Impact and implications of the GFATM crisis Sharonann Lynch Médecins Sans Frontières (MSF)

Context In November 2011 at its 25 th 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 At its 26 th 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 context International AIDS Assistance from Donor Governments: Commitments, Source: Kaiser/UNAIDS July 2012 GFATM year replenishment ( ) 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 ( ) Contributions: $22.2b Source: GFATM 3.6 million people currently on antiretroviral therapy 260 million people treated for malaria 9.3 million people treated for TB 64,000 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 year delay = 5 million new HIV infections 3-year delay = 3 million AIDS deaths People (millions)

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 SOURCE: CDC & Collaboration with John Stover, Futures Institute 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 perception UNAIDS 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 TB GFATM 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 1 s/ 2 nd 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 ( ) - 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: