The impact of the Global Fund’s Eligibility Policy on access of KAPs to HIV services in Romania

Abstract: In the light of the recent approval of the Revised Global Fund’s Eligibility Policy at the 39th Meeting of the Global Fund Board this article provides an overview of the Romanian “eligibility story” and continuous attempts of Romanian NGOs to break the political barriers within the Global Fund and prove their eligibility to receive an allocation for HIV component to be able to ensure the access of key affected populations in country to the needed HIV prevention services.

Article:

The impact of the Global Fund’s Eligibility Policy on access of KAPs to HIV services in Romania

Recent revision of the Global Fund’s eligibility policy could give a chance to Romania to become considered as an eligible for HIV allocation within the next allocation period

Doing much for HIV treatment but not for prevention

The HIV story in Romania has been marked by several dramatic episodes. The first was in late 1980s, when thousands of children got infected with HIV through dramatic nosocomial HIV epidemic, predominantly among orphans and hospitalized children.[1] Then the voices of parents and many supporters led to the introduction of the country’s large treatment programs – early on with donor support – to provide HIV treatment to all in need. Today, the country spends 70 million euros for HIV treatment[2], care and support reaching universal access and covering 12,247 people with HIV out of 15,212 as on 2017 which is a great achievement.

But when it comes to prevention – “the Romanian authorities practically invest no money in HIV prevention”, says Nicoleta Dascalu, project manager from the Romanian Association Against AIDS. That is why becoming ineligible for Global Fund’s support of HIV became another dramatic episode in Romanian HIV history.

Consequence of improperly planned transition from donors’ support in Romania

At the beginning of 2010, the country, a fresh member of the European Union, was praised for reaching out to people who inject drugs and even starting a pilot of opioid substitution therapy and needle exchange in prisons. This work was supported by the Global Fund as well as by the Dutch government through UNODC. However, both funding streams stopped in 2010-2011 and the government did not take over funding for NGOs. At the same time, the drug scene also changed with emerge of new psychoactive substances that were legal but could result in up to 10 times injections a day. While the legislative and policy environment in Romania did provide for harm reduction and other services targeted to key populations to be maintained, the Government had shown little commitment to fund such interventions, especially needle and syringe programs. “Most NGOs that had implemented harm reduction services just closed them down, because of lack of funding. The only services that continued were funded, by sheer luck, with money from European Union structural funds projects, dedicated to social and professional reintegration of drug users”, remembers Nicoleta Dascalu.

HIV prevalence among people who inject drugs started growing rapidly: from 3.3% in 2009 to 27.5% in 2013.[3] It was noted in a January 2016 article in the International Journal of Drug Policy that “a specific HIV outbreak among drug users (around 2011) has been directly linked to the significant decline in harm reduction services following the Global Fund transition out of the country[4]“.

Another part of the Romanian HIV story is that HIV prevalence among men who have sex with men also became high. In the EU funded study SIALON II[5], Bucharest recorded the highest HIV prevalence among the 13 cities in study – 18%. Nevertheless, as the country’s official report on the progress of implementation of UN Political commitments on HIV[6] acknowledges, there were no real programs remaining among MSM as on 2016.

Reasons of ineligibility of Romanian HIV component for Global Fund’s support

Since 2007, there has been a requirement in the Global Fund’s Eligibility Policy that in order for UMICs to be eligible for HIV funding, they must have at least high HIV disease burden and also be on the Organisation for Economic Co-operation and Development’s (OECD) Development Assistance Committee (DAC) List of Official Development Assistance (ODA) recipients. The list includes all low, lower middle and upper-middle income countries based on GNI per capita as published by the World Bank, with the exception of those being G8 members, European Union (EU) members, and countries with a firm date for entry into the EU making them ineligible to receive ODA. This requirement is the only reason why Romania lost its eligibility to receive funding for HIV response from the Global Fund and never became eligible again since 2010 when its last Global Fund HIV grant came to an end. At the same time for some reasons this requirement is not applicable for TB and Malaria components thus Romania is eligible to receive the Global Fund funding for TB response and currently is implementing Global Fund’s TB grant. For the 2017-2019 allocation period, Romania was one of only two countries in the entire world (the second one is Bulgaria) being not eligible because of this requirement as they joined the EU in 2007.

Theoretically Romania could become eligible if it met the requirements of so called “NGO rule” – another provision of the Global Fund’s Eligibility Policy which allows for potential eligibility for UMICs that meet the disease burden thresholds for HIV but are not on the OECD DAC List of ODA Recipients. Eligibility under this rule till recently was linked to the existence in country of “political barriers” which preclude the provision of evidence-informed interventions for key populations. Funding provided under this rule must be channeled through civil society and cannot directly fund governments.

In practice the “NGO rule” to date has allowed only one country to be funded – the Russian Federation – in the 2014-2016 allocation period. Romania could have been eligible for the 2014-2016 and 2017-2019 allocation periods, but according to the Global Fund “was not deemed to have substantive political barriers that would preclude providing services to key populations”.

Attempts to influence the situation

Romanian NGOs have tried few times to prove the Global Fund their right to receive an allocation for Romanian HIV component in accordance with “NGO rule”. In 2013 a targeted application for HIV grant was developed and submitted by Romanian NGOs to the Global Fund within the “NGO rule” but was not supported because the Global Fund Secretariat has considered the situation in Romania as a result of ‘lack of funding or political will rather than political barriers’, per se[7].

Another attempt was made in 2016 – a Joint statement of Romanian civil society organizations[8] was sent to the Global Fund’s Executive Director and Fund’s Board in advance to its Thirty Sixth Meeting urging the Board to prevent zero allocation for the HIV component for Romania for the next three years. But their voice has not being heard and Romania was allocated zero funding for the 2017-2019 period.

The last attempt was done in May 2018 when more than 40 international, regional and national organizations addressed[9] the members of the Global Fund Board on the eligibility related issues in advance to its Thirty Ninth Meeting. In their statement, among other issues, civil society organizations called the Global Fund Board not to restrict access to funding for HIV for countries not on the OECD DAC List of ODA specifically appealing to the case of Romania. In the opinion of the subscribers of the statement, “by continuously preserving this requirement the Global Fund itself creates a political barrier that precludes the provision of evidence-informed interventions for key populations in these countries”.

Also, in the same statement the organizations called for the revision of the language of the “NGO Rule” on “political barriers” as this terminology has no clear definition, is inconsistent with international law and could be interpreted against the interests of key affected populations in countries.

Revised Policy – the same eligibility status

One of the result of this Global Fund’s Thirty Ninth Meeting was approval of the Revised Eligibility Policy. In the revised version of the document the OECD DAC ODA Requirement unfortunately was left as it was before but the term “political barriers” in the provision on the exception to the OECD DAC ODA Requirement for HIV/AIDS was replaced with just “barriers” with a note that eligibility for funding under this provision will be assessed by the Secretariat as part of the decision-making process for allocations. It further clarifies that as part of its assessment, the Secretariat will look specifically whether there are laws or policies which influence practices and seriously limit and/or restrict the provision of evidence-informed interventions for key populations.

It is not clear yet if this replacement of the term “political barriers” with just “barriers” will somehow influence the chances of Romania to receive an allocation for its HIV component within the next allocation period but probably not much. As before it will be the Global Fund Secretariat to decide if there are demonstrated barriers in country to providing funding for interventions for key populations, as supported by the country’s epidemiology. And it is clear from the clarification note that as before when considering the eligibility under this provision the Global Fund Secretariat will probably look not if representatives of key affected populations actually have access to the required for them HIV prevention services of a certain quality and at a needed scale but will still consider the existence of the laws and policies which restricts provision of such services by the government.

The only chance to Romanian HIV component to become ever eligible again – is the elimination of the OECD DAC ODA Requirement for HIV/AIDS in the Eligibility Policy. “By keeping the OECD DAC ODA Requirement for HIV/AIDS components the Global Fund continues to restrict access of Romanian NGOs to vitaly needed funding which could allow to ensure an appropriate HIV response among key affected populations“, – says Dragos Rosca, the Executive Director of the Romanian Harm Reduction Network.

At the same time in the opinion of Nicoleta Dascalu from the Romanian Association Against AIDS “it is not the Global Fund responsibility to support AIDS prevention services in Romania, and, if Romania becomes eligible again, the new project should include a strong advocacy component, that should pressure national responsible institutions and make them fund prevention.”

[1] Dente K, Hess J. Pediatric AIDS in Romania – A Country Faces Its Epidemic and Serves as a Model of Success. Medscape General Medicine. 2006;8(2):11.

[2] the HIV treatment/patient/year in Romania is around 6,000 euro (https://ecdc.europa.eu/sites/portal/files/documents/HIV%20treatment%20and%20care.pdf p. 6)

[3] EMCDDA (2016). Statistical Bulletin. Table on HIV Prevalence accessed at: www.emcdda.europa.eu/data/stats2016#displayTable:INF-108

[4] http://www.ijdp.org/article/S0955-3959(15)00236-4/fulltext

[5] EU-funded project Sialon II. Report on a Bio-Behavioural Survey among MSM in 13 European Cities. Accessed at: http://www.sialon.eu/data2/file/133_Sialon%20II_Report%20on%20a%20Bio-behavioural%20Survey%20among%20MSM%20in%2013%20European%20cities.pdf

[6] Romania: Country Progress Report on AIDS Reporting period January 2015 – December 2015. Bucharest, April 2016. Available at: http://www.unaids.org/sites/default/files/country/documents/ROU_narrative_report_2016.pdf

[7] The Impact of Transition from Global Fund support to Governmental Funding on the Sustainability of Harm Reduction Programs. A Case Study from Romania. Eurasian Harm Reduction Network. 2016.

[8] Joint Statement from Romanian civil society urging Global Fund to maintain funding http://rhrn.ro/en/joint-statement-romanian-civil-society-organizations-advance-thirty-sixth-meeting-global-fund-board/

[9] Joint Statement of Civil Society Organizations in advance of the Thirty-Ninth Meeting of the Global Fund Board http://eecaplatform.org/en/joint-statement-of-civil-society-the-global-fund-board/

This text is the author’s version of the article published at www.aidspan.org

The sustainability of the results of the last Global Fund HIV grant for Russia are under a threat

Abstract: The results of the implementation of the recently closed HIV program in Russsia are under a threat due to the ineligibility of country for Global Fund‘s transition funding and unwillingness of the government to suppot the implemented activities. At the same time there is a chance that Ruissa could become eligible for GF HIV funding again starting from the next year and receive an allocation for the next 2020 – 2022 period.

Article:

The sustainability of the results of the last Global Fund HIV grant for Russia are under a threat

Although Russia could become eligible again for the Global Fund HIV funding and even receive allocation within the next allocation period

Conflict of interest: the author of the article is a member of the Coordinating Committee which was responsible for coordination and oversight of the implementation of the Global Fund HIV grant in Russia being discussed in this article.

Background  

By the end of implementation of its round-based model of grants’ distribution the Global Fund has invested more than 250 million USD within the Round 3, Round 4 and Round 5 HIV and TB grants to ensure the sustainable response to HIV and TB epidemics in Russia.

A 2010 study by Russian Federal AIDS Center estimated that less than 1% of key populations had access to HIV prevention programs in Russia. The majority of programs providing HIV prevention services to key populations in Russia were dependent on foreign funding. By 2014, the implementation of HIV programs financed by the Global Fund, including those targeted on key populations came to an end. The Russian government didn’t take any steps to fund or even acknowledge the need for HIV programming for key marginalized and criminalized populations, PWUD, SW and MSM/LGBT despite all those promises given by the Minister of Health in 2008 to step in and start paying for such services once the GF programs ended[1].

In light of this situation, the Global Fund has approved the 12 million USD HIV Program in Russia for the period 2015-2017 which was supported within the so called “NGO-Rule” – a provision within the Global Fund’s Eligibility Policy which allows for potential eligibility for UMICs that meet the disease burden thresholds for HIV but are not on the OECD DAC List of ODA Recipients. Local NGO Open Health Institute (OHI) was selected as the Principal Recipient (PR) to continue the activities initiated under two recent HIV programs supported by the Global Fund in Russia and to “create [an] environment for integration of…evidence-based programs into the national HIV strategy”, and to “strengthen the communities of Key Populations in order to increase their involvement in the dialogue with the authorities”[2].

Program details and its uniqueness

This program consisted of three intertwined components: HIV service delivery for PWID, SW and MSM, community systems strengthening (CSS), and removing legal barriers (RLB). From 2015 the activities included services for 17 PWID programs, 5 MSM, and 5 SW. Additionally, in both 2016 and 2017, 12 programs were co-financed and 20 more were given small grants for overcoming legal barriers and rights defense. By the end of its implementation the grant had shown very good results against the targets set (102% average performance of all indicators) and was rated B1, with eight out of ten of its indicators rated A1[3]. A 17 July 2017 Global Fund management letter[4] especially commended “increased mobilization of key affected populations…through the Community Systems Strengthening module,” and praised the Removing Legal Barriers Module for “[showing] excellent results and… contribut[ing] to increasing literacy of key affected populations to help them access health services or navigate through a punitive legal environment”.

The uniqueness of this project is that it was developed and implemented by the forces of the NGOs and communities’ representatives only, without any involvement and support from the governmental sector. The Coordinating Committee (analogue to CCM but without involvement of the governmental sector) was established by the civil society based National Dialogue to coordinate the implementation of the project. “The Coordinating Committee brought together key populations groups, groups of people living with HIV, NGO representatives and human rights advocates who had previously not found common ground, enabling them to forge a common platform and agenda”, says Victoria Dollen, Secretary of the Coordinating Committee.

Also, within the implementation of this project each key population group created sustainable key populations monitoring mechanisms (key populations Forums) to ensure key populations engagement into the meaningful dialogue with the government at all levels.

Reminding about the HIV situation in Russia and its impact on the EECA Region

The region of Eastern Europe and Central Asia (EECA) is the only region in the world where the HIV epidemic continues to grow[5], and Russia could be considered as a „driving force” of the epidemic in the region. According to UNAIDS 2018 Global AIDS Update “the HIV epidemic in Eastern Europe and central Asia has grown by 30% since 2010, reflecting insufficient political commitment and domestic investment in national AIDS responses across much of the region. Regional trends depend a great deal on progress in the Russian Federation, which is home to 70% of people living with HIV in the region. Outside of the Russian Federation, the rate of new HIV infections is stable. Insufficient access to sterile injecting equipment and the unavailability of opioid substitution therapy are stymying efforts in the Russian Federation to prevent HIV infections among people who inject drugs”.[6]

For several years now, there has been a concentrated HIV epidemic in Russia among such key groups affected by HIV as injecting drug users, men who have sex with men and sex workers[7], and in some regions of the country a generalized epidemic among the general population is even being observed[8]. About 70% of all HIV cases in Russia are associated with the use of injecting drugs and still the main way of HIV transmission is parenteral. Recent IBBS research conducted in seven cities of Russia within the implementation of the “NGO rule” HIV Program demonstrates 48,1 – 75,2% HIV prevalence among people who inject drugs (PWID), 7,1 – 22,8% among men who have sex with men (MSM), and 2,3-15.0% among sex workers (SW).[9] With more then 1 220 000 cases being registered as on the end of 2017, the coverage by HIV treatment of PLH in country is about 35%[10].

Given these facts, as well as taking into consideration the geopolitical position of the Russian Federation, the migration flows in the region, etc., it is clear that when planning a response to HIV epidemic in EECA region it is impossible to neglect an HIV situation in Russia and not to support HIV response in this country, as such approach can ultimately reduce to zero all efforts by donors and governments to counteract the HIV epidemic in neighboring countries.

Russia’s eligibility and perspective for sustainability of HIV services

The implementation of this last Global Fund’s HIV grant in Russia has ended on December 31st 2017 with a closure period to end on September 30th 2018. During the Thirty-Ninth Meeting of the Global Fund Board which took place in May 2018 a decision was made to preserve the OECD DAC ODA Requirement for HIV/AIDS in the Global Fund’s Eligibility Policy as well as the exception to OECD-DAC ODA Requirement for funding civil society for HIV/AIDS (formerly referred to as the “NGO Rule”). This means that there is a chance that Russia, as the only country in the world yet which has proved itself eligible for Global Fund’s HIV funding within the “NGO rule”, could be considered eligible under this provision again and may receive an allocation within the next allocation period 2020 – 2022.

Unfortunately, Russia was not eligible to receive any transition funding from the Global Fund to sustain the achievements of this HIV project and now there is a risk that most of the services on HIV prevention that are being carried out by the NGOs within this program, as well as initiatives aimed at advocacy and protection of the rights of representatives of communities, may cease their work in the nearest future, because the funding allocated by the state is not enough to support them, or such funding is not allocated at all.

In addition to inability to receive the transition funding country has lost about 650 000 USD[11] due to the internal regulations of the Global Fund Secretariat according to which all currency translation difference could not be spent on the program activities but should be returned to the Global Fund. This money also could be used to allow the continuation of the key project activities till the beginning of the new allocation period. At the same time the Coordinating Committee has a funding from the Global Fund to till 31.01.2020.

Urgent actions to ensure the sustainability of the project results are needed

The Russian Coordinating Committee is making now the attempts to attract the attention of the Global Fund’s Secretariat and Delegations to the Global Fund to this situation with threat to the sustainability of the results of the recent HIV project by calling to ensure the continuation of HIV prevention services and community-based response in Russia at least until the new allocations for 2020 – 2022 to be announced by the Global Fund Secretariat. There is no any sense to abandon after every three years everything which was achieved with the support of the Global Fund’s funding and then start everything from scratch – this is just a waste of money, time, efforts and lives of people affected by HIV.

“This NGO-Rule Program demonstrated that key affected populations can and in fact should design, implement, and control WHO recommended HIV prevention services among key populations. The Program is a success story and a best practice in creating key populations mechanisms for monitoring of service quality and human rights violations, and to engage key affected populations into the meaningful dialogue with the government”, says Mikhail Golichenko, Senior Policy Analyst from the Canadian HIV\AIDS Legal Network. “This Program was inexpensive tool to contribute to communities’ systems strengthening, support them to overcome the legal barriers and retain KAPs as equal parties in the dialogue with the Russian Government, and as such should not be lost due to the lack of funding”.

[1] S. Shonning. Community Systems Strengthening and Removing the Legal Barriers Modules of the Global Fund Program: Improving access to prevention, treatment and care for key population groups in Russia: Baseline and progress to date Report. January 2017 (on file with the author).

[2] The Global Fund, Charitable Donation Agreement, RUS-H-OHI (on file with the author)

[3] The Global Fund, RUS-H-OHI-RP: 3-SI-762018. Performance Letter Progress Report covering the period 1 January, 2017-31 December, 2017 (on file with the author).

[4] On file with the author

[5] http://www.unaids.org/sites/default/files/media_asset/Global_AIDS_update_2017_en.pdf

[6] UNAIDS 2018 Global AIDS Update. 2018. Online: http://www.unaids.org/sites/default/files/media_asset/miles-to-go_en.pdf

[7] https://www.avert.org/professionals/hiv-around-world/eastern-europe-central-asia/russia

[8] http://www.rbc.ru/society/02/11/2016/581997289a794704fcfaaa79

[9] Federal AIDS Center or Rospotrebnadzor. Information Note. HIV in Russia in 2017. Online: http://aids-centr.perm.ru/images/4/hiv_in_russia/hiv_in_rf_31.12.2017.pdf

[10] Ibid

[11] Presentation by E. Kryanina, ED of OHI (PR of the GF HIV grant) at the meeting of the Coordinating Committee on 07.06.2018. (on file with the author).

This text is the author’s version of the article published at www.aidspan.org

WEB developer is needed for a long-term contract

EHRA is looking for a specialist to provide long-term maintenance and support for both harmreductioneurasia.org  and eecaplatform.org websites. Application deadline is October 1, 2018. Please see the detailed Terms of Reference to familiarize yourself with the tasks, requirements and conditions. Applications can be submitted by contacting Irena Zubkova at irena@harmreductioneurasia.org

Application Form

General and Regional meetings of EHRA members to elect Steering Committee members

On 17-30 of September, 2018 EHRA conducts online Regional Meetings of its members to elect new Steering Committee representatives in the following regions:

  • Central Europe (Poland, Slovakia, Czech Republic, Hungary, Slovenia);
  • Ukraine-Moldova-Belarus;
  • Caucasus (Armenia, Azerbaijan, Georgia);
  • Central Asia (Kazakhstan, Kyrgyzstan, Tajikistan, Uzbekistan, Turkmenistan).

At the same time, General meeting of EHRA members to elect Steering Committee representatives from the community of people who use drugs will be conducted.

All members (individual and organizational), who are from the above-mentioned regions (in case of Regional meeting) and also who are identifying themselves as members of the community of people who use drugs (in case of General meeting) have a right to vote in the General and Regional meetings.

If you have any questions, please contact General Secretary of the General and Regional meetings – Irena Zubkova at members@harmreductioneurasia.org

Central Europe

Dominika Jašeková

Slovakia

Know your candidate
Motivation letter

Jan Stola

Poland

Know your candidate
Motivation letter

Ukraine, Moldova, Belarus

Ala Iatco

Moldova

Know your candidate
Motivation letter

Caucasus

Marina Chokheli

Georgia

Know your candidate
Motivation Letter


Irma Kirtadze

Georgia

Know your candidate
Motivation letter

Central Asia


Maram Azizmamadov

Tajikistan

Know your candidate
Motivation letter


Aibar Sultangaziev

Kyrgyzstan

Know your candidate
Motivation letter

Mirzosharif Odinaev

Tajikistan

Know your candidate
Motivation letter

PWUD
Community

Alexander Levin

Russia

Know your candidate
Motivation letter

Vitalii Rabinciuc

Moldova

Know your candidate
Motivation Letter

Status of transitions in the EECA region

Eastern Europe and Central Asia (EECA) is one of two regions, along with Latin America and the Caribbean, where planning for the transition away from Global Fund support is most advanced. The following table shows components in the various categories of transition from Global Fund support

* In the first column, only components still active as recently as 2015 are listed.

More information in the article