The region of Eastern Europe and Central Asia (EECA) is the only region in the world where the HIV epidemic continues to grow, and Russia could be considered 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”.

Given the significance of Russia’s epidemic, and taking into consideration the geopolitical position of the Russian Federation and migration flows in the region, it is critical to consider Russia’s escalating HIV epidemic when planning a response to the HIV epidemic in the EECA region, as it could negatively impact all efforts by donors and governments to counteract the HIV epidemic in neighbouring countries.

The last Global Fund HIV grant in Russia

The implementation of the last Global Fund HIV grant in Russia (RUS-H-OHI) ended on 31 December 2017, with a grant closure period ending on 30 September 2018. The $12-million grant provided for the period 2015 to 2017. Local NGO the Open Health Institute (OHI) was the Principal Recipient (PR), selected 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”, according to the Charitable Donation Agreement.

The program consisted of three intertwined components: HIV service delivery for people who inject drugs (PWID), sex workers and men who have sex with men (MSM), community systems strengthening (CSS), and removing legal barriers. From 2015 the activities included services for 17 programs for people who inject drugs (PWID), 5 for men who have sex with men (MSM), and 5 targeting sex workers (SW).

Additionally, in both 2016 and 2017, 12 programs were co-financed and 20 more were given small grants to help them overcome legal barriers and to protect the rights of communities’ representatives. According to the Global Fund Performance Letter Progress Report covering the period 1 January 2017 to 31 December 2017, by the end of its implementation, the grant had shown very good results against the targets set (102% average performance of all indicators): it was rated B1, with eight out of ten of its indicators rated A1.

A Global Fund management letter dated 17 July 2017 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 NGOs’ and communities’ representatives only, without any involvement or support from the governmental sector. The Coordinating Committee (similar to a CCM but without any involvement of the governmental sector) was established by the civil society-based National Dialogue to coordinate the implementation of the project.

Russia’s eligibility for Global Fund HIV funding

The Russian Federation, although classified as ‘high income’ at the time of the 2014-2016 allocations, was eligible for an HIV grant under the ‘NGO Rule’ – a provision within the Global Fund’s Eligibility Policy that allows for potential eligibility for upper-middle income countries (UMICs) that meet the disease burden thresholds for HIV but are not on the Organization for Economic Co-operation and Development (OECD) Development Assistance Committee (DAC) List of Recipients for Official Development Assistance (ODA).

As of 2014, eligibility under this rule was linked to the existence of political barriers (such as legislative and/or policy provisions) that preclude the provision of evidence-informed interventions (for example, provision of needle exchange programs, opioid substitution therapy, condoms) for key populations. Funding provided under this rule must be channelled through civil society and cannot directly fund governments.

The Global Fund uses the latest 3-year average of GNI per capita in order to determine income classification. Although Russia was reclassified as an upper-middle income country in 2016 by the World Bank, according to the Global Fund’s Eligibility Policy “a country component must meet eligibility criteria for two consecutive years in order to become newly eligible for an allocation”. This meant that, for the purposes of Global Fund eligibility in 2017, Russia was still considered ‘high income’ and therefore was not yet eligible for funding. For the same reason, Russia was not considered eligible to receive any transition funding after the termination of the current grant, which could enable it to sustain the results it has achieved.

During the 39th 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 the 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 could be considered eligible under this provision again, after what will have been two consecutive years as ‘upper-middle income’ (2016-2017) and may receive an allocation within the next allocation period from 2020 to 2022.

HIV epidemic in Russia requires urgent action

Since the beginning of the 2000s, there has been a concentrated HIV epidemic in Russia among key groups affected by HIV such as injecting drug users, men who have sex with men, and sex workers, and in some regions of the country, a generalized epidemic has been observed since 2016. Recent integrated biological and behavioral surveillance (IBBS) research conducted in seven Russian cities within the implementation of the ‘NGO rule’ HIV program demonstrates between 48.1% and 75.2% HIV prevalence among PWID, between 7.1 and 22.8% among MSM, and between 2.3% and 15% among SWsw. With more than 1.2 million people registered as HIV-positive by the end of 2017 (cumulatively since 1987, as registered by the Federal AIDS Center), treatment coverage with ART is about 35%.

Besides this last HIV grant, the Global Fund has invested more than $250 million within Round 3, Round 4 and Round 5 HIV and TB grants to ensure a sustainable response to Russia’s HIV and TB epidemics. But given that available state funding is not enough to support the activities implemented in Russia’s now-ending Global Fund HIV grants, there is a risk that most of the results achieved will be endangered.

The Russian Coordinating Committee is now making attempts to bring the attention of the Global Fund Secretariat and delegations to the Global Fund Board to this situation through open letters, to ensure the continuation of HIV prevention services and the community-based response, at least until the new allocations for 2020-2022 are announced by the Global Fund Secretariat.

“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”, said Mikhail Golichenko, a senior policy analyst from the Canadian HIV/AIDS Legal Network. “This program was an inexpensive tool to contribute to communities’ systems strengthening, support them to overcome the legal barriers and retain key affected populations as equal parties in the dialogue with the Russian government,” Golichenko said, “and as such should not be lost due to the lack of funding”.

Editor‘s note: The author 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 discussed in this article. 

– To see the September 12 letter from the Russian Coordinating Committee to members of the Developed Country NGO Delegation to the Board of The Global Fund to Fight AIDS, Tuberculosis and Malaria, regarding the case for support for Key Affected Populations’ Response to HIV Epidemic in Russia , click here

– To see the ‘Case for Support’ itself, for Key Affected Populations’ Response to HIV Epidemic in Russia, click here.