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Africa: AIDS Treatment Progress Reports

AfricaFocus Bulletin
Jul 1, 2006 (060701)
(Reposted from sources cited below)

Editor's Note

Newly-compiled performance results show that as of end April, 544,000 people have begun antiretroviral (ARV) treatment through Global Fund-supported programs - up from 384,000 six months ago. And despite the pressures for competition between the U.S. bilateral PEFPAR program and the Global Fund, reports from implementing agencies say the stress on operational level is on how to use resources from both programs to maximize action against AIDS. But sustainability of funding is a looming obstacle, with the projected overall funding gap for this year at some $5 billion.

This AfricaFocus Bulletin contains excerpts from a press release from the Global Fund to Fight AIDS, Tuberculosis, and Malaria ( and a report from AIDSMAP on the recent PEPFAR implementers' conference in Durban.

For earlier AfricaFocus Bulletins on health issues, see

Note: AfricaFocus Bulletin will be taking a break for the next two weeks. Publication will resume in the third week of July.

++++++++++++++++++++++end editor's note+++++++++++++++++++++++

New Global Fund Grant Results Show Substantial Impact

More than 40% Increase in People Reached Over Six Months

June 29, 2006

Global Fund to Fight AIDS, Tuberculosis, and Malaria

Johannesburg - With nearly 400 grants approved to combat HIV/ AIDS, TB and malaria, Global Fund-financed programs are proving that where money is invested, treatment and prevention efforts are working.

In its latest progress report published today, the Global Fund outlines the latest program results and looks at the initial data on how its grants affect health systems and indications of global impact in the fight against the diseases.

Newly-compiled performance results show that as of end April, 544,000 people have begun antiretroviral (ARV) treatment through Global Fund-supported programs - up from 384,000 six months ago. The new figures show a more than four-fold increase since December of 2004 in the number of people started on ARV treatment with support from the Global Fund.

Taken together, programs providing DOTS (Directly Observed Short Course Treatment) have detected and treated more than 1.4 million cases of tuberculosis worldwide. In addition, Global Fund-supported programs to combat malaria expanded distribution of insecticide-treated bed nets to 11.3 million, up from 7.7 million in December 2005.

Early indications of impact on the three diseases show both that the additional funding of the Global Fund bears a promise of substantially reducing the prevalence of these diseases. The potential for most rapid progress is in the field of malaria, where concentrated investments have drastically reduced mortality within periods of less than two years and carry promise for a global turnaround in the prevalence and mortality rates. ...

"This latest set of performance figures comes as very good news," said Richard Feachem, Executive Director of The Global Fund to Fight AIDS, Tuberculosis and Malaria. "These results demonstrate that where countries are given the resources they need, progress against this pandemic is possible. It shows that with sufficient global resources, we can drive back this scourge."

The report finds that the Global Fund's system of performance-based funding does appear not to penalize poor countries, as countries with the lowest wealth, health systems or human resources for health have no worse performance during their first two years of grant implementation. Even countries known as "fragile states" (due to extreme poverty, recent armed conflict or weak governments) do not fare significantly worse than other countries, with two thirds of them showing satisfactory performance. Many of these "fragile states" have developed a close collaboration between government and civil society in implementation of national health programs, compensating for weaknesses in public sector.

Civil society organizations are strong implementers, with 30 percent of their grants over-performing and the remaining 70 percent showing satisfactory performance. There are strong indications that countries can drastically increase their national absorptive capacity by channeling more of its health spending through non-governmental and faith-based organizations.

Global Fund support for efforts to combat AIDS account for 56 percent of the total US$ 5.4 million committed to date for programs in 131 countries to fight the three diseases. Of the US$ 3 billion allocated to AIDS, half is dedicated to prevention activities while the other half is allocated to treatment.

In 2005, the Global Fund was responsible for an estimated 20 percent of all international funding in support of efforts to combat HIV/AIDS, and approximately two-thirds of global funding for programs against TB and malaria.

Over the past three years, Global Fund financing has enabled nearly 53 countries to change from malaria drugs which have become increasingly ineffective to the new artemisinin-based combination therapy (ACT), which has the potential to drastically reduce mortality from malaria among children and pregnant mothers. In some countries, Global Fund grants have also provided blanket coverage of new, long-lasting insecticide-treated bed nets, which afford more durable, effective protection against malaria to vulnerable populations. The roll-out of ACT or other effective combination therapies and bed nets - in combination with targeted insecticide spraying and strengthening of expertise, infrastructure and training - is expected to reduce malaria mortality in large parts of Africa in the coming years.

On average, data compiled shows that grants to combat all three diseases are exceeding targets set out in their respective grant agreements, which serve as the basis of the Global Fund's performance-based grant evaluation. The new results released today represent the aggregation of numbers issued directly from reports on progress by individual grants.

While the new treatment and prevention figures demonstrate the Global Fund's expanding track record in saving lives, raising awareness among vulnerable populations and preventing further infections, the Global Fund's funding gap for years 2006 and 2007 threatens to curtail the momentum of funded programs as well as funding for new rounds of grants.

"New rounds of grants in 2006 and 2007 will provide the opportunity for countries to expand the considerable progress we are seeing against the three diseases", said Carol Jacobs, Chair of the Global Fund Board. "Donors need to make long-term commitments of sufficient resources to enable developing countries to plan for the future with confidence that funding for their lifesaving activities will not trail off." ...

PEPFAR and Global Fund both highly effective, but is the funding sustainable?

Theo Smart, June 23, 2006


[Excerpts only. For full text of this report and other reports from the conference, visit]

At the 2006 Annual Implementers' Meeting of the US President's Emergency Plan for AIDS Relief (PEPFAR), last week in Durban, South Africa, the 'implementers' (the teams working on the ground in PEPFAR's focus countries) reported success after success and gave numerous examples of just how rapidly effective smart and strategic investments in AIDS care and treatment can be. In a little over two years since disbursements began, PEPFAR has supported antiretroviral treatment (ART) for hundreds of thousands and care for literally millions of people infected or affected by HIV in resource-constrained settings.

And yet a shadow loomed over the meeting, held just ten days after the US delegation to the United Nations (UN) refused to set financial targets for universal access to prevention, care and treatment at UN High Level Meeting on AIDS and just two weeks before the continually cash-strapped Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) will be holding its own "Replenishment Conference," also in Durban, where the Global Fund board will be begging national, institutional and individual donors for enough money to hold a grant cycle this November - - much of which is desperately needed simply to sustain ongoing programmes whose earlier grants will soon be expiring.

This appears to be part of a growing pattern, according to the UN's Global Report on HIV/AIDS, which notes that after years of funding expansion, "existing pledges, commitments and trends suggest the rate of increase may be declining and that available funds will be US$ 8.9 billion in 2006 and US$ 10 billion in 2007. Those amounts will be far short of meeting the estimated requirements of US$ 14.9 billion in 2006, US$ 18.1 billion in 2007 and US$ 22.1 billion in 2008."

"The financial shortfalls that we are facing around the response to AIDS are ever more significant and calamitous," Stephen Lewis, Secretary-General's Special Envoy for HIV/AIDS in Africa said during the UN High Level Meeting.

"We are facing a shortfall overall of $5 billion this year, of $8 billion next year, of $10 billion in 2008. We are facing a minimum overall shortfall of $23 billion dollars which is, quite frankly at this moment in time, a scandalous betrayal of the commitments that the G8 made at Gleneagles in July of 2005."

In light of such financial uncertainty, a number of participants at the PEPFAR meeting expressed grave concerns about the long-term sustainability and expansion of the scale up of treatment and care globally, and whether there will continue to be reliable ongoing funding for both PEPFAR and the Global Fund. The presence at the PEPFAR meeting of activists from the American religious right, who have been attempting to drive a wedge between the two generally complementary organisations, only heightened worries among some participants that support for one or the other donor agency could be held hostage to American partisan politics.

Yet, the philosophical differences between the two donor organisations seemed relatively minor in light of the importance of their shared objective fighting the pandemic. For the most part, the true implementers (many of whom receive support from both funders) at the PEPFAR meeting appeared more interested in getting the work done than wasting too much time on ideological controversies or religious polemics. ...

PEPFAR background

President Bush established the Emergency Plan for AIDS Relief in July 2003 to increase the total US commitment to the effort to combat the HIV across the globe to an $15 billion over a five year period.

Only about $9 billion really represents new money, the lion's share of which is being directed to efforts in 15 focus countries that are burdened with about half of the world's HIV infections. Over the first two years, under two billion dollars of the new funds have actually been disbursed but the proposed funding is scaling up rapidly over the next few years, as more programmes come online and develop greater capacity to actually absorb and spend the money effectively.

Nevertheless, the results so far have been impressive. According to statistics put together by the US Office of the Global AIDS Coordinator (OGAC) as of March 31, 2006, PEPFAR has:

  • Directly supported ART for 366,800 people and contributed to the support (by strengthening local systems and capacity) making ART possible for 194,200 more.
  • Directly supported efforts to prevent mother to child transmission for about 4.5 million women, and preventive therapy for about 340,000 women - - preventing HIV transmission to an estimated 65,000 infants.
  • Provided HIV-related care and support to nearly 3 million people across the world, including more than 1.7 million people living with HIV/AIDS and more than 1.2 million orphans and vulnerable children.

While the funding has come from the US, these achievements are equally due to the dedication of PEPFAR's in-country partners - - both governmental and non-governmental - - implementing the programme on the ground.

Global Fund worries

But efforts supported by the Global Fund are under even more imminent danger of losing support.

"The Global Fund spends an immense amount of time and energy in a yearly begging exercise to get some donors to fulfil their commitments," Javier Hourcade Bellocq, who serves as an Alternate Board Member to the Global Fund (representing communities living with diseases) said at a press conference held during the UN High Level Meeting on AIDS.

"And even that seems not to be enough," he continued. "We are now facing the risk of not having sufficient resources to fund the 6th round of proposals that the board needs to approve in November 2006. We immediately need a new round to scale up prevention, treatment, care and support in our countries, and also to renew the first round of grants that's coming to an end real soon."

Since its creation in January 2002, the Global Fund has disbursed more than $2.2 billion to public and private recipients in over 127 countries (and promised more than $3 million more, which will be disbursed only after countries reach performance targets).

As of June 2006, according to their own statistics, Global Fund supported programmes have:

  • Distributed around 11.3 million insecticide-treated bednets to prevent malaria
  • Provided millions of courses of malaria treatment and enabled 53 countries to begin offering artemisinine-based combination therapy (ACT) (rather than older drugs which malaria resistance has rendered ineffective)
  • Detected and treated more than 1.4 million TB cases
  • Supported HIV care and prevention for hundreds of thousands of people and orphans in resource-limited settings
  • Provided ART for 544,000 people

Actually, Global Fund and PEPFAR must share credit for some patients on ART, because often each donor organisation supports different aspects of the same ART programme. For example, PEPFAR may provide support for the laboratory monitoring or staff training, while the Global Fund may purchase the actual medications, or vica-versa.

Speaking at the opening of the PEPFAR meeting, the Global Fund's Deputy Executive Director, Helen Evans, stressed this sharing of the burden of treatment: " Together, programmes financed jointly or separately by PEPFAR and the Global Fund have put 875,000 people on ART... this is a more than 40% increase in the last six months and more than a doubling within the last year."

To do its part to maintain this momentum of scale-up, the Global Fund announced a Sixth Call for Proposals in April this year. But shortfalls in funding commitments are now jeopardising a new round of grants - - and even the funding of the second phase of grants for projects already up and running. If there is to be one new grant cycle each year, in 2006 there will be a shortfall of $0.9 billion, and in 2007, a shortfall of $1.2 billion.

"I hate to even begin to imagine the day that the Global Fund will fail to meet its commitments," said Elizabeth Mataka, Executive Director of Zambia's of National AIDS Network who also serves as Global Fund board member on behalf of Developing Countries NGOs at the UN press conference. "If round six is not renewed in November, we will lose all the momentum we've worked so hard to gain."

"It is unthinkable that the global fund should have to make this appeal, and is a sad commentary on the G8 countries," said Ambassador Lewis. "Where is the sense of crisis? What is happening here?"

Is PEPFAR competing or cooperating in treatment scale-up?

Given the political climate in which the PEPFAR Implementers meeting and the UN High Level meeting took place, it would be only natural for some working in the respective funding organisations to become a bit competitive - - and yet publicly at least both appear to be striving for closer cooperation.

Given the fact that both organisations are funding similar work in the same areas, without close communication there is a capacity for overlap and creating redundant, parallel systems. In some cases, duplications of effort have led to competition for the same patients. In one case, a free PEPFAR ART site was established near an established fee-for service Global Fund site, and inadvertently siphoned patients away - - contributing to the failure of one country [Nigeria] to have the second phase of its first round Global Fund grant renewed.

According to Ms. Helen Evans, Deputy Executive Director of the Global Fund, such poor coordination ultimately led to a meeting in January 2006, between PEPFAR, the Global Fund and the World Bank to improve communications amongst country teams and to identify challenges to successful implementation as well as come up with concrete actions to tackle those challenges. ...

In her address at the start of the Implementers meeting, she asked participants to focus on closer cooperation, insisting that it is in both organisations' best interests to "convince tax payers and law makers that this effort is worth increased effort, predictable and long term investments in order to sustain and further scale up our work."

"How do we strengthen health systems to allow the scale-up to occur and to ensure that the scale-up is sustainable?" she said. "One of the obstacles to increasing access to treatment is the frailty of basic health systems in many countries."

In this regard, the Global Fund has certain advantages over PEPFAR because the Global Fund favours a country-driven approach which brings the key stakeholders (governmental and non-governmental organisations) in a country together to flesh out what they believe the country should ask for in its grant (and hammer out what they believe they can deliver). ...

Good examples of this process were presented from Kenya and Tanzania, where two different approaches to coordination have been followed.

In Kenya, coordination of donor activities takes place at the provincial level, where the word of the provincial ART officer is final. Lennah Nyabiage of the Kenyan Ministry of Health explained her role: coordinating all donor activities, including PEPFAR-funded programmes in Nyaza province.

"Partners often want to go to particular districts, but the Ministry of Health has to tell them to go to places without ART coverage. The provincial officer has to try to get partners to direct money where it is needed, rather than according to the preferences of partners."

Ms. Nyabiage has a lot of partners to coordinate in Nyaza province: the US Centers for Disease Control, Mildmay International, MSF, Catholic Relief Services and the German development agency GTZ are all directly supporting antiretroviral treatment in Nyaza province, largely through PEPFAR grants. ...

In Tanzania on the other hand, the division of labour has been coordinated at the national level, with provinces allocated to different consortia of organisations, even though most of the programmes are funded by PEPFAR. These consortia are responsible for all aspects of scale-up in a particular province. ...

But coordination doesn`t always work - - at least not as quickly as people living with HIV really need. Governments often drag their feet, lack competent leadership or are corrupt. Local stakeholder representation may be inequitable (with some groups being completely shut out) or negotiations between stakeholders can be influenced by politics or simply inefficient. As a result, the proposals the Global Fund receives, or the implementation of the funds on the ground, are not always as good as they could be.

It is in these situations where PEPFAR is particularly useful - - whenever Global Fund efforts meet an impasse which PEPFAR-funded programmes, by virtue of feeling less obliged to work through local government-led coordinating bodies, can more rapidly address. One advantage PEPFAR has is its ability to bypass government coordinating bodies, red-tape and logjams to direct funding to groups, community-based or otherwise, that can rapidly mobilise and get the work done. But this works especially well when PEPFAR and Global Fund keep each other informed of each others efforts and challenges in implementation. ...

AfricaFocus Bulletin is an independent electronic publication providing reposted commentary and analysis on African issues, with a particular focus on U.S. and international policies. AfricaFocus Bulletin is edited by William Minter.

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