Forging a common regional approach to the Global Fund’s Seventh Replenishment

Author:

Samuel Muniu and Ida Hakizinka

Article Type:

Article Number: 4

Sub-Saharan African countries come together to build consensus on how to deliver their support By:Samuel Muniu and Ida Hakizinka 4 FROM THE FIELDApr 22nd 2022

ABSTRACT In a meeting held on 11-13 April 2022, delegates drawn from African countries agreed on a common regional approach to the Global Fund’s seventh replenishment. The meeting was jointly organized by the African Constituency Bureau of the Global Fund and the Joint United Nations Programme on HIV and AIDS. Participants agreed on key messages to deliver to their respective countries’ leadership and other stakeholders to sensitize them on the need to pledge financial support to the Global Fund during the Seventh Replenishment meeting later this year.

Between 11 and 13 April 2022, the African Constituency Bureau for the Global Fund (ACB) and the Joint United Nations Programme on HIV and AIDS (UNAIDS) co-organized a consultative and resource mobilization meeting in Nairobi. The aim of the consultations was to come to a consensus concerning a common approach for Africa’s

advocacy for a successful Seventh Replenishment for the Global Fund. Participants from 19 sub-Saharan African countries discussed progress in implementing the Global AIDS Strategy (GAS) 2021-2026, as well as the GAS’ commonalities with the forthcoming Global Fund Strategy 2023-2028. They agreed on the key messages to be conveyed to their respective governments and other national stakeholders to encourage and influence their participation in and contribution to the Seventh Replenishment conference later this year.

The meeting was attended by senior government officials, including National AIDS Commission (NAC) directors and civil society organizations (CSOs) from Cameroon, Côte d’Ivoire, the Democratic Republic of Congo (DRC), Eswatini, Ghana, Guinea Bissau, Kenya, Malawi, Mali, Mozambique, Nigeria, Rwanda, Senegal, South Africa, South Sudan, Tanzania, Uganda, Zambia, and Zimbabwe.  Other attendees included the ACB, the Global Fund, UNAIDS, and the United Nations Children’s Fund (UNICEF). The guests of honor were Dr Jean-Jacques Mbungani Mbanda, the DRC’s Minister of Public Health and the incoming Global Fund Board member representing the West and Central Africa (WCA) region; Eamonn Murphy, Deputy Executive Director at UNAIDS; and Ruth Masha, the director of NACC Kenya representing the Permanent Secretary in Kenya’s Ministry of Health.

A summary of the HIV response in sub-Saharan Africa

Dr Fodé Simaga of UNAIDS told the meeting that in the forty years since the beginning of the HIV epidemic, 76 million people have been infected with HIV and of these 33 million people have died from AIDS.  In 2002, there were 1,500,000 new infections and 680,000 deaths. Every day there are 4,000 new HIV infections among both children and adults. Of these, 60% are in sub-Saharan Africa: 10% are among children under 15 years of age and 90% are among adults aged 15 years and older, of whom 51% are women. Young people, especially young women, disproportionally account for a higher proportion of new HIV infections. Indeed, young people aged 15-24 years account for 31% of new HIV infections among adults while young women in the same age group account for 20%.

According to Simaga, key populations (KPs) represent 40% while adolescent girls and young women (AGYW) account for the majority of the remaining 60% of new HIV infections in the region. However, reaching these vulnerable groups with HIV prevention, testing, and treatment has been a challenge. Thus, there is a need to prioritize HIV prevention among KPs and AGYW if the 2025 targets are to be met.

Simaga noted that, while funding is available for HIV prevention targeting these groups, countries’ existing legal and policy barriers are a constraint. He emphasized the need for more and better engagement of communities, including religious and traditional healers, to work towards a shared vision of a common prevention and treatment agenda. He concluded by indicating that demand for prevention interventions, such as condom provision, has decreased and countries will have to prioritize prevention if they want to receive more funding for prevention-related activities.

Country experiences and challenges in implementing differentiated service delivery

Since 2015, the World Health Organization (WHO) has recommended the adoption of differentiated service delivery (DSD) for HIV treatment. DSD is defined as “a client-centered approach that simplifies and adapts HIV services across the cascade, in ways that both serve the needs of people living with HIV better and reduce unnecessary burdens on the health system”. During the Nairobi meeting, participants reflected on their countries’ challenges in providing HIV prevention, testing, and treatment through DSD modalities and identified opportunities to improve the status of DSD implementation.

Dr Akudo Ikpeazu, director of Nigeria’s National Agency for the Control of AIDS, said that DSD was instrumental in helping the country to increase the number of people using antiretroviral therapy (ART) from about half a million to 1.7 million over a five-year period. Incorporating DSD into HIV services had enabled Nigeria to expand HIV service delivery for different groups, including pregnant women, breastfeeding mothers, children, adolescents, and KPs. According to Ikpeazu, for successful DSD implementation countries should consider the following

• Ground DSD in robust policies, guidelines, and operational manuals that spell out the ‘how’ of implementation.
• Establish DSD coordination mechanisms at national, sub-national, and community levels to improve accountability at each level.
• Put in place appropriate data tools and systems to support in capturing and reporting on DSD implementation.
• Improve procurement and supply chain management systems to ensure the availability of health products.
• Have appropriate laboratory delivery systems in place.

Participants from other countries provided their experiences in implementing DSD. For example, in Cameroon, DSD has resulted in the creation of additional targets that has helped the Ministry of Health advocate for more financial resources to cover treatment costs for the newly diagnosed HIV-positive. DRC is currently experimenting with the use of HIV self-testing kits and assisted tests for people who cannot self-test. The country developed a policy to involve communities in implementing DSD in regions with high HIV prevalence; volunteer community leaders were trained to offer DSD at the community level while CSOs were engaged in advocating for self-testing. In South Africa, DSD implementation involved strengthening community governance and leadership to ensure community ownership. This was made possible by putting the necessary supportive legal framework in place; for instance, the country established multi-month dispensing (MMD) through establishing a six-month antiretroviral medicines’ dispensing policy and provided funding to support sustainable DSD provision.

However, participants also identified challenges that hinder DSD implementation. These included the fact that DSD programs are still not widely accepted by Ministries of Health and health personnel, including physicians; the insufficient involvement of CSOs; and the lack of involvement of communities in task-shifting and task-sharing. Procurement and supply chain issues were also noted to be a key factor hampering successful DSD interventions.

Key messages regarding the Global Fund Seventh Replenishment and domestic financing

Participants asserted the importance of countries to offer their support for a fully funded Global Fund if the world is to achieve the 2025 targets and get back on track towards ending AIDS by 2030. This means that everyone must come together to ensure a successful Seventh Replenishment. Participants also agreed that there is a need for countries to prioritize evidence-based HIV programs to tackle inequalities among the most vulnerable and those affected by the epidemic. These HIV programs should use the latest knowledge, innovations, and strategies to tackle inequalities among AGYW, KPs, children, and men. Moreover, African countries must target adolescents and young people, KPs — particularly in those in closed settings — pregnant women, and children with tailored context-specific DSD HIV prevention and treatment services.

The meeting highlighted the need for countries to expand their partnership with the Africa Centres for Disease Control and Prevention (CDC) to leverage political commitment for a fully funded Global Fund. Besides the political commitment required for a successful Global Fund replenishment, Africa CDC strengthens the continent’s health security financing by pushing for domestic resource mobilization and engaging the private sector in financing health programs.

Participants also expressed a need for stronger global leadership, coordination, information, policy development, and knowledge-sharing to guide the global AIDS response. This cannot be achieved without the provision of adequate financing for key global institutions, such as UNAIDS, and to drive national efforts for the impact of the Global Fund investments at the country level as well as maximizing domestic and international partners’ investments in the HIV response.

Based on the lessons learned from the COVID-19 pandemic, participants noted the importance of creating an enabling environment for the local production of health products and technologies. Also, they stressed the value of building national and sub-national level resilient and sustainable systems for health that are essential to combat HIV. Participants also saw a need for increased domestic financing for sustainability and country ownership in the HIV fight, in line with the WCA HIV summit call to action to reinvent the response to the HIV pandemic and end AIDS in the region. The high-level summit held from 31 October to 2 November 2021 in Dakar, Senegal, committed among other things to increasing national and international resources for HIV in the WCA region by 33% by 2025 and removing financial barriers for people living with HIV in accessing health services.

Participants agreed to use multiple channels to disseminate the meeting’s messages

Finally, the meeting concluded with participants resolving to use various means to deliver its key messages to Heads of State, health and finance ministers, cabinet secretaries, CSOs, and bilateral and multilateral organizations. Participants committed to convening a multi-stakeholder meeting at the country level to provide a meeting debrief and update national stakeholders on opportunities for the Seventh Replenishment. To launch this exercise, participants will review the status of the previous pledges for the Sixth Replenishment (read more about the status of pledges in our article on President Biden pledges for the Global Fund’s seventh replenishment in this GFO issue) and, while recognizing the challenges countries are currently facing, advocate for those that have not met their pledges to do so. Then they will develop and disseminate an advocacy strategy to increase guarantees for the Seventh Replenishment, creating awareness through, for example, press releases. The culmination of this will be preparation for high-level government participation at the Seventh Replenishment conference.

While pushing for increased Global Fund funding, the participants will also advocate for countries to increase their own domestic financing for HIV. It is ALSO an opportunity for stakeholders to advocate for their countries to provide complementary funding to UNAIDS to support countries to achieve the necessary programmatic outcomes from investments to fight HIV; although, given existing financial constraints resulting from the economic downturn caused by COVID-19, this may be unlikely to happen.