The Global Fund Board recently approved a grant to civil society principal recipient (PR), Fundacion Centro de Informacion y Recursons para el Desarollo (CIRD), in Paraguay. The planned implementation period for the grant is 1 March 2018 to 28 February 2021.
When it reviewed Paraguay’s HIV program continuation funding request, the Technical Review Panel (TRP) noted that despite facing persistent challenges such as stigma and discrimination and gender-based violence, Paraguay’s HIV program had made progress, particularly regarding legislation, the provision of legal advice, sensitization training, the provision of antiretroviral therapy (ART) and health management information systems (HMIS).
The funding requests notes that while there is no legislation in Paraguay explicitly criminalizing individuals on the basis of their gender identity and sexual orientation, there has been an uptick in cruel, demeaning and violent behavior directed towards these populations. In 2016, nearly half (42%) of the complaints made at the Center for Counseling and Complaints on HIV and Human Rights pertained to sexual orientation or gender identify. Fear of discrimination and re-victimization has been identified as obstacles to accessing justice. However, the HIV grant has supported advocacy actions that have resulted in (a) the adoption of a government resolution allowing transgender individuals to use their preferred name in ministry-run health facilities and (b) awareness workshops to combat discriminatory attitudes among health personnel.
The funding request states that the country’s HIV epidemic remains stable and concentrated among key populations. As a result, the request is focused on transgender people, men who have sex with men (MSM) and female sex workers (FSW) whose HIV prevalence rates are estimated at 26%, 13% and 1.27%, respectively. This is in contrast with the HIV prevalence in the general population which stood at 0.43% in 2015. Although the incidence rate has slightly decreased since 2010, the mortality rate has increased. This is in part due to late diagnosis and gaps in linkage to care, retention and adherence to ART. As a result of what the TRP termed a “reduction” in the Global Fund grant for 2017–2019, interventions for other key populations, such as people who use drugs and people in closed settings such as prisons and detention centers, will be covered by domestic funds.
Paraguay is categorized as an upper-middle-income country by the World Bank and the Global Fund.
The funding amount requested by the CCM and approved by the Global Fund is $4.4 million. Paraguay also submitted a prioritized above allocation request (PAAR) of $1.8 million, of which $1.4 million was identified as quality demand by the TRP. Efficiencies of $79,389 were identified during grant-making and were used to fund some of the PAAR activities. In the end, $1.3 million was registered as unfunded quality demand (UQD).
The TRP considered the HIV funding request to be technically sound and strategically focused. It said that the HIV program remained relevant and appropriate for the epidemic; that it has been steadily performing; and that there was a strong country commitment evidenced by Paraguay’s growing share of domestic financing. The TRP noted that the focus on three key populations (MSM, transgender people and FSW) and on filling in gaps in the treatment cascade is fully aligned with the national strategic plan (NSP) and UNAIDS’ 90-90-90 global strategy. Finally, the TRP noted that Paraguay had successfully addressed all five issues raised by the TRP and the Grant Approvals Committee (GAC) when they reviewed the 2014–2016 funding request. These issues were as follows:
- further validate key population size estimation (key population mapping is being conducted in 2017);
- amend prioritization of the ART expansion plan to include co-infected patients, prisoners and other key and vulnerable populations;
- revise the ART monitoring plan and indicators in order to align to international guidance and standards and ensure strategies to improve adherence;
- clearly define and monitor linkages and collaboration among civil society organizations (CSOs) to ensure prevention programs remain effective and focused; and
- provide a detailed breakdown of the program management budget.
Weaknesses, gaps and action steps
The TRP identified three issues pertaining to the funding request to be cleared by the Secretariat. These issues were partially addressed during grant-making and will be fully addressed during grant implementation. Below we briefly summarize the issues, and we indicate what the outcomes have been (to date).
ISSUE: Weak HIV treatment cascade performance for key populations –– particularly for MSM and transgender people. The TRP recommended that the CCM further enhance actions or devise concrete, additional interventions to continue improving the care cascade to meet the 90-90-90 targets.
Outcome: Paraguay will conduct a mapping of MSM, FSW and transgender populations with corresponding “hot spots” within the framework of the HIV Prevalence and Risk Behaviors Surveys. This will also include a cartography of people diagnosed, retained in care and on ART, as well as the patient referral system. This will facilitate patient monitoring and attainment of national objectives related to the HIV continuum of care. Analysis of the new data will support the development of new strategies to improve HIV prevention and linkage to care and treatment –– and may result in reprogramming of the grant and revision of the performance framework.
ISSUE: Need for better transition planning to improve chances of long-term sustainability. The TRP noted than in an environment of decreasing external resources, there should be a multi-sectoral taskforce in place to develop a transition and sustainability plan to ensure continued support for prevention, testing, diagnosis, treatment and care for key populations. The TRP also said that the plan should be relevant for civil society organizations.
Outcome: Paraguay established a Transition and Sustainability (TS) Commission headed by the Vice-Minister of Health and comprised of senior bureaucrats and key technical and administrative experts. The commission’s main objectives are to develop and monitor the transition plan and find solutions to implement social contracting.
ISSUE: Ensuring the continuation of prevention, testing, treatment and care for people who use drugs and people in closed settings. Because these services are shifting from being financed by the Global Fund to being funded from domestic sources, there is a need to have the CCM and the national HIV program closely monitor these interventions to ensure they are effective and of high quality.
Outcome: Recent studies show that injection drug use is declining. Nevertheless, the Ministry of Health is implementing, through the National Addiction Control Center, advocacy, prevention and diagnosis activities for people who inject drugs. In 2018, there are plans to update a 10-year-old Interinstitutional Cooperation Agreement to reduce the number of patients and rehabilitate the largest number of inmates with health problems, including those with sexually transmitted infections. The current agreement allows for the national HIV program to periodically provide training, technical assistance, testing supplies and treatment for HIV to inmates in penitentiaries.
The PAAR deemed to be quality demand by the TRP initially included line items for the procurement of lubricants for condoms used by MSM, transgender people, and FSW and their clients, totaling $79,389.
This activity will now be funded thorough efficiencies identified during grant-making. However, the procurement of lubricants is conditional on the PR developing a three-page action plan to change the national legal framework to allow the procurement of lubricants as an HIV prevention health product and to facilitate future uninterrupted supply.
Funding landscape, co-financing and sustainability
The table below provides an overview of the country’s funding landscape for HIV for the 2018–2021 implementation period of the grant.
Table: Overview of Paraguay’s funding landscape in 2018–2021 ($ million)
|Estimated funding need for program:||101.4 m||
As % of funding need
|Change vs. previous period|
|Total domestic resources||58.3 m||57%||Increase|
|Total external resources (non-GF)||0.08 m||0.1%||Decrease|
|Total Global Fund resources||4.4 m||4%||Decrease|
|Total resources available||62.8 m||62%||Minor decrease|
|Unmet need gap||38.6 m||38%||Minor increase|
The TRP determined that Paraguay made sufficient co-financing commitments for the allocation period, as per the requirements of the Sustainability, Transition and Co-Financing (STC) policy. The government investment will continue to support activities in the following areas: purchase of HIV drugs and commodities (including procurement of antiretrovirals); supply chain management; communication strategies; trainings; and human resources.
Despite the reductions in external donor funding, the TRP assessed that Paraguay has sufficient financial resources and political will to cover the financial gap.
Paraguay was one of the first countries in the Latin American and Caribbean region to undertake a transition readiness assessment (TRA).
The TRA identified two key transition challenges: improving the legal framework for human rights and ensuring a long-term role for civil society in the national response to HIV. To this end, the grant will support (a) funding for a legal complaint center to hire a legal expert to follow up on instances of stigma and discrimination; and (b) training for health professionals to improve the quality of care delivered to key populations. The grant will also support strengthening the area of social contracting to ensure that CSOs can continue to provide prevention services to key populations during the grant after the country is no longer eligible for Global Fund support for HIV. These areas of work will be included in the country’s transition plan, which is being developed.
Although Paraguay’s TB component is currently receiving transition funding and is ineligible for further funding, and Paraguay’s current malaria grant is expected to be its last, Paraguay’s HIV component remains eligible for further funding. It is not on the list of components projected to transition by 2025 (this list has just been updated; see separate article in this issue).