On 24 September 2018, the Global Fund Board approved a $5.0 million donation to Venezuela. Owing to the severe humanitarian crisis in the country, this donation was made despite Venezuela not meeting the usual Global Fund eligibility criteria (see GFO article, October 2018).

The exceptional donation comes from funds designated by the Audit and Finance Committee for portfolio optimization. The Global Fund’s policy on exceptional funding, adopted in 2018, sets a ceiling of $20 million for such funding, for all potential recipients combined, for the 2017-2019 allocation period.

Eight months after the Board’s decision, an update report was published by The International Council of AIDS Service Organizations (ICASO) and Acción Ciudadana contra el SIDA (ACCSI) (Citizens Action against AIDS). The report is a follow-up piece to ICASO and ACCSI’s first exposé on the health emergency in Venezuela, released in November 2017 (see GFO article, October 2017).

The update report documents a deteriorating social, political and economic situation in the country, including challenges with the rollout of ARVs financed by the Global Fund donation.

Update on the procurement of ARVs in Venezuela

As Aidspan has previously reported, $4.9 million of the Global Fund donation to Venezuela is being channeled through the Pan American Health Organization (PAHO) Strategic Fund for the purchase of antiretroviral drugs (ARVs). According to the ICASO and ACCSI update, the first 100,000 bottles of the fixed dose combination Tenofovir/Lamivudine/Dolutegravir (TLD) purchased by PAHO with the Global Fund donation arrived in Venezuela on December 23, 2018. The second shipment of 200,000 bottles arrived on January 16, 2019. As of May 2019, nearly all 600,000 bottles bought by PAHO had arrived in country.

Once the customs and nationalization processes were completed, the drugs were transferred to the Jipana warehouse, where they were received by officials of the Ministry of Health together with PAHO, UNAIDS and the Red Venezolana de Gente Positiva (RVG+) (Venezuelan Network of Positive People).

The Global Fund Secretariat told the GFO that three shipments of ARVs have arrived in Venezuela and were being held in the central warehouse. A first distribution was done with support from PAHO and UNAIDS, the Secretariat said, to the 37 pharmacies that provide ARVs in the country’s 24 states. Patients are receiving ARVs (TLD), a Global Fund representative said, but uptake has been slow due to in-country issues including older regimens and local logistical challenges such as no transport due to lack of fuel. These issues were discussed with the Board as potential risks at the time the investment was approved, they said, and the Secretariat is working with PAHO, UNAIDS, civil society to accelerate the uptake of TLD in Venezuela.

The report situates the Global Fund donation for the procurement of ARVs in the context of Venezuela’s government-endorsed Master Plan, as well as other in-kind donations. Of the $100.9 million needed to respond to HIV over the Plan’s three-year period, $63.7 million is needed for medicines (Figure 1). The Global Fund’s $4.9 million donation for ARVs is complemented by more than $11.0 million in donated ARVs from AID for AIDS, UNICEF, and the governments of Brazil and Haiti.

Figure 1. Distribution of HIV resource needs in Venezuela 

Source: Venezuela 3-year Master Plan (June 2018-May 2021)

Community monitoring reveals delays in ARV distribution

The remaining $100,000 of the Global Fund donation is being routed through the Joint United Nations Programme on HIV/AIDS (UNAIDS) for civil society organizations to monitor the delivery of the medicines procured.

Community monitoring led by RVG+ has revealed numerous irregularities in the storage and distribution of different medicines throughout 2018, including donations from a variety of organizations and institutions, that have not been delivered to people living with HIV. (The Global Fund-financed ARVs only arrived in Venezuela at the end of December 2018.)

ICASO and ACCSI say the unjustified delays in distributing the medicines are due to a decision by the Ministry of Health to keep them in its centralized warehouses. Local organizations cited in the report suggest the government of Venezuela may be intentionally withholding these medicines from people living with HIV, planning to exchange the drugs for votes during electoral periods.

As part of the social monitoring component of the Master Plan, supported in part by the Global Fund donation, community observers were supposed to be present in each of the pharmacies that deliver ARVs in Venezuela. This aspect of community monitoring has not (yet) been implemented, due to the refusal of the Ministry of Health to grant access to the pharmacy facilities.

Alberto Nieves, the Executive Director of ACCSI, says more support is needed for civil society organizations to be able to hold government to account. “The impact of the complex humanitarian emergency on people living with HIV and their families, together with the constant violations of human rights, intimidation and violence against human rights defenders living with HIV requires more substantial technical and financial support from the international community,” says Nieves.

“Continued investments in community systems in Venezuela are of the utmost importance” says Mary Ann Torres, the Executive Director of ICASO. “We need the Global Fund to scale this up, not only for monitoring and advocacy, but also for health and legal service delivery,” she said. In recent months, ICASO has documented police raids of HIV service organizations as well as persecutions and arrests of human rights defenders and activists in Venezuela.

Sounding the alarm on resurgent TB and malaria epidemics

According to the Master Plan, the purchase of antiretroviral drugs for HIV was the most urgent need among the three health conditions. The Board’s decision was based on the availability of essential life-saving commodities for the three diseases in the country for the following 12-months. It was acknowledged, the Secretariat told the GFO, that there were still significant gaps in TB and malaria across the entire health system. The ICASO and ACCSI update shines a spotlight on alarming recent trends for TB and malaria:

• Venezuela was responsible for 53% of all malaria cases and 80% of all malaria deaths in Latin America and the Caribbean in 2017;
• A total of 10,185 (31.8 per 100,000 population) new and relapse TB cases were recorded in 2017, up 41% from 2014.

In the recommendations section of the update, ICASO and ACCSI note that the leadership shown by the Global Fund in the case of Venezuela is unique, however, the organizations say more support and cooperation from the Global Fund is required.

ICASO and ACCSI call on the Global Fund to assess the impact that Venezuela’s crises has had on other countries in the region, where approximately 2.4 million Venezuelan refugees and migrants have fled in search of health services and other relief. This information could inform potential reprogramming or realignment of Global Fund grants in neighbouring countries (Colombia has an HIV grant and Guyana has a malaria grant) to address urgent needs in border territories, especially in the area of malaria.

“ ‘Triple Threat’ calls for the urgent streamlining of plans to prevent the further loss of life and human dignity among people living with HIV and affected by TB, malaria, and other health conditions. Failure to do so not only affects Venezuela; left unchecked, these resurgent epidemics threaten global health security,” says Torres.

Speaking to the GFO for this article, Javier Hourcade Bellocq, Chair of GNP+ and civil society member of the LAC delegation to the Global Fund Board, said: “International CSOs acknowledge the fantastic effort made by the Global Fund Secretariat and the technical partners to procure and send the medications [to Venezuela], but we underestimated the situation. There is the increasing challenge of delivering any health services [in the country] and the hospitals are abandoned and dismantled. We witness attempts by the government to use aid politically, so that’s why the incredible job done by civil society in Venezuela, to monitor the Global Fund investment, is so vital.”

Bellocq also commented on the slow pace of new investment by donor governments who, he said, during the three years of discussing the exceptional contribution to Venezuela, had committed to contributing additional funding for AIDS, TB and malaria, but, he said, this had not happened “in a substantial way”.

“We are not seeing any new investment in responding to these three diseases,” Bellocq said. “Five million [USD] could save many lives but it is a drop in the ocean.”

The Secretariat told the GFO that the Global Fund notes with concern that the overall health situation in Venezuela continues to deteriorate. The Global Fund will consider a future request under the non-eligible countries in crisis approach in the coming months, noting that the initial request was for 12 months, and that all funding for ineligible countries in crisis is limited to $20 million over three years. Any future request for exceptional funding would be subject to Board approval and availability of funds, the Secretariat representative said.

Gemma Oberth is a policy advisor for ICASO. Gemma also consults directly with the Global Fund, supporting the Community, Rights and Gender Strategic Initiative. This was declared to Aidspan and was not considered a conflict of interest in light of the author’s unpaid contribution to the GFO in order to share the ICASO and ACCSI report findings.