Does the Global Fund Reach the Most Marginalized and At-Risk Populations? (Postcard from Vienna)

Under the banner “Rights Here, Right Now,” the International AIDS Conference currently taking place in Vienna is committed to translating funding for human rights-based programming for HIV to address the stigma and discrimination that often impede an effective response. On Wednesday, Global Fund executive director Michel Kazatchkine and others participated in a session titled “The Global Fund: Proving Impact, Promoting Rights.”  The majority of their discussion focused on how the Global Fund can better address the most vulnerable and marginalized populations—those living with and most at-risk of acquiring HIV/AIDS—rather than the successes of the Global Fund.

While the session was very interesting—perhaps, the most interesting of my four straight days here—the most dynamic takeaway was what was not said when a group of about ten Middle East and North Africa (MENA) representatives marched silently to the front of the room waving signs, wearing t-shirts, and taping stickers over their mouths with the slogan “I want to be eligible.” Their argument: The Global Fund’s current funding architecture doesn’t enable money to flow to the most at-risk populations in their countries.To be clear, the Global Fund DOES provide funding to countries in the Middle East and North Africa.  However, most of these countries fall within the lower-to-middle income range, which means that funding allocations are conditionally based upon their ability to address the “cost sharing” principles of the Fund (read: funding is shared between the Global Fund, domestic resources, and contributions from other donors).  A representative from the MENA group did not refute the importance of contributions from middle-income national governments to the HIV/AIDS response.  Rather, his concern is that in a region with a marginalized epidemic among populations that are so hidden and so stigmatized by these same governments, funds must go straight to the civil society organizations invested in these populations in order to be effective.Findings from a recent World Bank report, which offers the first comprehensive look at the evidence on the spread of HIV in a region where knowledge of the epidemic has been very limited and subject to controversy, confirms this view.  The report asserts that strengthening civil society contributions to HIV efforts is essential to the MENA region, where HIV transmission is concentrated in hidden and stigmatized populations. “A structural weakness of the HIV response in MENA is the meager contribution of nongovernmental organizations, community organizations and people living with HIV groups in the formulation, planning, and implementation of the response,” the report states.  In theory, the Global Fund's Country Coordinating Mechanism (CCM) model is one way for these countries to gather and invest in civil society.However, while CCMs are a good mechanism for bringing all sectors of the HIV/AIDS response together for planning and implementation, in many countries, national governments dominate the CCMs even though they are supposed to represent all sectors of the community.  In some lower-middle income countries, government-dominated CCMs PLUS a significant portion of the funding for the HIV/AIDS response coming from and handed to these national governments—which routinely stigmatizes the most at-risk populations, a la many MENA countries—leads to not only limited representation on the CCM, but also to limited programming targeted toward these marginalized populations.In fairness, I need to give the Global Fund some credit for recognizing that this is an issue.  Here in Vienna and at the replenishment prep meeting in March, Global Fund representatives acknowledged that the Fund’s work in middle-income countries has a “catalytic value…particularly in galvanizing domestic support and targeting particularly vulnerable communities.” However, as the Global Fund gears up for their replenishment—to be held October 4-5 of this year—they need to think hard about how the MENA region and others are represented within the current structure.  Beyond examining their overall impact on the disease as a justification for more funding, the Global Fund and its board should reassess how to strengthen the funding architecture—like the CCMs and cost sharing—that often present barriers to funding the most at-risk populations.