Letter to the Global Fund from MSF (Médecins Sans Frontières)

Dear Mark Dybul, Dear Members of the Secretariat and Global Fund Board of Directors,

We are writing to you on behalf of Médecins Sans Frontières (MSF) to share the report; “Out of focus: How millions of people in West and Central Africa are being left out of the global HIV response.”

The report identifies main barriers to HIV care in the West and Central Africa (WCA) region and outlines strategies to scale-up HIV services. MSF is calling upon international actors including the Global Fund to contribute to a plan to accelerate access to antiretroviral treatment (ART) in countries with a substantial treatment gaps, particularly in West and Central Africa.

The report illustrates and underlines areas of concern regarding policies that the Global Fund Board will discuss at its meeting in Abidjan this week, such as eligibility criteria and funding allocation methodology. Both rely heavily and increasingly on a simple formula and a limited set of indicators, including World Bank income classification (GNI per capita) and disease burden. MSF is concerned that insufficient attention and consideration will be given to significant unmet health needs across different types of epidemiological contexts and we would like to share these concerns for your consideration.

One in five new HIV infections worldwide and over a quarter of the 1.2 million AIDS-related deaths in 2014 were in the West and Central Africa region. Only one in four people of the 6.6 million people living with HIV have access to ART. Almost half of all new infections among children are from the region, and nine out of ten HIV positive children do not have access to ART. Yet West and Central Africa remains out of focus internationally since lower HIV prevalence do not garner enough support from international actors.

MSF is very concerned that institutions such as UNAIDS, PEPFAR and the Global Fund, are prioritizing ‘hot spots’ and highest burden areas at the expense of supporting countries with critical unmet needs. Such targeting risks leaving large regions with severe treatment gaps and unchecked epidemic growth. Also, the principle and promise of equity should underline the global effort to expand accesses.

MSF witnesses daily the human toll of the continued neglect of people living with HIV in the region: in MSF supported hospitals in Kinshasa and Conakry patients are admitted in advanced stages of AIDS and with opportunistic infections that have become relatively rare in other regions. In the Central African Republic, where HIV/AIDS is the leading cause of death amongst adults, hospitals are under strain under the high number of AIDS patients.

Our observations highlight the urgent need to overcome the current status quo. MSF is therefore calling for an ambitious catch-up plan for these countries. In order to close the treatment gap we propose concrete targets, such as tripling ART initiations by 2020 in countries with less than 30% HIV treatment coverage.

As one of the main funding agencies in WCA region, the Global Fund must increase its role to address the deadly ART treatment gaps and the Global Fund proposed Strategy for the period 2017-2022 can facilitate the implementation of a catch-up plan; supply chain management, human resources for health, service delivery through communities, adapted implementation approaches in challenging operating environments as well as differentiated care and innovative models of service delivery. These areas require particular fast tracking in the WCA region.

The Global Fund’s revised allocation methodology is expected to move significantly towards a formula-driven allocation of financing, increasingly aligned with two main factors: disease burden and country’s economic classification. While many high burden countries with lower ability to pay certainly are in need of increased funding, we reiterate our concerns raised in a letter to the Global Fund in July 2015; an allocation model based on blunt economic and disease level thresholds fails to capture true health needs and context specific difficulties or opportunities. The allocation model intends to significantly increase funding in a few countries with the highest disease burden, while its consequences for a large number of countries with lower prevalence and/or concentrated epidemics remain unclear and unpredictable. Notwithstanding significant unmet needs, people living with HIV and TB in these contexts face the risk of significant reductions of the resources needed for an accelerated disease response and in particular to reach the global goal of 90/90/90 by 2020.

Without a transparent and truly flexible allocation process that takes multiple factors into consideration, such a model risks pitting affected populations in different countries against each other, and undermining the Global Fund’s leverage to fight these diseases effectively. Beyond formula-based country allocations, a robust complementary mechanism should encourage ambitious country-led proposals and efforts that will enable investments in interventions aiming to overcome treatment gaps, remove access bottlenecks or overcome service delivery challenges.

We are also concerned about Global Fund plans for sustainability and transition strategies that overly rely on country-income classification to limit the scope of interventions that can be funded. This restricts implementation based on context-specific and inclusive assessments of needs.
The Global Fund strategy and policies should ensure that all transitioning countries continue to make progress in fighting the three diseases while increasing access to quality assured generic medicines, at the lowest prices available worldwide. The Global Fund should also promote generic competition in such countries through the use of TRIPS flexibilities while also supporting supply chain management.

People living outside certain pre-defined priority areas will continue to need and merit support in line with the Global Fund’s mandate to fight the three diseases. Existing treatment gaps cannot be ignored and populations perceived to be of marginal interest for epidemic control cannot once again be left behind.

MSF encourages the Global Fund Secretariat and Board to consider these points in their deliberations during the Board meeting. We look forward to further discussing these matters and would like to take the opportunity to propose a meeting with Mark Dybul and his team at their earliest convenience.

Yours sincerely,

Dr. Bart Janssens,

Director Operations, Médecins sans Frontières, Brussels.

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