Editor’s Note: In its audit reports, the Office of the Inspector General (OIG) comments on the performance of the programmes being implemented through Global Fund grants as well as on the systems in place for programme management, financial management and procurement. In the past, coverage of the OIG audit reports in GFO has focussed primarily on the systems. In this article, we report on the OIG’s findings with respect to the HIV programmes covered by the Global Fund’s grant in Uzbekistan. At the end of April 2012, the Global Fund's Office of the Inspector General (OIG) released the final report of an audit on three grants in Uzbekistan, administered by three principal recipients (PRs), including the Republican AIDS Center (RAC), PR for the Round 3 HIV grant. The RAC is part of the Ministry of Health (MOH). The audit was conducted between 17 August and 17 September 2009, and a further financial audit was conducted in the first quarter of 2010. The value of the HIV grant was $21 million, of which $15 million (71%) had been disbursed at the time of the audit. In this article, we report on some of the OIG’s findings with respect to the HIV programmes covered by the grant. In its comments, the OIG dealt with both the national HIV programme and the grant from the Global Fund. The OIG said that, overall, the RAC had successfully carried out work plans of the Round 3 grant, but that some planned activities have not been implemented. The OIG cited several examples:

• the substitution treatment component of the programme was terminated;
• a reproductive health curriculum for schools was not developed;
• teachers were not trained in reproductive health issues;
• palliative care was not provided to PLWHA; and
• protocols for palliative care were not developed.

According to the OIG, there is very low coverage of most-at-risk populations (MARPs) by trust points. (Trust points are service delivery units, usually located in public health facilities, and usually targeting MARPs.) The OIG said that of the people registered at these trust points, very few are tested for HIV (including zero coverage of men who have sex with men). The OIG said that according to trust point providers interviewed, the reason that MARPs are not tested for HIV is fear of stigma related to HIV status. The OIG said that the RAC should consider moving the trust points out of government health facilities. The OIG also recommended using rapid testing in the trust points. The OIG said that a significant proportion of people living with HIV do not seek care to initiate treatment with antiretrovirals (ARVs), and that the reasons include fear of stigma as well as difficulty travelling to the capital to begin treatment. The OIG said that the RAC and the MOH should give consideration to decentralising initiation of ARVs and clinical follow-up of patients to the regional level. The audit found that medicines for the treatment of opportunistic infections are not provided free of charge although they were meant to be under the Global Fund grant. The OIG said that people living with HIV have to buy these drugs at their own expense, which some of them cannot afford. The OIG said that there were stockouts of antibiotics and medicines for the treatment of sexually transmitted infections at the regional AIDS centres in Fergana and Andijan, as well as at the central level. There were also shortages of medical supplies such as gloves, syringes, intravenous sets and catheters which, the OIG said, has serious implications for people living with HIV. Other findings by the OIG include the following:

• pre-test counselling is not routinely done at all service delivery points;
• most infectious disease doctors, who are supposed to provide clinical oversight to patients on ARVs, have not had adequate in-service training; and
• there is poor coordination between HIV and TB programmes.

Response from the PR The audit report contained a section providing responses to the OIG’s recommendations from PRs and the other entities covered by the audit. With respect to the OIG’s recommendation that trust points be moved outside government health facilities, the RAC said that opening trust points elsewhere is not possible due to lack of funds. However, the RAC said, measures are being taken to strengthen the services provided at the trust points. The RAC also said that rapid tests would be used for MARPs, on a pilot basis, starting in 2012, if funding is obtained. Concerning the OIG’s recommendation that initiation of ARVs and clinical follow-up be decentralised, the RAC and the MOH said that this is now happening and that training programmes will be implemented for medical specialists in regional centres. With respect to the OIG’s findings that there were shortages of medicines and medical supplies, the RAC said that this is being addressed in a new single-stream-of-funding (SSF) grant. (The SSF grant consolidated the Round 3 HIV grant with activities in an approved Round 10 HIV proposal.) The RAC indicated that measures were being taken to address the other findings in the audit report. All of the OIG reports released in April 2012 are available on the Global Fund website here.