Russia has announced its pledge to commit $60 million to the Global Fund’s fourth replenishment cycle ahead of the anticipated end in 2014 of all Global Fund grants to the country.
In an executive order signed in late December 2013, Prime Minister Dmitry Medvedev said that the pledge would signal the completion of Russia’s transition, begun in October 2010, away from receiving Global Fund assistance and towards being exclusively a contributor to the global fight against AIDS, TB and malaria. In total, Russia has contributed some $317 million to the Global Fund since 2002, including $217 million reimbursed under a 2007 agreement with the World Bank.
Russia received five grants in all – worth some $378 million – since the Fund’s inception in 2002, three of which were aimed at strengthening the national HIV response. The country coordination mechanism was abolished in 2013, leaving the remaining two grants the responsibility of independent non-governmental organizations: the non-profit partnership ESVERO, previously known as Russian Harm Reduction Network, and the Open Health Institute (OHI).
ESVERO director Pavel Aksenov told Aidspan that Russia has achieved significant progress in strengthening its HIV response over the last decade, including significantly increased access to HIV treatment and diagnostics and prevention of mother-to child transmission. In the 12 years that anti-retroviral treatment has been available in Russia, the number of people under treatment has grown to 122,446 people, according to a 2013 UNAIDS report. Millions of people are tested annually for HIV, Askenov said, availing themselves of the diagnostic facilities that have been available in Russia for nearly a generation.
Aksenov said that while much of the success achieved in Russia can be attributed to the progressive transition of funding away from the Global Fund and towards domestic resources, there remains a considerable gap in support for essential HIV prevention services among the most-at risk populations: injected drug users, commercial sex workers and men who have sex with men chief among them.
Internationally recommended and evidence-based interventions such as harm reduction programs, condom distribution and opioid substitution therapy are illegal in Russia, illustrating the human rights challenges confronting NGOs working to support these populations.
For these groups, confidence in the state-run system’s ability to fully absorb all of the activities and programs supporting the HIV response is shaky. They cite the lack of a national strategy for HIV response and modifying restrictive legislation that outlaws the use of generic ARVs as two immediate tasks requiring attention. The higher cost of brand-name drugs means that maintaining the state’s claim of 100% coverage could be compromised by limited resources, and has been illustrated by the delays that plague enrollment in ART programs.
Additionally, there remain significant barriers to access to testing, including but not limited to confidentiality concerns. For injected drug users, for example, the administrative fines levied for ‘non-medical use of narcotics’ has prevented many from even seeking testing for fear of repercussions including jail time. Commercial sex workers also face similar challenges because of the criminalization of their livelihoods.
But it is among men who have sex with men that the institutionalized stigma and fear of persecution – or prosecution – have been the greatest obstacles to access. The risk, according to Open Health Institute contacted by Aidspan is that “if they come out as gay, they risk being injured or even fired from their jobs.”
For the NGOs continuing to work with people living with HIV, the risk of the Global Fund’s departure from Russia is less about the financial resources devoted to the HIV response than it is about the priorities emphasized by Global Fund-supported programs. “Although Global Fund program coverage is relatively small, it has helped to demonstrate the urgent need to expand prevention programs,” Aksenov said.
Examples of programs likely to be completely shut down once the state takes over include syringe and needle exchange activities and counseling services targeting IDUs, raising the risk of infection within this population.
Hope for the future of these types of programs could come from the re-application of the NGO rule (see article here) under which ESVERO and OHI have already received funding. The rule, established in 2011, allows upper-middle income countries with high disease burdens to apply for funding to be managed by NGOs, rather than CCMs, to target key services or populations.
Aksenov said that groups were convening a country dialogue to tailor a proposal under the revised eligibility and counterpart financing policy that would allow Russian NGOs to apply for one more allocation period after 2014.
"Now more than ever, NGOs working in HIV in Russia need to consolidate and work together in close coordination," said Aksenov.