Global Fund grant will expand HIV prevention, care and treatment services for key populations in Guyana

Author:

Kataisee Richardson

Article Type:

Article Number: 6

Program continuation request outlined human rights and legal challenges

ABSTRACT When it reviewed Guyana’s HIV program continuation funding request, the Technical Review Panel said that the request built on lessons learned from Guyana’s most recent programming for key populations. Issues raised by the panel were either fully or at least partially addressed during grant-making. The Global Fund Board recently approved funding for the HIV grant.

Among the batch of grants recently approved by the Board was an HIV grant to Guyana. The proposed timeframe for the grant was 1 January 2018 to 31 December 2020. The principal recipient (PR) is the Ministry of Health, which also managed Guyana’s previous HIV grant.

In 2017, Guyana submitted a program continuation request for its HIV component. Program continuation requests are meant to simplify the funding request process for well-performing grants that have been recently reviewed by the Technical Review Panel (TRP) and do not require significant programmatic overhaul.

The epidemiological context and geographic focus of interventions remain the same when compared to the previous request. The country continues to experience a mixed epidemic that disproportionately affects key and vulnerable populations –– men who have sex with men (MSM), female sex workers, transgender people, miners and loggers. The strategic focus was on increasing impact by implementing mixed strategies to intensify the linkages to treatment and instituting a “treat all” policy.

According to the TRP, the proposed program built upon the successes and lessons learned from Guyana’s most recent programming for key populations, and aligned with the mid-term evaluation and revision of the National Strategic Plan (NSP) (HIVISION 2020); 2020 HIV cascade projections; the Center for Disease Control’s (CDC’s) Allocative Efficiency and Program Effectiveness Study; and a 2016–2017 comprehensive reprogramming request to ensure alignment with Guyana’s goal of eliminating AIDS and its negative social and economic impacts on the population.

The amount approved for the grant was $4,539,985, which is slightly lower than the program split amount. The difference will be reallocated to the TB component. There was no prioritized above allocation request (PAAR). The table below provides an overview of the country’s funding landscape for HIV for the 2018–2020 period.

Notes:

*The new NSP is currently being costed and there is a sustainability committee that is looking into defining the areas that will be covered by domestic funding.

** Data in the funding landscape table may be modified in the coming months to ensure consistency across years and in data reported by the Ministry of Finance and the Ministry of Health to the Global Fund.

Notable strengths

The TRP considered the request to be technically sound and appropriate. It is aligned with the NSP and the 90-90-90 targets, the TRP said, and aims to implement the “treat all” approach and follow the World Health Organization (WHO) guidelines. The TRP found the program to be clear and well targeted, and deemed that it adequately addressed concerns raised by the TRP regarding the 2014–2016 grant.

The request takes into account the need to improve linkage to care for new persons newly diagnosed, antiretroviral therapy (ART) coverage, and retention of people living with HIV, the TRP observed. The request also notes the need to improve the supervision and program quality assessment of prevention strategies for key populations, and the proportion of miners and loggers tested for HIV. Finally, the TRP said, the funding request highlights the HIV program’s significant successes to date, such as increasing the proportion of pregnant women living with HIV receiving ART from 79% to 100%; ensuring that that all people diagnosed with HIV are screened for TB; and ensuring that 86% of co-infected TB/HIV patients receive ART during TB treatment.

In addition, the program continuation request outlined several key human rights and legal challenges that decrease equal access to health services for key populations; and suggested that the recommendations of a recent National Dialogue on HIV and the law will serve as strategic guidelines to develop the activities required to address those challenges.

Weaknesses, gaps and action steps

The TRP identified four issues pertaining to the funding request. The issues were discussed by the Secretariat and the PR during grant-making. Two were cleared and the remaining two were partially addressed. Below we summarize each issue as well as the outcome.

Not enough focus on transgender people. While transgender people have the highest HIV prevalence rate among identified key populations (8.4%), they were not addressed as a distinct population (rather, they were included with MSM).

Outcome: The issue was cleared by the TRP. The MOH submitted a revised strategy that contained new activities specifically for transgender people, including gathering baseline data for evidence-based decision-making and increasing the coverage area. This change resulted in increased targets in the performance framework and created a need to revise the budget to align with the additional interventions.

Weaknesses in procurement and supply chain management. There were weaknesses in the procurement and supply chain management systems that resulted in delays in the delivery of program commodities.

Outcome: The issue was partially addressed. The Grant Approvals Committee (GAC) said that the MOH understands the systemic supply issues and is currently creating a procurement master plan to address key issues in the system. The GAC added that there was a proposal to include a condition precedent in the grant confirmation form requiring that stock levels and consumption data be reviewed before procurement orders are made.

Lack of sustainability planning. Although Guyana has seen a 33% increase in domestic investment for HIV over the last period, it will soon face a substantial reduction in the availability of external funds to support the HIV response. The TRP said that Guyana needed to have a comprehensive discussion of sustainability issues.

Outcome: This issue is partially addressed by the launch of a committee tasked with drafting Guyana’s sustainability strategy by June 2018.

Treatment target plans not ambitious enough. The TRP highlighted that treatment scale-up targets are very low. It said that Guyana must intensify approaches to prevention in key populations –– especially MSM, transgender people and sex workers, all of whom are disproportionately affected by the HIV epidemic. Otherwise, the TRP said, the cost-effectiveness and impact of the program may be compromised.

Outcome: The issue was cleared during grant-making. The treatment targets were reviewed and more ambitious targets were submitted.

Sustainability

In the opinion of the TRP, Guyana has demonstrated a commitment to its HIV response by progressively increasing its investments in operating costs, human resources and medicines in order to maintain or scale up programming. This increase in domestic spending is intended to offset funding reductions from PEPFAR and the Global Fund, which the TRP said were in the order of 30% and 50% respectively.

As mentioned above, Guyana has launched a sustainability committee, comprised of government representatives from the MOH and the Ministry of Finance, civil society and other partners, to spearhead the discussion on sustainability and transition and deliver a sustainability and transition plan. The committee is supported by a consultant from Health Financing and Governance (HFG) Project, a USAID initiative. Guyana has also implemented a feasibility study on social contracting and will be conducting a transition readiness assessment this year.

Reactions from civil society

The TRP determined that the development of the program continuation request had been inclusive and had consolidated input from key population representatives. This sentiment was echoed by Devanand Milton, a transgender representative who is vice-chair of the CCM. She said that key populations and civil society were fully engaged in the process.

“Civil society organizations were given a small pot of money ($2,000 each) to conduct consultation sessions with their constituencies and report feedback to the CCM on challenges and recommendations,” Milton said. “I was invited by the National AIDS Program secretariat manager to submit recommendations that the transgender constituency be included in the proposal.”

However, Joel Simpson, managing director of Society Against Sexual Orientation Discrimination (SASOD) was critical of the funding request.

“It’s great that Guyana received more money from the Global Fund to fund the HIV response,” Simpson said, “but if the same ways of working persist, the Global Fund will continue to fail at reducing the HIV burden among key populations. Global Fund processes are caught up in government bureaucracies that are generally unresponsive to the human rights and health needs of key populations.”

Simpson added: “Civil society, much less key populations, do not play any meaningful role in decision-making processes. The country coordinating mechanism is dominated by the government with the support of the international agencies. The politics is beyond most of us in civil society.”