According to Médecins Sans Frontières, countries in West and Central Africa are lagging behind in the response to HIV. MSF said that most of the countries in the region struggle to offer antiretroviral therapy: 76% of those who need ART – five million people – are still awaiting treatment. That’s three out of every four people. Among children, nine out of every 10 children who need ARVs don’t have access. This information comes from a report entitled, OUT OF FOCUS: How Millions of People in West and Central Africa Are Being Left Out of the Global HIV Response. The WCA region is made up of 25 countries, most of them with relatively small populations. Their average prevalence rates are relatively low compared to Southern Africa. The relatively low prevalence – 2.3% in 2014 – nevertheless represents around 6.6 million people living with HIV, which was 18% of the global HIV burden that year. The region accounts for 21% of new HIV infections worldwide However, according to MSF, ART coverage rates in the WCA lag behind those of Southern Africa. “While countries faced with an overwhelming HIV burden have risen to the challenge by making major changes to their health services, countries in WCA have had less incentive to adapt their service delivery models, and less support to do so.” (The 25 countries in the WCA region are: Benin, Burkina Faso, Burundi, Cameroon, Cape Verde, Central African Republic, Chad, Congo, Côte d’Ivoire, Democratic Republic of the Congo, Equatorial Guinea, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Liberia, Mali, Mauritania, Niger, Nigeria, São Tomé and Príncipe, Senegal, Sierra Leone, and Togo.)

Source: Out of Focus

Why are the countries in the WCA lagging behind? According to MSF, there are several explanations. First, many countries struggle with weak health systems and competing health priorities, problems which are exacerbated in places prone to recurrent crises. “Many countries in WCA failed to implement some of the innovative methods used elsewhere for rolling out ART, due to resistance or a lack of awareness, instead resorting to ill-adapted approaches.” Second, the (U.S.) President’s Emergency Plan for AIDS Relief (PEPFAR), The Global Fund and UNAIDS all give priority to the same geographical areas or population groups with high transmission, but it is unclear what support is provided outside these hotspots. Third, the challenges created by the weak health systems, especially with respect to procurement and supply management, make it difficult for donors to manage investments and achieve impact. If a donor invests in treatment in countries in the WCA, and if the ARVs are not reaching the people who need them, this acts as a disincentive to further investment. Fourth, the WCA region relies too heavily on a single donor: The Global Fund. According to MSF, globally, international donor funding levelled off or grew modestly between 2010 and 2014. It said that while the US government’s contribution flat-lined at $5.6 billion in 2014, it remains the largest donor, providing nearly two-thirds of donor funds for HIV. “Other donor countries have shown a preference to provide HIV funding through multilateral channels, including the Global Fund. Overall contributions to the Global Fund for the 2014-16 period increased after the Global Fund went through significant reforms.” MSF said that with donors such as the World Bank and several bilateral funders withdrawing from HIV, and in particular from ARV funding, the Global Fund plays an increasingly important role in the ARV market, taking on about a third of ARV purchasing. The Global Fund tends to be the major – and often the only – donor that funds HIV activities in WCA countries, particularly the provision of ARVs. (PEPFAR has only four priority countries in the WCA.)  “The reliance on Global Fund grants alone creates a potentially precarious situation,” MSF said. “Without alternative sources of funding, any disruption in the institution’s grant disbursement can have serious consequences for country programs.” Several countries in the WCA are classified by the Global Fund as “challenging operating environments.” To mitigate these challenges and improve results in these contexts, The Global Fund allows for more flexibility in in both the applications process and in grant implementation. According to MSF, in practice the application of such flexibilities has so far been limited. It cited the examples of recent Global Fund proposals submitted by the Democratic Republic of Congo (DRC) and Guinea. Both proposals experienced significant delays, due to new and more demanding application processes which, in turn, contributed to delayed implementation. With respect to the proposal from Guinea, GFO has learned that The Global Fund required Guinea to develop a national strategy for key populations before the grant was signed. In its report, MSF puts forward several recommendations for increasing ART coverage in the WCA region, including, for example: create political pressure to mobilize around the 90-90-90 targets; tackle stigma and discrimination, educate patients and promote human rights; and drastically increase access to pediatric ARV formulations. The report includes case studies on three WCA countries: Central African Republic, DRC and Guinea. Gemma Oberth contributed some reporting for this article.