNAIDS report on the global AIDS epidemic 2013 [January 17, 2015]. Available from: http://www.unaids.org/sites/default/files/en/media/unaids/contentassets/documents/epidemiology/2013/gr2013/UNAIDS_Global_Report_2013_en.pdf.
2. UN-NGLS. UNAIDS and the post-2015 agenda: upcoming consultation [January 17, 2015]. Available from: http://un-ngls.org/spip.php?pag.
3. Kenworthy NJ, Parker R. HIV scale-up and the politics of global health. Global public health. 2014;9(1-2):1-6.
4. Schwartländer B, Stover J, Hallett T, Atun R, Avila C, Gouws E, et al. Towards an improved investment approach for an effective response to HIV/AIDS. The Lancet. 2011;377(9782):2031-41.
5. Kates J, Wexler A, Lief E. Financing the Response to HIV in Low- and Middle-Income Countries: International Assistance from Donor
Governments in 2012 2013 [January 17, 2015]. Available from: http://www.hst.org.za/sites/default/files/20130923_KFF_UNAIDS_Financing.pdf.
6. TGF. The Global Fund Operations Policy Manual 2014 [January 17, 2015]. Available from: file:///C:/Documents%20and%20Settings/Administrator/My%20Documents/Downloads/Core_OperationalPolicy_Manual_en.pdf.
7. 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.